Guidelines for the inpatient treatment of

severely malnourished children

A. General principles for routine care (the ‘10 Steps’)

B. Emergency treatment of shock and severe anemia

C. Treatment of associated conditions

D. Failure to respond to treatment

E. Discharge before recovery is complete

1| Guidelines Stabilization Care

 A. General principles for routine care
(the ‘10 Steps’)
 Step 1. Treat/prevent hypoglycemia

 Step 2. Treat/prevent hypothermia

 Step 3. Treat/prevent dehydration

 Step 4. Correct electrolyte imbalance

 Step 5. Treat/prevent infection

 Step 6. Correct micronutrient deficiencies

 Step 7. Start cautious feeding

 Step 8. Achieve catch-up growth

 Step 9. Provide sensory stimulation and emotional support

 Step 10. Prepare for follow-up after recovery

2| Guidelines Stabilization Care

 An initial stabilization phase
where the acute medical conditions are managed;
and a longer rehabilitation phase.

3| Guidelines Stabilization Care

 Step 1. Treat/prevent hypoglycemia
Hypoglycemia and hypothermia usually occur together
and are signs of infection.
• Check for hypoglycemia whenever hypothermia (axillary <35.0C)
is found
• Frequent feeding is important in preventing both conditions.

Treatment:
If the child is conscious and dextrostix shows <3mmol/l or
54mg/dl give:
 50 ml bolus of 10% glucose or sugar water ( orally or by nasogastric
(NG) tube.
 Then feed starter F-75 every 30 min. for two hours
 (giving one quarter of the two-hourly feed each time)
 antibiotics
 two-hourly feeds, day and night
4| Guidelines Stabilization Care
 Treatment:
If the child is unconscious, lethargic or convulsing give:
 IV sterile 10% glucose (5ml/kg), followed by 50ml of 10% glucose
or sugar water by Ng tube.

Then give starter F-75 every 30 min. for two hours

(giving one quarter of the two-hourly feed each time)

 antibiotics

 two-hourly feeds, day and night

5| Guidelines Stabilization Care

 Monitoring:
 Blood glucose:

-if this was low, repeat dextrostix taking blood from finger or

heel, after two hours. Once treated, most children

stabilize within 30 min.

-If blood glucose falls to <3 mmol/ l give a further 50ml bolus
of 10% glucose or sugar water, and continue feeding

every 30 min. until stable

-level of consciousness: if this deteriorates, repeat dextrostix

6| Guidelines Stabilization Care

 Prevention:

Feed two-hourly, start straightaway or if necessary,rehydrate

first. Always give feeds throughout the night

Note: If you are unable to test the blood glucose level,

assume all severely malnourished children are
hypoglycemic and treat accordingly.

Sugar Water: Add two teaspoonful of sugar in 100ml of clean

drinking water

7| Guidelines Stabilization Care

 Step 2. Treat/prevent hypothermia
Treatment:
 If the axillary temperature is <35.0C.
 feed straightaway (or start rehydration if needed)
 rewarm the child: either clothe the child (including head), cover
with a warmed blanket and place a heater or lamp nearby (do not
use a hot water bottle), or put the child on the mother’s bare
chest (skin to skin) and cover them
 give antibiotics

Monitor:

 body temperature: during rewarming take temperature two

hourly until it rises to >37.oC (take half-hourly if heater is used)

 ensure the child is covered at all times, especially at night

8| Guidelines Stabilization Care

 Step 2. Treat/prevent hypothermia
Prevention:
 feed two-hourly, start straightaway
 always give feeds throughout the day and night
 keep covered and away from draughts
 keep the child dry, change wet nappies, clothes and bedding
 avoid exposure (e.g. bathing, prolonged medical examinations)
 let child sleep with mother at night for warmth

9| Guidelines Stabilization Care

 Step 3. Treat/prevent dehydration
Note: Low blood volume can coexist with edema. Do not use the IV
route for rehydration except in cases of shock and then do so with
care,

infusing slowly to avoid flooding the circulation and overloading the

heart

10 | Guidelines Stabilization Care

 Diagnosis
Clinical signs of some and severe dehydration
Signs Some Severe
Recent frequent watery diarrhoea Yes, > 3 times a day Yes, profuse

