Inpatient Therapeutic Care (ITC)

Inpatient Management Part I

Inpatient Therapeutic Care

Inpatient care for children with SAM is provided in

order to:
• Stabilize children with SAM aged 6 to 59 months
who also have medical complications or a lack of
demonstrated appetite sufficiently to allow them to
continue their nutritional rehabilitation with OTC.
• Provide complete nutritional rehabilitation in
inpatient care for children with SAM where there is
no access to OTC.
• Children in outpatient care may also be referred to
inpatient care for a period of more intensive
treatment/monitoring when they are not
responding appropriately to treatment as an
outpatient.
• Recover infants < 6 months with SAM who require
intensive treatment
 CMAM Triage

Age, anthropometric measurements, edema check

SAM

Appetite test, History, Clinical examination

Outpatient Therapeutic Care (OTC) In-Patient Care (ITC)

 passes appetite test  fails appetite test OR
 no medical complication  medical complication OR
 no severe edema (+++) or MK*  severe edema (+++) OR MK*

Fail appetite test, worsening edema or Phase I/

development of a medical complication Stabilisation
Rehabilitation
REFERRAL
Transition
Return of appetite, sufficient loss of edema
and resolving complications

Rehabilitation
(if no OTC)
Recovery
(link to other services – including
SFP if available)
*Marasmic Kwashiorkor
Phase I/ Stabilization

 For SAM patients with

 an inadequate appetite and/or
 an acute major medical complication OR
 +++ edema
 The therapeutic milk used during this phase is
F75
• promotes repair of physiological and metabolic
functions and electrolyte balance.
 Primary objective is not weight gain but to restore
basic metabolism
 100 kcal/kg/day or 130 ml/kg/day
 Rapid weight gain at this stage is dangerous, that
is why F75 is formulated so that patients do not
gain weight
Transition Phase

- Marks transition from Phase I/Stabilization to

OTC
- introduced because sudden change to large
amounts of diet, before physiological function
is fully restored, can be dangerous and lead to
electrolyte disequilibrium
- During this phase the patients start to gain
weight and appetite, lose edema
- Diet is transitioned from F75 to RUTF (or
F100)
- The quantity of RUTF given increases the
energy intake by about 30%.
- Approximately 130 to 150 kcal/kg/day
Phase 2

• Where it is not possible to refer to OTC, children

remain as inpatients until cured of acute
malnutrition
• This phase continues treatment with F100
therapeutic milk or RUTF, increasing the intake
so as to promote rapid weight gain
• The child remains under treatment until the
anthropometric criteria for discharge are
reached.
 • anthropometric measurements and edema check
• triage of emergency cases
• history, medical examination and appetite test
1. Admission • referral to OTC where required
• recording

• emergency medical management

• routine mediciness & additional medicines
• F75
• orientation to caregiver
2. Phase 1 • monitoring of feeds
treatment
• every 12 hr and daily medical and anthropometric monitoring
• recording and assessment of readiness for transition

• transition to RUTF
• continue medical treatments
• monitoring of feeds
3. Transition • every 12 hr and daily medical and anthropometric monitoring
• recording
• assessment of readiness for OTC/Phase 2

• orientation to caregiver
• RUTF till next OTC distribution
4a. Discharge to • referral documentation and communication with OTC
OTC
 • anthropometric measurements and edema check
• triage of emergency cases
• history, medical examination and appetite test
1. Admission • referral to OTC where required
• recording
•emergency medical management
•routine mediciness & additional medicines
•F75
•orientation to caregiver
2. Phase 1 •monitoring of feeds
treatment
•every 12 hr and daily medical and anthropometric monitoring
•recording and assessment of readiness for transition
•transition to RUTF
•continue medical treatments
•monitoring of feeds
3. Transition •every 12 hr and daily medical and anthropometric monitoring
•recording
•assessment of readiness for OTC/Phase 2

• rehabilitation with RUTF (or F100)

• daily monitoring
• health and nutrition education
4b. Phase 2 in
ITC • recording
• assessment of readiness for discharge

• orientation to caregiver
• recording
5. Discharge
from ITC • links to other services
 Criteria for Admission to ITC or OTC (6-59 months)
Factor Inpatient Therapeutic Care Outpatient Therapeutic Care
Edema Bilateral pitting edema Grade 3 (+++) Bilateral pitting edema Grade 1 or 2 (+ and
++)
OR Marasmic Kwashiorkor*
Anthropometry MUAC <115mm OR W/H or W/L < -3SD MUAC <115mm OR W/H or W/L< -3SD

AND one of the below AND both of the below

Appetite Negative appetite test with RUTF Positive appetite test with RUTF
Medical Any of the below NO medical complications
complications
Vomiting Intractable (empties contents of stomach)
Temperature Fever

or Hypothermia
Respiration rate Tachypnea

And any chest in-drawing (for children > 6 months)

Anaemia Very pale (severe palmar pallor, roof of the mouth
(oropharynx), nailbeds, eye palpebrae), difficulty breathing

Superficial Extensive skin infection requiring Intra-Muscular antibiotics

infection
Alertness Very weak, apathetic, unconscious

Fitting/convulsions
Hydration status Recent history of diarrhea/vomiting with appearance of
sunken eyes
 Criteria for Admission to ITC or OTC (6-59 months)

Factor Inpatient Therapeutic Care

Edema Bilateral pitting edema Grade 3 (+++)
OR Marasmic Kwashiorkor*
Anthropometry MUAC <115mm OR W/H or W/L < -3SD
AND one of the below
Appetite Negative appetite test with RUTF
Medical Any of the below
complications
Vomiting Intractable (empties contents of stomach)
Temperature Fever > 38.5°C (101.3 °F) axillary or > 39.0°C (102.2°F) rectal
Hypothermia < 35°C (95 °F) axillary or < 35.5°C (96°F) rectal
Respiration rate ≥ 50 resp/min from 6 to 12 months
≥ 40 resp/min from 1 to 5 years
≥ 30 resp/min for over 5 year olds
And any chest in-drawing (for children > 6 months)
 Criteria for Admission to ITC or OTC (6-59 months)

Factor Inpatient Therapeutic Care

Medical Any of the below
complications
Anaemia Very pale (severe palmar pallor, roof of the mouth (oropharynx), nailbeds,
eye palpebrae), difficulty breathing
Superficial Extensive skin infection requiring Intra-Muscular antibiotics
infection
Alertness Very weak, apathetic, unconscious
Fitting/convulsions
Hydration Recent history of diarrhea/vomiting with appearance of sunken eyes
status
Assessment and Admission to ITC

Prioritization of Activities in ITC

• Identify SAM (MUAC & Edema)
• Triage emergency cases and provide emergency care if required
• Take weight for calculation of medical and nutritional treatment and
to set the baseline for weight monitoring during treatment.
• Give first line antibiotics
• Initiate feeding with F75
• Complete assessment and record on the patient chart
– Medical and nutritional treatment is dependent on very accurate
weighing
– Inaccurate weighing may lead to incorrect treatment and have very
serious consequences for the child
Assessment and Admission to ITC

