presna

1. Community-based Management Of Acute
Malnutrition (CMAM)
PREPAIRED BY DEREJE ZEWDIE
Injibara JULAY 2025

2. What is Nutrition ?
 Nutrition is the science of Ingestion, Digestion, Absorption, Assimilation,
Biosynthesis, Transport, Metabolism, Excretion, and actions of the
nutrients within the body for
Physical and mental growth and development,
Prevention of diseases,
Development of the immune system

3. What are NUTRIENTS ?
 Nutrients – components in foods that an organism uses to survive and
grow
 Macronutrients – carbohydrates, fats, proteins, and dietary fiber,
needed in large quantities to provide energy and support a healthy body
 Micronutrients – vitamins and minerals like iron, calcium, iodine, and
zinc, required in smaller amounts but are still critically important for
maintaining optimal health

4. What is malnutrition ?
Malnutrition :- refers to any imbalance in
nutrition –either too little or too much
nutrient intake.(WHO Definition)
Types
2.Over nutrition
-over weight
-obesity
-NCD
1.Under Nutrition
-wasting /acute malnutrition
-stunting/chronic malnutrition
-under weight/low weight for age
-micronutrient deficiencies

5. Most common cause of morbidity
and mortality among children under
5 years.
Result of deficiency of protein,
energy, minerals as well as
vitamins
Children with acute malnutrition
are 12 times more likely to die
compared to other well nourished
children.
Overview of the Management of Acute Malnutrition

6. Cont…
 The Community-Based Management of Acute
Malnutrition (CMAM), consists of four main
components:
1. Community Outreach/Mobilization:
2. Supplementary Feeding Program (SFP):
Targeted Supplementary Feeding Program (TSFP) And
Blanket Supplementary Feeding Program (BSFP).
3. Outpatient Treatment Program (OTP):
4. Inpatient Treatment/ Stabilization Centre (SC):

7. • Screening!!!!
Weight (uni-scale, beam scale and salter
scale),one hr before or after if admitted
Height (>=2yrs )
Length (<2yrs and <87cm)
MUAC (acromion and olecranon)
 Edema

8. 1. Admission and Discharge Criteria for Children 6-59 Months

10. The anthropometric indicator that is used to
confirm SAM should also be used to assess
whether a child has reached nutritional
recovery, i.e
If MUAC is used to identify that a child has
SAM, then MUAC should be used to assess and
confirm nutritional recovery and discharge.

11. Cont…
Similarly, if WFH/L is used to identify that a child
has SAM, and then WFH/L should be used to assess
and confirm nutritional recovery and discharge.
Children admitted with only bilateral pitting edema
should be discharged based on either MUAC or
WFH/L.
Children receiving SAM or MAM treatment should
be discharged when they reach a MUAC ≥ 12.5 cm or
WFH/L ≥ -2 z-scores and have no bilateral pitting
oedema for two consecutive visits.

12. Cont…
Note:
MAM cases with medical complications need
to be managed at TSFP and provided medical
care based on:
Integrated Community Case Management (ICCM)
Integrated Management of Newborn and
Childhood illness (IMNCI) protocol.

13. Infants age UNDER 6 MONTHS f or Severe Acute
Malnutrition (SAM)
Any grade of bilateral pitting edema (+, ++ or +++) OR
WFL < - 3 z score

15. Cont…
NOTE:
All infants 0-6 months of age with SAM with or
without medical complications should be referred to
the SC.
Visible severe wasting is no longer recommended as
diagnostic criteria of SAM, due to its subjective
nature, but can be used during community screening,
so as to refer to health facility for further evaluation.

18. 2. Use of Antibiotics in Children 0-59 Months
Only amoxicillin is used as a routine medication for
all patients with SAM without medical complications.
If a patient is HIV positive and receiving
cotrimoxazole according to the National Guidelines
for Comprehensive HIV Treatment and Care, then
amoxicillin is given in addition as a routine SAM
medication.

20. Vitamin A is not given to patients if they are receiving
therapeutic foods that comply with WHO
specifications.
Vitamin A is given on admission only if the
therapeutic foods provided are not fortified as
recommended in the WHO specifications and vitamin
A is not part of other daily supplements.

