Diarrhoea in severe acute malnutrition: the bolus that could kill
An 18-month-old girl is brought to a health centre with four days of watery diarrhoea and vomiting. Weight 7.2 kg, mid-upper arm circumference 10.5 cm, bilateral pitting pedal oedema, lethargic, sunken eyes, skin pinch returning very slowly. Axillary temperature 35.4 °C, pulse 150/min and weak, capillary refill 4 seconds, respiratory rate 46/min without chest indrawing. Capillary glucose 2.4 mmol/L. The health centre stocks Ringer's lactate, 5% dextrose, half-strength Darrow's with 5% dextrose, and F-75. There is no paediatric ward, no oxygen beyond a self-inflating bag, and no blood. The nurse proposes 20 mL/kg of Ringer's lactate as a rapid bolus, repeated twice if the child does not improve, "as we do for any child with diarrhoea and shock".
1. Do you agree with the nurse's fluid plan? Justify your answer and write the fluid prescription you would give, with volumes, rates and timing.
Read the worked answer
I do not agree. She is shocked, but she also has severe acute malnutrition with oedema. In malnutrition the myocardium is wasted, albumin is low, and sodium handling is abnormal; standard 20 mL/kg rapid boluses cause fluid overload and heart failure. The child may die of the treatment rather than the dehydration.
Immediate step first: hypoglycaemia
- 10% dextrose 5 mL/kg = 36 mL intravenously now, then start a maintenance dextrose-containing fluid.
- Recheck glucose in 30 minutes; if there is no intravenous access, give the same volume of 10% dextrose by nasogastric tube.
Fluid prescription for shock in severe acute malnutrition
- Ringer's lactate with 5% dextrose (or half-strength Darrow's with 5% dextrose) 15 mL/kg over 1 full hour by infusion - that is 108 mL over 60 minutes, roughly 1.8 mL/minute.
- Reassess at the end of the hour: pulse rate and volume, capillary refill, respiratory rate, liver size, and whether she is more alert.
- If improving: repeat 15 mL/kg over the next hour, then stop intravenous fluid and switch to oral or nasogastric ReSoMal, 5 mL/kg every 30 minutes for 2 hours, then 5–10 mL/kg/hour.
- If not improving: treat as septic shock. Give whole blood 10 mL/kg over 3 hours if blood is obtainable; otherwise continue cautiously and get antibiotics in immediately.
Do not give the second and third 20 mL/kg boluses proposed, and do not add potassium to the resuscitation fluid until urine output is confirmed.
2. Forty minutes into the first infusion the pulse slows, the liver edge becomes palpable and she becomes more drowsy. What is happening and what do you do?
Read the worked answer
This is fluid overload with incipient cardiac failure, not improvement. A slowing pulse with a newly palpable liver, increasing drowsiness and (if listened for) basal crackles means she is being fluid-loaded faster than her heart can cope.
Actions, in order
- Stop the infusion immediately.
- Sit her up, keep her warm, and give oxygen if any is available; be ready to bag if she stops breathing.
- Give furosemide 1 mg/kg = 7 mg intravenously. This is one of the few situations in malnutrition where a diuretic is used - for pulmonary oedema, not for the oedema of kwashiorkor, which is never treated with diuretics.
- Recheck glucose; the dextrose infusion has also stopped.
- Reassess in 15–20 minutes: respiratory rate, liver size, alertness. Only restart fluid, at a slower rate (10 mL/kg over 2 hours), if perfusion is still poor and there are no signs of overload.
- Move to small frequent feeds of F-75 as soon as she can take them.
Learning point for the unit: the trigger was giving a shock bolus at standard paediatric volumes to a child with severe acute malnutrition. Document the incident and re-brief the nursing staff - this is a systems fix, not just an individual error.
3. List the other immediate treatments she needs in the first 24 hours, with doses, and state what you would deliberately not give.
Read the worked answer
Give
- Broad-spectrum antibiotics on suspicion of sepsis: ampicillin 50 mg/kg IV/IM 6-hourly (360 mg) plus gentamicin 7.5 mg/kg once daily (54 mg).
- Vitamin A 200,000 IU orally as a single dose (she is over 12 months).
- Zinc 20 mg daily for 10–14 days.
- Potassium and magnesium in the oral rehydration solution (ReSoMal already contains them); check for and treat hypokalaemia if intravenous fluids are used.
- Warmth: cover the head, skin-to-skin with the mother, cap the temperature checks at half-hourly until above 36.5 °C.
- F-75 at 130 mL/kg/day (about 940 mL/day, 6–8 feeds) once shock has resolved and she is taking orally; no high-energy F-100 until she is stable and oedema is resolving.
- Screen for HIV and tuberculosis; ask about BCG and immunisations.
Do not give
- Iron - it worsens outcomes in the stabilisation phase and is started only in rehabilitation.
- Diuretics for the nutritional oedema - they cause dangerous electrolyte loss and do not treat the cause.
- A high-protein or high-sodium diet, and do not give F-100 during stabilisation.
- Routine antibiotics by mouth only - she needs parenteral cover until 48 hours of improvement.
Why it matters: the commonest cause of death in this child in the next 48 hours is unrecognised sepsis, hypoglycaemia or heart failure from fluid - not the diarrhoea itself.