Management of Medical

Complications
Inpatient Therapeutic Care
Module 6b

Jonna Alvarez Masongsong, MD, FPSMS, MAHA, MPH

Provincial Health Officer II – Davao del Sur
Provincial Nutrition Action Officer
Learning objectives
Identify and manage the SAM child with:

o Hypothermia

o Hypoglycemia

o Dehydration and Shock

FIRST of all,

If clinical assessment is delayed for any reason, and

the child is able to take oral fluids, give:

10% sugar water

Identify Hypothermia
• Low body temperature
✓axillary temperature is below 35°C
✓rectal temperature of < 35.5°C more reliable indicator of hypothermia

• Always check for hypoglycemia whenever hypothermia is detected

 Treat and Prevent Hypothermia
1. Re-warm the child by:
o Skin to skin contact
o Covering the child with a warmed blanket
o Promptly do diaper / nappy changes
o Prevent draughts / keep child away from open windows
o Avoid exposure, prolonged medical examinations
o Increasing the room temperature
2. Feed the child (or start oral rehydration for dehydration if required)
3. Give antibiotics
4. Do not use hot water bottles for warming due to danger of burning
fragile skin.
 Treat and Prevent Hypothermia
1. Re-warm the child by:
o Putting the child on the mother’s bare chest (skin to skin) and cover them
o Covering the child (including head) with a warmed blanket, if able
o Promptly do diaper / nappy changes
o Prevent draughts / keep child away from open windows
o Avoid exposure, prolonged medical examinations
o Increasing the room temperature with a heater or lamp placed nearby
2. Feed the child (or start oral rehydration for dehydration if required)
3. Give antibiotics
4. Do not use hot water bottles for warming due to danger of burning
fragile skin.
2. Feed the child

Start feeding as soon as possible, within 2 to 3 hours.

· Continue breastfeeding in infants less than 6 months old.
· For those over 6 months to 60 months old, feed with F75 every 30 min. for two
hours (giving one quarter of the two-hourly feed each time).
· Continue the feeding through day and night.

Recommended feeding schedule

For over 6 months old:

**For those over 6 months to 60 months old, feed with F75 every 30 min. for two
hours (giving one quarter of the two-hourly feed each time).

Example: If a SAM child with weight of 6 kg is to start feeding, calculate F75

starter feed as follows:

(6 kg x 11 ml) = 66 ml

66 ml / 4 feeds = 16.5 ml -- give 16.5 ml every 30 minutes for two hours

 Treat and Prevent Hypothermia
1. Re-warm the child by:
o Putting the child on the mother’s bare chest (skin to skin) and cover them
o Covering the child (including head) with a warmed blanket, if able
o Promptly do diaper / nappy changes
o Prevent draughts / keep child away from open windows
o Avoid exposure, prolonged medical examinations
o Increasing the room temperature with a heater or lamp placed nearby
2. Feed the child (or start oral rehydration for dehydration if required)
3. Give antibiotics
4. Do not use hot water bottles for warming due to danger of burning
fragile skin.
REVIEW!
REVIEW!

These regimens should be adapted to local resistance patterns.

 Treat other infections as appropriate:
–
Meningitis  lumbar puncture for confirmation  treat with the antibiotic regime
–
Other specific infections (pneumonia, dysentery, skin or soft-tissue infections)  give antibiotics as
appropriate.
–
Add antimalarial treatment if the child has a positive blood film for malaria parasites or a positive
malaria rapid diagnostic test.
–
TB is common, but anti-TB treatment should be given only if TB is diagnosed or strongly suspected
–
Treat HIV-exposed children as recommended.

Pocket Book of Hospital Care for Children: Guidelines for the

Management of Common Childhood Illnesses. 2nd edition.
Monitor Hypothermia
• Take the child's temperature every 2 h until it rises to > 36.5 °C.
• Take it every 30 min if a heater is being used.
• Encourage for infants to be kept on skin to skin contact.
• Ensure that the child is covered at all times.
• Keep the head covered, to reduce heat loss.
• Check for hypoglycemia whenever hypothermia is found.
Identify Hypoglycemia
• Low level of blood glucose < 3 mmol/L (or < 54 mg/dl)
• Typically, patients are also hypothermic
• Hypoglycemia + hypothermia = serious infection
• Other signs of hypoglycemia:
✓lethargy
✓convulsions
✓Sweating and pallor may not occur
• Often the only sign before death is drowsiness
Be AWARE of Hypoglycemia when: vomiting, long intervals without food,
waiting for admission, irregular feeding
 Treat Hypoglycemia
Treat for hypoglycemia even without capability
for blood sugar check when child has symptoms

