Guidelines for the inpatient treatment of severely malnourished childr - PDF document

Guidelines for the inpatient treatment of severely malnourished children1Dr Sultana Khanum, former Regional Adviser, Nutrition for Health and Development, WHO South-East Asia Regional OfficeProfessor Ann Ashworth & Ms Claire Schofield, London School of Hygiene and Tropical MedicineProfessor Alan Jackson, University of Southampton 1. Child nutrition disorders – therapy 2. Starvation – therapy 3. Guidelines ISBN 92 4 154609 3 (NLM classification: WS 115)Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 country, territory, city or area or of its authorities, or concerning the Guidelines for the inpatient treatment of severely malnourished children3A. General principles for routine care (the ‘10 Steps’)10Treat/prevent hypoglycaemia11Step 2.Treat/prevent hypothermia11Step 3.Treat/prevent dehydration12Correct electrolyte imbalance14Treat/prevent infection14Correct micronutrient deficiencies16Start cautious feeding16Achieve catch-up growth18Provide sensory stimulation and emotional support19Prepare for follow-up after recovery20B. Emergency treatment of shock and severe anaemia211.Shock in severely malnourished children212.Severe anaemia in malnourished children22C. Treatment of associated conditions231.Vitamin A deficiency232.Dermatosis233.Parasitic worms244.Continuing diarrhoea245.Tuberculosis (TB)24D. Failure to respond to treatment251.High mortality252.Low weight gain during the rehabilitation phase25E. Discharge before recovery is complete28Weight-for-height reference table30Monitoring records32Appendix 3.Recipes for ReSoMal & electrolyte/mineral solution33Antibiotics reference table35Recipes for starter and catch-up formulas38Appendix 6.Volume of F-75 to give for children of differentweights40Appendix 7.Volume of F-75 for children with severe (+++)oedema41Range of volumes for free feeding with F-10042Weight record chart43Structured play activities44Discharge card47 Guidelines for the inpatient treatment of severely malnourished children4 Guidelines for the inpatient treatment of severely malnourished children5rate can be reduced to less than 5%. The evidence base for effectivehas not changed for the past five decades, and that one in four severelymalnourished children died during treatment in the 1990s. In any decade,malnutrition, but it is rather the result of poor treatment practices. Where mortality•firstly, severe malnutrition represents a medical emergency with an•secondly, there is an impairment of the cellular machinery. Tissueincludes remedying multiple specific deficiencies. These may not be•thirdly, tissue deficits and abnormal body composition are obvious,but cannot be safely corrected until the cellular machinery has beenadequately repaired. Rehydration with intravenous fluids can increasetreatment is also dangerous. Many prescribe a high protein diet forchildren with kwashiorkor, but this can be fatal. Many prescribediuretics to get rid of oedema. This procedure can be fatal. Prescribing subsequently to 3.9% from an earlier 17%. In South Africa, the mortality ratedecreased from 30-40% to less than 15%. Emergency relief organizations Guidelines for the inpatient treatment of severely malnourished children7Joe Millward, Dr Harry Campbell, Ann Burgess and Patricia Whitesell for Guidelines for the inpatient treatment of severely malnourished children8 Guidelines for the inpatient treatment of severely malnourished children9birthday. Seven out of every 10 of these deaths are due to diarrhoea, The WHO manualdeveloped to improve inpatient treatment of severe malnutrition. The WHO/treatment in the same way as if they were well nourished. MalnourishedA.General