AO7

Clinical Protocols and

Nursing Guidelines
Revised 2014
Malnutrition Ward AO7

Department of Paediatrics and Child Health

University Teaching Hospital
Ministry of Health, Lusaka
 IMPORTANT NOTE REGARDING THE USE OF CLINICAL PROTOCOLS

This book comprises of clinical guidelines, which have been made compatible with the resources
generally available at the AO7 ward of the University Teaching Hospital, Lusaka.

The protocol is largely based on WHO Guidelines for the management of severe malnutrition. The
recommendations in the book represent collective local and / or regional experience and reflect the
current state of the practices in appropriately comparable settings. This document has been
prepared in good faith. However, the AO7 Staff cannot accept any legal responsibility arising from
the use of these clinical protocols.

Standard Treatment Guidelines in any field apply to the “average” patient. It is important to note
that the guidelines given in this booklet are neither comprehensive nor the final guidelines for the
management of any particular condition or situation. They are not rigid rules and the prescriber
should consult more detailed texts and adapt / modify the management as necessary when there
are special circumstances, for example coexisting morbidities, complications, the availability of
drugs, investigations, instruments and equipment and other factors. Likewise, while due care has
been taken to check all dosages, the prescriber still has to accept the final responsibility of his / her
prescription(s).

It is assumed that users of the book will have the specific expertise of medical practitioners; with
a variable access to specialists/consultants.

Clinical Protocols require regular revision, and the inputs, feedbacks and constructive suggestions of
the users are of major value and importance and would be welcomed and appreciated.

Dr. Beatrice Amadi Dr. V K Pandey

2014
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 This Protocol is divided in three parts:

1. Part 1 (Page 4 - 13) AO7 Protocols in Brief : This part contains

the necessary instructions for the Nurses as well as for the Doctors
in brief. This part is intended for the quick reference.
2. Part 2 (Pages 14 - 27) Detailed instruction for the DOCTORS.

3. Part 3 (Pages 28 - 31) Detailed instruction for the NURSES.

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 Part 1: AO7 Protocols in Brief

Identifying and assessing the children with severe malnutrition

Infants and children who are 6–59 months of age and have a mid-upper arm circumference
<115 mm or a weight-for-height/length <–3 Z-score of the WHO growth standards, or have
bilateral oedema, should be immediately admitted to a programme for the management of
severe acute malnutrition.

Criteria for inpatient or outpatient care

Children who are identified as having severe acute malnutrition should first be assessed with a
full clinical examination to confirm whether they have medical complications and whether they
have an appetite. Children who have appetite (pass the appetite test) and are clinically well and
alert should be treated as outpatients despite having SAM.

Only the children who have medical complications, severe oedema (+++), or poor
appetite (fail the appetite test), or present with one or more Integrated Management
of Childhood Illness (IMCI) danger signs should be treated as inpatients.

TREATMENT PLAN:
Note that treatment procedures are similar for both the types of SAM (either with oedema or
wasting). The approximate time-scale is given in the box below:

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 PROCEDURES ON ARRIVAL OF PATIEN IN AO7
FOR THE NURSES:
On receiving a patient from the Admission Ward, the nurse on duty in AO7 would ensure a proper
hand-over. Then He / she will do the following:

- Quickly assess the general condition of the patient.

- Determine that the patient fulfils the criteria for the admission to the Malnutrition Ward (A07)
by re-weighing and measuring the length / height of the patient, assisted by the ward attendant
on duty.
- Criteria for admission: Severe wasting with SD<-3 weight for height or oedema of both feet
- Fill-out the Critical Care Pathway Chart (CCP), Feeding Chart, Weight Chart and Temperature
Charts.
- Check to see that the Drug Chart has been completed correctly and all necessary drug are
written with dosages and, if there is diarrhoea, the fluid orders (IV or ORS) have been written.
- Do the Feeding Test : Give the initial feed of F-75 and see if the patient is able to drink orally. If
not, then insert the Nasogastric (NG) tube immediately.
- If the patient has diarrohoea, explain to mother how to give ReSoMal and put in the area of
Admission Bay designated for the patients with diarrhoea.
- Explain the ward routine to the mothers:
o Feeding schedule.
o Show mother where to get ReSoMal.
o Stress the importance on feeding the child on time at each feed and the need to
wake up the sleeping child for feeding day and night
o To report all diarrhoea episodes to the Ward Attendant.
o To keep the baby dry all the time to avoid hypothermia
o To keep the baby covered all the time with a cap and socks and check that the socks
remain dry.
o Orient the mother with the lay out of the ward and location of wash-basins and
toilets.
o Give her tips of personal hygiene and keep the bed and surroundings clean.
- Allocate a bed to the patient and inform the doctor immediately so that the patient may be
reviewed AS EARLY AS POSSIBLE.
- GIive the instructions to the Ward Attendant to monitor and record the following on the
appropriate Charts:
o Pulse / Heart Rate o Temperature
o Respiratory Rate o Record all diarrhoeal episodes
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IMPORTANT: EXPLAIN THE NEED TO FOLLOW WARD RULES, MAINTAIN HYGIENE AND KEEP THE BED
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AND SURROUNDING TIDY AND FREE OF CLUTTER

FOR THE DOCTORS:
- Review all newly admitted patients ASAP
- MEDICAL HISTORY, especially ask for the following:
 Usual diet before current episode
 Breastfeeding history
 Food and fluids in past few days
 Recent sinking of eyes
 Duration and frequency of vomiting and diarrhoea, appearance of vomit or diarrhoeal
stools, presence of blood/mucus in stools
 Time when urine was last past
 Contact with people when measles or tuberculosis
 Any deaths of siblings
 Birth weight
 Milestone reaching (seating up, standing)
 Immunizations
 VCT (pregnancy, after birth or child)
 Health of parents if alive: if died, ask when and cause of death
 Drug history, ask if taking ARV’s (from local clinic or UTH. If UTH get the file from
children’s’ clinic)
- PHYSICAL EXAMINATION:
 Weight and length or height
 Oedema
 Enlargement or tenderness of liver
 Severe pallor
 Signs of circulatory collapse: cold hands and feet, weak radial pulse, diminished
consciousness
 Temperature: hypothermia or fever
 Thirst
 Eyes: corneal lesions indicative of Vitamin A deficiency
 Ears, mouth, throat, evidence of infection
 Skin: evidence of dermatosis, infection
 Respiratory rate and type of respirations, signs of pneumonia or heart failure

 CHECK THE CONDITION OF THE PATEINT AND ENSURE THE DRUGS AND DOSAGES ARE
CORRECT
 Write out rehydration plan for the patients depending of hydration status for all patients
with diarrhoea.
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 Assess for presence of shock and treat accordingly

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 Investigate all the patients as follows:

 Blood Sugar ASAP and Haemoglobin on admission

 Full blood count, ESR
 Malaria slide (thick and thin smear)
 Blood culture
 Urinalysis
 Urine m/c/s
 Gastric lavage for AFB
 Lumbar puncture if indicated
 Chest x-ray
 Routine counselling and testing (RVT)
 Reducing substances if passing watery, urine like stool (ask mother remove nappy and put patient on
plastic)

- Urgent Cross-Match if the patient is very pale or appears in Septic Shock. Please follow-up the
blood in Blood Bank.
- If >4 stools → start ReSoMal (Intra-gastric Drip for rehydration (10ml/kg/hr. to run for 3hrs)
- In cases of Cholera or profuse watery diarrhoea, use standard WHO Low Osmolarity ORS (and
NOT the ReSoMal)
 Ensure patient is on correct amount of feeds, particularly if has severe oedema (+++)
 Discuss additional management plan with the nurse
 Explain condition of the patient and planned management to the mother and reassure her that
everything possible is being done for her child.

