Acute Gastroenteritis

Revised March 2011
Acute Gastroenteritis
(including management of dehydration, bloody diarrhoea and cholera)
Important Points in History

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Diarrhoea
o frequency of stools, number of days, blood or mucous in stools
local reports of cholera outbreak or other contacts unwell
recent antibiotic or other drug treatment
attacks of crying with pallor in an infant
feeding history
fever
local mankhwala
Important Points in the Examination

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Assess for emergency signs ABCCCD
Shock (cold hands, capillary refill >3 secs, fast, weak pulse) – see shock protocol
Severe Malnutrition (visible severe wasting or oedema of both feet) – see
malnutrition p 72
Assess Hydration – see table below
Abdominal examination looking particularly for surgical problems e.g. distension,
tenderness, guarding or a mass
Is there any evidence of serious non-intestinal infection?
Relevant Investigations

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Blood glucose if low BCS, or lethargic
Stool culture rarely indicated or available (but important if suspected cholera see below)
U and Es in individual circumstances
Indications for Admission
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Gastroenteritis with severe dehydration
Unable to tolerate oral fluids/ORS
Social concerns
Uncertainty about diagnosis
Drug Treatment

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Treatment with antiemetics and antimotility drugs is inappropriate in children
Treatment with antibiotics is rarely indicated, but see acute bloody diarrhoea and
cholera section below for specific indications.
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Revised March 2011
Assessing hydration
For all children with diarrhoea, hydration status should be classified as severe dehydration,
some dehydration or no dehydration and appropriate treatment given.
Classification
Severe
Dehydration
Some
Dehydration
No dehydration
Signs or Symptoms
Two or more of the following signs:
 Lethargy/unconsciousness
 Sunken Eyes
 Unable to drink/drinks poorly
 Skin pinch goes back very slowly
(≥ 2 seconds)
Two or more of the following signs:
 Restlessness/irritability
 Sunken eyes
 Drinks eagerly/thirsty
 Skin pinch goes back slowly
Not enough signs to classify as some or
severe dehydration
Treatment
Give fluid for severe
dehydration
PLAN C
Give Fluid for some
dehydration
After rehydration
advise mother on
home treatment and
when to return
immediately
PLAN B
Give fluid and food to
treat diarrhoea at
home
Advise mother on
when to return
immediately
PLAN A
Fluid management of SEVERE dehydration – malnourished child – p 75
Fluid management of SEVERE dehydration – Adequately nourished child (Plan C)
Children with severe dehydration should be given rapid IV rehydration followed by oral
rehydration therapy. Start IV fluids immediately. While the drip is being set up, give ORS
solution if the child can drink.
Aim to give 100mls/kg of Ringers Lactate (or if not available Normal Saline or 1/2 Strength
Darrows) as follows:
<12 months
>12 months
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First, give 30mls/kg in
1 hour
30 minutes
Then, give 70mls/kg in
5 hours
2.5 hours
Reassess the child every 15–30 minutes.
If hydration status is not improving, check that the drip is running. If drip is running
and hydration status is not improving give the IV drip more rapidly.
If the child shows signs of fluid overload, slow the drip down.
Also give ORS (about 5 ml/kg/hour) as soon as the child can drink: usually after 3–4
hours (infants) or 1–2 hours (children).
Reassess an infant after 6 hours and a child after 3 hours. Classify dehydration.
Then choose the appropriate plan (A, B, or C) to continue treatment.
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Revised March 2011
Fluid management of SOME dehydration – malnourished child - see p75
Fluid management of SOME dehydration – Adequately nourished child (Plan B)
These children can in general be given ORS and observed for about 4 hours (usually
in the ORS room of A and E)
In the first 4 hours, give the child the following approximate amounts of ORS solution,
according to the child‟s weight (or age if the weight is not known):
Weight
<6kg
6 - 10 kg
10-12 kg
12-19 kg
19-50 kg
Age *
<4 months
4 – 12 months
12 months – 2 years
2 – 5 years
5 – 15 years
Amount of ORS in 4 hours
200 – 400 mls
400 – 700 mls
700 – 900 mls
900 – 1400 mls
1400 – 2000 mls
* Use the child‟s age only when you do not know the weight. The approximate amount of
ORS required (in ml) can also be calculated by multiplying the child‟s weight (in kg) by 75.
 If the child wants more to drink, give more.
 Show the mother how to give ORS solution.
o a teaspoonful every 1–2 minutes if the child is under 2 years;
o frequent sips from a cup for an older child.
o If the child vomits, wait 10 minutes. Then continue, but more slowly.
o Continue breastfeeding whenever the child wants.
 After 4 hours:
o Reassess the child and classify the child for dehydration.
o If the child has improved and the situation allows, most children can be
discharged after this time.
o Select the appropriate plan (A, B or C) to continue treatment.
o Begin feeding the child.
Fluid management of NO deydration (Plan A)
Children with diarrhoea but no dehydration should receive extra fluids to prevent
dehydration. They should continue to receive an appropriate diet for their age, including
continued breastfeeding. Most of these children can be discharged with advice as below:
1. Give extra Fluid (as much as the child will take)
 Tell the Mother:
— Breastfeed frequently and for longer at each feed.
— If the child is exclusively breastfed, give ORS or clean water in addition to
breast milk.
— If the child is not exclusively breastfed, give one or more of the following:
ORS solution, food-based fluids (such as soup, rice water, and yoghurt
drinks), or clean water.
 It is especially important to give ORS at home when:
— the child has been treated with Plan B or Plan C during this visit.
— the child cannot return to a clinic if the diarrhoea gets worse.
 Teach the Mother how to mix and give ORS. Give the Mother 2 packets of ORS
to use at Home. Show the Mother how much fluid to give in addition to the
usual fluid intake:
— Up to 2 years 50 to 100 ml after each loose stool
— 2 years or more 100 to 200 ml after each loose stool
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Revised March 2011

