Sever acuate Malnutrition

2. 2 2

3. 3
Admission to TFU
TFC
Direct Admission How?
Different
health
delivery
units
TB/ARTChronic illnes?
OTP
Refferal
How?
Infants
< 6months
How do SAM cases come
to TFU for admission?

4. 4
THE STEPS IN THE PROTOCOL for SAM CASE
MANAGEMENT - AT TFU
1. Admission
Admission Criteria
Admission Procedure
2.Phase one (Acute Phase)
Complications
3.Transition Phase
4.Phase Two (Phase of Recovery)
5.Discharge
Discharge Criteria
Discharge Procedure
6.Follow up

5. Criteria for inpatient care
• Children who are identified as having SAM should
first be assessed with a full clinical examination to
confirm whether they have medical complications
and whether they have an appetite or not.
• Children who have appetite (pass the appetite test)
and are clinically well and alert should be treated
as outpatients.
• Children who have medical complications, severe
oedema (+++), or poor appetite (fail the appetite
test), or present with one or more Integrated
Management of Childhood Illness (IMCI) danger
signs should be treated as inpatients
5

6. Where to manage children with severe acute
malnutrition who have oedema
• Children with severe acute malnutrition who
have severe bilateral oedema (+++),1 even if
they present with no medical complications
and have appetite, should be admitted for
inpatient care
• Once children are stabilized, have appetite and
reduced oedema and are therefore ready to move
into the rehabilitation phase, they should transition
from F-75 to ready-to-use therapeutic food over
2–5 days, as tolerated. 6

7. Criteria for transferring children from
inpatient (SC) to outpatient (OTP) care
• Children with SAM who are admitted to SC can
be transferred to OTP when their medical
complications, including oedema, are resolving
and they have a good appetite, and are clinically
well and alert.
• The decision to transfer children from inpatient to
outpatient care should be determined by their
clinical condition and not on the basis of specific
anthropometric outcomes such as a specific
MUAC or weight-for-height/length
7

8. Criteria for discharging children
from treatment
• a. Children with SAM should only be discharged
from treatment when their:
— WFH/length is ≥–2 Z-score and they have had no
oedema for at least 2 weeks, or
— MUAC is ≥12.5 mm and they have had no
oedema for at least 2 week
• Children with severe acute malnutrition who are
discharged from treatment programmes should be
periodically monitored to avoid a relapse
8

9. • The anthropometric indicator that is used to confirm SAM
should also be used to assess whether a child has
reached discharge, i.e. if MUAC is used to identify that a
child has SAM, then MUAC should be used to assess and
confirm nutritional recovery. Similarly, if weight-for-height
is used, then WFH should be used to assess and confirm
nutritional recovery.
• Children admitted with only bilateral pitting oedema
should be discharged from treatment based on whichever
anthropometric indicator, mid-upper arm
circumference or weight-for-height is routinely
used in programmes.
9
Criteria for discharging children
from treatment

10. Fluid management of children with SAM
• Children with SAM who present with some
dehydration or severe dehydration but who are
not shocked should be rehydrated slowly, either
orally or by NG tube, using oral ReSoMal (5–10
mL/kg/h up to a maximum of 12 h)
• Full-strength, standard WHO low-osmolarity oral
rehydration solution (75 mmol/L of sodium)
should not be used for oral or nasogastric
rehydration in children with SAM who present
with some dehydration or severe dehydration.
Give either ReSoMal or diluted standard WHO
low-osmolarity ORS with added potassium and
glucose, unless the child has AWD 10

11. Identifying and managing infants who are
less than 6 months of age with SAM
• Infants who are less than 6 months of age with
SAM and any of the following complicating factors
should be admitted for inpatient care:
a. any serious clinical condition or medical complication
as outlined for infants who are 6 months of age or older
with severe acute malnutrition;
b. recent weight loss or failure to gain weight;
c. ineffective feeding (attachment, positioning and
suckling) directly observed for 15–20 min, ideally in a
supervised separated area;
d. any pitting oedema;
e. any medical or social issue needing more detailed
assessment or intensive support 11

