MANAGEMENT OF COMPLICATED SEVERE ACUTE MALNUTRITION

In-patient care

• Refer child to hospital: prevent hypoglycaemia by giving small sips of sugar water, keep the child warm, first dose of antibiotics (ampicillin + gentamicin)
• Triage the children to fast-track seriously ill patients for assessment and care: treat shock, hypoglycaemia, and
  corneal ulceration, immediately
• General treatment involves 10 steps in two phases: initial stabilisation for 1 week and rehabilitation (for weeks 2-6) as in the table below

ISSUE	STABILISATION	REHABILITATION
	DAYS 1-2	DAYS 3-7	WEEKS 2-6
Hypoglycaemia	give	give	not given
Hypothermia	give	give	not given
Dehydration	give	give	not given
Electrolytes	give	give	given
Infection	give	give	not given
Micronutrients	give	give with No iron	give *With iron
Initiate feeding	give	give	not given
Catch-up feeding	not given	not given	given
Sensory stimulation	not given	not given	not given
Prepare for follow-upnot givengivengiven

Note

• Iron is given after 2 days on F-100; if patient is taking RUTF, do NOT give iron

MANAGEMENT OF COMPLICATIONS IN SAM

HYPOGLYCAEMIA (BLOOD SUGAR <3 MMOL/L OR <54 MG/DL)

• All severly malnourished children are at a risk of hypoglycaemia, and should be given a feed or 10% glucose
  or sucrose, immediately on admission
• Frequent 2 hour feeding is important

TREATMENT

Immediately on admission

• Give 50 ml of glucose or sugar water (one rounded teaspoon of sugar in 3 tablespoons of water) orally or by
  NGT, followed by first feed as soon as possible

If child is able to drink

• Give first feed of F-75 therapeutic milk, if available, every 30 minutes for 2 hours, then continue with feeds
  every 2 hours for 24 hours
  • Then give feeds every 2 or 3 hours, day and night

If child is unconscious

• Treat with IV 10% glucose at 5 ml/kg
• If IV access cannot be quickly established, give 10% glucose or sucrose solution by NGT tube. To make
  10% solution, dilute 1 part of 50% glucose with 4 parts of water OR 1 part of glucose 50% with 9 parts of glucose 5%
  • If IV glucose not available, give 1 teaspoon of sugar moistened with 1-2 drops of water sublingually, and
    repeat every 20 minutes to prevent relapse
  • Monitor children for early swallowing which delays absorption; if it happens, give another dose of sugar
  • Start on appropriate IV/IM antibiotics

Monitoring
If initial blood glucose was low, repeat measurement after 30 minutes

• If blood glucose falls to <3 mmol/L (<54 mg/dL), repeat the 10% glucose or oral sugar solution, and ensure
  antibiotics have been given
  • If it is higher, change to 3 hourly feeds of F-75
• If rectal tempearture falls to <35.5°C, or if level of consciousness deteriorates, repeat the blood glucose
  measurement and treat accordingly

Prevention

• Feed every 2 hours, starting immediately (see below), or if child is dehydrated, rehydrate first. Continue feeding throught the night
• Encourage mothers to watch for any deterioration, help feed and keep the child warm
• Check on abdominal distension

HYPOTHERMIA (AXILLARY TEMPERATURE <35°C AND RECTAL
TEMPERATURE <35.5°C)

Often associated with hypoglycaemia or serious infection

• Feed child immediately as in hypoglycaemia above
• Warm the child: make sure the child is well covered, especially the head, with cloths, hats, and blankets
  • If available, use a heater but not pointing directly at the child. DO NOT use hot water bottles or flourescent lamps
• Encourage caretaker/mother to sleep next to her child and kangaroo technique for infants (skin-to-skin
  contact, direct heat/warmth transfer from mother to child)
• Keep the ward closed during the night and avoid wind drafts inside
• Give appropriate IV or IM antibiotics
• Change wet nappies, clothes and bedding to keep child and bed dry
• Quickly clean the patient with a warm wet towel and dry immediately. Avoid washing the baby directly in the first few weeks of admission

