guidelines for the integrated management of severe acute malnutrition

ACF-In Guidelines for the integrated management of SAM In-patient 68
Do NOT give intravenous infusions of quinine to a severely malnourished case within the first two
weeks of treatment 98 . This is frequently part of the National protocol for malaria treatment. The toxic
dose of quinine (10mg/l) is very close to the therapeutic dose (5 to 10mg/l) and the elimination half-life
is prolonged in severely malnourished children [45,50]. In the severely malnourished quinine can
induce prolonged and dangerous hypotension, hypoglycaemia, arrhythmia and cardiac arrest. Quinine
is less effective than the artemisinins recommended as first and second line treatments [44].
Impregnated bed nets should always be used in malaria endemic regions.
Measles
In in-patients, all children from 9 months without a vaccination card should be given measles vaccine
both on admission (and a second dose in week 4 th as an outpatient OTP. 99 )
Medicines given under specific circumstances only
1. Vitamin A
There is sufficient vitamin A in F75, F100 and RUTF to correct mild vitamin A deficiency; high doses of
vitamin A are not required in the child without clinical signs of deficiency and may be dangerous
[21,22].
High doses of vitamin A are only given to severely malnourished children under the following
circumstances 100 :
- Where the child has any clinical signs of vitamin A deficiency.
- In children over 9 months, where there is an active measles epidemic and the child has not
been vaccinated against measles.
The dose regimen is given in the table below:
Table 13: Vitamin A systematic treatment
Age Vitamin A IU orally in day 1
6 to 11 months One blue capsule (100,000IU = 30,000ug)
12 months and more Two blue capsules (200,000IU = 60,000ug)
98 Review of the records described in Grellety [49] shows that 90% of children that received intravenous quinine died.
99 The first measles dose often does not give a protective antibody response. It is given because it ameliorates the severity of
incubating measles, partially protects from nosocomial measles and has a non-specific immune-stimulatory action. The
second dose (week 4 dose) is given to provoke protective antibodies.
100 This is a change in policy. There is an increased mortality in oedematous children and an increase in nosocomial
infections in marasmic children who are given high doses of vitamin A on admission [21,22]. Furthermore the increase in
plasma vitamin A may be as great with low and high doses of vitamin A [51]. The levels of retinol binding protein are very
low in the malnourished child. There are significant changes in plasma vitamin A levels in children who have clinical
vitamin A deficiency [52,53]; however, the treatment of severe clinical vitamin A deficiency with massive doses vitamin A
in the malnourished child is often ineffective [54] and the response appears to be determined more by improvement of the
entire diet and recover of liver function [54]. Nevertheless, it is prudent at the present time to give a vitamin A dose to
children with clinical eye signs as well as the improved diet until further evidence is available and the findings have been
confirmed.