12. • infants with SAM who are admitted for inpatient care should
be given parenteral antibiotics to treat possible sepsis
• Feeding approaches should prioritize establishing, or re-
establishing, effective exclusive breastfeeding by the
mother or other caregiver
• Supplementary suckling approaches should, where feasible,
be prioritized;
— SAM but no oedema, expressed breast milk should be
given, and, where this is not possible, diluted F-100 may
be given, either alone or supplementary with breast milk;
• should not be given undiluted F-100 at any time (owing to
the high renal solute load and risk of hypernatraemic
dehydration.
• weight gain on either exclusive breastfeeding or replacement
feeding is satisfactory, e.g. more than 5 g/kg/day for at least
3 successive days, 12

13. 13
Adress Birth Date Age Sex
Serial # Registration # First name Name
Date Weight Height W/H Oedema MUAC Diagnosis Date Weight Height W/H Oedema MUAC
Admission Discharge
Outcome

14. 14
History and Examination sheet for severe malnutrition - page 1 - History
Reg N............... Parent’s name:....................... First name:..................... Age.........d/m/y Sex ..........
Date of examination: ...../....../...... Examinor’s name....................................... Status ....................
Who is giving the history? patient/mother/ father/ sister/ grandmother/ aunt/ other........................
Is this person the main caretaker for the patient at home? yes/ no If not, who is the caretaker?.............................
History of present illness
How long has the patient been ill? ............h/ d/ wk/ mo/ yr
What are the complaints - in the patients own words - and how long has each been present?
1.............................................................................................................. ............h/ d/ wk/ mo/ yr
2.............................................................................................................. ............h/ d/ wk/ mo/ yr
3.............................................................................................................. ............h/ d/ wk/ mo/ yr
4.............................................................................................................. ............h/ d/ wk/ mo/ yr
Describe the details of the complaints, how they have progressed, and the factors associated with each one
......................................................................................................................................................................................
................................................................................................................................................................................
................................................................................................................................................................................
................................................................................................................................................................................
................................................................................................................................................................................
................................................................................................................................................................................
................................................................................................................................................................................
................................................................................................................................................................................
............................................................................................................................
Systematic questions (give additional details of abnormalities above)
Appetite hungry/ normal/ poor/ very poor Weight is decreasing/ steady/ increasing ..........d/ wk/ mo
Swelling: none/ feet/ legs/ face/ all over..........d/ wk/ mo Eyes sunken no/ recent/ longstanding
Diarrhoea N Y ..........h/d/wk/mo stools per day ....... Normal/ watery/ soft/ blood/ mucus/ green/ pale
Vomiting N Y .. .......h/d/wk/mo. No per day............ Repeated episodes of Diarrhoea N Y
Breathing: normal/ fast/ noisy/ difficult for .......h/d/wk Cough: N Y - for.......d/wk/mo
Fever N Y Convulsions N Y Unconsiousness N Y
Treatment: Patient has already seen Dr/ Clinic/ Hospital/ Traditional healer ............times for this illness.
Treatment given ..........................................................................................................................................
Past and social history
Past diseases: describe...............................................................................................................
Mother / father absent N Y reason........................ .....wk/mo/yr Patient: twin/ fostered/ adopted/ orphan
Gestation: early/ normal or........wk/ mo Birth weight: large/ normal/ small or .........Kg/Lb
Mother’s age .......yr no live births ............ no Living children ..............
Family eating together: no adults.......... no children..........
Resources (food income crops livestock)..........................................................................................................
Diet history
breast feed alone for .......wk/ mo age stopped breast feeding..........wk/mo
Food before ill breast/ milk/ porridge/ family plate/ fruit/ leaves/ drinks/ other
Food since ill breast/ milk/ porridge/ family plate/ fruit/ leaves/ drinks/ other
Describe:
.................................................................................................................................................
Last 24h -describe
Examination sheet –
this can be adapted
to local circumstance

