Severe Acute Malnutrition, Diarrhoea and a Locked Therapeutic Food Store

Classification. Severe acute malnutrition: weight-for-height z-score −3.4 and MUAC 10.5 cm (below 11.5 cm). Severe dehydration on clinical signs - lethargy, sunken eyes, skin pinch of 3 seconds, drinking poorly. She also has hypoglycaemia (2.4 mmol/L) and hypothermia (35.6 °C), and looks septic.

Is she in shock? In severe acute malnutrition, shock is lethargy or unconsciousness plus cold hands, capillary refill over 3 seconds and a weak, fast pulse. She meets all four. Hypotension is not required - it is a late sign in children.

First hour, in order:

1. Glucose first: 10% glucose 5 mL/kg = 34 mL IV, then recheck in 30 minutes. Hypoglycaemia will kill her while you are still calculating fluids.
2. Warm her: skin-to-skin or radiant warmer, hat and blanket; recheck temperature every 30 minutes.
3. Shock fluid: Ringer's lactate with 5% glucose, 15 mL/kg = 102 mL over 1 hour. This is deliberately smaller than the 20 mL/kg bolus used in well-nourished children because the malnourished myocardium overloads easily.
4. Reassess at one hour. If pulse slows, capillary refill shortens, hands warm and she is more alert, repeat 15 mL/kg over one hour, then move to oral or nasogastric rehydration. If there is no improvement, treat as septic shock: maintenance fluids only, antibiotics, and blood transfusion 10 mL/kg over 3 hours - which means activating referral, since there is no blood bank on site.
5. Antibiotics (ampicillin plus gentamicin) after cultures if feasible, and start oxygen if saturations fall.

Do not use standard oral rehydration salts - they contain too much sodium and too little potassium for a malnourished child. ReSoMal is the correct oral solution once shock is corrected.

The key point: she does not need ready-to-use therapeutic food tonight. RUTF belongs to the transition phase, once appetite has returned and oedema is resolving. In the stabilisation phase the correct feed is F-75 starter formula, which should already be stocked on the ward. The closed pharmacy is a real problem for tomorrow, not for tonight - and confusing the two could cost her a feed.

Plan for 24 hours.

• F-75 at 130 mL/kg/day = 884 mL/day for 6.8 kg, given as about 110 mL every 3 hours (eight feeds), by nasogastric tube initially because she drinks poorly, then by cup as she improves.
• Add potassium and magnesium to the feeds; do not give diuretics for any oedema.
• Breastfeeding continues as she is able; do not stop it.
• Vitamin A, folic acid 5 mg on day one, zinc 20 mg daily for 10–14 days for the diarrhoea, and measles vaccination if she is due and not already immunised.
• ReSoMal for ongoing stool losses once the shock is corrected: 5 mL/kg (34 mL) every 30 minutes for the first two hours, then adjusted to losses.

Practical steps for the RUTF gap: ask the in-charge to authorise opening the store out of hours, borrow from another ward or a neighbouring facility, contact the nutrition officer, and document the stock-out and the escalation - a stock-out that is not recorded is a stock-out that never happened. Meanwhile, the mother is given a demonstration of feeding and is fed herself.

Monitoring and the reasoning behind each item.

• Glucose hourly until stable: she has already had one hypoglycaemic episode and is not feeding well.
• Temperature 4-hourly: hypothermia in malnutrition is a sign of sepsis and a marker of death risk, not just of a cold ward.
• Pulse, respiratory rate, capillary refill and level of consciousness: to detect fluid overload. Watch for rising respiratory rate, chest indrawing, a newly enlarged liver, a gallop rhythm or puffy eyelids - stop or slow the fluids if these appear.
• Daily weight with a consistent scale, and daily MUAC; also watch for refeeding syndrome - increasing weakness, falling temperature, arrhythmia, and mental state changes in the first days of feeding.
• Stool and urine output, and the nature of the stools; ongoing losses change the rehydration volume.
• Signs of infection: she needs antibiotics regardless of whether a focus is found.

Answering the mother. Do not start with 'you cannot leave'. Start by acknowledging the 15 km walk and the four hungry days. Then be concrete: tonight her daughter is receiving the correct milk through the tube, the milk is not the pharmacy item, and by morning the therapeutic food will be arranged - and if it is not, you will personally escalate it. Involve the social worker, ask whether another relative can bring the other children, and offer for her to see the in-charge. If she still insists on leaving, this becomes an escalation and safeguarding matter: inform the medical officer, document the discussion and the risk of death from untreated severe acute malnutrition, give written follow-up at the nearest health facility, and arrange community follow-up - while keeping the child's best interests as the test applied to every decision.