Management of SAM patient with Malabsorption

Hi.  Does the child breastfeed?  Can mother's milk or human donor milk be provided?

Hello,

The management of this child requires further investigation.

Hello

We have managed to save children with the same symptoms by placing a nasogastric feeding tube to pass RESOMAL and F75 alternately, respecting the weight dose until the diarrhea stops. Include flagyl in its treatment at a low dose (max 10g/kg) for 3 days.

Flagyl is max 10 mg/kg to my knoweldge. 

Hello,an NG tube may help and include flagyl in low doses for at least three days.incase the child doesn't respond further investigation is necessary.

I think it is important to split meals including resomal, while looking for other causes, also to stop any rehydration when the estimated or measured weight deficit has been reached

This sounds like a challenging problem. 

First I would say the chlid very likely has a serious complicating diagnosis, a medical illness that is causing the child to be very wasted.  This could be HIV infection, cancer, tuberculosis or another condition dependent on your geography.  In such cases the child will never get better unless this problem is addressed,

The vomiting and diarrhea are not in response to what is being fed, but rather the underlying illness. Keep in mind that some absorption of nutrients and electrolytes is occurring with the vomiting/ diarrhea.  For example vomiting 5 min after oral intake loses just 50% of the fed contents. So 50% remains in the child's gut! I would continue to feed the child while diarrhea and vomiting occur, do not alter oral intake on the basis of whether child is vomiting.  In the cases of the most profuse diarrhea, cholera, success is achieved by continued feeding. 

Please give the child some diluted milk.  F-75 is fine.  Do not fear lactose, the fine study of Berkley with lactose free F-75 showed in the most fragile guts, lactose does not make the situation worse.

What is the child's actual weigth and length?

This is not likely to be a problem of congenital malaborption.

While antibiotics may be warranted, do not withhold food to give antibiotics.

given the child's length, it seems the child was healthy and grew well the first 1.5-2 yrs of life. An estimate of the child's maximum weight is about 10kg, probably long before he/ she came under your care. But now presents very wasted, with a severe pulmonary infection.  And has lost 3-4 kg of weight. Energy/ nutrient requirements are of course large with this huge inflammatory process. You are trying to diagnose the cause of the pneumonia. You can start TB treatment as this is is a difficult definitive diagnosis to make. A less common fungal infection might be a cause, aspergillis, cryptococcus, or pneumocystis? A loculated bactreial infection with empyema? Empyemas do not improve unless drained.  A manufestation of advanced stage of cancer?  These problems are diffiuclt, perhaps impossible, to treat in a resource limited setting.  Where are you located?  Is the child a boy or a girl?  Any family exposures?

At this time you can place an NG tube, and feed the child dilute milk all the time in an effort to preserve the child's life. The primary problem is very unlikely to be malabsorption.

Hello everyone

Thank you for these fruitful exchanges which show another facet of the management of wasting/acute malnutrition. I would like to ask Mark a question: what do you think of a little girl of 25 months, 10kg and 80cm? According to her mother, the little one was born with a weight of 2400g, she was breastfed exclusively until 6 months, after which she had no appetite. But when she was weaned at 24 months, she began to eat well.

I agree with what Prof. Manary has written. It seems that there are three important things to focus on.

The first is infection -- if the pneumonia is not improving with typical antibacterial coverage (ceftriaxone +/- cloxacillin might be a reasonable choice to start with), then you must think strongly about TB. Make sure to check HIV status also. Remember that GeneXpert has a relatively low sensitivity in young malnourished children so you should have a low threshold for treatment even if the test is negative.

In terms of dehydration, if there is a concern for diarrhea losses, then be sure to continue to provide ReSoMal (or ORS if you do not have it available) to account for stool losses -- typically 50-100 mL per loose stool is needed to help compensate for fluid losses. Use an NG tube if you need to.

In terms of nutrition, it does seem like F75 will still be necessary. You can use smaller and more frequent dosing if needed due to vomiting and diarrhea -- for example, take the total daily dose and divide by 12 and provide this amount every 2 hours. Or even divide by 24 and provide the amount every 1 hour.

If the child is drinking by mouth, one trick I have used is to mix the F75 with ReSoMal to dilute it even further and make it "thinner" for the child to drink with less difficulty. (Of course be sure the child still gets enough F75 over the whole day.)

If you are in a place with access to an infusion pump, you could in an extreme case have the F75 run as a continuous very slow NG infusion over 24 hours.

On the whole, as the gut mucosa recovers and the brush border enzymes (disaccharidases, etc.) recover, the diarrhea will start to slow down. If the diarrhea has been persistent for some time, consider other GI infections -- protozoa or opportunistics due to HIV/malnutrition.