10 Steps to Recovery

Steps 1-2Treat/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 3Treat/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

Ingredient Amount

Water 2 Liters

WHO-ORS One 1 Little Packed

Sugar 50 g

Electrolytes 40 mL

2. Combined Electrolyte/mineral solution (for rehydration solution and feeds)

Ingredient Amount (g)

Potassium Chloride 224

Tripotassium Chloride 81

Magnesium Chloride 76

Zinc Acetate 8.2

Copper Sulfate 1.4

Water Make Up to 2500 mL

New ORS FormulationReduced osmolarity

ORS grams/litre Reduced osmolarity ORS

mmol/litre

Sodium chloride 2.6 Sodium 75

Glucose, anhydrous 13.5 Chloride 65

Potassium chloride 1.5 Glucose, anhydrous 75

Trisodium citrate, dihydrate 2.9 Potassium 20

    Citrate 10

    Total Osmolarity 245

 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 111 111 75-90 75

Sodium 90 50 60-70 75

Chloride 80 40 60-70 65

Potassium 20 20 20 20

Citrate 10 30 10 10

Osmolarity 311 251 210-260 245

• 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

VolumeBody Weight Fluid Per Day

0-10 kg 100 mL/kg

11-20 kg 1,000 mL + 50 mL/kg for each kg > 10 kg

>20 kg 1500 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 kg 4 mL/kg/hr

10-20 kg 40 mL/kg/hr + 2 mL/kg/hr x (wt-20)

>20 kg 60 mL/kg/hr + 1 mL/kg/hr x (wt-20)*

* The maximum fluid rate is normally 100 mL/hr

Step 4Correct 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 0.3-0.6 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 CompositionFluid Na Cl K Ca Lactate

Normal Saline (0.9% NaCl)

154 154

½ Normal Saline (0.45%

NaCl)

77 77

0.2 Normal Saline (0.2%

NaCl)

34 34

Ringers Lactate 130 109 4 3 28

Step 5Treat 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 6Correct 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 (2nd week of treatment

Step 7Start 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:

DAYS FREQUENCY VOL/KG/FEED VOL/KG/DAY1-2 2 hourly 11 mL 130 mL3.5 3 hourly 16 mL 130 mL

6-7+ 4 hourly 22 mL 130 mL

STEP 7:Start Cautious feeding

Step 8Rebuild Wasted Tissues

STEP 8: Rebuild Wasted Tissues• Rebuild wasted

tissues

Frequent feeds (every 4 hours) of a catch-up diet with unlimited amounts150-220kcal/kg/day4-6g protein/kg/day

Step 9Provide TLC

Step 9: TLC• Stimulation, play, and loving

care

Starting from admission, provide:1. tender, loving care2. structured play and physical activity as soon as the child is well enough3. a cheerful, stimulating environment4. mother’s involvement

Step 10Preparation 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

SOME POINTERS:

The family should…

Give energy and nutrient dense foods at least 5x per day

Establish play time with the child so that mental development may improve

Thank you!!