Preventing and treating hypogylcaemia in severely malnourished children
Biological, behavioural and contextual rationale
Hypoglycaemia, also known as low blood sugar, is defined by WHO as a blood glucose or blood sugar concentration of less than three millimoles per litre (mmol/l) or less than 54 milligrams per decilitre (mg/dl) in children with severe malnutrition1.
Hypoglycaemia is a common complication in malnourished children and can lead to brain damage – since glucose is the main fuel for the brain – and ultimately death. Treating or, ideally, preventing hypoglycaemia is vital during the initial stabilization phase of the treatment of severe malnutrition1–7.
The underlying causes for the development of hypoglycaemia in children with severe malnutrition are many. First, the quantity of stored glucose in the body is reduced in a malnourished child because of muscle wasting. Second, mechanisms for re-establishing glucose equilibrium by converting protein and fat reserves into glucose are impaired. Third, the immune response to infections, which are common in malnourished children, uses up glucose. Fourth, glucose absorption is impaired. And fifth, a long journey to a hospital and the process of admission to the hospital may result in the child not being fed for several hours 1,4,8,9.
WHO has developed guidelines for children with severe malnutrition that include the prevention of hypoglycaemia. These guidelines recommend that severely malnourished children should be prioritized for admission to a hospital ward, that they should be given formula diet feeding (F-75) immediately upon admission, and that they should be fed at least every two to three hours day and night6, 12. The F-75 formula diet provides severely malnourished children with 75 kilocalories (kcal) or 315 kilojoules (kJ) per 100 ml during the initial stabilization phase of treatment. It consists of dried skimmed milk, sugar, cereal flour, oil, mineral mix and vitamin mix, and thus is low in protein, fat and sodium, and high in carbohydrates1.
The signs of hypoglycaemia in children with severe malnutrition include a body temperature of less than 36.5 °C, lethargy, limpness and loss of consciousness. Since hypoglycaemia can lead to death during the first two days of treatment, treatment should be started immediately if hypoglycaemia is suspected, even if blood glucose levels cannot be tested1.
If the hypoglycaemic child is conscious and is able to drink, then he/she should be given 50 ml of 10% glucose or 10% sucrose (one rounded teaspoon of sugar in 3.5 tablespoons water). Then he/she should be provided, orally, with an F-75 diet every 30 minutes for two hours1.
However, if the child is unconscious, cannot be aroused or is convulsing, then he/she must receive intravenously 5 ml/kg of body weight of sterile 10% glucose, followed by 50 ml of 10% glucose or sucrose by nasogastric tube. If intravenous glucose cannot be given immediately, then the nasogastric dose should be given first. When the child regains consciousness, a F-75 diet should be started and fed frequently to prevent recurrence1.
In both cases, the patient should receive broad-spectrum antimicrobials to treat serious systemic infection, which is an underlying cause of hypoglycaemia1,9.
Providing the severely malnourished child with unspecialized diets that are high in energy, protein, and sodium in the first days of treatment will exert stress on vital organs and is thus life threatening10. For this reason, the guidelines recommend small and frequent carbohydrate-based feedings that can gradually release glucose into the blood stream without resulting in metabolic imbalances11,12.
Individualized care and good practices, including the prevention or treatment of hypoglycaemia, are effective at reducing the mortality rate of in-patients4,9,14,13.
However, shortfalls, such as insufficient monitoring of the feedings by health professionals15, neglect of night feedings5, inadequacy of the meals provided5,10,15, unfamiliarity with best practices and guidelines for the treatment of severe malnutrition16,5 continue to compromise care. Further training of health-care providers should be considered.
1 Management of severe malnutrition: a manual for physicians and other health workers. Geneva, World Health Organization, 1999.
2 Achoki R, Opiyo N, English M. Mini-review: management of hypoglycaemia in children aged 0–59 months. Journal of Tropical Pediatrics, 2010, 56(4):227–234.
3 Zijlmansa WC et al. Glucose metabolism in children: influence of age, fasting, and infectious diseases. Metabolism Clinical and Experimental, 2009, 58:1356–1365.
4 Ashworth A. Treatment of severe malnutrition. Journal of Pediatric Gastroenterology and Nutrition, 2001, 32:516–518.
5 Puoane T et al. Evaluating the clinical management of severely malnourished children – a study of two rural district hospitals. South African Medical Journal, 2001, 91:137–141.
6 Maitland K et al. Children with severe malnutrition: can those at highest risk of death be identified with the WHO protocol? PLoS Medicine, 2006, 3(12):2431–2439.
7 Klatt EC, Beatie C, Noguchi TT. Evaluation of death from hypoglycemia. American Journal of Forensic Medicine & Pathology, 1988, 9(2):122–125.
8 Bandsma RH et al. Impaired glucose absorption in children with severe malnutrition. Journal of Pediatrics, 2011, 158:282–287.
9 Karaolis N et al. WHO guidelines for severe malnutrition: are they feasible in rural African hospitals? Archives of the Diseases of Childhood, 2007, 92:198–204.
10 Schofield C, Ashworth A. Why have mortality rates for severe malnutrition remained so high? Bulletin of the World Health Organization, 1996, 74(2):223–229.
11 Southall D et al. eds. International child health care: a practical manual for hospitals worldwide. London, BMJ Books, 2002.
12 Goulet O. Nutritional support in malnourished paediatric patients. Paris, Baillière Tindall, 1998.
13 Ashworth A, et al. WHO guidelines for management of severe malnutrition in rural South African hospitals: effect on case fatality and the influence of operational factors. The Lancet, 2004, 363:1110–15.
14 Bernal C et al. Treatment of severe malnutrition in children: experience in implementing the World Health Organization guidelines in Turbo, Colombia. Journal of Pediatric Gastroenterology and Nutrition, 2008, 46:322–328.
15 Nziokia C et al. Audit of care for children aged 6 to 59 months admitted with severe malnutrition at Kenyatta National Hospital, Kenya. International Health, 2009, 1:91–96.
16 Ashworth A, Schofield C. Latest developments in the treatment of severe malnutrition in children. Nutrition, 1998, 14(2):244–245.