guidelines for the integrated management of severe acute malnutrition

ACF-In Guidelines for the integrated management of SAM In-patient: Complications 75
increase the weight beyond the pre-diarrhoeal weight. “Prophylactic” administration of
ReSoMal to prevent recurrence of dehydration is never given.
2. If the patient is newly admitted, it is extremely difficult to judge the amount of fluid that has been
lost in the child with marasmus as all the clinical signs are unreliable. Because of the narrow
therapeutic window and the danger of going from under-hydration to over-hydration, the
estimated weight deficit should be very conservative. It is better and much less dangerous to
slightly under-estimate the amount of weight deficit than to over-estimate the weight deficit in
malnourished children 112 .
• In practice, the weight loss is generally 1% to 3% of body weight in most children and in
a few up to 5%.
• Do not attempt to increase body weight by more than 5% in conscious children.
• If there is weight gain of up to 5% of body weight with rehydration, the truly dehydrated
child will show dramatic clinical improvement and be out of immediate danger from
death due to dehydration; treatment can then be continued with F75.
During re-hydration breastfeeding should not be interrupted. Begin to give F75 as soon as
possible, orally or by naso-gastric tube. ReSoMal and F75 can be given in alternate hours if there is
still some dehydration and continuing diarrhoea. Introduction of F75 is usually achieved within 2-3
hours of starting re-hydration.
Treatment of shock from dehydration in the marasmic patient
Only if there is definite dehydration (a history of fluid loss, a change in the appearance of the eyes)
and the patient has all of the following:
� Semi-conscious or unconscious and
� Rapid weak pulse and
� Cold hands & feet and
� Poor capillary refill in the nail beds
Then the patient should be treated with intravenous fluids. The amounts given should be half or less
of that used in normally nourished children.
Use one of the following solutions that are used in normally nourished children
• Half strength Darrow’s solution
• Half strength Ringer-Lactate with 5% dextrose
• Half strength Saline with 5% dextrose
� Give 15 ml/kg IV over the first hour and reassess the child.
� If there is continued weight loss or the weight is stable, repeat the 15ml/kg IV over the next hour.
Continue until there is weight gain with the infusion. (15mg/kg is 1.5% of body weight, so the
expected weight gain after 2 hours is from 0% up to 3% of body weight)
112 This is a “balance of risks”, if the child is not in danger of death from dehydration then it is safe to proceed cautiously
and avoid the danger of fluid overload and heart failure, either immediately, or later when the diet-induced electrolyte
movements occur. This was not such a major danger previously when the diets used (e.g. high energy milk, etc.) did not
repair the cell membranes or mobilise oedema rapidly. With modern diets there are usually profound electrolyte movements
during the early phase of recovery.