21. Vitamin A:
Give age appropriate dose of Vitamin A on Day 1 Day 2,
and Day 15 (with or without edema) if:
The child has visible clinical signs of vitamin A deficiency
(Bitot’s spots, corneal clouding, or corneal ulceration)
The child has signs of eye infection (pus, inflammation)
The child has measles now or has had measles in the past 3
months
The child has persistent diarrhea

25. 3. Folic Acid Supplementation for Children 0-
59 Months
Folic acid should not be given routinely to
SAM children receiving therapeutic foods (F-
75, F-100 or RUTF) that comply with WHO
specifications, as they contain enough amounts
of folic acid.

26. 4. Therapeutic Feeding Approach for SAM with Medical Complications
How can we prepare F-75 or F-100 Feeds?
1. Boil water to make it safe for drinking.
2. Ensure that the water temperature is not below 70ºc (i.e.,
cooled for not less than 3-5 minutes after boiling).
3. Add the water to the F-75 or F-100 therapeutic milk
powder.
4. Whisk the mixture vigorously until the powder dissolves in
the water.
5. Cool the prepared milk to feeding temperature before
administering

27. Cont…

31. Cont….

32. Cont…
Note that children’s weights listed on the F-75 Reference
Card are all in even digits (3.0 kg, 3.2 kg, 3.4 kg, etc.).
If a child’s weight is between these (for example, if the
weight is 3.1 kg or 3.3 kg), use the amount of F-75 given
for the lower weight i.e.,3 kg or 3.2 kg
Note:
Give F-75 to infants with bilateral pitting edema and
change to F-100-Diluted when the edema is resolved.

33. Cont…
While the child is on F-75, keep using the starting
weight to determine feeding amounts even if the
child’s weight increases because the weight is not
expected to increase on F-75.
For an edematous child, also continue using the
child’s starting weight to determine the amount of F-
75, even when the edema (and weight) decreases.

34. An NGT should be used if the child:
Takes less than 80% of the prescribed diet on two
consecutive feeds during stabilization
Has pneumonia (rapid respiration rate) and difficulty
swallowing
Has painful lesions/ulcers of the mouth
Has a cleft palate or other physical deformity
Is very weak and shows difficulty remaining conscious
The NGT should only be used in the stabilization phase.

35. Remove the NGT
When the child either takes: 80% of the day’s
amount orally; or
Two consecutive feeds fully by mouth.
Exception:
If a child takes two consecutive feeds fully by
mouth during the night, wait until morning to
remove the NGT, just in case it is needed again
in the night.

36. Monitoring during Stabilization Phase
Measure and record weight on the SC Multi-
chart and plot it on the chart each day.
Assess and record the degree of oedema (0, +,
++, +++) each day.
Measure MUAC on admission, and then once
per week.
Monitor body temperature, pulse, and
respiration every 4 hours.

37. Cont…
Assess and record any standard clinical signs
(stools, vomiting, dehydration, cough, skin
conditions, and perianal lesions) daily.
Note and record in the patient record each day
whether the patient is absent, vomits, or
refuses a feed, and whether the patient is fed
by NGT or is given an IV infusion or blood
transfusion.

38. 5. Therapeutic Feeding Approach for SAM with
Medical Complications During Transition Period
During the transition period, RUTF is introduced
alongside F-75.
The child drinks water freely.
If the child does not consume the prescribed amount
of RUTF, F-75 is used to top-up the feed.
The amount of RUTF is increased over 2–3 days until
the child consumes the full required amount of RUTF.

39. Cont…

40. Specialized Nutritious Foods

41. Criteria to transfer the child from Phase 1 to transition phase:
Return of appetite (i.e., easily finishes all F-75 milk).)
and
Subsiding bilateral pitting
No IV line, No NGT and
Medical complications are improving
Note:
Children with +++ edema should wait in stabilization
phase at least until their edema has reduced to ++
edema.
These children are particularly vulnerable

42. Transition Phase to the
Stabilization Phase
Weight gain of more than 10 g/kg/day in association with
an increase in respiratory rate (indicative of excess fluid
retention)
Increasing or developing edema
A rapid increase in the size of the liver
Any sign of fluid overload
Tense abdominal distension
A complication that necessitates an IV infusion
A need for feeding by NGT
Significant refeeding diarrhea leading to weight loss

