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1. Stabilization Care Guidelines1|
Guidelines for the inpatient treatment of
severely malnourished children
A. General principles for routine care (the ‘10 Steps’)
B. Emergency treatment of shock and severe anemia
C. Treatment of associated conditions
D. Failure to respond to treatment
E. Discharge before recovery is complete

2. Stabilization Care Guidelines2|
A.General principles for routine care
(the ‘10 Steps’) 10
Step 1. Treat/prevent hypoglycemia
Step 2. Treat/prevent hypothermia
Step 3. Treat/prevent dehydration
Step 4. Correct electrolyte imbalance
Step 5. Treat/prevent infection
Step 6. Correct micronutrient deficiencies
Step 7. Start cautious feeding
Step 8. Achieve catch-up growth
Step 9. Provide sensory stimulation and emotional support
Step 10. Prepare for follow-up after recovery

3. Stabilization Care Guidelines3|
An initial stabilization phase
where the acute medical conditions are managed;
and a longer rehabilitation phase.

4. Stabilization Care Guidelines4|
Step 1. Treat/prevent hypoglycemia
Hypoglycemia and hypothermia usually occur together and are
signs of infection.
•Check for hypoglycemia whenever hypothermia (axillary <35.0C) is
found
•Frequent feeding is important in preventing both conditions.

5. Stabilization Care Guidelines5|
Treatment:
If the child is conscious and dextrostix shows <3mmol/l or
54mg/dl give:
•50 ml bolus of 10% glucose or sugar water ( orally or by
nasogastric (NG) tube.
•Then feed starter F-75 every 30 min. for two hours
(giving one quarter of the two-hourly feed each time)
•antibiotics
•two-hourly feeds, day and night

6. Stabilization Care Guidelines6|
Treatment:
If the child is unconscious, lethargic or convulsing give:
• IV sterile 10% glucose (5ml/kg), followed by 50ml of 10% glucose or
sugar water by Ng tube.
Then give starter F-75 every 30 min. for two hours
(giving one quarter of the two-hourly feed each time)
• antibiotics
• two-hourly feeds, day and night

7. Stabilization Care Guidelines7|
Monitoring:
Blood glucose:
-if this was low, repeat dextrostix taking blood from finger or
heel, after two hours. Once treated, most children
stabilize within 30 min.
-If blood glucose falls to <3 mmol/ l give a further 50ml bolus
of 10% glucose or sugar water, and continue feeding
every 30 min. until stable
-level of consciousness: if this deteriorates, repeat dextrostix

8. Stabilization Care Guidelines8|
Prevention:
Feedtwo-hourly,startstraightawayorifnecessary,rehydrate
first.Alwaysgivefeedsthroughoutthenight
Note:Ifyouareunabletotestthebloodglucoselevel,
assumeallseverelymalnourishedchildrenare
hypoglycemicandtreataccordingly.
SugarWater:Addtwoteaspoonfulofsugarin100mlofclean
drinkingwater

9. Stabilization Care Guidelines9|
Step 2. Treat/prevent hypothermia
Treatment:
If the axillary temperature is <35.0C.
feed straightaway (or start rehydration if needed)
rewarm the child: either clothe the child (including head),
cover with a warmed blanket and place a heater or lamp
nearby (do not use a hot water bottle), or put the child on the
mother’s bare chest (skin to skin) and cover them
give antibiotics

10. Stabilization Care Guidelines10|
Step 2. Treat/prevent hypothermia
Monitor:
body temperature: during rewarming take temperature
two hourly until it rises to >37.oC (take half-hourly if
heater is used)
ensure the child is covered at all times, especially at
night

11. Stabilization Care Guidelines11|
Step 2. Treat/prevent hypothermia
Prevention:
feed two-hourly, start straightaway
always give feeds throughout the day and night
keep covered and away from draughts
keep the child dry, change wet nappies, clothes and bedding
avoid exposure (e.g. bathing, prolonged medical examinations)
let child sleep with mother at night for warmth

12. Stabilization Care Guidelines12|
Step 3. Treat/prevent dehydration
Note: Low blood volume can coexist with edema. Do not use the IV route
for rehydration except in cases of shock and then do so with care,
infusing slowly to avoid flooding the circulation and overloading
the heart

