MODULE 6B

Inpatient Therapeutic Care (ITC) 2:

Management of Medical Complications

Resource Speaker
Designation
Management of Medical
Complications
Inpatient Therapeutic Care
Learning objectives
Identify and manage the SAM child with:
• Hypothermia
• Hypoglycemia
• 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

• Prepare by mixing 10g or 1 tablespoon of sugar in 100mL of
water
Identify Hypothermia
• Low body temperature
• axillary temperature is below
35°C
• rectal temperature of < 35.5°C
(a more reliable method)
• Always check for hypoglycemia
whenever hypothermia is
detected
 Treat and Prevent Hypothermia
1. Re-warm the child by:
• Putting the child on the mother’s bare chest (skin-to-skin) and
cover them
• Covering the child (including head) with a warmed blanket, if
able
• Promptly do diaper / nappy changes
• Prevent draughts / keep child away from open windows
• Avoid exposure, prolonged medical examinations
• Increasing the room temperature with a heater or lamp placed
nearby
 Treat and Prevent Hypothermia
2. Feed the child
• Start feeding as soon as possible, within 2 to 3 hours.
• Continue breastfeeding in infants less than 6 months old. Or feed breastmilk
by cup, spoon, dropper or needle-less syringe. (Refer to Session on
Nutritional Management of the Child 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. Consider indications for NG tube
placement.

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 * 11 ml) = 66 ml

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

Treat and Prevent Hypothermia
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:
•If meningitis is suspected, do a lumbar puncture for confirmation, where possible,
and treat with the antibiotic regime
•If you identify other specific infections (such as 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.
Note: Take temp every 30 min if a heater is being used.
• Whenever possible, encourage for infants to be kept on skin to
skin contact.
• 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 hypoglycemia whenever hypothermia is found.
 Identify Hypoglycemia
• Low level of blood glucose < 3 mmol/L
(or < 54 mg/dl)
• Typically, patients are also hypothermic (low
temperature)
• Hypoglycemia + hypothermia = serious
infection
• Other signs of hypoglycemia:
▪ Lethargy, limpness, and loss of consciousness
▪ 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.F-75 every 30 minutes for first two hours (giving ¼ of the total
recommended two hours’ feed)
Give per rectal diazepam
3.Measures to keep child warm
(0.5mg/kg body weight) for
4.Give antibiotics convulsion even after giving IV
glucose
Monitor Hypoglycemia
•If the initial blood glucose was low,
repeat the measurement (using finger or
heel prick blood and measure 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,
o Give the full volume of the daily feeding in fewer rations (5 or 6 times
daily)
o 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
o Typical non-elastic skin and sunken eyes
• Take a detailed medical history
o Determine recent fluid loss from acute diarrhea or vomiting – sudden
onset or past few days
o Elicit how well / frequent the child has voided, particularly the last 6
hours, ask about urine color
This is KEY
Identification of dehydration and shock
Physical examination
•Level of consciousness
•Skin pinch test – unreliable especially in marasmus which typically is (+) for this test
•Sunken eyes – confirm that this finding only occurred lately, elicit history for fluid loss
• Marasmic children can have sunken eyes due to loss of fat behind eyeball
•Absent are the usually visible and full superficial veins on the head, neck, and limbs
•Palpate and check if liver is enlarged
•Check extremities if cold, clammy (hands and feet)
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 when that the patient is
semi-conscious or cannot be roused PLUS any of the following:
•Cold extremities
•Slow capillary refill in the nail beds (longer than 3 seconds)
•Fast or weak / absent radial / femoral pulse
• Children 2 to 12 months - pulse rate greater than 160/ min
• Children 1 to 5 years - pulse rate greater than 140 / min