For SAM cases assessed not to have emergency care

requirements
• Conduct IMCI medical check
• Take a medical history
• Conduct the Appetite test
• Take weight for calculation of medical and nutritional
treatment and to set the baseline for weight
monitoring during treatment.
• Initiate feeding with F75 or refer to OTC if there are
no medical complications and good appetite is
demonstrated
• Record all information on a patient chart
 CMAM Triage

Age, anthropometric measurements, edema check

SAM

Appetite test, History, Clinical examination

Outpatient Therapeutic Care (OTC) In-Patient Care (ITC)

 passes appetite test  fails appetite test OR
 no medical complication  medical complication OR
 no severe edema (+++) or MK*  severe edema (+++) OR MK*

Fail appetite test, worsening edema or Phase I/

development of a medical complication Stabilisation
Rehabilitation
REFERRAL
Transition
Return of appetite, sufficient loss of edema
and resolving complications

Rehabilitation
(if no OTC)
Recovery
(link to other services – including
SFP if available)
*Marasmic Kwashiorkor
Medical Management

Emergency Treatment
• Assess the child’s airway, breathing, and circulation and
administer lifesaving interventions according to Pediatric
Advanced Life Support (PALS) protocols.
• Immediately treat life threatening complications
– Hypoglycemia
– Hypothermia
– Dehydration & hypovolemic shock
– Hypernatremic dehydration
– Treatment of septic shock
– Heart failure
– Absent bowel sounds, gastric dilation & intestinal splash
• The medical / fluid management of children with SAM is
different from normally nourished children. Modified protocols
should be applied according to annexes on the treatment of
complications.
Use of Drugs in Acute Malnutrition

• Children with acute malnutrition have

– Abnormal liver and kidney functions
– Changed levels of enzymes needed to
metabolize & excrete drugs
– Excess reabsorption (enterohepatic
circulation) of drugs excreted in the bile
– Decreased body fat (increased
concentration of fat-soluble drugs)
– Defective blood-brain barrier (in
kwashiorkor)
Use of Drugs in Acute Malnutrition

• Drugs that cause appetite loss should not be used such

as anti-emetics
• drugs affecting liver, pancreatic, renal, cardiac or intestinal
functions should not be used
• Malnutrition is treated first before standard doses of drugs
are given
• If really needed, initially give reduced doses of drugs
– Standard doses are given in the later stages of OTP treatment or
have lesser degrees of malnutrition
• Common drugs such as paracetamol do not work in AM
and can cause liver damage
Routine Medications

• Systemic Antibiotics
– Given to every SAM patients even w/o clinical
signs of infection
– they nearly all have small bowel bacterial
overgrowth (SBBO)
• causes malabsorption of nutrients
• failure to eliminate substances excreted in
the bile, fatty liver, intestinal damage and
• can cause chronic diarrhoea
Routine Medicines in Phase I/Stabilization

• If complications are NOT present:

Medication Route Dose Prescription

4 - 9.9 kg 250mg On admission

Amoxicillin*
Oral / NGT 10 - 13.9 kg 500mg Twice daily for 5-7
Oral / NGT
14 - 19 kg 750mg Days

*Where there is amoxicillin resistance give amoxicillin - clavulanic acid combination

• If indicated, Metronidazole (10 mg / kg / day) may be used to treat

small bowel overgrowth of bacteria not responding to amoxicillin.
Note that the dosage of metronidazole is reduced for children with
SAM.
• If complications ARE present:

Routine medications for SAM with complications

Medication Route Dose Prescription
On admission
Ampicillin* IM/IV 50 mg / kg
6 hourly for 2 days
4 - 9.9 kg 250mg
Followed by
Orally / NGT 10 - 13.9 kg 500mg Twice daily for 5 days
Amoxicillin 14 - 19 kg 750mg

• and

On admission
Gentamycin IM/IV 5 mg/kg
Once daily for 7 days
• If the child does not improve within 48 hrs or
deteriorates within 24 hrs. add;

Medication Route Dose Prescription

Once daily with

Ceftriaxone* IM/IV 75-100 mg/kg
Gentamycin

Care must be taken in reconstituting and administering Ceftriaxone via the IM or

IV route. Please refer to the product data sheet for precautions. Cefotaxime
(100 mg / kg / day on 1st day followed by 50 mg / kg / day on subsequent days)
may be preferred in septic shock.
Duration and Administration of Antibiotic treatment

• Given continuously until transferred to OTP

• OR during Acute Phase plus 4 more days
• Should be given orally or through NGT
• Infusions with antibiotics should not be used
because of the danger of inducing heart failure
Note: The following medication is NOT routinely given in Phase 1.
• Vitamin A
– supplementation is not routinely indicated where commercially prepared F75 /
F100 or RUTF are provided for treatment.
– Vitamin A supplementation should be given on admission when other
preparations are used without adequate vitamin A content
• A single dose of vitamin A is given on admission only if the child presents
with
– Clinical signs of vitamin A deficiency (xeropthalmia, bitot spots)
– An active case of measles
or
– If commercial F75 / F100 / RUTF is not available
Medication Age Dose

6 – 12 months 100,000 IU
Vitamin A
Greater than 12 months 200,000 IU
Note: The following medication is NOT routinely given in
Phase 1.
• Folic acid is present in adequate amounts in
therapeutic milks and RUTF to treat mild anemia. If
moderate anemia is diagnosed then give a stat dose of
5 mg on admission. There is no requirement for daily
doses.
• Anthelminthics are absorbed through the gut and the
active metabolite generated in the liver. Early in
treatment, poor absorption in the gut and poor liver
function may render the drug ineffective.
Note: The following medication is NOT routinely given in Phase 1.
• Zinc is present in F75 and F100 therapeutic milks and in RUTF.
Episodes of diarrhea should be treated with antibiotics and ReSoMal
if indicated by the presence of dehydration. If commercially prepared
F75 / F100 / RUTF is not available then zinc should be used in the
management of diarrhea
• Iron is not given in Phase 1 as it increases the risk of mortality in
children with SAM through the increased risk of infection and sepsis.
Iron is given only in Phase 2 where it is added to the therapeutic milk
(see Phase 2 care). Iron tablets do not need to be given to children
receiving RUTF as iron is already present in RUTF in adequate
amounts.
• Measles: Children with SAM treated in inpatient care should be
vaccinated for measles on admission from 6 months of age. The
dose should be repeated on discharge from inpatient care Phase 2
or when the child reaches 9 months in the outpatient setting
Routine Medicines in Phase 2

• Deworming/Antihelminthic treatment is given in Phase 2 (day

7) for children who remain as inpatients
Medication Age Dose Prescription

Mebendazole 12 – 23 months 250 mg Single dose on day 7

≥ 24 months 500 mg Single dose on day 7

Additional medicines in Phase 1 and 2

• Other medicines are given in phase 1 and

2 (e.g. for fungal infection such as
candidiasis) depending on symptoms
presenting according to appropriate
national guidelines for treatment of the sick
child
 Therapeutic Milk & RUTF

F-75 Therapeutic milk F-100 Therapeutic milk RUTF

Plumpy’nut®
or Eezee Paste

Stabilization phase in Rehabilitation of severe Ready-to-use therapeutic food

severe acute malnutrition acute malnutrition (RUTF)