Tell the mother to:
— Give frequent small sips from a cup.
— If the child vomits, wait 10 minutes. Then continue, but more slowly
— Continue giving extra fluid until the diarrhoea stops
2. Zinc Supplements
 These are recommended by WHO, but usually not locally available.
 If you are prescribing Zinc, the dose is:
— Up to 6 months 1/2 tablet (10 mg) per day for 10–14 days
— 6 months and more 1 tablet (20 mg) per day for 10–14 days
 Show the Mother how to give the Zinc:
— Infants, dissolve the tablet in a small amount of clean water, expressed milk
or ORS in a small cup or spoon; Older children, tablet can be chewed or
dissolved in a small amount of clean water in a cup or spoon.
 Remind the Mother to give the Zinc supplements for the full 10-14 days.
3. Continue Feeding
4. When to Return
 Return if the child develops any of the following signs:
— drinking poorly or unable to drink or breastfeed
— becomes more sick
— develops a fever
— has blood in the stool.
Contents of Modified ORS and ReSoMal
Glucose (mmol/L)
Sodium (mmol/L)
Potassium (mmol/L)
Chloride (mmol/L)
Citrate (mmol/L)
Magnesium (mmol/L)
Zinc (mmol/L)
Copper (mmol/L)
WHO ORS
75
75
20
65
ReSoMal
125
45
40
70
7
3
0.3
0.045
Cholera
Suspect cholera in children over 2 years old who have acute watery diarrhoea and signs of
severe dehydration, if cholera is occurring in the local area. Cholera outbreaks are
particularly seen in the rainy season. Cholera classically causes profuse diarrhoea (ricewater stool) with a characteristic odour and vomiting. It leads rapidly to severe dehydration
and patients may be shocked.
For all children with suspected cholrea
 Assess and treat dehydration and shock as for other acute diarrhoea.
 Try to accurately estimate losses and replace appropriately with ORS.
 Monitor response to rehydration and adjust accordingly
 Children with cholera often need large amounts of IV fluids. Several litres is not
unusual.
 Give erythromycin 12.5mg/kg qds for 3 days to shorten disease and reduce infectivity
 Guardian advice
— Give accurate directions re volumes of ORS to give.
— Advise about sanitation precautions.
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Revised March 2011