Recent sunken eyes Yes Yes

Recent rapid weight loss 1-5 % 5-10%

Thirst Drinks eagerly Drinks poorly

Absence of tears No Yes

Weak/absent radial pulse No Yes

Cold hands or feet No Yes

Mental state Restless and irritable Lethargic/coma

Urinary output Decreased Absent

11 | Guidelines Stabilization Care

 DEHYDRATION / REHYDRATION
In Malnourished Children
 All the signs of dehydration in a normal child occur in a severely
malnourished child who is not dehydrated – only history of fluid loss and
very recent change in appearance can be used
 Giving a malnourished child who is not really dehydrated treatment of
dehydration is very dangerous
 Misdiagnosis of dehydration and giving inappropriate treatment is the
commonest cause of death in severe malnutrition
 The treatment of dehydration is different in the severely malnourished
child from the normally nourished child

12 | Guidelines Stabilization Care

 DEHYDRATION / REHYDRATION
In Malnourished Children
 Infusion are almost never used and are particularly dangerous

 ReSoMal must not be freely available in the unit – but only taken when
prescribed

 The management is based mainly on accurately monitoring changes in

weight

 Severely wasted patients cannot excrete excess sodium and retain it in

their body. This leads to volume overload and compromise cardiovascular
system. The resulting heart failure can be very acute (sudden death) or
be misdiagnosed as pneumonia

13 | Guidelines Stabilization Care

 Diagnosis
 History of recent changes in appearance of eyes

 History of recent fluid loss

 Check the eyes lids to see if there is lid-retraction.

 Check if patient is unconscious or not

 Check if patient has recently lost weight (if in SC)

14 | Guidelines Stabilization Care

 Dehydration , septic shock
and hypoglycaemia
 If there is a history of recent watery diarrhoea and recent change in the
appearance of the eyes usually with the retraction of eyelid then treat the
child for dehydration.

 If this history and signs are not present, the child appears to be
dehydrated without a history of excess fluid loss or child has oedema then
consider treating for septic shock.

15 | Guidelines Stabilization Care

 Dehydration , septic shock
and hypoglycaemia
 Signs of shock present:
 No history of major fluid loss
 No history of recent eyes sinking
 Fast weak pulse, cold peripheries, pallor and drowsiness
 Eyelid drooping/normal or closed when asleep/unconscious

 Septic shock
 Eyelid retracted or slightly open when asleep/unconscious

 Septic shock + hypoglycaemia

16 | Guidelines Stabilization Care

 Oral Treatment of Dehydration

 The main complications of diarrhoea are dehydration, hypoglycaemic

shock and congestive heart failure due to over-hydration as a result of the
treatment.
 Severely malnourished children are very sensitive to overloading the
system with fluids and electrolytes.

 Therefore no ReSoMal (Rehydration Solution for

Malnourished) or ORS is given to prevent dehydration.
 ReSoMal is only given when dehydration is diagnosed.

17 | Guidelines Stabilization Care

 ReSoMal
ReSoMal = Rehydration Solution for Severe Malnourished patients
 Presentation

- Sachet containing 84 g of powder, to be diluted in 2 liters of clean, boiled and

cooled water for treatment of 3 children
- Sachet containing 420 g of powder, to be diluted in 10 liters of clean, boiled
and cooled water for treatment of 15 children
Composition for one liter
 Glucose 55 mmol Citrate 7 mmol
 Saccharose 73 mmol Magnesium 3 mmol
 Sodium 45 mmol Zinc 0.3 mmol
 Potassium 40 mmol Copper 0.045 mmol
 Chloride 70 mmol
 Osmolarity 294 meq /liter

18 | Guidelines Stabilization Care

 Oral rehydration with ReSoMal for severe
Malnourished
During the first 2 hrs During the next 10 hrs Total over 12 hrs
Weight 5 ml/kg Total over 2 hrs 5 ml/kg Total over 10 70 ml/kg
hrs
in kg every 30 minutes 20 ml/kg every hour
50 ml/kg
3 15 ml every 30 min 60 ml 15 ml every hour 150 ml 210 ml

4 20 ml every 30 min 80 ml 20 ml every hour 200 ml 280 ml

5 25 ml every 30 min 100 ml 25 ml every hour 250 ml 350 ml

6 30 ml every 30 min 120 ml 30 ml every hour 300 ml 420 ml

7 35 ml every 30 min 140 ml 35 ml every hour 350 ml 490 ml

8 160 ml 400 ml 560 ml

40 ml every 30 min 40 ml every hour

9 180 ml 450 ml 630 ml

45 ml every 30 min 45 ml every hour

10 500 ml 700 ml
50 ml every 30 min 200 ml 50 ml every hour

19 | Guidelines Stabilization Care

Alternative recipes in the absence of ReSoMal
 Solutions can be made by using one of the following types of
rehydration salts:

 · Standard WHO-ORS (sachet containing 3.5 g of sodium chloride,

1.5 g of potassium chloride, 20 g of glucose, total weigh: 27.9 g per
sachet)

 *
Water Standard WHO-ORS Sugar CMV*

2 liters 1 sachet 50 g 1 measure

10 liters 5 sachets 250 g 5 measures

 CMV® mineral and vitamin complex: 1 measure = 6,5 grams.

20 | Guidelines Stabilization Care

 Step 4. Correct electrolyte imbalance
 All severely malnourished children have excess body sodium even though
plasma sodium may be low (giving high sodium loads will kill).
Deficiencies of potassium and magnesium are also present and may take
at least two weeks to correct. Edema is partly due to these imbalances.
Do NOT treat edema with a diuretic.

21 | Guidelines Stabilization Care

 Step 5. Treat/prevent infection
 In severe malnutrition the usual signs of infection, such as fever, are often
absent, and infections are often hidden.

 Therefore give routinely on admission:

-broad-spectrum antibiotic (s) AND

 measles vaccine if child is > 6m and not immunized (delay if the child is in
shock)

22 | Guidelines Stabilization Care

Antibiotics for Severely Malnourished Children:

23 | Guidelines Stabilization Care

 Step 6. Correct micronutrient deficiencies
 No need of supplementation while using Therapeutic feed but
Vitamin A is recommended to all malnourish children except
patient with edema.

 Some authorities recommend Folic acid at admission.

24 | Guidelines Stabilization Care

 Step 7. Start cautious feeding

Monitor and note:

 amounts offered and left over
 Vomiting
 frequency of watery stool
 daily body weight
Weighing chart for F75
To 100ml Add 20.5g
To 250ml Add 50g
To 500ml Add 100g
To 1000ml Add 205g
You can make up 2 feeding at 1 time BUT divide the mix into 2 jugs and store the
second feed separately in the fridge.

Ensure the open bag of powder is sealed again properly to stop contamination

25 | Guidelines Stabilization Care

 Step 8. Achieve catch-up growth
 In the rehabilitation phase a vigorous approach to feeding is required to
achieve very high intakes and rapid weight gain of >10 g gain/kg/d.
The recommended milk-based F-100 contains 100 kcal and 2.9 g
protein/100 ml

Monitor during the transition for signs of heart failure:

 respiratory rate
 pulse rate
 If respirations increase by 5 or more breaths/min and pulse by 25 or
more beats/min for two successive 4-hourly readings, reduce the volume
per feed (give 4-hourly F-100 at 16 ml/kg/feed for 24 hours,
 then 19 ml/kg/feed for 24 hours, then 22 ml/kg/feed for 48 hours, then
increase each feed by 10 ml as above).
 After the transition give:
 frequent feeds (at least 4-hourly) of unlimited amounts of a catchup
formula 150-220 kcal/kg/d

26 | Guidelines Stabilization Care

Monitor progress after the transition by assessing the rate
of weight gain:

• weigh child each morning before feeding. Plot weight

• each week calculate and record weight gain as g/kg/day

If weight gain is:

• poor (<5 g/kg/d), child requires full reassessment

• moderate (5-10 g/kg/d), check whether intake targets are being

met,or if infection has been overlooked

• good (>10 g/kg/d), continue to praise staff and mothers

27 | Guidelines Stabilization Care

Step 9. Provide sensory stimulation and emotional
support

In severe malnutrition there is delayed mental and

behavioral development.

Provide:

• tender loving care

• a cheerful, stimulating environment

• structured play therapy 15-30 min/d

• physical activity as soon as the child is well enough

• maternal involvement when possible (e.g. comforting,

feeding, bathing,play)

28 | Guidelines Stabilization Care

 Step 10. Prepare for follow-up after recovery

 A child who is 85% weight-for-length (equivalent to -1SD) can be

considered to have recovered (TFC). The child is still likely to
have a low weight-for-age because of stunting. Good feeding
practices and sensory stimulation should be continued at home.

