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1 Running Head
World Health Organization
Geneva
MANAGEMENT OF SEVEREMALNUTRITION:
A MANUAL FOR PHYSICIANS
AND OTHER SENIOR HEALTH
WORKERS
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1 Running Head
The World Health Organization was established in 1948 as a specialized agency of the UnitedNations serving as the directing and coordinating authority for international health matters andpub lic hea lth. One of WHOs constitutional functions is to provide ob jective and reliable informa-tion and advice in the field of human health, a responsibility that it fulfils in part through its
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i Running Head
Managementof severemalnutrition:
a m anual forphysician s and
other sen ior
health workers
World H ealth Organ izationGeneva
1999
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ii Management of severe malnutrition: a manual for physicians and other senior health workers
The World Health Organization welcomes requests for permission to reproduce or translate itspublications, in part or in full. Applications and enquiries should be addressed to the Office of
Publications, World Health Organization, Geneva, Switzerland, which will be glad to provide thelatest information on any changes made to the text, plans for new editions, and reprints andtranslations already available.
World Health Organization 1999
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pro vision s of Protocol 2 of the Un iversal Cop yright Conven tion. All rights reserved.
The designations em ployed and th e presentation o f the m aterial in this publication d o not im plythe expression of any opinion whatsoever on the part of the Secretariat of the World HealthOrganization con cerning th e legal status o f any coun try, territory, city or area or of its auth orities,or concern ing the delimitation of its frontiers or bou nd aries.
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produ cts are d istinguished by initial capital letters.
Typeset in Hong Kong
Printed in England
97/ 11527Best-set/ Clays8500
WHO Library Cataloguing in Publication Data
Managem ent of severe malnu trition: a man ual for ph ysicians and oth er senior health workers.
1.Child nutr i tion disorders therapy 2.Nutri tion disorders therapy 3.Manuals 4.Guidelines
ISBN 92 4 154511 9 (NLM Classifica tion : WD 101)
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iii Running Head
Contents
iii
Preface v
Ackn owledgem ents vi
1. Introduction 1
2. Treatment facilities 3
3. Evaluation of the malnourished child 4
3.1 Assessm ent of nutritional status and criteria for adm ission 43.2 History and physical exam ination 5
3.3 Laboratory tests 5
4. Initial treatment 7
4.1 Princip les of m anagem en t 7
4.2 Hypoglycaem ia 7
4.3 Hypotherm ia 8
4.4 Dehydration and sep tic shock 8
Diagnosis 8
Treatm ent of dehydration 9
Treatm ent of sep tic shock 12
4.5 Dietary treatm ent 12
Form ula diets for severely m aln ourished children 13
Feeding on adm ission 13
Nasogastric feeding 14
Feeding after the appetite im proves 15
Milk in toleran ce 16
Recording food in take 16
4.6 Infections 16
Bacterial in fections 16
Measles an d other viral in fection s 17
4.7 Vitam in deficiencies 17
Vitam in A deficiency 17
Other vitam in deficiencies 18
4.8 Very severe an aem ia 18
4.9 Congestive heart failu re 184.10 Derm atosis of kwashiorkor 19
5. Rehabilitation 20
5.1 Princip les of m anagem en t 20
5.2 Nutritional rehabilitation 20
Feeding children un der 24 m on ths 20
Feeding children over 24 m onths 21
Folic acid and iron 21
Assessing p rogress 22
5.3 Em otional and physical stim ulation 22
The environm en t 23
Play activities 23
Physical activities 23
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iv Management of severe malnutrition: a manual for physicians and other senior health workers
5.4 Teaching paren ts how to preven t m alnu trition from recurrin g 24
5.5 Preparation for discharge 24
Criteria for discharge 24
Appropriate diets 24
Im m unization 25
Plan n ing follow-up 25
6. Follow-up 26
7. Failure to respond to treatment 27
7.1 General p rinciples 27
7.2 Problem s with the treatm ent facility 27
Type of facility 27
Staff 28
In accurate weigh ing m achin es 28
Problem s with preparing or givin g food 28
7.3 Problem s with individual ch ildren 29
Feeding 29
In fection 30Serious u nd erlying disease 33
7.4 Learn ing from failure 34
8. Management o f malnutrition in disas ter s ituations and re fugee camps 35
8.1 General considerations 35
8.2 Establishing a therapeutic feedin g cen tre 35
Location an d capacity 35
Water supply and san itation 35
Cooking facilities and supp lies 35
Staff 35
8.3 Criteria for enrolm en t and discharge 35
8.4 Princip les of m anagem ent 36
8.5 Evaluation of the therapeu tic feeding cen tre 36
9. Malnutrition in adolescents and adults 37
9.1 Princip les of m anagem en t 37
9.2 Classification of m alnu trition 37
Adults (over 18 years) 37
Adolescen ts (1018 years) 38
9.3 History and physical exam ination 38
9.4 In itial treatm en t 38
9.5 Rehabilitation 39
9.6 Criteria for discharge 39
9.7 Failure to respond to treatm en t 39
References 40
Appendices 41
1. NCHS/ WHO norm alized reference values for weight-for-height andweight-for-length 41
2. Sam ple recordin g form 43
3. Physiological basis for treatm ent of severe m aln utrition 50
4. Com position of m ineral and vitam in m ixes 53
5. Desirab le d aily n utrien t in take du rin g in itial p hase of treatm en t 54
6. Drug dosages for treatm en t of in fection s 55
7. Toys for severely m alnourished ch ildren 58
8. Sam ple curricu lum for p lay therapy 59
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v Running Head
v
Preface
Malnutrition remains one of the most common causes of morbidity and mortality
among children throughout the world. Approximately 9% of children below 5 years of
age su ffer from wasting (weight-for-height b elow 2 standard deviations (2 SD) of
the Nationa l Cente r for Health Statistics (NCHS)/WHO reference values) and are at risk
of death or severe imp airment of growth an d psychological developm ent.
This ma nua l is based on The treatment and management of severe proteinenergy
malnutrition, which was published by WHO in 1981. Since then, many advances havebeen ma de in th e treatm ent of severe m alnutrition. An improved oral rehydration salts
(ORS) solution has been developed for the treatment of dehydration. Advances in
knowledge of the physiological roles of micronutrients have led to improved dietary
management during the initial phase of treatment. It has been shown that physical
and psychological stimulation, as well as care and affection, are necessary during the
rehabilitation phase in order to prevent retardation of growth and psychological
development.
This m anu al provides guidelines for the trea tm ent o f severely malnou rished children
(below 5 years of age) in hospitals and health centres. The treatment of severely mal-
nou rished adolescents an d ad ults is also b riefly considered. The m anu al is inten ded for
health personnel working at central and district level, including physicians, nurses,
m idwives an d a uxiliaries.
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vi Management of severe malnutrition: a manual for physicians and other senior health workers
Acknowledgements
vi
The World Health Organization is p articularly grateful to Dr M.H.N. Golden , University
of Aberd een , Aberd een , Scotland , for his exten sive con tribution to the d evelopm ent o f
the final draft of this manual. It also thanks Professor J. Waterlow, London School of
Hygiene a nd Tropical Medicine, Lon don , England , for his assistance in th e developm ent
of the initial draft. The World Health Organization also acknowledges the valuable
contributions of the many experts who assisted in the development of the manual,
including: Dr A. Ashworth , Lon don Schoo l of Hygiene an d Tropical Medicine, Londo n,Englan d; Dr M. Behar, Gene va, Switzerlan d; Ms R. Bhat ia, Office of th e Un ited Na tions
High Commissioner for Refugees (UNHCR), Geneva, Switzerland; Dr M. Bolaert,
Mdecins sans frontires, Brusse ls, Belgium ; Dr F. Chew, Institu te of Nutrition of Cen tral
Am erica an d Pan am a (INCAP), Guate ma la; Dr S. Grantha m -McGregor, Institute of Child
Health, London, England; Dr G. Lopez de Romana, Institute of Nutritional Studies,
Lima, Peru; Dr V. Reddy, National Institute of Nutrition, Hyderabad, India; Dr B.
Sch rch, Inte rnation al Dietary Energy Con sultancy Group (IDECG), Lausan ne, Switzer-
land; Dr N. Scrimshaw, United Nations University, Boston, MA, USA; and Dr B. Torun,
INCAP, Guatem ala. It is also grate ful to the st aff of hosp itals in Banglade sh, Brazil, India
and Viet Nam and Action contre la faim, Paris, France, who provided many valuable
practical comm ents on the fin al draft.
The following WHO staff m em bers provided su bstan tial techn ical cont ributions an d
com m ents: Dr K. Bailey, Programm e of Nutrition, WHO, Geneva, Switzerlan d; Dr D.
