Diagnosis

If there is any suspicion of hypoglycaemia and when blood glucose can be measured quickly (e.g. with Dextrostix®), this should be done immediately. Hypoglycaemia is present when the blood glucose is < 3 mmol/litre (< 54 mg/dl). If blood glucose cannot be measured, it should be assumed that all children with severe acute malnutrition are hypoglycaemic and given treatment.

Treatment

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Give 50 ml of 10% glucose or sucrose solution (one rounded teaspoon of sugar in three tablespoons of water) orally or by nasogastric tube, followed by the first feed as soon as possible.

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Give the first feed of F-75 therapeutic milk, if it is quickly available, and then continue with feeds every 2 h for 24 h; then continue feeds every 2 or 3 h, day and night.

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If the child is unconscious, treat with IV 10% glucose at 5 ml/kg or, if IV access cannot be quickly established, then give 10% glucose or sucrose solution by nasogastric tube. If IV glucose is not available, give one teaspoon of sugar moistened with one or two drops of water sublingually, and repeat every 20 min to prevent relapse. Children should be monitored for early swallowing, which leads to delayed absorption; in this case another dose of sugar should be given. Continue with 2 h oral or nasogastric feeds to prevent recurrence.

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Start on appropriate IV or IM antibiotics.

Monitoring

If the initial blood glucose was low, repeat the measurement (using finger or heel prick blood and measure with the Dextrostix®, when available) after 30 min.

• If blood glucose falls to < 3 mmol/litre (< 54 mg/dl), repeat the 10% glucose or oral sugar solution.
• If the rectal temperature falls to < 35.5 °C, or if the level of consciousness deteriorates, repeat the Dextrostix® measurement and treat accordingly.

Prevention

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Feed every 2 h, starting immediately (see initial refeeding) or, when dehydrated, rehydrate first. Continue feeding throughout the night.

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Encourage mothers to watch for any deterioration, help feed and keep the child warm.

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Check on abdominal distension.

Diagnosis

• If the axillary temperature is < 35 °C (< 95°F) or does not register on a normal thermometer, assume hypothermia. When a low-reading thermometer is available, take the rectal temperature (< 35.5 °C or < 95.9 °F) to confirm hypothermia.

Treatment

All children with hypothermia should be treated routinely for hypoglycaemia and infection.

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Feed the child immediately and then every 2 h unless they have abdominal distension; if dehydrated, rehydrate first.

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Re-warm the child: Make sure the child is clothed (especially the head); cover with a warmed blanket and place a heater (not pointing directly at the child) or lamp nearby, or put the child on the mother's bare chest or abdomen (skin-to-skin) and cover them with a warmed blanket and/or warm clothing.

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Keep the child away from draughts.

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Give appropriate IV or IM antibiotics.

Monitoring

• Take the child's rectal temperature every 2 h until it rises to > 36.5 °C. Take it every 30 min if a heater is being used.
• Ensure that the child is covered at all times, especially at night. Keep the head covered, preferably with a warm bonnet, to reduce heat loss.
• Check for hypoglycaemia whenever hypothermia is found.

Prevention

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Feed immediately and then every 2–3 h, day and night.

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Place the bed in a warm, draught-free part of the ward, and keep the child covered.

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Use the Kangaroo technique for infants, cover with a blanket and let the mother sleep with child to keep the child warm.

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Avoid exposing the child to cold (e.g. after bathing or during medical examinations).

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Change wet nappies, clothes and bedding to keep the child and the bed dry. Dry carefully after bathing, but do not bathe if very ill.

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Use a heater or incandescent lamp with caution.

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Do not use a hot water bottle or fluorescent lamp.

Diagnosis

Dehydration tends to be overdiagnosed and its severity overestimated in children with severe acute malnutrition because it is difficult to determine dehydration accurately from clinical signs alone. Assume that all children with watery diarrhoea or reduced urine output have some dehydration. It is important to note that poor circulatory volume or perfusion can co-exist with oedema.

Treatment

Do not use the IV route for rehydration, except in cases of shock. Rehydrate slowly, either orally or by nasogastric tube, using oral rehydration solution for malnourished children (5–10ml/kg per h up to a maximum of 12 hours). The standard WHO ORS solution for general use has a high sodium and low potassium content, which is not suitable for severely malnourished children. Instead, give special rehydration solution for malnutrition, ReSoMal.