principles for routine care (the’10 steps’)B.Emergency treatment of shock and severe anaemiaC.Treatment of associated conditionsD.Failure to respond to treatmentE.Discharge before recovery is complete 1.Treat/prevent hypoglycaemia 2.Treat/prevent hypothermia 3.Treat/prevent dehydration 4.Correct electrolyte imbalance 5.Treat/prevent infection 6.Correct micronutrient deficiencies 7.Start cautious feeding 8.Achieve catch-up growth 9.Provide sensory stimulation and emotional support10.Prepare for follow-up after recovery Days 1-2Days 3-7Weeks 2-61.Hypoglycaemia2.Hypothermia3.Dehydration4.Electrolytes5.Infection6.Micronutrients7.Cautious feeding8.Catch-up growth9.Sensory stimulation10.Prepare for follow-up Ashworth A, Jackson A, Khanum S, Schofield C. Ten steps to recovery: Child health dialogue, Guidelines for the inpatient treatment of severely malnourished children11•50 ml bolus of 10% glucose or 10% sucrose solution (1 rounded(NG) tube. Then feed starter F-75 (see step 7) every 30 min. for two•antibiotics (see step 5)•two-hourly feeds, day and night (see step 7)•IV sterile 10% glucose (5ml/kg), followed by 50ml of 10% glucose•antibiotics•two-hourly feeds, day and night•blood glucose: if this was low, repeat dextrostix taking blood from•rectal temperature: if this falls to •level of consciousness: if this deteriorates, repeat dextrostix•feed two-hourly, start straightaway (see step 7) or if necessary,•always give feeds throughout the night •feed straightaway (or start rehydration if needed)•rewarm the child: either clothe the child (including head), cover with a•give antibiotics (see step 5)• body temperature: during rewarming take rectal temperature two-• ensure the child is covered at all times, especially at night• feel for warmth hypothermia is found•feed two-hourly, start straightaway (see step 7)•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/carer at night for warmth Guidelines for the inpatient treatment of severely malnourished children13Low blood volume can coexist with oedema. Do not use the IVTreatment:It is difficult to estimate dehydration status in a severely malnourished child•ReSoMal 5 ml/kg every 30 min. for two hours, orally or by nasogastric•5-10 ml/kg/h for next 4-10 hours: the exact amount to be given should•continue feeding starter F-75 (see step 7)•pulse rate•respiratory rate•urine frequency•stool/vomit frequency eyelids. If these signs occur, stop fluids immediately and reassess afterone hour.To prevent dehydration when a child has continuing watery diarrhoea:•keep feeding with starter F-75 (see step 7)•replace approximate volume of stool losses with ReSoMal. As aguide give 50-100 ml after each watery stool. (Note: it is common for•if the child is breastfed, encourage to continue NOT treat•extra potassium 3-4 mmol/kg/d•extra magnesium 0.4-0.6 mmol/kg/d•when rehydrating, give low sodium rehydration fluid (e.g. ReSoMal)•prepare food without saltadded directly to feeds during preparation. Appendix 3 provides a recipe for Guidelines for the inpatient treatment of severely malnourished children15In severe malnutrition the usual signs of infection, such as fever, are often on admission:•broad-spectrum antibiotic(s) •�measles vaccine if child is 6m and not immunisedSome experts routinely give, to broad-spectrum (see Appendix 4 for antibiotic give:•Co-trimoxazole 5 ml paediatric suspension orally twice daily for 5(apathetic, lethargic) or •Ampicillin 50 mg/kg IM/IV 6-hourly for 2 days, then oral amoxycillin 15mg/kg 8-hourly for 5 days, or if amoxycillin is not available, continue•Gentamicin 7.5 mg/kg IM/IV once daily for 7 days fails to improve clinically within 48 hours, ADD•Chloramphenicol 25 mg/kg IM/IV 