guidelines for the integrated management of severe acute malnutrition

ACF-In Guidelines for the integrated management of SAM In-patient: Complications 80
formula 119 ; this can lead to hypernatraemic dehydration even in wet or cold climates; it is lethal in hot
and dry climates and seasons of the year. Apart from bacterial contamination, this is a reason why
mothers should not be allowed to reconstitute F75 or F100, and formula feeding should be so strongly
discouraged. The malnourished child is particularly at risk because he has a very low renal
concentrating ability and a high surface area relative to the mass of his body.
During development of the high plasma osmolarity, there is a balancing increase in intra-cellular
osmolytes to prevent water being drawn out of the cells 120 . During treatment, if the extracellular fluid
osmotic pressure is reduced to quickly leaving a high intracellular osmotic pressure, there is sudden
cellular swelling that can lead to cerebral oedema (swelling of the brain) to a sufficient degree to give
convulsions and death.
Although hypernatraemia is difficult to treat safely it is easy to prevent safely. Malnourished
children, particularly those in dry and hot environments should be given continuous access to sufficient
water, without a high content of ions that require renal excretion, to fulfil their requirements for water.
Note: in desert areas where the humidity is very low and the day-time temperature is very high ALL
the children must be given water to drink at frequent intervals. If F100 is used in transition phase and
recovery phase, then it should be further diluted and the intake table adjusted for the additional
volume required to be given at each feed.
Diagnosis
The first sign to appear is a change in the texture and feel of the skin. It develops plasticity similar to
the feel of dough (flour and water mixed for bread making). The eyes can sink somewhat. The
abdomen frequently then becomes flat and may progress to become progressively sunken and
wrinkled (so called “scaphoid abdomen” or “prune belly”). The child may then develop a low-grade
fever if there is insufficient water evaporation to excrete the heat generated during normal metabolism.
The child becomes progressively drowsy and then unconscious. Convulsions follow and if treatment
for hypernatraemia is not instituted this leads to death. The convulsions are not responsive to the
normal anti-convulsants (phenoparbitone, diazepam etc.). Failure to control convulsions with anticonvulsants
may be the first indication of the underlying diagnosis 121 .
The diagnosis can be confirmed by finding an elevated serum sodium. Normally hypernatraemia is
diagnosed when the serum sodium is more than 150mmol/l.
Treatment
- For insipient hypernatraemic dehydration – that is a conscious, alert child whose is only showing
changes in the texture and feel of the skin, the best diet to give is breast milk. This can be
supplemented with up to about 10ml/kg/h of 10% sugar-water in sips (little by little) over several hours
until the thirst of the child is satisfied. At this early stage treatment is relatively safe; it is the stage
when impending water deficiency should be recognised and treated 122 . The child should not drink very
large amounts of water rapidly.
119 All infant formulae have a very much higher renal solute load than breast milk. In very hot and dry climates even
correctly made up infant formulae can result in hypernatraemic dehydration. This is a real danger that arises from the failure
of breast feeding in such climates. Because of the low renal solute load of human breast milk, exclusive breast feeding is
the best way to avoid hypernatraemic dehydration.
120 This is the same mechanism that occurs in diabetic coma, where the osmolyte in the extracellular fluid causing
hyperosmolar coma is glucose and not sodium: the same care has to be taken with hypernatraemia as with diabetic coma.
121 In desert areas, such as the Sahel, the major differential diagnosis is meningitis/ encephalitis. Frequently, children with
hypernatraemic dehydration are misdiagnosed and treated with antibiotics without confirming the diagnosis of meningitis.
122 This in most likely to occur In-Patients that have been carried for long distances to the clinic/OTP in the sun, without the
mother stopping to rest or give the child something to drink. It is important that those arriving at clinics, OTP etc. are given
water/sugar-water to drink on arrival and not to be kept waiting to be seen without shade.