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Give the ReSoMal rehydration fluid orally or by nasogastric tube, more slowly than you would when rehydrating a well-nourished child:

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Give 5 ml/kg every 30 min for the first 2 h.

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Then give 5–10 ml/kg per h for the next 4–10 h on alternate hours, with F-75 formula. The exact amount depends on how much the child wants, the volume of stool loss and whether the child is vomiting.

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If not available then give half strength standard WHO oral rehydration solution with added potassium and glucose as per the ReSoMal recipe below, unless the child has cholera or profuse watery diarrhoea.

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If rehydration is still required at 10 h, give starter F-75 (see recipes) instead of ReSoMal, at the same times. Use the same volume of starter F-75 as of ReSoMal.

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If in shock or severe dehydration but cannot be rehydrated orally or by nasogastric tube, give IV fluids, either Ringer's lactate solution with 5% dextrose or half-strength Darrow's solution with 5% dextrose. If neither is available, 0.45% saline with 5% dextrose should be used (see Chart 8)

Monitoring

During rehydration, respiration and pulse rate should fall and urine start to be passed. The return of tears, a moist mouth, less sunken eyes and fontanelle, and improved skin turgor are also signs that rehydration is proceeding, but many severely malnourished children will not show these changes even when fully rehydrated. Monitor weight gain.

Monitor the progress of rehydration every 30 min for 2 h, then every hour for the next 4–10 h. Be alert for signs of overhydration, which is very dangerous and may lead to heart failure. Check for:

• weight gain to ensure that it is not quick and excessive.
• increase in respiratory rate
• increase in pulse rate
• urine frequency (Has the child urinated since last checked?)
• enlarging liver size on palpation
• frequency of stools and vomit.

If you find signs of overhydration (early signs are respiratory rate increasing by 5/min and pulse rate by 25/min), stop ReSoMal immediately and reassess after 1 h.

Prevention

Measures to prevent dehydration due to continuing watery diarrhoea are similar to those for well-nourished children (see treatment plan A), except that ReSoMal fluid is used instead of standard ORS.

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If the child is breastfed, continue breastfeeding.

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Initiate re-feeding with starter F-75.

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Give ReSoMal between feeds to replace stool losses. As a guide, give 50–100 ml after each watery stool.

Treatment

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Give extra potassium (3–4 mmol/kg per day).

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Give extra magnesium (0.4–0.6 mmol/kg per day).

The extra potassium and magnesium should be added to the feed during its preparation if not pre-mixed. See recipefor a combined electrolyte/mineral solution. Add 20 ml of this solution to 1 litre of feed to supply the extra potassium and magnesium required. Alternatively, use commercially available pre-mixed sachets (specially formulated for malnourished children).

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When rehydrating, give low sodium rehydration fluid (ReSoMal) (see recipe).

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Prepare food without added salt.

Treatment

Give all severely malnourished children:

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a broad-spectrum antibiotic

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measles vaccine if the child is ≥ 6 months and not vaccinated or was vaccinated before 9 months age. Delay vaccination if the child is in shock.

Monitoring

If the child is still anorexic after 7 days of antibiotic treatment, continue for a full 10-day course. If anorexia persists, reassess the child fully.

Treatment

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Give vitamin A on day 1 and repeat on days 2 and 14 only if child has any signs of vitamin A deficiency like corneal ulceration or a history of measles (see section 7.5.1).

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< 6 months, 50 000 U

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6–12 months, 100 000 U

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> 12 months, 200 000 U

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Start iron at 3 mg/kg per day after 2 days on F-100 catch-up formula. Do not give iron in the stabilization phase, and do not give iron if the child is receiving ready-to-use therapeutic food (RUTF).