— Treat the guardian with doxycycline 300mg stat.
Complete a case-based surveillance reporting form
When there is a Cholera Outbreak (with a laboratory confirmed index case)
 All suspected cases should be managed in the health centres
 Admission or Attendance in Hospital should be avoided as far as possible
 If you see a child with suspected cholera
— Manage as detailed above
— See in Cholera room in A+E
— After stabilization transport should be arranged back to Health Centre
— Details of the DHO designated driver can be found in Room 6 of adult OPD
— Complete a case-based surveillance reporting form
— Out of hours transport back to health centre may be difficult
 Isolate (combo ward or side room PSCW or admissions)
 Transport to health centre as soon as possible
When there is no confirmed cholera outbreak
 If you see a child with suspected cholera
o Manage as detailed above
o If possible see in Cholera room in A+E
o Complete a case-based surveillance reporting form
o Send a stool sample for culture (special bottle)
o Isolate the child as above until further information available
Acute Bloody Diarrhoea/Dysentery
Dysentery is diarrhoea presenting with loose frequent stools containing blood.
Most episodes are due to Shigella and nearly all require antibiotic treatment.
Diagnosis
The diagnostic signs of dysentery are frequent loose stools with visible red blood. Others
include: abdominal pain, fever, convulsions, lethargy, dehydration (see above), rectal
prolapse.
Treatment
Children with severe malnutrition and dysentery, and young infants (<2 months old) with
dysentery should be admitted to hospital. In addition children who are toxic, lethargic, have
abdominal distension and tenderness or convulsions are at high risk of sepsis and should be
hospitalized. Others can be treated at home.
 Give an oral antibiotic – Nalidixic acid 15mg/kg for 5 days
 The management is otherwise the same as for acute watery diarrhoea.
Follow-up
It is important to ensure that children are followed up to ensure a response to treatment. If
there is no improvement after 2 days assess for other conditions and change the child to
another antibiotic (Ciprofloxacin). If there is still no improvement, discuss with seniors and
refer to the WHO handbook of hospital care for children.
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Chronic or Persistent Diarrhoea (PD)
Definition
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Diarrhoea with or without blood that persists for at least 14 days or more
Usually follows an episode of acute gastroenteritis
SEVERE persistent diarrhoea = PD + some or severe dehydration
Important Points in the History
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Duration of diarrhoea
Presence of blood in stool
Use of antibiotics and other drugs
Usual feeding practices
Important Points in the Examination
Determine whether
 Signs of dehydration
 Signs of malnutrition
 Look for markers of immune deficiency
 Evidence of non intestinal infections such as pneumonia, septicaemia, UTI, otitis
media
Who to admit?
 PD + some or severe dehydration
 PD + severe malnutrition
Investigations
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VCT
Stool microscopy – Giardia, Entamoeba histolytica, isospora
Relevant tests for associated infections
Treatment
(a) Assessment, resuscitation and early stabilisation
 Oral rehydration is usually effective (WHO treatment plan B)
 IV fluids (WHO plan C) only if essential e.g. worsening diarrhoea with ORS, vomiting,
severe dehydration with acidosis
 Screen and treat associated secondary infections
 Persistent bloody diarrhoea treat with Nalidixic acid 12.5 mg/kg
 Treat amoebiasis with metronidazole: 7.5 mg/kg, 3 times a day.
 If Giardia seen/ suspected, give metronidazole 5 mg/kg 3 times a day
 If HIV+ consider treatment for isospora (high dose cotrimoxazole) and helminthiasis
(stat albendazole) – see HIV guidelines
(b) Feeding
 Many children will have poor appetite until diarrhoea lessens and serious infection
has been treated. Special diets are therefore required. Besides giving child energy
and nutrition feeding will also speed up gut recovery.
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Revised March 2011
Infants under 6months
 Mothers must be encouraged to breastfeed exclusively. Breastfeeding must never
be stopped under any circumstances
 For non breastfeeding infants, encourage use of breast milk substitutes that are low
in lactose e.g. yoghurt
Children aged 6month or more
 Encourage mothers/guardians to start feeding their children as soon as they are able
 Consider nasogastric feeding for children not able to feed orally.
 Goal is to give daily intake of at least 110kcalories/kg of a diet low in lactose
 Use of Moyo feeds (F75, F100) – discuss with Moyo staff
(c) Micronutrient supplementation
All children with PD and malnutrition should have an initial dose of Vitamin A
A 2 week daily intake of
 multivitamins
 folic acid
 minerals ( not necessary if using F75, F100)
 WHO recommend zinc 10mg OD as part of mineral mix or separate supplement
 Iron therapy should not be started until recovery from diarrhoea has started
Monitoring
 Body weight
 Temperature
 Food/fluid intake
 Number of diarrhoeal stools
Children should resume appropriate diet for their age as soon as treatment successful
Discharge when
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Steady weight gain (at least 3 days of successive weight gain)
Fewer diarrhoeal stools
Absence of fever
Follow up and Rehabilitation
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Discuss and address underlying risk factors with guardian – appropriate feeding
(breast feeding, supplementary feeding); environmental hygiene and sanitation; HIV
Consider referral to community supplementary feeding program
Reference:
WHO Pocket Book of Hospital Care for Children (Geneva 2005)
WHO The treatment of diarrhoea – a manual for physicians and senior health workers
(Geneva 2005)
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Revised March 2011
Fluid Management
Before Giving IV fluids – THINK – does this child need IV fluids?
Be particularly careful with infants and in severe malnutrition
(avoid if possible)
Includes:
a. Maintenance fluids
b. Calculating how fast the IVI should drip
c. How to make up fluids containing 5% or 10% Dextrose
d. Glucose and electrolyte content of IV fluids.
Does not include:
e. Treatment of Shock
- Well nourished/Severely Malnourished child (see shock protocol)
f. Management of Dehydration
- Well-nourished child (see acute gastroenteritis protocol)
- Severely malnourished child (see malnutrition protocol)
- Hypernatraemic dehydration (see acute electrolyte imbalance protocol)
g. Maintenance fluids for neonates (see neonatal protocols)
1. Maintenance Fluids
Calculating fluid requirement for 24 hours: Assuming no dehydration and no extra losses
(e.g. from a surgical drain or from an NGT) a child will require over 24 hours:
100mls/kg for the first 10kg of body weight
+ 50mls/kg for the second 10kg of body weight
+ 20mls/kg for every kg thereafter
Example. A 14 kg boy will need
100mls x 10kg for his first 10kg
+ 50mls x 4kg for his next 4kg
=
1000mls
=
200mls
=
1200mls over 24hours
Which is 50mls per hour (1200mls / 24hours)
Example A 35kg girl will need
100mls/kg for her first 10kg
+ 50mls/kg for her next 10kg
+ 20mls/kg for her last 15kg
=
1000mls
=
500mls
=
300mls
=
1800mls over 24 hours
Which is 75mls per hour (1800mls / 24hours)
If there are other ongoing losses (e.g. from and NGT or from a drain) these should be added
to the total daily fluid requirements
These fluid requirements are the same whether the child takes the fluid orally, by NGT or IV
drip.
Calculating oral fluids requirements per feed:
Example A 7 kg baby who is too breathless to breast feed, but is able to drink expressed
milk from a spoon or cup will require:
 100mls x 7kg = 700mls per 24 hours
 If the mother is feeding the child every 3 hours, then there will be a total of 8 feeds
per day
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Revised March 2011