13. Stabilization Care Guidelines13|
Diagnosis
Clinical signs of some and severe dehydration
Signs Some Severe
Recent frequent watery diarrhoea Yes, > 3 times a day Yes, profuse
Recent sunken eyes Yes Yes
Recent rapid weight loss 1-5 % 5-10%
Thirst Drinks eagerly Drinks poorly
Absence of tears No Yes
Weak/absent radial pulse No Yes
Cold hands or feet No Yes
Mental state Restless and irritable Lethargic/coma
Urinary output Decreased Absent

14. Stabilization Care Guidelines14|
DEHYDRATION / REHYDRATION
In Malnourished Children
All the signs of dehydration in a normal child occur in a severely malnourished
child who is notdehydrated –only history of fluid loss and very recent
change in appearance can be used
Giving a malnourished child who is not really dehydrated treatment of
dehydration is very dangerous
Misdiagnosis of dehydration and giving inappropriate treatment is the
commonest cause of death in severe malnutrition
The treatment of dehydration is differentin the severely malnourished child
from the normally nourished child

15. Stabilization Care Guidelines15|
DEHYDRATION / REHYDRATION
In Malnourished Children
Infusion are almost never used and are particularly dangerous
ReSoMal must not be freely available in the unit –but only taken when
prescribed
The management is based mainly on accurately monitoring changes in weight
Severely wasted patients cannot excrete excess sodium and retain it in their
body. This leads to volume overload and compromise cardiovascular system.
The resulting heart failure can be very acute (sudden death) or be
misdiagnosed as pneumonia

16. Stabilization Care Guidelines16|
Diagnosis
History of recent changes in appearance of eyes
History of recent fluid loss
Check the eyes lids to see if there is lid-retraction.
Check if patient is unconscious or not
Check if patient has recently lost weight (if in SC)

17. Stabilization Care Guidelines17|
Dehydration , septic shock
and hypoglycaemia
If there is a history of recent watery diarrhoea and recent change in the
appearance of the eyes usually with the retraction of eyelidthen treat the
child for dehydration.
If this history and signs are not present, the child appears to be dehydrated
without a history of excess fluid loss orchild has oedema then consider
treating for septic shock.

18. Stabilization Care Guidelines18|
Dehydration , septic shock
and hypoglycaemia
Signs of shock present:
No history of major fluid loss
No history of recent eyes sinking
Fast weak pulse, cold peripheries, pallor and drowsiness
•Eyelid drooping/normalor closedwhen asleep/unconscious
Septic shock
•Eyelidretractedor slightly open when asleep/unconscious
Septic shock + hypoglycaemia

19. Stabilization Care Guidelines19|
Oral Treatmentof Dehydration
The main complications of diarrhoea are dehydration, hypovolaemic shock
and congestive heart failure due to over-hydration as a result of the treatment.
Severely malnourished children are very sensitive to overloading the system
with fluids and electrolytes.
Therefore no ReSoMal (REhydration SOlution for MALnourished) or
ORS is given to prevent dehydration.
ReSoMal is only given when dehydration is diagnosed.

20. Stabilization Care Guidelines20|
ReSoMal
ReSoMal = Rehydration Solution for Severe Malnourished patients
Presentation
-Sachet containing 84 g of powder, to be diluted in 2 liters of clean, boiled and
cooled water for treatment of 3 children
-Sachet containing 420 g of powder, to be diluted in 10 liters of clean, boiled and
cooled water for treatment of 15 children
Composition for one liter
Glucose 55 mmol Citrate 7 mmol
Saccharose73 mmol Magnesium 3 mmol
Sodium 45 mmol Zinc 0.3 mmol
Potassium 40 mmol Copper 0.045 mmol
Chloride 70 mmol
Osmolarity294 meq /liter

21. Stabilization Care Guidelines21|
Oral rehydration with ReSoMal for severe
Malnourished
During the first 2 hrs During the next 10 hrs Total over 12 hrs
Weight
in kg
5 ml/kg
every 30 minutes
Total over 2 hrs
20 ml/kg
5 ml/kg
every hour
Total over 10 hrs
50 ml/kg
70 ml/kg
3 15 mlevery 30 min 60 ml 15 mlevery hour 150 ml 210 ml
4 20 mlevery 30 min 80 ml 20 mlevery hour 200 ml 280 ml
5 25 mlevery 30 min 100 ml 25 mlevery hour 250 ml 350 ml
6 30 mlevery 30 min 120 ml 30 mlevery hour 300 ml 420 ml
7 35 mlevery 30 min 140 ml 35 mlevery hour 350 ml 490 ml
8
40 mlevery 30 min
160 ml
40 mlevery hour
400 ml 560 ml
9
45 mlevery 30 min
180 ml
45 mlevery hour
450 ml 630 ml
10
50 mlevery 30 min 200 ml 50 mlevery hour
500 ml 700 ml

