Severe malnutrition[1]b2
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Severe Malnutrition
Summary of WHO Management Guidelines
Children Age 6 Months to 5 Years
Blair Thedinger
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Severe Malnutrition Mortality
• Responsible for 35% of deaths among children under five.
• Median under-five case-fatality rate for severe acute malnutrition typically ranges from 30% to 50%
• Management by WHO guidelines in a hospital setting cut mortality by 55%
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Diagnosis of Severe Acute Malnutrition
Any ONE of the following:• Weight to length <70% of expected• Symmetrical pitting edema of at least the feet
(kwashiorkor)• “Visible Severe Wasting”- Specifically: gluteal
muscle wasting, and visible rib outlines or other bony prominence on chest wall.
• Mid upper arm circumference (MUAC) less than 11.5 cm
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Visible Severe Wasting
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Symmetrical Edema in Lower Extremities
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Mean Upper Arm Circumference
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Step 1: Initial Assesment
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Important Aspects of History
• How acute is the malnutrition? Get the feeding / social history
• Is the child more sick right now? How so?• Does the child want to eat? (if yes watch them
try to feed) • If caretaker is not the mother, what happened
to the mother?• Any siblings deceased? Sick contacts?
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Important Points of Physical
• Level of Consciousness / Response• Hydration (difficult to assess) • Signs of Anemia• Signs of Infections• Extent of edema• Eye signs• Feces
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Step 2: Hypoglycemia
• Glucose absorption and production impaired.• Patients have often travelled for long distances
with little food to the health center.• Infection / Sepsis• If any one of the following: Unconscious? Limp?
Lethargic? Hypothermia? - TREAT IMMEDIATELY • Hypoglycemia = <56 mg/dl or <3mmol/l
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Step 2: Hypoglycemia
• Child Unconscious / Lethargic / Hypothermic– Immediately give D10 5ml/kg IV if IV is available.
Then 50 ml of 10% Glucose or Sucrose per NG. If child regains consciousness start feeding
• Conscious – Able to Take PO– Give 50ml of 10% glucose or sucrose or Formula
75 kcal/100ml. Begin frequent feeding q2-3 hours with F-75 to prevent recurrence
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Step 2: Hypothermia
• Should be taken as sign of sepsis• Axillary temp <35 C or <95 F. If does not
register assume hypothermia• Treat for hypoglycemia• Warming efforts (Kangaroo care)• Remove wet clothes and cover• If heat lamps need to monitor closely
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Step 3: Dehydration / Shock• Difficult to assess in malnourished children• IV fluids are dangerous, especially in a situation with no effective
monitoring • Reliable Signs: Watery Diarrhea; Thirst (absent in severe
dehydration); Sunken eyes (only if developed recently); low urine output;
• Unreliable Signs in Malnurished Child: Elastic skin and dry mucous membranes are not reliable in severely malnourished children
• If Dehydrated:– Give ReSoMal ** orally. NO IV FLUIDS
• 5ml/kg q30 x 2 hours. • 5-10 ml/kg q 1 hour for 6 hours
– Switch to F-75 after 6 hours still at above dose / frequency until rehydrated then switch to re-feeding protocol.
** ReSoMal = Recommended ORS solution for severely malnourished children
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Step 3: Dehydration / Shock• Shock?• Weak or absent radial pulse? Hypothermic? Lethargic
or Unconscious? Cold extremities? Decrease urine flow?