Benbouzid, Programme of Nutrition, WHO, Geneva, Switzerland; Dr G. Clugston,
Programm e of Nu trition, WHO, Geneva, Switzerland; Dr B. de Beno ist, WHO Region al
Office for Africa, Brazzaville, Congo; Dr M. de Onis, Programme of Nutrition, WHO,
Geneva, Switzerlan d; Dr O. Fontain e, Division of Child H ealth a nd Developm ent , WHO,
Geneva, Switzerland; Dr S. Khanum, WHO Regional Office for South-East Asia, New
Dehli, India; and Dr N.F. Pierce, Division of Child Health and Development, WHO,
Geneva, Switzerlan d.
The finan cial support of IDECG and UNHCR towards the developm ent and pub lica-
tion of this ma nu al is also gratefully acknowledged .
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1 Running Head
Table 1. Time-frame for the management of a child with severe malnutrition
Activity Initial treatment: Rehabilitation: Follow-up:
days 12 days 37 weeks 26 weeks 726
Treat or prevent:hypoglycaemia hypothermia dehydration
Correct electrolyte imbalance
Treat infection
Correct micronutrient deficiencies
Begin feeding
Increase feeding to recover lost weight(catch-up growth)
Stimulate emotional and sensorialdevelopment
Prepare for discharge
This manual provides practical guidelines for the management of patients with severe
malnutrition.1
It seeks to prom ote the b est available thera py so as to reduce th e risk of
deat h, shorten th e length of time spen t in hospital, and facilitate reha bilitation an d full
recovery. Emph asis is given here to th e ma na geme nt of severely m alnou rished children;
the m anagem ent of severely malnourished ad ults and adolescents is also con sidered
briefly.
Severe malnutrition is both a medical and a social disorder. That is, the medicalproblems of the child result, in part, from the social problems of the h ome in which the
child lives. Malnutrition is the end result of chronic nutritional and, frequently, emo-
tional deprivation by carers who, because of poor understanding, poverty or family
problems, are una ble to provide th e child with the n utrition a nd care he or she requires.
Successful m anagem ent of the severely ma lnourished child requ ires that both med ical
an d social problem s be recognized an d corrected . If the illness is viewed as being on ly a
med ical disorder, the child is likely to relapse when he o r she return s hom e, and other
children in th e family will remain a t risk of developin g the sam e prob lem.
1.
Introduction
1
1 Malnutrition and malnourished are used as synonyms of undernutrition and under-
nourished, respectively.
without iron with iron
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2 Management of severe malnutrition: a manual for physicians and other senior health workers
Management of the child with severe malnutrition is divided into three phases.
These are:
Initial treatment: life-threatening problems are identified an d treated in a h ospital
or a residen tial care facility, specific deficiencies are corrected, m etab olic abn orm ali-ties are reversed an d feeding is begun .
Rehabilitation:intensive feeding is given to recover most of the lost weight, emo-
tional and p hysical stimulation are increased, the m other or carer is trained to con-
tinue care at h ome, an d p reparations are mad e for discharge of the child.
Follow-up:after discharge, the ch ild an d th e childs family are followed t o pre vent
relapse an d assure the continued physical, men tal and em otional developmen t of the
child.
A typical time-frame for the management of a child with severe malnutrition is
shown in Table 1.
Successful man agem ent of the severely m alnou rished child does not requ ire soph is-
ticated facilities and equ ipm en t or highly qu alified p ersonn el. It does, however, require
that each child be treated with proper care and affection, and that each phase of treat-men t be carried out p roperly by approp riately trained and dedicated health workers.
When this is done, the risk of death can be substantially reduced 1 and the opportunity
for full recovery greatly improved.
1 For the p urpo ses of this ma nu al, a case-fatality rate of>20% is considered unacceptable, 1120%
is poor, 510% is mod erate, 14% is good a nd39.5 C or 103 F), an tipyretics should
be given.
4.7 Vitamin deficiencies
Vitamin A deficiency
Severely m alnou rished children a re at high risk of developin g blind ness du e to vitamin
A deficiency. For this reason a large dose of vitam in A shou ld be given routin ely to all
malnou rished children on day 1, un less there is definitive evidence that a dose has b een
given during the past month. The dose is as follows:1
50000 International Units (IU)
orally for infan ts 12 mon ths o f age. If there are an y clinical signs of vitam in
A de ficien cy (e.g. nigh t blind ne ss, conjun ctival xerosis with Bitots spots, corn eal xerosis
or ulceration , or keratom alacia), a large dose sho uld b e given on the first 2 days, followed
by a third d ose at least 2 weeks later (see Table 10). Oral treatm en t is preferred, except a t
the beginning in children with severe anorexia, oedematous malnutrition or septic
shock, who should b e given IM treatment. For oral treatmen t, oil-based p reparations are
1 The international standard (or reference preparation) of vitamin A has been discontinued.However, the international units for vitamin A are still used extensively, particularly in the
labelling of capsules and injectable preparations.
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18 Management of severe malnutrition: a manual for physicians and other senior health workers
preferred, but water-miscible formulations may be used if oil-based formulations are
not a vailable. Only water-m iscible form ulations shou ld be used for IM treatm ent .Great care must be taken during examination of the eyes, as they easily rupture in
children with vitamin A deficiency. The eyes should be examined gently for signs of
xerophth almia, corneal xerosis and ulceration , cloud iness and kerat om alacia. If there is
ocular inflammation or ulceration, protect the eyes with pads soaked in 0.9% saline.
Tetracycline e ye drop s (1%) shou ld be instilled four tim es da ily un til all signs of inflam -
m ation or u lceration resolve. Atropin e eye drops (0.1%) should also be app lied an d the
affected eye(s) shou ld be ban daged , as scratching with a finger can cau se ruptu re of an
ulcerated cornea. More details on the management of vitamin A deficiency are given
elsewhere (5, 6).
Other vitamin deficiencies
All m alnou rished children sh ould receive 5m g of folic acid orally on d ay 1 an d the n 1 m g
orally per day thereafter. Many malnourished children are also deficient in riboflavin,
ascorbic acid, pyridoxine, thiamine and the fat-soluble vitamins D, E and K. All diets
shou ld be fortified with th ese vitam ins by addin g the vitamin m ix (see App en dix 4).
4.8 Very severe anaemia
If the haemoglobin concentration is less than 40g/l or the packed-cell volume is less
than 12%, the child has very severe anaemia, which can cause heart failure. Children
with very severe anaemia need a blood transfusion. Give 10ml of packed red cells or
whole blood p er kg of bod y weight slowlyover 3 hou rs. Where testing for HIV an d viral
hepatitis B is not possible, transfusion should be given only when the haemoglobin
concentration falls below 30g/l (or packed-cell volume below 10%), or when there aresigns of life-thre aten ing he art failure. Do notgive iron du ring the initial phase o f treat-
m ent, as it can have toxic effects and m ay reduce resistance to infection.
4.9 Congestive heart failure
This is usu ally a com plication of overhydration (especially when an IV infusion or stan -
dard ORS solution is given ), very severe an aem ia, blood or p lasma tra nsfusion, or giving
a diet with a high sodium content. The first sign of heart failure is fast breathing (50
breaths per m inute or m ore if the child is aged 2 month s up to 12 mon ths; 40 breaths per
m inute o r mo re if the ch ild is aged 12 m ont hs up to 5 years). Later signs are respiratory
distress, a rapid pulse, engorgement of the jugular vein, cold hands and feet, and
cyanosis of the fingertips and under the tongue. Heart failure must be differentiated
Table 10. Treatment of clinical vitamin A deficiency inchildren
Timing Dosagea,b
Day 1:12 months of age 200 000 IU
Day 2 Same age-specific dose
At least 2 weeks later Same age-specific dose
a For oral administration, preferably in an oil-based preparation, except in children withsevere anorexia, oedematous malnutrition or septic shock.
b See footnote on page 17.
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19 4. Initial treatment
from respiratory infection and septic shock, which usually occur within 48 hours of
adm ission, whereas he art failure usually occurs som ewha t later.
When heart failure is caused by fluid overload, the following measures1
should be
taken:
1. St op alloral inta ke and IV fluids; the treatm ent of heart failure takes preced en ce over
feeding the child. No fluid shou ld be given u ntil the hea rt failure is impro ved, even if
this takes 2448 hours.
2. Give a diuretic IV.2 The most a pprop riate choice is furosemide (1 mg/ kg).
3. Do no t give digitalis un less the d iagnosis of heart failure is un equ ivocal (jugular
venou s pressure is elevated ) andthe p lasma potassium level is normal. In that case,
5 g/ kg of bo dy weight o f digoxin m ay be given IV as a sin gle dose, or o rally, if th e IV
preparation is not available.
