Severe acute malnutrition with diarrhoea: the fluid decision
A 14-month-old girl is brought to a district hospital in July with four days of watery diarrhoea and two days of vomiting. She weighs 7.2 kg and is 71 cm long, her mid-upper arm circumference is 11.0 cm, and she has bilateral pitting oedema to the dorsum of both feet. She is lethargic, has sunken eyes and a capillary refill of 4 seconds; axillary temperature is 35.8 °C. Her mother stopped breastfeeding three months ago and has been giving diluted cow's milk and rice water. The admitting doctor writes: 'Ringer lactate 20 mL/kg IV bolus now, repeat if pulse remains weak; frusemide 10 mg IV if oedema increases; start 5% dextrose with potassium; weigh daily only.' The hospital has no paediatric intensive care unit, ReSoMal is in the store, and the doctor says using ReSoMal will delay resuscitation. The blood glucose result is not yet available.
1. How would you classify this child's nutritional and hydration status, and why is the IV bolus order not automatically correct?
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Classification
- Severe acute malnutrition with bilateral pitting oedema (kwashiorkor-type): MUAC 11.0 cm is below 11.5 cm, plus oedema. Weight-for-height is unreliable when oedema is present.
- Dehydration is present but cannot be graded by the usual WHO signs alone: sunken eyes, lethargy and slow capillary refill occur in severe malnutrition and sepsis without dehydration. Hypothermia (35.8 °C) and lethargy also point to possible sepsis or hypoglycaemia.
Why 20 mL/kg is not automatic A malnourished child has reduced cardiac reserve, low albumin and fragile electrolyte balance; rapid boluses readily cause fluid overload and heart failure. Intravenous fluid in severe acute malnutrition is reserved for shock - and the accepted regimen is 15 mL/kg over one hour of Ringer lactate with 5% dextrose (or half-strength Darrow's with 5% dextrose), reassessed every 10–15 minutes, not 20 mL/kg repeated blindly. If shock is absent, the child should receive ReSoMal 5 mL/kg every 30 minutes for two hours orally or by nasogastric tube. Before any fluid, check and treat hypoglycaemia (10% dextrose 5 mL/kg IV) and warm the child - the temperature of 35.8 °C must be corrected simultaneously.
2. The doctor insists on 20 mL/kg and dismisses ReSoMal. How do you handle this professionally, and which findings would make you stop the bolus?
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Professional handling
- State the concern once, clearly and specifically: '20 mL/kg repeated in severe acute malnutrition risks pulmonary oedema; national and WHO guidance is 15 mL/kg over one hour, then reassess.' Offer a workable compromise - the smaller bolus, an infusion pump or gravity-controlled set, and half-hourly reassessment.
- Ask for a paediatric opinion by phone and record the time, the names and the advice given.
- If the order stands, document your concern and the doctor's decision in the nursing notes. Do not simply refuse care; monitor closely so harm is detected early.
- Escalate to the duty medical superintendent if the child deteriorates and the order is not revised.
Stop signs during the bolus (check every 10–15 minutes)
- Rising respiratory rate or new grunting, basal crepitations, falling SpO2.
- Increasing liver size, new gallop or tachycardia, raised jugular venous pressure.
- Worsening drowsiness, or failure of heart rate and perfusion to improve.
If any appear, stop the infusion, sit the child up, give oxygen and call the doctor immediately.
3. Outline your plan for the next 48 hours and name the traps in the rehabilitation phase.
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Stabilisation (first 48 hours)
- Treat hypoglycaemia and hypothermia; broad-spectrum antibiotics for possible sepsis because the usual signs are blunted.
- F-75 at 100 kcal/kg/day: about 110–130 mL/kg/day divided two-hourly if oedema is resolving (use the lower end while oedema persists). No diuretics - oedema resolves with feeding, and frusemide worsens electrolyte loss.
- ReSoMal for ongoing losses (5–10 mL/kg per loose stool), potassium and magnesium supplements, zinc, vitamin A.
- No iron in the stabilisation phase; it is started only in rehabilitation.
- Monitor weight, temperature, respiratory rate, stool and vomit output, blood glucose, and hydration every few hours; feed by nasogastric tube if intake is poor.
Traps in rehabilitation
- Rushing to F-100 before appetite returns and oedema has resolved - precipitates refeeding syndrome and heart failure.
- Missing the fall in potassium, magnesium and phosphate that accompanies rapid weight gain.
- Overfeeding a child who is still catabolic, or discharging before the appetite test is passed.
- Forgetting stimulation, play and the mother's education on continued feeding; and forgetting to screen siblings.