43. Cont…
NOTE:
It is common for patients to have some change
in stool frequency when their diet changes.
This does not need to be treated unless there is
weight loss.
Having several loose stools without weight
loss is not a criterion for moving back to the
stabilization phase

44. How we calculate daily weight gain?
Only children in phase 2 are expected to gain weight.
W2 – W1 = ___ kg
___kg x 1000 = ____ grams gained
Example
Ketema began taking F-100 in the in the SC.
On Day 6 Ketema weighed 7.32 kg.
On Day 7 he weighed 7.4 kg.
His weight gain in g/kg/day can be calculated as
follows:

45. Cont…
7.4 kg – 7.32 kg = 0.08 kg
0.08 kg x 1000 = 80 grams gained
80 grams ÷ 7.32 = 10.9 g/kg/day
Interpretation of weight gain
Good weight gain = 10gm/kg/day or more
Moderate weight gain = 5-10gm/kg/day
Poor weight gain = less than 5gm/kg/day

46. Transition Phase to the
Rehabilitation Phase in SC
A good appetite: Takes all the F-100 prescribed
for the transition phase.
Edema reduced to moderate (++) or mild (+).
If wasting with bilateral pitting edema, edema
should completely disappear.
Medical complications are resolving.
Clinically well and alert

47. Rehabilitation phase to
Stabilization Phase:
Develops any signs of a complication
Develops or increases edema.
Develops re feeding diarrhea, which is
sufficient enough to bring weight loss.
Loses weight for 2 consecutive weighing
Has static weight for 3 consecutive weighing
Fulfills any of the criteria of “failure to
respond to treatment”

48. Infants below six months with no prospect to breast-fed
• F-75 (for edematous) or diluted F-100 (for non-
edematous)
• A nasogastric tube should not be used for more
than 3 days
• should only be used in the initial phase
Substantial weight gain is not expected during
stabilization.

49. Transition
signs of recovery and is F-100 diluted:
 Increase the volume by 30%
 Monitor the infant’s weight.
• When the infant shows the signs of recovery and is
taking F-75 (edematous):
Give F-100-Diluted provided at 150–170 mL/kg
per day, or increased by one third over the initial
amount given, providing 110–130 kcal/kg per day.

50. Conti…….
• The criteria for further increasing the amount of
feed given to the child are as follows.
A good appetite:
 the child is taking at least 90% of the infant
formula (F-100-Diluted) prescribed
 Complete loss of bilateral pitting edema; or
 The child has been taking these amounts for at
least 2 days;
 No other medical problem

51. Rehabilitation
infants should be fed using a cup and a saucer
increase the volume of milk rations for
another 30%.
 If the infant is still hungry after finishing the
ration, Increase the rations of 5 ml per meal.

52. Discharge criteria
• Infant is feeding well with the replacement feed.
• Has adequate weight gain and has a WFL ≥ -2 z-
score.
• No bilateral pitting edema.
• Clinically well and alert.
• Infant has been checked for immunization and
other routine interventions.
• linked with community-based follow-up and
support

54. 6. Fluid Management of with SAM with Medical
Complications
Children 0-59 months with SAM who present
with dehydration but not in shock should be
rehydrated slowly, either orally or by NGT
using ReSoMal (5-10ml/kg/h up to a
maximum of 12 hours).
ORS should not be used for oral or nasogastric
rehydration in children with SAM with
dehydration.

55. Cont…
ORS is recommended instead of ReSoMal if a
patient is diagnosed with profuse watery
diarrhoea or acute watery diarrhoea (AWD).
Therapeutic foods already contain adequate
zinc, therefore children with SAM and AWD
receiving F-75, F-100 or RUTF should not
receive additional zinc supplements.

56. Important things NOT to do and why
1. Do not give diuretics to treat edema
The edema is partly due to potassium and magnesium
deficiencies that may take about 2 weeks to correct.
2. Do not give high protein formula
Too much protein could overload the liver, heart, and
kidneys and may cause death.
3. Do not give IV fluids routinely
IV fluids can easily cause fluid overload and heart
failure in a severely malnourished child.