*caloric density of 75 *caloric density of 100 *500 kcal per 96 g sachet

kcal/100 ml kcal/100 ml
*low in protein, fat and *nutritional value equal to
sodium and rich in RUTF
carbohydrates
*used as therapeutic milk
for <6m old infants
*consists of a peanut-based
paste, with sugar, vegetable fat
and skimmed milk powder,
enriched with vitamins and
minerals
Route of Administration

• Oral by cup (The muscle weakness, slow swallowing and poor

peristalsis of these children makes aspiration pneumonia very common)
– The child should be sitting straight, with the mother’s arm encircles the
child and holds a saucer under the child’s chin
– the milk is given by cup, any dribbles that fall into the saucer are returned
to the cup
– The child should never be force fed.
– The meals for the caretakers should never be taken
beside the patient, to avoid patient sharing caretaker’s meal.
The only food apart from F75 that the child
should receive is breast milk.
• Meal times of the children should be sociable.
• Make the mothers should sit together in a semi-
circle around an assistant
• Encourage the mothers, talk to them, correct
any faulty feeding technique and observe how
the child takes the milk.
• It is better to have a “feeding” area where all the
children and mothers are brought together. The
children can encourage each other.
Meals of Caretakers

• Arrange a separate room for the caretakers to

take their own meals
• They should never be taken beside the patient
• Sharing the mother’s meal with the child can
be dangerous
AMOUNTS OF F75 TO GIVE IN ACUTE PHASE

500ml water + 102.5gm sachet

Nutritional Management

• For new admissions to ITC, use F75 for

Phase 1 nutritional management
• For admissions coming from OTC who are
already demonstrating appetite, RUTF can
be used and Phase 2 entered directly
Phase 1/Stabilization

• The diet used for children aged 6-59 months in

stabilization is F75 therapeutic milk
• F75 is a low protein formulation (high protein at this
stage increases the risk of death) containing the
right balance of macro and micronutrients to
stabilize the child’s condition.
• F75 provides 75 kcal / 100 ml and allows
micronutrient deficiencies to be corrected and the
abnormal pathophysiology of the child to be
restored.
• The F75 already contains all of the micronutrients
required for stabilization. There is no need for
additional micronutrient supplementation.
Phase 1/Stabilization

• It is possible to make F75 at the health facility if the

commercial preparation is not available.
• It is essential to add combined mineral and vitamin
mix (CMV) in order to provide the micronutrients
essential to recovery. F100 diluted can also be used
as a TEMPORARY substitute in an emergency if
supplies are not available.
• Commercial formula is not in most cases a suitable
substitute and if the caregiver brings commercial
formula with them to the hospital, they must be
strongly advised NOT to use the formula for the
child.
F75

• Calculate the quantity of F75 to give

– The energy requirement of the child in Phase 1 is 100 kcal / kg /
day.
– This translates to 130 ml of F75 milk / kg / day.
• Prepare F75, alternate F75 recipe or F100
diluted as a temporary measure (administering
the same volumes as given for F75).
• The milk should be given in divided feeds ideally
every 2-3 hours in Phase 1 depending on the
condition of the child (6-8 feeds per day).
F75

• Pre-prepared feeds may be used overnight but only where

functional refrigeration units are available for storage following
preparation
• The milk should be warmed before use.
• Unused refrigerated milk should be disposed of after 12
hours.
• When F75 is not available, F100 can be diluted to make a
TEMPORARY alternative to F75. This is an emergency
measure only and is not acceptable as a standard
replacement to F75.
• If clinical assessment is delayed for any reason, give 10%
sugar water (10g or 1 tablespoon of sugar in 100 ml of water)
if child is able to take oral fluids in order to prevent
hypoglycemia. Fruit juice may be given if no sugar water is
available
Variation in number of feeds

• Reducing the number of feeds per day is not

ideal since sick children are often unable to
drink large volumes of milk and when the
number of feeds is reduced, the volume of each
feed is increased.
• If for any reason the frequency of feeds
(particularly during the evening or night shift)
cannot be guaranteed (e.g. due to staff
shortages), the volume of milk given must be
recalculated as it is preferable to feed the child
the required amount of milk for the day over
fewer feeds (to minimize the risk of
hypoglycemia).
Variation in number of feeds

Note:
• The reduced number of feeds should be a
temporary measure only while issues of staffing
etc. are addressed. It should not be adopted as
standard practice.
• Six (6) feeds per day is the minimum
• The time between the last feed of the day and
the first of the following day should be
minimized as much as possible.
• It is essential that the prescription of milk is
adjusted according to how many feeds can
realistically be given per day.
Feeding Method

• Feeding should be done orally by cup and saucer

unless a particular need for Naso Gastric Tube
(NGT) feeding is identified
• Breastfed children 6-59 months should always be
offered breast-milk before the diet and always on
demand
• Children with SAM have weak muscles and
swallow slowly. This makes them prone to
develop aspiration pneumonia. Appropriate
feeding techniques are therefore important
Appropriate Feeding Technique (video)
Appropriate Feeding Technique

• The child should ideally be sat upright on the caregiver’s

lap against her/his chest, with one arm behind his back
• The caregiver’s arm encircles the child and holds a
saucer under the child’s chin
• Any dribble that fall into the saucer are returned to the
cup
• The child should never be force-fed, have his/her nose
pinched or lie back and have the milk poured into the
mouth. (even with a spoon)
Appropriate Feeding Technique

• Never give more therapeutic milk than what is

prescribed for the child in Phase 1 even if the child cries
for more food. The child may continue to breastfeed on
demand
• Meal times should be sociable. The assistant should
encourage the caregivers, talks to them, corrects any
faulty feeding technique and observe how the child
takes the milk
• The meals for the caregivers should not be taken beside
the patient. It is almost impossible to stop the child
demanding some of the caregiver’s meal; sharing of the
caregiver’s meal with the child can be dangerous for the
child in Phase 1
Indications for Using NGT

A NG tube of the appropriate size should be used if the

child:
• Is unable to consume at least 75% of the milk provided
(the ITC chart is designed to monitor percentage of each
feeding consumed),
• Has pneumonia (rapid respiration rate) and has
difficulties swallowing
• Has painful lesions of the mouth
• Has cleft palate or other physical deformity
• Shows disturbed level of consciousness

The use of a NG tube should not exceed three days and

should only be used in the stabilization phase (Phase 1).
Transition Phase

Transition Phase is entered once:

• Medical complications are resolving
• Appetite returns
• Edema is reducing

Transition Phase normally takes 1-3 days but may

take longer. It signals a change in the nutritional
management of the child. The amount of energy
provided in transition Phase in increased by 30%
(to 130 kcal / kg / day) and the amount of protein
is increased.
Transition Phase

Transition may be divided into two distinct

management approaches.
• Transition to outpatient care for SAM where it is
available
• Transition to Phase 2 inpatient care where
outpatient care for SAM is not available

Availability in this sense primarily means that outpatient

care must be available AND accessible to the caregiver
following discharge from the hospital.
 • anthropometric measurements and edema check
• triage of emergency cases
• history, medical examination and appetite test
1. Admission • referral to OTC where required
• recording

