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 94 intake and gradually increased; judicious supplements of phosphorus 153 could be given if refeeding syndrome is suspected although this has not been studied adequately to make a definitive recommendation. 153 Most « cola » drinks contain phosphoric acid, which appears to be innocuous.
ACF-In Guidelines for the integrated management of SAM In-patient: SAM and HIV/AIDS 95 Severe Acute Malnutrition and HIV/AIDS The HIV epidemic is affecting most societies in the Developing world. It affects mainly sexually active young adults. These adults are the caretakers and parents of children and the providers for, and protectors of, their families. A sick parent cannot work and earn to provide for the children and without treatment will die. HIV affected communities are becoming poorer. The prevalence of severe malnutrition is increasing in both HIV negative as well as HIV positive children. Where there is an effective Voluntary Testing and Counselling (VCT) programme and, at least, prophylaxis and treatment for opportunistic infections is available. Then VCT should be offered to all patients with severe malnutrition and their caretakers. Where anti-retroviral treatment is available there should always be VCT associated with the identification and management of SAM. There is a need for there to be a willing and capable caretaker for the SAM patient. Where the parent has HIV/AIDS, additional support needs to be available as the parent will have recurrent illness. During these illnesses she may not be able to care for her children. Indeed, OTP may not be feasible. Where one grandmother has to care for many grandchildren without obvious means of support it may not be possible for the grandmother to give special care to the malnourished child; in others the household is headed by a child, normally an older sibling. Community mobilisation and support, as well as local NGOs, can be invaluable in these circumstances. Many of these children have to be treated in a facility initially (not necessarily a hospital), some need to be cared for in special programmes or facilities using the OTP protocol. All societies have traditional mechanisms and social networks that care for orphans. However, in many regions the large numbers of orphans have stretched these cultural responses for orphans beyond their capacity to absorb any more children. Orphanages and similar institutions frequently admit large numbers of severely malnourished children. The residents should always be screened for severe malnutrition and appropriate treatment given. The staff of such institutions should be trained in the basic care of the severely malnourished, and should be able to give OTP care. They can even be the base for an OTP site. They should be particularly screened for TB at the time of HIV testing, as co-infection is particularly common. TB, HIV and SAM are linked and frequently appear in the same patients. Most children with HIV infection respond to the treatment of severe malnutrition in the same way as those without HIV infection. Those with a very low CD4 count have a slightly higher mortality. Those with a reasonably high CD4 count appear to have the same mortality risk as noninfected children. The treatment of the malnutrition is the same whether the patient is HIV positive or negative; exactly the same protocol is used (both in and out-patients). The drugs that are used for TB and HIV are quite toxic to the liver and pancreas. These organs are particularly affected by SAM. If treatment with anti-TB drugs or ARVs is started in the severely malnourished patient they are likely to develop very severe side effects from the drugs. Such side effects lead to withdrawal of many of the patients from the ARV treatment programmes. Neither TB nor HIV are rapidly fatal illnesses 154 . All antiviral drugs have significant side effects, and their toxicity and 154 The natural history of untreated TB in adults is: after 2 years one third are dead, one third have self-cured and one third progress to chronic extra-pulmonary TB. As 33% die in 24 months this is about 1.5% chance of death each month. A delay of one week or so in starting treatment will have little effect upon the overall mortality rate (unless the patient has tuberculosis meningitis or milliary TB). Similarly, if opportunistic infections are prevented or controlled HIV is not a rapidly fatal condition. On the other hand the mortality from the severe malnutrition with modern treatment less than 5%, but with conventional treatments rises to 20% or higher within a the first week to treatment.
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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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