 Show parent how to:

• feed frequently with energy- and nutrient-dense foods

• give structured play therapy

 Advise parent o to

-bring child back for regular follow-up checks

-ensure booster immunizations are given

-ensure vitamin A is given every six months

29 | Guidelines Stabilization Care

 B. EMERGENCY TREATMENT OF SHOCK

 Hypoglycemia?

 Dehydration?

 Septic Shock?

30 | Guidelines Stabilization Care

 B. EMERGENCY TREATMENT OF SHOCK
 Shock from dehydration and sepsis are likely to coexist in severely
malnourished children. They are difficult to differentiate on clinical
signs alone.

Children with dehydration will respond to IV fluids. Those with septic

shock and no dehydration will not respond.

The amount of fluid given is determined by the child’s response.

Over hydration must be avoided.

31 | Guidelines Stabilization Care

 To start treatment:
 give oxygen
 give sterile 10% glucose (5 ml/kg) by IV
 give IV fluid at 15 ml/kg over 1 hour. Use Ringer’s lactate with
5%dextrose; or half-normal saline with 5% dextrose; or half- strength
Darrow’s solution with 5% dextrose; or if these are unavailable,
Ringer’s lactate
 measure and record pulse and respiration rates every 10 minutes
 give antibiotics

32 | Guidelines Stabilization Care

 If there are signs of improvement (pulse and
respiration rates fall):
 repeat IV 15 ml/kg over 1 hour; then

• switch to oral or nasogastric rehydration with ReSoMal, 10 ml/kg/h for

up to 10 hours.

(Leave IV in place in case required again);

Give ReSoMal in alternate hours with starter F-75, then

• continue feeding with starter F-75

33 | Guidelines Stabilization Care

 If the child fails to improve

after the first hour of treatment (15 ml/kg),

 assume that the child has septic shock. In this case:

 give maintenance IV fluids (4 ml/kg/h) while waiting for blood,

 when blood is available transfuse fresh whole blood at 10 ml/kg

slowly over 3 hours; then

 begin feeding with starter F-75

34 | Guidelines Stabilization Care

 If the child gets worse
 during treatment (breathing increases by 5 breaths

or more/min and pulse increases by 25 or more beats/min):

 stop the infusion to prevent the child’s condition worsening

35 | Guidelines Stabilization Care

C. TREATMENT OF ASSOCIATED CONDITIONS

1.Vitamin A Deficiency-Single dose, if not received in previous one

month

Don’t give Vitamin A in case of edema.

Xerophthalmia

Age Dose Day 0 Day 1 Day 14

6-12 100,000 Y Y Y
months
1-5 Years 200,000 Y Y Y

36 | Guidelines Stabilization Care

 If there is corneal clouding or ulceration,
 give additional eye care to prevent extrusion of the lens:

 instill chloramphenicol or tetracycline eye drops (1%) 2-3 hourly as

required for 7-10 days in the affected eye
- instill atropine eye drops (1%), 1 drop three times daily for 3-5 days
-cover with eye pads soaked in saline solution and bandage

Note: children with vitamin A deficiency are likely to be photophobic

and have closed eyes.

It is important to examine the eyes very gently to prevent rupture.

37 | Guidelines Stabilization Care

2. Severe anemia in malnourished children
A blood transfusion is required if:
• Hb is less than 4 g/dl OR
• if there is respiratory distress and Hb is between 4 and 6 g/dl
Give:
• whole blood 10 ml/kg body weight slowly over 3 hours
• furosemide 1 mg/kg IV at the start of the transfusion
It is particularly important that the volume of 10 ml/kg is not
exceeded in severely malnourished children.
If the severely anemic child has signs of cardiac failure,
transfuse packed cells (5-7 ml/kg) rather than whole blood.

38 | Guidelines Stabilization Care

Severe Palmer Pallor

39 | Guidelines Stabilization Care

 Monitor for signs of transfusion reactions

If any of the following signs develop

during the transfusion, stop the transfusion:

• fever

• itchy rash

• dark red urine

• confusion

• shock

40 | Guidelines Stabilization Care

 Blood Transfusion
 Also monitor the respiratory rate and pulse rate every 15 minutes. If
either of them rises, transfuse more slowly. Following the
transfusion, if the Hb remains less than 4 g/dl or between 4 and 6
g/dl in a child with continuing respiratory distress,
 DO NOT repeat the transfusion within 4 days. In mild or moderate
anemia, oral iron should be given for two months to replenish iron
stores
 BUT this should not be started until the child has begun to gain weight.