• emergency medical management

• routine mediciness & additional medicines
• F75
• orientation to caregiver
2. Phase 1 • monitoring of feeds
treatment
• every 12 hr and daily medical and anthropometric monitoring
• recording and assessment of readiness for transition

• transition to RUTF
• continue medical treatments
• monitoring of feeds
3. Transition • every 12 hr and daily medical and anthropometric monitoring
• recording
• assessment of readiness for OTC/Phase 2

• orientation to caregiver
• RUTF till next OTC distribution
4a. Discharge to • referral documentation and communication with OTC
OTC
Transition to RUTF in preparation for OTC

• The aim is to prepare the SAM child for nutritional

rehabilitation in outpatient care i.e. to eat sufficient
RUTF to gain weight and recover, whilst ensuring
they get all the nutritional requirements they need
currently. This is done by gradually introducing and
increasing the proportion of the daily feeding
provided by RUTF
• Prepare indicated dose of RUTF, the usual F75
quantity for the child and a glass of drinking water
• The caregiver should be instructed to wash their
hands
• Ask the caregiver to offer the child the RUTF (refer
to appetite test)
Transition Phase (F100 or RUTF)

• Preferable to use RUTF

– Monitoring at night is not needed
– Patients need to become habituated to RUTF before they go home
– Full day’s amount of RUTF can be given to caregiver and the amount
CHECKED 5x during the day

• Those not taking sufficient RUTF are either given F100 for a
few days and RUTF re-introduced

• No other food should be given to the patient

• Breastfed children should always get the breast milk before

RUTF or F100 and on demand

• Should be offered as much water to drink during and after

RUTF intake
Transition to RUTF in preparation for OTC

• Observe the child eating the RUTF

• After each mouthful, breast milk or a sip of water
should be offered to the child
• If the child fails to eat the required amount of
RUTF at each feed, the child should finish the
feed by being offered the ration of F75 to drink
in addition to any RUTF that has been eaten.
The time taken to eat the RUTF and F75 (if
necessary) should be no more than 1 hour.
Transition to RUTF in preparation for OTC

• Record the amount of both F75 and RUTF taken

on the patients treatment chart
• After each feed, the RUTF should be placed in a
cool dry place, safe from insects and re-used at
the next scheduled feeding time
• The process of offering both RUTF and F75
continues until the child is able to take the
required amount for 24 hours.
Transition to RUTF in preparation for OTC

Note:
• The child must NEVER be force fed. It is vital to get a true indication of
appetite so that the child can be safely transitioned to outpatient care.
• RUTF is a thick paste and plenty of clean drinking water should be
available for the child to drink. Older children can ask for water when they
are thirsty but young children must be offered the water regularly when
taking RUTF.
• A thirsty child may refuse RUTF, which may be mistaken for poor appetite.
Children over 6 months but with developmental delay in the motor skills
associated with chewing food may have some difficulty manipulating the
thick paste in the mouth, sips of water will help

• This change to RUTF normally takes 1-3 days but may take longer. When
at least 75% of the full OTC daily amount of RUTF is eaten in 24 hours and
there are no other issues identified during monitoring, the child is judged to
be ready to continue their rehabilitation at home with OTC. The child may
then be discharged from the ITC facility (e.g. hospital) and referred to the
OTC nearest to their home (or the referring OTC if previously enrolled).
RUTF in Transition Phase

RUTF is nutritionally equivalent to F100, except that RUTF has iron

Amount of F100 milk to be given to children aged 6-59
months in transition Phase

WEIGHT OF THE CHILD (KG) 6 FEEDS PER DAY 5 FEEDS PER DAY
Less than 3.0 F100 full strength should not be used
3.0 – 3.4 75 ml per feed 85 ml per feed
3.5 – 3.9 80 95
4.0 – 4.4 85 110
4.5 – 4.9 95 120
5.0 – 5.4 110 130
5.5 – 5.9 120 150
6.0 – 6.9 140 175
7.0 – 7.9 160 200
8.0 – 8.9 180 225
9.0 – 9.9 190 250
10.0 – 10.9 200 275
11.0 – 11.9 230 275
12.0 – 12.9 250 300
13.0 – 13.9 275 350
14.0 – 14.9 290 375
 • anthropometric measurements and edema check
• triage of emergency cases
• history, medical examination and appetite test
1. Admission • referral to OTC where required
• recording
•emergency medical management
•routine mediciness & additional medicines
•F75
•orientation to caregiver
2. Phase 1 •monitoring of feeds
treatment
•every 12 hr and daily medical and anthropometric monitoring
•recording and assessment of readiness for transition
•transition to RUTF
•continue medical treatments
•monitoring of feeds
3. Transition •every 12 hr and daily medical and anthropometric monitoring
•recording
•assessment of readiness for OTC/Phase 2

• rehabilitation with RUTF (or F100)

• daily monitoring
• health and nutrition education
4b. Phase 2 in
ITC • recording
• assessment of readiness for discharge

• orientation to caregiver
• recording
5. Discharge
from ITC • links to other services
Transition to Phase 2 using F100

• When there is no outpatient treatment available, the child

must be treated and cured of SAM entirely within the
inpatient (care) setting.
• For children remaining in inpatient care, the energy
requirement of 130 kcal / kg / day is given in the form of
F100 therapeutic milk. F100 contains 100 kcal / 100 ml of
milk.
• In transition Phase, the volume of milk the child has been
receiving in Phase 1 remains the same; only the type of milk
changes
• The child should continue to breastfeed on demand.
• When at least 90% of the prescribed F100 ration is being
taken orally and no other issues are identified during
monitoring the child is judged to be ready to continue their
rehabilitation in Phase 2.
Phase 2

DIET
• In Phase 2, the energy and protein intake of the child is increased to 200
kcal/kg/day giving F100 therapeutic milk. During Phase 2, iron is added to
the therapeutic milk. The amount of iron to be added is:
– 200 mg Ferrous Sulfate (1 tablet) in 2 liters therapeutic milk
– 100 mg Ferrous Sulfate (1/2 tablet) in 1 liter therapeutic milk
• If smaller quantities of milk are being made, crush 100mg (1/2 iron tablet)
and mix thoroughly in 10 ml of water (ensure the tablet is well crushed and
leaves no sediment).
• Add 10 mg Ferrous Sulfate (1 ml of 10 ml Iron solution) in each 100 ml of
therapeutic milk

• Feeds should be given at least 5 times per day. The next table gives milk
volumes depending on whether 5 or 6 feeds per day are given.
Amount of F100 to be given in Phase 2

WEIGHT in Kg F100 (6 feeds per day) in ml F100 (5 feeds per day) in ml

< 3 KG Do not use full strength f100 use diluted f100

3.0 to 3.4 110 130

3.5 - 3.9 125 150
4.0 - 4.9 135 160
5.0 - 5.9 160 190
6.0 - 6.9 180 215
7.0 - 7.9 200 240
8.0 - 8.9 215 260
9.0 - 9.9 225 270
10.0 – 11.9 230 280
12.0 – 14.9 260 310
Responsive Feeding and Emotional Stimulation