8-hourly for 5 days identified, ADD:•specific antibiotics if appropriate•antimalarial treatment if the child has a positive blood film for malaria day course. If anorexia still persists, reassess the child fully, checking forand mineral supplements have been correctly given give iron initially but wait until the•Vitamin A� orally on Day 1 (for age 12 months, give 200,000 IU; for•Multivitamin supplement•Folic acid 1 mg/d (give 5 mg on Day 1)•Zinc 2 mg/kg/d•Copper 0.3 mg/kg/d•Iron 3 mg/kg/d but only when gaining weight A combined electrolyte/mineral/vitamin mix for severe malnutrition isavailable commercially. This can replace the electrolyte/mineral solutionbut still give the large single dose of vitamin A and folic acid on Day 1, and Guidelines for the inpatient treatment of severely malnourished children17the child’s fragile physiological state and reduced homeostatic capacity.•small, frequent feeds of low osmolarity and low lactose•oral or nasogastric (NG) feeds (never parenteral preparations)•100 kcal/kg/d•1-1.5 g protein/kg/d•130 ml/kg/d of fluid (100 ml/kg/d if the child has severe oedema)•if the child is breastfed, encourage to continue breastfeeding butrecipes). Give from a cup. Very weak children may be fed by spoon, dropper1-22-hourly 11 ml3-53-hourly 16 ml4-hourly 22 mlvolume/feed already calculated according to body weight. Appendix 7 gives the remaining feed by NG tube (see Appendices 6 and 7 (Column 6) for•amounts offered and left over•vomiting•frequency of watery stool•daily body weight is signalled by a return of appetite,To change from starter to catch-up formula:•replace starter F-75 with the same amount of catch-up formula F-•increase each successive feed by 10 ml until some feed remains Guidelines for the inpatient treatment of severely malnourished children19•respiratory rate•pulse rate•frequent feeds (at least 4-hourly) of unlimited amounts of a catch-•150-220 kcal/kg/d•4-6 g protein/kg/d•if the child is breastfed, encourage to continue (Note: breast milk does•weigh child each morning before feeding. Plot weight (Appendix 9•each week calculate and record weight gain as g/kg/d•poor ()()•moderate (5-10 g/kg/d), check whether intake targets are being met,• g/;&#xkg/d;&#x, ch;&#xild ;&#xrequ;&#xires;&#x ful;&#xl re; sse;&#xssme;&#xnt s;î S;ìti;&#xon D;good (10 g/kg/d), continue to praise staff and mothers* divide by the child’s average weight in kg to calculate the weight gain as g/kg/day. •tender loving care•a cheerful, stimulating environment•structured play therapy 15-30 min/d (Appendix 10 provides examples)•physical activity as soon as the child is well enough•maternal involvement when possible (e.g. comforting, feeding, bathing,•feed frequently with energy- and nutrient-dense foods•give structured play therapy•bring child back for regular follow-up checks•ensure booster immunizations are given•ensure vitamin A is given every six months Guidelines for the inpatient treatment of severely malnourished children21•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%•measure and record pulse and respiration rates every 10 minutes•give antibiotics (see step 5)•repeat IV 15 ml/kg over 1 hour; then•switch to oral or nasogastric rehydration with ReSoMal, 10 ml/kg/hfor up to 10 hours. (Leave IV in place in case required again); Give•continue feeding with starter F-75•give maintenance IV fluids (4 ml/kg/h) while waiting for blood,•when blood is available transfuse fresh whole blood at 10 ml/kg over 3 hours; then•begin feeding with starter F-75 (step 7) •stop the infusion to prevent the child’s condition worsening•Hb is less than 4 g/dl•or if there is respiratory distress and Hb is between 4 and 6 g/dl•whole blood 10 ml/kg body weight