Monitoring

• Take child’s rectal temperature every 2 hours until it rises to <36.5°C, If using a heater, take it every 30
  minutes
• Cover the child at all times, especially at night. Keep head covered with hat to prevent heat loss
• Check for hypoglycaemia

DEHYDRATION

• In both oedema and non-oedematous SAM, the margin of safety between dehydration and over-hydration is very narrow. Exercise care and caution to avoid over-hydration and risk of cardiac failure
  • Assume that all children with watery diarrhoea or reduced urine output have some dehydration

TREATMENT

• Do NOT use IV route for rehydration, except in cases of shock
• Rehydrate slowly, either orally or by NGT using ReSoMal, a specially prepared rehydration solution for
  malnutrition, The standard ORS has a high sodium and low potassium content, which is not suitable for SAM,
  except if profuse diarrhoea is present
• Give ReSoMal more slowly than you would when rehydrating a well-nourished child
  • Give 5 ml/kg every 30 minutes for the first 2 hours
  • Then give 5-10 ml/kg per hour for the next 4-10 hours, with F-75 formula. Exact amount depends on how
    much the child wants, the volume of stool loss and whether the child is vomiting

If ReSoMal not available:

• Give half strength standard ORS, with added potassium and glucose as per the ReSoMal recipe below, unless the child has cholera or profuse watery diarrhoea
• If rehydration still required at 10 hours, give starter F-75 instead of ReSoMal, at the same times. Give the same
  volume of starter F-75 as of ReSoMal

If child is unconscious, in shock or severe dehydration

• Give IV fluid Darrow’s solution or Ringer’s lactate and 5% glucose (or if not available, ½ saline and 5% glucose
  at 15 mL/kg the first hour and reassess
  • If improving, give 15 mL/kg in second hour
  • If conscious, give NGT ReSoMal
  • If not improving, treat for septic shock

Monitoring

• ONLY rehydrate until the weight deficit is corrected and then STOP, DO NOT give extra fluid to ”prevent
  recurrence” (from specialist’s notes)
• During rehydration, respiration and pulse rate should fall and urine passing should start
• Return of tears, moist mouth, improved skin tugor and less sunken eyes and fontanelle are a sign of rehydration. SAM children will not show these and so weight gain
  should be measured
• Monitor progress of rehydration every 30 minutes for 2 hours, then every hour for the next 4-10 hours

Be alert for signs of overhydration, which is dangerous and can lead to heart failure. Check for:

• Weight gain (make sure it is not quick or excessive)
• If increase in pulse rate by 25/minute, respiratory rate by 5/minute is present, stop ReSoMal. Reassess after
  1 hour
• Urine frequency (if child urinated since last check)
• Enlarging liver size on palpation
• Frequency of stools and vomit

Prevention

• Same as in dehydration in well-nourished child, except that ReSoMal is used instead of standard ORS. Give
  30-50 ml of ReSoMal (for child <2 years) and 100 ml (for child ≥2 years) after each watery stool.
  • Small, frequent, unformed stools are common in SAM and should not be confused with profuse watery stools,and they do not require treatment
• Continue breastfeeding
• Initiate re-feeding with starter F-75
• Give ReSoMal between feeds to replace stool lossess. Give 50-100 ml after each watery stool

Recipe for ReSoMal using the standard WHO ORS

INGREDIENT	AMOUNT
Water	2 litres
WHO-ORS	One 1-litre packet
Sucrose	50 g
Electrolyte/mineral solution	40 ml

ELECTROLYTE IMBALANCE

• All SAM children have deficiencies of potassium and magnesium, which may take up to 2 weeks to correct
• Oedema is partly due to potassium deficiency and sodium retention
  • Do not treat oedema with diuretics
  • Giving high sodium doses could kill the child