REHYDRATION PLAN FOR PATIENTS WITH DIARRHOEA:

 If diarrhoea and/or vomiting, give ReSoMal - 5 mls/kg every 30 minutes for first 2 hours
 Monitor Respiratory Rate and Pulse Rate at beginning and at end of 30mintutes
 Ask if patient is passing urine, time of last urine, number of stool, number of vomits and check for
hydration signs

AFTER 2 HOURS:
 From 3rd hour - up to 10 hours, give ReSoMal 5 -10 ml /kg every hour.
 The exact amount depends on how much the child wants, volume of stool loss and whether the child is
still vomiting.
 Monitor every hour.
 If the child is still dehydrated at 6 hours and 10 hours (of starting the rehydration), give F-75 feed at
these hours instead of ReSoMal (in the same amount)
 There after initiate F-75 feeds

STOP ReSoMal if: increase in Pulse Rate and Respiratory Rate or jugular veins engorged or increasing oedema
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IF NO DEHYDRATION:
Children under 2 years should be given 50-100 ml (between 1/4 and 1/2 feeding cup) of ReSoMal
after each loose stool
Older children give 100-200ml
Continue this until diarrhoea stops

INTRAVENOUS REHYDRATION:
The only indication for IV infusion in a severely malnourished child is circulatory collapse caused
by severe dehydration of septic shock.
Signs of shock: lethargic/unconscious: cold hands, slow capillary refill (>3sec), weak/fast pulse.
For IV Bolus, use one of the following in order of preference:
- Half-strength Darrow’s solutions with 5% glucose (dextrose)
- Ringers lactate solution with 5% glucose (*)
- 0.45% (half-normal) saline 5% glucose (*)
- (*) if you use any of these, add potassium chloride 20mmol to every litre of fluid
Amount of IV fluids: 15 ml/kg over 1 hour
Monitor RR and PR every 30 minutes.
If RR and PR are slower after 1 hour (Improvement): Repeat same amount of IV for 2nd hour

After 2 hours :
 From 3rd hour - up to 10 hours, give ReSoMal 5 -10 ml /kg every hour.
 The exact amount depends on how much the child wants, volume of stool loss and whether the child is
still vomiting.
 Monitor every hour.
 If the child is still dehydrated at 4 hours, 6 hours, 8 hours and 10 hours (of starting the rehydration), give F-
75 feed at these hours instead of ReSoMal (in the same amount).. in other words alternate feeds with
ReSoMal as long as the child is dehydrated.
 There after initiate F-75 feeds

IF NO IMPROVEMET ON IV FLUIDS, DO NOT REPEAT BOLUS. TREAT AS SEPTIC SHOCK

INSTEAD GIVE MAINTENANCE FLUID (4ML/KG/HOUR) AND ARRANGE BLOOD
TRANSFUSE whole fresh blood (10ml/kg) AND TRANSFUSE OVER 3 HOURS.
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Comparison of clinical signs of dehydration and septic shock in the severely
malnourished child
Clinical sign Some Severe Incipient septic Developed shock
dehydration dehydration shock
Watery Yes Yes Yes or no Yes or no
diarrhoea
Thirst Drinks eagerly Drinks poorly No No

Hypothermia No No Yes or no Yes or no

Sunken eyes Yes Yes No No

Weak or absent No Yes Yes Yes

radial pulse

Cold hands and No Yes Yes Yes

feet

Urine flow Yes No Yes No

Mental status Restless, irritable Lethargic, Apathetic Lethargic

comatose
hypoglycaemia Sometimes sometimes Sometimes Sometimes

Patients Without Diarrhoea

- Give 3 hourly feeds - F-75
- Investigate all patients as outlined above.
- URGENT X-MATCH IF PATIENT IF VERY PALE. PLAESE FOLLOW UP BLOOD IN BLOOD BANK

Criteria for transferring children from inpatient to outpatient care

Children with severe acute malnutrition who are admitted to hospital can be transferred
to outpatient care when their medical complications, including oedema, are resolving
and they have a good appetite, and are clinically well and alert. The decision to transfer
children from inpatient to outpatient care should be determined by their clinical
condition and not on the basis of specific anthropometric outcomes such as a specific
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mid-upper arm circumference or weight-for-height/length.

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DRUGS:

Antibiotics:
No complications: Amoxicillin (50-100mg TDS PO)
For septicaemia: IV ampicillin (100-200/kg/day QID) + Gentamycin (7.5mg/kg/day OD or BD)
X-pen (100mg-200mg/kg/day QID)
Second line drugs:
Chloromphenicol (100mg/kg/day QID) Use as first line with Ampicillin for suspected meningitis
Cefotaxime (100 mg/kg/day QID)
Ciproflaxacillin (5-10mg/kg/day BD)

For RVD with suspected atypical pneumonia: High dose Co-trimoxazole (30 mg/kg/dose QID)
For PCP prophylaxis: all HIV positive patients give single daily dose of cortrimoxazole (consult the
age appropriate guidelines for dose)
For severe and deep mouth ulcers, Metronidazole (7.5mg/kg/day TDS) IV or PO

Antimalrials:
Follow the current National Guidelines for the treatment of Malaria (Refer to appropriate
literature)

ANTIHELMINTHIC:
Mebendazole 100mg BD for 3 days or Albendazole 400 mg. Stat

VITAMIN A: on days 1, 2 and 8

Vitamin A is not given if the patient is
<6 months 50,000 IU
receiving F-75 or F-100 (which
6-12 months 100,000 IU
already contains Vitamin A), but if
>12 MONTHS 200,000 IU
eye signs are present, give the stat
Slow K (If diarrhoea present) 600 mg od dose of Vitamin A.

ANTIFUNGAL:
Ketoconazole (<15 kg: 50 mg OD, <15-30 kg: 100 mg OD, >30 Kg 200 mg OD) or
Nystatin suspension (if on ARVs) 100,000 units QID (may be increased to 500,000 units QID if
poor response in immune compromised patients

Severe dermatosis with ulceration

Soak in 1% potassium permanganate or apply GV paint or zinc oxide ointment if available

Please refer to current guidelines for other infections e.g. HIV, Tuberculosis,
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Dysentery, Enteric Fever and Malaria etc.

