Patients with severe malnutrition are enrolled into an inpatient setting for optimal care .The treatment and management of Protein Energy Malnutrition(PEM) depends on the severity of cases. Complicated cases will require resuscitation while less complicated cases won’t. At this point, 3 critical areas need immediate address including the issue on electrolyte imbalances, infections and anaemia.
Manage Electrolyte Imbalances
To manage electrolyte imbalances , diarrheoa that may be present has to be addressed .This is because it causes the loss of nutrients and fluids. Also, since the child may likely have reduced cardiac function, reduced ability for kidney function, liver damage, renal impairment and changes in hormonal patterns, great caution has to be taken when introducing any form of treatment as rapid changes can exacerbate the already impoverished condition.
It is likely that severely malnourished children are lacking in potassium and contain abnormally high sodium levels thus are recommended an oral rehydrated solution (ReSoMal) within the first 6 to 10 hours. The retention of potassium serum levels is key to manage effective cardiac output. Along with this, sodium and water levels need to be managed through intravenous therapy.
Treating Infections
Infections also need to be treated specifically sepsis, gastroenteritis and pneumonia that are common among PEM patients.Bacterial infections are treated by routine antibiotic administration while vitamin deficiencies, particular Vitamin A can be administered intra-muscularly in required dosages-usually 30 mg each day for 3 days. The haemoglobin levels should not drop below 5 g/dl, since then a blood transfusion may be required . The child should be recommended a diet rich in iron sources such as spinach, kales, legumes, egg yolks ,liver etc and vitamin C food sources like citrus fruits to facilitate the absorption of the iron- rich foods.
Common Complications To Be Managed
Complications such as hypothermia should be treated by ensuring that child is covered with warm clothing. Thermal shock should be managed intravenously or by blood transfusion or through the administration of glucose saline. Hypoglycemic patients should receive glucose mixed with water orally, though if unconscious, a dextrose solution is dispensed followed by the infusion of glucose .
Introduction of Oral Feeding
Once the child can feed orally, intravenous therapy should be discontinued. Feeding should be introduced gradually and the intake of macro-nutrients should be as per patient’s tolerance. Small frequent feeding is preferable with spacing of 1-2 hours between feeding especially within the first 2 days of reintroducing feeding, then the frequency of feedings can be reduced as per tolerance levels. Low-protein milk formulas are introduced with the aim of intake of 100 kcal/kg/day, prior to integrating a normal diet , which is also introduced gradually over the subsequent few weeks.
Mineral and vitamin supplementation
Mineral and vitamin supplementation should accompany dietary management and provided several times in a day. A daily dosage of 100 g folic acid and 60g iron is usually provided to treat anaemia.
When the child begins to gain weight and length, protein and energy needs can be increased. The proper initiation of feeding should commence by introducing liquid formulas as you gradually change their consistency. Sufficient amounts of macro-nutrients should be included with- energy : 170 – 200 kcal per kg of body weight and protein : 3 – 4 g/kg of body weight. Milk can be supplemented with sugar and oil to enhance energy content. Patients with lactose intolerance should be fed on milk substitutes. Both proteins and calories are needed in large quantities.
Failure to respond to treatment
In certain cases a child may fail to respond to treatment. Failure to respond to treatment may be as a result of infections, malabsorption, reduced feeding or psychological factors , all of which should be addressed to proceed with treatment.
To prevent relapses:
The caregivers should be counselled on affordable foods they can include after the treatment, and how they can combine them to reduce risk of deficiencies and relapses. Moreover, a follow-up arrangement is scheduled to monitor and evaluate patient’s progress.