slowly over 3 hours•furosemide 1 mg/kg IV at the start of the transfusionseverely malnourished children. If the severely anaemic child has signs of•fever•itchy rash•dark red urine•confusion•shockthem rises, transfuse more slowly. Following the transfusion, if the Hb remainsdistress, DO NOT repeat the transfusion within 4 days. In mild or moderate until the child has begun to gain weight. Guidelines for the inpatient treatment of severely malnourished children231. Vitamin A deficiency•vitamin A� on days 1, 2 and 14 (for age 12 months, give 200,000 IU;•instil chloramphenicol or tetracycline eye drops (1%) 2-3 hourly as•instil atropine eye drops (1%), 1 drop three times daily for 3-5 days•cover with eye pads soaked in saline solution and bandage•hypo-or hyperpigmentation•desquamation•ulceration (spreading over limbs, thighs, genitalia, groin, and behind•exudative lesions (resembling severe burns) often with secondary•apply barrier cream (zinc and castor oil ointment, or petroleum jelly•omit nappies so that the perineum can dry •give mebendazole 100 mg orally, twice daily for 3 daysDiarrhoea is a common feature of malnutrition but it should subside during and are common causes of continuing•metronidazole (7.5 mg/kg 8-hourly for 7 days) if not already given Only rarely is diarrhoea due to lactose intolerance.•substitute milk feeds with yoghurt or a lactose-free infant formula•reintroduce milk feeds gradually in the rehabilitation phasemay be suspected if diarrhoea worsens substantially•use isotonic F-75 or low osmolar cereal-based F-75 (see Appendix 5•introduce F-100 gradually5. Tuberculosis (TB)If TB is strongly suspected (contacts with adult TB patient, poor growth•perform Mantoux test (false negatives are frequent)•chest X-ray if possible Guidelines for the inpatient treatment of severely malnourished children25•within 24 hours: consider untreated or delayed treatment of•within 72 hours: check whether the volume of feed is too high or the•at night: consider hypothermia from insufficient covers, no night feeds•when changing to catch-up F-100: consider too rapid a transition•whether this is for all cases (need major management overhaul)•whether this is for specific cases (reassess child as for a newPossible causes of poor weight gain are:a)Inadequate feeding•that night feeds are given•that target energy and protein intakes are achieved: is actual intake •feeding technique: is the child fed frequently and offered unlimited•quality of care: are staff motivated/gentle/loving/patient?•all aspects of feed preparation: scales, measurement of ingredients,mixing, taste, hygienic storage, adequate stirring if the ingredients•�that if giving family foods, they are suitably modified to provide 100b)Specific nutrient deficiencies•adequacy of multivitamin composition and shelf-life•preparation of electrolyte/mineral solution and whether this is correctly•that, if modified family foods are substantially replacing F-100, electrolyte/c)Untreated infection•re-examine carefully•repeat urinalysis for white blood cells•examine stools•if possible, take chest X-rayd)HIV/AIDSthough it may take longer and treatment failures may be common. Lactose Guidelines for the inpatient treatment of severely malnourished children27e)Psychological problems•abnormal behaviour such as stereotyped movements (rocking), •�is aged 12 months•has completed antibiotic treatment•has good appetite and good weight gain•has taken potassium/magnesium/mineral/vitamin supplement for 2•is not employed outside the home•is specifically trained to give appropriate feeding (type, amount and•has the financial resources to feed the child•lives within easy reach of the hospital for urgent readmission if the•can