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 Vitamins and minerals – not required if CMV (Combined Mineral & Vitamin mix) is available.
If not, Zinc: 10 mg OD <6 months
10 mg BD > 6months

HAEMATINICS
Folic acid 5mg OD

SEVERE ANAEMIA
 Blood transfusion 10ml/kg whole blood or 5-7 ml/kg packed cell volume
 Give Furosemide 1mg/kg IV before transfusion
 Transfuse over 2 hours.
 Transfusions may be repeated if needed.

CONGESTIVE CARDIAC FAILURE

First sign is fast breathing, later respiratory distress, rapid pulse, engorgement of the jugular vein,
cold hands and feet and cyanosis of fingertips and under the tongue.
o Stop all oral intakes and IV fluids, treatment of heart failure takes precedence over feeding
the child.
o No fluids should be given until the heart failure if improved, even if this takes 24-48hours
o Give diuretic IV (Frusemide 1mg/kg)

MOVEMENT OF PATEINTS ON THE WARD:

BAY 1: ADMISSION/ ACUTE BAY
All newly admitted cases to remain for at-least 2 days and for up to 7 days or longer if severely ill.

BAY 2: TRASNSITION BAY

Recognise readiness for transition:
- Return of appetite (easily finishes 3 hourly feed) All patients who fulfil
- Reduced oedema or minimal oedema these criteria will be
- Child may also smile at this stage moved to Bay 2

First 48 hours (2 days) in BAY 2:

- Give F-100 according to WHO Reference Charts for F-100.

- However for the logistic reasons F-100 may be given 3 hourly, but adjust the volume of each
feed so that the total volume of F-100 is same as given in the Reference Chart.
o Do not increase this amount for two days

Then on the 3rd day

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- Increase each feed by 10ml as long as the child is finishing feed

 - If the child does not finish a feed, offer the same amount at the next feed: then if the feeds are
finished, increase by 10ml. Enter the feeding plan for next day. Mark an arrow (instruction for
increasing the feed) next to the starting amount of feed e.g. 95↑. (see the example below)
Date: 13/10/12 Type of feed: F-100 Give 8 feeds of 95↑ml

- Continue increasing the amount until some feed is left (now baby is taking about 30ml/kg/feed)
- If the child is breastfeeding, encourage the mother to breastfeed between feeds of F-100

On the 4th day, if the child is finishing the minimum amount on the F-100 Reference Chart for age, and
is gaining weight, MOVE THE CHILD TO BAY 3 and start iron sulphate.

BAY 3: REHABILITATION BAY

- The child can feed freely on F-100 to an upper limit of 220kcak/kg/day (equal to 220ml/kg/day
maximum) 4 HOURLY
- Introduce and start RUTF gradually… do not force, do not rush (Responsive Feeding)
- Most children will consume at least 150kcal/kg/day. Any amount less than this indicates that the
child is not being fed properly or is unwell.
- During rehabilitation, encourage the child to feed as much as he wants at each feed.
- Encourage mother to sit with child and actively encourage eating. Never leave the child alone to
feed.
- Discuss issues of ARVs, if the child tested ‘reactive’ on RVT. If mother is willing to start child on
treatment, do the necessary investigations- CD4, %FBC, LFTs and U/Es + creatinine
- If the child is finishing the maximum amount indicated on F-100 reference card and is gaining
weight, Start HEPS X 2 per day, and continues RUTF

PLAN FOR DISCHARGE

Continue on RUTF. Do not exceed maximum. Give two additional feeds of HEPS 1 cups.

Intensify health education for mother/carer. Emphasize: family planning, how to treat diarrhoea at home
(oral rehydration), personal hygiene, if already on ARV’s or ATT reinforce compliance, continued
breastfeeding.

IF HIV positive, refer to PCOE for starting the HAART.

Show parent or carer how to:
-feed frequently with energy and nutrient dense foods
-give structured play therapy
-give supplements of RUTF
-give a prescription of folic acid, iron and multivitamins
-advise to bring child back for follow-up checks.
-Refer to Community Therapeutic Centre (CTC) in catchment area of home of the patient
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-ensure that immunizations are given

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-ensure vitamin A every 6 months

Criteria for discharge from Out-patient care:
CHILD Weight-for-height has reached -1SD (90%) of median reference values (Ideal
but not possible).
Eating an adequate amount of a nutritious diet that mother can prepare at
home (HEPS)
Gaining weight at a normal or increased rate
All vitamin and mineral deficiencies have been treated
All infections and other conditions have been or being treated, including
anaemia, diarrhoea, intestinal parasitic infections, malaria, TB, Otitis media
and RVD
Full immunization programmed started
MOTEHR OR Able and willing to look after child
CARER Knows how to prepare appropriate foods and to feed the child
Understands the need to play with child
Knows how to give home treatment for diarrhoea, fever and acute
respiratory infections and how to recognise the sings that means she must
seek medical assistance.

HEALTH Able to ensure follow-up of the child and support for the mother.
WORKER

RECIPE FOR ReSoMal ORAL REHYDRATION SOLUTIONS

INGREDIENTS AMOUNT
Water (boiled and cooled) 2 litters
WHO-ORS sachet One litter-sachet.
Sugar 50g
Electrolyte/mineral mix 1 scoop
ReSoMal contains approximately 45mmol Na, 40mmol K and 3mmolMg/l

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 Part 2

DETAILED PROTOCOL FOR THE MANAGEMENT OF SEVERE MALUTRITION - WARD A07

(Adapted from WHO guidelines)
Importance of severe malnutrition as a health problem.

Severe malnutrition is one of the most common causes of morbidity and mortality among children under
the age of 5years worldwide. Many severely malnourished children died at home without care, but even
when hospital care is provided, case fatality rates may be high.

Severely malnourished children often die because doctors unknowingly use practices that are suitable
for most children, but highly dangerous for severely malnourished children.

With appropriate case management in hospitals and follow-up care, the lives of many children can be
saved, and severe malnutrition wards can dramatically lower case fatality rates. In certain hospitals, that
have used these case management methods over a period of time, case fatality has been reduced from
over 30% to less than 5%.

SIGNS OF SEVERE MALNUTRITION

SEVERE WASTING (skin and bone appearance)

It is important to remove the child’s cloths in order to examine for severe wasting. A severely
wasted child will have the following signs:
- Outline of the child’s ribs easily seen
- The skin of the upper arms look loose
- The skin of the thighs look loose
- The ribs and shoulder bones easily seen
- Flesh missing from the buttocks
- ‘baggy pants’ appearance

OEDEMA

Oedema is swelling from excess fluid in the tissues. It is usually seen in the feet, lower legs and arms. In
severe cases, it may also be seen in the upper limbs and face. To be considered a sign of severe
malnutrition, oedema must appear in both feet. If the swelling is only in one foot, it may just be a sore or
infected foot.

The extent of oedema is commonly rated the following way:

+ Mild: both feet
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++ Moderate: both feet, plus lower legs, hands and lower arms
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+++ Severe: generalized oedema including both feet, legs, hands and face
DERMATOSIS

In severe malnutrition, this skin condition is more common in children who have oedema than in wasted
children. It may appear as patches of the skin that are abnormally light or dark in colour, shedding of skin
in scales or sheets and ulceration of the skin of the perineum, groin , limbs, behind ears and in the
armpits.