4.10 Dermatosis of kwashiorkor
This is characterized by hypo- or hyperpigmentation, shedding of the skin in scales or
sheets, and u lceration of the skin of the perineum , groin, limbs, behind the ea rs and
arm pits. There m ay be widesp read weep ing skin lesions which ea sily becom e infected.
Spontaneous resolution occurs as nutrition improves. Atrophy of the skin in the
perineum leads to severe diaper dermatitis, especially if the child has diarrhoea. The
diape r area should be left unco vered. If the diap er area becom es colon ized with Candida
spp., it should be treated with nystatin ointment or cream (100000IU (1g)) twice daily
for 2 weeks and the ch ild sh ould b e given oral nystatin (100000 IU four tim es daily). In
other affected areas, application of zinc and castor oil ointment, petroleum jelly or
paraffin gauze dressings helps to relieve pain and prevent infection. The zinc supple-
men t contained in the mineral mix is particularly imp ortant in these children, as they
are u sually severely deficient.
Bath e the affected area s in 1% pota ssium perm an ganat e solution for 1015 m inute s
daily. This dries the lesions, helps to prevent loss of serum, and inhibits infection.Polyvidone iodine, 10% ointment, can also be used. It should be used sparingly, how-
ever, if the lesions are e xtensive, as the re is significan t systemic ab sorption .
All children with kwashiorkor-related derm atosis shou ld receive systemic an tibiotics
(see section 4.6).
1 There is no reported experience in malnourished children of angiotensin-converting enzymeinhibitors or other drugs used to treat con gestive heart failure.
2
Diuretics sh ould neverbe used to reduce oedema in malnourished children.
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20 Management of severe malnutrition: a manual for physicians and other senior health workers
20
5.
Rehabilitation
The child is deem ed to h ave entered the rehabilitation phase when his or her appetite
has returned. A child who is being fed by NG tub e is notconsidered ready to enter the
rehabilitation pha se.
5.1 Principles of management
The principal tasks during the rehabilitation phase are:
to encourage the child to eat as much as possible;
to re-initiate and/ or encourage breastfeeding as necessary;
to stimulate emotional and physical developmen t; and
to prepare the m other or carer to continue to look after the child after discharge.
The child shou ld remain in hospital for the first part of the reha bilitation pha se.
When allthe criteria in the box below have been met (usually 23 weeks after admis-
sion), the ch ild can be tran sferred to a n utrition rehabilitation centre.
Criteria for transfer to a nutrition rehabilitation centre Eating well
Mental state has improved: smiles, responds to stimuli, interested in surroundings Sits, crawls, stands or walks (depending on age) Normal temperature (36.537.5C) No vomiting or diarrhoea No oedema Gaining weight: >5 g/kg of body weight per day for 3 successive days
5.2 Nutritional rehabilitation
The most impo rtant determ inant of the rate of recovery is the am oun t of energy con-
sumed. However, at the start of the rehabilitation phase, the child is still deficient in
protein an d various m icronu trients, including potassium , magnesium, iron an d zinc.
These must also be given in increased amou nts. Infants und er 24 month s can be fedexclusively on liquid o r sem i-liquid formu las. It is usua lly app ropriate to intro du ce solid
foods for older ch ildren .
Feeding children under 24 months
During reha bilitation, F-100 diet shou ld be given e very 4 hou rs, night a nd day. Tran si-
tion to the reh abilitation p hase involves increasing the am oun t of diet given at each feed
by 10m l (e.g. if the first feed is 60m l, the second should be 70m l, the th ird 80m l, and so
on) un til the ch ild refuses to finish the feed.
When a feed is not finished, the same am oun t should be offered at th e next feed. If
that feed is finished, the amount offered for the following feed should be increased by
10 m l. Continu e this process un til som e food is left after most feeds. The am oun t being
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21 5. Rehabilitation
offered should th en b e dispensed for the child at each feed on subsequen t days. The
amo unts of each feed offered an d taken shou ld be recorded on the feeding chart (Ap-
pend ix 2) and any food not taken shou ld be discarded; neverreuse it for the n ext feed.
During rehabilitation mo st children take between 150 and 220 kcalth/ kg (630920 kJ/ kg)
per d ay. If inta ke is below 130kcalth or 540kJ/kg per d ay, the child is failing to resp on d
(see section 7).
The attitud e of those feeding the ch ild is crucial to success. Sufficien t time m ust be
spent with th e child to enab le him or h er to finish each feed. The child m ust be actively
encouraged to eat while sitting comfortably on the mothers or nurses lap. Children
must neverbe left alon e to take what th ey want.
During the first few days of reha bilitation, children with oede m a m ay not gain weight,
despite an adequate intake. This is because oedema fluid is being lost while tissue is
being restored. Thus, progress in these children is seen as decreased o edem a rather than
rapid weight gain. If the ch ild is neither gaining weight n or showing decreased oed em a,
or if there is increa sing oedem a, the child is failing to respo nd (see section 7).
F-100 should be continued until the child achieves 1 SD (90%) of the median
NCHS/ WHO referen ce values for weight-for-height (see App end ix 1). When this occu rsappetite dim inishes an d increasing amou nts of food a re left un eaten. The child is now
ready for the discharge ph ase of treatment.
Feeding children over 24 months
Children over 24 months can also be successfully treated with increasing quantities of
F-100; it is not essential to u se a d ifferent d iet. This has p ractical value in refugee cam ps
where it is important to keep the num ber of different diets to a m inimum . For most older
children, however, it is app ropriate to int rodu ce solid food, especially for tho se who wan t
a m ixed d iet. Most traditiona l mixed d iets have a lower energy conten t tha n F-100. They
are also relatively deficient in minerals, particularly potassium and magnesium, and
contain sub stances which inhibit the absorption of zinc, copper an d iron. Moreover, the
diets are u sually deficient in various vitam ins. Thu s, local food s shou ld be fortified to
increase their content o f energy, minerals and vitamins. Oil should be added to increase
the en ergy content, an d the mineral and vitamin m ixes used in F-100 should be add ed
after cooking (see section 4.5 and Appen dix 4). Other ingred ients, such a s dried skimm ed
milk, may also be a dded to increase the protein an d m ineral conten t. The en ergy content
of mixed diets shou ld be at least1kcalth or 4.2kJ/ g.
To avoid the effects of food substances which reduce the absorption of minerals,
F-100 should b e given between feeds o f the m ixed d iet. For examp le, if the m ixed d iet
is given th ree tim es da ily, F-100 should also b e given three times d aily, ma king six feeds
a day. Water intake is not usually a problem in children over 2 years because they can
ask for it when they are th irsty.
At the b eginning of rehabilitation , the children sho uld be fed every 4 hou rs, day and
night (six feeds p er 24 hou rs). When th ey are growing well an d a re no longer at risk ofdeveloping hypotherm ia or hypoglycaem ia, one of the n ight-time feeds can be om itted,
making five feeds per 24 hours. This allows the child longer undisturbed sleep and
m akes it much easier to m ana ge the child as a day-pa tient. It is also less taxing for those
caring for the child.
Folic acid and iron
Nearly all severely malnourished children have anaemia and should be given supple-
mentary folic acid and iron. They should also continue to receive the vitamin and
mineral mixes in their food throughout rehabilitation.
Iron should neverbe given during the initial phase of treatmen t, but m ust be given
during the rehabilitation phase. It should only be given orally, never by injection.
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22 Management of severe malnutrition: a manual for physicians and other senior health workers
Children with m oderate or severe anaem ia should be given elemental iron, 3 mg/ kg per
day in two divided doses, up to a maximum of 60mg daily, for 3 months ( 7). It is
preferable to give iron sup plements between meals using a liquid preparation.
All children must be given 5mg of folic acid on day 1 and then 1mg per day
thereafter.
Assessing progress
The child should be weighed daily and the weight plotted on a graph (see Fig. 1 and
App end ix 2). It is useful to ma rk the p oint th at is equivalent to 1 SD (90%) of the m edian
NCHS/ WHO referen ce values for weight-for-height on the grap h, which is the ta rget
weight for discharge. The usua l weight gain is abou t 1015 g/ kg per da y. A child who
does not gain at least 5 g/ kg per day for 3 consecu tive da ys is failing to respon d to
treatment (see section 7). With high-energy feeding, most severely malnourished
children re ach their target weight for discharge a fter 24 weeks.
5.3 Emotional and physical stimulation
Severely malnourished children have delayed mental and behavioural development,
which, if not treated, can becom e the most serious long-term result of malnutrition.
Emotional an d p hysical stimulation through p lay programm es that start du ring reha-
bilitation and continue after discharge can substantially reduce the risk of perman ent
men tal retardation and emotional imp airment.
Fig. 1 An example of a weight chart for a severely malnourished boy
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23 5. Rehabilitation
Care must be taken to avoid sensory deprivation. The childs face must not be
covered; the child m ust be able to see and h ear what is happen ing around h im or her.