be visited weekly•is trained to give structured play therapy•is motivated to follow the advice given•are trained to support home care•are specifically trained to examine the child clinically at home, to decide•are motivated Guidelines for the inpatient treatment of severely malnourished children29contain approximately 100 kcal and 2-3 g protein per 100 g. A practical•give appropriate meals at least 5 times daily•give high energy snacks between meals (e.g. milk, banana, bread,•assist and encourage the child to complete each meal•give electrolyte and micronutrient supplements. Give 20 ml (4•breastfeed as often as the child wants•World Health Organization, •World Health Organization, Management of the child with a serious Guidelines for the inpatient treatment of severely malnourished children30 Boys’ weight (kg) Length(cm) Girls’ weight (kg)-3 SD-2 SD-1 SDMedianMedian-1SD-2SD-3 SD-4 SD(60%)(70%)(80%)(90%)(90%)(80%)(70%)(60%)1.82.1 2.5 2.8 3.1 3.3 2.9 2.62.21.81.82.2 2.5 2.9 3.3 3.4 3.0 2.62.31.91.82.2 2.6 3.1 3.5 3.5 3.1 2.72.31.91.92.3 2.8 3.2 3.7 3.7 3.3 2.82.42.01.92.4 2.9 3.4 3.9 3.9 3.4 3.02.52.12.02.6 3.1 3.6 4.1 4.1 3.6 3.12.72.22.22.7 3.3 3.8 4.3 4.3 3.8 3.32.82.32.32.9 3.5 4.0 4.6 4.5 4.0 3.53.02.42.53.1 3.7 4.3 4.8 4.8 4.2 3.73.12.62.73.3 3.9 4.5 5.1 5.0 4.4 3.93.32.72.93.5 4.1 4.8 5.4 5.3 4.7 4.13.52.93.13.7 4.4 5.0 5.7 5.5 4.9 4.33.73.13.34.0 4.6 5.3 5.9 5.8 5.2 4.63.93.33.54.2 4.9 5.6 6.2 6.1 5.4 4.84.13.53.84.5 5.2 5.8 6.5 6.4 5.7 5.04.43.74.04.7 5.4 6.1 6.8 6.7 6.0 5.34.63.94.35.0 5.7 6.4 7.1 7.0 6.3 5.54.84.14.55.3 6.0 6.7 7.4 7.3 6.5 5.85.14.34.85.5 6.2 7.0 7.7 7.5 6.8 6.05.34.55.15.8 6.5 7.3 8.0 7.8 7.1 6.35.54.85.36.0 6.8 7.5 8.3 8.1 7.3 6.55.85.05.56.3 7.0 7.8 8.5 8.4 7.6 6.86.05.25.86.5 7.3 8.1 8.8 8.6 7.8 7.06.25.46.06.8 7.5 8.3 9.1 8.9 8.1 7.26.45.66.27.0 7.8 8.6 9.3 9.1 8.3 7.56.65.86.47.2 8.0 8.8 9.6 9.4 8.5 7.76.86.06.67.4 8.2 9.0 9.8 9.6 8.7 7.97.06.26.87.6 8.4 9.210.0 9.8 8.9 8.17.26.47.07.8 8.6 9.410.310.0 9.1 8.37.46.67.18.0 8.8 9.710.510.2 9.3 8.57.66.77.38.2 9.0 9.910.710.4 9.5 8.77.86.97.58.3 9.210.110.910.6 9.7 8.88.07.17.68.5 9.410.211.110.8 9.9 9.08.17.27.88.7 9.610.411.311.010.1 9.28.37.47.98.8 9.710.611.511.210.3 9.48.57.68.19.0 9.910.811.711.410.5 9.68.77.77.88.9 9.911.012.111.810.8 9.78.67.67.99.010.111.212.312.011.0 9.98.87.78.19.210.311.512.612.311.2 10.19.07.9 Length is measured for children below 85 cm. For children 85 cm or more, height is measured. Recumbent length is onaverage 0.5 cm greater than standing height; although the difference is of no importance to individual children, a correction m SD: standard deviation score (or Z-score). Although the interpretation of a fixed percent-of-median value varies across ageGorstein J et al. Issues in the assessment of nutritional status using. Bulletin of the World Health Organization, 1994, 72:273-283). Guidelines for the inpatient treatment of severely malnourished children31 Boys’ weight (kg) Length(cm) Girls’ weight (kg)-3 SD-2 SD-1 SDMedianMedian-1SD-2SD-3 SD-4 SD(60%)(70%)(80%)(90%)(90%)(80%)(70%)(60%) 8.3 9.410.511.712.8 8812.511.410.3 9.2 8.1 8.4 9.610.711.913.0 8912.711.610.5 9.3 8.2 8.6 9.810.912.113.3 9012.911.810.7 9.5 8.4 8.8 9.911.112.313.5 9113.212.010.8 9.7 8.5 8.910.111.312.513.7 9213.412.211.0 9.9 8.7 9.110.311.512.814.0 9313.612.411.210.0 8.8 9.210.511.713.014.2 9413.912.611.410.2 9.0 9.410.711.913.214.5 9514.112.911.610.4 9.1 9.610.912.113.414.7 9614.313.111.810.6 9.3 9.711.012.413.715.0 9714.613.312.010.7 9.5 9.911.212.613.915.2 9814.913.512.210.9 9.610.111.412.814.115.5 9915.113.812.411.1 9.810.311.613.014.415.715.414.012.711.3 