15. 15
H istory and Exam ination sheet for severe m alnutrition - p age 2 - Exam ination
R eg N ............... Parent’s nam e:....................... First nam e:.....................
Age.........d/m /y Sex ..........
General does the patient look: not-ill/ ill/ very ill/ com atose
Mood and behaviour norm al/apathetic/ inactive/ irritable/repeated
m ovem ents
Development / regression Patient can: sit/ crawl/ stand/ walk
Ear Nose & Throat
Eyes norm al/ conjunctivitis/ xerosis/ keratom alacia m ild/ m od/
severe
Mouth normal/sore/red/sm ooth tongue/candida/herpes/angular stom atitis
Membrane Colour: norm al/pale/jaundiced/cyanosed Gums normal/
bleeding
Ears normal/ discharging Teeth number __
/__
normal/ caries/ plaque
R espiratory system & C hest
Breathing norm al/ noisy/ assym etrical/ laboured/ wheeze/ indrawing
Rate ......./min or m ore /less than 50 /60 Chest norm al/ asym etric/ pigeon/
sulcus
C ardiovascular system & Hydration
Oedema none/+/++/+++/uncertain feet/ pretibial/ hands/ face/
generalised
Hydratation norm al/ dehydrated/ shock/ uncertain Passing urine N Y
Eyes norm al/ sunken/ staring Peripheries normal/ warm / cold
Pulse rate ...../min norm al/ strong/ weak Heart sounds normal/ gallop/
m urm ur
G astro-Intestinal
Stool not seen/ normal/ soft/ watery/ green/ pale/ m ucus/ blood/
Abdomen: normal/ distended/ tender/ visible peristalsis
bowel sounds: normal/ active/ quiet/ absent splash N Y
Liver .......cm below costal margin norm al/ firm / hard sm ooth/ irregular
Spleen not felt/ felt/ large - norm al/ firm / hard - tender/ painless
N ervous system
Tone norm al/ stiff/ floppy
Meninges normal/stiff neck/Brudzinski/fontanelle bulging
Reflexes norm al/ increased/ decreased/ absent
Skin H air B one Lym ph Nodes
Skin change none/m ild/m od/severe peeling/ raw / ulcers infection/ cuts/
bruises
Perineum norm al/rash/raw /candidia Purpura N Y
Hair black/ brown/ red/ blond norm al/easily plucked/ balding
Scabies none/ local/generalised Eyelash norm al/ long
Lymph nodes none/ groin/ axilla/ neck Tender/ painless Soft/
firm / hard/ fixed
Ribs ends norm al/ swollen/ displaced Gynecomastia N Y
Describe abnormalities below and draw on diagram
...........................................................................................................................… … … … ......
… … … … … … … … … … … … … … … … … ......................................................................… … … .

16. 16
Taking history
qThe aim of taking history is to obtain
and document a complete picture of
the patient’s present medical condition
qMother is asked whether the child has
diarrhoea, vomiting, passing of urine,
appetite and whether she is breast
feeding
qDocument if there is any other problem
reported by the mother

17. 17
Physical examination
qPhysical examination is concerned with signs
which are objective to the medical condition of
the child and done by health worker
qThe examination is systematically done from the
head to the toes (see table below)

18. 18
Physical Examination
Does the patient look Not-ill / ill / very ill / comatose
Mood and behaviour Normal / apathetic / inactive / irritable
Eyes Normal / sunken / staring /conjunctivitis
Ears Normal / discharging
Mouth Normal / sore / red / candida
Breathing Normal /noisy / asymmetrical / laboured /
wheeze / in-drawing / rate……/ min
Oedema None / + / ++ / +++
Hydration Normal / dehydrated / shock / uncertain
Passing urine Yes / no
Skin change None / mild / moderate / severe
Scabies None / localized / generalised
Lymph nodes None / groin / axilla / neck
Tender / painless / soft / firm / hard / fixed