TREATMENT

• Give extra potassium (3-4 mmol/kg per day)
• Give extra magnesium (0.4-0.6 mmol/kg per day)
• Add extra potassium and magnesium to the feeds. If not already pre-mixed, add 20 ml of the combined
  electrolyte/mineral solution to 1 litre of feed, or use premixed sachets for SAM
• Use ReSoMal to rehydrate
• Prepare food without added salt

INFECTIONS

• In SAM, usual signs of bacterial infection, e.g. fever, are usually absent, yet multiple infections are common.
• Assume all SAM cases have an infection, and treat with antibiotics immediately. Hypoglycaemia and hypothermia are often signs of severe infection

TREATMENT

Broad spectrum antibiotics

• Benzylpenicillin 50,000 IU/kg IM or IV every 6 hours
• Or ampicillin 50 mg/kg every 6 hours for 2 days
• Then, oral amoxicillin 25-40 mg/kg every 8 hours for 5 days
  PLUS
• Gentamicin 7.5 mg/kg once a day for 7 days

Measles vaccination

• If child is ≥ 6 months and not vaccinated, or was vaccinated before 9 months of age. Delay vaccination if
  child is in shock

Other specific infections

• Treat other specific infections if diagnosed as appropriate, e.g., malaria, pneumonia, dysentery, softtissue
  infections, mengingitis, TB, HIV
• If parasitic worms are diagnosed, delay treatment until the rehabilitation phase. Give albendazole 200-400 mg
  single dose
  • In endemic areas, give mebendazole orally twice a day for 3 days to all SAM children 7 days after admission
  • If HIV diagnosed, start ART as soon as possible after stabilisation of metabolic compilcations

Monitoring

• If child is still anorexic after 7 days of antibiotic treatment, continue for a full 10-day course. If anorexia
  persists, reassess child fully

MICRONUTRIENT DEFICIENCIES

• All SAM children have vitamin and mineral deficiencies
• Anaemia is common, but DO NOT give iron initially, instead wait until the child has a good appetite and has
  started gaining weight, usually in the second week, because iron can make infections worse
• RUTF already contains adequate iron so do not add. F-100 does not contain iron, so iron supplements are needed
• F-75, F-100 and RUTF already contain multivitamins (including vitamin A and folic acid) zinc and copper.
  Additional doses are not needed
• If there are no eye signs or history of measles, then do not give a high dose of vitamin A as therapeutic foods already contain adequate amounts

ONLY IF child has signs of vitamin A deficiency like corneal ulceration or history of measles

• Give Vitamin A on day 1, and repeat on days 2 and 14
  Child <6 months: 50,000 IU Child 6-12 months: 100,000 IU Child >12 months: 200,000 IU

Note: If a first dose was given in the referring centre, treat on days 1 and 14 only

Iron

• Give iron in the second week of nutritional rehabilitation
  • Do not give in the stabilization phase
  • Do not give in children receiving RUTF
• Start iron at 3 mg/kg per day after 2 days on F-100 catchup formula

If child is not on any pre-mixed therapeutic foods, give the following micronutrients daily for at least 2 weeks

• Folic acid at 5 mg on day 1; then 1 mg daily
• Multivitamin syrup 5 ml
• Zinc 2 mg/kg per day
• Copper at 0.3 mg/kg per day

INITIAL RE-FEEDING DURING STABILISATION PHASE

In the initial phase, feeding should be gradual.

The essential features of initial feeding are:

• Frequent (every 2-3 hours) oral small feeds of low osmolality and low lactose. Never leave the child alone or
  forcefeed the child, as this can cause aspiration pneumonia Nasogastric tube feeding if the child is eating ≤ 80% of the amount offered at two consecutive feeds
• Calories at 100 kcal/kg per day (do not exceed)
• Protein at 1-1.5 g/kg per day
• Liquid at 130 ml/kg per day or 100 ml/kg per day if child has severe oedema
• Milk-based formulas, such as F-75 (with 75 kcal and 0.9 g protein/100 ml), will be satisfactory for most children
  • Starter F-75 formula can be commercially supplied or locally prepared from basic ingredients
  • In children who get osmotic diarrhoea with commercial preparation, prepare a cereal based F75 as in the table overleaf

