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Treatment
In the previous section, you looked at what the stabilisation and rehabilitation phases aim for and where they should be managed.
Now click each step for more information.
Step 1: Hypoglycaemia
Definition:Hypoglycaemia means low level of glucose in the blood.
In SAM, hypoglycaemia exists if the glucose level is <3 millimoles
3> per litre.
Signs: The signs of hypoglycaemia include hypothermia, and becoming
drowsy, lethargic or limp or cannot be roused.
Prevention: Feed SAM children every 3 hours day and night, starting
immediately. Feed every 2 hours if the child is ill.
Treatment:If the child is conscious, immediately give 50 ml of 10%
glucose solution, or 50 ml F75 starter formula or 50ml of 10% sugar
solution. (Give whichever is available quickest) Give F75 every 2 hours
(give 1/4 of the dose every 30 minutes for the first 2 hours).
Keep warm and start antibiotics immediately (See step 7 for volumes
of F75). If the child is unconscious, give sterile 10% glucose
solution intravenously (5 ml/kg body weight). If IV glucose cannot be
given immediately, give 50ml 10% glucose or sugar solution by nasogastric tube. Give F75 every 2 hours (give 1/4 of the dose every 30 minutes for the first 2 hours). Keep warm and start antibiotics immediately by nasogastric tube.
Definition:Hypoglycaemia means low level of glucose in the blood.
In SAM, hypoglycaemia exists if the glucose level is <3 millimoles
3> per litre.
Signs: The signs of hypoglycaemia include hypothermia, and becoming
drowsy, lethargic or limp or cannot be roused.
Prevention: Feed SAM children every 3 hours day and night, starting
immediately. Feed every 2 hours if the child is ill.
Treatment:If the child is conscious, immediately give 50 ml of 10%
glucose solution, or 50 ml F75 starter formula or 50ml of 10% sugar
solution. (Give whichever is available quickest) Give F75 every 2 hours
(give 1/4 of the dose every 30 minutes for the first 2 hours).
Keep warm and start antibiotics immediately (See step 7 for volumes
of F75). If the child is unconscious, give sterile 10% glucose
solution intravenously (5 ml/kg body weight). If IV glucose cannot be
given immediately, give 50ml 10% glucose or sugar solution by nasogastric tube. Give F75 every 2 hours (give 1/4 of the dose every 30 minutes for the first 2 hours). Keep warm and start antibiotics immediately by nasogastric tube.
Step 2: Hypothermia
Definition: Hypothermia means low body (rectal) temperature, which is
below 35.5°C.
Prevention: Keep SAM children warm, dry and feed frequently,
and at night keep the room hot, dress them warmly (including the head)
and cover with a blanket. Keep children covered as much as possible
during examinations.
Treatment:Feed the child immediately and then every 2 hours at least
for the first day. Rewarm the child either by skin-to-skin contact or
dressing the child in warm clothes, (Including the head), wrapping
in a blanket and placing a heater nearby. Temperature should be
monitored every 2 hours during re-warming (or every 30 minutes
if using a heater) and considered normal when it is 36.5°C.
Definition: Hypothermia means low body (rectal) temperature, which is
below 35.5°C.
Prevention: Keep SAM children warm, dry and feed frequently,
and at night keep the room hot, dress them warmly (including the head)
and cover with a blanket. Keep children covered as much as possible
during examinations.
Treatment:Feed the child immediately and then every 2 hours at least
for the first day. Rewarm the child either by skin-to-skin contact or
dressing the child in warm clothes, (Including the head), wrapping
in a blanket and placing a heater nearby. Temperature should be
monitored every 2 hours during re-warming (or every 30 minutes
if using a heater) and considered normal when it is 36.5°C.
Step 3: Dehydration
Definition:Dehydration means having too little fluid in the body.
Signs: Dehydration in SAM is difficult to diagnose as the signs
of SAM are similar to the ones caused by dehydration. WHO recommends
you assume that a child is dehydrated if the child has watery diarrhoea
Prevention: Keep feeding, including breastfeeding. Replace the volume
of stool loss withRehydration Solution for Malnutrition (ReSoMal).
As a guide, give 50-100ml for each watery stool.
Treatment: Give ReSoMal 5ml/kg every 30 minutes for the first 2 hours,
orally or by nasogastric tube. Then give 5-10ml/kg in alternate hours
for up to 10 hours (Give F75 in the other alternate hours). Stop
ReSoMal when there are 3 or more hydration signs,or signs of fluid
overload.