19. 19
Management principles
With the current SAM protocol mortality can
be less than 5%
LOW mortality is achieved by:
1. Critically using multichart
2. Restricting the use of fluids, specially IV
3. Treating in phases
4. Preventing hypoglycemia and hypothermia
5. “Early” diagnosis and treatment

20. 20
Treatment Phases
Phase 1
Transition Phase
Phase 2
Patients in the different phases should always be nursed
together, physically separate from those in other
phases or patients with other diseases.
20

21. 21
Phase I or Acute Phase
• Feeding using 24/7 principle
• Routine medicine – Vit-A, Folic Acid, etc
• Surveillance and Monitoring using Multichart
• Management of Complications with 2nd line
drug
• Malnourished children are passive and do
not cry or complain – this means that they
are systematically ignored in a busy ward
There must be a separate space and staff
to provide 24/7 services.

22. 22
Therapuetic Feeding
F- 75 :100 kcal/kg/24 hrs
Feed every 3 hour using the look-up table
F75 has less sodium, proteins, fat, lower osmolarity and renal solute load
than F100. It is less energy dense
Quantities: 100kcal/130ml/kg/d for children
Feed by cup & saucer or NG-tube (not spoon)
22

23. 23
Amounts of F75 to give during Phase 1
3/7/2024 23

24. 24
Preparation
Add either one large packet of F-75 to 2 liters
of water
or
one small packet to 500 ml of water.
Where very few children are being treated
smaller volumes can be mixed using the red
scoop (20 ml water per red scoop of F-75
powder)
3/7/2024 24

25. 25
Therapeutics milk preparation area

26. 26
Feeding technique
1. Child should be on carer’s lap
against chest and straight
2. Never force fed
3. Meal time should be sociable,
the carers should sit together
4. Observe and correct faulty
feeding
5. The meal for carers should not
be taken beside the patient
6. Don’t use spoon
3/7/2024 26

27. 27
The spoon should not be used only the
cup

28. 28
Naso-gastric feeding : Indication
Taking less than 75% of prescribed diet per
24 hours in Phase 1
Pneumonia with a rapid respiration rate
Painful lesions of the mouth
Cleft palate or other physical deformity
Disturbances of consciousness.
3/7/2024 28

29. 29
Routine medicine :antibitotics
Antibiotics should be given
to all patients, even if they
do not have clinical signs
of systemic infection
Wherever possible
antibiotics should be given
orally or by NG tube.
In-patient care: every day
during Phase 1 + four
more days or until transfer
to OTP/phase 2.
29

30. 30
Antibiotics ...
First line treatment
Oral Amoxycillin 50 - 100mg/kg/d ( dosage twice per
day)
Second line treatment:
Add Chloramphenicol (50mg/kg/d divided to 3 doses)
(do not stop amoxicillin) or
Add Gentamycin (5mg/kg/d once a day) (do not stop
amoxicillin)
Third line: individual medical decision.
Frequently a systemic anti-fungal (Fluconazole) is
added for any patient who has signs of severe sepsis
or systemic candidiasis
30

31. 31
VITAMIN A
On the day of admission
(day 1) & the day of
discharge (TFU) or at the
4th week of those in OTP
give vitamin A for all
children except for those
with oedema
Dosage
6 to 11
months:100,000IU
12 months and above:
200,000IU
3/7/2024

32. 32
MEASLES VACCINE
All children from 9 months
without a vaccination card
should be given measles
vaccine
Vaccine both on admission
and discharge after Phase 2
32

33. 33
Folic acid
On the day of admission, one single dose of
folic acid (5mg) can be given to children
with clinical signs of anaemia.
33

34. 34
Malaria treatment
According to the national protocol
34

35. 35
Monitoring / Surveillance
Weight - each day
The degree of oedema (0 to +++) each day
Body temperature twice per day
Stool, vomiting, dehydration, cough,
respiration rate, liver size, each day
MUAC each week
Height after 21 days 35

36. 36
Criteria to progress from phase 1 to the
transition phase
At least the beginning of the loss of oedema
AND
The return of a good appetite
AND
No NGT, infusions, no severe medical
problems
36