Therefore the baby will require 700mls / 8 feeds every feed
Which is approx 90mls of milk per feed
Feeds (EBM) can also be given 3 hourly via NG tube.
Show the mother how many syringes or cups to be given at each feed.
2. Calculating How Fast The IVI Should ‘Drip’

To work out how fast the IVI should drip the first you need to first determine two things:
1) What type of giving set do you have?
 There are three types of giving sets available at QECH
 Standard paediatric – 60 drops in 1 ml
 Standard adult – 20 drops in 1ml
 Other adult – 15 drops in 1ml
 Every time you set up an IVI you should check on the giving set package
to determine what type you are using
2) What rate do you want the fluids to run at – in mls/hr
You can now work out how many “drops per minute” the IVI should drip:
Formula:
desired rate ml/hr x giving set drops per ml
60
= no. of drops per min
This can be simplified for each of the giving sets:
Type of giving Set
15 drops per 1 ml
20 drops per 1 ml
60 drops per 1ml
Desired rate ml/hr ÷ 4 = no. of drops per min
Desired rate ml/hr ÷ 3 = no. of drops per min
Desired rate ml/hr
= no. of drops per min
Examples
 Maintenance fluids for a 7.2kg boy. With a „60 drops per 1 ml‟ giving set.
o His maintenance fluid requirements are 7.2kg x 100mls = 720mls per 24 hours
o This is 30mls per hour
o (ml/hr = drops per min for 60 drops per 1ml giving set)
o 30mls per hour means that the IVI should be „dripping‟ at 30 drops per minute
o This is 1 drop every 2 seconds
 Maintenance fluids for a 33kg girl. With a „20 drops per 1 ml‟ giving set.
o Her maintenance fluid requirements are
(10kg x 100mls) + (10kg x 50mls) + (13kg x 20mls) = 1760mls per 24 hours
o This is 73.3mls per hour
o (Desired rate ml/hr ÷ 3 = no. of drops per min for 20 drops per 1ml giving set)
o 73 † 3 means that the IVI should be „dripping‟ at 24 drops per minute
o This is 4 drops every 10 seconds.
3. How to make up fluids containing 5% or 10% Dextrose
If you want to give a child IV fluids containing 5% dextrose or 10% dextrose and there is no
suitable fluid available you will have to make it up by mixing 50% Dextrose and another IV
fluid.
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Revised March 2011
Desired Dextrose
Concentration
5% Dextrose
10% Dextrose
10% Dextrose
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
Amount of 50%
Dextrose
1 part 50 % Dextrose
1 part 50 % Dextrose
1 part 50% Dextrose
Amount of other fluid
9 parts Ringers or N. Saline
4 parts Ringers or N. Saline
9 parts 5% Dextrose containing fluid
(eg 1/2 Strength Darrows or 5% Dextrose)
If there is a burette available use a burette.
If no burette available make sure you empty out some of the bag of Ringers
Lactate/Normal Saline before adding dextrose. This will ensure that:
o Less 50% dextrose is needed
o If the IV fluids are accidentally left to run through the child will receive less
fluid to overload them.
The total volume in the bag should not exceed 500mls, but should usually be less –
particularly in infants.
Examples:
To make up 100 mls of R/L with 10% dextrose in a burette:
 Put 80ml of fluid (Normal Saline/Ringers Lactate) in burette.
 Draw up 20ml of 50% Dextrose and add to burette. (80 ÷ 4 = 20 ml)
 This makes 100ml of Normal Saline/Ringer‟s Lactate with 5% Dextrose.
 Label the burette using white tape, writing the type of fluid, time of commencement
and rate to be given at.
To make up 400 ml of R/L with 5% dextrose without a burette.
 Take a 1L bag of Ringers Lactate and drain it until 360 ml remain.
 Draw up 40ml of 50% dextrose and add it to the bag. (360 ÷ 9 = 40 ml)
 This makes 400 ml of Ringers Lactate with 5 % Dextrose.
 Label the bag using white tape, writing the type of fluid, time of commencement and
rate to be given at.
4. Glucose and Electrolyte content of IV fluids (contents per litre)
½ Strength
Darrows / 5%
Dextrose
Ringer‟s
Lactate
Normal Saline
0.9%
5% dextrose
Sodium Potassium
mmol/l mmol/l
61
17
Calcium Chloride Lactate
mmol/l
mmol/l
mmol/l
51
27
Dextrose
50g
Energy
kcal/l
200
130
2
0
0
0
0
50g
200
5
111
154
154
69
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Revised March 2011
The Jaundiced Child
See separate section on neonatal jaundice.
Remember the SEPTIC child may also be jaundiced.
Causes
Prehepatic
(Haemolysis)
1. Malaria (incl Tropical
splenomegaly
syndrome)
2. Sepsis
3. Sickle cell disease
4. G6PD deficiency
5. Thalassaemia
6. Hereditary
spherocytosis
Hepatic Disease
1. Infective Hepatitis
2. Cirrhosis
3. Drugs
4. Malignancy
5. Metabolic disease
6. Schistosomiasis (late
stage)
Posthepatic
(Obstructive)
1. Biliary atresia
2. Gallstones
3. Choledochal cyst
4. Worms (ascaris in
common bile duct)
Important points in history
o
o
o
o
o
Family history of hereditary haemoglobinopathy, liver disease
Previous need for transfusion (Hep B,C)
Drugs ingested: Triomune, anti TB meds or others suggesting G6PD
deficiency
Anorexia, abdominal pain, pruritis
Colour of stool and urine –normal colour of stools suggests unconjugated
jaundice and haemolysis, tea-colored urine and pale stools suggests
obstructive causes of jaundice
Important points in examination
A full physical examination is necessary. Particular signs may point to a diagnosis, or may
be important in different conditions.
o
o
o
o
o
o
o
o
Assess growth and nutritional state – poor in chronic liver disease
Pallor-suggests haemolysis if acute
Look for frontal bossing or maxillary overgrowth (sickle cell disease or
thalassaemia)
Bruising, bleeding
Hepatosplenomegly (malaria, longstanding haemolysis)
Liver tenderness – suggestive of acute hepatitis
Look for signs of chronic liver disease (eg. spider naevi, clubbing,
leukonychia, liver palms, scratches due to pruritis, ascites, distended
abdominal veins)
Abdominal masses – malignancy, choledochal cyst
Investigations




