Infants presenting with severe malnutrition (especially kwashiorkor) are very sick and a number will die within a week of starting treatment. They must all be hospitalised immediately. This phase of treatment usually lasts about a week:
- Correct and avoid hypoglycaemia, hypothermia or dehydration. Check the blood glucose 6 hourly for the first few days and whenever the child’s temperature falls below 35.5 °C. A feed of 50 ml of 10% glucose orally should correct hypoglycaemia. Correct any dehydration slowly with oral fluids. Avoid intravenous fluids if possible. Do not use diuretics to reduce the oedema.
- Give broad spectrum antibiotics (ampicillin and gentamicin if clinically septic or co-trimoxazole if there is no obvious site of infection) to all children for a week. Assume that all children with severe malnutrition have a bacterial infection.
- Start with oral or nasogastric feeds every 3 hours, both day and night, as soon as possible. Usually a starter formula or, if diarrhoea is present, a lactose-free formula 100 ml/kg/24 hours is used for the first week. High volume feeds may cause heart failure.
- Give oral potassium chloride 0.5 g/kg/day (4 to 6 mmol/kg/day) as these children are severely potassium depleted, especially children with kwashiorkor. Also give extra magnesium, 0.4 to 0.6 mmol/kg/day, as well as zinc 2 mg/kg/day, folic acid 5 mg per day, multivitamin syrup 10 ml per day and vitamin A 50 000 to 100 000 units on day 1.
- Do not give oral iron yet. Iron can be very dangerous as these children do not have enough protein to carry iron safely in the blood stream.
Give frequent, small lactose-free feeds for the first week.