37. Transition phase
•Feeds
•Routine medicine
•Monitoring

38. 38
Transition phase : DIET
THE ONLY difference is a change in the diet
that is given from F75 to F100-
(100kcal/100ml) is given instead of F75
Feed the patient in exactly the same way as
in Phase 1
The same volume is given so that the energy
intake increases by 30% and the child
starts to gain tissue.
(expected weight gain is about 6g/kg/d)

39. 39

40. 40
Criteria to move back from transition phase to
phase1
If the patient gains weight more rapidly than
10g/kg/d (this indicated excess fluid
retention)
If there is increasing oedema
If a child who does not have oedema
develops oedema
If there is a rapid increase in the size of the
liver
If any other signs of fluid overload develop.

41. 41
If tense abdominal distension develops
If the patient gets significant re-feeding
diarrhea so that there is weight loss.
If patient develops medical complication
If Naso-Gastric Tube is needed
If patient takes less than 75% of the
feeds in Transition Phase
Criteria to move back from transition phase
to phase1 cont…

42. 42
A good appetite – finishes the feed that is
given without a significant pause
No need of waiting for Complete loss of
oedema  OTP transfer
No other medical problem
Criteria to progress from the Transition
Phase to Phase 2

43. Phase 2 or the phase of
recovery
Feeds
Routine medicine
Monitoring

44. 44
Class of weight
( kg)
ml per feed
6 feeds /24 h
Ml / 24 h
Less than 3kg Full strength F100 is NOT used at
this weight
3.0 - 3.4 110 650
3.5 - 3.9 120 750
4.0 - 4.9 150 900
5.0 - 5.9 180 1000
6.0 - 6.9 210 1250
7.0 - 7.9 240 1500
8.0 - 8.9 270 1650
9.0 - 9.9 300 1800
10.0 - 11.9 350 2100
12.0 - 14.9 450 2600
15.0 - 19.9 550 3250
20.0 - 24.9 650 3900
25.0 - 29.9 750 4500
30.0 - 39.9 850 5000
40.0 - 60.0 1000 6000

45. 45
Routine medicine
Iron: is added to the F100 in Phase 2. Add 1
crushed tablet of ferrous sulphate (200mg) to
each 2 liters to 2.4litres of F100.
For lesser volumes: 1000 to 1200ml of F100,
dilute one tab of ferrous sulphate (200mg) in
4ml water and add 2ml of the solution.
For 500ml to 600ml of F100, add 1ml of the
solution. RUTF already contains the
necessary iron.
* De-worming: Albendazole or Mebendazole is
given at the start of the Phase 2 for patients
that will remain as in-patients.

46. 46
Criteria to move back from phase 2
to phase 1
In patients who develop any signs of a
complication should be returned to Phase 1

47. 47
DISCHARGE CRITERA
Option 1 - TFU Option 2 - OTP
Cured (D1)
•W/H > = 85% or W/L
> =85%
for 2 consecutive
weeks
AND
•No Oedema for 10
•Target weight gain
reached
AND
•No Oedema for 2
consecutive visits
Please take care of MUAC discharge issue

48. 48
OTHER DISCHARGES
(important for reporting)
Death
(D2)
Patient that has died while s/he was in the programme or in
transit to another component of the programme, but has not yet
been admitted to that facility. The death should be confirmed by a
home visit, where possible
Unknown
(D3)
Patient that is absent for 3 consecutive weighing (21 days), but the
outcome (actual defaulting or death) is not confirmed/ verified by
a home visit
Defaulter (D4)
A child who has been absent for 2 consecutive weighing visits (14
days), confirmed by home visit

49. 49
OTHER DISCHARGE cont…
Non-responder (D5) Patient that has not reached the discharge criteria after 2 months in the
outpatient programme. Where possible, non-responders from the OTP
should be transferred to the TFU for detailed investigation
Medical transfer (D6)
Patient that is referred to a higher level health facility / hospital for
medical reasons and this health facility will not continue the nutritional
treatment or transfer the patient back to the programme
Transfer out (E)
to outpatient (E1)
to in-patient (E2)
Patient that has started the nutritional treatment in the programme and
is referred to another health facility to continue the treatment

