Swollen Feet, Rice and Salt, and a Mother Who Will Not Go
A 22-month-old girl is brought by her mother to an anganwadi health check in a tea garden area. She has had swelling of both feet for ten days and diarrhoea for three days, and she is irritable and takes breast milk poorly. Weight is 7.6 kg, length 78 cm, mid-upper arm circumference 11.5 cm, and both feet show pitting oedema up to the ankles. No other signs of infection are visible, but she is lethargic. Her hair is sparse and depigmented, and the mother says the family eats rice with a little salt and occasional greens. The anganwadi worker has oral rehydration salts, zinc and a referral slip to the nutrition rehabilitation centre 20 km away, but the mother refuses to go, saying her husband will not allow it and that the child was fine before the swelling appeared.
1. Classify the child's nutritional status and list the features that make this a high-risk case.
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Classification: severe acute malnutrition with bilateral pitting oedema, the kwashiorkor type, and it is complicated. The oedema is the defining sign: bilateral, pitting to the ankles, and not explained by another disease. A mid-upper arm circumference of 11.5 cm is at the severe acute malnutrition cut-off for children aged 6 to 59 months, and 7.6 kg at 78 cm is far below the expected range. What makes it complicated rather than uncomplicated is the lethargy and irritability, poor feeding, three days of diarrhoea, and the risk of hypoglycaemia and hypothermia that comes with oedema.
Why she is at high risk of dying:
- Infection is often present without fever, and the usual signs may be missing.
- Diarrhoea plus oedema makes dehydration hard to judge and fluid overload easy to cause.
- Electrolyte shifts, especially low potassium and magnesium with sodium excess, affect the heart.
- Sparse, depigmented hair points to chronic deficiency, but iron must not be given in the acute phase.
- Refeeding too fast can precipitate heart failure.
She needs facility-based care. An outpatient packet and a referral slip are not enough for a lethargic child with oedema, diarrhoea and poor feeding.
2. The mother still refuses referral. What will you do in the next hour, and how will you counsel her without simply overriding her?
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Do not simply accept the refusal, and do not simply override it.
Immediate care while negotiating:
- Check for danger signs: can she drink, is she vomiting, is she convulsing, is the axillary temperature below 35.5 °C? Check blood glucose if a glucometer is available, and treat below 54 mg/dL.
- Keep her warm and give small, frequent feeds of F-75 if available; continue breastfeeding.
- Give oral rehydration salts in small sips for the diarrhoea, with zinc 20 mg daily for 14 days at this age.
- Give the first dose of a broad-spectrum antibiotic according to local protocol and vitamin A on schedule.
- Do not give iron now.
Counselling: explain that the swelling is not caused by the food or by water; it means her body has too little protein and is leaking fluid, and children with this swelling can die suddenly from infection or heart failure. They need a centre where the heart and blood sugar can be watched. Ask what is actually stopping her: money, her husband's permission, other children, or the distance. Involve the ASHA and anganwadi worker, offer to speak to the husband or a respected elder, and help arrange transport. If she still refuses, record an informed refusal, teach the danger signs, plan a home visit within 24 hours and inform the medical officer the same day. A refusal that threatens the child's life may need escalation under child protection procedures.