Urine dipstick for bilirubin and urobilinogen – suggests prehepatic disease
PCV/FBC
Malaria parasites
Sickle cell test
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Revised March 2011

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
Blood film
Liver function tests:
o Conjugated bilirubin in liver disease or biliary obstruction,
o Unconjugated bilirubin in haemolysis or hepatitis.
o Transaminases raised in hepatitis
Abdominal ultrasound (shrunken liver in cirrhosis, large bright inflamed liver in
hepatitis, tumours of liver, biliary atresia, choledochal cysts or gallstones)
Hepatitis B serology if hepatitis is considered.
VDRL
If there is ascites, a diagnostic/ therapeutic tap may be necessary.
If clotting screen is necessary – discuss with Johns Hopkins lab (near Lepra)
Treatment
 Pre hepatic (Haemolysis)
o Blood transfusion if PCV 15% or less.
o Treat underlying cause of haemolysis including sepsis and malaria
o Treat with quinine/LA for malaria even if malaria parasites are negative and
the child has evidence of haemolysis (jaundice, low PCV), and fever.
o Sickle cell crisis: (see sickle cell p45)

IV fluids – hyperhydration, oxygen, pain management, antibiotics
o Stop any possible offending drugs

Hepatic disease
o Blood sugar level - daily and more frequently if the child has a decreased
conscious state – maintain BSL between 4-9 mmol/l.
o Vitamin K: iv if bleeding actively – have a low threshold for its use if chronic
liver disease (longstanding jaundice, bruising, signs of chronic liver disease).
o Vitamin A - if chronic liver disease is suspected.
o Diet: Low protein, high carbohydrate. Feed 2 hourly.
o Fluid balance monitoring if encephalopathic– need approximately 2/3
maintenance fluid requirement. Monitor daily weight.
o Antibiotics if febrile and jaundiced and MP’s are negative. Give Quinine in this
situation.
o Surgical review if varices and GI bleeding. Crossmatch blood.
o In chronic liver disease consider prophylactic ranitidine, nystatin PO
o Avoid Paracetamol. Use ibuprofen if required.

Post hepatic disease
o Surgical management for obstruction due to gallstones or choledochal cysts
o Albendazole for worms
Complications


Haemolysis
o Cardiac failure secondary to severe anaemia
Liver disease
o GIT bleeding from varices, hemorrhoids secondary to portal hypertension
o Oedema due to hypoproteinaemia
o Fat-soluble (ADEK) vitamin deficiency
o Hepatic encephalopathy
o Hypoglycaemia
o Hepatorenal syndrome
o Pancreatitis
o Sepsis – particularly gram negative sepsis
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Revised March 2011
Malnutrition - Emergency Care and Initial Management
Important Points in History