There may be weeping lesions. When the skin is raw and weeping, this poses a very high risk for bacteria
to get into the body, causing infection. The extent of dermatosis can be described in the following way.

+ Mild: discoloration or a few rough patches of skin

++ Moderate: multiple patches on arms and/or legs

+++ Severe: flaking skin, raw skin, fissures (opening in the skin)

EYE SIGNS

Children with severe malnutrition may have signs of eye infection and/or Vitamin A deficiency.
Bitot’s Spots – Superficial foamy white spots on the conjunctiva. (Vitamin A def)
Pus and inflammation – signs of eye infection
Corneal Ulceration – severe sign of Vitamin A Def. If not treated, the lens of the eye may push out and cause
blindness.
Corneal Ulceration is urgent and requires immediate treatment with Vitamin A and Atropine
(to relax the eye)

STUNTING

This is unusually low height or length for age, often due to chronic malnutrition. A stunted child may be adequate
in weight-for height but low in weight for age because he is very short. Stunted children should be managed in the
community rather than the hospital.

INITIAL MANAGEMENT (BEFORE ADMISSION TO AO7):

The first step to check the child for emergency signs and provide emergency treatment as necessary. Any
child presenting to the hospital should be checked for emergency signs as part of standard procedure.

Some of the initial management procedures may be performed in the emergency room, before the child
is admitted to A07. A severely malnourished child should be seen as quickly as possible in the emergency
room. The following initial treatment must be carried out before transfer to A07:

THE FOCUS OF INITIAL MANAGEMENT IS TO PREVENT DEATH WHILST STABILIZING THE CHILD!!

In the OPD emergency room the following must be done:

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 ASSESS QUICKLY
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 GIVE 10% GLUCOSE

  IDENTIFY/TREAT SHOCK
 START ANTIBIOTICS – Broad spectrum e.g. Xpen and Gentamycin
 PRRECRIBE VITAMIN A, FOLATE, ANTIMALARIA, SLOW K (if there is diarrhoea)
 KEEP WARM
 TRANSFER TO A07

DO NOT TRANSFER GASPING PATIENTS TO A07

TREAT SHOCK BEFORE TRANSFER
IF BLOOD TRANSFUSION IS NEEDED, TRANSFER TO AO7 ONLY AFTER THE BLOOD TRANSFUSION

CRITERIA FOR ADMISSION TO A07

Only children with SEVERE MALNUTRITION are admitted to A07.
They must fulfil the following criteria:

 MARASMIC – SEVERELY WASTED: Wt/Ht Z SCORE ≤ 3

 KWASHIORKOR – UNDERWEIGHT WITH NUTRITIONAL OEDEMA GRADE 3

Children who do not fulfil the above criteria MUST NOT be admitted to A07. They should be sent to the
ward of admitting unit where they will be treated for the medical and nutritional problems. This will
ensure that only the very severe cases are admitted to A07. Ignoring the above criteria will result in
overcrowding, increased cross infection and increased mortality as space is limited on the ward. PLEASE
ENSURE THAT YOU ADHERE TO THIS ADMISSION CRITERIA STRICTLY. FOR OCCASIONAL EXCETIONS,
DISCUSS WITH THE SISTER-IN-CHARGE AND THE SENIOR REGISTRAR OF THE UNIT.

ON ADMISSION TO A07:
FILL IN CCP CHART

 Measure Wt and Ht (Length)

 Calculate Wt/Ht Score
 Perform Haematocrit

IDENTIFY SHOCK
 Decide on hydration state
 Rehydrate/feed the child
 Use NG tube if necessary
 Check drug chart to see if all necessary drugs have been prescribed (Add on or correct doses if
necessary)
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 Keep warm
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 EXPLAIN TO MOTHER
 Care of her child
 Ward routine
 Reassure her

MANAGE HYPOGLYCAEMIA:
 In severely malnourished children, hypoglycaemia is low blood sugar of <3mmol/litre
 The hypoglycemic child is usually hypothermic, lethargic, limp and may have loss of
consciousness
 Sweating and pallor may not occur in malnourished children with hypoglycemia
 Often the only sign before death is drowsiness
 Short term cause of hypoglycemia is lack of food
 Severely malnourished – more at risk than other children
 Severely malnourished need to be fed more frequently, including during the night
 Malnourished children may arrive at the hospital hypoglycemic if they have been vomiting, been
too sick to eat or had a long journey without food
 Children may develop hypoglycemia in the hospital if they are kept waiting for admission if not
fed regularly
 Hypoglycemia and hypothermia are also signs of septicemia

The child may die if not given glucose (and then food) quickly, or if there is a long time between feeds.

MANAGE A SEVERELY MALNOURISHED CHILD WITH SHOCK

Shock is a dangerous condition with severe weakness, lethargy, or unconsciousness, cold extremities and
fast, weak pulse. It is caused by:

 Diarrhea with severe dehydration  Burns

 Hemorrhage  Sepsis
In severely malnourished children, some of the signs of shock may appear ll the time, so it is difficult to
diagnose. Thus, IV fluids are given in severe malnutrition only if the child meets the following criteria:

The severely malnourished child is considered to have SHOCK if he/she:

 Is Lethargic or unconscious and
 Has cold hands
Plus either:
 Slow capillary refill (longer than 3 seconds)
 Weak or fast pulse

To check capillary refill:

 Press the nail or the thumb or big toe for 2 seconds to produce blanching of the nail bed
 Count the seconds from release until return of the pink colour. If it takes longer than 3 seconds,
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capillary refill is slow.

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For a child 2months up to 12months of age, a fast pulse is 160 beats or more per minute
For a child 12months to 5 Years of age, a fast pulse is 140 beats or more per minute
If the child is in shock (meets criteria in box above):
 Give Oxygen
 Give Sterile 10% glucose 5ml/kg by IV stat
 Give IV fluids as described below
 Keep the child warm

Giving IV fluids:
Shock from dehydration or sepsis are likely to coexist in severely malnourished children. They are
difficult to differentiate on clinical grounds alone. Children with dehydration will respond to IV fluids.
Those with septic shock and no dehydration will not respond. The amount of IV fluids given must be
guided by the child’s response. Over hydration can cause Heart Failure and Death.

To give IV fluids:

Check the starting respiratory and pulse rates and record them on the CCP. Also record the starting time.
Infuse IV fluids at [Link] over 1 hour. Use one of the following solutions listed in order of preference:

 Half strength Darrow’s solution with 5% glucose

 Ringer’s lactate solution with 5% glucose*
 0.45%(half normal)saline with 5% glucose*
* If either of these is used, add sterile potassium chloride (20mmol/l) if possible.

 Observe the child and check respiratory and pulse rates every 30 minutes (every 10 minutes if more
staff are available is ideal)
 If the respiratory rate (RR) and pulse rate (PR) increase, STOP IV.

