Severe Acute Malnutrition with Dehydration and Hypoglycaemia: Stabilise Before You Astringe

Classification: severe acute malnutrition (weight-for-height below -3 SD, visible severe wasting, no oedema) with severe dehydration (lethargy, sunken eyes, skin pinch over 2 seconds, no urine) plus hypoglycaemia 48 mg/dL and hypothermia 36.1 C. Lethargy with capillary refill over 3 seconds means he is in shock.

First hour, in order: keep warm with skin-to-skin contact and covering; treat hypoglycaemia immediately with 10% dextrose 5 mL/kg IV, or by nasogastric tube if no IV access, and recheck glucose in 30 minutes; secure IV access and give Ringer's lactate 15 mL/kg over one hour, then reassess; if improving, repeat 15 mL/kg over the next hour and then switch to oral or nasogastric ReSoMal. Start broad-spectrum antibiotics, give zinc 20 mg daily for 14 days, vitamin A according to protocol, and continue breastfeeding.

Reasoning behind the fluid choice: a malnourished child has altered cardiac muscle and low albumin, so standard rapid boluses and the full 100 mL/kg Plan C can precipitate fluid overload and heart failure. Smaller, slower aliquots with reassessment between them are safer. If he were not in shock, nasogastric ReSoMal 5 mL/kg every 30 minutes would be preferred over IV fluid for the same reason. Do not give iron in this stabilisation phase.

The decoction does not treat what is killing him. Astringents reduce stool volume but do not replace the water, sodium and potassium he has already lost; reducing the number of stools can create a false sense of control while the deficit deepens. In a lethargic child who is vomiting, any oral preparation also carries an aspiration risk, and an unstandardised bark decoction with honey has unknown concentration and contamination.

Classical reasoning: stambhana in the acute stage of atisara with ama and active loss is premature; the sequence is rehydration and pachana, then astringent or binding therapy once the stool is non-bloody, the child is alert and the losses are settling. Binding early can also mask a continuing infective or invasive process.

What to say to the mother: her intention is right but the timing is wrong; the decoction may be considered in a few days once he is drinking, passing urine and the stools are reducing, and then a standardised preparation is preferable. Meanwhile, praise her for bringing him and redirect her effort into ORS, continued feeding and hand hygiene. Document the counselling and the plan to reintroduce Kutajarishta or Balachaturbhadra later if the stool pattern persists.

Rehabilitation: begin F-75 starter formula at about 130 mL/kg/day, divided two- to three-hourly, by nasogastric tube if he cannot take orally; continue breastfeeding. Move to F-100 only when appetite has returned and oedema, if present, has resolved, then increase for catch-up growth. Give zinc, vitamin A, folic acid, potassium and magnesium; defer iron until the stabilisation phase is complete and infection is controlled.

Three parameters that stop or slow feeding:

1. Rising respiratory rate with a falling pulse or increasing hepatomegaly - the earliest sign of fluid overload and incipient heart failure from too much or too fast feed.
2. New or increasing periorbital or pedal oedema, or a weight gain curve steeper than expected, indicating overfeeding.
3. Persistent or recurrent hypoglycaemia and hypothermia, or deteriorating consciousness - this suggests sepsis or inadequate intake rather than simple malnutrition, and needs reassessment and slower feeding with antibiotics reviewed.

Also track stool and vomit frequency and urine output; if diarrhoea continues with poor urine output despite ReSoMal, reconsider cholera or another invasive cause. Follow up weight, feeding and development after discharge, and involve the mother in feeding demonstrations before she goes home.