22. Stabilization Care Guidelines22|
Alternative recipes in the absence of ReSoMal
Solutions can be made by using one of the following types of
rehydration salts:
· Standard WHO-ORS (sachet containing 3.5 g of sodium chloride, 1.5
g of potassium chloride, 20 g of glucose, total weigh: 27.9 g per
sachet)
*
CMV® mineral and vitamin complex: 1 measure = 6,5 grams.
Water Standard WHO-ORS Sugar CMV*
2 liters 1 sachet 50 g 1 measure
10 liters 5 sachets 250 g 5 measures

23. Stabilization Care Guidelines23|
Step 4. Correct electrolyte imbalance
All severely malnourished children have excess body sodium even though
plasma sodium may be low (giving high sodium loads will kill). Deficiencies of
potassium and magnesiumare also present and may take at least two weeks
to correct. Edema is partly due to these imbalances. Do NOT treat edema
with a diuretic.

24. Stabilization Care Guidelines24|
Step 5. Treat/prevent infection
In severe malnutrition the usual signs of infection, such as fever, are often
absent, and infections are often hidden.
Therefore give routinely on admission:
-broad-spectrum antibiotic (s) AND
measles vaccine if child is > 6m and not immunized (delay if the child is in
shock)

25. Stabilization Care Guidelines25|
Antibiotics for Severely Malnourished Children:

26. Stabilization Care Guidelines26|
Step 6. Correct micronutrient deficiencies
No need of supplementation while using Therapeutic feed but Vitamin A is
recommended to all malnourish children except patient with edema.
Some authorities recommend Folic acid at admission.

27. Stabilization Care Guidelines27|
Step 7. Start cautious feeding
Monitor and note:
• amounts offered and left over
• vomiting
• frequency of watery stool
• daily body weight

28. Stabilization Care Guidelines28|
Weighing chart for F75
To 100ml Add 20.5g
To 250ml Add 50g
To 500ml Add 100g
To 1000ml Add 205g
You can make up 2 feeding at 1 time BUT divide the mix into 2 jugs and store the
second feed separately in the fridge.
Ensurethe open bag of powder is sealed again properly to stop contamination

29. Stabilization Care Guidelines29|
Step 8. Achieve catch-up growth
In the rehabilitation phase a vigorous approach to feeding is required to
achieve very high intakes and rapid weight gain of >10 g gain/kg/d.
The recommended milk-based F-100 contains 100 kcal and 2.9 g protein/100 ml

30. Stabilization Care Guidelines30|
Monitor during the transition for signs of heart failure:
respiratory rate
pulse rate
–If respirations increase by 5 or more breaths/min and pulse by 25 or more
beats/min for two successive 4-hourly readings, reduce the volume per feed (give
4-hourly F-100 at 16 ml/kg/feed for 24 hours,
–then 19 ml/kg/feed for 24 hours, then 22 ml/kg/feed for 48 hours, then increase
each feed by 10 ml as above).
After the transition give:
–frequent feeds (at least 4-hourly) of unlimited amounts of a catchup formula 150-
220 kcal/kg/d

31. Stabilization Care Guidelines31|
Monitor progress after the transition by assessing the
rate of weight gain:
• weigh child each morning before feeding. Plot weight
• each week calculate and record weight gain as g/kg/day
If weight gain is:
• poor (<5 g/kg/d), child requires full reassessment
• moderate (5-10 g/kg/d), check whether intake targets are being met,or
if infection has been overlooked
• good (>10 g/kg/d), continue to praise staff and mothers

32. Stabilization Care Guidelines32|
Step 9. Provide sensory stimulation
and emotional support
In severe malnutrition there is delayed mental and behavioral
development.
Provide:
• tender loving care
• a cheerful, stimulating environment
• structured play therapy 15-30 min/d
• physical activity as soon as the child is well enough
• maternal involvement when possible (e.g. comforting, feeding,
bathing,play)