9.910.411.813.214.616.015.614.312.911.510.110.612.013.414.916.315.914.513.111.710.310.812.213.715.116.616.214.713.311.910.511.012.413.915.416.916.515.013.512.110.611.212.714.215.617.116.715.313.812.310.811.412.914.415.917.417.015.514.012.511.011.613.114.716.217.717.315.814.312.711.211.813.414.916.518.017.616.114.513.011.412.013.615.216.818.317.916.414.813.211.612.213.815.417.118.718.216.615.013.411.912.514.115.717.419.018.616.915.313.712.112.714.416.017.719.318.917.215.614.012.312.914.616.318.019.619.217.515.914.212.613.214.916.618.320.019.517.916.214.512.813.515.216.918.620.319.918.216.514.813.013.715.517.218.920.720.318.516.815.013.314.015.817.519.321.120.618.917.115.313.614.316.117.919.621.421.019.217.415.613.814.616.418.220.021.821.419.617.715.914.114.916.718.520.422.221.820.018.116.214.315.217.018.920.722.622.220.318.416.514.615.517.419.221.123.022.720.718.816.814.915.817.719.621.523.423.121.119.117.115.116.118.020.021.923.923.621.619.517.415.416.418.420.422.324.324.122.019.917.815.616.718.720.722.824.824.622.420.218.115.917.019.121.123.225.225.122.920.618.416.217.319.421.523.625.725.723.321.018.716.417.619.821.924.126.226.223.821.419.016.717.920.122.324.526.826.824.321.819.416.9 Length is measured for children below 85 cm. For children 85 cm or more, height is measured. Recumbent length is onaverage 0.5 cm greater than standing height; although the difference is of no importance to individual children, a correction m SD: standard deviation score (or Z-score). Although the interpretation of a fixed percent-of-median value varies across ageGorstein J et al. Issues in the assessment of nutritional status using. Bulletin of the World Health Organization, 1994, 72:273-283). Guidelines for the inpatient treatment of severely malnourished children32Appendix 2Monitoring records (temperature, respiratoryrate, and pulse rate)Monitor respiratory rate, pulse rate and temperature 2-4 hourly until after transitionto F-100 and patient is stable. Then monitoring may be less frequent (e.g., twice daily)Danger Signs: Watch for increasing pulse and respirations, fast or difficult breathing, sudden increase ordecrease in temperature, rectal temperature below 35.5° C, and other changes in condition. Guidelines for the inpatient treatment of severely malnourished children33Water (boiled & cooled)2 Sugar50 gElectrolyte/mineral solution (see below)40 mlWeigh the following ingredients and make up to 2500 ml. Add 20 ml ofWater: make up to add selenium if available (sodium selenate 0.028 g, NaSeO 10H 3.5g sodium chloride, 2.9g trisodium citrate dihydrate, 1.5g potassium chloride, 20g glucose. Dissolve the ingredients in cooled boiled water. Store the solutionMake fresh each month.•Make a 10% stock solution of potassium chloride (100 g KCl in 1 litre•For oral rehydration solution, use 45 ml of stock KCl solution instead•For milk feeds, add 22.5 ml of stock KCl solution instead of 20 ml•If KCl is not available, give Slow K (½ crushed tablet/kg/day)•Give 50% magnesium sulphate intramuscularly once (0.3 ml/kg up to•Make a 1.5% solution of zinc acetate (15 g zinc acetate in 1 litre of Guidelines for the inpatient treatment of severely malnourished children35 Summary: Antibiotics for Severely MalnourishedIF:GIVE: IV or IM (7.5 mg/kg), once dailyfor 7 days, IV orFollowed by: respiratory or urinary tractIM (50 mg/kg),oral (15 mg/kg), everyevery 6 hours for 28 hours for 5 days8 hours for 5 days (give every 6 hours ifIf a specific infectionSpecific antibiotic as directed on pages Guidelines for the inpatient treatment of severely malnourished children36Doses for specific formulations and bodyweight ranges every 8 hours forevery 6 hours forevery 6 hours forevery 8 hours forevery 6 hours forevery 6 hours for3 up to 6 kg6 up to 8kg8 up to 10kg1/4 tablet1/2 tablet1/2 tablet2.5 ml5 