The child should neverbe wrapped or tied to prevent him or her moving around in
the cot.
It is essential that the mother (or carer) be with her child in hospital and at the
nutrition rehabilitation centre, and that she be en couraged to feed, hold, comfort and
play with h er child as mu ch as p ossible. The num ber of other ad ults who interact with
the ch ild sho uld be a s few as possible. Each a du lt should talk, smile and show affection
towards the child. Medical procedures, such as venepu ncture, should be done by the
m ost skilled p erson a vailable, preferably out o f earsho t an d sight of the ot her ch ildren .
Immed iately after any un pleasant procedure th e child shou ld be held an d com forted.
The environment
The austerity of a traditional hospital has n o place in th e treatm ent of m alnourished
children. Rooms should be brightly coloured, with decorations that interest children.
Colourful mobiles should be hung over every cot, if possible. The staff should wearnorm al clothing rather than uniforms. Brightly coloured a prons m ay be used to protect
their clothing. A radio can provide background music. The atmosphere in the ward
should be relaxed, cheerful and welcoming.
Toys shou ld always be a vailable in th e childs cot an d roo m , as well as in th e play
area; they should be changed frequently. Toys should be safe, washable and app ropriate
for the childs age and level of development. Inexpensive toys made from cardboard
boxes, plastic bottles, tin cans an d similar m aterials are best, becau se moth ers can copy
them . Examp les of suitable toys are described in App end ix 7.
Play activities
Malnou rished children ne ed interaction with oth er children d uring rehab ilitation. After
the initial phase of treatment, the child should spend prolonged periods with other
children on large play mats, and with th e m other or a play guide. The ch ild can also be
fed in the p lay area. These activities do n ot increase the risk of cross-infection a pp re-
ciably an d the b ene fit for the ch ild is sub stantial.
One person, usually a nurse or volunteer, should be responsible for developing a
curriculum of play activities and for leading the play sessions. Activities should be
selected to develop both motor and language skills, and new activities and materials
shou ld be introdu ced regularly. One aim sho uld be to p lay with each ch ild, individu ally,
for 1530 minu tes each d ay, in add ition t o informal group p lay. A sam ple curriculum of
play activities, arran ged b y level of developm ent , is provided in App end ix 8. Mothers can
be train ed to su pervise play session s.
Learn ing throu gh play shou ld be fun for children . A childs efforts to p erform a t ask
shou ld always be p raised an d n ever criticized. When a ch ild is taught a skill, the n urse orvolun teer shou ld dem on strate the skill first, then help th e child do it, an d fina lly let the
child d o it alone. This sequence should be repeated un til the ch ild h as m astered the skill.
Physical activities
Physical activities promote the development of essential motor skills and may also
enhance growth during rehabilitation. For those children who are unable to move,
passive limb m ovements an d splashing in a warm b ath a re helpful. For other children,
play should include su ch activities as rolling on a m attress, runn ing after an d tossing a
ball, climbing stairs, and walking. The duration and intensity of physical activities
shou ld increa se as the childs nut rition al status and gen eral condition im prove. If there
is sufficient space, an outdoor p layground sho uld be developed.
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24 Management of severe malnutrition: a manual for physicians and other senior health workers
5.4 Teaching parents how to prevent malnutrition from recurring
All parents should know how to prevent malnutrition from recurring. Before the child
is discharged, ensure th at the p arents or carers und erstand the causes of malnutrition
and how to prevent its recurrence, including correct feeding and continuing to stimulatethe childs mental and emotional development. They must also know how to treat,
or obtain treatmen t for, diarrhoea and other infections, and un derstand the importance
of regular (every 6 months) treatment for intestinal parasites. The parents have much
to learn; teaching them should not be left until a few days before the child is
discharged.
The moth er (or carer) should spend as mu ch time as possible at the n utrition reha -
bilitation centre with her child. This may be facilitated by providing the mother with
money for transportation and meals. The mother, in turn, should help prepare her
childs food, and feed and look after her child. A rotation of mothers may also be
organized to h elp with general activities on th e ward, includin g play, cooking, feedin g,
bathing an d ch anging the children, under supervision. This will enab le each m other to
learn ho w to care for her child at ho m e; she will also feel that sh e is contributin g to the
work of the cen tre. Teach ing of mo thers shou ld includ e regular sessions at which impo r-
tant p arenting skills are dem onstrated an d p ractised. Each m other should be taught the
play activities that are a pp ropriate for her child, so that she a nd o thers in th e fam ily can
continue to make toys and play with the child after discharge.
The staff must be friendly and treat the mothers as partners in the care of the
children. A mother should never be scolded, blamed for her childs problems, humili-
ated or m ade to feel un welcome. Moreover, helping, teaching, counselling and b efrien d-
ing the moth er are an essential part of the long-term treatm ent of the child.
5.5 Preparation for discharge
During rehabilitation, preparations should be made to ensure that the child is fully
reintegrated in to the fam ily and com m un ity after discha rge. As the childs hom e is the
environment in which severe malnutrition developed, the family must be carefully
prep ared to preven t its recurrence. If possible, the childs hom e shou ld be visited by a
social worker or nurse before discharge to ensure that adequate home care can be
provided. If the ch ild is aban doned or conditions at the childs hom e are u nsuitable,
often b ecause of death or absen ce of a carer, a foster hom e should be sou ght.
Criteria for discharge
A child may be con sidered to h ave recovered and be read y for discharge when the ch ilds
weight-for-height ha s reached 1 SD (90%) of the m edian NCHS/ WHO referen ce values
(see Appendix 1). To achieve this goal, it is essential that the child receives as many
meals as possible per day. In some instances, a child m ay be discharged before he or sh e
has reached the target weight-for-height for discharge; however, since the child is notyet recovered, he or she will need continuing care (as an outpatient). To en sure that
relapse does n ot occur, it is imp ortant tha t allthe criteria listed in Table 11 have been
m et before the child is discharged.
Appropriate diets
During rehabilitation the child should be fed at least five times daily. After reaching
1 SD of the m edian NCHS/ WHO reference values, the child should be fed at least three
times da ily at hom e. Adjustm ent to th is chan ge in frequen cy of feeding should take place
un der sup ervision before discharge. This is don e by gradually redu cing and e ventua lly
stopping the supplemen tary feeds of F-100 and adding or increasing the m ixed d iet until
the ch ild is eating as he or she will at ho m e.
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25 5. Rehabilitation
Table 11. Criteria for discharge from non-residential care
Criteria
Child Weight-for-height has reached 1 SD (90%) of NCHS/WHO median
reference values
Eating an adequate amount of a nutritious diet that the mother canprepare at home
Gaining weight at a normal or increased rate
All vitamin and mineral deficiencies have been treated
All infections and other conditions have been or are being treated,including anaemia, diarrhoea, intestinal parasitic infections, malaria,tuberculosis and otitis media
Full immunization programme started
Mother or carer Able and willing to look after the child
Knows how to prepare appropriate foods and to feed the child
Knows how to make appropriate toys and to play with the child
Knows how to give home treatment for diarrhoea, fever and acuterespiratory infections, and how to recognize the signs that mean shemust seek medical assistance
Health worker Able to ensure follow-up of the child and support for the mother
Before discharge, the m other (or carer) must p ractise preparing the recomm ended
foods an d feeding them to the child. It is essential that the m other dem onstrates that she
is able an d willing to d o these tasks, and that she und erstands the im portance o f con-
tinued correct feeding for her child. Appropriate mixed diets are the same as those
normally recommended for a healthy child. They should provide at least 110kcal th or
460 kJ/ kg per day and also sufficient vitamins an d m inerals to supp ort continued
growth. Breast-feeding should be con tinue d; anima l m ilk is also an imp ortan t source of
energy and protein. Solid foods should include a well-cooked staple cereal, to which
vegetable oil should be added (510ml for each 100g serving) to enrich its energy
cont ent. The cereal shou ld be soft and m ashed ; for infants u se a thick pap . A variety of
well-cooked vegetab les, including oran ge and dark-green leafy ones, shou ld be given. If
possible, includ e fruit, meat, eggs or fish. The m oth er shou ld be enco uraged to give the
child extra food between meals.
Immunization
Before discharge, the ch ild shou ld be imm un ized in accordance with n ational guide-lines. The mother should be informed of where and when to bring the child for any
required booster doses.
Planning follow-up
Before discharge, m ake an a pp ointm en t to see the ch ild 1 week after discharge. Follow-
up visits shou ld preferably take place at a spe cial clinic for malnou rished children , not at
a gene ral paed iatric clinic.
If possible, arrange for a health worker or field nurse trained to provide practical
advice on health and nutrition to visit the family at home. Also arrange for a social
worker to visit the family, in order to find a way of solving the familys social and
economic problems.
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26 Management of severe malnutrition: a manual for physicians and other senior health workers
26
6.