41 | Guidelines Stabilization Care

 3. Dermatosis
 Signs:

• hypo-or hyperpigmentation
• desquamation
• ulceration (spreading over limbs, thighs, genitalia, groin, and
behind the ears)
• exudative lesions (resembling severe burns) often with
secondary infection, including Candida
Zinc deficiency is usual in affected children and the skin quickly
improves with zinc supplementation. In addition:
• apply barrier cream (zinc and castor oil ointment, or petroleum
jelly or paraffin gauze) to raw areas
• omit nappies so that the perineum can dry

42 | Guidelines Stabilization Care

Exudative Lesion

43 | Guidelines Stabilization Care

Exudative Lesion

44 | Guidelines Stabilization Care

Dermatitis with Fungal infection

45 | Guidelines Stabilization Care

 4. Parasitic Infestation

De-worming on second week(1-5 years)

-Albendazole400mg
 1 to 2 years ½ tablet single dose
 >= 2years 1 tablet single dose

OR

-Mebendazole500mg

1-2year 250mg single dose

≥2Years 500mg
single dose

46 | Guidelines Stabilization Care

 4. Tuberculosis (TB)

 If TB is strongly suspected (contacts with adult TB patient, poor

growth despite good intake, chronic cough, chest infection not
responding to antibiotics):

• perform Mantoux test (false negatives are frequent)

• chest X-ray if possible
• If test is positive or there is a strong suspicion of TB, treat according
to national TB guidelines.
• BCG diagnostic

47 | Guidelines Stabilization Care

 D. FAILURE TO RESPOND TO TREATMENT
 Failure to respond is indicated by:
1. High mortality
2. Low weight gain during the rehabilitation phase
Mortality

>20% Unacceptable
11-20% Poor
5-10% moderate
<5% Good

48 | Guidelines Stabilization Care

 2. Low weight gain during the rehabilitation phase

 Poor: <5g/kg/d

 Moderate: 5-10g/kg/d

 Good: >10 g/kg/d

 If weight gain is <5 g/kg/d determine:

• whether this is for all cases (need major

management overhaul)

• whether this is for specific cases (reassess child as

for a new admission)

49 | Guidelines Stabilization Care

 Possible causes of poor weight gain are:
a) Inadequate feeding

b) Specific nutrient deficiencies

c) Untreated infection

e) Psychological problems

50 | Guidelines Stabilization Care

 E. DISCHARGE BEFORE RECOVERY IS COMPLETE

 The child
 has completed antibiotic treatment
 has good appetite and good weight gain
 has taken
potassium/magnesium/mineral/vitamin
supplement for 2 weeks (or continuing
supplementation at home is possible)

51 | Guidelines Stabilization Care

 E. DISCHARGE BEFORE RECOVERY IS COMPLETE

SC.
• Clinically well, Social Smile, Appetite good and gaining weight

TFC
The mother
 is not employed outside the home
 is specifically trained to give appropriate feeding (type, amount and
frequency)
 has the financial resources to feed the child
 lives within easy reach of the hospital for urgent readmission if the
child becomes ill
 can be visited weekly
 is trained to give structured play therapy
 is motivated to follow the advice given

52 | Guidelines Stabilization Care

 E. DISCHARGE BEFORE RECOVERY IS COMPLETE

 Local health workers

 are trained to support home care
 are specifically trained to examine the child
clinically at home, to decide when to refer
him/her back to hospital, to weigh the child, and
give appropriate advice
 are motivated

53 | Guidelines Stabilization Care

 Composition of liquid diets (cooked volume 1 liter)

Ingredients Infant formula Milk Suji Milk Suji 100

Whole milk powder (g) 60 40 80
Rice powder (g) - 40 50
Sugar (g) 50 25 50
Soya oil (g) 20 25 25
Magnesium chloride (g) 0.5 0.5 0.5
Potassium chloride (g) 1.0 1.0 1.0
Calcium lactate ( g) 2.0 2.0 -
Energy (kcal/100 ml) 69 67 100
Protein (g/100ml) 1.5 1.4 2.6
Protein-energy ratio (%) 9 8 10
Fat-energy ratio (%) 47 47 40

54 | Guidelines Stabilization Care