Severely malnourished toddler with diarrhoea, hypoglycaemia and a request for a 20 mL/kg bolus
A 14-month-old girl is brought to a malnutrition ward with 4 days of watery diarrhoea and vomiting. Weight is 6.1 kg and length 71 cm, with weight-for-length below −3 z and MUAC 10.4 cm; there is visible severe wasting and no oedema. She is lethargic but arousable, with sunken eyes, drinking poorly and a skin pinch that returns very slowly. Temperature is 36.0 °C, respiratory rate 46, pulse 150/min, capillary refill 4 seconds and blood glucose 2.4 mmol/L. There is no blood in the stool and no stool microscopy yet. The ward stocks ReSoMal, F-75, F-100 and ready-to-use therapeutic food, amoxicillin, ampicillin and gentamicin, and vitamin A. There is no paediatric intensive care and no ventilator; intravenous fluids and nasogastric tubes are available. A nurse suggests 'a rapid 20 mL/kg bolus of normal saline, like we do for other children with diarrhoea'.
1. Classify her dehydration and circulatory state, and explain whether the nurse's bolus is appropriate. What fluid plan would you write?
Read the worked answer
She has severe acute malnutrition (weight-for-length below −3 z, MUAC 10.4 cm, visible severe wasting) with clinical signs of shock - lethargy, capillary refill of 4 seconds, tachycardia, hypothermia - plus hypoglycaemia. Dehydration and septic shock overlap and cannot be cleanly separated at the bedside.
The 20 mL/kg bolus is the wrong reflex here. In severe acute malnutrition the myocardium is wasted, potassium is depleted and sodium handling is abnormal; rapid large boluses cause fluid overload and heart failure. Trial evidence in African children (FEAST) showed that rapid boluses increased mortality in febrile children with impaired perfusion, and malnourished children are the group most at risk.
What to write instead:
- Treat the glucose first: 10% glucose 5 mL/kg IV, or 50 mL of 10% glucose by nasogastric tube if no line; recheck in 30 minutes. Keep her warm.
- Shock with severe malnutrition: Ringer's lactate with 5% dextrose (or half-strength Darrow's with 5% dextrose) 15 mL/kg over 1 hour intravenously.
- Reassess at 1 hour. If perfusion improves, repeat 15 mL/kg over another hour, then switch to ReSoMal by nasogastric tube. If there is no improvement, treat as septic shock, review for other causes, and consider transfusion if the haemoglobin is very low.
- If shock resolves and dehydration persists: ReSoMal 5 mL/kg every 30 minutes for 2 hours by mouth or nasogastric tube, then 5–10 mL/kg/hour for up to 10 hours, reassessing for over-hydration. ReSoMal is used deliberately - lower sodium, higher potassium, added magnesium and glucose.
Watch for a rising respiratory rate, gallop rhythm or enlarging liver at every step.
2. How do you manage the hypoglycaemia and the infection risk, and what supportive medicines does she need?
Read the worked answer
These three problems are linked: infection drives hypoglycaemia and hypothermia, and both worsen outcome.
- Hypoglycaemia (2.4 mmol/L): give 10% glucose 5 mL/kg IV immediately and recheck after 30 minutes. Start F-75 as soon as she can take it and feed two-hourly, including overnight - the commonest cause of recurrent hypoglycaemia is a missed night feed. If she cannot take oral feeds, give glucose-containing maintenance fluid by nasogastric tube and never leave her without a glucose source.
- Infection: in severe acute malnutrition the usual signs (fever, leucocytosis, localising findings) are often absent, so treat empirically. Give broad-spectrum antibiotics - ampicillin 50 mg/kg IV every 6 hours plus gentamicin 7.5 mg/kg once daily - rather than oral amoxicillin, because she is lethargic, hypoglycaemic and shocked, which marks complicated disease. Reassess when cultures and stool microscopy return; treat cholera or shigella if identified.
- Supportive care: vitamin A on admission, zinc for the diarrhoea, folic acid, and potassium and magnesium as provided in F-75/ReSoMal.
- Do not give iron in the stabilisation phase - it is of no benefit acutely and iron is deferred until rehabilitation.
- Screen and treat for other problems: check for corneal changes, ear discharge, skin breakdown and worm infestation, and confirm measles and HIV status.
3. She improves over 48 hours. Describe the feeding transition and the monitoring that detects refeeding syndrome and heart failure.
Read the worked answer
Improvement is not the same as recovery; the transition phase is where children are lost.
Feeding sequence:
- Continue F-75 (about 130 mL/kg/day, roughly 100 kcal/kg/day, in eight feeds) through the stabilisation phase until appetite returns, oedema - if present - resolves and acute problems are controlled. For her, that is around 16 mL per feed.
- Only then move to a transition phase with F-100 or ready-to-use therapeutic food, increasing gradually to about 150–220 mL/kg/day, with catch-up growth targets of 5–10 g/kg/day. Rapid escalation is the mistake.
Monitoring for refeeding syndrome and heart failure - check at every feed:
- Respiratory rate and pulse: a rising respiratory rate or new tachycardia is the earliest sign of fluid overload.
- Liver size and the presence of a gallop rhythm or new oedema; weigh daily and watch for a sudden weight gain that is fluid, not tissue.
- Temperature (hypothermia recurs with sepsis), blood glucose, stool frequency and hydration state.
- Electrolytes where available: hypophosphataemia, hypokalaemia and hypomagnesaemia define refeeding syndrome. Potassium and magnesium are already supplemented in F-75 and the therapeutic food.
What to do if overload appears: stop the feeds, give a diuretic only if there is clear pulmonary oedema, and restart at a lower volume. Do not treat the oedema of malnutrition with diuretics - that is a different problem and diuretics will worsen the electrolyte depletion.