Confirmation of hypovolemic shock by observing response to treatment

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

Edematous patients thus cannot be dehydrated…

•But they are frequently hypovolemic
•Due to low protein → low oncotic pressure → decreased
intravascular fluid → low circulating blood volume
Management of dehydration and
shock
• Oral rehydration solutions ALWAYS preferable to IV rehydration
o 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
o The unconscious child able to take fluids orally or by NGT
o Resuscitation from shock
• Maintain IV access (heplock, NOT KVO) only for
o IV antibiotics in Phase 1/Transition
o Children with decreased consciousness
o Those with contraindication for oral or NGT feeds
o Remove once without indication
o 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
• 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 SAM patients
• Oral Rehydration solutions for SAM
• Rehydration Solution for Malnutrition
(ReSoMal) should be 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
Diarrhea (AWD) or Cholera
Dilute 42 g sachet
in 1 liter water
Rehydration for SAM patients
Oral Rehydration solutions for SAM
✓Rehydration Solution for Malnutrition (ReSoMal) Dilute 42 g sachet
should be used as the standard therapy for children with
SAM diagnosed with dehydration in 1 liter water
✓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 Diarrhea (AWD) or Cholera
XStandard (full strength) Oral Rehydration Solution
(ORS) does not have a suitable formulation for the
treatment of dehydration in children with SAM.
•Where ReSoMal is not available, a modified, half-
strength solution of LO-ORS may be used with added Dilute 42 g sachet
potassium and glucose. in 1 liter water
Rehydration for SAM patients
Oral Rehydration solutions for SAM

Therapeutic CMV (Combined Mineral and Vitamin Mix), tin 800g/CAR-6

Inpatient Therapeutic Care Requirement

Therapeutic CMV, 800 g. tin, carton of 6 tins. Use to prepared ReSoMal

[from the current ORS (WHO formula) + sugar + water], phase 1 milk (F-
75) and enriched high energy milk (F-100)

1 levelled measuring scoop can be

used to prepare 2 liters of F75
therapeutic milk (See SAM MOP
Alternative F75 Recipes)
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 F-75 is
usually achieved within
2-3 hours of starting re-
hydration.

ReSoMal and F-75 can

be given in alternate
hours if there is still
some dehydration and
continuing diarrhea.
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 via face mask or nasal cannula
• Give broad spectrum, first line / second line antibiotic
• 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
• They have reduced function of the cardiac, renal and abnormal
cardiovascular systems
• They have abnormal responses to an increase in fluid load → heart
failure/death
• 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 (and calculate the target weight gain)
•Heart/Pulse rate, temperature, respiration rate VITAL SIGNS
•Heart sounds (over-hydration may result in a gallop rhythm)
•Observe for signs of respiratory distress (chest indrawing, nasal flaring)
•Observe for vomiting or diarrhea (estimate volumes and correlate with weight
loss)
•Reassess the costal margin of the liver
•Reassess the absence or presence of jugular venous distension
•Monitor for presence or absence of urine output and, if present, urine color
Monitoring during rehydration
Immediately STOP Rehydration when
• Target weight for rehydration is achieved (then start F-75)
• There is development of edema (then start F-75)
• Jugular venous distension is observed
• Jugular veins become engorged when abdomen is pressed
• An increase in the costal margin of the liver of 1cm or more
• Tenderness of the liver on palpation
Immediately STOP Rehydration when
• An increase in respiratory rate of 5 breaths per minute or more
• Increase in pulse/heart rate of 25 beats/min or more
• Development of grunting expiratory sounds/labored
breathing/increased respiratory effort
• Development of pulmonary rales or crepitation on auscultation
• Development of a triple rhythm (gallop) in the heart sounds or
brachial pulse
Test yourself!!
Tina is a 3 year old girl with severe wasting. She has no edema. Her
mother said that Tina has been having loose stools since late last night.
Her urine is almost orange.
Tina is awake but not active. T 36.0.C Her heart rate is 150 per minute.
Her blood glucose is 50 mg/dl.

What is your assessment?

What should be given to treat her hypoglycemia?
What should be done to treat hypothermia?
What should be given to treat her dehydration?
Test yourself!!
Tina is a 3 year old girl with severe wasting. She has no edema. Her
mother said that Tina has been having loose stools since late last night.
Her urine is almost orange.
Tina is awake but not active. T 3.5.C Her heart rate is 150 per minute.
Her blood glucose is 50 mg/dl.

What is your assessment?

What should be given to treat her hypoglycemia?
What should be done to treat hypothermia?
What should be given to treat her dehydration?
Test yourself!!
Tina is a 3 year old girl with severe wasting. She has no edema. Her
mother said that Tina has been having loose stools since late last night.
Her urine is almost orange.
Tina is awake but not active. T 3.5.C Her heart rate is 150 per minute.
Her blood glucose is 50 mg/dl.

What is your assessment?

What should be given to treat her hypoglycemia?
What should be done to treat hypothermia?
What should be given 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.