A 14-Month-Old With Severe Acute Malnutrition, Diarrhoea and Hypoglycaemia
A 14-month-old girl is brought to a nutrition rehabilitation ward with four days of watery diarrhoea and poor feeding. She weighs 6.7 kg, length 72 cm, mid-upper arm circumference 10.6 cm, and has no bilateral pitting oedema. She is lethargic, has sunken eyes and a slow skin pinch, and drinks poorly from a cup. Axillary temperature is 35.4 degrees Celsius, pulse 152/min, respiratory rate 48/min without chest indrawing, capillary refill two seconds. Blood glucose is 44 mg/dL and haemoglobin 8.4 g/dL. Stool is watery with no blood and no rice-water appearance. The mother says the child is passing urine less often. No paediatric intensive care bed is available; the ward stocks ReSoMal, low-osmolarity oral rehydration salts, F-75, ready-to-use therapeutic food, amoxicillin and ceftriaxone. The nurse is asked to write the first 24-hour plan while the medical officer finishes the ward round.
1. Classify this child and write the fluid, glucose and drug plan for the first six hours, with volumes.
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Classification. Mid-upper arm circumference 10.6 cm, below the 11.5 cm cut-off for children aged 6-59 months, with no oedema, confirms severe acute malnutrition. Lethargy, sunken eyes, a slow skin pinch and drinking poorly meet the criteria for severe dehydration on the integrated management algorithm. Crucially, she is not in shock: capillary refill is two seconds, extremities are not described as cold, and there is no weak or absent pulse. That single distinction drives everything that follows.
Fluids. In severe acute malnutrition with severe dehydration but without shock, the route is oral or nasogastric and the volumes are small and frequent. ReSoMal at 5 mL/kg = 33 mL every 30 minutes for two hours, given by nasogastric tube if she will not take it by cup. Reassess after two hours: if improving, continue at 5-10 mL/kg per hour alternating with F-75; if the skin pinch is still slow, repeat the two-hour cycle; if she deteriorates into shock, switch to Ringer's lactate with 5% glucose at 15 mL/kg over one hour and involve the medical officer immediately.
Glucose. At 44 mg/dL she is hypoglycaemic. Give 10% glucose 5 mL/kg = 33 mL intravenously (or, if no access is achievable, give expressed breast milk or sugar solution by nasogastric tube) and start F-75 feeding within 30 minutes so the glucose does not fall again. Recheck glucose in 30 minutes.
Drugs and warmth. Amoxicillin 15 mg/kg = about 100 mg orally every 8 hours for five days (broad-spectrum cover is routine in severe acute malnutrition); zinc 20 mg daily for 14 days; vitamin A per national protocol; keep her warm with skin-to-skin contact and a cap for the 35.4 degrees temperature, and recheck temperature every 30 minutes until above 36.5 degrees.
Monitor hourly: pulse, respiratory rate, temperature, glucose, urine output and conscious level for the first six hours.
2. Explain why a rapid intravenous bolus is dangerous in this child, using the physiology of severe acute malnutrition.
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The myocardium and the cell membrane are both altered. In severe acute malnutrition there is cardiac muscle wasting, reduced cardiac output reserve, low serum albumin and low total body potassium with sodium retention. The sodium-potassium pump is downregulated, so cells cannot handle a sodium load; administered sodium stays extracellular and pulls water with it. A rapid bolus therefore loads a small, weak heart and a leaky circulation, producing pulmonary oedema and cardiac failure within minutes - the classical picture of a malnourished child who is drowned by resuscitation.
Why standard oral rehydration salts are not the answer either. Low-osmolarity oral rehydration salts contain about 75 mmol/L sodium; ReSoMal was formulated for malnutrition with roughly 45 mmol/L sodium and additional potassium and magnesium, precisely to avoid sodium overload while replacing deficits slowly. Some national protocols now use low-osmolarity salts with added potassium; whichever product the ward stocks, the principles are the same - small volumes, frequent sips or nasogastric feeds, and reassessment every 30 minutes.
The trap to avoid. Shock and severe dehydration look similar but are managed very differently. Shock in severe acute malnutrition means cold hands, capillary refill over three seconds, weak fast pulse and altered consciousness; that child receives 15 mL/kg over one hour of Ringer's lactate with 5% glucose and is reassessed. Our child has none of those, so intravenous fluid is reserved for glucose correction.
Watch for overhydration - a rising respiratory rate, new basal crepitations, a fall in SpO2, a rising pulse or the appearance of pitting oedema means stop the fluids, sit the child up, give oxygen and call the medical officer.
3. Set the feeding plan and the monitoring parameters for the first 48 hours, including what would make you escalate.
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Feeding. Start F-75 as soon as the hypoglycaemia is corrected and the child is able to take it - do not wait for rehydration to finish. Give 130 mL/kg/day, that is 6.7 x 130 = about 870 mL/day, divided into eight feeds of roughly 110 mL every three hours, by cup or nasogastric tube. Continue breastfeeding on demand between feeds. Do not give F-100 or ready-to-use therapeutic food during stabilization; the higher energy and protein load belongs to the rehabilitation phase once appetite has returned and oedema has resolved. Weigh daily and recalculate volumes.
Re-feeding syndrome. A malnourished child starting to feed can shift potassium, magnesium and phosphate into cells, producing heart failure and arrhythmia. Watch for a rising pulse, a falling SpO2, new breathlessness, oedema, a change in conscious level or an abnormal rhythm. Check electrolytes where available, particularly potassium, magnesium and phosphate, and ensure potassium is being replaced.
Monitoring schedule. For the first 24-48 hours record pulse, respiratory rate, temperature, glucose and conscious level every 30 minutes for six hours, then hourly; intake and output, stool frequency and consistency, and weight daily; examine for eye and ear infection and skin lesions at every shift.
Escalation triggers: respiratory rate above 60 or apnoea; SpO2 below 90%; pulse that rises further despite fluids; new pitting oedema; convulsion; glucose below 54 mg/dL after treatment; blood in stool; inability to take nasogastric feeds; or a child who becomes more lethargic rather than more alert. Any of these means the medical officer is called, an intravenous line is sited and transfer is considered - even when no intensive care bed is free, the decision to escalate must be made and documented rather than deferred.