33. Stabilization Care Guidelines33|
Step 10. Prepare for follow-up after recovery
A child who is 85% weight-for-length (equivalent to -1SD) can be
considered to have recovered (TFC). The child is still likely to have a
low weight-for-age because of stunting. Good feeding practices and
sensory stimulation should be continued at home.
Show parent how to:
• feed frequently with energy-and nutrient-dense foods
• give structured play therapy
Advise parent o to
-bring child back for regular follow-up checks
-ensure booster immunizations are given
-ensure vitamin A is given every six months

34. Stabilization Care Guidelines34|
B. EMERGENCY TREATMENT OF SHOCK
Hypoglycemia?
Dehydration?
Septic Shock?

35. Stabilization Care Guidelines35|
B. EMERGENCY TREATMENT OF SHOCK
Shock from dehydration and sepsis are likely to coexist in severely
malnourished children. They are difficult to differentiate on clinical
signs alone.
Children with dehydration will respond to IV fluids. Those with septic shock
and no dehydration will not respond.
The amount of fluid given is determined by the child’s response.
Over hydration must be avoided.

36. Stabilization Care Guidelines36|
To start treatment:
give oxygen
give sterile 10% glucose (5 ml/kg) by IV
give IV fluid at 15 ml/kg over 1 hour. Use Ringer’s lactate with
5%dextrose; or half-normal saline with 5% dextrose; or half-strength
Darrow’s solution with 5% dextrose; or if these are unavailable,
Ringer’s lactate
measure and record pulse and respiration rates every 10 minutes
give antibiotics

37. Stabilization Care Guidelines37|
If there are signs of improvement (pulse and
respiration rates fall):
repeat IV 15 ml/kg over 1 hour; then
• switch to oral or nasogastric rehydration with ReSoMal, 10 ml/kg/h for up
to 10 hours.
(Leave IV in place in case required again);
Give ReSoMal in alternate hours with starter F-75, then
• continue feeding with starter F-75

38. Stabilization Care Guidelines38|
If the child fails to improve
after the first hour of treatment (15 ml/kg),
assume that the child has septic shock. In this case:
give maintenance IV fluids (4 ml/kg/h) while waiting for blood,
when blood is available transfuse fresh whole blood at 10 ml/kg slowly
over 3 hours; then
begin feeding with starter F-75

39. Stabilization Care Guidelines39|
If the child gets worse
during treatment (breathing increases by 5 breaths
or more/min and pulse increases by 25 or more beats/min):
stop the infusion to prevent the child’s condition worsening

40. Stabilization Care Guidelines40|
C. TREATMENT OF ASSOCIATED CONDITIONS
1.Vitamin A Deficiency-Single dose, if not received in previous one month
Don’t give Vitamin A in case of edema.
Xerophthalmia
Age Dose Day 0Day 1 Day 14
6-12 months100,000 Y Y Y
1-5 Years 200,000 Y Y Y

41. Stabilization Care Guidelines41|
If there is corneal clouding or ulceration,
give additional eye care to prevent extrusion of the lens:
instill chloramphenicol or tetracycline eye drops (1%) 2-3 hourly as
required for 7-10 days in the affected eye
-instill atropine eye drops (1%), 1 drop three times daily for 3-5 days
-cover with eye pads soaked in saline solution and bandage
Note: children with vitamin A deficiency are likely to be photophobic and
have closed eyes.
It is important to examine the eyes very gently to prevent rupture.

42. Stabilization Care Guidelines42|
2. Severe anemia in malnourished children
A blood transfusion is required if:
• Hb is less than 4 g/dl OR
• if there is respiratory distress and Hb is between 4 and 6 g/dl
Give:
• whole blood 10 ml/kg body weight slowly over 3 hours
• furosemide 1 mg/kg IV at the start of the transfusion
It is particularly important that the volume of 10 ml/kg is not
exceeded in severely malnourished children.
If the severely anemic child has signs of cardiac failure,
transfuse packed cells (5-7 ml/kg) rather than whole blood.

43. Stabilization Care Guidelines43|
Severe Palmer Pallor

44. Stabilization Care Guidelines44|
Monitor for signs of transfusion reactions
If any of the following signs develop
during the transfusion, stop the transfusion:
• fever
• itchy rash
• dark red urine
• confusion
• shock

45. Stabilization Care Guidelines45|
Blood Transfusion
Also monitor the respiratory rate and pulse rate every 15 minutes. If
either of them rises, transfuse more slowly. Following the transfusion, if
the Hb remains less than 4 g/dl or between 4 and 6 g/dl in a child with
continuing respiratory distress,
–DO NOT repeat the transfusion within 4 days. In mild or moderate anemia,
oral iron should be given for two months to replenish iron stores
–BUT this should not be started until the child has begun to gain weight.