Follow-up
Although m uch im proved at the tim e of discharge, the child usually rema ins stunte d an d
men tal developm ent is delayed. Management of these conditions an d p reventing the
recurrence of severe malnutrition requires sustained improvement in feeding of the
child and in oth er paren ting skills. Plann ed follow-up of the ch ild at regular intervals
after discharge is essential. This shou ld include an efficient strategy for tracing children
who fail to atten d follow-up app ointm ents. Such children are at increased risk of recur-
rence of ma lnutrition or o f developing other serious illnesses.As the risk of relapse is greatest soon after discharge, the child shou ld be seen a fter 1
week, 2 weeks, 1 m ont h, 3 mon ths an d 6 m ont hs. Provided th e childs weight-for-height
is no less than 1 SD (90%) of the m edian NCHS/ WHO reference values, p rogress is
considered satisfactory. If a problem is foun d, visits shou ld be m ore frequen t un til it is
resolved. After 6 months, visits should be twice yearly until the child is at least 3 years
old. Children with frequent problems should remain under supervision longer. The
moth er should know the location and regular opening hou rs of the nearest nutrition
clinic and be en couraged to b ring her child witho ut an app ointm ent if the child is ill or
a previous app ointmen t was missed.
At each visit the mother should be asked about the childs recent health, feeding
practices and p lay activities. The child shou ld be examined , weighed and m easured, an d
the results recorded (see App end ix 2). Any n eeded vaccine shou ld be given. Trainin g of
the mother should focus on areas that need to be strengthened, especially feeding
practices, and mental and physical stimulation of the child. Attention should also be
given to feeding practices for other children in the fam ily, and for pregnan t or lactating
wome n, as these are likely to be ina dequ ate. If vitam ins or m edicines are needed , they
should be p rovided.
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27 7. Failure to respond to treatment
27
7.
Failure to respond to treatment
7.1 General principles
When the treatment guidelines in this manual are followed, a severely malnourished
child without comp lications should show definite signs o f imp rovemen t within a few
days and should con tinue to improve thereafter. Failure to achieve initial improvemen t
at the expected rate is termed primary failure to respond, whereas deterioration of the
childs condition, when a satisfactory respon se has been established, is term ed second-
ary failure to respond.
A child who meets any of the criteria in Table 12 should be diagnosed as failing to
respond. When this diagnosis is mad e it is essential that practices in the trea tm ent u nit
are carefully reviewed and the child is thoroughly re-evaluated. The objective is to
identify the cause for failure to respond and to correct the problem by making specific
changes to p ractices in the u nit or to th e childs treatmen t. Treatmen t should n ever be
changed blindly; this is more likely to be harmful than to help the child. The most
frequent causes of failure to respond are listed in the box below and considered in
section s 7.27.3.
Frequent causes of failure to respond
Problems with the treatment facility: Poor environment for malnourished children Insufficient or inadequately trained staff Inaccurate weighing machines Food prepared or given incorrectly
Problems of individual children: Insufficient food given Vitamin or mineral deficiency Malabsorption of nutrients Rumination Infections, especially diarrhoea, dysentery, otitis media, pneumonia, tuberculosis,
urinary tract infection, malaria, intestinal helminthiasis and HIV/AIDS Serious underlying disease
7.2 Problems with the treatment facility
Type of facility
Failure to respond is more likely when a malnourished child is treated in a general
paediatric ward than in a special nutrition unit. This is because the risk of cross-
infection is increased in a gen eral ward, it is mo re difficult to p rovide th e ne cessary care
and attention, and staff are less likely to have the essential skills and attitudes for
management of malnourished children. Wherever possible, malnourished children
should be managed in a special nutrition unit. If this is not possible, they should be
treated in a sp ecially designa ted area o f a paed iatric ward, by staff specifically trained in
the treatm ent of severe m alnutrition.
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28 Management of severe malnutrition: a manual for physicians and other senior health workers
Table 12. Criteria for failure to respond to treatment
Criteria Time after admission
Primary failure to respond:Failure to regain appetite Day 4Failure to start to lose oedema Day 4Oedema still present Day 10Failure to gain at least 5g/kg of body weight per day Day 10
Secondary failure to respond:Failure to gain at least 5 g/kg of body weight per day During rehabilitation
for 3 successive days
The special nutrition unit must, however, be well organized. If essential food sup-
plies or med ications are n ot available, weighing scales do n ot work prop erly, diagnostic
facilities or administrative procedures are inadequate, or there are insufficient trainedstaff, treatment failure and mortality will be high. An effective management system
shou ld ensure careful mon itoring of each ch ild, prop er training of nu rses and au xiliary
staff, use of the m ost experienced staff as sup ervisors, reliable supp lies of drugs an d food
supplemen ts, and reliable record-keeping.
Staff
Experienced staff (including junior staff) who understand the needs of malnourished
children and are familiar with the important details of their m anagem ent a re essential
for a well-functionin g treatm ent facility. It is imp ortan t, therefore, tha t loss of experi-
ence d staff be avoided whe rever possible. For th is reason, staff of the treat m ent facility
should nottake pa rt in the rou tine rotation of staff that is practised in m an y hospitals. If
staff must be changed, this should be done one person at a time so as to minimize
disruption of routines in th e facility.
The attitude of staff towards a p articular child can determine whether treatm ent of
the child will succeed or fail. If staff believe that a child is beyond helping, th ey ma y give
less attention to the ch ild. Such children often fail to respond to treatm ent, which seems
to con firm t he o pinion of the staff. This clinical prejudice ma y be difficult to correct,
especially when it reflects the views of the m ost experienced staff. It is essential tha t staff
are rem inded frequen tly that each childs well-being depen ds on their efforts and that
every child mu st be given th eir full attention .
Inaccurate weighing machines
Machine s used for weighing children ea sily becom e inaccu rate an d, thu s, give m islead-ing inform ation on the p rogress of children in th e facility. Weighing ma chine s mu st be
checked and adjusted daily following a standard procedure. Records of daily checks
shou ld be kept. Weighing mach ines used for preparing food or for mea suring the ingre-
dients of the m ineral mix should be checked and adjusted weekly.
Problems with preparing or giving food
Standa rd hygiene practices should b e used when storing, preparing and han dling food
in the kitchen of the hospital or nutrition rehabilitation centre. Hands shou ld be washed
with soap after defecation and before food is handled. Foods should be thoroughly
cooked an d served prom ptly. Any cooked food tha t will be stored for more tha n 2 hou rs
shou ld be refrigerated (after allowing it to cool to room tem pera ture) and re -hea ted un til
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29 7. Failure to respond to treatment
it is thorou ghly hot (and t hen allowed to cool) before be ing served. Persons with infec-
tions on their hands should not han dle food.
Each p erson involved in p reparing food shou ld be checked to en sure that th ey are
following the co rrect proce du res for weighing, measu ring, mixing, cooking an d storing
the food. Observe the feeds being made; check that the recipes are correct and all
ingredients are added .
Ensure that sufficient time is allocated to feeding each child and that there are
eno ugh staff, day and n ight, for this task. Rem em ber th at feeding a malno urished ch ild
takes more time an d p atience than feeding a no rmal child. If it is assumed that it takes
about 15 minutes to feed ea ch child and that food is given every 3 hours, one person is
nee ded , day and n ight, to feed 12 children. When food is given every 2 hou rs, more staff
are ne eded . If there a re no t eno ugh staff, treatme nt of a child may fail because insuffi-
cient time is taken for feeding. Having the m othe r help with feeding her ch ild can relieve
this situation.
7.3 Problems with individual children
Feeding
Is enough food being given?
Recalculate the food requiremen t for the child. Ensure that the correct amoun t is being
offered at the required times, and that the a mou nt taken by the child is measured an d
recorded accura tely. Observe the m easurin g and giving of food. Check the ca lculation of
the daily energy inta ke of the ch ild. Review the feedin g guidelines in sections 4.5 and 5.2,
giving pa rticular attent ion to feeding du ring the n ight, as this is often d one less well tha n
during the day.
A child treated at a nutrition rehabilitation centre m ay fail to respond because th e
feeds p rovided at ho m e are too few or too small, or incorrectly prep ared . Such failures
usua lly ind icate th at th e family was not ad equ ately counselled initially. If, desp ite cor-
rective me asures, the child fails to respon d, the child should be read m itted to hosp ital.
Are sufficient vitamins and minerals being given?
Nutrient deficiency can result from the increased requ irements related to th e synthesis
of new tissue du ring rapid growth. When this hap pen s, there is usu ally an initial period
of rapid growth, after which growth slows or stops even thou gh food int ake is adeq uate .