57. Cont…
4. Do not give iron early in treatment
Giving iron early in treatment lead to “free iron” in
the body.
Free iron can cause problems in three ways:

58. Cont…
I. Free iron is highly reactive and promotes the
formation of free radicals, which may engage in
uncontrolled chemical reactions with damaging
effects.
II. Free iron promotes bacterial growth and can make
some infections worse.
III. The body tries to protect itself from free iron by
converting it to ferritin.This conversion requires
energy and amino acids and diverts these from other
critical activities.

61. INTITAL MANAGEMENT
OF MALNUTRATION
INTITAL MANAGEMENT
OF MALNUTRATION

62. Out line
 Management of hypoglaycimia
 management of hypothermia
 Management of shock
 Management of sever animia
 Management of with SAM
 Emergency eye care

63. 1.Manage Hypoglycemia
• What is Hypoglycemia?
• Hypoglycemia is a low level of glucose in the blood. In severely
malnourished children, the level
 considered low is less than <54 mg/dl (< 3 mmol/L). The
hypoglycemic child is usually hypothermic (low temperature) as
well.
• Other signs of hypoglycemia include
• Lethargy,
• Limpness,
• Loss of consciousness.
• Eye-lid retraction (due to overactive sympathetic
nervous system, thus a child sleep with eyes slightly open).

64. Cont. ……………
• Test blood glucose level
 Determine blood glucose level, hemoglobin level and blood
type, in case transfusion is needed.
 There may not be enough time to take and test a blood
sample right away
 If hypoglycemia is suspected, give treatment immediately
without laboratory confirmation.
 If no testing strips are available, or if it is not possible to get
enough blood to test, assume that the child has
hypoglycemia.

65. Cont. ………..
• Treat Hypoglycemia
 If blood glucose is low or hypoglycemia is suspected,
immediately give the child a 50 ml bolus of 10% glucose or
10% sucrose orally or by NG tube
 Though 50 ml is a very small amount, but it can make a big
difference to the child.
 If only 50% glucose solution is available, dilute one part to
five parts sterile or boiled water to make a 10% solution

66. Cont. ……
Mixture Gives Gives
12.5 ml of 40% dextrose + 37.5
ml of Distilled water
50 ml of
10%
Dextros
e
7.5 ml of 40% dextrose + 42.5 ml
of 5% dextrose
10 ml of 50% dextrose + 40 ml
Distilled water
6 ml of 50% dextrose + 44 ml of
5% dextrose

67. Cont. ………..
• If the child can drink, give the 50 ml bolus orally. If the
child is alert but not drinking, give the 50 ml by NG tube
(i.e., 37.5 ml of distilled water with12.5 ml of 40% dextrose).
• If the child is lethargic, unconscious, or convulsing, give 5
ml/kg body weight of sterile 10% glucose by IV, followed by
50 ml of 10% glucose or sucrose by NG tube.
 If the IV dose cannot be given immediately, give first dose
through NG tube.

68. Cont. …….
• Start feeding F-75 half an hour after giving glucose and give it
every half-hour during the first 2 hours (giving 1/4 of the 2-hour
F-75 feed each time).
• Take another blood sample after 2 hours and check the child’s
blood glucose again.
 If blood glucose is now 54 mg/dl (3mmol/l) or higher, change to
2- hourly feeds (12 feeds per day) of F-75.
 If still low, make sure antibiotics and F-75 have been given.
 Keep giving F-75 every half-hour and treat with second-line
antibiotics

69. 2. Manage Hypothermia
• What is Hypothermia?
 Hypothermia is low body temperature.
 A severely malnourished child is hypothermic if the rectal
temperature is below 35.5 0C or if the axillary temperature
is below 35 0C.
 The hypothermic child has not had enough calories to warm the
body.
 If the child is hypothermic, he is probably also hypoglycemic.
 Both hypothermia and hypoglycemia are signs that the child has
a serious systemic infection.