• In addition to nutritional management in Phase

2, as the child is continuing their treatment in an
institutional environment, it is important to also
support play and emotional stimulation as an aid
to psychological recovery.
• This should be done by:
– Encouraging the caregiver to talk to the child with
good eye contact during feeding
– Providing a brightly colored ward environment
– Providing toys suitable for children of various ages
Orientation and care for caregivers

The admission of a child into inpatient care is always a worrying time

for the caregiver.
 Care should be taken to ensure that all the procedures and
treatments their child will receive are explained properly, and the
next stage of the child’s treatment also explained.
 The opportunity should also be taken to ensure they receive proper
nutrition counselling and care that facilitates their support for their
child.
 Whenever possible care will be given so as to promote (or restore)
age appropriate breastfeeding practices including breastfeeding
overnight (particularly important in facilities not providing feeds
during night-time)
Orientation and care for caregivers

General advice to the caregiver to be given by the nurse in charge;

• The mother should continue to breastfeed the child on demand. It is
important to breastfeed the child BEFORE each feed of therapeutic
milk
• The child is severely malnourished and needs medicines and a
special therapeutic milk in order to aid recovery (be sure to
distinguish the therapeutic milk from commercially available feeds, it
is important not to give messages which promote the use of artificial
milk after discharge)
• Inform the mother of the importance of the therapeutic milk and its
timely feeding to the child according to the inpatient unit timetable
• The child does not need to eat any additional food during their time
in Phase 1 or transition. The diet provided is complete.
Orientation and care for caregivers

General advice to the caregiver to be given by the nurse in charge;

• If the child is bottle-feeding this must be stopped immediately.
Bottles must be taken and disposed of. Their use is strictly forbidden
in inpatient care for SAM
• Unless contraindicated due to a critical illness the mother should
interact frequently with the child through talk and play. Severe acute
malnutrition affects the child psychologically and play is essential for
the child’s emotional recovery from illness
• For all caregivers and particularly those of infants <6 months of age
IYCF messages should be discussed including those related to
exclusive breastfeeding, timely introduction of complementary foods
and continued breastfeeding.
Orientation and care for the caregiver

In addition some specific actions should be taken to care for the

caregiver themselves in order to facilitate their support for the child
• Assessment of the physical and mental health status of the
caregiver with the provision of relevant treatment and support
• Other ward routines for meal times, washing of clothes and
attending to hygiene needs must be discussed as soon as
possible after admission
• Counsel the mother on maternal nutrition and self-care
• Counsel the mother on good IYCF practices including exclusive
breastfeeding, continued breastfeeding, and age appropriate
complementary feeding (including meal frequency and food
diversity)
• Commercial milk formula: she may drink it herself to improve her
own nutritional status or be discarded. It should NEVER be fed to
the child during the infant’s time in inpatient care.
• The mother should receive multiple micronutrient tablets daily
during admission if the child up to the age of 2 years is
breastfeeding
Monitoring in Phase 1

SURVEILLANCE
• After every therapeutic milk feed:
– Record any breastfeeding taken before the therapeutic milk
– Record the amount of therapeutic feed taken carefully on the therapeutic
surveillance sheet
– For infants < 6 months – note the amount of therapeutic milk given

• Every 12 hours:
– Measure and record the child’s temperature
– Measure and record the child’s respirations
– Measure and record the child’s pulse rate
Monitoring in Phase 1

SURVEILLANCE
• On a daily basis
– Indicate the prescription for therapeutic milk
– Measure and record the weight
– Measure and record the level of edema
– Record symptoms such as cough
– Indicate if the child has a nasogastric tube

• On a weekly basis:
– Measure MUAC
– Where a child has a complication or is undergoing fluid rehydration the monitoring needs
to be much closer and should be indicated by the clinical staff on an individual patient
basis.
– In order to correlate the nutritional treatment with clinical recovery and any change in the
weight of the child, the therapeutic milk intake must be accurately monitored and recorded.
This is a vital part of the child’s medical and nutritional care
Monitoring in Transition Phase
SURVEILLANCE
The child should be observed closely for any signs of deterioration
during the Transition Phase

Continue to monitor as above for phase 1.

In addition after every feed:
• Record the amount of RUTF or F100 taken
• Record the amount of F75 taken

In addition be vigilant for any of the following signs that the child is not
coping with the transition;
• Rapid increase in the size of the liver
• Any sign of fluid overload
• tense abdominal distension
• any significant re-feeding diarrhea involving weight loss
• any complication arising which necessitates intravenous fluids
• edema not reducing, any increasing edema or edema developing
when it was previously absent
ITP Patient Monitoring

MUAC Once a week

Height Every 2 weeks
Weight Every day
Edema Every day
Temperature 2x a day or more often
Heart rate, Respiratory rate 2x a day or more often
CRT (capillary refill time) 2x a day or more often
Feeding information Each meal time
(amount,consumption,route)
Medications Each administration of meds
Diarrhea, vomiting Each time it happens
Medical findings/observation Every day
(cough, dehydration, etc.)
Monitoring in Transition Phase

SURVEILLANCE
 It is not unusual for children to pass several very
soft stools during the recovery process of the
intestinal tract.
 Unless there are signs of Re-feeding syndrome,
Acute watery diarrhea or osmotic diarrhea there is
no need for the child to pass back into Phase 1.
 There is also no need to treat the diarrhea unless
the child loses weight. The child should continue
RUTF (or F100 if transitioning to Phase 2 inpatient
care) and be observed closely; the diarrhea should
NOT be treated with Zinc.
Referral from Transition back to to Phase 1

Refer back to Phase 1 care with F75 if:

• There is a deterioration in clinical status of the
child or any of the above signs are noted

Switch from RUTF to F100 for transition if the

child is:
• stable but appetite is not improving after 3 days
in transition (the required amount of each feed
is not being taken). In this case switch to F100
and transition the child to Phase 2. Transition
onto RUTF can be attempted again after a
couple of days.
 Criteria to Move Back from Transition to Acute Phase

• Rapid increase in liver size

• Refeeding diarrhea with
• Signs of fluid overload
weight loss
(increased RR)
• Complications requiring
• >10g/kg/day increase in IV infusion (malaria,
weight dehydration)
(excess fluid retention)
– Example: 4kg infant, >0.04kg/d • Deterioration in child’s
condition
• If tense abdominal
distention develops • Increasing edema
– abnormal peristalsis, small bowel
overgrowth and perhaps excess
carbohydrate intake
• If patient develops
edema
Monitoring in Phase 2

SURVEILLANCE
During treatment in Phase 2 the child should continue to be
monitored until recovery. Observations should be recorded
systematically on the Therapeutic Surveillance Sheet.

Daily observations
• Record RUTF or F100 intake after each feed
• Measure weight
• Assess edema
• Measure respiratory rate
• Measure heart rate
• Measure temperature
• Assess clinical status (vomiting, diarrhea, dehydration,
cough)
• Assess nutritional status against discharge criteria
Monitoring in Phase 2

SURVEILLANCE
During treatment in Phase 2 the child should
continue to be monitored until recovery.
Observations should be recorded systematically
on the Therapeutic Surveillance Sheet.