Deficiencies of potassium, magnesium, zinc, copper or iron may be responsible. Diets
are often deficient in these m inerals and com mercial vitamin and mineral preparations
do not provide th em in sufficient am oun ts for severely malnou rished children. This
problem can be avoided by ensuring that th e m ineral and vitamin mixes described in
App end ix 4 are ad ded to th e childs food every day.
Is the child ruminating?
Rum ination is a condition tha t occurs in up to 10% of severely m alnou rished, emotion -
ally im paired ch ildren . It shou ld be susp ected wh en a child eats well, but fails to gain
weight. Children with th is condition regurgitate food from the stom ach into the m outh,
and then vomit part of it and swallow the rest. This usually happens when they are
igno red, so it ma y no t be observed. Such ch ildren are usu ally thought to h ave vom iting
without diarrhoea because they often smell of vomit, and may have vomit-stained
clothes or bedding. They are often unusually alert and suspicious, may make stereo-
typed chewing movemen ts, and do not ap pear distressed by vomiting.
Rum ination is best treated by staff m em bers who ha ve experien ce with this prob lem
and give special attention to the child. They need to show disapproval whenever the
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30 Management of severe malnutrition: a manual for physicians and other senior health workers
child b egins to rum inate, without being intimidating, and to encou rage other less harm -
ful beh aviours.
InfectionUnrecognized infections are a frequent cause of failure to respond. Those most often
overlooked include pneumonia, urinary tract infection, otitis media and tuberculosis.
Others includ e m alaria, dengue , viral hepatitis B an d HIV infection. Children who fail to
respon d to treatm ent sh ould be investigated for infection as follows:
1. Exam ine the child carefully. Measure the ch ilds temp erature, pulse rate and respira-
tion rate every 3 hou rs. As already men tioned , infection in a m alnou rished child often
causes hypothermia.
2. If possible, obtain a ch est X-ray. Exam ine the u rine for pus cells. Examine a nd cu lture
the sputum or a tracheal aspirate for tubercle bacilli. Examine the stool for signs of
blood, Giardiatroph ozoites or cysts and Strongyloides stercoralislarvae, and cu lture
for bacterial path ogens. Culture th e blood an d test for the p resence of viral hep atitis
B and m alaria. Exam ine and culture the cerebrospinal fluid.
Specific infections are d iscussed below.
Persistent diarrhoea
This is diarrhoea that occurs every day for at least 14 days. Weight loss is common.
ReSoMal shou ld be given to p revent or tre at d ehydration (see section 4.4). If the stool
cont ains visible blood, treat th e child with an oral antim icrobial that is effective against
most local strains ofShigella (see treatment guidelines for dysentery below). If cysts
or trophozoites ofGiardia are found in the stool, treat the ch ild with m etronidazole,
5 m g/ kg orally three times d aily for 5 days. Blind an timicrobial therap y, however, is
ineffective and should not be given. Every child with persistent diarrhoea should be
examined for non-intestinal infections, such as pneumonia, sepsis, urinary tract infec-
tion and otitis media. Antimicrobial treatment of these infections should follow stan-
dard guidelines. Antidiarrh oeal drugs shou ld neverbe u sed. Such dru gs are not effective
in children an d some m ay be dangerous.
Feeding guidelines are th e sam e as for severe malnu trition. Breast-feeding should be
cont inued as often and for as lon g as the ch ild wan ts. Milk into lerance is rare when th e
recommended feeding guidelines for malnutrition are followed. However, if it occurs
(see section 4.5), replace the animal milk with yoghurt or a commercial lactose-free
formula. Persistent d iarrhoea u sually resolves when the ch ild be gins to gain weight.
Further d etails of treatmen t of diarrhoe a are available elsewhere (8).
Dysentery
This is diarrhoea with visible blood in the stool. Shigella is the most frequent cause,
especially of cases that are severe. Treatment is with an oral antibiotic to which most
local strains ofShigella are sensitive. Unfortunately, the choice of antimicrobials for
treatm ent o f shigellosis has narro wed con siderably in recen t years as the p revalence of
antimicrobial resistance has increased. Resistance to ampicillin and cotrimoxazole
(sulfamethoxazole + trimethoprim), formerly the drugs of choice, is now widespread.
Nevertheless, cotrimoxazole (25mg of sulfamethoxazole + 5mg of trimethoprim/kg
orally twice daily for 5 d ays) and, in a few areas, am picillin (25m g/ kg four times d aily for
5 days) ma y still be effective against m ost en dem ic strains. Nalidixic acid (15m g/ kg four
times d aily for 5 da ys), which was formerly reserved for th e treatm ent of resistant cases
of shigellosis, is now th e dru g of choice in m an y areas. If there is no im provem ent (less
blood in the stool or passage of fewer stools) after 2 days, the antibiotic should be
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31 7. Failure to respond to treatment
changed to another to which local strains ofShigella are sensitive (see Appendix 6).
Accordingly, health facilities in a reas whe re the re is a high inciden ce of bloody diarrho ea
should ensure that several antimicrobials known to be effective against most local
strains ofShigellaspp. are kept in stock.
Amoebiasis. Am oeb iasiscan cau se dysentery, liver abscess and oth er system ic comp lica-
tions, but is rare in children under 5 years. Treatment for amoebiasis should be given
when motile trophozoites ofEntamoeba histolyticacont aining ingested erythrocytes are
found in a fresh stool sample or when bloody diarrhoea continues after successive
treatment with two antibiotics that are usually effective for Shigella. The finding of
am oeb ic cysts in the stools is not sufficien t for a diagnosis of am oebiasis. Treatm ent is
with me tron idazole oral suspen sion, 10m g/ kg three times d aily for 510 days (see Ap-
pen dix 6).
Giardiasis. Intestinal infection with Giardia is common and usually has no adverse
effect on well-nourished children. However, in severely malnourished children, treat-
m ent for giardiasis should be given wh en cysts or troph ozoites ofGiardiaare seen in the
stool. Treatme nt is with m etron idazole, 5m g/ kg orally three times da ily for 5 days (seeAppendix 6).
Further d etails of treatme nt for children with dysent ery are available elsewhere (9).
Otitis media
Otitis media occurs frequently in children, often in connection with hospital-acquired
upper respiratory infection. There are no specific clinical signs, except when the ear-
drum has ruptured, causing drainage from the ear. The diagnosis usually requires ex-
am ination of the ears with an otoscop e, looking for loss of the tym pa nic light reflex or
perforation of the eardrum . Typical signs of inflam ma tion m ay not be present. Treat-
m ent is with cotrimoxazole (25m g of sulfam etho xazole + 5m g of trimeth oprim/ kg twice
daily), amp icillin (25m g/ kg four tim es daily) or am oxicillin (15m g/ kg three tim es daily)for 5 days (see Appendix 6). A cotton wick should be used to dry any drainage from
the ear.
Pneumonia
Pneum onia is ma nifested by fast breathing and, som etimes, chest indrawing. Cough,
crackly breat h soun ds and a bn orm alities on chest X-ray are frequ ently absent. The cut-
off for fast brea thing is 50 tim es per m inute or m ore if the child is aged 212 mon ths, or
40 tim es per m inute or m ore if the ch ild is aged 12 mon ths to 5 years. Children with fast
breathing should be d iagnosed a s having pn eum onia an d given a n o ral antimicrobial for
5 da ys. Cotrimo xazole (sulfameth oxazole + trimeth oprim ), amp icillin or a m oxicillin is
usua lly effective (see ab ove). Children with fast breathin g and chest ind rawing shou ld be
treated with ben zylpen icillin, 50000 IU/ kg IM four times d aily for at least 5 days, unt il
they imp rove, and then with oral am picillin o r am oxicillin (see ab ove). Oxygen shou ld
also be given if the breat hing rate is over 70 breath s per m inute .
For further d etails of treatment for children with otitis media an d p neum onia, see
reference 10.
Urinary tract infections
Urinary tract infections occu r frequen tly, with a similar inciden ce in b oys and girls. Such
infections are usually asymptomatic and are diagnosed using dip-stick tests or by
finding large numbers of leukocytes on microscopic examination of fresh urine (at
least 10 leukocytes p er m icroscope field (X40 ma gnification)). Cotrimoxazole (25m g of
sulfamethoxazole + 5 m g of trim etho prim / kg twice da ily for 5 da ys) is usually effective.
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32 Management of severe malnutrition: a manual for physicians and other senior health workers
Alternatively, amp icillin (25 m g/ kg four times d aily for 5 d ays) can b e given (see App en-
dix 6).
Skin infectionsBacterial infections. These in clude p ustu les, imp etigo, infected fissures (especially be-
hind the ears) and indolent ulcers. Treatmen t should include washing the affected area
with soap and water, and gently removing deb ris and crusts by soaking in warm saline or
clean warm water. Dry the ch ild carefully and a pp ly polyvidone iod ine, 10% ointm ent , or
chlorhexidine, 5% lotion, to the affected area. Widespread superficial and deep-seated
infections sh ould b e treated with ben zylpen icillin, 50000 IU/ kg IM four tim es daily for at
least 10 days. If abscesses are p resent, th ey should b e drain ed su rgically.