ml5 ml1.5 ml2 ml2.5 ml1 tablet11/2 tablet2 tablets1 ml1.75 ml2.25 ml2 ml3.5 ml4.5 ml0.4 ml0.7 ml0.9 ml1/4 tablet1/2 tablet1/2 tablet1 ml1.25 ml1.5 ml1 tablet11/2 tablet2 tablets2.5 ml4 ml5 ml Guidelines for the inpatient treatment of severely malnourished children37 Doses for selected antibiotics, for specificformulations and body weights Weight of childDose of iron syrup: ferrous fumarate100 mg/5 ml (20 mg elemental iron per ml) 3 - 6 kg0.5 ml 6 - 10 kg0.75 ml10 - 15 kg1 ml Doses for iron syrup for a common formulation DURATION3 kg4 kg5 kg6 kg7 kg8 kg 9 kg 10 kg11 kg12 kgChloramphenicolIV or IM:25 mg/kgmixed with 9.2 ml0.7511.251.51.7522.252.52.753every 8 hours sterile water toif suspect ofIM: vial of 1 gmeningitis)mixed with 3.2 ml0.30.40.50.60.70.80.911.11.2for 5 dayssterile water toGentamicinIV or IM:7.5 mg/kgcontaining 20 mg2.2533.754.55.2566.757.58.259once daily(2 ml at 10 mg/ml),2.2533.754.55.2566.757.58.259containing 80 mg0.50.750.91.11.31.51.71.922.25 Guidelines for the inpatient treatment of severely malnourished children38Appendix 5Recipes for starter and catch-up formulas •using an electric blender: place some of the warm boiled water inthe blender, add the milk powder, sugar, oil and electrolyte/mineral•if no electric blender is available, mix the milk, sugar, oil and electrolyte/•store made-up formula in refrigeratorF-75F-100F-135258090Sugar (g)1005065Vegetable oil (g)30 (or 35 ml)60 (or 70 ml)85 (or 95 ml)solution (ml)2020201000 ml1000 ml1000 mlEnergy (kcal)75100135Protein (g)0.92.93.3Lactose (g)1.34.24.8Potassium (mmol)4.06.37.7Sodium (mmol)0.61.92.20.430.730.8Zinc (mg)2.02.33.00.250.250.34% energy from protein51210% energy from fat365357Osmolarity (mOsmol/1)413419508 Guidelines for the inpatient treatment of severely malnourished children39•full-cream dried milk 35 g, 100 g sugar, 20 g (or ml) oil, 20 ml electrolyte/•full-cream cow’s milk (fresh or long life) 300 ml, 100 g sugar, 20 g (or•full-cream dried milk 110 g, 50 g sugar, 30 g (or ml) oil, 20 ml electrolyte/•full-cream cow’s milk (fresh or long life) 880 ml, 75 g sugar, 20 g (or ml) Section D2, poor •full-cream dried milk 130 g, 70 g sugar, 40 g (or 45 ml) oil, 20 ml•full-cream cow’s milk (fresh or long life) 880 ml, 50 g sugar, 60 g (or 65•cereal-based, low-osmolar F-75 (334 mOsmol/l). Replace 30 g of the•isotonic versions of F-75 (280 mOsmol/l) are available commercially (see Appendix 7 for children with severe (+++ oedema)Volumes in these columns are rounded to the nearest 5 ml.Feed 2-hourly for at least the first day. Then, when little or no vomiting, modest diarrhoea () Weightof child(kg)2.22.62.83.03.23.63.84.04.24.44.65.05.25.45.66.06.26.46.66.87.07.47.67.88.08.28.48.89.09.29.49.8Volume of F-75 per feed (ml)aEvery 2 hoursb(12 feeds)202525303035354040454550555555606565707075758080859090909595105105110110Every 3 hoursc(8 feeds)3035404545555560606570758080859095100105110115120120125130135140140145145155155160160Every 4 hours(6 feeds)4550555560707580859090105110115125130130135140145155160160165175180185190195200205210215220Daily total26028633836439041646849452054657259865067670272878080683285888491096298810401066109211441170119612221274130080% of daily totala23026529031033537539541543546048052054056058062564566568570573077079081083085587591593596098010201040 Guidelines for the inpatient treatment of severely malnourished children41Volumes in these columns are rounded to the nearest 5 ml.Feed 2-hourly for at least the first day. Then, when little or no vomiting, modest diarrhoea () Weight with+++ oedema(kg)3.23.43.64.04.24.44.65.05.25.45.65.86.06.46.66.87.07.27.47.88.08.28.48.89.09.29.49.69.810.210.410.610.811.211.411.611.812.0Volume of F-75 per feed (ml)aEvery 2 