TREATMENT

• If child is breastfeeding, continue breastfeeding but add the prescribed amounts of the starter formula as in the
  table below:

  Days	Frequency	Volume/ kg feed	Volume/ kg per day
  1-2	2 hours	11 ml	130 ml
  3-5	3 hours	16 ml	130 ml
  ≥6	4 hours	22 ml	130 ml

• Feed from a cup or bowl. Use a spoon, dropper or syringe to feed very weak children
• Teach the mother or caregiver to help with the feeding
• Night feeds are essential, since long periods without a feed may lead to hypoglycaemia and death
• If child is vomiting, during or after a feed, estimate amount vomited and offer that amount again. If child
  keeps vomiting, offer half the amount of feed twice as often (e.g. every 1 hour) until vomiting stops

Monitoring

Monitor and record:

• Amounts of feed offered and left over
• Vomiting
• Stool frequency and consistency
• Daily body weight

Recipe for refeeding formula F-75 and F-100

If pre-mixed formulas are not available, prepare as below

INGREDIENT	F-75 (STARTER) CEREAL-BASED*	F-100 (CATCH-UP)
Dried skimmed milk	25g	80 g
Sugar	70 g	50 g
Cereal flour	35 g	—
Vegetable oil	27 g	60 g
Electrolyte/mineral solution mix	20 g	20 g
Water: make up to 1000 ml	1000 ml	1000 ml

Note

• Cook cereal-based formula for 4 minutes and add mineral/vitamin mix after cooking

Transition phase

This phase is designed to prepare the child for phase 2 or outpatient management (catch up growth).

Signs that a child is ready for transition:

• Return of appetite
• No episodes of hypoglycaemia (metabolically stable)
• Reduction in or disappearance of all oedema

Make a transition from starter formula to catch-up formula, gradually over 2–3 days. DO NOT switch at once.

MANAGEMENT

• Make a gradual transition from starter F-75 to catch-up formula F-100 or RUTF over 2-3 days, as tolerated
• Give RUTF or a milk-based formula, e.g, F-100 containing 100 kcal/100 mL and 2.9 g of protein per 100
  ml. Replace starter F-75 with an equal amount of catchup F-100 for 2 days.

If RUTF is available

• Start with small but regular meals of RUTF and encourage child to eat often (first, 8 meals per day, and
  later, 5-6 meals per day)
• If child cannot eat whole amount of RUTF per meal in the transition phase, top-up with F-75 to complete the
  feed, until child is able to eat a whole RUTF meal
• If child cannot take at least half of the RUTF in 12 hours, stop RUTF and give F-75. Try introducing RUTF
  again in 1-2 days until the child is able to take adequate amount
• If still breastfeeding, offer breast milk first before each RUTF feed

If RUTF is not available or child does not accept it, give F-100

• In the first 2 days, give F-100 every 3-4 hours (the same amount of F-75 that they were being given). Do not
  increase volume for 2 days
• On the 3rd day, increase each successive feed by 10 ml until child finishes the meal
  • If the child does not finish the meal, offer the same amount for the next meal
  • Keep adding 10 ml until the child leaves a bit of most of his meals (i.e. point at which intake is likely to have reached 200 ml/kg per day)
• If child is being breasfed, encourage mother to breastfeed in between F-100 rations
• After a gradual transition, give:
  • Frequent feeds, unlimited amounts
  • 150-220 kcal/kg per day
  • 4-6 g of protein/kg per day

Caution

• F-100 should never be given to take home. Transition to RUTF

Monitoring

• Monitor the child at least every 4 hours during transition
• Return child to stabilization phase if:
  • Child develops loss of appetite, cannot take 80% of the feeds, develops or increased oedema, medical conditions not improving, any signs of fluid overload, significant re-feeding diarrhoea