Candidiasis. Oral candidiasis causes creamy-white lesions in the mou th an d m ay be
pain ful, making feeding difficult. The d iagnosis is confirm ed b y the pre sence o f typical
yeast form s on Gram staining of scrapings from the lesion. Cand idiasis can a lso involve
the oesophagus, stomach, rectum and moist tissues (e.g. axillae, groin). In systemic
can didiasis, the respiratory tract and blood m ay be involved. Nystatin oral suspen sion,
100000 IU four times daily is recom m end ed for oral, oesop hageal an d rectal cand idiasis.
Nystatin cream (100000IU (1g)) should be applied to affected areas of skin twice
daily for 2 weeks. Children over 2 years with systemic candidiasis should be given
ketocon azole, 5 m g/ kg orally daily un til rem ission is obtained .
Scabies. Scabies is caused by a mite tha t burrows sup erficially into the skin an d cau ses
inten se itching; the scratch ed lesions often beco m e second arily infected. Linda ne, 0.3%
lotion , should b e ap plied to affected areas o nce daily for 2 days. If this is not a vailable,
benzyl benzoate, 25% lotion, may be used. Although cheaper, it is more irritating; it
should be avoided in malnourished children, unless there is no alternative available.
Family mem bers should also be treated to prevent infestation or reinfestation.
Tuberculosis
Tubercu losis is an imp ortan t cause of failure to respo nd . The diagn osis is m ade b y chest
X-ray and e xaminat ion or culture of sputu m o r trachea l secretions. Occasionally, typical
tuberculous lesions can be seen in the fundus of the eye. The Mantoux test is often
negative owing to anergy, but may become positive as the childs nutritional status
improves.
Antituberculosis drugs should be given only when tuberculosis is diagnosed, and
treatm ent sh ould follow guidelines pub lished by WHO (11) or n ationa l guidelines. Chil-
dren with HIV infection are at increased risk of tuberculosis and should be treated if
tuberculosis is suspected. As the recomm ended drugs are hep atotoxic, they should b e
used with caution in any child with an enlarged or tender liver. The recommended
treatment schedule is described in Appendix 6.
Helminthiasis
Ascariasis, hookworm infection and trichuriasis. Infection with Ascaris lumbricoides
(roundworm), Ancylostoma duodenale or Necator americanus (hookworm), and
Trichuris trichiura (whipworm) is comm on in children who play outside. Whipworm
infections can cause dysentery, anaemia and, occasionally, prolapse of the rectum.
Hookworm infections can cause severe anaem ia. Treatmen t of these infections sho uld
be delayed until the rehabilitation phase of treatment for severe malnutrition.
Albend azole (400m g in a single do se) and m eben dazole (100 m g twice daily for 3 days
for inpatient treatment or 500mg in a single dose for outpatient treatment) are both
effective in ch ildren over 2 years. If these drugs are n ot available or the ch ild is un der 2
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33 7. Failure to respond to treatment
years, hoo kworm can be treate d with pyrante l (10m g/ kg in a single dose) and ascariasis
with pyran tel or pipe razine. Piperazine is also effective in wh ipworm infection s. Chil-
dren aged 212 years should be given 75mg/kg of piperazine in a single dose to a
maximum of 2.5g, while those under 2 years should receive 50mg/kg in a single dose
administered under medical supervision (see Appendix 6).
Strongyloidiasis. Infection with Strongyloides stercoralisis also comm on in ch ildren who
play outside. The diagnosis is made by detectin g typical larvae in th e faeces. In p atients
whose imm un e systems are depressed by disease, the larvae m ay become widely dis-
seminated, giving rise to life-threatening pulmonary, cerebral and hepatic complica-
tions. Albend azole is the dru g of choice for children over 2 years; 400 m g should b e given
in a single oral dose. If albendazole is unavailable or the child is under 2 years,
iverm ectin sho uld be given; the dosage is 200g/ kg in a single oral dose. Tiabend azole
is effective, bu t causes severe ano rexia, which is dangerou s for m alnou rished children .
Malaria
Malaria is diagnosed by microscopic examination of a blood smear for malarial para-sites. Malaria often appears during the rehabilitation phase of treatment for malnutri-
tion. Malnourished children with malaria should receive a full course of antimalarial
therapy with th e dosage based on body weight.
Non-falciparum malaria. Infections with Plasmodium ovale, P. malariaeor susceptible
form s ofP. vivaxm ay be treated with chloroq uine. The total daily dose of chloroquine is
25 m g of base/ kg orally given o ver 3 days as follows (see App end ix 6):
Days 1 and 2: 10m g of base/ kg in a single dose
Day 3: 5 mg of base/ kg in a single dose.
Falciparum malaria. A single drug should be given following national recommenda-
tions. Drugs that m ay be recomm ended for children include ch loroquine (see above),
quinine and pyrimetham ine + sulfado xine. The d ose of quinine is 8 m g of base/ kg orallyevery 8 hou rs for 7 days. The d ose of pyrim etha m ine + sulfado xine is adjusted a ccording
to th e bod y weight of the ch ild as follows:
510kg: 12.5mg + 250m g orally in a single do se
1120kg: 25m g + 500m g orally in a single do se.
HIV infection and AIDS
Children with acquired immunodeficiency syndrome (AIDS) are likely to present with
severe malnu trition. In som e coun tries up to half of the ch ildren p resentin g with severe
m alnutrition h ave AIDS. Treatm ent of m alnut rition in ch ildren with HIV infection or
AIDS is the sam e as in ch ildren who a re HIV-negative. Interstitial lymp hocytic pn eum o-
nia is specifically associated with HIV infection. If findings on X-ray are typical of inter-
stitial lymphocytic pneumonia, an HIV test should be performed. Treatment is with
steroids.
Severely m alnou rished children shou ld notbe tested routin ely for HIV. Knowledge o f
HIV status plays no role in management of the child, except to diagnose interstitial
lym ph ocytic pn eum on ia. When an HIV test is don e, the results shou ld notbe revealed to
the staff. Otherwise, a po sitive test may cause th em to ne glect the ch ild.
Serious underlying disease
Malnutrition may result from unrecognized congenital abnormalities, inborn errors
of metabolism, malignancies, immunological diseases and other diseases of the major
organs. Examina tion of a child who fails to respon d to treatm en t should include a search
for serious und erlying disease. Any problem identified sho uld be treated a pp ropriately;
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34 Management of severe malnutrition: a manual for physicians and other senior health workers
however, the associated ma lnutrition should b e m anaged a ccording to th e guidelines in
this man ual.
7.4 Learning from failureAccurate records should be kept of all children who fail to respond to treatm ent a nd of
all deaths. These should include, as a minimum, details of the childs age, sex, date of
admission, weight-for-height (or length) on admission, principal diagnoses, treatment
and, where app ropriate, date an d time of death, and ap parent cau se of death. Periodic
review of these records can help to iden tify areas where case m anagem ent p ractices
should be carefully exam ined an d im proved. For example, deaths that occur within the
first 2 days are often due to hypoglycaemia, un recognized or m isman aged septic shock,
or other serious infection, whereas death s that occur a fter day 2 are often d ue to heart
failure. An increase in de ath s occurring at night or at weekends suggests that mo nitoring
and care of children at tho se times should b e reviewed an d im proved. The o bjective
shou ld be to ach ieve a case-fatality rate of
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35 8. Management of Malnutrition in Disaster Situations and Refugee Camps
35
8.
Management of malnutritionin disaster situations andrefugee camps
8.1 General considerations
Health workers in disaster situations an d refugee camps may h ave to m anage a large
num ber of severely malnou rished ch ildren. Although the principles of mana gement are
the sam e as in other situations, treatment mu st follow a routine, rather than an ind i-
vidual, approach. This often requires that a therapeutic feeding centre be established.
This is usually necessary when a cluster survey shows over 10% of children aged 6
m ont hs to 5 years with low weight-for-height (below 2 SD of the m edian NCHS/ WHO
reference values) (12).
8.2 Establishing a therapeutic feeding centre
Location and capacity
If possible, the therapeutic feeding centre should be in or near a hospital. It may be
located in simp le buildings or tents. One cen tre can serve up to 50 children. If there a re
more than 50100 children, a second cen tre should b e established. Each centre shou ld
include a special care unit, to provide roun d-th e-clock care du ring initial treatm ent , an d
a day-care unit, to provide care during rehabilitation.
Water supply and sanitation
A m inimu m of 30 litres of water shou ld be a vailable p er child per d ay. If less than 10 litres
of water are available pe r child per da y, the cen tre will be un able to fun ction. A latrine
and a bath ing area are required for every 20 persons.
