10 Steps to Recovery

Steps 1-2 Treat/prevent hypoglycemia and hypothermia

STEP 1: Treat Hypoglycemia STEP 2: Treat Hypothermia Usually occur together Associated with some severe illnesses and infection Frequent feeding is important Hypoglycemia: blood sugar < 3mmol/l Signs and symptoms: Confusion, abnormal behavior, visual disturbances Heart palpitations, tremor, anxiety, sweating, hunger

If confirmed, give through mouth or NGT tube: 50 ml of 10% glucose solution or sugar water (1 rounded teaspoon of sugar in 3.5 tablespoon water) Feed every 2 hours, day and night. Start straightaway or rehydrate first, if needed. STEP 1: Treat Hypoglycemia

Check for the blood sugar again: After 30 minutes and again after 2 hours If it is low on either occasion, repeat the 50 ml glucose solution or sugar water. If unable to test, assume all severely malnourished children have hypoglycemia. STEP 1: Treat Hypoglycemia

STEP 2: Treat Hypothermia Hypothermia Temperature: 35 C (axillary), 35.5 (rectal) Children lose heat faster than adults do. There is sympathetic nervous system excitation shivering, hypertension, tachycardia, tachypnea, and vasoconstriction

Feed straightaway Make sure the child is warm Put the child on the mother’s bare chest or abdomen and cover them Clothe the child and cover with a warmed blanket Place a heater or lamp nearby STEP 2: Treat Hypothermia

Check: the rectal temperature every 2 hours until it rises above 36.5 C The child is covered all times, especially at night For hypoglycemia Assume the child has hypothermia when the thermometer does not measure low temperatures and the child’s temperature is too low to register. STEP 2: Treat Hypothermia

To prevent hypothermia and hypoglycemia: Feed the child every 2 hours, start straightaway Always feed during the night Keep the child covered and away from draughts Avoid exposure STEP 1: Treat Hypoglycemia STEP 2: Treat Hypothermia

Step 3 Treat/Prevent Dehydration

Do not use the standard WHO oral rehydration salt solution Give modified solution instead. Do not use IV route except in shock, and then do so with care. STEP 3: Treat/ Prevent Dehydration

1. Modified ORS Solution IngredientAmount Water2 Liters WHO-ORSOne 1 Little Packed Sugar50 g Electrolytes40 mL

2. Combined Electrolyte/mineral solution (for rehydration solution and feeds) IngredientAmount (g) Potassium Chloride224 Tripotassium Chloride81 Magnesium Chloride76 Zinc Acetate8.2 Copper Sulfate1.4 Water Make Up to2500 mL

New ORS Formulation Reduced osmolarity ORS grams/litre Reduced osmolarity ORS mmol/litr e Sodium chloride2.6Sodium75 Glucose, anhydrous13.5Chloride65 Potassium chloride1.5Glucose, anhydrous75 Trisodium citrate, dihydrate 2.9Potassium20 Citrate10 Total Osmolarity245

Standard ORS solution Reduced Osmolarity ORS solutions (mEq or mmol/l) (mEq or mmol/l) (21) (mEq or mmol/l) (6, 14, 22-27) (mEq or mmol/l) (13, 15-18, 28-29) Glucose Sodium Chloride Potassium20 Citrate Osmolarity

Monitor progress of rehydration every 30 minutes for the first 2 hours every hour for the next 6-12 hours Check pulse, respiratory rates, input and output (urine, stool, vomitus) STEP 3: Treat/ Prevent Dehydration

Signs of TOO much Rehydration Increase RR Increase PR Edema Puffy eyelids * If these signs occur, STOP fluids immediately and reassess the child’s condition after 1 hour.

When a child has watery diarrhea: Start feeding straightaway Replace the approximate volume of stool losses with the modified rehydration solution. Encourage continued breastfeeding if the child is breastfed STEP 3: Treat/ Prevent Dehydration

Body Weight Method for Daily Maintenace Fluid Volume Body WeightFluid Per Day 0-10 kg100 mL/kg kg1,000 mL + 50 mL/kg for each kg > 10 kg >20 kg1500 mL + 20 mL/kg for each kg >20 kg* * The MAXIMUM fluid per day is 2,400 mL