Length of the history: ask presenting complaint and complaints from the preceding
3/12 period. When last completely well – playing / smiling?
Feeding history: Breast Fed (exclusive for how long), weaning (age and with what?),
energy density and frequency of present diet?
Availability and type of food at home?
Anorexia or lack of appetite (< 75% of expected food intake in 20 minutes)?
Vomiting or diarrhoea (and if so duration, aspect, quantity and frequency)?
Previous Illnesses: especially chronic cough (duration & contacts), and persistent
diarrhoea? Chronic otitis media, night sweats, thrush?
Growth chart in Child Health Passport: please copy onto CCP and MOYO CCP!
Oedema distribution and duration; when did it start and what preceded it?
Photophobia (did the child have a recent measles contact)?
Lethargy & apathy/irritability?
Developmental delay (both as a cause and effect of malnutrition)?
Vaccinations up to date (especially measles)?
Mothers HIV status and that of other members of the nucleus family and compliant to
Co-trim and HAART?
Social, Economic and Family History (clues of immune suppression), deaths of other
sibs, orphaned, disruption of family-, economic- or care provision, other difficulties?
Important Points in Examination
Because of their poor nutrition, severely malnourished children are immunecompromised, and hence show limited or no signs of infection and inflammation.



















Assess ABC, and Blantyre Coma Score,
Weight and Height/Length, and MUAC,
Severe wasting (and realise that <50% of under fives are stunted)
Hypothermia (common) or fever (rare in severe malnutrition)
Oedema (and its distribution) and Capillary Refill Time
Flaky paint dermatitis, peri-oral and peri-orbital cheilosis
Hair texture and colour
Liver size and tenderness, liver disease (pale stools grave prognostic sign!),
Abdominal distension (Small Bowel Bacterial Overgrowth presents with distended
tympanic abdomen),
Candidiasis: oral / groin (weeping & exudative and/or fissures?),
Localising signs of infection (usually absent): evidence of focal or widespread
infection e.g. pneumonia, GIT, Skin, ear infections, UTI and septicaemia,
Lymph nodes palpability is rare in malnutrition; hence, suspect EP-TB and/or HIV
Pallor
Evidence of eye disease: photophobia (measles and Vit A deficiency), corneal
dryness, Bitot‟s spots, corneal ulceration or keratomalacia, all suggesting vitamin A
deficiency
Evidence of rickets
Dehydration vs. hypo-volaemia (beware – may be difficult to assess)
Cardiac Failure (difficult to diagnose in an oedematous child)
HIV disease: lymphadenopathy, skin changes, Kaposi etc.,
Renal disease (acidosis).
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Relevant Investigations
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Blood Sugar (if lethargic, irritable, low BCS, diarrhoea or vomiting, hypothermic),
MPS (malaria apparently not common in oedematous malnourished children),
PCV
Urinalysis (if unsure if diagnosis = kwash)
Blood Culture (low threshold)
Faecal samples for ova and parasites,
HIV testing should be done as soon as possible
Mantoux test: suppressed in severe malnutrition as in HIV infection. If >5 mm
positive, suggests tuberculosis infection
Chest X ray.
Indications for Admission to Moyo House
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Bipedal oedema present or
Weight/Height <75%
Monitoring during admission
Normal monitoring of malnourished children entails (use MOYO CCP):
 Daily temperature, respiratory and heart rate as a minimum,
 Fluid and dietary intake as prescribed to gauge appetite,
 Daily weight and assessment of its growth rate (> 5g/kg/day),
 Loss of oedema and weight,
 Stool and urine output, diarrhoea,
 Mood: apathy, irritability and appetite.
In addition sick children monitored in HDU require regular (6 hourly) assessments of:
 BCS,
 Blood pressure and CRT, pulse rate,
 Oxygen Saturation and respiratory rates
 Fluid intake and Urine output,
The basic principles in Therapeutic Feeding:
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Feed volumes and types are calculated and prescribed daily using the tables and
charts in Moyo
Place NGT if the child finishes less than 75% of the formula milk for 2 consecutive
feeds. Other reasons for inserting an NGT are reduced level of consciousness,
lethargy or convulsions, pneumonia with rapid breathing, painful lesions in the mouth
or cleft palate or deformity. The NGT should be removed when the child takes 75% of
the day‟s diet orally, or takes 2 consecutive feeds fully by mouth.
F75 contains 75 kcal/0.9g protein/100mls, F100 contains 100kcal/2.9g
protein/100mls. Both contain extra minerals and vitamins
If possible, continue breastfeeding (including HIV exposed children). To ensure good
lactation, the mother should breastfeed before the child is fed with F75.
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Phases of Therapeutic feeding:
1.
Phase I Resuscitation/Stabilisation
a. High risk for hypothermia, hypoglycaemia and infections.
b. All children are initially put on F-75 feeds 8 times per day. Volume =
130mls/kg day (100 mls/kg if very oedematous)
c. If appetite is returning, child is more active and alert, complications are