If child is not on any of the pre-mixed therapeutic foods, give the following micronutrients daily for at least 2 weeks:

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folic acid at 5 mg on day 1; then 1 mg daily

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multivitamin syrup at 5 ml

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zinc at 2 mg/kg per day

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copper at 0.3 mg/kg per day

Treatment

The essential features of initial feeding are:

• frequent (every 2–3 h) oral small feeds of low osmolality and low lactose
• nasogastric feeding if the child is eating ≤ 80% of the amount offered at two consecutive feeds
• calories at 100 kcal/kg per day
• protein at 1–1.5 g/kg per day
• liquid at 130 ml/kg per day or 100 ml/kg per day if the child has severe oedema
• in addition, if the child is breastfed, encourage continued breastfeeding, but make sure the prescribed amounts of starter formula are given:

The suggested starter formula and feeding schedules given below are designed to meet these targets. Milk-based formulas, such as starter F-75 (with 75 kcal and 0.9 g protein/100 ml), will be satisfactory for most children (see recipes). As cereal-based F-75 partially replaces sugar with cereal flour, it has the advantage of lower osmolarity, which may benefit some children with persistent diarrhoea, but it has to be cooked.

Feed from a cup or a bowl. Use a spoon, dropper or syringe to feed very weak children.

A recommended schedule, with a gradual increase in the feed volume and a gradual decrease in feeding frequency, see Table 22. For children with a good appetite and no oedema, this schedule can be completed in 2–3 days.

Note: If staff resources are limited, give priority to 2-hourly feeds for only the most seriously ill children, and aim for at least 3-hourly feeds initially. Ask mothers and other carers to help with feeding. Show them what to do, and supervise them. Night feeds are essential, and staff rosters may have to be adjusted. If, despite all efforts, not all the night feeds can be given, the feeds should be spaced equally through the night to avoid long periods without a feed (with the risk of increased hypoglycaemia and mortality).

If the child's intake (after allowing for any vomiting) does not reach 80 kcal/kg per day, despite frequent feeds, coaxing and re-offering, give the remaining feed by nasogastric tube. Do not exceed 100 kcal/kg per day in this initial phase.

In very hot climates, children might need extra water, as these foods may not contain enough water if the children are sweating.

Monitoring

Monitor and record:

• amounts of feed offered and left over
• vomiting
• stool frequency and consistency
• daily body weight

Treatment

Make a gradual transition from starter F-75 to catch-up formula F-100 or ready-to-use therapeutic food over 2–3 days, as tolerated.

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Replace starter F-75 with an equal amount of catch-up F-100 for 2 days. Give a milk-based formula, such as catch-up F-100 containing 100 kcal/100 ml and 2.9 g of protein per 100 ml (see recipes) or ready-to-use therapeutic food (see below).

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On the third day if on F-100, increase each successive feed by 10 ml until some feed remains uneaten. The point at which some feed remains unconsumed is likely to be when intake reaches about 200 ml/kg per day.

After a gradual transition, give:

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frequent feeds, unlimited amounts

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150–220 kcal/kg per day

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4–6 g of protein/kg per day.

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If on ready-to-use therapeutic food:

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Start with small but regular meals of RUTF and encourage the child to eat often (first 8 meals per day, and later 5–6 meals per day). If the child cannot eat the whole amount of RUTF per meal in the transition phase, top up with F-75 to complete the feed, until is able to eat a full RUTF meal.

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If the child cannot take at least half of recommended amount of RUTF in 12 h, stop RUTF and give F-75. Try introducing RUTF again in 1–2 days until the child is able to take adequate amounts.

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If still breastfeeding, offer breast milk first before every RUTF feed.

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After the transition phase, refer the child for rehabilitation in outpatient care or to a community feeding programme.

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Wash hands before giving feeds.

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Sit with the child on the lap and gently offer the feeds.

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Encourage the child to eat the RUTF without forced feeding.

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Offer plenty of clean water in a cup, when the child is eating RUTF.

Monitoring

Avoid causing heart failure. Monitor for early signs of congestive heart failure (rapid pulse, fast breathing, basal lung crepitations, enlarging liver, gallop heart rhythm, raised jugular venous pressure). If both pulse and breathing rates increase (breathing by 5 breaths/min and pulse by 25 beats/min), and the increase is sustained for two successive 4-hourly readings, then:

• Reduce the volume fed to 100 ml/kg per day for 24 h.
• Then, gradually increase as follows:

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  115 ml/kg per day for next 24 h

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  130 ml/kg per day for the following 48 h

• Thereafter, increase each feed by 10 ml as described earlier.

Assess progress. After the transition, monitor progress by the rate of weight gain:

• Weigh the child every morning before feeding, and plot the weight.
• Calculate and record the weight gain every 3 days as g/kg per day (see box below).

