|Guidelines for the Inpatient Treatment of Severely Malnourished Children (UNICEF - WHO - OMS, 1998, 21 p.)|
There are ten essential steps:
· 1. Treat/prevent hypoglycaemia
· 2. Treat/prevent hypothermia
· 3. Treat/prevent dehydration
· 4. Correct electrolyte imbalance
· 5. Treat/prevent infection
· 6. Correct micronutrient deficiencies
· 7. Initiate refeeding
· 8. Facilitate catch-up growth
· 9. Provide sensory stimulation and emotional support
· 10. Prepare for follow-up after recovery
These steps are accomplished in two phases: an initial stabilisation phase where the acute medical conditions are managed; and a longer rehabilitation phase. Note that treatment procedures are similar for marasmus and kwashiorkor. The approximate time-scale is:-
STEP 1. TREAT/PREVENT HYPOGLYCAEMIA
Hypoglycaemia and hypothermia usually occur together and are signs of infection. Check for hypoglycaemia whenever hypothermia (axillary < 35.0oC: rectal < 35.5oC) is found. Frequent feeding is important in preventing both conditions.
If dextrostix is below 3mmol/l give:-
· 50ml bolus of 10% glucose or 10% sucrose solution (1 rounded teaspoon of sugar in 3.5 tablespoons water), orally or by nasogastric tube. Then feed every 30 mins for 2 hours (giving one quarter of the 2-hourly feed each time)
· antibiotics (see step 5)
· 2-hourly feeds, day and night (see step 7)
· if blood glucose was low, repeat dextrostix with finger/heel prick blood after 2h. Once treated, most children stabilise within 30min. If blood glucose falls below 3mmol/l repeat 50ml bolus of 10% glucose or sucrose solution, and continue feeding every 30 min until stable
· rectal temperature: if this falls <35.5oC, repeat dextrostix
· level of consciousness: if this deteriorates, repeat dextrostix
· feed 2-hourly, start straightaway (see step 7) 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 hypoglycaemic and treat accordingly.
STEP 2. TREAT/PREVENT HYPOTHERMIA
If the axillary temperature is <35.0oC, take the rectal temperature using a low reading thermometer.
If the rectal temperature is below 35.5oC (<95.9oF):-
· feed straightaway (or start rehydration if needed)
· rewarm the child: either, clothe the child (including head), cover with a warmed blanket and place heater or lamp nearby (do not use hot water bottle), or put child on mother's bare chest (skin to skin) and cover them
· give antibiotics (see step 5)
· take rectal temperature 2-hourly until it rises to >36.5oC (take half-hourly if heater is used)
· ensure the child is covered at all times, especially at night
· feel for warmth
· check for hypoglycaemia whenever hypothermia is found
· feed 2-hourly, start straightaway (see step 7)
· always give feeds throughout the night
· keep covered and away from draughts
· avoid exposure (eg bathing, prolonged medical examinations)
Note: if a low reading thermometer is unavailable and the child's temperature is too low to register on an ordinary thermometer, assume the child has hypothermia.
STEP 3. TREAT/PREVENT DEHYDRATION
Note: low blood volume can coexist with oedema. Do not use the IV route for rehydration except in shock and then do so with care, infusing slowly to avoid flooding the circulation and overloading the heart. (See Section E:Emergency treatment).
The standard WHO oral rehydration salts solution contains too much sodium and too little potassium for severely malnourished children. Instead give special Rehydration Solution for Malnutrition (ReSoMal). (For recipe see appendix 1).
It is difficult to estimate dehydration status in a severely malnourished child using clinical signs alone. So assume all children with watery diarrhoea may have dehydration and give:-
· ReSoMal 5ml/kg every 30min for 2h, orally or by nasogastric tube, then
· 5-10ml/kg/h for next 4-10h: the exact amount to give should be determined by how much the child wants, and /or stool loss and whether vomiting. Replace the ReSoMal doses at 6h and 10h with an equal amount of F-75 if rehydration is continuing at these times
· initiate refeeding with starter F-75 (see step 7)
During treament, rapid respirations and pulse rate should slow and the child begin to pass urine.
assess progress of rehydration half-hourly for 2h, then hourly for the next 6-12h observing:-
· pulse rate
· respiratory rate
· urine frequency
· stool/vomit frequency
(Return of tears, moist mouth, eyes and fontanelle less sunken, and improved skin turgor, are also signs that rehydration is proceeding, but note that many severely malnourished children will not show these changes even when fully rehydrated).
