Effective Management

Most of the severely malnourished children who arrive in the facility have diarrhoea which sometimes persists even though they are being fed. What are the causes and how can we overcome this problem?

There are 4 main causes:-

  • Giving large feeds, or the wrong type of feed: Malnutrition damages the gut mucosa, reduces enzyme production, and flattens the villi, so the gut has less capacity to digest and absorb and is easily overloaded, causing diarrhoea
  • Micronutrient deficiencies: Adequate amounts of nutrients are needed to repair the damaged gut. If deficiencies are not corrected, diarrhoea may persist. Zinc, folic acid, and Vitamin A are especially important in restoring gut function
  • Small bowel overgrowth: Bacteria may colonise the upper gut in severe malnutrition and impair absorption, and this can lead to persistent diarrhoea. Potassium deficiency contributes to bacterial colonisation by slowing gut motility
  • Re-infection: Diarrhoeal pathogens spread easily and malnourished children have poor immunity so easily catch new infections.


  • Feed small amounts: feed frequently. Use a feed chart to calculate the correct amount
  • Give F75 initially: it has low lactose
  • Correct deficiencies: zinc, folic acid and other micronutrients
  • Treat small bowel overgrowth with metronidazole
  • practise good hygiene, including hand washing. Boil water for making feeds and rehydration fluid

What is osmotic diarrhoea and what are the causes?

Osmotic diarrhoea is a form of watery diarrhoea. It is caused by disordered water and electrolyte transport in the small intestine as a result of osmotic imbalance between the gut and the extracellular fluid. For example, reduced production of enzymes in a malnourished child may lead to slow absorption of sugars (e.g. sucrose, lactose) and, if present in sufficient quantity, these will exert a high osmotic load in the gut.

To maintain osmotic balance, fluid passes from the body into the gut. This causes watery stools. (Note: osmotic diarrhoea is not common in malnutrition if children are given small frequent feeds, and if the sugar content is not too high).

Can we give a diuretic to get rid of oedema in SAM children?

No. This would be very harmful. It would increase the loss of potassium and make electrolyte imbalance worse.

Some of the SAM children admitted to the facility improve after about 4 days, but then deteriorate around day 6 or 7. Is this because of an electrolyte imbalance, hormonal influences or something else?

This is unusual if the WHO guidelines are followed fully. Making the transition to F100 too early or too fast may be a cause, or acquiring a new infection on the ward.

How can we combine feeding and rehydrating in SAM children with dehydration?

2-hourly feeding is best for dehydrated children. Give ReSoMal every 30 min for the first 2 hours. Then for up to10 hours give ReSoMal and F75 in alternate hours. So:-

  • At 0 min, 30min, 60min, 90min give ReSoMal 5ml/kg
  • At 2h, give ReSoMal 5-10ml/kg
  • At 3h give F75
  • At 4h, give ReSoMal if still needed
  • At 5h, 7h, 9h etc give F75
  • At 6h, 8h and 10h give ReSoMal if still needed and then stop

(NB look for signs of overhydration each time before
administering fluid)

Are there instances where children do not respond to treatment? If yes, is there guidance on what should be done in such instances?

Yes. It may be impossible to rescue some extremely ill children even with the best care, as their organs and systems may be irreparably damaged.

Ideally one should try to intervene earlier, by identifying children before they become severely malnourished or seriously ill. At hospital, give them priority so they are not kept waiting as any delay can worsen their condition.

What can I do to ensure the standard management protocol is followed?

You can:-

  • Train all staff; explain what to do and why
  • Provide clear instructions and job aids
  • Supervise staff; induct new staff
  • Provide job descriptions which list assigned tasks
  • Observe ward procedures
  • Review children’s feeding charts and case notes
  • Monitor the mortality rate, and rates of weight gain in the rehabilitation phase
  • Hold regular staff meetings at which problems, causes, and solutions are discussed

Can a mixed diet of F100 and family food be given during rehabilitation of severely malnourished children? If yes, what are the implications?

Yes. Family foods can be given in the catch-up phase provided they are modified to be equivalent to F100. You have to make sure the foods offered are rich in energy and protein. For example, enrich thick porridge with pounded groundnuts, sesame or other oilseeds, or add milk, sugar and margarine. (See Ashworth & Burgess 2003 for more recipes).

Why are prophylactic antibiotics prescribed in the guidelines?

This is a wrong perception. The antibiotics are being prescribed because infections are often silent in severe malnutrition. So the antibiotics are a treatment, not a prophylaxis. It is important to treat severely malnourished children with antibiotics straightaway, even if they have no clinical signs, so that hidden infections can be controlled.

What causes refeeding deaths in children with SAM and how can it be avoided?

Refeeding deaths have been attributed to sudden overactivity of the sodium pump when children are given relatively large amounts of F100 or other high-energy diet early in recovery. The result is a sudden efflux of sodium from cells leading to circulatory overload, the first signs of which are increased pulse and respiratory rates, and may be mistaken for pneumonia. To avoid refeeding deaths make sure there is a gradual transition to the high-energy diet.

Further Reading

Ashworth A, Jackson A, Uauy R. Focusing on malnutrition management to improve child survival in India. Indian Pediatr. 2007 Jun;44(6):413-6. Link

Patrick J. Death during recovery from severe malnutrition and its possible relationship to sodium pump activity in the leucocyte. Br Med J. 1977 Apr. Link

Chevalier P, Sevilla R, Zalles L, Sejas E, Belmonte G, Parent G, Jambon B. Immuno-nutritional recovery of children with severe malnutrition. Sante. 1996 Jul-Aug;6(4):201-8 Link

World Health Organization. Management of the Child with a Serious Infection or Severe Malnutrition. Geneva: WHO, 2000. Link

Maitland K, Berkley JA, Shebbe M, Peshu N, English M, Newton CR. Children with severe malnutrition: can those at highest risk of death be identified with the WHO protocol? PLoS Med 2006;3:e500[Medline] Link

Community-based Therapeutic Care (CTC). A Field Manual. First Edition, 2006. Valid International

Roediger WE. Metabolic basis of starvation diarrhoea: implications for treatment. Lancet. 1986 May 10;1(8489):1082-4. Link

Schofield C, Ashworth A. Severe malnutrition in children: high case-fatality rates can be reduced. Afr Health. 1997 Sep;19(6):17-8.