Weekly observations
• Measure MUAC

Two-weekly observations
• Measure height / length
Referral from Phase 2 back to Phase 1

• Refer back to Phase 1 care with F75 if:

• There is a deterioration in clinical status of the
child
• This should be accompanied by a thorough
assessment reassessment of the child’s
treatment
 Discharge from Transition to OTC

CATEGORY DISCHARGE CRITERIA

Child aged 6 to 59 - Medical complications resolved (or chronic
months conditions controlled)
AND
- edema subsiding (must have reduced to at least +2)
AND
- Appetite for RUTF (must be able to eat at least 75%
of outpatient ration)
Discharge Procedure from Transition to OTC

• Before the child is discharged from the inpatient

care unit to a health facility offering outpatient
care for SAM which is accessible to them the
following should be done;
• Explain to the caregiver that the child has
recovered sufficiently to be discharged and
congratulate them.
• An adequate supply of RUTF must be given to
last until the next possible appointment in
outpatient care
• The caregiver must understand (and repeat) the
key messages for giving RUTF
Discharge Procedure from Transition to OTC

• The caregiver must understand (and repeat) the

medications to be given after discharge (these
are any courses of medicines that the child
needs to complete after discharge)
• Call the relevant RHU / BHS clinical staff to
notify them of the child’s transfer to outpatient
care. RHU / BHS clinical staff should advise the
BHW / BNS of the child’s return
• Complete a referral slip and give it to the
caregiver. This should be presented to the staff
of the outpatient health facility at the next
appointment
Discharge Procedure from Transition to OTC

• Record the following on the referral slip:

– Hospital registration / treatment number
– MUAC (measurement)
– Weight (measurement)
– Height (measurement)
– Weight for Height Z score
– Grade of edema
– Ration of RUTF given (number of packets on
discharge)
– Medications received and medicines to be continued
after discharge
– Clinical condition on discharge
Discharge Procedure from Transition to OTC

• Record the child as a “discharge to outpatient

care” in the tally sheet / monthly report
• Record the ration of RUTF given in the stock
register
• Complete other relevant clinical records and
registers
Criteria to Progress from Transition Phase to OTP
(Discharge Criteria)
• A good appetite
– Must consume >90% of RUTF or F100

• Medical complications controlled or resolving

• For edematous patients

– Edema resolving ( + edema)
– OR good appetite (taking all diet in transition phase) and edema
reduced to ++

• Clinically well and alert

• Recovery phase at home when:

– There is a capable caretaker
– The caretaker agrees to out-patient treatment
– There is a sustained supply of RUTF
– An OTP is in operation in the area close to the patient’s home
• All children discharged from the ITC are a
priority for outreach follow-up during their
first week in the OTP
Discharge from Phase 2
CATEGORY DISCHARGE CURED CRITERIA
Children 6-59 months
- Admitted on MUAC, edema, or MUAC ≥ 125mm for 2 consecutive days
both MUAC and WHZ And
No edema for 10 days
And
Clinically well
Discharge Procedure from Phase 2

• Before the child is discharged from the inpatient

care unit the following should be done;
• Explain to the caregiver that their child has
recovered sufficiently to be discharged and
congratulate them.
• The caregiver must understand (and repeat) the
medications which must be given after
discharge
• Complete other relevant clinical records and
registers
Discharge Procedure from Phase 2

• Complete a referral slip and advise the

caregiver to attend the nearest local health
facility;
– Record the child’s registration number on all
documentation
– Record the MUAC and WFH (measurement on
discharge)
– Record any continuing medications
– Advise attendance at a growth monitoring program
• Advise attendance at the local health facility for
further nutrition counselling
 ITP Discharge Procedure

• Assess the clinical status, bilateral • mother/caregiver is also given

pitting edema, MUAC, weight, and any remaining medications and
height, and appetite tested
instructions

• referral slip to outpatient care is

completed • Key messages about the use of
RUTF and basic hygiene are
• mother/caregiver is informed discussed again with the
where and on which day to go for mother/caregiver
OTP

• The mother/caregiver is informed

• is given sufficient RUTF to last
until the next outpatient care on what to do if the child’s
follow-on session condition deteriorates before
their OTP ff-up
Record Outcome (for Phase 2)

• Register the patients discharged in the registration book and chart

according to the following possibilities:
– Cured: the patient has reached the criteria for discharge cured
– Dead: if the patient died during treatment in the facility or during
transit to another facility
– Defaulter: if the patient has not returned for 3 consecutive days
and a home visit, neighbor, village volunteer or other reliable
source confirms that the patient is not dead
– Discharge as non-cured: If a child does not reach the discharge
criteria within 3 months in ITC and all referral and follow-up
options have been tried they may be discharged as non-cured
and linked with the OTC or MAM program where possible and to
social support systems
Managing Links

• The child being treated for (severe) acute malnutrition

has usually suffered some combination of nutritional
deficit and / or infection, and often may come from the
poorest families in the community . In order to continue
healthy growth and prevent relapse, follow up care
should be sought. Depending on services available
locally, the following should be considered.
– Referral to a TSFP (if available) or other supplementary or
school feeding program
– On-going IYCF / nutrition counselling (e.g. IYCF Peer
counselling, Family Development Sessions, Pabasa sa
Nutrisyon, promotion of good nutrition)
– Referral to Mother support groups, well baby clinic
– Referral to multiple micronutrient supplementation or
complementary feeding support if available.
Managing Links

• Enrolment in a growth monitoring program

Operation Timbang Plus (if not yet enrolled)
Referral to a food security program
• Provide list of social welfare services available and
referral to any relevant programs such as:
– Sustainable Livelihood and Pantawid Pamilyang Pilipino
Programs (if eligible)
– Kapit-Bisig Laban sa Kahirapan-Comprehensive and
Integrated Delivery of Social Services (KALAHI -CIDSS),
– Self-Employment Assistance-Kaunlaran (SEA-K)
Program)
• Ensure enrolment and coverage of the child and
mother in PhilHealth.
IPF Patient Card
Referral or Transfer Slip
Practical Considerations

• Caretakers and hospital workers should wash their

hands before preparing and feeding the milk/RUTF and
handling the patients

• Minimal handling of patients by hospital staff

• Water source
– Water should be clean/potable , warm

• Clean and dry cups, saucers and utensils

– Separate closed container for the clean cups and
utensils

• Ward should be “child-friendly”

Questions?
Inpatient Therapeutic Program (ITP)
Inpatient Management II
Outline

Inpatient Management II
– When to Refer
– Management of Common Complications
• Pneumonia
• Dehydration
– Scenarios
• Non-responder
• Deterioration
– Referral to Tertiary Care Facility
When to Refer

• Patient is semi-conscious or unconscious

• Patient does not respond to treatment
• Has signs of dehydration
• Patient’s condition deteriorates after having
progressed satisfactorily initially
Management of Common Complications
(FEVER)
• FEVER
– Malnourished children have diminished or absent inflammatory
response and poor temperature regulation
– Malnourished children do not respond to anti-pyretics
– Moderate fever (up to 38.5C) do not need to be treated actively
– T>39C should be slowly cooled down
• Placing a damp/wet room-temp cloth over child’s scalp and re-
dampen whenever dry
• If Temp does not go down, then the damp/ wet cloth should cover a
larger body area
• Put child in a ventilated area or fan the child