If the child is conscious, give:

1. 50mL bolus of 10% glucose or sucrose solution* orally or by
nasogastric (NG) tube.
2. Feed F75 every 30 minutes for first two hours (giving ¼ of the total
recommended two hours’ feed)
3. Keep the child warm
4. Antibiotics
*Sucrose solution = 1 rounded teaspoon of sugar in 3.5 tablespoons water
Treat Hypoglycemia
If the child is lethargic, unconscious or convulsing, give:
1. 10% Glucose
• IV (5mL/kg body weight) AND
• 50mL by NGT to prevent rebound hypoglycemia; may also use sucrose solution
➢Defer NGT dose if child will receive IVF for shock as the child will receive glucose via
IVF
2. F75 every 30 minutes for first two hours (giving ¼ of the total
recommended two hours’ feed)
3. Measures to keep child warm Give per rectal diazepam
4. Give antibiotics (0.5mg/kg body weight) for
convulsion even after giving
IV glucose
Monitor Hypoglycemia

• If the initial blood glucose was low, repeat

the measurement 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 blood sugar test and treat
accordingly.
Prevent Hypoglycemia
The short term cause: lack of food

• Feed frequently every 3 hours including waking the child during the
night

• If unable to feed and monitor the child overnight,

→Give the full volume of the daily feeding in fewer rations (5 or 6 times
daily)
→Decrease number of rations = increase the volume of therapeutic milk
per feeding
Identify dehydration and shock
Misdiagnosis and mistreatment for dehydration is
the most common cause of death in children with SAM

Regardless of hydration status, signs of dehydration are present in SAM

❖Typical non-elastic skin and sunken eyes

This is KEY
Take a detailed medical history
❖determine recent fluid loss from acute diarrhea or vomiting – sudden
onset or in the past few days
❖Elicit how well / frequent the child has voided, particularly the last 6
hours, ask about urine color
Identification of dehydration and shock
Physical examination
➢Level of consciousness
➢Skin pinch test
➢Sunken eyes
▪ Marasmic children can have sunken eyes due to loss of fat behind eyeball
➢Absent: superficial veins on the head, neck, and limbs
➢Palpate liver
➢Check extremities
Vital signs check: Heart rate, temperature, blood pressure, weight

A diagnosis of dehydration should ALWAYS be a provisional diagnosis.

The response to treatment must be observed before the diagnosis can be confirmed.
Assume hypovolemic shock when
The following signs are also present:
Decreased level of consciousness : semi-conscious or cannot be roused
PLUS any of -
• Cold extremities
• Slow capillary refill time OR
• Fast /weak /absent: radial / femoral pulse
-- 2 to 12 months : >160 beats/min
-- 1 to 5 years : > 140 beats/min

Confirmation of hypovolemic shock by observing response to treatment

Dehydration in children with nutritional edema
Children with bilateral edema cannot be dehydrated
➢ are overhydrated
➢increased total body water, increased sodium levels

Edematous patients thus cannot be dehydrated,

➢ frequently hypovolemic
Management of dehydration and shock
❖Oral rehydration solutions ALWAYS preferable to IV rehydration
➢Give when child is conscious or has an NGT and aspiration risk low
❖Continue BREASTFEEDING
Intravenous solutions only for IV infusions are a NO, NO for a child
➢unconscious child able to take fluids orally or by NGT
➢Resuscitation from shock
Maintain IV access (heplock NOT KVO) only for
➢IV antibiotics in Phase 1/Transition
➢Children with decreased consciousness
➢Those with contraindication for oral or NGT feeds
➢ Remove once without indication
➢ Re-site frequently (q 5 days) if with continuing need for access
Remember!
❖ Children with SAM usually have reduced cardiac contractility and renal
function.
❖ Rehydration therapy should be cautious than for the normally nourished
❖ SAM children fail to compensate for increased intravascular volumes (as what
happens in typical IV fluid resuscitation) → heart failure

❖ The treatment of a child with nutritional edema is the same with septic shock
and different from what is done for a child with wasting.
Rehydration for Marasmic patients
Oral Rehydration solutions for SAM Dilute 42 g sachet
 Rehydration Solution for Malnutrition (ReSoMal) should be in 1 liter water
used as the standard therapy for children with SAM
diagnosed with dehydration
 Low Osmolarity Oral Rehydration Solution (LO-ORS) may be used for the treatment of children
with SAM but only for those who have a positive diagnosis of Acute Watery Diarrhoea (AWD) or
Cholera

• Where ReSoMal is not available, a modified, half-strength solution of LO-ORS may be used with
added potassium and glucose.
 