46. Stabilization Care Guidelines46|
3. Dermatosis
Signs:
• hypo-or hyperpigmentation
• desquamation
• ulceration (spreading over limbs, thighs, genitalia, groin, and
behind the ears)
• exudative lesions (resembling severe burns) often with secondary
infection, including Candida
Zinc deficiency is usual in affected children and the skin quickly
improves with zinc supplementation. In addition:
• apply barrier cream (zinc and castor oil ointment, or petroleum jelly
or paraffin gauze) to raw areas
• omit nappies so that the perineum can dry

47. Stabilization Care Guidelines47|
Exudative Lesion

48. Stabilization Care Guidelines48|
Exudative Lesion

49. Stabilization Care Guidelines49|
Dermatitis with Fungal infection

50. Stabilization Care Guidelines50|
4. Parasitic Infestation
De-worming on second week(1-5 years)
-Albendazole400mg
•1 to 2 years ½ tabletsingle dose
•>= 2years 1 tablet single dose
OR
-Mebendazole500mg
1-2year 250mg single dose
≥2Years 500mg single dose

51. Stabilization Care Guidelines51|
4. Tuberculosis (TB)
If TB is strongly suspected (contacts with adult TB patient, poor growth
despite good intake, chronic cough, chest infection not responding to
antibiotics):
•perform Mantoux test (false negatives are frequent)
•chest X-ray if possible
•If test is positive or there is a strong suspicion of TB, treat according to
national TB guidelines.
•BCG diagnostic

52. Stabilization Care Guidelines52|
D. FAILURE TO RESPOND TO TREATMENT
Failure to respond is indicated by:
1. High mortality
2. Low weight gain during the rehabilitation phase
Mortality
>20% Unacceptable
11-20% Poor
5-10% moderate
<5% Good

53. Stabilization Care Guidelines53|
2. Low weight gain during the rehabilitation phase
Poor: <5g/kg/d
Moderate: 5-10g/kg/d
Good: >10 g/kg/d
If weight gain is <5 g/kg/d determine:
• whether this is for all cases (need major
management overhaul)
• whether this is for specific cases (reassess child as for
a new admission)

54. Stabilization Care Guidelines54|
Possible causes of poor weight gain are:
a)Inadequate feeding
b) Specific nutrient deficiencies
c) Untreated infection
e) Psychological problems

55. Stabilization Care Guidelines55|
E. DISCHARGE BEFORE RECOVERY IS COMPLETE
The child
• has completed antibiotic treatment
• has good appetite and good weight gain
• has taken potassium/magnesium/mineral/vitamin supplement for 2 weeks (or
continuing supplementation at home is possible)

56. Stabilization Care Guidelines56|
E. DISCHARGE BEFORE RECOVERY IS COMPLETE
SC.
•Clinically well, Social Smile, Appetite good and gaining weight
TFC
The mother
–is not employed outside the home
–is specifically trained to give appropriate feeding (type, amount and
frequency)
–has the financial resources to feed the child
–lives within easy reach of the hospital for urgent readmission if the child
becomes ill
–can be visited weekly
–is trained to give structured play therapy
–is motivated to follow the advice given

57. Stabilization Care Guidelines57|
E. DISCHARGE BEFORE RECOVERY IS COMPLETE
Local health workers
• are trained to support home care
• are specifically trained to examine the child clinically at home, to decide when to
refer him/her back to hospital, to weigh the child, and give appropriate advice
• are motivated

58. Stabilization Care Guidelines58|
Ingredients Infant formula Milk Suji Milk Suji 100
Whole milk powder (g) 60 40 80
Rice powder (g) - 40 50
Sugar (g) 50 25 50
Soya oil (g) 20 25 25
Magnesium chloride (g) 0.5 0.5 0.5
Potassium chloride (g) 1.0 1.0 1.0
Calcium lactate ( g) 2.0 2.0 -
Energy (kcal/100 ml) 69 67 100
ml)Protein (g/100 1.5 1.4 2.6
Protein-energy ratio (%) 9 8 10
Fat-energy ratio (%) 47 47 40
Composition of liquid diets (cooked volume 1 liter)

59. Stabilization Care Guidelines59|
Thanks