*Stop active cooling when Temp falls below 38C

Management of Common Complications
(PNEUMONIA)

Respiratory Rate

• ≥60 respirations/minute for

under 2 months

• ≥ 50 respirations/minute
from 2 to 12 months

• ≥ 40 respirations/minute
from 1 to 5 year-olds

• ≥ 30 respirations/minute for
over 5 year-olds.
Management of Common Complications
(DEHYDRATION)

*DIARRHEA is not a medical complication

Refeeding Diarrhea

• Intestinal atrophy
– Limited capacity to absorb large amounts of
carbohydrates

• Pancreatic atrophy
– Carbohydrate, protein and fat digestion is compromised

• When the patient starts on F75, some patients

have increased number of stools, and stools are
less formed

• More common with edematous malnutrition

Dehydration

• Misdiagnosis and inappropriate treatment for

dehydration is the most common cause of death of the
severely malnourished patient.
• It is difficult to diagnose dehydration in children with
SAM
– the signs of dehydration such as non-elastic skin and sunken
eyes are often present in the severely malnourished patient
regardless of hydration status.
– It is important to take a detailed medical history and determine if
there was a recent fluid loss from acute diarrhea or vomiting.
• Children with SAM usually have reduced cardiac
contractility and renal function.
• Rehydration therapy in these patients is more cautious
than for a normally nourished child as the child cannot
compensate for increased intravascular volumes in the
same way, which may quickly precipitate heart failure.
Dehydration

• If a child is conscious or has a nasogastric tube in place

and the risk of aspiration is low, oral rehydration
solutions are ALWAYS preferable to intravenous
rehydration solutions.
• Intravenous solutions should only be used when the
child is unconscious or is being resuscitated from shock.
– An intravenous infusion should never be present in a child who
is able to take fluids orally or by nasogastric tube.
• The treatment of dehydration and hypovolemic shock
differs for children with wasting and children with
edematous malnutrition
– A child with edema should not be diagnosed with dehydration
although they may be hypovolemic. The rehydration of children
with edema is the same as the treatment of a child with septic
shock
 Dehydration
• Diagnosis of dehydration in marasmic patients
– + skin pinch test
• Marasmic skin NORMALLY lies in folds & is inelastic
– Sunken eyes
• Marasmic eyes are NORMALLY sunken
• Main diagnosis comes from the HISTORY
– recent fluid loss: frequent, sudden watery stools
– Recent change in child’s appearance
– Mother must say that the eyes have changed to become sunken since
the diarrhea started
– Absence of visible full superficial veins (head, neck, limbs)
– Check for urine output
– Must not have edema
• A diagnosis of dehydration should ALWAYS be a provisional
diagnosis.
– The response to treatment must be observed before the diagnosis can
be confirmed.
– Concomitant signs of dehydration may include increased
heart rate, temperature and/or reduced blood pressure.
Use of IV Lines in ITC

Intravenous access should be maintained only for those children in which it is

indicated, i.e.:
• Children receiving intravenous antibiotics in Phase 1 / Transition Phase
• Children with decreased consciousness unable to safely tolerate oral fluids
• Children with hypovolemic / septic shock
• Children in whom oral or NG tube fluids are contraindicated

IV access which is used intermittently (e.g. for IV antibiotics) must be flushed

every 8 hours with 2ml of sterile normal saline or Heplock®.
• Peripheral IV access must be cleaned with alcohol at each use.
• Intravenous access must not be maintained with slow infusion IV fluids “to
keep the line open”. This places the child with SAM in danger of fluid
overload.

All IV access must be removed when there is no indication for its use.
– IV access should not be left in place “just in case it is needed”. Peripheral IV access
should be removed (and re-sited if needed) every 5 days or more frequently if signs of
phlebitis or infection develop.
– Central venous access (including peripherally inserted central cannula, PICC) should
be maintained according to the physicians instructions.
Diagnosis of Shock with Dehydration
in the Marasmic Patient
If the following signs are also present:
• Decreased level of consciousness so that the patient is semi-
conscious or cannot be roused
• Slow capillary refill in the nail beds (longer than 3 seconds) OR
• Fast or weak / absent radial / femoral pulse
– Children 2-12 months - pulse rate greater than 160 / min
– Children 1 - 5 years - pulse rate greater than 140 / min

Then hypovolemic shock is provisionally diagnosed (confirmation of

the diagnosis is only made following observation of the response to
treatment).
• The differential diagnosis of hypovolemic shock and septic shock
and is often very difficult in a child with SAM.
• If another illness such as viral infection, malaria or other severe
condition is present, septic shock should be assumed. Septic shock
is often seen in individuals who are immunocompromised or have
hospital acquired infections. Mortality due to multiple organ failure
may exceed 50%.
Treatment of Dehydration in Marasmic Patients

• BEFORE starting rehydration treatment

– Weigh the child
– Mark the edge of the liver & costal margin on the skin
– Record the Respiratory Rate
– Record the Pulse Rate
– Record the Capillary Refill Time (CRT) in seconds
– Record the heart sounds ( presence or absence of gallop
rhythm)

• Managed entirely by
– Weight changes
• The weight should be monitored regularly (at least
every hour) during rehydration to assess the response
to treatment. Rehydration therapy should aim to replace
the estimated fluid losses up to a maximum of 5% body
weight.
– Clinical signs of improvement
– Clinical signs of over-hydration
Re-hydration of Marasmic Patients

Oral Rehydration solutions

• Rehydration Solution for Malnutrition (ReSoMal) should be used
as the standard therapy for children with SAM diagnosed with
dehydration
• Low Osmolarity Oral Rehydration Solution (LO-ORS) may be
used for the treatment of children with SAM but only for those who
have a positive diagnosis of Acute Watery Diarrhoea (AWD) or
Cholera
• Standard (full strength) Oral Rehydration Solution (ORS) does
not have a suitable formulation for the treatment of dehydration in
children with SAM.
• Where ReSoMal is not available, a modified, half-strength solution of
LO-ORS may be used with added potassium and glucose.