70. Cont. …….
• Take temperature
 Rectal temperatures are preferred because they more
accurately reflect core body temperature.
 If axillary temperatures are taken, convert them to rectal by
adding 0.5 0c.
• Warm the child
 Severely malnourished children have difficulty controlling
their body temperature and so must be kept warm and fed
frequently.
 Hypothermia is very dangerous. If the child is hypothermic,
re-warming is necessary to raise temperature

71. Cont. …….
• Maintain temperature (prevent hypothermia)
 The following measures are important for all severely
malnourished children:
• Feed F-75 every 2 hours, starting straight away.
• Keep the patient covered and away from draughts.
• Warm your hands before touching the patient
• Keep the child dry and promptly change wet nappies,
clothes, and bedding.
• Avoid prolonged exposure (e.g., bathing, prolonged medical
examinations).
• Let the child sleep with the mother/caregiver at night for
warmth.
• Dry the child thoroughly after bathing.

72. Cont. …..
• Actively re-warm the hypothermic child
 In addition to keeping the child covered and keeping the room
warm, use one of the following rewarming techniques if the child is
hypothermic:
• Have the mother hold the child with his skin next to her skin when
possible (technique kangaroo),
• Give warm Fluid to the mother.
• Use a heater with caution.
 Use indirect heat (not too close).
• Monitor temperature every 30 minutes to make sure the child does
not get too hot.
• Do NOT use hot water bottles due to danger of burning fragile skin.

73. Cont. …..
Kangaroo
technique

74. 3. watery diarrhea and/or vomiting and
Dehydration
• Recognize Dehydration and the need for ReSoMaL
Misdiagnosis and incorrect treatment for dehydration is
among the common causes of death in children with
SAM .
It is often difficult to determine hydration status in a
severely malnourished child, as the usual signs of
dehydration.

75. Cont. …….
Consider the diagnosis of dehydration in non-
edematous child and give ReSoMaL if there are:
 Definite history of significant recent fluid loss Clear
history of a recent change in the child’s appearance
 If the eyes are sunken then the mother must say that
the eyes have changed to become sunken since the
diarrhea or vomiting started

76. Cont. …….
• Edematous children are over-hydrated, but they are
frequently hypovolemic due to extravasation fluid.
 If the child with edema has definite watery diarrhea
and is deteriorating clinically (excessive weight loss,
more than 2% of the body weight per day), the child
is dehydrated.

77. Cont. ………..
• General Signs of Dehydration to follow during rehydration
 Lethargic
 A lethargic child is not awake and alert .
 He is drowsy and does not show interest in what is happening
around him.
 A severely malnourished child is usually apathetic
 and, as dehydration worsens, the child progressively loses
consciousness.
 Restless, irritable
 The child is restless and irritable all the time.

78. Cont. ……
• Sunken eyes:-
 The eyes of a severely malnourished child may always appear
sunken, regardless of the child’s hydration status.
 Ask the mother if the child’s eyes appear unusual.
• Thirsty
 See if the child reaches out for the cup when you offer ReSoMaL.
 When it is taken away, see if the child wants more.
• Dry mouth and tongue:-
 Feel the child’s tongue and the inside of the mouth with a clean,
dry finger to determine if they are dry.
 The salivary and lacrimal glands are atrophied in severe acute
malnutrition, so the child usually has a dry mouth and absent
tears.

79. Cont. …..
• Skin pinch goes back slowly
 Using your thumb and first finger, pinch the skin on the child’s
abdomen halfway between the umbilicus and the side of the
abdomen.
 (Note: the skin pinch may always go back slowly in a wasted
child.)
 Edema may mask diminished elasticity of the skin.
 Also, in severely malnourished children, the loss of supporting
tissues and absence of subcutaneous fat make the skin thin and
loose.

