Inpatient management of severe malnutrition: time for a change in protocol and practice

Brewster DR.

A review has been published in Annals of Tropical Paeditrics which suggests the following eight changes to reduce case-fatality rates in severe acute malnutrition (SAM) in African hospitals:

  1. Use of low lactose, low osmolality milk feeds during the early stage of treatment, especially for HIV-exposed infants and diarrhoeal cases;
  2. More cautious use of high carbohydrate loads (ORS, ReSoMal, sucrose and 10% dextrose) during initial stabilisation;
  3. More careful grading up and down of feed volumes according to the child's responses during the early rehabilitation phase;
  4. Rapid rehydration of children in shock with Ringer's lactate, as for well-nourished children, with closer monitoring for heart failure;
  5. Greater use of 3rd-generation cephalosporin and fluoroquinolone antibiotics (e.g. ceftriaxone, ciprofloxacin) to treat sepsis owing to resistant organisms;
  6. Consider adding glutamine-arginine supplements as gut-protective agents in addition to zinc and vitamin A;
  7. The addition of phosphate to existing potassium and magnesium supplements for those at risk of the refeeding syndrome;
  8. Introduce better tools for diagnosis and clearer management of combined HIV and tuberculous infections in infants.

What do you think? Are these justified, practical and feasible? Contribute below.

Link to access paper

Comments

  • I am concerned about making use of low lactose, low osmolality milk feeds during the acute phase for children on the PMTCT program whereby a mother is breastfeeding. This could result in mixed feeding practices at home and therefore negate the PMTCT intervention. Should breastfeeding moms not be encouraged rather to express their milk and feed more regularly (ie. 2hrly).

    Comment by Megan Carlsson — 2012-03-13 06:30 | # - re

  • My concern is the rapid rehydration from shock with ringer's lactate as we do for the well nourished. Will the frail heart of the severely malnourished withstand that rapid influx of fluid and sodium load?

    Ogah A.O Uganda

    Comment by Ogah Adenike, Dr. Mrs — 2011-09-27 02:23 | # - re

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