Oral Rehydration Solutions such (ORS or ReSoMal) for the treatment of dehydration must NEVER be
freely accessible to caregivers on the hospital ward.
Modified ReSoMal
Prepare from standard ORS and mineral mix solution, as follows:
• Wash hands.
• Empty one 1-litre standard ORS packet into container that holds more than 2
liters.
• Measure and add 50 grams of sugar.
• Measure 40 milliliters or one leveled scoop of CMV in a graduated medicine cup
or syringe; add to other ingredients.
• Measure and add 2 liters cooled boiled water.
• Stir until dissolved.
• Use within 24 hours.
Test yourself!!

True or False.
0.9 NaCl IV solution is recommended for use in fluid resuscitation for
shock in children with SAM.

FALSE – SAM children have high serum sodium

Remember Reductive Adaptation?
Preferred IV fluids are:
1. Ringers Lactate Solution with 5% Dextrose
2. 0.45% Saline with 5% Dextrose
 Treatment of dehydration/hypovolemic shock in severe wasting

Continue
breastfeeding!
Introduction of F75 is
usually achieved
within 2-3 hours of
starting re-hydration.
ReSoMal and F75 can
be given in alternate
hours if there is still
some dehydration and
continuing diarrhoea.
Treatment of the child with nutritional edema
If (+) watery diarrhea
(+) clinical deterioration
→ Replace fluid loss with 30ml ReSoMal per episode of watery stool.
❖The fluid management of hypovolemia for a child with edema is the
same as the treatment for septic shock.
Treatment protocol for septic shock
• Give oxygen
• Give broad spectrum antibiotics
• Treat / prevent hypoglycemia in unconscious patients
• Treat / prevent hypothermia
• Conscious patients should be started on F75 (or sugar water) orally / NGT (Phase 1
protocols)
• Keep physical disturbance of the child to the minimum required to deliver emergency
care

If there is a decreased level of consciousness due to poor cerebral perfusion:

• Whole blood transfusion 10mL/kg over at least 3 hours OR Blood transfusion should be given
• Intravenous rehydration solutions at 10mL/kg/hr within 24 hours of admission.
During blood transfusion, oral
feeding must be discontinued.
Monitor every 10 minutes for signs of clinical changes.
Monitoring during rehydration
Remember!

• SAM children have abnormal pathophysiology.

• Avoid diuretics in a SAM child with heart failure. Just avoid over
hydration.

• Rehydration aim is to restore pre-diarrhea weight or no more than 5%

of the child’s weight.
Reassess, Reassess!! and Record
Every 30 - 60 mins assess:
✓Weigh the patient
✓Check the VITAL SIGNS
✓Heart sounds
✓Observe for signs of respiratory distress
✓Observe for vomiting or diarrhea
✓Reassess: costal margin of the liver
✓ : absence or presence of jugular venous distension
✓Monitor: urine output and, color
Monitoring during rehydration
Immediately STOP Rehydration when:
• Target weight is achieved  start F75
• Edema  start F75
• Jugular venous distension is observed
• An increase in: costal margin of the liver ( 1cm or more )
• : respiratory rate (5 breaths per minute or more)
• : pulse/heart rate (25 beats/min or more)
• Development of : increased respiratory effort
• : pulmonary rales or crepitations
• : triple rhythm (gallop) in the heart sounds
Test yourself!!
Tina is a 3 year old girl with severe
wasting. She has no edema.
Her mother said that Tina has been •What should be given to treat
having loose stools since late last her hypoglycemia?
night. Her urine is almost orange.
Tina is awake but not active. T 35 C
Her heart rate is 150 per minute. •What should be done to treat
Her blood glucose is 50 mg/dl. her hypothermia?

What is your assessment? •What should be done to treat

her dehydration?
Summary
• Children with SAM may not manifest the true severity of their illness.
• Hypothermia and hypoglycemia mark a serious infection.
• SAM children with medical complications are treated with antibiotics.
• Dehydration is best treated with ReSoMal.
• IV fluids for re-hydration should be administered with caution.
• The management of dehydration/shock between the severely wasted
and those with nutritional edema is different.
• Early re-establishment of oral feeding is desired among SAM children
with medical complications.