Critical appraisal of the management of severe malnutrition: 3. Complications

Abstract

The high case-fatality of severe malnutrition is due to infections, dehydration, electrolyte disturbances and heart failure. We focus on the evidence about managing these complications of severe malnutrition. Signs of circulatory collapse in severely malnourished children should be treated with intravenous or bone marrow infusion of Ringer's lactate with additional dextrose and potassium at a rate 20-40 mL/kg fast with close monitoring of vital signs. Recommendations for slow or restricted fluids in the face of shock are unsafe, and hypotonic or maintenance solutions must be avoided to prevent hyponatraemia. However, the evidence that severely malnourished children do not tolerate excessive fluid administration is good, so caution must be exercised with regards to fluids in the initial phase of treatment. There is also good evidence that wide spectrum antibiotics need to be given empirically for severe malnutrition to prevent the otherwise unavoidable early mortality. There is a need for improved protocols for tuberculosis diagnosis, HIV management and treatment of infants under 6 months with severe malnutrition. The contribution of environmental enteropathy to poor growth and nutrition during the weaning period means that there should be more priority on improving environmental health, particularly better hygiene and less overcrowding. A T-cell mediated enteropathy contributes to growth failure and malnutrition, and it is related to environmental contamination of enteric organisms in the weaning period rather than allergic responses.

Treatment Outcomes and Associated Risk Factors of Severely Malnourished under Five Children Admitted to Therapeutic Feeding Centers of Mekelle City, Northern Ethiopia

“…Similar findings were reported from Kenya where diarrhea was a common complication (49%) resulting in higher mortality in children hospitalized with severe acute malnutrition [22] and children with severe malnutrition are more prone to infections than others due to the immunosuppressive effect of malnutrition and the loss of the protective mucosal barrier in the gastrointestinal tract [23]. Moreover, studies have shown that severely malnourished children are more prone to gut barrier dysfunction [24], Escherichia coli bacteraemia [25] and higher mortality from invasive bacterial infection [26].…”

The effects of malnutrition on cardiac function in African children

“…It is estimated that malnutrition affects over 150 million children worldwide and is associated with 45% of all child deaths 1. Malnutrition-related mortality is primarily associated with infection or dehydration, but often there is no other identifiable cause of death 2 3. Some researchers have proposed that cardiac dysfunction may be associated with these unexplained deaths either directly or through decompensation after aggressive fluid resuscitation 4–6.…”

Symposium 5: Joint BAPEN and Nutrition Society Symposium on ‘Feeding size 0: the science of starvation’ Severe malnutrition: therapeutic challenges and treatment of hypovolaemic shock

“…It is argued that with strict adherence to these guidelines the mortality should be < 5% (13,14) . Whilst high case-fatality rates are often attributed to faulty case management, the evidence for this assertion is poor and other workers have suggested that outcome is largely dependent on other antecedent factors, including the frequency of additional life-threatening complications (4,(15)(16)(17)(18) . The current guidelines have largely been based on expert or consensus opinion.…”