guidelines for the integrated management of severe acute malnutrition

ACF-In Guidelines for the integrated management of SAM In-patient: Failure to respond to treatment 99
� A severe medical complication (see section on complications)
� Drug toxicity (see section on drugs)
� Insufficient food given (criteria for NGT not applied)
� Food taken by siblings or caretaker
� Sharing of caretaker’s food
� Mal-absorption
� Psychological trauma
� Rumination (and other types of severe psychosocial deprivation)
� Infection, especially: viral infections, bacterial infection resistant to the antibiotics being used,
fungal infection, diarrhoea, dysentery, pneumonia, tuberculosis, urinary infection/ Otitis media,
malaria, HIV/AIDS, Schistosomiasis/ Leishmaniasis, Hepatitis/ cirrhosis.
� Other serious underlying disease: congenital abnormalities (e.g. Down’s syndrome),
neurological damage (e.g. cerebral palsy), inborn errors of metabolism.
When a child fails to respond then the common causes must be investigated and treated appropriately
according to the manual.
Every child with unexplained primary failure to respond should have a detailed history and
examination performed. In particular, they should be checked carefully for infection as follows:
1. Examine the child carefully. Measure the temperature, pulse rate and respiration rate
accurately.
2. Where appropriate, examine urine for pus cells and culture blood. Examine and culture
sputum or tracheal aspirate for TB; examine the fundi for retinal tuberculosis 158 ; do a chest xray.
Examine stool for blood, look for trophozoites or cysts of giardia; culture stool for
bacterial pathogens. Test for HIV, hepatitis and malaria. Examine and culture CSF.
Deterioration/regression after having progressed satisfactorily initially is usually due to:
� Electrolyte imbalance with movement of sodium from the cells and an expansion of the
circulation to give fluid overload 159 or to re-feeding syndrome.
� Inappropriate dosage of drugs 160 , or use of drugs not recommended in the severely
malnourished child.
� Inhalation of diet into the lungs. There is poor neuro-muscular coordination between the muscles
of the throat and the oesophagus in malnutrition. It is quite common for children to inhale food
into their lungs during recovery if they are: 1) force fed, particularly with a spoon or pinching of
the nose; 2) laid down on their back to eat, and 3) given liquid diets. Inhalation of part of the diet
158 Gastric aspirates are very rarely positive in the malnourished child with active TB – particularly if there is overnight
feeding; this test should not be relied on, is difficult to perform well and is traumatic for the child. If it is used, overnight
feeds should not be given.
159 This usually occurs 2 to 4 days after admission. It is more likely to occur in a patient who has been treated aggressively
for dehydration in the emergency department or on admission.
160 The half-life of most drugs is prolonged in the severely malnourished child. If standard doses are given, but not
eliminated, then the level builds up in the child from day-to-day until toxic levels are reached. Drug regimens should be
reviewed or stopped in any patient that deteriorates under care.