treated and oedema visibly decreasing THEN change to transition phase.
2. Transition (TR) phase
a. Prescribe F100 in the same frequency and volume as it was given with F75.
b. If the child takes this well, increase the volume daily by 10%. If this is
accepted for a period of 4 days without increase in stool frequency or
diarrhoea then assume the small bowel mucosa can accommodate larger
carbohydrate loads and begin RUTF (Chiponde).
c. When on chiponde F100 is switched back to F75 in the same volumes.
Prescribe amount of chiponde as per charts and tables in Moyo
3. Rehabilitation and Catch-Up Phase (II)
a. Begin when consistently gaining weight and finishing at least 50% of
Chiponde target amount, when active, alert and free of complications.
b. During this final catch-up phase in the NRU, the child receives Likuni Phala at
6 a.m. and 6 p.m. instead of F75, and F75 & RUTF for the remaining 6 feeds.
4. When to move back a phase?
a. If worsening of vomiting or diarrhoea, increasing oedema or signs of fluid
overload, loss of appetite move back to phase I and review the same day.
b. These children have a high risk of cardio-vascular compromise while
appearing hypovolaemic.
Complications of Malnutrition
a. Hypoglycaemia (blood sugar < 3mmol/l)
 Give 1ml/kg of 50% dextrose. If alert give orally or by NGT. If lethargic by iv
 Feed with F75 immediately (avoid rebound hypoglycaemia)
 Give 1/6 of the 3 hourly amount of F75 every half-an-hour
 Repeat a blood sugar after 30 minutes: if it is >3mmol/l change to 3 hourly feeds
 If still low, make sure antibiotics have been given, and continue half-hourly F75.
 Transition F75 feeds from half hourly to two hourly feeds
 Emphasise the importance of night feeds
b. Hypothermia (axillary temperature of below 350C)
 Prevent by giving free blanket, closing windows and discouraging baths in
early morning. Preferably wash just with a wet cloth at lunchtime in the sun,
after a feed and immediately dry in a warm blanket.
 Cover the child, including the head
 Move the child away from windows
 Change wet clothing promptly
 Encourage the mother to practice kangaroo care
 Use a heater or lamp
 Monitor temperature until> 350 C
c. Hypovolaemic- and or septic shock
Defined in malnourished children if lethargic, obtunding/unconscious, cold hands,
plus either slow-capillary refill (>2sec) or a weak or fast pulse, and gallop rhythm.
 Give Oxygen and broad spectrum antibiotics. Check glucose
 Keep the child warm (preferably on resuscitaire with overhead heater/lamp)
 Carefully monitor pulse and respiratory rate
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establish IV -or if impossible IO- access,
Give bolus of 15 ml/kg of ½ strengths Darrows or Ringers Lactate + 5 % Glucose
over 1 hr and check pulse and respiration rate again
If the pulse rate increases by 10/min, or the respiratory rate is up by 5/min, the cause
of the shock is most likely sepsis, and give whole blood if available (15-20 ml/kg over
6 hours plus halfway 1mg/kg Frusemide i.v.).Continue i.v. fluids at maintenance rate
(4ml/kg/h) while awaiting the blood.
If the pulse rate and/or respiration rate decrease after the first bolus but child remains
still in shock, then repeat the bolus (15 ml/kg/hr) and then give ReSoMal by NGT
10mls/kg/hr for up to 10h. Then start phase I formula. If unable to tolerate oral feeds,
continue i.v. at 2-4 ml/kg/hr and try oral feeds at slower rate.
If the child is no longer in shock, oral rehydration via NGT is the preferred treatment
option. Give 5 ml/kg of ReSoMal every 30 min for 2 hrs and then 5-10 ml hourly for
the next 4-10 hours. If diarrhoea or vomiting during resuscitation add 30-50 ml of
ReSoMal per diarrhoea or vomiting.
d. Dehydration
 Use only RESOMAL in malnourished children. Do NOT use regular ORS
 Give ReSoMal as follows (see acute gastroenteritis p63 for constituents)
How often to give ReSoMal
Every 30 minutes for first 2 hours
Alternate hours (with F75 at the usual volume) for
up to 10 hours
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Amount to Give
5ml/kg
5 – 10ml/kg
If the child has already received IV fluids for shock and is switching to ReSoMal, omit
the first 2 hour treatment with ReSoMal and start with the amount for the next period
of 10 hours.
Monitor carefully. If there are signs of “over” hydration e.g. emerging oedema around
eyes, stop ReSoMal.
If the hydration status improves give RESOMAL only after loose stools:
o For children <2 years, give 50 –100 ml. after each loose stool
o For children >2 years, give 100 – 200 ml. after each loose stool
e. Bacteraemia and septicaemia in severely malnourished: empiric antibiotics
 All children on Moyo get a 1st or 2nd line antibiotic on admission
 Take a blood culture on admission and if antibiotics need to be changed
IF
No complications
(rarely the case in admitted children)
Complications: and usually the case
on admission! (All children with
kwashiorkor, shock, hypoglycaemia,
hypothermia, dermatosis with raw skin/
fissures, pneumonia, UTI, lethargic,
child appears unwell)
Failure to respond (if child fails to
lose oedema, remains anorexic, or
clinically septic / sick)
GIVE
1st Line AB treatment = Co-trimoxazole
120 mg if < 5kg 5 BD
240 mg if > 5 kg BD
2nd Line AB treatment (prescribed to
most admitted children)