Cooking facilities and supplies
A collective kitchen should be organized and a reliable supply of fuel for cooking en-
sured. The food requirement should be based on the estimated number of severely
malnourished children plus their mothers or carers. Secure storage facilities are re-quired for food and med ical supplies.
Staff
Each centre shou ld include, as a minimum , one part-time doctor, three nurses and 10
nu rsing aides. The moth ers or carers of the ch ildren m ay also provide assistance .
8.3 Criteria for enrolment and discharge
The criteria for admission d epen d on the ob jectives of the programm e and the resources
available. In general, children whose weight-for-height is below 3 SD or 70% of the
med ian NCHS/ WHO reference values, or who have oedem a, should be adm itted to the
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36 Management of severe malnutrition: a manual for physicians and other senior health workers
therapeutic feeding centre. Discharge usually takes place when the childs weight-for-
height has reached at least 2 SD or 80% (pre ferably 1.5 SD or 85%) of the N CHS/WHO
m edian referen ce values on two con secutive weighings, 1 week ap art. In som e situations
the circum ference of the m id upper arm (13) is used as a criterion for adm ission. The
criteria can be m odified in accordan ce with national guidelines, resources of the centre
an d cap acity for follow-up, bu t shou ld always be clearly defin ed.
8.4 Principles of management
The principles of man agement are the same a s in a ho spital setting. The d octor should
evaluate each child daily. Initial treatment should include vitamins, minerals,
an thelm inthics (see page 32) an d an timicrobials (see section 4.6).
8.5 Evaluation of the therapeutic feeding centre
A med ical team should m onitor the hea lth an d n utritional status of the entirepopulation
of the refugee cam p or disaster area by:
calculating m ean daily mortality rates at weekly intervals;
mo nitoring the availability of food, and its macro- and micronutrient conten t, at
m on thly intervals; an d
condu cting anth ropom etric (weight an d height or length) surveys every 3 mon ths.
The rates of coverage, success an d m ortality of the cen tre shou ld be regularly evalu-
ated by th e following criteria:
Coverage rate: The n um ber of severely malnourished children en rolled at the centre
divided by the total number of severely malnourished children in the population,
based on the m ost recent survey.
Recovery rate: The number of children reaching criteria for discharge divided by the
total number of discharges, deaths, defaulters and transfers.
Mortality rate: The num ber of deaths amon g children at the centre divided b y the total
nu mb er of children en rolled at the centre.
The interpretation of these figures dep ends on local conditions, resources and com -
peting health priorities. Most programmes can achieve coverage rates of at least 80%,
with recovery rates of>50%, and m ortality rates of
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37 9. Malnutrition in adolescents and adults
37
9.
Malnutrition in adolescentsand adults
Severe m alnutrition occurs as a primary disorder in adolescents and adults in cond itions
of extrem e privation and fam ine. It also occurs in situation s of dep end ency, for examp le,
in the elderly, those with m ental illnesses and emo tional problems, and in prisoners.
Malnutrition in adolescents and adults is commonly associated with other illnesses,
such as chronic infections, intestinal malabsorption, alcohol and drug dependence,
liver disease, endocrine an d auto imm un e diseases, cance r and AIDS. In such ca ses both
the m alnutrition a nd the un derlying illness m ust be treated.
9.1 Principles of management
The physiological changes and principles of management of adolescents and adults
with severe malnu trition a re the sam e as those in ch ildren . In gene ral, the guidelines for
management of children should be followed. There are, however, differences in the
classification of malnutrition, the am oun t of food requ ired and the d rug dosages.
Except in famine conditions, adolescents and adults rarely associate wasting or
oede m a with their diet. As a conseq uen ce, they do not b elieve that altering their diet will
help them. Even in famine conditions, they are often very reluctant to eat anything
except trad ition al foods, which th ey view as perfectly satisfactory. Moreover, the foods
they are allowed are often restricted by cultural and religious beliefs. They are often
reluctant to take formu la feeds un less they can b e persuad ed th at such feeds are a form
of medicine. This prob lem is one of the m ost difficult aspects of treating adolescents an d
adults.
9.2 Classification of malnutrition
Adults (over 18 years)
Body mass index
The degree o f thinne ss is assessed u sing the b ody m ass index (BMI) as the indicator. BMI
is defined as the body weight (in kg) divided by the square of the height1
(in metres).
Table 13 gives th e BMI cut-off values for defin ing grades of m alnut rition in ad ults.
When an adu lt is too ill to stan d or has a spina l deform ity, the half arm sp an sh ould
be m easured. This is the distance from the m iddle of the sternal notch to the tip of the
middle finger with the arm held out horizontally to the side. Both sides should be
measured. If there is a discrepancy, the measurements should be repeated and the
longest one taken . The h eight (in m etres) can then be calculated as follows:
Height = ( )[ ]+0 73 2 0 43. .half arm sp anThe BMI is then comp uted from th e calculated h eight an d m easured weight.
1 Short height, in adults, usually represents chronic malnutrition in childhood. As there is notreatment available, short adult height is mainly of theoretical interest, except that stuntedwomen have an increased risk of complications d uring delivery and are likely to have low-birth-
weight an d short ch ildren them selves.
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38 Management of severe malnutrition: a manual for physicians and other senior health workers
Oedema
Exam ine the a nkles and lower legs for pitting oedem a. If symm etrical oede m a is present,
its cause m ust be d etermined. In add ition to ma lnutrition, causes in ad ults include pre-
eclamp sia (in p regnant wom en), severe proteinuria (neph rotic syndrome), nep hritis,
acute filariasis (the limb is hot and painful), heart failure and wet beriberi. Non-
nu tritional causes of oede m a can rea dily be iden tified by the history, ph ysical exam ina-tion an d urina lysis.
Adu lts with a BMI below 16.0 or with oed em atou s malnu trition shou ld be adm itted
to hospital.
Adolescents (1018 years)
A WHO Expert Com m ittee has recom m end ed BMI-for-age as the b est indicator of thin-
ness for use in adolescence, the cu t-off value b eing
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39 9. Malnutrition in adolescents and adults
Table 14. Dietary requirements for initial treatment ofseverely malnourished adolescents and adults
Age Daily energy Volume of diet(years) requirementa required (ml/kg
per hour)
(kcalth/kg) (kJ/kg) F-75 F-100
710 75 315 4.2 3.01114 60 250 3.5 2.51518 50 210 2.8 2.01975 40 170 2.2 1.7>75 35 150 2.0 1.5
a Individual needs may vary by up to 30% from these figures.
9.5 Rehabilitation
An imp roving app etite indicates the be ginning of reha bilitation. During reha bilitation it
is usual for adolescents and adults to become very hungry, often refusing the formula
feed an d dem and ing enormous am oun ts of solid food. When this happen s, a diet should
be given th at is based on trad ition al foods, but with ad ded o il, mineral mix and vitamin
m ix. Provide a wide variety of foods an d allow the pat ients to eat a s mu ch as th ey want.
If possible, continue to give the formula feed with the vitamin and mineral mixes be-
tween m eals and at night. If necessary, present the formu la feed as a med icine.
9.6 Criteria for discharge
Adolescent s and ad ults can be discha rged when th ey are eating well an d gaining weight,
they have a reliable source of nu tritious food ou tside the hosp ital, an d an y othe r health
problems have been diagnosed and treatm ent begun . Adults should continue to receive
a sup plemen ted d iet as outpa tients until their BMI is 18.5; for a dolescents, th eir diets
should be supplemented until their BMI-for-age is 5th percentile of the median
NCHS/ WHO referen ce values.
9.7 Failure to respond to treatment
Failure to respond to treatmen t in adu lts and adolescents is usually due to an u nrecog-
nized underlying illness (see page 37), a nutrient deficiency or refusal to follow the
treatment regimen.
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40 Management of severe malnutrition: a manual for physicians and other senior health workers
40
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41 Appendix
41
Appendix 1NCHS/ WHO n orm alized referen ce values forweight-for-height an d weight-for-len gth
Boys weight (kg) Lengtha(cm) Girls weight (kg)
4 SD 3 SD 2 SD 1 SD Median Median 1 SD 2 SD 3 SD 4 SD
1.8 2.1 2.5 2.8 3.1 49 3.3 2.9 2.6 2.2 1.81.8 2.2 2.5 2.9 3.3 50 3.4 3.0 2.6 2.3 1.9
1.8 2.2 2.6 3.1 3.5 51 3.5 3.1 2.7 2.3 1.91.9 2.3 2.8 3.2 3.7 52 3.7 3.3 2.8 2.4 2.01.9 2.4 2.9 3.4 3.9 53 3.9 3.4 3.0 2.5 2.12.0 2.6 3.1 3.6 4.1