Oral Rehydration Solutions such (ORS or ReSoMal) for the treatment of

dehydration must NEVER be freely accessible to caregivers on the
hospital ward.
Re-hydration of Marasmic Patients

Intravenous Rehydration Solutions

• Ringers Lactate Solution with 5% Dextrose
• 0.45% Saline with 5% Dextrose
Treatment of dehydration / hypovolemic shock in a child with
severe wasting

SAM with severe

dehydration Decreased consciousness
Conscious and / or
Hypovolemic shock

ReSoMal Intravenous Solution

 10 ml/kg first 2 hrs 15ml/kg first 1 hour
 5-10 ml/kg Next 10 hrs

REASSESS

If conscious: If improving:
Insert nasogastric tube and 15 ml/kg second hour
start ReSoMal (10 ml / kg / hr)
REASSESS

If not improving:

DIAGNOSE SEPTIC SHOCK

Monitoring the progress of rehydration therapy

• The therapeutic window for rehydration therapy is narrower

for a child with SAM than for a normally nourished child due
to the abnormal pathophysiology.
• The reduced function of the cardiac, renal and abnormal
cardiovascular system results in abnormal responses to an
increase in fluid load.
• It is much easier to quickly overhydrate the child resulting in
heart failure and death, as the increased fluid volume in the
cardiovascular system cannot be excreted normally.
• A child with SAM in heart failure may not respond well to
diuretic medications.
• Avoiding over-hydration and heart failure is easier and far
preferable to treating them.
 Algorithm for monitoring rehydration therapy in a severely wasted
patient
Monitor Weight*
Every 30-60 mins

Weight Gain Weight stable Weight loss

Clinically No Clinical
improved improvement Increase ReSoMal Increase ReSoMal
by 5ml/kg/hr by 10 ml/kg/hr

STOP ALL
Continue to REHYDRATION Reassess every
target FLUIDS Reassess every
weight and 60 mins
start F75 Give F75 and 60 mins until
reassess. target weight is Until target weight is reached
Diagnose reached
septic shock

* The goal of rehydration therapy is based on the improvement of clinical status. A maximum target weight
for rehydration therapy should be no more than 5% of body weight
Monitoring the clinical status during the rehydration of the marasmic child
• Every 30-60 mins assess:
• Weight the patient (and calculate the target weight gain)
• Heart/Pulse rate, temperature, respiration rate
• Heart sounds (over-hydration may result in a gallop rhythm)
• Observe for signs of respiratory distress (chest indrawing, nasal flaring)
• Observe for vomiting or diarrhea (estimate volumes and correlate with
weight loss)
• Reassess the costal margin of the liver
• Reassess the absence or presence of jugular venous distension
• Monitor for presence or absence of urine output and, if present, urine color
• During rehydration therapy, breastfeeding should not be interrupted; the
child should be breastfed on demand. Successful rehydration results in an
improvement of the clinical status of the child with an improvement in the
level of consciousness, and normal heart/pulse rate and blood pressure.
Rehydration stopped immediately if:

• Target weight for • Signs of fluid overload

rehydration has been – Prominent neck veins
achieved (start F75) – Neck veins engorge when liver is
pressed

– Increase in liver size by >1cm

• Visible veins become
full
• Development of
edema (start F75)
– Development of liver tenderness
– Increase in RR by ≥5breaths/minute
• >50/minute in infants
• >40/minute in children 1-5 y/o
– Development of “grunting” on
expiration

– Rales or crepitations in the lungs

– Gallop rhythm
Diagnosis of dehydration in children with edema
• Patients with bilateral edema are overhydrated and
have increased total body water and increased sodium
levels. Edematous patients thus cannot be
dehydrated, although they are frequently hypovolemic.
The hypovolemia (relatively low circulating blood
volume) is due to a dilatation of the blood vessels with
a low cardiac output.
Treatment of dehydration in children with edema
• If a child with edema has watery diarrhea, and the child
is deteriorating clinically, then the fluid lost can be
replaced on the basis of 30ml ReSoMal per episode of
watery stool.
• The fluid management of hypovolemia for a child with
edema is the same as the treatment for septic shock.
Re-hydration of Marasmic Patients

• Resomal (rehydration
solution for malnourished
children) Composition ReSoMal ORS
(mmol/l)
• contains less sodium, more
potassium and more Sodium 45 90
magnesium, zinc and
copper

• 1 sachet in 2 liters of water Potassium 40 20

Rehydration with Resomal

• Start with Resomal 10ml/kg/hr for 2 hours

– Stop as soon as child reaches target rehydrated weight
– TARGET weight is pre-diarrheal weight
– If w/o pre-diarrheal wt, weight gain with rehydration should be
up to 5% of initial weight

• Adjust according to weight changes

• Every hour
– Weigh the child
– Assess liver size, RR, pulse rate, CRT

• With weight gain, there should be clinical improvement

• Make a major reassessment after 2 hours

• During re-hydration breastfeeding should not be
interrupted.
• Begin to give F75 as soon as possible, orally or by
naso-gastric tube.
– ReSoMal and F75 can be given in alternate hours if there is
still some dehydration and continuing diarrhoea.
– Introduction of F75 is usually achieved within 2-3 hours of
starting re-hydration.
Persistent or Chronic Diarrhea

• (without an acute watery exacerbation) do not need acute

rehydration therapy.
• The appropriate treatment of persistent diarrhoea is
nutritional
– Almost often due to nutrient deficiency and will resolve with F75 and
suppression of small bowel bacterial overgrowth.
• if the diarrhoea persists even after Amoxycillin, a course
of metronidazole (10mg/kg/day) can be given
• Check for mucus and blood in the stool, amoebiasis and
shigella dysentery.
Non-Responder
(Failure to respond to treatment )

Criteria for failure to Time after

• Requires extensive respond Admission
history, physical Primary failure to *day of
admission is
examination or Respond (Acute Phase)
counted as Day 0
laboratory tests Failure to Improve or Day 4
Regain Appetite
Failure to start to lose Day 4
• Patient should be edema
seen by a more Edema still present Day 10
senior and
Failure to fulfill criteria for Day 10
experienced staff OTP
Secondary failure to
Respond
Deterioration after At any time
admission in the Acute
phase
Usual Causes of Failure to Respond
(Problems of individual children)
– A severe medical
complication
– Drug toxicity
– Insufficient food given
– Food taken by siblings or
caretaker
– Sharing of caretaker’s food
– Malabsorption
– Psychological trauma
– Rumination
• repeated
regurgitation of food,
with weight loss or
failure to thrive,
developing after a
period of normal
functioning.
– Infection
– Congenital abnormalities,
neurological damage, inborn
errors of metabolism
Usual Causes of Failure to Respond
(Problems with the IPF)

• Failure to apply • Failure to complete the

protocol properly SC card correctly

• Poor environment • Poorly trained staff

for the malnourished
children
• Insufficient staff
• Excessively (particularly at night)
intimidating, strict or
cross staff • Inaccurate weighing
machines
• Failure to treat the
children in a
separate area • F75 not prepared or
given correctly
Deterioration
(after having progressed satisfactorily initially)
• Electrolyte imbalance
– Movement of sodium
from the cells &
expansion of
circulation to give
fluid overload or to
refeeding syndrome
• Inappropriate dosage of
drugs
• Use of drugs not
recommended for SAM
• Inhalation of diet into
lungs
• Nosocomial infection
– Contracted in the center
from another patient,
visitor, sibling or
household member
• “reactivation” of
infection during
recovery as the
immune and
inflammatory system
recovers
• Use of traditional
medicines
Action Required

• The common causes should be examined to

identify and solve the problems

• Review of the supervision of staff

• Refresher training, if necessary

• Recalibration of scales

• The medical staff should go through the

common causes and identify if they are affecting
the patient
Referral to Tertiary Care

• For patients with medical complications

requiring medical equipments, laboratory
work-ups and medications not available in
the SC
Questions?