Definition:Dehydration means having too little fluid in the body.
Signs: Dehydration in SAM is difficult to diagnose as the signs
of SAM are similar to the ones caused by dehydration. WHO recommends
you assume that a child is dehydrated if the child has watery diarrhoea
Prevention: Keep feeding, including breastfeeding. Replace the volume
of stool loss withRehydration Solution for Malnutrition (ReSoMal).
As a guide, give 50-100ml for each watery stool.
Treatment: Give ReSoMal 5ml/kg every 30 minutes for the first 2 hours,
orally or by nasogastric tube. Then give 5-10ml/kg in alternate hours
for up to 10 hours (Give F75 in the other alternate hours). Stop
ReSoMal when there are 3 or more hydration signs,or signs of fluid
overload.
Step 4: Electrolyte imbalance
Definition:Electrolyte imbalance in SAM means an imbalance of three
important electrolytes (potassium, magnesium and sodium). All children
with SAM have deficiencies of potassium and magnesium, and they have
excess body sodium. The imbalance of the three contributes to oedema
and heart failure. Do not treat oedema with a diuretic as this
makes the potassium deficiency worse.
Signs:The main signs are oedema and poor appetite. Apathy and
weakness are other signs.
Treatment: Give extra potassium 3-4 mmol/kg/d, and magnesium
0.4-0.6 mmol/kg/d for at least 2 weeks. Limit sodium by rehydrating
with ReSoMal and preparing food without salt. CMV (combined mineral
and vitamin mix) is designed for children with SAM and contains the
extra potassium, magnesium, zinc, copper and vitamins that they need.
Or an electrolyte/mineral solution can be made at a pharmacy.
Either of these can be added to feeds and ReSoMal during preparation. If neither is available, use 10% potassium chloride solution (22.5ml per litre of feed or ReSoMal) or Slow K tablets (1/2 crushed tablet/kg/d).
Definition:Electrolyte imbalance in SAM means an imbalance of three
important electrolytes (potassium, magnesium and sodium). All children
with SAM have deficiencies of potassium and magnesium, and they have
excess body sodium. The imbalance of the three contributes to oedema
and heart failure. Do not treat oedema with a diuretic as this
makes the potassium deficiency worse.
Signs:The main signs are oedema and poor appetite. Apathy and
weakness are other signs.
Treatment: Give extra potassium 3-4 mmol/kg/d, and magnesium
0.4-0.6 mmol/kg/d for at least 2 weeks. Limit sodium by rehydrating
with ReSoMal and preparing food without salt. CMV (combined mineral
and vitamin mix) is designed for children with SAM and contains the
extra potassium, magnesium, zinc, copper and vitamins that they need.
Or an electrolyte/mineral solution can be made at a pharmacy.
Either of these can be added to feeds and ReSoMal during preparation. If neither is available, use 10% potassium chloride solution (22.5ml per litre of feed or ReSoMal) or Slow K tablets (1/2 crushed tablet/kg/d).
Step 5: Infections
Signs: The usual signs such as fever are often absent in SAM due to
a damaged immune system, and infections are often hidden.
Hypoglycaemia and hypothermia are signs of serious infection.
Prevention: Wash hands to prevent cross-infection. Allow only one
child per bed. Give measles vaccine if a child is over 6 months and
not immunised. Keep food, utensils and the environment clean
Treatment:Assume all SAM children have hidden infections and treat
with broad spectrum antibiotics straightaway. If there are no
complications, give oral amoxicillin (25mg/kg) orally twice daily for 5
days.If the child looks ill or lethargic or has complications, give
gentamicin IV or IM (7.5mg/kg) once a day for 7 days and ampicillin
IV or IM (50mg/kg) every 6 hours for 2 days followed by amoxicillin oral
(25-40mg/kg) every 8 hours for 5 days. (The type of antibiotic may need
to be adapted locally, depending on local patterns of resistance. Gram-negative cover is essential if the child looks ill).
Signs: The usual signs such as fever are often absent in SAM due to
a damaged immune system, and infections are often hidden.
Hypoglycaemia and hypothermia are signs of serious infection.