• Give IV volume• D5LR, D5 ½ NS, or D5 ½ Darrows at 15 ml/kg over 1
hour• Place NG tube and give ReSoMal at same time• Reassess frequently and discontinue IVF if– Increased respiratory rate– Jugluar veins distended
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Step 4 - InfectionSeverely Malnourished Children Should be Considered
Immunocompromised• Lymph glands, tonsils and the thymus are atrophied• Cell-mediated immunity is severely depressed• IgA levels in secretions are reduced• Complement components are low • Phagocytes do not kill ingested bacteria efficiently • Tissue damage does not result in inflammation or migration
of white cells to the affected area • Acute phase immune response is diminished • Typical signs of infection, such as an increased white cell
count and fever, are frequently absent
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Step #4 Infection
• BACTERIAL: ALL severely malnourished children get treatment– If no hypoglycemia, hypothermia, or shock give:
• Cotrimoxazole 4mg/20mg PO BID x 5 days– If these are present give:
• Ampicillin 50 mg/kg IM/IV q6 x 7 days• Gentamycin 7.5 mg/kg IM/IV qDay x 7days
– If not improving after 48 hours or suspect meningitis give in addition:• Chloramphenicol 25mg/kg q6 hours IV / IM – switch to PO at
q8 ASAP.
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Step #4 Infection
• MALARIA: Blood smear on every child as available. If positive treat based on severity.– Severe:
• Quinine 20 mg/kg IV/IM loading dose in dextrose over 4 hours
• Then 12 hours after start of loading dose 10 mg/kg over 2 hours Q8 (Switch to PO when able)
– Non-severe: • Artemether/Lumefantrine 3 day pack, Other Artemenisin
based combination, or Sulfadoxine/Pyrimethamine 25/1.5 mg/kg as a single dose (Much less effective and can contribute to resistance development)
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Step #4 Infection• TB: Common but should not give treatment until you have
a diagnosis or is very strongly suspected clinically• HIV: If signs of opportunistic infection then test. If mother
HIV positive and child untested then test. • MEASLES: Give vaccine to all children at admission unless
proof of recent vaccine.• GI: If able to send stool for analysis
– If Helminlithiasis give mebendazole 100 mg PO BID for 3 days or if in area with high infection rate give to everyone once improving.
– If bloody diarrhea assume Shigella infection and treat: Nalidixic acid (15mg/kg four times daily for 5 days)
– If Giardia give Metronidazole 7.5 mg/kg PO q8 hours for 7 days
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Step #5 Feeding• What food do you give?
– F-75 for initial re-feeding – for F-75 recipe see WHO pediatric Handbook. Alternatives are listed if milk is unavailable
• How much do you give?– For 1st 2 days give 11 ml/kg/feed, then 16ml/kg/feed on days 3-
5, then 22ml/kg/feed on days 6 onwards • How often do you give feedings?
– Days 1-2 = q2 hours. Days 3-5 = q3hours. Days 6 onwards q4hours. This includes throughout the night.
• When documented weight gain you transition to F-100 or other “catch up” formula and then increase feeds by 10ml per day.
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Step #6 Micronutrients
ALL severely malnourished children need at least 2 weeks of daily vitamins. All children should be getting either ReSoMal or F-75 that is fortified with Electrolyte and Mineral Powder Mix. In addition: 1. Vitamin A as below 2. Folic acid 5mg on day 1 and then 1mg/day 3. Iron 3 mg Fe/kg/day – start AFTER the
child starts gaining weight
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Step #6 Micronutrient
• Eyes and Vitamin A– An estimated 250 000 to 500 000 vitamin A-
deficient children become blind every year, half of them dying within 12 months of losing their sight. (WHO)
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Step #6 Micronutrient
Severe Anemia:
Determine by clinical exam or Hbg < 4 g/dl or <6g/dl if child has respiratory distress)
Whole blood or pRBCs at 10 ml/kg slowly over 3 hours Lasix at 1mg/kg with transfusion
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Ready for Rehab?
• ( ) Hungry, and feeding without an NG tube?
• ( ) Mental status normal (interactive)?• ( ) Sits, crawls, walks as normal?• ( ) Temperature normal?• ( ) No Vomiting or Diarrhea?• ( ) No Edema?• ( ) GAINING WEIGHT ( >5 g/kg or body
weight for 3 successive days)
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Malnutrition is not Natural