guidelines for the integrated management of severe acute malnutrition

More documents

Recommendations

Info

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.
ACF-In Guidelines for the integrated management of SAM In-patient: Complications 81 - For developed hypernatraemic dehydration, treatment must be slow. If it is possible to measure serum sodium then the aim is to reduce the serum sodium concentration by about 12 mmol/24h, to correct the hypernatraemia more quickly than this risks death from cerebral oedema. If it is not possible to measure the serum sodium then aim to take at least 48h to correct hypernatraemic dehydration. The treatment should start slowly and as the serum sodium approaches normality, the rate of repletion can be increased. The text-book treatment of hypernatraemia is to give normal saline, slowly, either orally or intravenously. This is dangerous in the severely malnourished child and should not be used as it is based upon the premise that the excess sodium given can be safely excreted by the kidney; this is not the case in the severely malnourished child. Progress is assessed by serial weighting of the child. � First, put the child in a relatively humid, thermo-neutral (28˚ to 32˚ C) environment. This is critical to prevent further losses of water from the child and to prevent hyperthermia if the humidity of the air is increased in a hot environment 123 . � Weigh the child on an accurate balance and record the weight. The objective of treatment is to put the child into positive water balance of about 60ml/kg/d 124 which is equivalent to 2.5ml/kg/h of plain water. This amount should not be exceeded until the child is awake and alert. � If the child is conscious or semi-conscious and there is no diarrhoea, then put down a nasogastric tube and start 2.5ml/kg/h of 10% sugar water 125 . Do not give F75 at this stage as it gives a renal solute load (mainly as potassium). Never give F100 or infant formula. Expressed breast milk can be safely given and is the best “rehydrating” fluid if available. � Reweigh the child every 2 hours. • If the weight is static or there is continuing weight loss, recheck the immediate environment to try to prevent on-going water losses. Then increase the amount of sugar-water intake to compensate for the on-going weight loss (calculated as g/h and increase the intake by this amount). • If the weight is increasing continue treatment until the child is awake and alert � If there is accompanying diarrhoea then give one fifth normal saline in 5% dextrose orally or by NG-tube. 123 If the child is small, this can be in an incubator similar to that used for neonates. It can also be achieved with aerosol sprays into the atmosphere or a humidifying tent, such as that used to treat bronchiolitis. If such facilities are not available, hanging wet sheets in the room or spraying the walls with water intermittently will both humidify and cool the atmosphere. Wet clothes should not be placed directly onto the child unless he has a high fever. In one study in Tchad (daytime climate - 43˚C, 15% humidity) the turnover of water in malnourished children was one third of body water per day (250ml/kg/d)[63]. It is critical to prevent this on-going excessive water loss from the body, otherwise it is very difficult to judge the amount of fluid to give to the child as the amount of fluid needed for slow rehydration, is a relatively small faction of the requirements for replacing on-going losses, which are unmeasured and very difficult to assess with any accuracy. The only way to judge on-going losses and the rate of rehydration is with serial accurate weights. 124 The extra-cellular fluid volume is about 250ml/kg, depending upon the level of body fat and the extent of cellular atrophy. If the extra-cellular sodium concentration is about 160mmol/l and this is to be reduced by 12mmol/day then the extracellular fluid should be expanded by about 0.75% per day. But the extra water given will be distributed in both the intra and extracellular compartments so it is necessary to have a positive water balance of 0.75% of body water per day. In malnutrition there is a higher body water percentage than in normal children. Therefore the daily positive water balance should be about 60ml/kg/day = 2.5ml/kg/hour. 125 Sugar water should be used rather than plain water. It is isotonic and so empties from the stomach and is absorbed more quickly. The treatment will last for about 48h; sugar water prevents hypoglycaemia in these children.
Page 1 and 2:
�� ACF INTERNATIONAL GUID
Page 3 and 4:
ACF-In Guidelines for the integrate
Page 5 and 6:
Page 7 and 8:
Page 9 and 10:
Page 11 and 12:
Page 13 and 14:
Page 15 and 16:
Page 17 and 18:
Page 19 and 20:
Page 21 and 22:
Page 23 and 24:
Page 25 and 26:
Page 27 and 28:
Page 29 and 30: ACF-In Guidelines for the integrate
Page 79: ACF-In Guidelines for the integrate
Page 131 and 132:
Page 133 and 134:
Page 135 and 136:
Page 137 and 138:
Page 139 and 140:
Page 141 and 142:
Page 143 and 144:
Page 145 and 146:
Page 147 and 148:
Page 149 and 150:
Page 151 and 152:
Page 153 and 154:
Page 155 and 156:
Page 157 and 158:
Page 159 and 160:
Page 161 and 162:
Page 163 and 164:
Page 165 and 166:
Page 167 and 168:
Page 169 and 170:
Page 171 and 172:
Page 173 and 174:
Page 175 and 176:
Page 177 and 178:
Page 179 and 180:
Page 181 and 182:
Cover photography: © ACF, Anne-Dom
show all

guidelines for the integrated management of severe acute malnutrition

Create successful ePaper yourself

Delete template?

Save as template?