Prevention: Wash hands to prevent cross-infection. Allow only one
child per bed. Give measles vaccine if a child is over 6 months and
not immunised. Keep food, utensils and the environment clean
Treatment:Assume all SAM children have hidden infections and treat
with broad spectrum antibiotics straightaway. If there are no
complications, give oral amoxicillin (25mg/kg) orally twice daily for 5
days.If the child looks ill or lethargic or has complications, give
gentamicin IV or IM (7.5mg/kg) once a day for 7 days and ampicillin
IV or IM (50mg/kg) every 6 hours for 2 days followed by amoxicillin oral
(25-40mg/kg) every 8 hours for 5 days. (The type of antibiotic may need
to be adapted locally, depending on local patterns of resistance. Gram-negative cover is essential if the child looks ill).
Step 6: Micronutrient deficiencies
Definition: Micronutrient deficiencies refer to mineral and vitamin
deficiencies. All SAM children have micronutrient deficiencies.
They are caused mainly by inadequate intake, loss of nutrients (e.g. zinc)
in stools during diarrhoea,and use of micronutrients to fight infections.
Signs:Signs include changes in the appearance of the eyes,
skin and hair, oedema, diarrhoea, and pallor (anaemia).
Treatment:Give the following daily for at least 2 weeks: Vitamin A
5000 IU/day*, multivitamin supplement*, folic acid 1mg/day* (give
5mg on day 1), zinc* 2mg/kg/d), copper* 0.3mg/kg/d). Those starred
are present in CMV and in manufactured F75, F100 and ready-to-use
therapeutic food (RUTF) that comply with WHO specifications. In the
rehabilitation phase, add iron 3mg/kg/day. Do not give iron
in the stabilisation phase.If a SAM child has eye signs of Vitamin A
deficiency or has had recent measles, give a high dose of vitamin A orally
on Days 1, 2 and 15 (for age >12 months, give 200,000 IU; for age 6-12 months give 100,000 IU; for age 0-5 months give 50,000 IU).
Definition: Micronutrient deficiencies refer to mineral and vitamin
deficiencies. All SAM children have micronutrient deficiencies.
They are caused mainly by inadequate intake, loss of nutrients (e.g. zinc)
in stools during diarrhoea,and use of micronutrients to fight infections.
Signs:Signs include changes in the appearance of the eyes,
skin and hair, oedema, diarrhoea, and pallor (anaemia).
Treatment:Give the following daily for at least 2 weeks: Vitamin A
5000 IU/day*, multivitamin supplement*, folic acid 1mg/day* (give
5mg on day 1), zinc* 2mg/kg/d), copper* 0.3mg/kg/d). Those starred
are present in CMV and in manufactured F75, F100 and ready-to-use
therapeutic food (RUTF) that comply with WHO specifications. In the
rehabilitation phase, add iron 3mg/kg/day. Do not give iron
in the stabilisation phase.If a SAM child has eye signs of Vitamin A
deficiency or has had recent measles, give a high dose of vitamin A orally
on Days 1, 2 and 15 (for age >12 months, give 200,000 IU; for age 6-12 months give 100,000 IU; for age 0-5 months give 50,000 IU).
Step 7: Cautious feeding
Definition: In the stabilisation phase cautious feeding is required
as a SAM child has a fragile physiological state, and the organs in the
body are unable to cope with too much food. The aim is to provide
100kcal/kg/d and 1-1.5g protein/kg/d.
Treatment: Give small amounts of a special starter formula (F75)
every 2-3 hours day and night for the first few days (8-12 feeds
over 24 hours). F75 is made from milk, sugar and oil and is low in protein,
lactose and sodium, and high in sugar. And the formula is constituted
to provide 75kcal and 0.9 g protein per 100 ml, so giving 130 ml/kg
body weight per day will meet the energy and protein targets.
For children with generalised oedema, give 100ml/kg/day. Click here for
F75 feed chart. Feed orally or by nasogastric tube. Do not use parenteral
preparations. Children who are breastfed should receive the prescribed
amount of F75 and encouraged to breastfeed. For infants <6m,
breastfeed where possible and give a supplement of expressed breast milk, F75, infant formula, or diluted F-100.
Definition: In the stabilisation phase cautious feeding is required
as a SAM child has a fragile physiological state, and the organs in the
body are unable to cope with too much food. The aim is to provide
100kcal/kg/d and 1-1.5g protein/kg/d.
Treatment: Give small amounts of a special starter formula (F75)
every 2-3 hours day and night for the first few days (8-12 feeds
over 24 hours). F75 is made from milk, sugar and oil and is low in protein,
lactose and sodium, and high in sugar. And the formula is constituted
to provide 75kcal and 0.9 g protein per 100 ml, so giving 130 ml/kg
body weight per day will meet the energy and protein targets.