After two hours of IV fluids, switch to oral or nasogastric rehydration with ReSoMal. Give 5-10 ml/kg
ReSoMal in alternate hours with F-75 for upto 10 hours or longer if necessary. Leave the IV line in place
in case need again.

If no improvement with IV fluids, give blood transfusion:

 If the child fails to improve after the first hour of IV fluids, then assume that the child has septic
shock.
 Give maintenance IV fluids (4ml/kg/hour) while waiting for blood.
 When blood is available, STOP ALL ORAL INTAKE AND IV FLUIDS, give diuretic to make room for the
blood, then transfuse whole flesh blood at 10ml/kg slowly over 3 hours. If there are signs of heart
failure, give packed cells instead of whole blood as these have smaller volume.

MANAGE VERY SEVERE ANAEMIA

 Very severe anaemia is haemoglobin concentration of <40g/l (or packed cell volume <12%)
 Can cause heart failure and must be treated with blood transfusion
13

 As malnutrition is usually not the cause of very severe anaemia, it is important to investigate other
possible causes such as malaria and intestinal parasite. (e.g. hookworm)
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  Mild or moderate anaemia is very common in severely malnourished children and should be treated
LATER with iron, after the child has stabilized. Do not give Iron as it can damage the cell membrane
and worsen the infection.
 Give blood transfusion if Hb <40g/l.
 Stop all oral intake and IV fluids during transfusion.
 Look for signs of congestive heart failure ( fast breathing rate respiratory distress, rapid pluse,
engorgement of the jugular vein, cold hands and feet, cyanosis of the fingertips and under the
tongue.)
 If no signs of CCF, give 10ml/kg whole fresh blood. If there is CCF, GIVE PACKED CELLS, 5-7ML/KG
instead of whole blood.
 Give frusemide 1mg/kg IV
 GIVE BLOOD TRANSFUSION SLOW;Y OVER THREE HOURS

GIVE EMEGENCY EYE CARE FOR CORNEAL ULCERATION

Corneal ulceration is very dangerous. If there is an opening in the cornea, the lens of the eye can extrude
(push out) and cause blindness.
- Wash your hands
- Touch the eyes extremely gently and as little as possible. The child’s eyes may be sensitive to light and
may be close.
- If eyes are closed, wait until the child opens his eyes and check them. Only pull down the lower
eyelids to check
- Wash hands after examination

GIVE VITAMIN A AND ATROPINE EYE DROPS IMMEDIATELY FOR CORNEAL ULCERATION
CHILDS AGE VITAMIN A DOSE
<6 months 50 000IU
6-12 Months 100 000IU
>12 months 200 000IU

 Also instil one drop of atropine (1%) into the affected eye(s) to relax the eye and prevent the lens
from pushing out
 Tetracycline eye drops and bandaging are also needed, but may wait later in the day
 All severely malnourished children need vitamin A on day 1, 2 and 8 (if not on F-75 or F-100)

MANAGE DIARRHOEA AND/OR VOMITING WITH ReSoMal

- ReSoMal is rehydration solution for malnutrition. It is a modification of the oral rehydration solution
(ORS) recommended by WHO.
- ReSoMal contains less sodium, more sugar and more potassium than the standard ORS and is
intended for severely malnourished children with diarrhoea.
- It should be given by mouth of nasogastric head.
- IN CASES OF PROFUSE WATERY DIARRHOEA (EG. CHOLERA, CRYPTOSPORIDIUM, GIVE STANDARD
LOW OSMOLARITY ORS INSTEAD OF RESOMAL.
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 RECOGNISE THE NEED FOR ReSoMaL
- It is difficult to determine dehydration status in the severely malnourished child , as the usual sign of
dehydration may be present in these children at the time, whether or not they are dehydrated.
- Ask the mother if the child had watery diarrhoea or vomiting. If the child has vomiting or diarrhoea
ASSUME dehydration and give ReSoMal (ask about blood in stool- will need isolation and will affect
choice of antibiotics)
- Even if a severely malnourished child has oedema, he may be dehydrated. The oedema increases loss
of control of fluid distribution in the body, rather than too much fluid. If the child has diarrhoea or
vomiting, give ReSoMal even if the child has oedema.
- Note the signs of dehydration in order to detect improvements later, even though the signs may be
misleading, if they go away after giving ReSoMal, you will know that the ReSoMal had a good effect.

SIGNS OF DEHYDRATION
 lethargic
 Irritable, restless
 Sunken eyes
 dry mucous membranes and mouth/tongue
 thirsty
 skin pinch goes back slowly

How often to give ReSoMal Amount to give

Every 30 mins for first 2hrs 5ml/kg weight
Every hour for up to 10 hrs or more if 5-10ml/kg*
necessary
*the amount offered in this range should be based on the child’s willingness to drink and the amount of
ongoing losses in stool. If still dehydrated, give F-75 on 6th and 10th hour in the same amount.

- If the child has already received IV fluids for shock and is switching for ReSoMal , omit the first 2 hours
treatment and start with the amount for the next period of up to 10hrs (or more if necessary)

GIVE ANTIBIOTICS
Give all severely malnourished children antibiotics for presumed infection. Give first dose of antibiotics
while other initial treatments are going on, as soon as possible.

Selection of antibiotics depends on presence or absence of antibiotics, complications include: septic

shock, hypothermia, hypoglycaemia, skin infections or dermatosis (+++ with raw skin/fissures)
respiratory or urinary tract infections, or lethargic/sticky appearance.

For A07, the recommended antibiotics are detailed previously in this protocol.

FEEDING: Feeding is a crucial part of managing severe malnutrition, however feeding MUST BE
STARTED CAUTIOUSLY, IN FREQUENT, SMALL AMOUNTS. If feeding begins aggressively, or if feeds
15

contain too much protein or sodium, the child’s system may be overwhelmed and the child may die.
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To prevent death, feeding must be initiated as soon as possible with F-75, the “starter” formula used
until the child is stabilised. F-75 is specially made to meet the child’s needs without overwhelming the
body’s system at this early stage of treatment. F-75 contains 75kcal and 0.9g protein per 100ml. F-75 is
low in protein, low in sodium and high in carbohydrate, which is more easily handled by the child and
provides much-needed glucose.

When the child is stabilised (usually after 2-7 days), the “catch-up” formula F-100 is used to rebuild
wasted tissues. F-100 contains 100kcal and 2.9g protein per 100ml.