If the weight gain is:

• poor (< 5 g/kg per day), the child requires a full re-assessment
• moderate (5–10 g/kg per day), check whether the intake targets are being met or if infection has been overlooked
• good (> 10 g/kg per day).

Treatment

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Admit infants with any of the above complicating factors.

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Give parenteral antibiotics to treat possible sepsis, and appropriate treatment for other medical complications.

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Re-establish effective exclusive breastfeeding by the mother or other caregiver. If not possible, give replacement commercial infant formula with advice on safe preparation and use.

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For infants with severe acute malnutrition and oedema, give infant formula or F-75 or diluted F-100 (add water to formula in recipes up to 1.5 litres instead of 1 litre) to supplement breastfeeding.

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For infants with severe acute malnutrition with no oedema, give expressed breast milk; and when not possible, commercial infant formula or F-75 or diluted F-100, in this order of preference.

During nutritional rehabilitation, the basic principles for older children apply; however, young infants are less able to excrete salt and urea in their urine, especially in hot climates. Therefore, the preferred diets in the stabilization phase are (in order of preference):

• breast milk (if available in sufficient quantity)
• commercial infant formula

Assessment of the physical and mental health of mothers or caretakers should be promoted and relevant treatment or support provided.

Discharge

Infants less than 6 months of age admitted to inpatient care can be transferred to outpatient care if:

• all clinical conditions or medical complications including oedema are resolved or the child is clinically well and alert,
• the child is breastfeeding effectively or feeding well,
• weight gain is satisfactory e.g. above the median of the WHO growth velocity standards or more than 5gm/kg per day for at least 3 successive days.

Before discharge, the infant's vaccination status and other routine interventions should be checked and provided as appropriate. Mothers or caregivers should then be linked with any necessary community follow-up and support. A child should only be discharged from all nutritional care only when he or she:

• is breastfeeding effectively or feeding well with replacement feeds, and
• has an adequate weight gain, and
• has a weight-for-length equal or higher than -2 z scores.

Monitoring

Monitor the pulse and breathing rates, listen to the lung fields, examine the abdomen for liver size and check the jugular venous pressure every 15 min during the transfusion.

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If either breathing or heart rate increases (breathing by 5 breaths/min or pulse by 25 beats/min), transfuse more slowly.

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If there are basal lung crepitations or an enlarging liver, stop the transfusion and give furosemide at 1 mg/kg IV.

Note: Do not repeat transfusion even if the Hb is still low or within 4 days of the last transfusion.

Treatment

Inadequate feeding

Check:

• that night feeds are given
• that target energy and protein intakes are achieved. Is the actual intake (i.e. what was offered minus what was left over) correctly recorded? Is the quantity of feed recalculated as the child gains weight? Is the child vomiting or ruminating?
• feeding technique: Is the child given frequent feeds in unlimited amounts?
• quality of care: Are staff motivated, gentle, loving and patient?
• all aspects of feed preparation: scales, measurement of ingredients, mixing, taste, hygienic storage, adequate stirring if separating out
• whether the complementary foods given to the child are energy-dense enough
• adequacy of multivitamin composition and shelf-life
• preparation of mineral mix and whether correctly prescribed and administered. If you are in a goitrous region, check whether potassium iodide is added to the electrolyte/mineral mix (12 mg/2500 ml), or give all children Lugol iodine (5–10 drops a day).
• if complementary foods are given, check that they contain electrolyte/mineral solution.

Untreated infection

If feeding is adequate and there is no malabsorption, suspect a hidden infection if there is recurrence of oedema, hypoglycaemia or hypothermia. The following are easily overlooked: urinary tract infections, otitis media, TB and giardiasis. In such cases:

• re-examine carefully
• repeat urine microscopy for white blood cells
• examine the stools
• if possible, take a chest X-ray.

Consider treatment in the absence of a confirmatory diagnosis.

HIV/AIDS

Children with HIV and AIDS can recover from malnutrition, but it may take longer, and treatment failures are commoner. Initial nutritional treatment of severe acute malnutrition in children with HIV/AIDS should be the same as for HIV-negative children.

For other HIV-related conditions, see Chapter 8.

Psychological problems

Check for abnormal behaviour, such as stereotyped movements (rocking), rumination (i.e. self-stimulation through regurgitation) and attention-seeking. Treat by giving the child special love and attention. For children who ruminate, firmness with affection can assist. Encourage the mother to spend time playing with her child.