There are ten essential steps:

1.Treat/prevent hypoglycaemia

2. Treat/prevent hypothermia

3. Treat/prevent dehydration

4. Correct electrolyte imbalance

5. Treat/prevent infection

6. Correct micronutrient deficiencies

7. Initiate refeeding

8. Facilitate catch-up growth

9. Provide sensory stimulation and emotional support

10. Prepare for follow-up after recovery

These steps are accomplished in two phases: an initial stabilisation phase where the acute medical conditions are managed; and a longer rehabilitation phase. Treatment procedures are similar for marasmus and kwashiorkor.

Barbara E Golden. University of Aberdeen, Scotland, United Kingdom

The manual (WHO, 1999) is for senior health workers who are able, if necessary, to change the status quo and provide fairly intensive initial management in a ‘special nutrition unit’ within a hospital followed by non-residential but still comprehensive care in a nearby ‘nutrition rehabilitation centre’.

Severe malnutrition is defined as a weight for length or height of < 70% of the WHO reference, equivalent to a SD Score of < -3, and/or nutritional oedema. Mortality in these children in most settings is 20 – 50%. The aim is to reduce this to < 5%.

Management is divided into 3 phases. Following clinical evaluation, the first phase involves resuscitation, resolution of infection and reversal of abnormal metabolism. This may involve treatment and does require prevention of hypoglycaemia, hypothermia, dehydration, electrolyte imbalance, specific deficiencies, heart failure, shock, in fact, any stress whatsoever. Intravenous fluids pose a major risk of iatrogenic stress so are avoided if possible. Oral ReSoMal is the recommended treatment for dehydration. Compared with the standard WHO ORS, it contains less sodium but more potassium and magnesium, zinc and copper, all likely to be grossly deficient in the malnourished child with acute diarrhoea. Frequent breastfeeding is encouraged and F-75 is the recommended other feed as its relatively low protein, fat and sodium contents and osmolarity provide minimal stress. Every effort is made to ensure the child receives exactly maintenance energy intake at this stage. F-75 contains extra minerals and vitamins but further supplements of Vitamin A and folic acid are also recommended. Iron is contraindicated because of its potential toxicity and aggravation of infection..

Usually within one week, the second, or rehabilitation phase, is heralded by increased appetite and improvement of major abnormalities including loss of oedema. The principles of management change to include feeding to appetite, stimulating emotional and physical development and preparing for home. At this stage, the feed is changed to F-100 which provides 100 kcal (420kJ) per 100ml, with 12% energy from protein and 53% from fat. Like F-75, it also provides extra minerals and vitamins but not iron. Apart from the mineral and vitamin mixes, these two feeds can be prepared from usually available ingredients or the feeds themselves are available commercially. The manual recommends continuing folic acid and commencing supplementary iron when the child has successfully moved into the rehabilitation phase. During this phase, provided there are no setbacks, the child’s intake increases steadily and the frequency of feeding can be reduced. Weight gain is rapid. The child’s mother or closest carer now becomes the major player. She must be shown how to make home as conducive as possible to normal growth and development of her child. This includes teaching of nutrition and food preparation, best behaviour towards her child and the value of play for mental and physical development. She must be taught how to prevent recurrence.

When the child has reached 90% weight for length or height (SD Score of –1), he or she is ready for discharge home and the Follow-Up Phase commences. Ideally, the child is recalled or visited at intervals for up to 3 years to ensure that recurrence of malnutrition is prevented and that healthy physical and mental development is promoted, supported and achieved.

Bhandari NR. Gandhi Medical College, Bhopal, India