Severe Acute Malnutrition with Diarrhoea and Hypoglycaemia
Amara is a 14-month-old girl brought to a rural health centre with 3 days of watery diarrhoea and vomiting. She weighs 6.1 kg, has a mid-upper-arm circumference of 10.6 cm and visible severe wasting. She is lethargic, with a temperature of 35.3°C, heart rate 150/min, respiratory rate 48/min and sunken eyes; skin pinch is slow. Her capillary glucose is 1.9 mmol/L. She has not passed urine for 8 hours. The mother stopped breastfeeding a month ago because she was told her milk was 'bad'. The centre has Ringer's lactate, nasogastric tubes, F-75 therapeutic milk, oral rehydration salts but no ReSoMal, and no paediatric intensive care. The nearest referral hospital is 3 hours away.
1. What is the immediate resuscitation sequence, and what would you avoid?
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The first priority is hypoglycaemia: give 10% dextrose 5 mL/kg intravenously or, if no intravenous access, give sugar solution by nasogastric tube and repeat glucose in 30 minutes. She is also hypothermic, so warm her and cover her head. These steps come before rehydration because untreated hypoglycaemia and hypothermia can kill quickly.
The next judgement is whether she is in shock. Lethargy, delayed skin pinch, sunken eyes, fast pulse and no urine for 8 hours suggest severe dehydration, but in severe acute malnutrition the signs overlap with sepsis and shock. If she has shock with impaired consciousness or weak pulse, give 15 mL/kg of Ringer's lactate with dextrose over 1 hour and reassess. If she is not in shock, avoid rapid intravenous fluids; use oral or nasogastric rehydration with oral rehydration salts, giving 5 mL/kg every 30 minutes for 2 hours, then reassess.
I would avoid: rapid large-volume intravenous fluids, diuretics, routine sodium bicarbonate, and giving food before the airway and glucose are safe. I would also avoid assuming that the diarrhoea alone explains the lethargy; sepsis must be treated. Start broad-spectrum antibiotics according to local guidelines after cultures if possible.
2. How would you manage fluids and feeding over the first 48 hours?
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Over the first 48 hours the aim is slow, careful rehydration and early feeding, not rapid correction. If she is not in shock, continue oral or nasogastric rehydration with small frequent volumes and reassess every 30–60 minutes for overhydration: rising respiratory rate, new crepitations, a rising pulse or an enlarging liver are warning signs. If she is vomiting, pass a nasogastric tube and give small volumes rather than stopping feeds.
Feeding:
- start F-75 at about 130 mL/kg/day, divided into feeds every 2–3 hours;
- continue breastfeeding if possible, but the mother has stopped; a breastfeeding counsellor should explore restarting or expressing, without blaming her;
- give vitamin A, zinc and appropriate antibiotics;
- monitor weight daily, but do not expect rapid weight gain in the first days.
Fluids and electrolytes: use oral rehydration salts rather than ReSoMal if ReSoMal is unavailable, but monitor closely because the sodium content differs. Watch for heart failure, especially if intravenous fluid was given. Check potassium and magnesium if possible; malnutrition often causes deficits, but treatment must be guided by monitoring. If she remains anuric, becomes more lethargic or develops respiratory distress, escalate care.
3. What determines referral, and how would you prepare her for transfer?
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Referral is indicated if she remains in shock after initial fluids, has recurrent hypoglycaemia, develops respiratory distress or signs of heart failure, cannot take oral or nasogastric feeds, has persistent vomiting, or shows no improvement in consciousness or urine output. The 3-hour journey is a real risk, so the decision should be made early rather than after she deteriorates.
Before transfer:
- correct glucose and temperature;
- secure intravenous access or a nasogastric tube;
- give the first dose of antibiotics;
- send a referral letter with weight, MUAC, glucose readings, fluids given, urine output and feeding plan;
- keep her warm and accompany her with someone able to monitor and give glucose;
- discuss with the family why transfer is needed and what will happen if they refuse.
If transfer is refused, document the discussion and provide the best possible local care with frequent review. The key judgement is that severe acute malnutrition with hypoglycaemia and possible sepsis is not a condition for watchful waiting at a centre without intensive care.