75 The Acutely Unwell Malnourished Child

Priya 07/11/18

One group of kids will present acutely unwell with signs of critical illness

These children are UNWELL, start with ABCs like anything else

The other group are “uncomplicated malnutrition”. They’re getting admitted as their family are worried, or they’ve failed community management.

These children likely still get abx , but less unwell than acute kids. BUT you do need to think, am i Missing anything else?

75.1 Oedema

Mild (1) = Just feet

Moderate (2) = arms or legs

Severe (3) = everywhere

75.2 10 Steps of Management

  • Hypoglycaemia
  • Temp
  • Dehydration
  • Electrolytes
  • Infections
  • Micronutrients
  • Feeding
  • Catch up growth
  • Sensory
  • Follow up

75.2.1 Hypoglycaemia

So you will treat all empirically

Conscoius get sugar water

Not get IV and NG

75.2.2 Temperature

Wrap the baby up! (Or wrap them up under skin to skin)

Avoid burns from heaters

75.2.3 Dehydration

Conscious get ReSoMal 10ml/hr PO/NG ?????

Not get IV fluids 15ml/hr (cautiously as v high risk of fluid overload). Ringers lactate with 5% dectrose. Consider transfusion if no improvement. If no avail ??? Check numbers

ReSoMal is rehydration for malnourished kids, has less sodium.

Normal ORS may cause hypernatraemia

NG tubes are hated by mums. They associate with poor outcomes and often v resistant. “Force feeding” orally can cause an aspiration.

75.2.4 Electrolytes

Kids will generally have high sodium and low potassium. Rehydration will often fix this.

Labs will often be inaccessible.

75.2.5 Infection

Empiric Abx for all kids.

Get IV if sick.

Consider TB if child not responding to treatment (first or second line)

SCREEN FOR HIV!

Remember that kids may need deworming when stable and growing. Remember hygiene in hopsital

75.2.5.1 Measles

All babies with measles should get 200 000 units of vitamin A

Give measles vaccine to all non infected kids

Isolate properly

75.2.6 Micronutrients

Severe anaemia kids need blood. Also consider if no improvement after 24 hours

75.2.7 Feeding and Catch Up Growth

Now consider cautious feeding

Start with F-75 with low protein, low fat, low sodium, high energy and sugar, plus micronutrients. 75 = 75 cal per 100 mls

Once they’re starting to gain weight on that, switch to F-100 or RUTF (plumpynut). The advantage is RUTF can be taken home = shorter hospital stay. High protein, high fat, low sodium.

You need to have a scale, and a way to measure the kids.

75.2.8 Sensory and emotional Support

These babies need stimulating for neurodevelopment. The mums may need to relearn how to play with the kids.

Malnourished causes impaired cognition, impaired cognition causes malnourishment.

75.2.9 Preparing for Follow Up/Recovery

Keep the child for a little while, cooking lessons for mum, transitional phase.

Remember regular review, and stopping unnecessary treatment when improving (antibiotics), if they’re getting worse change your plan. It’s normal for babies to get diarrhoea on F75 and also on transition to F100. YOU NEED GOOD COMMUNICATION ON THE SKIN

75.2.10 HIV

Is a major risk factor for death. If suspected, treat empirically.

75.3 Babies under 6 months

way more vulnerable, way more likely to die

benefit from breastfeeding support

dilute F-100 with more water

These babies need an infant formula

75.4 Deaths and community opinion

Kids dying in hospital and on discharge may reduce chance of families attending. Will families attend hospital if their kid gets unwell again?