Continuing rapid respiratory and pulse rates during rehydration suggest coexisting infection or overhydration. Signs of too much fluid (overhydration) are increasing respiratory and pulse rates, increasing oedema and puffy eyelids. If these signs occur, stop fluids immediately and reassess after 1h.
when a child has continuing watery diarrhoea
· continue feeding with starter F-75 (see step 7)
· replace approximate volume of stool losses with ReSoMal. As a guide give 50-100ml after each watery stool. (Note: it is common for malnourished children to pass many small unformed stools: these should not be confused with profuse watery stools and do not require fluid replacement)
· if the child is breastfed, encourage to continue
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 which may take at least 2 weeks to correct. Oedema is partly due to these imbalances. (NB Do NOT treat oedema with a diuretic). Give:-
· extra potassium 2-4mmol/kg/d
· extra magnesium 0.3-0.6mmol/kg/d
· when rehydrating give low sodium rehydration fluid (eg ReSoMal)
· prepare food without salt
The extra potassium and magnesium can be prepared in a liquid form and added directly to feeds during preparation. Appendix 1 provides a recipe for a combined electrolyte/mineral solution. Adding 20ml of this solution to 1 litre of feed will supply the extra potassium and magnesium required.
STEP 5. TREAT/PREVENT INFECTION
In severe malnutrition the usual signs of infection, such as fever, are often absent. Therefore give routinely to ALL admissions:-
· broad-spectrum antibiotic(s) AND
· measles vaccine if child is > 6m and not immunised (delay if in shock)
Note: Some experts routinely give in addition to broad-spectrum antibiotics, metronidazole (7.5mg/kg 8-hourly for 7 days) to hasten repair of the intestinal mucosa and reduce the risk of oxidative damage and systemic infection arising from the overgrowth of anaerobic bacteria in the small intestine.
Choice of broad-spectrum antibiotic
a) if the child appears to have no complications give:
· Co-trimoxazole 5ml paediatric suspension orally twice daily for 5 days (2.5ml if weight <4kg). (5ml is equivalent to 40mg TMP+200mg SMX).
b) if the child is severely ill (apathetic, lethargic) or has complications (hypoglycaemia; hypothermia; skin, respiratory tract or urinary tract infection) give:
· Ampicillin 50mg/kg IM/IV 6-hourly for 2 days, then oral amoxycillin 15mg/kg 8-hourly for 5 days, or if amoxycillin is not available, continue with ampicillin but give orally, 50mg/kg 6-hourly)
· Gentamicin 7.5mg/kg IM/IV once daily for 7 days
If the child fails to improve clinically within 48h, ADD:
· Chloramphenicol 25mg/kg IM/IV 6-hourly for 5 days
Where specific infections are identified, ADD specific antibiotics if appropriate. Add antimalarial treatment if the child has a positive blood film for malaria parasites.
If anorexia persists after 5 days of antibiotic treatment, complete a full 10-day course. If anorexia still persists, reassess the child fully, including checking for sites of infection, potentially resistant organisms, and that vitamin and mineral supplements have been correctly given.
STEP 6. CORRECT MICRONUTRIENT DEFICIENCIES
All severely malnourished children have vitamin and mineral deficiencies. Although anaemia is common, do NOT give iron initially but wait until the child has a good appetite and starts gaining weight (usually week 2) as giving iron can make infections worse.
· Multivitamin supplement
· Folic acid 1mg/d (give 5mg on Day 1)
· Zinc 2mg/kg/d
· Copper 0.2mg/kg/d
· once gaining weight, iron 3mg/kg/d
· Vit A orally on Day 1 (if aged >1 year give 200,000 iu; age 6-12m give 100,000iu; age 0-5m give 50,000iu) unless there is definite evidence that a dose has been given in the last month
Appendix 1 provides a recipe for a combined electrolyte/mineral solution. Adding 20ml of this solution to 1 litre of feed will supply the zinc and copper needed, as well as potassium and magnesium. This solution can also be added to ReSoMal.
Note: A combined electrolyte/mineral/vitamin mix for severe malnutrition is available from Nutriset, BP35, 76770 Malaunay, France (Fax +33 35 756161). This replaces the electrolyte/mineral solution and multivitamin and folic acid supplements mentioned in steps 4 and 6. But still give the large single dose of vitamin A and folic acid on Day 1, and iron daily after weight gain has started.