50. Treatment of Complications
How to diagnose and treat?

51. 51
–Dehydration
–Septic shock
–Heart failure
–Severe anaemia
–Hypoglycaemia
–Hypothermia
–Infections
Common Complications

52. 52
Dehydration
• Malnourished children are SENSITIVE to excess
sodium intake!
• All the signs of dehydration in a normal child
occur in a severely malnourished child who is
NOT dehydrated – only a HISTORY of fluid
loss and very recent change in appearance
can be used
• Giving a malnourished child who is not really
dehydrated treatment for dehydration is very
dangerous
• Misdiagnosis of dehydration and giving
inappropriate treatment is the commonest cause
of death in severe malnutrition.

53. 53
Dehydration
• The treatment of dehydration is different in the
severely malnourished child from the normally
nourished child
• Infusions are almost never used and are
particularly dangerous
• ReSoMal must not be freely available in the unit
– but only taken when prescribed
• The management is based mainly on accurately
monitoring changes in weight

54. 54
Dehydration - Diagnosis
• History of recent change in appearance of eyes
• History of recent fluid loss
• NO OEDEMA - Oedematous patients are over-
hydrated and not dehydrated (although they are
often hypovolaemic from septic shock)
• Check the eyes lids to see if there is lid-
retraction – a sign of sympathetic over-activity
• Check if the patient is unconscious or not

55. 55
Conscious Unconscious
Sleeping Awake
Eyes not closed Eyes closed
Dehydration or
Hypoglycaemia
Mild/Mod
Eye-lid
retracted
Eye-lid
normal
Dehydration or
Hypoglycaemia
Mild/Mod
Eyes not closed Eyes closed
Dehydration or
hypoglycaemia
Mild/moderate
Eyes Sunken
Not recent Recent onset
Not dehydrated
How to diagnose dehydration in severe malnutrition

56. 56
Conscious
Unconscious
Resomal
ONLY Rehydrate until the weight
deficit (measured or estimated) is
corrected and then STOP – DO
not give extra fluid to “prevent
recurrence”
IV fluid
Darrow’s solution
or 1/2 saline & 5% glucose
or Ringer lactate & 5% dextrose
at 15ml/kg the first hr & reassess
- 5ml/kg /30min first 2hrs
- 5 to 10ml/kg/hr 12 hrs
- If improving, 15ml/kg 2nd hr;
- If conscious, NGT: ReSoMal
- If not improving =>Septic shock
Treatment of Dehydration

57. 57
• If there is continued weight loss, then:
– Increase the rate of administration of
ReSoMal by 10ml/kg/hour
– Formally reassess in one hour
• If there is no weight gain, then:
– Increase the rate of administration of Resomal
by 5ml/kg/hour
– Formally reassess every hour
• If there is clinical improvement but there are still
signs of dehydration
– continue with the treatment until the
appropriate weight gain has been achieved.

58. 58
• If there is weight gain and deterioration of the
child’s condition with the rehydration therapy
– Then the diagnosis of dehydration was definitely
wrong.
– Stop and start the child on F75 diet.
• If there is no improvement in the mood and look
of the child or reversal of the clinical signs
– Then the diagnosis of dehydration was probably
wrong:
– either change to F75 or alternate F75 and Resomal.