Chloramphenicol 25 mg/kg t.d.s. i.v. and
Gentamicin 7.5 mg/kg o.d. i.v. /i.m.
Give Ciprofloxacin 10 mg/kg b.d .p.o as
2nd line alternative drug.
3rd Line AB treatment
Ceftriaxone 100 mg/kg OD IV/IM for 7
days
Or if the child can swallow, and Gram
Negative-sepsis is suspected then
Ciprofloxacin 10 mg/kg OD PO 7 days
(and in case NTS infection for 14 days).
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Revised March 2011
f.
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Conditions needing special antibiotic treatment
Extensive/infected skin lesions Cloxacillin 50mg/kg/day t.d.s. PO.
Distended abdomen suspect bacterial overgrowth of the small gut. Metronidazole
7.5-10 mg/kg p.o. t.d.s. for 7 days.
Persistent Diarrhoea with suspected protozoan infections of the gut (Cryptosporidium
Parvum, Giardia intestinalis, Amoebiasis). Metronidazole 7.5-10 mg/kg TDS for 7
days. Consider high dose Co-trimoxazole (60 mg/kg b.d.) if HIV infection (Isospora,
Cyclospora).
Infected skin lesions or open sores GV paint is indicated
Kwashiorkor dermatoses (scaling skin), zinc ointment is indicated.
Candida infection of the perineum is best treated with removing diapers to dry the
area and apply GV paint (Nystatin cream bd. if available).
Oral Candidiasis. Treat initially with GV/nystatin. Commonly needs fluconazole.
Oesophageal Candidiasis is suspected in HIV infected children who have extensive
oral Candidiasis with persistent vomiting and anorexia. Use fluconazole. Remember
ketoconazole is contra-indicated in children on nevirapine.
g. Anaemia (PCV<12%)
Only transfuse children with a PCV<12%, and then preferably with fresh whole blood.
 If stable await senior review,
 If unstable give a blood transfusion with whole blood (10-15 ml/kg in 6 hours),
 Frusemide (1mg/kg) should be given to all children receiving a blood transfusion,
 If no signs of cardiac failure, infuse 10-15 mls/kg of blood over 3-6 hours,
 If signs of congestive cardiac failure, infuse 7-10 mls/kg of blood over 3-6 hours
NB Only give Fe therapy (3 mg elemental Fe/kg/day) in catch-up growth phase on discharge
h. Photophobia, Xerosis, Bitot’s spots, xerophtalmia and corneal ulceration
 give vitamin A immediately and repeat at day 2 and 14 (see formulary for dose)
 In case of ulceration and or keratomalacia:
 One drop of Atropine 1% should be instilled into each eye, three times a day,
 Chloramphenicol or tetracycline eye ointment 2-3 hourly for 7/7 in each eye,
 Eye pads and advise mother to keep the child out of bright sunlight.
 Seek ophthalmological advice as soon as possible,
Failure to respond to treatment
1. Definition: During rehabilitation/catch-up phase (phase II) the child‟s expected weight
gain is about 10-15 g/kg per day. Hence, a child who does not gain at least 5g/kg per
day for 3 consecutive days should be reviewed carefully for failure.
2. The most common causes for not reaching the expected weight gains are:
 Inadequate dietary intake (insufficient amount of F75, F100 or Chiponde, the
prescribed (night-) feeds are not given as prescribed, spillage [easily 10% of
prescribed volume], vomiting, anorexia). CONSIDER NGT
 Glossitis due to thrush or folate deficiency
 Chronic diarrhoea, and malabsorption
 Lack of supervisory staff, and/or exhausted guardians from feeding every 3 hours
 Inaccurate or faulty recording and weighing
3. Manage treatment failure by:
 Review the exact amount of food that the child is taking and calculate the caloric
intake per day (should be > 150 kcal/kg/d).
 Treating HIV infection (the decision to start HAART should be discussed with senior
staff)
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Revised March 2011
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Correct micronutrient deficiencies: is the child receiving a catch-up diet which does
not contain adequate amounts of micronutrients (K, Fe etc.),
Look for underlying occult infection (e.g. TB, HIV, bacteraemia, UTI, Otitis, Thrush),
TB infection should be suspected in any child who does not gain weight for more
than 7 days on AB, who has a TB contact, or symptoms or signs suggestive of TB.
Treat the treatable conditions and increase the caloric intake by increasing the
amount of F100 and or RUTF/Chiponde.
4. Remember alternative reasons for failure to thrive such as:
 Congenital Cardiac Disease,
 Celiac disease or other malabsorptive GI-diseases
 Cerebral palsy or other causes of bulbar palsy
 Social and parental deprivation
 Metabolic disease
 Renal Disease
 Liver Disease
When to Discharge
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Take advice from Moyo regarding current policy
Usually when oedema cleared, infection treated, good appetite and gaining weight
Play
Severely malnourished children often have a delayed mental and behavioural development.
Half an hour focussed and well directed play per day has proven to significantly increase
catch-up growth in height and the child‟s cognitive development. Play activities don‟t need
fancy equipment and examples how to make simple, but effective, toys from daily household
cleaning materials can be found with the nursing or Umodzi staff. Children on Moyo should
be seen by the play therapist every day.
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