80. What is ReSoMal?
 ReSoMaL is a rehydration solution for malnutrition.
 Contains less sodium, more sugar, and more potassium than
standard ORS
 It should be given by mouth or by nasogastric tube.
 Do not give standard ORS to severely malnourished children.
 However, if has profuse watery diarrhea as in the case of cholera,
should be given standard ORS and not ReSoMaL

81. Cont. …………….
• Contents of ReSoMaL as prepared from standard ORS:
o Water 2 liters
o WHO-ORS one 1 liter packet
o Sugar 50 g
o Mineral mix solution* 40 ml or one leveled
scoop CMV
• *The mineral mix solution is the same as that is used in making
F-75 and F-100.
• Alternatively, a commercial product, called Combined Mineral
Mix (CMV), may be used.
• If CMV or mineral mix is not available, prepare without the
mixes

82. Cont. ……
• Prepare ReSoMaL
 If using commercial ReSoMaL, follow the package instructions.
 If preparing ReSoMal from standard ORS and mineral mix
solution, prepare as follows:
• Wash hands.
• Empty one 1-litre standard ORS packet into container that holds
more than 2 liters.
• Measure and add 50 grams of sugar.
• Measure 40 milliliters or one leveled scoop of CMV in a
graduated medicine cup or syringe; add to other ingredients.
• Measure and add 2 liters cooled boiled water.
• Stir until dissolved.
• Use within 24 hours.

83. Calculate amount of ReSoMaL to give
 For a child who has dehydration but no sign of shock, give
ReSoMaL as follows, in amounts based on the child’s weight:
 Every 30 minutes for first 2 hours 5 ml/kg body weight
 Alternate hours for up to 10 hours 5 - 10 ml/kg*
• If the child has already received IV fluids for shock and is
switching to ReSoMaL, omit the first 2-hour treatment and
start with the amount for the next period of up to 10 hours.

84. Cont. …………………..

85. Exercise
1. Yetayesh arrived at the hospital in shock and received IV fluids
for two hours. She has improved and is now ready to switch to
ReSoMal.
Yetayesh weighs 8.0 kilograms. For up to _____ hours, she
should be given ReSoMal. The amount of ReSoMal to offer is
________ milliliters per hour.
2. Rediet has watery diarrhea and is severely malnourished with
no edema. He weighs 6.0 kilograms. He is dehydrated but has no
shock. He should be given ________ ml ReSoMaL every _____
minutes for ____ hours. Then he should be given ____ - ____ ml
ReSoMal in _____________ hours for up to ____ hours. In the
other hours during this period, ______ should be given.

86. Determining target weight for rehydration: -
• For children with non-edematous severe acute malnutrition with
watery diarrhea:
• if pre-diarrheal weight is known, use it to control weight gain
during hydration;
• If pre-diarrheal weight is not known, presume a 5% loss of body
weight and determine the target weight before giving the ReSoMaL.
For example: Weight of child = 5.3kg
5.3kg +5% = 5.56 kg (expected rehydration weight)
• For severely malnourished children with edema and with watery
diarrhea:
• Rehydration must be done more cautiously
• Give 30 ml of ReSoMaL per watery stool until diarrhea
stops

87. Cont. ……
• Give ReSoMaL slowly
 Too much fluid, too quickly, can cause heart failure.
 The best way to give ReSoMaL is by cup, even with a very sick
child.
 A nasogastric (NG) tube can be used for giving ReSoMaL at the
same rate if the child is too weak to take enough fluid voluntarily.
 It is essential to stop giving ReSoMaL when the child reaches the
target weight

88. Monitor the child who is taking ReSoMaL
 Monitor the child’s progress every half hour for the first two hours; and
do major reassessment of the child’s condition after the first 2 hours.
 Then monitor hourly, i.e., every time the child takes F-75 or ReSoMaL
• Signs to check
• Respiratory rate - Count for a full minute.
• Pulse rate - Count for 30 seconds and multiply by 2.
• Weight
• Urine frequency – Ask: Has the child urinated since last checked?
• Liver size: mark before any infusion
• Stool or vomit frequency – Ask: Has the child had a stool or
vomited since last checked?
• Signs of hydration - Is the child less lethargic or irritable?

89. Cont. ….
• Signs of improving hydration status
• Fewer or less pronounced signs of dehydration, for example:
• less thirsty*
• less lethargic*
• Slowing of rapid respiratory and pulse rates
• Passing urine
• Gaining weight with clinical improvement
• If a child has three or more of the above signs of improving
hydration status, stop giving ReSoMal.
• Instead, offer ReSoMal after each watery diarrhea.
• Continue monitoring even after improved hydration status
and ReSoMal stopped.