59. 59

60. 60
Diagnosis of Dehydration in
Kwashiorkor Patients
• All children with Oedema have an increased total
body water and sodium
• Oedematous children are unlikely to dehydrated
• If a child with Kwashiorkor has definite watery
diarrhoea with weight loss, give Resomal 30 ml
per watery diarrhoea
• Management of hypovolaemia in Kwashiorkor is
similar to management of septic shock

61. 61
Monitoring Rehydration
FLUID BALANCE is measured at intervals by WEIGHING the child – the
change in weight gives a very accurate estimate of fluid balance. Do not
attempt to measure the volume of fluid lost this is much less
accurate and very time-consuming – it is quick and accurate
to weigh the child.
THERE MUST BE AN ACCURATE SCALE IN PHASE ONE,
that is easy to use and safe for acutely ill children
 Monitor every hour
• the liver edge marked on the skin before any rehydration
treatment starts
• the weight, the respiration and pulse rate
• the heart sounds

62. 62
Eye-lid drooping/normal or closed
when asleep/unconscious
Septic shock Septic shock with
Hypoglycaemia
•No History of recent eyes sinking
•No history of major fluid loss
Eye-lid retracted or slightly open when
asleep/ unconscious
Signs of Septic shock present
Fast weak pulse, cold peripheries, pallor,
drowsiness
Note: Lid retraction without shock
– treat immediately for hypoglycaemia
How to diagnose septic shock

63. 63
How to diagnose and treat Septic Shock?
• Diagnosis = Septic shock to be present
a fast weak pulse with
cold peripheries
Pallor
Disturbed consciousness
• Treatment
- Give second line and first line antibiotics together
- Kept warm to prevent or treat hypothermia,
- Give sugar-water by mouth or NGT as soon as the
diagnosis is made (to prevent hypoglycaemia).
- Physically disturb as little as possible

64. 64
Septic shock
Conscious
Unconscious
Loosing conscious
F 75 by mouth or
NGT
- Darrow’s solution,
or 1/2 saline & 5% glucose,
or Ringer Lactate & 5% glucose
at 15ml/kg the first hr
- Reassess every 10min(see p.37)
- If possible, Blood transfusion: 10ml/kg in
3 hours, without anything else.
- If improving, F-75;
- If conscious, NGT: F75

65. 65

66. 66
All rehydration (oral or intravenous) therapies should
be stopped immediately if
– The target weight-increase has been achieved
– The visible veins become full (go to F75)
– The development of oedema (overhydration – go to F75)
– The development of prominent neck or superficial veins*
– An increase in the liver size by more than one
centimetre.*
– The development of tenderness over the liver.*
– An increase in the respiration rate by 5 breaths per
minute or more*
– The development of a “grunting” respiration.*
– The development of crepitations in the lungs*
– The development of a triple rhythm*

67. 67
Diagnosis
• Physical deterioration with a gain in weight
• An increase in liver size.
• Tenderness over the liver
• An increase Resp Rate (>50/min for 5 to 11mo &
>40/min for 1-5 years, or an acute increase in
respiration rate of more than 5 breaths/min).
• ”Grunting respiration” during each expiration –
sign of “stiff lungs”.
• Crepitations in the lungs
• Prominent superficial and neck veins
• Heart sounds - Development of triple rhythm
• Increasing or reappearance of oedema during treatment
• A fall in Hb concentration (needs laboratory) – falling Hb is
usually a sign of fluid overload and NOT of loss of red cells
How to diagnose Heart Failure

68. 68
Weight Increase Weight decrease
Pneumonia
Aspiration
Fluid overload
Heart failure
Weight stable
Examine daily weights
Respiratory distress

69. 69
• Stop all intake of fluids or feeds (oral or IV)
• No fluid or food should be given until the heart
failure has improved or resolved (even 24-48 hours.)
• Small amounts of sugar-water can be given
orally if worried about hypoglycaemia
• Give frusemide (1mg/kg) – usually not very effective.
• Digoxin can be given in small single dose
(5 mcg/kg – note that this is lower than the normal dose of digoxin).
• Even if very anaemic do not transfuse –
Heart Failure treatment takes precedence
Treatment of heart failure

70. 70
- Weight
- Respiration rate & sound
- Liver size
- Pulse rate
- Jugular vein or visible veins engorgement
- Heart sounds
Monitoring during treatment of heart failure

