guidelines for the integrated management of severe acute malnutrition

ACF-In Guidelines for the integrated management of SAM In-patient: Complications 79
- The appropriate treatment is to change the dietary regimen because it is the diet that is the cause of
the diarrhoea. Usually, the diarrhoea can be ignored, as the amoxicillin suppresses the small bowel
overgrowth and the intestine repairs with the improved nutrition in F75 so that osmotic diarrhoea
subsides after a few days. If this does not suffice or there is weight loss then dividing the diet into
many feeds, each smaller so that they do not overwhelm the limited capacity for digestion and
absorption. This is the main indication for feeding overnight that is all that is required.
For a few children this is insufficient as the intestine or pancreas is sufficiently damaged that even
small amounts of F75 can provoke osmotic diarrhoea initially.
- One strategy is to add pancreatic enzymes directly to the feed just before it is given. These are
available commercially and are used to treat children with pancreatic insufficiency due to cystic fibrosis
–the same dose is used for the severely malnourished child as those with cystic fibrosis. These
preparations contain enzymes to digest fat and protein as well as carbohydrate. The enzymes can be
withdrawn after a few days as the nutritional state of the child improves and the pancreas recovers.
Nearly all children with SAM have some degree of pancreatic atrophy, however, there appears to be
regional differences in the degree of pancreatic atrophy seem in SAM children [60] so that the order in
which these strategies are applied will depend upon local experience.
- The diet can be changed to one where the F75 is fermented or based upon yoghurt instead of
unfermented milk [61,62]. In this case the diet will have to be prepared locally as there is no
commercial preparation. This removes lactose from the diet. However, the amount of lactose in F75 116
is very small and unlikely to overwhelm the absorptive capacity even in children with lactase
deficiency.
The diet can be changed to one based upon goat’s milk or eggs (see annex 15 for recipes).
2. HYPERNATRAEMIC DEHYDRATION 117
Hypernatraemic dehydration is common in areas with a low relative humidity (dry atmosphere)
particularly if there is also a high temperature 118 . It is most often due to loss of water without loss of
salt, leading to “pure water” deficiency. This is because water is lost through the skin and breath at a
high rate under these conditions. It can also occur if solutions high in sodium (or other osmolyte that is
not metabolised) are given so that when the water is lost the osmotically active solute remains in the
body. In areas where bottle feeding is common, mothers frequently over-concentrate the infant
that it is much less likely to cause osmotic diarrhoea. If F75 is to be prepared in the facility then the recipes containing
starch (particularly rice starch) should be used (if possible with the addition of some germinated grain flour to add amylase
which reduces the viscosity).
114 The stool composition with “osmotic diarrhoea” is different from infective diarrhoea. With osmotic diarrhoea the
unabsorbed sugar is largely responsible for the increased stool output which thus contains much less sodium than with
infective diarrhoea. The aim of treatment is always to replace losses so the electrolyte composition of the fluids used in
treatment should match that of the stool − ReSoMal or ORS are inappropriate treatments for osmotic diarrhoea. The
management is to change the diet that is provoking the diarrhoea.
115 If there is weight loss then the diarrhoea can also be due to a nosocomial infection.
116 F100 and RUTF have several time greater lactose than F75 (F75 = 1.3g/100ml, F100 = 4.2g/100ml); it is more likely that
the mal-absorption of sucrose is responsible for the osmotic diarrhoea (7g/100ml)
117 This is the same as “hyper-osmolar syndrome” and other synonyms that denote that the plasma osmolarity is increased
above normal. The increased osmoles can be urea if a very high protein diet has been taken with compromised renal
function or glucose in patients with glucose intolerance. In the SAM patient the hyperosmolarity is normally sodium and
chloride.
118 The dry atmosphere is the more important feature. Where the climate is very hot and wet, much less water is lost so that
the child presents first with fever because of an inability to excrete the heat generated during metabolism.