Complications of Malnutrition

Hypoglycaemia

(blood sugar <3 mmol/l or <54 mg/dl)

• Give 5 ml/kg 10% glucose. If alert give orally or by NGT; if lethargic give IV (5ml/kg 10% glucose or 2 ml/kg of 25% glucose, or 1ml/kg of 50% glucose). Feed straight away, keep warm & dry, consider infection.
• Repeat a blood sugar after 30 min.
• Feed with F75 as per MOYO feeds (avoid rebound hypoglycaemia)
• Instruct mothers to and ensure mothers do feed at night as well
• Check temperature and assess for infections

Hypothermia

(axillary temperature < 35.0C)

• Prevent by giving blanket, and close windows
• Cover the child including the head with a woollen hat.
• Instruct mothers to change wet clothing and nappies promptly
• Use a heater or lamp
• Monitor temperature until> 35.0 C
• Check glucose

Shock

(Differential diagnosis hypovolaemic- and or septic shock)

Definition: AVPU = ≤P, cold peripheries, capillary refill (>3 sec) AND a weak fast pulse

• Think "ABC", Don’t Ever Forget Glucose (DEFG)
• Give O2 and broad spectrum antibiotics
• Keep warm Hypothermia
• Establish IV- or IO- access,
• Bolus with 15 ml/kg
  of ½ strengths Darrows + 5% Dextrose or
  Ringers Lactate + 5 % Dextrose over 1 hr
  and check heart rate and respiratory rate again
• If the pulse rate OR respiratory rate increases , the cause of the shock is most likely sepsis. Give whole blood 10 ml/kg over 4 hours plus 1mg/kg Furosemide IV at beginning of transfusion. Continue same IV-fluids at maintenance rate while awaiting the blood. Change antibiotics to Ceftriaxone.
• If the pulse rate and/ or respiration rate decreases after the first bolus but child still remains shocked, repeat the bolus. It is more likely the child is behind in fluids/dehydrated. Then start F75. If unable to tolerate full oral feeds, continue 50% IV and 50% F75.
• If the child is no longer in shock, give 5 ml/kg of ReSoMal every 30 min for 2 hrs and then return to 100% F75. Replace every loss (diarrhoea or vomiting) with 5 ml/kg of ReSoMal.

Dehydration

Use ReSoMal 5 ml/kg every 30 minutes for 2 hours (="ReSoMal challenge") in malnourished children (very thin evidence, if O/S: give ORS).
Than reasses, if the child is no longer dehydrated, give 5 ml/kg per loss. Monitor carefully. Be aware of volume overload. In case of emerging oedema around eyes, taper or stop fluids.

Anaemia (PCV<12%)

Only transfuse children with a PCV<12% (Hb <4 g/dl or <6 g/dl and respiratory distress), and then preferably with fresh whole blood.

• If stable await senior review,
• If unstable give a blood transfusion with whole blood (10 ml/kg in 4 hours, halfway Furosemide (1mg/kg))
• If signs of congestive cardiac failure, infuse 7ml/kg of packed cells over 3 hours
• Only give Fe therapy (3 mg elemental Fe/kg/day) on discharge

Photophobia, Xerosis, Bitot’s spots, xerophtalmia and corneal ulceration

• Give vitamin A immediately (< 6 months 50,000 IU, 6-12 months 100,000 IU, > 12 months 200,000 IU) and repeat at day 2 and 14
• In case of ulceration and or keratomalacia:
• Seek ophthalmological advice as soon as possible, cover the eye and keep child out of direct sunlight

Multidisciplinary Teams

Malnourished children are also "mentally malnourished". Once stabilized, they should be engaged into social interaction and play therapy. Encourage parents to make use of the play therapy room across from Moyo Ward and to converse and play a lot with their children.

Physiotherapy
Involve physiotherapy early in children with CP.

Nutritionist(when available)
Get them to help to get a full history of the child’s/family’s feeding habits at home.