How will you treat hypothermia in a 3-year-old child with severe acute malnutrition (SAM)? How will you prevent hypothermia in an SAM child?

Treatment of Hypothermia in a 3-year-old Child with Severe Acute Malnutrition (SAM)

The World Health Organization (WHO) provides comprehensive guidelines for managing hypothermia in SAM children, emphasizing a multi-pronged approach that includes re-warming, nutritional support, and concurrent treatment of underlying conditions.

1. Diagnosis and Initial Assessment:

• Temperature Measurement: If the axillary temperature is < 35°C (< 95°F) or does not register on a standard thermometer, hypothermia is assumed. A low-reading thermometer can confirm rectal temperature < 35.5°C (< 95.9°F).
• Associated Conditions: Hypothermia in SAM children often indicates coexisting hypoglycemia or serious infection, which must be immediately investigated and treated.

2. Active Re-warming:

This is a critical first step to prevent further heat loss and raise the body temperature.

• Skin-to-Skin Contact (Kangaroo Mother Care): The child should be placed on the mother's bare chest or abdomen and covered with a warmed blanket and/or warm clothing. This method is highly effective and promotes bonding.
• Warm Environment: The child should be clothed, especially the head, and covered with a warmed blanket. They should be placed in a warm, draught-free part of the ward (ideally 25-30°C) near a heater or an incandescent lamp (not pointing directly at the child).
• Avoid Exposure: Minimize exposure to cold during examinations or after bathing.

3. Nutritional Support and Hydration:

Prompt feeding is vital to provide energy for thermogenesis.

• Immediate Feeding: Begin feeding immediately, or rehydrate first if dehydrated. Administer F-75 therapeutic milk (or sugar solution if F-75 is unavailable) every 2 hours, day and night, unless there is abdominal distension.
• Frequent Feeds: Continue feeds every 2-3 hours to prevent hypoglycemia, which can exacerbate hypothermia.
• Rehydration (if needed): If dehydrated, rehydrate slowly using ReSoMal (Rehydration Solution for Malnutrition) orally or via nasogastric tube. IV fluids should be avoided unless the child is in shock, as rapid rehydration can be dangerous in SAM children.

4. Treatment of Coexisting Conditions:

• Hypoglycemia: All SAM children with hypothermia should be treated for hypoglycemia. If conscious and blood sugar is below 3 mmol/L, give 50 ml of 10% glucose solution orally or via nasogastric tube. Repeat if blood sugar remains low after 30 minutes. If unconscious, IV 10% glucose at 5 ml/kg is indicated.
• Infection: Assume all severely malnourished children have an infection, as typical signs like fever may be absent. Administer broad-spectrum antibiotics routinely. For severely ill children (apathetic, lethargic, with complications like hypoglycemia or hypothermia), IV/IM Ceftriaxone 100mg/kg/day for 7 days is often recommended. Otherwise, Ampicillin and Gentamicin may be used.
• Electrolyte Imbalance: Correct electrolyte imbalances by providing extra potassium and magnesium daily. Limit sodium intake.

5. Monitoring:

• Temperature: Monitor rectal temperature every 2 hours until it rises above 36.5°C, then every 4 hours. If a heater is used, monitor every 30 minutes.
• Blood Glucose: Check blood glucose levels whenever hypothermia is found and monitor every 3 hours until stable.
• General Condition: Monitor vital signs and overall clinical status regularly.

Prevention of Hypothermia in an SAM Child

Preventing hypothermia is as crucial as treating it, especially in SAM children who have compromised thermoregulation.

1. Maintaining a Warm Environment:

• Adequate Clothing: Ensure the child is always appropriately clothed, especially the head, using bonnets or caps to reduce heat loss.
• Warm Bedding: Provide sufficient warm blankets. Mothers sleeping with their children (Kangaroo Mother Care) is an excellent preventive measure, especially for infants.
• Draught-Free Spaces: Keep the child in a warm, draught-free area, maintaining an ambient temperature of 25-30°C.
• Minimize Exposure: Avoid exposing the child to cold during bathing, diaper changes, or medical examinations. Perform procedures quickly and re-cover the child promptly.

2. Frequent and Adequate Feeding:

• Regular Feeds: Feed the child every 2-3 hours, day and night, even if the child seems drowsy or uninterested. This ensures a continuous supply of energy to maintain body temperature and prevent hypoglycemia.
• Nutrient-Dense Foods: Provide appropriate therapeutic feeds (e.g., F-75, F-100, or Ready-to-Use Therapeutic Food - RUTF in the rehabilitation phase) that are rich in energy and protein.
• Encourage Breastfeeding: For breastfed infants, encourage continued and frequent breastfeeding.

3. Early Detection and Prompt Treatment of Infections:

• Vigilance for Infection: Malnourished children may not show typical signs of infection. Any change in behavior, lethargy, or refusal to feed should raise suspicion.
• Hygiene: Strict handwashing before preparing feeds and after dealing with any child helps prevent cross-infection.
• Vaccination: Ensure children are up-to-date with their vaccinations, including measles, which can weaken immunity.

4. Education and Parental Involvement:

• Caregiver Training: Educate mothers and caregivers on the importance of keeping the child warm, frequent feeding, and recognizing early signs of hypothermia and illness.
• Monitoring: Teach mothers how to take the child's temperature and encourage them to watch for any deterioration.

5. Community-Based Management of Acute Malnutrition (CMAM) Programs:

These programs play a vital role in preventing severe complications like hypothermia by providing early identification, referral, and nutritional support at the community level. They include:

• Community Outreach: Screening children for SAM using Mid-Upper Arm Circumference (MUAC) tapes.
• Outpatient Therapeutic Programs (OTPs): For uncomplicated SAM, providing RUTF and regular medical check-ups.
• Stabilization Centers (SCs): For complicated SAM (including hypothermia), providing inpatient care and close monitoring.

By integrating these treatment and preventive measures, healthcare providers can significantly reduce morbidity and mortality associated with hypothermia in severely malnourished children.