RECIPES FOR F-75 AND F-100

Alternatives Ingredients Amount of F-75 Amount of F-100

Dried skimmed milk (DSM) DSM 50g 160g

Sugar 200g 100g
Vegetable oil 60g 120g
Mineral mix 1 scoop 1 scoop
Water to make 2000ml 2000ml

Dried whole milk (DWM) DWM 70g 220g

Sugar 200g 100g
Vegetable oil 40g 60g
Mineral mix 1 scoop 1 scoop
Water to make 2000ml 2000ml

Fresh cow’s milk, or full Liquid milk 600ml 1760ml

cream (whole) long life milk. Sugar 200g 150g
Vegetable oil 40g 40g
Mineral mix 1 scoop 1 scoop
Water to make 2000ml 2000ml

COMPOSITION OF F-75 AND F-100 (AMOUNT PER 100ml)

CONSTITUENT F-75 F-100

Energy 75kcal 100kcal
Protein 0.9g 2.9g
Lactose 1.3g 4.2g
Potassium 3.6mmol/l 5.9mmol/l
Sodium 0.6mmol/l 1.9mmol/l
Magnesium 0.43mmol/l 0.73mmol/l
Zinc 2.0mg 2.3mg
Copper 0.25mg 0.25mg
Percentage of energy from:
-protein 5% 12%
- Fat 32% 53%
Osmolarity 333mOsmol/l 419mOsmol/l
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FEED THE CHILD WITH F-75

On the first day, feed the child a small amount of F-75 every 3 hours, (8 feeds in 24 hours, including
through the night) if the child is hypoglycaemic give ¼ of the 2 hourly amount every half-hour for the first
2 hours until the child’s blood glucose is at least 3 mmol/l.

Night feeds are extremely important, many children die from hypoglycaemia due to missed feeds at
night children must be awaken for these feeds.

Given the child’s starting weight and frequency of feeding, use the table to look up the amount needed
per feed. (check the F-75, reference card for the amounts require.)

The front of the F-75 reference card is for severely malnourished children with no oedema, or with mild
or moderate oedema. The reverse side is for children admitted with severe (+++) oedema.

On the front side of the card, the amounts per feed ensure that the child will be offered a total of
130ml/kg of F-75. This amount of F-75 will give the child 100kcal/kg/day and 1-1.5g protein/kg/day. This
amount is appropriate until the child is stabilised.

If the child has severe oedema (+++), his weight will not be a true weight: the child’s weight may be 30%
higher due to excess fluid. To compensate, the child with severe oedema should be given only
100ml/kg/day of F-75. Amounts per feed for the child with severe oedema are shown on the reverse side
of the F-75 Reference Card.

Tips for using the F-75 reference card:

- Be sure that you use the correct side of the card. Use the front side for most children, including those
with mild or moderate oedema. Use the reverse side only if the child is admitted with severe oedema
(+++).
- Note that the children’s weight in the F-75 Reference card are all in even digits (2.0kg, 2.2kg, 2.4kg,
etc) if the child’s weight is between (e.g. if the weight is 2.1kg or 2.3kg) use the amount of F-75
indicated for the next lower weight.
- While on F-75, keep using the starting weight to determine feeding amounts even if the child’s
weight changes. ( the weight is not expected to increase on F-75)
- If the child starts with oedema, continue using the F-75 table for severe oedema for the entire time
that the child is on F-75. Also, continue using the child’s starting weight to determine the amount of
F-75, even when the oedema (and weight) decreases. The volume per feed on the chart is already
based on the child’s estimated true weight.

RECORD THE CHILDS 24-HOUR FEEDING PLAN ON THE FEEDING CHART.

FEED THE CHILD F-75 ORALLY OR BY NG TUBE IF NECESSARY.
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ORAL FEEDING:

- It is best to feed the child with a cup (and spoon if needed). Encourage the child to finish the feed. It
may be necessary to feed a very weak child with a syringe or dropper. DO NOT USE FEEDING
BOTTLES.
- It takes skill to feed a very weak child, so nursing staff should do this task at first if possible.
- Mothers may help with feeding after the child becomes stronger and more willing to eat. NEVER
LEAVE THE CHILD ALONE TO FEED,
- Encourage breastfeeding on demand between formula feeds. Ensure that the child still gets the
required feeds of F-75 even if breastfeeding.

FEEDING CHILDREN WHO HAVE DIARRHOEA AND VOMITING:

- If the child has continuing watery diarrhoea after he has been rehydrated, offer ReSoMal between
feeds to replace losses from stools. Children under 2 years give 50-100ml after each loose stool.
Older children should be given 100-200 ml after each loose stool. The amount given in this range
should be based on the child’s willingness to drink and the amount of on-going losses in the stool.
- If the child vomits during or after a feed, estimate vomited amount and offer that amount of feed
again. If the child keeps vomiting, offer half the amount of feed twice as often (small frequent feeds
until vomiting stops!)

NASOGASTRIC (NG) FEEDING:

- It may be necessary to use a nasogastric (NG) tube if the child is very weak. Has mouth ulcers that
prevent drinking, or if the child cannot take enough F-75 by mouth.
- The minimum acceptable amount for the child to take is 80% of the amount offered. At each feed,
offer the F-75 orally first. Use and NG TUBE if the child does not take 80% of the feed ( i.e. leaves
more than 20%) for 2 or 3 more consecutive feeds.
- NG feeding should be done by experienced staff. The NG should be checked every time food is put
down check placement by injecting air with a syringe and listening for gurgling sounds in the
stomach. Change the tube if blocked. Do not push/plunge F-75 through the NG tube: let it drip in, or
use gentle pressure.
- Abdominal distension can occur with oral or NG feeding, but it is more likely with NG feeding. If the
child develops a hard distended abdomen with very little bowl sound. Give 2ml of a 50% solution of
magnesium sulphate IM.

REMOVE THE NG TUBE WHEN THE CHILD TAKES;

- 80% of the days amount orally or

- Two consecutive fully by mouth
Exception; if a child takes two consecutive feeds fully by mouth during the night, wait until the morning
to remove the NG tube, just in case it is needed again at night!
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RECORD INTAKE AND OUTPUT ON A 24-HR FOOD INTAKE CHART.

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FEED THE CHILD IN TRANSITION

- It may take up to 7 days, or even longer, for the child to stabilize on F-75
- When the child has stabilized, one can begin to offer F-100 , the higher calorie, higher protein “catch-
up” feed intended to rebuild wasted tissues
- Eventually the child will be offered F-100 freely
- However, it is extremely important to keep the transition to free feeding on F-100 GRADUIALLY and
monitor carefully.
- If transition is too rapid, heart failure may occur

Recognise readiness for transition:

Look for the following signs of readiness, usually after 2-7 days:
- RETURN OF APETITE (easily finishes 3hly feeds of F-75)
- REDUCED OEDEMA OR MINIMAL OEDEMA
The child may also smile at this stage.

Begin giving F-100 slowly and gradually:

 transition takes 3 days, during which F-100 should be given according to the following schedule:
 First 24hours (2days): give F-100 every 3 hours in the same amount as you gave F-75. DO NOT
INCREASE THIS AMOUNT FOR 2 DAYS
 Then on the 3rd day: increase each feed by 10ml as long as the child finishes feeds. If the child does
not finish the feed, offer the same amount at the next feed: then if feed finished, increase by 10ml.
continue increasing the amount until some food is left after most feeds (usually when amount
reaches about 30ml/kg per feed)
 If the child is breastfeeding , encourage the mother to breastfeed between feeds of F-100

Monitor the child carefully during transition:

 Every 3 hours, check the child’s respiratory and pulse rate.
 If F-100 is introduced carefully and gradually, problems are unlikely:
 However, increasing respiratory rate and pulse rate may signal heart failure (call doctor for help!)