90. Signs of over hydration
• Stop ReSoMal if any of the following signs appear:
• Child’s weight exceeds the target weight
• Increased respiratory rate by 5 breaths and pulse rate by 25 beats
per minute. (Both must increase to consider it a problem.)
• Jugular veins engorged. (Pulse wave can be seen in the neck.)
• Sudden increase in liver size and tenderness
• Increasing edema (e.g., puffy eyelids).
• Increasing weight with clinical deterioration

91. Monitoring a child on rehydration with ReSoMal

92. After rehydration, offer ReSoMal after each loose stool
 When the child has three or more signs of improving hydration
(see above), stop giving ReSoMal routinely in alternate hours.
 However, watery diarrhea may continue after the child is
rehydrated.
 If diarrhea continues, give ReSoMal after each watery diarrhea
to replace stool losses and prevent dehydration:
• < 2 years: give 50-100 ml after each watery stool
• 2 years and older: give 100 – 200 ml after each watery stool.
Base the amount given in these ranges on the child’s willingness to
drink and the amount of stool loss.
• F-75 is given in alternate hours during this period until the child
is rehydrated

93. Manage a severely malnourished child with shock
• What is shock?
 Shock is a generalized hypo perfusion of tissues and a
dangerous condition with severe weakness, lethargy, or
unconsciousness, cold extremities, and fast, weak pulse.
 It is caused by diarrhea with severe dehydration, hemorrhage,
burns, or sepsis.
 In severely malnourished children, some of the signs of shock
may not appear all the time, so it is difficult to diagnose.
 Thus, IV fluids are given in severe malnutrition only if the
child meets the following criteria:

94. Cont. ………
• The severely malnourished child is considered to have
shock:-
 if he/she is lethargic or unconscious and
 has cold hands plus either:
 slow capillary refill* (longer than 3 seconds), or
 weak, fast** or absent radial or femoral pulses

95. Cont. ……..
• Give oxygen, IV glucose, and IV fluids for shock
• If the child is in shock •
 Give oxygen (for infants 0.5 to 1 lit per minutes and for older
children 1 to 2 lit per minute).
• Give sterile 10% glucose 5 ml/kg by IV
• Give IV fluids
• Keep the child warm.

96. Cont. ………
• Giving IV fluids
 Shock resulting from dehydration and sepsis are likely to coexist
in severely malnourished children.
 They are difficult to differentiate on clinical signs alone.
 Children with shock due to dehydration will respond to IV fluids.
 Those with septic shock and no dehydration will not respond.
 The amount of IV fluids given must be guided by the child’s
response.
 Over-hydration can cause heart failure and death.

97. To give IV fluid
• Check the starting respiratory and pulse rates and record them
including the starting time on the Multichart and shock follow
up chart
• Infuse IV fluid at 15ml/kg over 1 hour. Use one of the
following solutions
• Ringer’s lactate solution with 5% glucose*
• 0.45 % normal Saline with 5% glucose*
• *If either of these is used, add sterile potassium chloride
(20 mmol/l) if possible.
• Observe the child and check respiratory and pulse rates every
10 minutes.
• Follow the liver size, child is passing urine and weight gain.

98. Cont. ……….
• If the respiratory rate and pulse rate increase and child is gaining
weight, stop the IV rehydration and assume septic or cardiogenic
shock.
• • If respiratory rate and pulse rate are slower after 1 hour, the child
is improving.
• Repeat the same amount of IV fluids for another hour.
• Continue to check respiratory and pulse rates every 10 minutes.
• After 2 hours of IV fluids, switch to oral or nasogastric rehydration
with ReSoMaL (special rehydration solution for children with
severe malnutrition).
• Give 5-10 ml/kg ReSoMaL per hour and continue to give
F-75 alternate hours for up to 10 hours.

99. Cont. …
• If no improvement with IV fluids, give blood transfusion
 If the child fails to improve after the first hour of IV fluids, then
assume that the child has septic shock.
 Give maintenance IV fluids (4 ml/kg/hour) while waiting for
blood.
 When blood is available, stop all oral intake and IV fluids, give
a diuretic to make room for the blood, and then transfuse whole
fresh blood at 10 ml/kg slowly over 3 hours.
 If there are signs of heart failure, give packed cells instead of
whole blood as these have a smaller volume.