STEP 7. INITIATE REFEEDING
In the initial stabilisation phase a cautious approach is required because of the child's fragile physiological state and reduced homeostatic capacity. Feeding should be started as soon as possible after admission and should be designed to provide just sufficient energy and protein to maintain basic physiological processes. The essential features of feeding in the initial phase are:
· small, frequent feeds of low osmolarity and low lactose
· oral or NG feeds (never parenteral preparations)
· 1-1.5g protein/kg/d
· 130ml/kg/d of liquid (100ml/kg/d if the child has severe oedema)
· if the child is breastfed, continue to breastfeed but give starter formula first
The suggested starter formula and feeding schedules (see below) are designed to meet these targets.
Milk-based formulas such as starter F-75 containing 75kcal/100ml and 0.9g protein/100ml will be satisfactory for most children (see appendix 2 for recipes). Give from a cup. Very weak children may be fed by spoon, dropper or syringe.
A recommended schedule in which volume is gradually increased, and feeding frequency gradually decreased is:-
For children with a good appetite and no oedema, this schedule can be completed in 2-3 days (eg 24h at each level). Appendix 3 shows the volume/feed already calculated according to body weight.
If intake (after allowing for any vomiting) does not reach 80kcal/kg/d despite frequent feeds, coaxing and re-offering, give the remaining feed by NG tube. (Do not exceed 100 kcal/kg/d in this initial phase).
Monitor and note:-
· amounts offered and left over
· stool frequency and consistency
· daily body weight
During this initial phase, diarrhoea should gradually diminish and oedematous children should lose weight. If diarrhoea continues unchecked despite cautious refeeding, or worsens substantially, see section B4 (continuing diarrhoea).
STEP 8. FACILITATE CATCH-UP GROWTH
In the rehabilitation phase a vigorous approach is required to achieve very high intakes and rapid weight gain of >10g gain/kg/d. Readiness to enter the rehabilitation phase is signalled by a return of appetite, usually about one week after admission. A gradual transition is recommended to avoid the risk of heart failure which can occur if children suddenly consume huge amounts.
To make a gradual transition from starter to catch-up formula:-
· replace starter F-75 with the same amount of catch-up formula F-100 for 48h. The recommended milk-based F-100 contains 100kcal and 2.9g protein/100ml (see appendix 2 for recipe). Modified porridges or modified family foods can be used provided they have comparable energy and protein concentrations.
· then increase each successive feed by 10ml until some feed remains uneaten. The point when some remains unconsumed is likely to occur when intakes reach about 30ml/kg/feed (200ml/kg/d).
Monitor during the transition:-
· respiratory rate
· pulse rate
If respirations increase by >5 breaths/min and pulse by >25 beats/min for two successive 4-hourly readings, reduce the volume per feed (give 4-hourly F-100 at 16ml/kg/feed for 24h, then 19ml/kg/feed for 24h, then 22ml/kg/feed for 48h, then increase each feed by 5-10ml as above).
After the transition give:-
· frequent feeds (at least 4-hourly) of unlimited amounts of a catch-up formula
· 4-6g protein/kg/d
· if the child is breastfed, encourage to continue (Note: breast milk does not have sufficient energy and protein to support rapid catch-up growth, so give F-100 first.)
Monitoring after the transition:-
Progress is assessed by the rate of weight gain.
· Weigh child each morning before being fed. Plot weight.
· Each week calculate and record weight gain as g/kg/d.
If weight gain is:
· poor (<5g/kg/d), child requires full reassessment (see section C)
· moderate (5-10g/kg/d), check whether intake targets are being met, or if infection has been overlooked
STEP 9. PROVIDE SENSORY STIMULATION AND EMOTIONAL SUPPORT
In severe malnutrition there is delayed mental and behavioural development. Provide:-
· tender loving care
· a cheerful stimulating environment
· structured play therapy 15-30 min/d (appendix 4 provides examples)
· physical activity as soon as well enough
· maternal involvement when possible (eg comforting, feeding, bathing, play)
STEP 10. PREPARE FOR FOLLOW-UP AFTER RECOVERY
A child who is 90% weight-for-length (equivalent to -1SD) can be considered to have recovered. 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 or carer how to:-
· feed frequently with energy- and nutrient-dense foods
· give structured play therapy
Advise parent or carer to:-
· bring child back for regular follow-up checks
· ensure booster immunizations are given
· ensure 6-monthly vitamin A is given