DEWORMING IN SAM CASES

It is recommended to give deworming tablet in second visit due to following reason:
- Side effect of Albendazole is nausea/vomiting. Generally SAM children have poor appetite and RUTF is a new food for them. So, albendazole may contribute to less intake or refusal of RUTF by SAM children if we give in first visit. So, it is suggested to give in second visit and by that time child will be familiar with RUTF and may have improved appetite.
- SAM children may have GI tract infection and it will obstruct proper absorption of deworming tablet. Broad spectrum antibiotic Amoxicillin is given at the time of admission and it will recover if there is any infection. So, it is suggested to give deworming tablet on second visit for its better absorption

Dear Faiza,

The approved Kenyan IMAM guidelines state that deworming medication should be given on the second visit, Amoxicillin is what is given during the first visit.

Albendazole is a very safe and well tolerated drug with very few side effects and no major contraindications. It is often given safely with other drugs. The recommended dose is 400 mg for any person 2 years or older. Heavy infections with whipworm (Trichuris) may benefit from 3 days treatment. Albendzole is not recommended to be given to children < 12 months; the use of albendazole for children aged 12-23 months is unclear, but it has been given. The tablets are usually flavoured, so can be chewed. Young children should ideally be given a syrup or the tablet should be crushed and mixed with water. Young children should not be given whole tablets as they can cause choking.

The drug is poorly absorbed from the gut which is important because it needs to act on worms living in the gut, such as Ascaris and hookworms in the small intestine and whipworms (Trichuris) lower down the gut in the large intestine. Albendazole and mebendazole both affect the metabolism of worms so that they die; other deworming drugs such as pyrantel paralyse worms so that they are expelled from the gut by normal peristalsis.

As large numbers of worms can cause malabsorption, blood loss (in the case of hookworms and Trichuris) and loss of appetite, treating them may lead to better absorption of nutrients and an improved appetite.

If a child is suspected of having a large number of Ascaris, perhaps because many eggs have been seen by examining a faecal sample under a miscoscope, the child should be monitored after treatment for 48h. Very rarely Ascaris can get tangled and cause intestinal obstruction.

I am not aware of international guidelines that say that a malnourished child should not be given albendazole at the first visit. I doubt that there have been clinical trials of the effect of giving albendazole at the first or second visit, but national guidelines should be followed or clinical judgement applied, especially if intestinal worms are known to be common.

As per Indian Guideline which is based on WHO Guideline for SAM management, it should be given to children before discharge from health facility. But here we are not using RUTF and other therapeutic feeding is given to children i.e. F - 75 in initial phase and then F - 100 in catch up phase.

Many thanks to Dr Andrew Hall for the detailed explanation. Perusal of Guidelines of both India and Bangladesh for management of SAM ( currently restricted to Facility Based Management only with F75 and F100) both mention deworming with Albendazole/Mebendazole only after stabilisation of the child i.e. 2nd week of treatment ( Bangladesh guideline) or at discharge in the Indian guideline.

In this situation a follow up question to Dr Hall - in the event of a child who has received Deworming routinely as part of a Biannual deworming programme should the child be dewormed again? Recently there has been some panic created in India after deworming in a mass campaign caused children to fall seriously ill.

Any guidance on this will be much appreciated

The WHO recommend that all children older than 2 years are treated twice a year when the prevalence of infections with intestinal worms is >50% and once a year when it is >20%. Although all children are given treatment during a mass treatment campaign, only infected children can be 'dewormed'. This means that unifected children are also treated, but the drugs used are considered to be so safe when used as a single dose, that treating unifected children is not harmful. The drugs are also very inexpensive, much less than the cost of any diagnostic test, another reason for giving mass treatment.

However when very large numbers of children are treated on the same day during a campaign then there is a high probability that some treated children will become sick by chance, and the two may become associated. For example if 1 in 5000 children get diarrhoea a day then if 100,000 children are treated with an anthelmintic on a given day, 20 of them will develop diarrhoea by chance alone. I made up those numbers to illustrate the point. If there are any side effects they may be as a result of the death of worms in the gut and do not last long. Nevertheless any child who is currently sick should not be treated and any child who is unwell after treatment should be monitored, especially in case there is a more serious underlying condition.

There is probably no harm in treating a child more than twice a year especially if the prevalence of worms is high (it can reach >90%) as the rate of reinfection can be fast, especially in crowded environments with very poor sanitation. There is no protective immunity to worms and children can become reinfected immediately after being treated. The aim of repeated mass treatment is to keep the worm burden, the number of worms in the gut, as small as possible. This also contributes to reducing transmission as there are fewer worms to deposit eggs into the gut and pass out in faeces, but making sure that children use a sanitary latrine is also important if the cycle of transmission is to be broken.