guidelines for the integrated management of severe acute malnutrition

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ACF-In Guidelines for the integrated management of SAM In-patient: Complications 88 � Give furosemide (1mg/kg) 138 . � Digoxin can be given in single dose (5 micrograms/kg – note that this is lower than the normal dose of digoxin. A loading dose is not given. Use the paediatric preparation, not small quantities of the adult preparation) 139 . If heart failure is associated with severe anaemia the treatment of the heart failure takes precedence over the treatment of the anaemia. A patient in heart failure should never be transfused (unless there are facilities and experience with exchange-transfusion) – the child with severe malnutrition and heart failure, should be treated in much the same way as a neonate with rhesus incompatibility. 6. HYPOTHERMIA Severely malnourished patients are highly susceptible to hypothermia, (rectal temperature below 35.5 o C or under arm temperature below 35 o C). � The room should be kept warm, especially at night (the thermo-neutral temperature for malnourished is from 28 o C and 32 o C) 140 . Windows and doors should be kept closed at night. A maximum-minimum thermometer should be on the wall (at least in the nutrition ward) to monitor the temperature. � The children should be in adult beds and sleep with their mothers 141 . There should be adequate blankets. � Warming is by the “kangaroo technique” for children with a caretaker: the child is placed on the chest of the mother skin-to-skin and the mother’s clothes wrapped around the child. � Put a hat on the child. Most heat is lost through the head; hats should be worn by malnourished children. � Give hot drinks to the mother so her skin gets warmer 142 (plain water, tea or any other hot drink). � Monitor body temperature during re-warming. 137 Do not be concerned about the child becoming temporarily slightly “re-malnourished” because of this. Such remalnutrition will allow the sodium to re-enter cells and prevent further excess sodium efflux from the cells. The heart failure normally occurs because treatment has been excessively aggressive leading to an electrolyte disequilibrium syndrome. Of course the sodium will need to be excreted from the cells during further treatment, but treatment should proceed much more slowly and cautiously in any patient that has had an episode of heart failure. 138 Loop and other diuretics do not work in many of the children. Diuretics are given because it works partially in some of the children. However, one should never rely on diuretics to lead to excretion of the excess body sodium and reduce the intravascular volume. They should not be given if there is insufficient magnesium or potassium in the diet: there is ample Mg and K in F75. It is relatively ineffective in patients with hyponatraemia and may itself exacerbate hyponatraemia. 139 Other drugs (Angiotensin converting enzyme inhibitors, Angiotensin receptor blockers, etc) have not been assessed in heart failure associated with SAM [76]. 140 Although the thermo-neutral temperature for malnourished patients is 28 o C to 32 o C, this is often uncomfortably warm for the staff and caretakers who tend to adjust the room to suit themselves; they are well-nourished, clothed and active whereas the patient is malnourished, with a low metabolic rate, and inactive. 141 This facilitates breast feeding, bonding and keeps the child warm. The mother also gets some rest so that she is more capable of caring for her child, understanding information, making decisions and less likely to default. The beds should be low-to-the-ground so that children can get onto them unaided, are not frightened when they look over the edge and do not hurt themselves if they fall. Mattresses on the floor are often the best, even if the hospital authorities are conventional. This is how many poor people normally rest. The hospital environment should be as close as possible to a home in paediatrics. Normal high beds and caged cots are for the convenience of the staff – they do not have to bend to examine the patient and it is easy to give medicine: they are designed for the staff and not for the patient. 142 HOT drinks physiologically increase the skin blood flow of the mother and increase the rate of heat transfer from the mother to the child. The drinks should be as hot as the mother can tolerate. The cooling effect of increased cutaneous blood flow on the core temperature is why it is traditional to give very hot tea in desert areas.
ACF-In Guidelines for the integrated management of SAM In-patient: Complications 89 � Treat for hypoglycaemia and give second-line antibiotic treatment. 7. FEVER The malnourished child has a diminished or even absent inflammatory response and very poor temperature regulation. If the children are in a warm environment their body temperature rises because they do not sweat sufficiently 143 . During a hot day when the environmental temperature is above the thermo-neutral range of 28°C to 32°C most of the children will develop “fever”. They can also develop fever because they are wrapped in blankets during the day. Children, who cannot “excrete” heat because they do not sweat, will remain febrile unless heat is withdrawn from the body. Malnourished children do not respond to anti-pyretics. Because they fail to work, caretakers and staff often repeat the dosage inappropriately 144 , frequently leading to toxicity. Antipyretics are much more likely to be toxic in the malnourished than a normal child. Aspirin should never be used [79] in these situations. Paracetamol should not be used in the severely malnourished child. Not only should it not be given because it does not work, overdose with paracetamol is the commonest cause of acute hepatic failure in children [33] and 2% of children with an overdose show nephrotoxicity [80], the antidote is sulphydryl containing drugs – it is precisely these same compounds that are universally reduced in oedematous malnutrition making toxicity much more likely [81]. Furthermore, the half-life of paracetamol is greatly prolonged in malnutrition [82] so that repeated standard doses will lead to high blood concentrations making toxicity more likely even in the absence of liver abnormality. Currently paracetamol is dispensed in large quantities for either fever or a history of fever from the mother; this is because it is deemed to be exceptionally safe by the staff. Moderate fevers, up to 38.5°C, do not need to be tr eated actively. These children should have blankets, any hat and most clothes removed, and kept in the shade in a well-ventilated area. They should be given water to drink. They should be checked for malarial parasites. Fevers of over 39°C, where there is the possibility of hyperpyrexia developing, should be slowly cooled. • Placing a damp/wet room-temperature cloth over the child’s scalp, re-dampen the cloth whenever it is dry • Put the child in a ventilated area or fan the child 145 . • The rate of fall of body temperature must be monitored and when it is below 38°C active cooling should STOP. There is a great danger of inducing hypothermia with aggressive cooling. • Give the child abundant water to drink 143 The core temperature of children exposed to an environment of 38°C rose by 0.75°C per hour – they all developed fever, whereas the recovered children did not [77]. When the air temperature is at or above body temperature, heat will be gained by conduction, convection and radiation, the only way that metabolic heat (about 100kcal/kg/d) can be lost is by evaporation. In these circumstances no drugs or physiological change will reduce the body temperature. 144 Ninety per cent of children admitted with malaria have aspirin measureable in their blood, 20% have received more than the recommended dose and about 5% have acute aspirin poisoning as the cause of coma rather than cerebral malaria [78]. Furthermore, because they induce nitric oxide salicylates may exacerbate malaria and other conditions provoking a strong nitric oxide response [79] and should not be given to febrile children in malaria’s areas. 145 If the air temperature is above 38°C then the room can be cooled by wetting the walls and “misting” the air with a fine water spray from time to time.
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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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