On the 3rd day, when feeds should increase by 10ml, (as long as the child is taking all that is offered),
mark an arrow by starting amount per feed. E.g. 95↑

FEED FREELY WITH F-100

 Transition takes 3 days. After transition, the child is in the “rehabilitation” phase and can feed on F-
100 to an upper limit of 220kcal/kg/day (this is equal to 220ml/kg/day)
 Most children will consume at least 150 kcal/kg/day: any amount less than this means the child is not
being feed freely or is unwell.
 The F-100 reference card shows the 150-220 kcal/kg/day range of intake suitable for children of
different weights up to 10 kg.
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Encourage the child to eat freely at each feed

 During the rehabilitation phase, encourage the child to eat as much as he wants at each feed, within
the range shown on the F-100 reference card.
 Continue to feed every 4 hours within this range let the mothers sit with the child and actively
encourage eating.
 Never leave the child alone to feed

Record intake/output: determine if intake is acceptable:

 record each feed on the 24hr food intake chart

 to determine if daily intake is acceptable, compare the volume taken on the range given on the table
on the F-100 Reference Card
 if the child is not taking the minimum amount, there may be a problem such as an infection, or the
child may need more encouragement to eat.
 In general if the child is gaining weight rapidly, he is doing well
 If the child has diarrhoea but is still gaining weight, there is no need for concern, and no change is
needed in the diet.

ADJUST FEEDING PLAN AS NECESSARY

 During rehabilitation, the child is expected to gain weight rapidly, and the amount of F-100 given
should be increased as the child grows.
 The more energy that is packed in, the faster the child will grow
 To plan feeds for the next day: use the child’s current weight to determine the appropriate range of
F-100 each day
 Choose the starting amount within the age range. Base the starting amount on the amount of feed
taken the previous day. If the child finishes most feeds, offer the same amount as the day before
 Do not exceed the maximum range for the child’s current weight.

DAILY CARE
Handle the child gently:

- severely malnourished children should be held very gently especially in the beginning of their care
- the severely malnourished Childs body is fragile and bruises easily
- the child needs all his energy to recover, so he should stay calm and not become upset
- it is important to speak quietly and handle children as little as possible at first
- hold and touch children with loving care when feeding, bathing, weighing and caring for them
- through tone of touch and gentle manner and caring attitude, nurses will set a good example for the
mothers providing tender, loving, care
20

- THEY WILL ALSO WIN THE TRUST OF THE MOTHERS AND MAKE THEM STAY IN THE HOSPITAL WITH
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THEIR CHILDREN FOR THE NECESSARY LENGTH OF TIME

- It is critical for mothers to stay with their children in the hospital
- The number of other adults interacting with the child should be limited, and the most skilled staff
should perform the medical procedures, preferably out of earshot and sight of other children
- Nurses can set a hood example by:
-removing the child cloths gently
-bathing the child gently
-talking softly to the child when giving treatment
-holding the child close while feeding
-encouraging the mother who is providing care
-comforting a child after providing a painful procedure

As the child recovers, stimulation of the child should increase. Play, physical activities, and mental and
emotional stimulation become very important to the child’s complete recovery.

Care for skin and bathe the child:

- bathe children daily unless very sick
- if very sick, wait until child is recovering to bathe him/her
- if child does not have skin problems, or has mild/moderate dermatosis, use regular soap for
bathing
- if severe dermatosis (+++) bathe for 10-15min/day in 1% potassium permanganate solution ( to
make a 1% solution, dissolve a crystal in enough water so that the colour is slightly purple and
still transparent. ) sponge on affected areas while child is seating in basin. This dries the lesions,
help to prevent loss of serum and inhibit infections
- -if child has severe dermatosis and is too sick to be bathed, dab 1% potassium permanganate on
affected spots, and dress oozing areas with a gauze to keep them clean. -apply barrier cream to
raw areas. Useful ointments are zinc and castor oil ointment, petroleum jelly, or paraffin gauze
dressing. These help to relive pain and prevent infection.
- use a different tube of ointment for each child to avoid spreading infections.
- if diaper are becomes colonized with Candida, use nystatin or Ketoconazole ointment or cream
after bathing. Candidiasis is also treated with oral nystatin or oral Ketoconazole
- leave off diapers (nappies) so that the affected area can dry. Be sure to dry the child well after
bath and warp the child warmly.

Give folic acid:

Folic acid is a vitamin of the B complex that is important for treating and preventing anaemia and
repairing the damaged gut. Each child should be given 5mg daily.

Give a multivitamin:
If combined mineral/multivitamin mix (CMV) is used in preparing feeds, then the feeds will include
appropriate vitamins. Otherwise give vitamin drops daily (not including iron)
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Give Iron:
After two days on F-100, give iron daily:
- Even if the child is anaemic, he should not be given iron until he is recovering and has been two
days on F-100(i.e. after 2 days of transition).
- If given earlier, iron can have toxic effects and reduce resistance to infection
- Give 3mg/kg elemental Fe/kg/day in 2 divided doses
- Always give iron orally, never by injection. Preferably give iron between meals using liquid
preparation

Doses of iron syrup for a common formulation:

Weight of child Dose of iron syrup

Ferrous Fumarate 100 mg per 5ml
(20 mg elemental iron per ml)
3 up to 6kg 0.5 ml
6 up to 10kg 0.75 ml
10 up to 15kg 1 ml

Care for the eyes:

If the child has: Then:

Bitot’s spots only (no other eye signs) No eye drops needed

Pus or inflammation Give chlaramphenicol or tetracycline (1%) eye

drops
Corneal clouding or Give both:
Corneal ulceration -chloramphenicol or tetracycline (1%) eye
drops, 1 drop, 4 times daily and
-atropine (1%) eye drops, 1 drop, 3 times daily

Consult ophthalmologist-clinic 7, if there are pus, inflammation, corneal clouding and corneal
ulceration

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 Part 3- Nursing Care in AO7: Instructions for the nursing staff

MONITOR PULSE, RESPIRATIONS, AND TEMPERATURE, AND WATCH FOR DANGER SIGNS
- Measure pulse, count respirations and measure temperature every 4 hours, before
feeding
- This monitoring is very important because increase in pulse rate or respiratory rate can
signal a problem such as infection or heart failure from over hydration due to feeding or
rehydrating too fast.
- An increase or decrease in temperature to above or below normal can indicate infection

It is critical to monitor the child closely (every 4 hours) during initial treatment and during transition to
free feeding on F-100.

- AFTER THE CHILD IS STABLE AND FEEDING FREELY ON F-100, you may decrease monitoring of
pulse, respirations, and temperature to ONCE A DAY as long as the child is gaining weight.
- If there is NO WEIGHT GAIN, or if the child LOSES WEIGHT, resume monitoring every 4 hours.

