Severe Malnutrition

Summary of WHO Management Guidelines

Children Age 6 Months to 5 Years

Blair Thedinger

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%

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

Visible Severe Wasting

Symmetrical Edema in Lower Extremities

Mean Upper Arm Circumference

Step 1: Initial Assesment

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?

Important Points of Physical

• Level of Consciousness / Response• Hydration (difficult to assess) • Signs of Anemia• Signs of Infections• Extent of edema• Eye signs• Feces

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

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

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

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

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

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

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.

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)

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

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.

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

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)

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

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)

Malnutrition is not Natural