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How to Diagnose and Treat Severe
Anaemia
Check Hb at admission if any
clinical suspicion of anaemia
- Hb >= 40g/l or
-Packed cell vol>=12%
-or between 2 and 14
days after admission
- Hb < 40g/l or
- Packed cell vol<12%
No acute treatment
Iron during phase 2
ONLY during the first 48
hours after admission:
Give 10ml/kg whole or
packed cells 3hours - No
food for 3 to 5 hrs

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Hypoglycaemia
• The good results of day-care show that
significant hypoglycaemia is very uncommon
• Best prevented by regular feeding
• Often there are no clinical signs at all
• Treatment has no adverse effects
• Always treat children with septic shock as if
they also have hypoglycaemia

73. 73
 Give the patient:
- If Conscious: about 50 ml of 10% sugar water (~10g or
two tea spoons of sugar in 100ml) or F-75 by mouth
- If Loosing consciousness: 50 ml of 10%sugar water
by NGT.
- If Unconscious: Give sugar water by NGT AND
glucose as a single IV injection (~ 5ml/kg of 10% solution –
stronger solutions of glucose clot and obliterate the vein).
 Start second-line and first line antibiotics together
 Reassess after 15 minutes; If rapid improvement
does not occur then revise your diagnose.
•Check for eye-lid retraction (sign of active sympathetic
nervous system activity)
•Check if the patient is loosing consciousness
How to diagnose and treat Hypoglycaemia

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Hypothermia – effect of the environment
35.0
35.5
36.0
36.5
37.0
37.5
-30 0 30 60 90 120 150
Time (min)
Core
Temperature
(
o
C)
• Thermoneutral
temperature range is
28oC to 32oC
• Nearly all hypothermia is
due to a low
environmental
temperature, lack of
cover or washing – The
figure shows the effect of
lowering room
temperature to 25oC

75. 75
Warm the patient using the “kangaroo
technique” for children with a caretaker
Put a hat on the child and wrap mother an child
together
Give hot drinks to the mother (hot water is sufficient)
to warm her skin.
Monitor body temperature during re-warming.
Treat for hypoglycaemia and give second-line
antibiotic treatment.
•Check the T of the patient:T rectal<35° - T axi. <35.5° C
•Check the temperature (T) of the room (28 - 32°C)
•Check that the child sleeps with his/her mother
•Do not wash severely ill children!
How to diagnose and treat Hypothermia

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Kangaroo Technique

77. 77
Fever
• Is the child on routine antibiotics?
• Does malaria rolled out or treatment given for
malaria ?
• Most fever is due to a high environmental
temperature.
• Treat with sponging with room-temperature
water. (never use alcohol)
• Give EXTRA WATER to drink
• Do NOT give aspirin or paracetamol – it does not work in the
severely malnourished and they have defective liver function.
• Children on admission may have aspirin poisoning if the
mother has noted the fever

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Fever - Effect of changing from 29oC to 38oC
36.5
37.0
37.5
38.0
-30 0 30 60 90
Time Minuets
Temperature
(oC)

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Infection
• All severely malnourished children should
get antibiotics for presumed infection even
if they don’t have clinical sign of systemic
infections
• Give one course of Amoxicillin for all
• If the child has sign of sever infection
( Pneumonia/Severe Pneumonia, septic
shock, sepsis, urinary tract infections…)
second line antibiotics should be added

80. 80
Treating Infection

81. 81
A marasmic child had a weight of 5.5kg at 1 year of
age;
He had 6 loosed stools yesterday and his weight the
next day decreased to 5.2kg.
His liver size was drawn on the skin and the
respiratory rate recorded.
 What will be your advice?

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• He lost 300g which is 6% of his body weight. He
has no oedema.
• The nurse ordered 25ml (5ml/kg) of ReSoMal
every 30 min for the 2 first hours and then the
same amount in the next 2 hours. He had
improved and he then was given F75 with the
other children in Phase 1.
• When they took his weight, after 4 hours, he was
5.45kg, the liver size was the same and the
respiratory rate was around 40/min’.