RECOGNIZE DANGER SIGNS:

- If pulse increases by more than 25 or more beats per minute,
Confirm in 30minutes*
- If respiratory rate increases by 5 or more breaths per minute,
Confirm in 30 minutes*
*if on IV fluids, confirm in 10minutes and watch closely
If above increases in pulse AND respiratory rates are BOTH confirmed, they are a danger sign. Together
these increases suggest AN INFECTION OR HEART FAILURE FROM OVERHYDRATON DUE TO FEEDING
OR REHYDRATING TOO FAST

NURSE: Call a Doctor for help

Stop feeds and ReSoMal and slow fluids until a Doctor has checked the child.

If just the respiratory rate increases, determine if the child has fast breathing, which may indicate
pneumonia.

If the child is from 2 up to 12 months old – 50 breaths/min or more is fast

If the child is 12 more up to 5 years- 40 breaths/min or more is fast

If only the pulse increases, there is no cause for concern- may be due to crying or fear

If a child’s rectal temperature drops below 35.5 C or the axillary temperature drops below 35 C the child
is hypothermic and needs re-warming:
- Have the mother hold the child next to her skin or
- Use a heater or Lamp with caution
23

Be sure the room temperature is warm (25-30 C, if possible) and the child is covered.
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 Hypothermia may be a sign of infection. If the temperature drops suddenly CALL A DOCTOR.

Increase in temperature can also indicate infections. CALL A DOCTOR FOR HELP IF THERE IS A SUDDEN
INCREASE OR DECREASE IN TEMPERATURE.

In addition to watching for increasing pulse or respirations and changes in temperature, watch for
danger signs such as:
- Anorexia (loss of appetite) - Difficulty breathing
- Change in mental state (e.g. becomes - Difficulty feeding or waking (drowsy)
lethargic) - New oedema
- Jaundice - Large weight changes
- Cyanosis (tongue /lips turning blue from - Increased vomiting
lack of oxygen) - Petechiae (bruising)

ALERT A DOCTOR if any of these danger signs appear

PROVIDE CONTINUING CARE AT NIGHT:

MANY DEATHS in severely malnourished children OCCUR AT NIGHT because a feed is omitted or the
child becomes uncovered and cold
It is extremely important that enough number of staff are assigned to work at night, and that they are
properly trained.

Night staff must:

- Keep each child covered to prevent hypothermia
- Ensure that each child is fed according to schedule during the night. THIS WILL INVOLVE GENTLY
WAKING THE CHILD TO FEED
- Take 4-hourly measurements of pulse, respirations, and temperature
- Watch carefully for DANGER SIGNS AND CALL A DOCTOR, if necessary

MONITORING

MONITOR OVERAL WEIGHT GAIN ON THE WARD

Once a month, review records for the ward for a given week (for example the first week of the month)
and compile data on a WEIGTH GAIN TALLY SHEET for the ward.

To complete the tally sheet:

 Identify the children who were on F-100 for the entire week
 Calculate the average daily weight gain for each of these children: Add the daily weight gains
recorded on the child’s chart for seven days of the week being reviewed. Divide by 7.
 Determine if the child’s average daily weight gain was poor, moderate or good during that week.
 Record the child’s name in the appropriate column of the tally sheet
 When the process is complete on each child on the F-100, total the columns
24

 Determine what percentage of the children on F-100 had poor, moderate or good weight gain. To
do this:
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Divide total in each column by the total children in F-100. Express as a percentage.
Compare the results to tally sheets from similar weeks in other months
Use the Tally sheet as a basis for discussion and problem solving with staff .
Example weight gain tally sheet for the ward:

Week of 13/2/2014 Good weight gain: Moderate weight Poor weight gain:
≥10g/kg/day gain: 5 to 10g/kg/day <5g/kg/day
No. Of children on F- Mazuba Kalumbu Womba
100 for entire week Taonga Estelle Peter
12 Liseli Monde
Totals 4 6 2
% of children on F- 33% 50% 17%
100 in ward

If the weight gain of 10% or more of the children on F-100/ RUTF is poor, there is a problem that must
be investigated.

If there is a negative change as compared to previous month, there may also be a problem e.g. if the
percentage of children in the “ moderate” column increases and the percentage in the “excellent “
column decreases, investigate the reasons for this change.

State the problem specifically:

Describe the problem as completely and specifically as possible.
Determine if the children who are not gaining weight adequately have certain things in common. Eg:
 How long have they been on the ward?
 What are their ages?
 Are they located in a certain area of the ward?
 Are they cared for by certain staff?
 Are they receiving food or drinks that interfere with prescribed feeds?
You may think of other questions to ask to determine common factors. If there are no apparent current
factors than assume the problem is throughout the ward.

Stating the problem specifically will help to look for the cause(s) which can be addressed during a ward
meeting.

MONITOR HYGIENE:
 Hand washing  Dish washing
 Mothers’ cleanliness  Toys
 Bedding and laundry  Pests(cockroaches in the kitchen and
 General maintenance ward)
 Food storage
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SOLVE PROBLEMS ON THE WARD:
There are some problems that require individual solutions and should be handled privately, e.g. if you
find a particular staff member is doing a procedure incorrectly or dangerously, correct that person
privately

Some problems may be solved by working with staff members as a group to discuss causes and possible
solutions, e.g.
 A diarrhoea outbreak on the ward
 An increasing case fatality rate or
 Procedural problems involving all or many of the staff

WORK TOGETHER TOWARDS A SOLUTION

INVOLVING MOTHER IN CARE:

There are many ways to encourage mothers’ involvement in hospital care. Mothers must be taught to:
 Prepare food
 Feed children
 Bathe and change children and
 Play with children, supervise play sessions, and make toys

THE STAFF MUST BE FRIENDLY AND TREAT MOTHERS AS PARTNERS IN THE CARE OF THE CHILDREN.

A MOTHER SHOULD NEVER BE SCOLDED OR BLAMED FOR HER CHILD’S PROBLEMS OR MADE TO FEEL
UNWELCOME.

TEACHING, COUNSELLING AND BEFRIENDING THE MOTHER IS ESSENTIAL TO LONG-TERM TREATMENT

OF THE CHILD.

A SHOULD HAVE A PLACE TO SIT ON THE WARD. THEY ALSO NEED WASHING FACILITIES AND A TOILET,
AND A WAY TO OBTAIN FOOD FOR THEMSELVES

SOME MOTHERS MAY NEED MEDICAL ATTENTION THEMSELVES IF THEY ARE SICK OR ANAEMIC

THE STAFF SHOULD ALSO MAKE OTHER FAMILY MEMBERS FEEL WELCOME

ALL THE FAMILY MEMBERS ARE IMPORTANT TO THE HEALTH AND WELL BEING OF THE CHILD

WHEN POSSIBLE, FATHERS SHOULD BE INVOLVED IN DISCUSSIONS OF THE CHILD’S TREATMENT AND
HOW IT SHOULD BE CONTINUED AT HOME
26

FATHERS MUST BE KEPT INFORMED AND ENCOURAGED TO SUPPORT MOTHERS’ EFFORTS IN CARE OF
THE CHILDREN.
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