For children with generalised oedema, give 100ml/kg/day. Click here for
F75 feed chart. Feed orally or by nasogastric tube. Do not use parenteral
preparations. Children who are breastfed should receive the prescribed
amount of F75 and encouraged to breastfeed. For infants <6m,
breastfeed where possible and give a supplement of expressed breast milk, F75, infant formula, or diluted F-100.
Step 8: Catch-up growth
Definition: To achieve rapid weight gain of >10 g gain/kg body weight/d
in the rehabilitation phase, the target intakes are 150-220kcal/kg/d
and 4-6g protein/kg/d. A child is ready for this Step when infections
are under control and the organs are beginning to work properly again.
Readiness is signalled by return of appetite and loss of most or all the
oedema.A gradual transition is recommended to avoid the risk of
heart failure.
Treatment: To make the transition, replace
starter F75 with the same amount of catch up formula F100
(or 100-130kcal/kg/d of RUTF) for 48 hours, and then increase each feed
by 10 ml until some is left uneaten. After the three transition days,
give as much as the child can eat of F100 (a milk-based formula
containing 100kcal and 2.9 g protein/100 ml), or RUTF, and/or highly
nutrient dense family food. Feed at least seven times in 24 hours. For
infants <6m, breastfeed where possible and give a supplement of expressed breast milk, infant formula or diluted F100. Click here for F100 feed chart
Definition: To achieve rapid weight gain of >10 g gain/kg body weight/d
in the rehabilitation phase, the target intakes are 150-220kcal/kg/d
and 4-6g protein/kg/d. A child is ready for this Step when infections
are under control and the organs are beginning to work properly again.
Readiness is signalled by return of appetite and loss of most or all the
oedema.A gradual transition is recommended to avoid the risk of
heart failure.
Treatment: To make the transition, replace
starter F75 with the same amount of catch up formula F100
(or 100-130kcal/kg/d of RUTF) for 48 hours, and then increase each feed
by 10 ml until some is left uneaten. After the three transition days,
give as much as the child can eat of F100 (a milk-based formula
containing 100kcal and 2.9 g protein/100 ml), or RUTF, and/or highly
nutrient dense family food. Feed at least seven times in 24 hours. For
infants <6m, breastfeed where possible and give a supplement of expressed breast milk, infant formula or diluted F100. Click here for F100 feed chart
Step 9: Sensory stimulation
Definition: In severe malnutrition, there is delayed mental, motor
and behavioural development. SAM children need sensory stimulation and
emotional support for their mental and behavioural
development.
Treatment:Provide tender loving care, a cheerful and stimulating
environment, structured play therapy for 15-30 minutes
per day, and physical activity as soon as
the child is well enough. Also make sure to involve parents or
carers when possible. Each play session should include
movement and language activities.
Definition: In severe malnutrition, there is delayed mental, motor
and behavioural development. SAM children need sensory stimulation and
emotional support for their mental and behavioural
development.
Treatment:Provide tender loving care, a cheerful and stimulating
environment, structured play therapy for 15-30 minutes
per day, and physical activity as soon as
the child is well enough. Also make sure to involve parents or
carers when possible. Each play session should include
movement and language activities.
Step 10: Prepare for follow-up
Definition: A child who reaches -2SD weight-for-height/length or
MUAC 125mm can be considered to have recovered. The child is still likely
to have a low weight-for–age because of stunting.
Management: Good feeding practices and sensory stimulation
should be continued at home. Show the parent or carer how to feed
frequently with energy and nutrient-dense foods and how to give
structured play therapy. Also, ensure that discharged children
are followed up regularly, weighed, and given booster immunizations.
Teach the danger signs that indicate when to take children to a
clinic urgently.
Definition: A child who reaches -2SD weight-for-height/length or
MUAC 125mm can be considered to have recovered. The child is still likely
to have a low weight-for–age because of stunting.
Management: Good feeding practices and sensory stimulation
should be continued at home. Show the parent or carer how to feed
frequently with energy and nutrient-dense foods and how to give
structured play therapy. Also, ensure that discharged children
are followed up regularly, weighed, and given booster immunizations.
Teach the danger signs that indicate when to take children to a
clinic urgently.
1. Hypoglycaemia
2. Hypothermia
3. Dehydration
4. Electrolyte
5. Infections
6. Micronutrient
7. Cautious feeding
8. Catch-up growth
9. Sensory stimulation
10. Prepare for follow-up
Please complete the question.