100. 5. Manage very severe anemia
• What is very severe Anemia?
 Anemia is a low concentration of hemoglobin in the blood.
 Very severe anemia is a hemoglobin concentration of < 4 g/dl (or
hematocrit <12%).
 If it is not possible to test hemoglobin, rely on clinical judgment.
For example, you can judge the degree of anemia based on paleness
of gums, lips, palm, and inner eyelids.
• Severe anemia can cause heart failure and must be treated with a
blood transfusion.
 As malnutrition is usually not the cause of the anemia, it is
important to investigate other possible causes such as malaria and
intestinal parasites (for example, hookworm).

101. Cont. ……….
 Symptoms of moderate and severe anemia may appear between
day two and day 14 of treatment of malnutrition, due to the
movement of fluids from tissues (edema and intracellular water) to
vascular space.
 This temporary excess of fluids will produce delusional anemia
(i.e. pseudo-anemia) that should never be treated with blood
transfusions (this risk aggravating the problem and inducing
cardiac overload and death).
• Pseudo-anemia normally resolves spontaneously after 2 or 3 days
• when kidney function recovers, and excess fluids can be
eliminated.
• For these reasons, transfusion is not recommended between 48
hours and day 14 unless there is heart failure and the cause is
other than dilution anemia.

102. Give blood transfusion
• Give blood transfusion in the first 48 hours if:
• Hgb is < 4 g/dl, (Hct is < 12 %), or
• Hgb 4 to 6 g/dl (Hct 12 to 18%) and respiratory distress
• Stop all oral intake and IV fluids during the transfusion.
• Look for signs of congestive heart failure such as fast breathing,
respiratory distress, rapid pulse, engorgement of the jugular vein, cold
hands and feet, cyanosis of the fingertips and under the tongue.
• Give a diuretic* to make room for the blood. Furosemide (1 mg/kg,
given by IV)
• If there are no signs of congestive heart failure, transfuse whole
fresh blood at 10 ml/kg slowly over 3 hours.
If there are signs of heart failure, give 5-7 ml/kg packed cells over 3
hours instead of whole blood.

103. 6.Give emergency eye care for corneal
clouding and ulceration
• Examine the eyes
 Wash your hands.
 Touch the eyes gently and as little as possible.
 Wash your hands again after examining the eyes.
• What are corneal clouding and ulceration?
 corneal ulceration is a break in the surface of the cornea.
 Corneal clouding is haziness of the surface of the cornea (eye
surface)
 If the child has corneal clouding and ulceration, give vitamin A
immediately

104. 7. Managing Heart failure
• Diagnosis
• Physical deterioration with weight gain
• Sudden increase in liver size
• Tenderness of the liver,
• Crackles in lungs,
• Prominent superficial and neck veins,
• Engorgement of the neck veins when the abdomen (right upper
quadrant) is pressed,
• Increased edema or reappearance of edema, among other clinical
signs and symptoms.

105. Cont. ......................
• Treatment
 Stop all intakes of oral or IV fluids.
 No fluid or therapeutic feeds should be given until heart
failure has improved (even if this takes 24 to 48 hours).
 Small amounts of sugar-water can be given orally to
prevent hypoglycemia.
• Give Furosemide (1 mg/kg) single dose, repeat if
necessary.

106. Treat Infections
• Give all severely malnourished children antibiotics for presumed
infection even if they do not have clinical sign of systemic
infections.
• Give the first dose of antibiotics while other initial treatments are
going on, as soon as possible.
• If no medical complications or only failed appetite test, give
first line antibiotics: Oral Amoxicillin (preferred).
• If medical complications present, Give, Gentamicin, plus IV
Ampicillin for 2 days followed by oral Amoxicillin, and continue
Gentamycin IM.

107. Cont. ...........
• If the child fails to improve within 48 hours, change to
Ciprofloxacin and Ceftriaxone)
• If specific infections are identified which require a specific
antibiotic not already being
given, give an additional antibiotic to address that infection.
• • For example, dysentery may require additional antibiotics.
Certain skin infections such as Candidiasis require specific
treatments.
• Antimalarial treatment should be given according to the national
protocol.

108. Thank You!!!