Intended for healthcare professionals

Rapid response to:

Clinical Review

Management of the severely malnourished child: perspective from developing countries

BMJ 2003; 326 doi: (Published 18 January 2003) Cite this as: BMJ 2003;326:146

Rapid Response:

Hypophosphataemia in children with protein-energy malnutrition


In their review article on the management of the severely
malnourished child (1) Bhan et al outline the most important electrolyte
imbalances and micronutrient deficiencies found and the recommended
supplementation to correct them.

We are concerned that phosphate is not mentioned in their review.
Severe hypophosphataemia (plasma phosphate concentration below 0.3
mmol/L), associated with increased mortality, has been widely described in
children with protein-energy malnutrition, especially when these are
accompanied by severe diarrhoea (2-4).

Additionally, hypophosphataemia is a well-known complication of the
refeeding syndrome as phosphate (and potassium) are taken up by cells
whose metabolism is ‘reactivated’ by the influx of the glucose
provided(5). This is worse with parenteral nutrition but has also been
described with enteral nutrition(5).

It is often forgotten that organophosphate compounds such as ATP,
creatine phosphate and 2-3 diphosphoglycerate play a central role in the
provision of energy to the cell, the generation of energy in myocytes and
the delivery of oxygen to tissues from haemoglobin respectively. Thus, it
is not surprising that every cell in the body is affected by
hypophosphataemia which is manifested as a non-specific syndrome that
affects the gastrointestinal, central nervous, muscular and haemopoietic

Jose C. Cabrera-Abreu
consultant chemical pathologist

Geoff H. Lester
consultant clinical biochemist

1. Bhan MK, Bhandari M, Bahl R. Management of the severely
malnourished child: perspective from developing countries. BMJ

2. Freiman I, Pettifor JM, Moodley GM. Serum phosphate in protein energy
malnutrition. J Pediatr Gastroenterol 1982;1:547-50

3. Waterlow JC, Golden MH. Serum inorganic phosphate in protein-energy
malnutrition. Eur J Clin Nutr 1994;48:503-6.

4. Manary MJ, Hart CA, Whyte MP. Severe hypophosphatemia in children with
kwashiorkor is associated with increased mortality. J Pediatr 1998;133:789

5. Cundy T, Reid I. Calcium, phosphate and magnesium. In: Marshall W,
Bangert S, eds. Clinical biochemistry, metabolic and clinical aspects.
Edinburgh: Churchill Livingstone, 1995:87-116.

Competing interests:  
None declared

Competing interests: No competing interests

31 January 2003
Jose C Cabrera-Abreu
consultant chemical pathologist
Jose Cabrera-Abreu, Geoff Lester
Royal Berkshire and Battle Hospitals, Reading RG1 5AN