C. Failure to respond to treatment

Failure to respond is indicated by:

1. High Mortality

Case fatality rates vary widely. Those >20% should be considered unacceptable, 11-20% poor, 5-10% moderate, and those <5% good.

If mortality is >5%, determine whether majority of deaths occur:-

· within 24h: consider untreated or delayed treatment of hypoglycaemia, hypothermia, septicaemia, severe anaemia or incorrect rehydration fluid or volume

· within 72h: check whether refeeding with too high a volume/feed or wrong formulation

· at night: consider hypothermia from insufficient covers, no night feeds

· when changing to catch-up F-100: consider too rapid a transition

2. Low Weight Gain during the Rehabilitation Phase

Poor: <5g/kg/d
Moderate: 5-10g/kg/d
Good: >10g/kg/d

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

· is this for all cases (need major management overhaul)
· for specific cases (reassess child as for a new admission)

Possible causes of poor weight gain are:-

a) Inadequate feeding

Check:

· that night feeds are given

· that target energy and protein intakes are achieved. Is actual intake (offered minus leftovers) correctly recorded? Is the quantity of feed recalculated as the child gains weight? Is the child vomiting or ruminating?

· feeding technique. Is the child fed frequently and offered unlimited amounts?

· quality of care. Are staff motivated/gentle/loving/patient?

· all aspects of feed preparation: scales, measurement of ingredients, mixing, taste, hygienic storage, adequate stirring if separating out

· if giving family foods with catch-up F-100, that they are suitably modified to provide >100kcal/100g (if not, re-modify). If resources for modification are limited, or children are not inpatients, compensate by replacing catch-up F-100 with catch-up F-135 containing 135kcal/100ml (see appendix 2 for recipe)

b) Specific nutrient deficiencies

Check:

· adequacy of multivitamin composition, shelf-life

· preparation of electrolyte/mineral solution and whether correctly prescribed and administered. If in goitrous region, check KI is added to the electrolyte/mineral solution (12mg/2500ml) or give all children Lugol's iodine (5-10 drops/day)

· that if modified family foods are substantially replacing F-100, electrolyte/mineral solution is added to the family food (20ml/day)

c) Untreated infection

If feeding is adequate and there is no malabsorption, some hidden infection can be suspected. Easily overlooked are: urinary tract infections, otitis media, TB and giardiasis.

· re-examine carefully
· repeat urinalysis for white blood cells
· examine stool
· if possible, take chest X-ray

Alter the antibiotic schedule (step 5) only if a specific infection is identified. (Blind antimicrobials are unlikely to be successful if step 5 has been followed.)

d) HIV/AIDS

In children with HIV/AIDS, good recovery from malnutrition is possible though it may take longer and treatment failures may be common. Lactose intolerance occurs in severe HIV-related chronic diarrhoea. Treatment should be the same as for HIV negative children.

e) Psychological problems

Check for:-

· abnormal behaviour such as stereotyped movements (rocking), rumination (self-stimulation through regurgitation) and attention seeking

Treat by giving the child special love and attention. For the ruminator, firmness, but with affection and without intimidation, can assist.