E. Emergency treatment

1. Shock in severely malnourished children

Shock from dehydration and sepsis are likely to co-exist in severely malnourished children. They are diffcult 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 guided by the child's response. Overhydration must be avoided.

To start treatment:-

· infuse IV fluid at 15ml/kg over 1 hour. Use half normal saline with 5% dextrose or Ringer's lactate with 5% dextrose, (if unavailable, give Ringer's lactate alone). Reassess after this.

If child is severely dehydrated there should be an improvement with IV treatment and respiratory and pulse rates will fall. In this case:-

· repeat IV 15ml/kg over 1 hour once more and then switch to oral or nasogastric rehydration with ReSoMal, 10ml/kg/h for up to 10 hours. (Leave IV in place in case required again). Then initiate refeeding with starter F-75.

If child fails to improve after the first 15ml/kg/h, then assume that the child has septic shock. In this case:-

· give maintenance IV fluids (4ml/kg/hour) while waiting for blood. When blood is available, transfuse fresh whole blood at 10ml/kg slowly over 3h. Then initiate refeeding with starter F-75 (step 7)

2. Severe anaemia in malnourished children

A blood transfusion is required if:

· Hb is less than 4g/dl
· or if there is respiratory distress and Hb between 4 and 6g/dl

(In mild or moderate anaemia, iron should be given for two months to replete iron stores BUT this should not be started until after the initial stabilisation phase has been completed).

Give:

· whole blood 10ml/kg bodyweight slowly over 3 hours
· furosemide 1mg/kg IV at the start of the transfusion

It is particularly important that the volume of 10ml/kg is not exceeded in severely malnourished children. If the severely anaemic child has signs of cardiac failure, transfuse packed cells rather than whole blood.

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

Also monitor the respiratory rate and pulse rate every 15 minutes. If either of them rise, transfuse more slowly.

Following the transfusion, if the Hb remains less than 4g/dl or between 4-6g/dl in a child with continuing respiratory distress, DO NOT repeat the transfusion.