Avoid causing heart failure

• Early signs of congestive heart failure (e.g. rapid pulse, fast breathing, basal lung crepitations, enlarging liver,
  gallop heart rhythm, raised jugular venous pressure
• If pulse is increased by 25 beats/minute and breathing rate by 5 breaths/minute, and the increase is sustained
  for two successive 4-hourly readings, then:
  • Reduce volume fed to 100 ml/kg per day for 24 hours
• Then gradually increase as follows:
  • 115 ml/kg per day for next 24 hours
  • 130 ml/kg per day for the following 48 hours
• Then, increase each feed by 10 ml as described earlier

Recommended amounts for RUTF

CHILD’S WEIGHT (KG)	TRANSITION PHASE	REHABILITATION PHASE
	PACKETS PER DAY (92 G, 500 KCAL)	PACKETS PER DAY (92 G, 500 KCAL)	PACKETS PER WEEK SUPPLY
4-4.9	1.5	2	14
5-6.9	2.1	2.5	18
7-8.4	2.5	3	21
8.5-9.4	2.8	3.5	25
9.5-10.4	3.1	4	28
10.5-11.9	3.6	4.5	32
>12kg	4.0	5	35

Patient instructions on how to give RUTF

• Wash hands before giving the RUTF
• Sit with child on the lap and gently offer RUTF
• Encourage child to eat RUTF without force-feeding
• Give small, regular meals of RUTF and encourage child to eat 5-6 meals a day
• If still breastfeeding, continue offering breast milk first before every RUTF feed
• Give only the RUTF for 2 weeks, if breastfeeding continue to breastfeed and gradually introduce foods recommended for the age
• When introducing recommended foods, ensure that the child completes his daily ration of RUTF before giving
  other foods
• Offer plenty of clean water, to drink from a cup, when the child is eating the RUTF

CATCH-UP GROWTH OR REHABILITATION PHASE

Criteria for transfer from transition phase

• Good appetite (child takes >80% of daily ration of RUTF)
• Significantly reduced oedema or no oedema
• Resolved medical complications and completed parenteral antibiotics
• Clinically well and alert

After the transition phase

Children with complicated SAM can be transferred to outpatient care during rehabilitation phase. The child
will require continuing care as an outpatient to complete rehabilitation and prevent relapse.

• Carefully assess the child and the available commuinty support
• Refer the child for rehabilitation in outpatient care or to a community feeding programme if possible, otherwise keep the child admitted

TREATMENT

If the child cannot be managed as outpatient (e.g. no easily accessible nutritional rehabilitation services where the child lives)

• Keep the child admitted until full discharge from nutritional program
• Continue with RUTF or F-100, but increase amount as the child gains weight

If the child can be managed as outpatient

• Discharge the mother with 2-week supply of RUTF according to the table above
• Counsel caregivers on outpatient treatment and link them to a community nutritional programme if
  available. Ensure that mother/caregiver:
  • Brings back the child for weekly supplements
  • Is available for child care
  • Has received specific counselling on appropriate child feeding practices (types, amount, frequency) and basic hygiene
  • Has resources to feed child (if not, give advice on available support)

Monitoring (by rate of weight gain)

• Weigh child every morning before feeding, and plot the weight
• Calculate and record weight gain every 3 days as g/kg per day

For example Current weight of child = 6300 g Weight 3 days ago = 6000 g Weight gain in grams: 6300-6000 = 300 g Average daily weight gain = 300 g ÷ 3 days = 100 g/day Child’s average weight: (6000 + 6300) ÷ 2 = 6150 g (6.15 kg) Divide by child’s average weight in kg: 100 g/day ÷ 6.15 kg = 16.3 g/kg per day

If the weight gain is:

• Poor (<5 g/kg per day), child needs a full reassessment
• Moderate (5-10 g/kg per day), check if intake targets are being met or if infection has been overlooked
• Good (>10 g/kg/day): continue rehabilitation

SENSORY STIMULATION

Provide:

• Tendor loving care
• A cheerful, stimulating environment
• Structured play therapy for 15-30 minutes/day
• Physical activity as soon as the child is well enough
• As much maternal involvement as possible (e.g.,
  comforting, feeding, bathing, playing)
• Provide suitable toys and play activities for the child