Hourly Maintenance Rate For Body Weight of: 0-10 kg4 mL/kg/hr kg40 mL/kg/hr + 2 mL/kg/hr x (wt-20) >20 kg60 mL/kg/hr + 1 mL/kg/hr x (wt-20)* * The maximum fluid rate is normally 100 mL/hr

Step 4 Correct Electrolyte imbalance

All severely malnourished children have TOO much sodium in their bodies. They also have potassium and magnesium deficiencies which may take at least 2 weeks to correct. Edema is partly due to this deficiencies STEP 4: Correct Electrolyte imbalance

Give Extra potassium 2-4 mmol/kg/day Extra magnesium mmol/kg/day Modified ORS solution (see step 3) Prepare food without salt Extra potassium and magnesium can be prepared in liquid form and added directly during preparation STEP 4: Correct Electrolyte imbalance

IVF Composition FluidNaClKCaLactate Normal Saline (0.9% NaCl) 154 ½ Normal Saline (0.45% NaCl) Normal Saline (0.2% NaCl) 34 Ringers Lactate

Step 5 Treat Infections

STEP 5: Treat Infection Severe malnutrition: No Fever Given routinely to ALL admission: Broad spectrum antibiotics Measles vaccine to unimmunized Metronidazole (7mg/kg tid for 7 days)* Mebendazole: Children > 2 years

Treat Infections: Antibiotics No complications  Co-trimoxazole Given for 5 days, twice daily If < 4 kg, give 2.5 ml If > 4kg, give 5 ml

Treat Infections: Antibiotics If severely ill + complications (lethargic, hypoglycemic, hypothermic, skin lesions)  Gentamicin + Ampicillin Gentamicin: 3.5 mg/kg IM or IV q12h for 7 days Ampicillin: 50 mg/kg IM or IV q6h for 2 days then shift to oral for 5 days

Treat Infections: Antibiotics If fails to improve within 48h  Gentamicin + Ampicillin + Chloramphenicol Gentamicin: 3.5 mg/kg IM or IV q12h for 7 days Ampicillin: 50 mg/kg IM or IV q6h for 2 days then shift to oral for 5 days Chloramphenicol: 25mg/kg IM q6h for 5 days

Poor appetite continues after 5-7 days of antibiotic, complete 10 day course. If still anorexic, fully RE-ASSESS the patient STEP 5: Treat Infection

Step 6 Correct Micronutrient deficiencies

STEP 6: Correct micronutrient deficiencies Give Multivitamin supplement Folic acid 1mg/day Zinc 2mg/kg/day Copper 0.2 mg/kg/day Do NOT give Iron (3mg/kg/day) until the child starts gaining weight (2 nd week of treatment

Step 7 Start cautious feeding

Start cautious feeding in the stabilization phase (days 1-7) The amount and type of food given is important. Feeds should be started as soon as possible and provide just sufficient energy and protein to maintain basic physiological processes. STEP 7:Start Cautious feeding

Give: Small, frequent feeds of a milk-based starter formula 100kcal/kg/day 1-1.5g protein/kg/day 130mL/kg/day (100mL/kg/day if the child has edema) If the child is breastfed, encourage continued breastfeeding (give starter formula first) STEP 7:Start Cautious feeding

Very weak children may be fed by spoon, dropper, syringe (remove needle) or nasogastric tube During this phase, diarrhea should gradually diminish and children with edema should lose weight STEP 7:Start Cautious feeding

A typical schedule for feeding is: DAYSFREQUENCYVOL/KG/FEEDVOL/KG/DAY 1-22 hourly11 mL130 mL 3.53 hourly16 mL130 mL hourly22 mL130 mL STEP 7:Start Cautious feeding

Step 8 Rebuild Wasted Tissues

STEP 8: Rebuild Wasted Tissues Rebuild wasted tissues

Replace starter formula with an equal amount of catch-up formula for 2 days Increase each feed by 10mL until some feed remains uneaten. A child should have  200mL/kg/day of catch-up formula Frequent feeds (every 4 hours) of a catch-up diet with unlimited amounts kcal/kg/day 4-6g protein/kg/day

Step 9 Provide TLC

Step 9: TLC Stimulation, play, and loving care

Step 10 Preparation for follow up after discharge

Involve parents in feeding and playing with their child Child= 90% weight-for- length can be considered to be ready for discharge Good feeding practices and stimulation should continue at home

Give energy and nutrient dense foods at least 5x per day Establish play time with the child so that mental development may improve

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