hoursb(12 feeds)25253030353540404045454550505555606060656565707075757580808585859090959595Every 3 hoursc(8 feeds)4040455050556060656570707580808590909595100105110110115115120125125130130135140140145145150Every 4 hours(6 feeds)505560656570758085859095105105110115120125125130135140145145150155155165165170175180185185190195195Daily total30032034036040042044046050052054056058060064066068070072074078080082084088090092094096098010201040106010801120114011601180120080% of dailytotal255270290320335350370400415430450465480510530545560575590625640655670705720735750770785815830850865895910930945960 Volumes per feed are rounded to the nearest 5 ml. Range of volumes per 4-hourly feedof F-100 (6 feeds daily) Guidelines for the inpatient treatment of severely malnourished children43 Name: Sipho age 14 months, sex: male, wt on admission: 4 kg, ht: 65 cm, oedema •teach local songs and finger and toe games•get child to laugh and vocalise, repeat what (s)he says•describe all activities•teach action words with activities e.g. ‘bang bang’ as (s)he beats a•teach concepts at every opportunity, examples are in italics in the•bounce the child up and down and hold him/her under the arms so•prop the child up, roll toys out of reach, encourage the child to crawl•hold hand and help the child to walk•when starting to walk alone, give a toy•Swing the ring within reach and tempt the child to grab it•suspend ring over the crib and encourage the child to knock it and•let child explore the ring, then place it a little distance from child with•sit child on lap, then holding the string, lower the ring towards the Guidelines for the inpatient treatment of severely malnourished children45•Let the child explore rattle. Show child how to shake it saying ‘shake•encourage child to shake the rattle by saying ‘shake’ but without•teach child to beat drum with shaker saying ‘bang bang’•roll drum out of reach and let child crawl after it, saying ‘fetch it’•get child to say ‘bang bang’ as (s)he beats drum•Let the child explore blocks and container. Put blocks into container and •teach the child to take out blocks by turning container upside down•teach the child to hold a block in each hand and bang them together•let the child put blocks in and out of container saying and •cover blocks with container saying ‘where are they, they are •turn the container upside down and teach the child to put blocks of the container•teach the child to stack blocks: first stack two then gradually increase then •line up blocks horizontally: first line up two then more; teach the child go, fast slow and building. Make up games•Put an object in the bottle, shake it and teach the child to turn the •Let the child play with two bottle tops then teach the child to stack low•Sit the child on your lap. Get the child to turn the pages, pat pictures•Teach the word •teach the child to identify his/her own body parts and those of the doll•put the doll in a box as a bed and give sheets, teach the words ‘bed sleep’ and describe the games you play Guidelines for the inpatient treatment of severely malnourished children47 Guidelines for the inpatient treatment of severely malnourished children48Discharge card Recommendations for Feeding During Sickness and Health*A good daily diet should be adequate in quantity and include an energy-rich food (for example, thick cereal with added oil); meat,fish, eggs, or pulses; and fruits and vegetables Guidelines for the inpatient treatment of severely malnourished children49 Department of Nutrition for Health and Development +41-22-791 2624 Regional Office for South-East AsiaNew Delhi - 110 002, IndiaTelephone : 91-11-2337080491-11-2337019720 A1211 Geneva 27, SwitzerlandTelephone : +41-22-791 2476