Healthcare practitioners’ perspectives on barriers to early identification of refeeding syndrome in hospitalised children with severe acute malnutrition: a qualitative descriptive study

Abstract

Introduction: Reducing severe acute malnutrition in children is central to the Sustainable Development Goals, yet severe acute malnutrition remains a leading cause of childhood mortality in developing countries. Refeeding syndrome in children with severe acute malnutrition is a poorly understood, potentially fatal complication during stabilisation. Early detection is essential to prevent adverse outcomes. However, healthcare practitioners inconsistently recognise refeeding syndrome, particularly in resource-limited public hospitals, where severe acute malnutrition is common, but the condition itself remains understudied. The objective of this study was to explore healthcare practitioners’ experiences of identifying refeeding syndrome among hospitalised children aged 6 to 59 months with severe acute malnutrition in public hospitals in the City of Tshwane, South Africa. Methods: A qualitative descriptive study design was employed. Using purposive sampling, 20 healthcare practitioners (paediatricians, medical doctors, nurses, and dieticians) from paediatric wards in public hospitals within the City of Tshwane were recruited. Semi-structured interviews were audio-recorded, transcribed verbatim, and anonymised. Data were analysed using reflexive thematic analysis following Braun and Clarke's approach, supported by NVivo 15 software. An inductive coding strategy allowed themes to emerge. Trustworthiness was established using Lincoln and Guba's criteria. Ethical approval was obtained from the University's ethics committee, and all participants provided written informed consent. Results: Fivethemes were developed:: (1) Awareness vs. practice: “known on paper,” but under-recognised; (2) Reactive rather than proactive identification; (3) Managing RFS through standard SAM care; (4) Interprofessional collaboration is essential but fragile; and (5) Health system constraints undermine early identification. Participants emphasised the need for clearer clinical guidance and strengthened multidisciplinary collaboration. Conclusion: Participants’ accounts suggest that knowledge, organisational and resource constraints may hinder early identification of refeeding syndrome in children with severe acute malnutrition. The findings identify priorities for developing and evaluating context-sensitive guidance, multidisciplinary training and service support; the effectiveness of these strategies was not assessed.