guidelines for the integrated management of severe acute malnutrition

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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.
ACF-In Guidelines for the integrated management of SAM In-patient 69 2. Folic acid There is sufficient folic acid in F75, F100 and RUTF to treat mild folate deficiency 101 . However, all children who have clinical anaemia should be given one single dose of folic acid (5mg) on the day of admission. 3. Antihelminthics 102 It is safe to delay treatment with antihelminthics until the patient is admitted to OTP; all patients over one year in OTP are treated for intestinal worms 103 . 4. Other nutrients The F75 (and F100, F100 diluted, RUTF) already contains all the nutrients required to treat the malnourished child. Additional potassium, magnesium or zinc should not be given to the patients. Such a “double dose”, one coming from the diet and the other prescribed, is potentially toxic. In particular, additional potassium should never be given with these diets. Even for children with diarrhoea do NOT give additional zinc as this can increase mortality [10]. Iron should never be given to the severely malnourished in-patient even if the child is anaemic [18,55- 58]. RUTF contains modest, but adequate, amounts of iron, and even if it is used only in transitionphase and recovery-phase, additional iron should not be given. Table 14: Summary table of systematic treatment of patients (table to be reviewed based on previous changes) Systematic treatment Direct admission only to in-patient (Acute-phase- IPF) Amoxicillin - Every day in Acute-phase + 4 more days in Transition or until transfer to OTP Malaria - Coartem (artemether-lumefantrine) Measles vaccine from (9 months) Surveillance - 1 vaccine at admission if no card (second will be given in OTP) � Weight is measured, entered and plotted on the multi-chart each day 104 . � The degree of oedema (0 to +++) is assessed each day. � Body temperature is measured twice per day. 101 A 10kg child taking maintenance amounts of diet will receive about 400 micrograms of folic acid per day. The RDA (USA) for such a child is 80 micrograms per day. 102 It is important to keep the number of drugs given to the severely malnourished to a minimum. Most drugs affect appetite, furthermore any drug which potentially affects the level of consciousness (anti-emetics for example), crosses the bloodbrain barrier, or causes nausea should be avoided. The appropriate dose of most drugs has not been determined in malnourished children and even standard doses can be toxic because of changes in drug metabolism. 103 Where systemic helminths are suspected (e.g. stronglydoides, filariasis, schistosomiasis etc), particularly in older or HIV positive patients, then the appropriate antihelminthics treatment should be given in the acute phase. 104 Length or Height is also taken after 21 days for those few children who remain as in-patients for the recovery phase
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Cover photography: © ACF, Anne-Dom
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guidelines for the integrated management of severe acute malnutrition

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