A 3-year-old boy is brought to the emergency department by his parents due to fatigue and refusal to eat. His family recently arrived in the United States from Syria. He has had watery diarrhea for the past several days but no fevers or vomiting. His appetite has been decreased for several weeks. Today, he has refused to eat but has drunk a few cups of water and juice. Limited medical records show that tuberculosis skin testing was negative and catch-up vaccines were administered at the time of immigration. Temperature is 36.1 C (97 F), blood pressure is 100/65 mm Hg, pulse is 100/min, and respirations are 22/min. Height is 91 cm (36 in) and weight is 12 kg (26 lb 8 oz), corresponding to the 10th and 5th percentiles, respectively. Physical examination shows a gaunt, tired-appearing boy. Oral mucous membranes are dry but without ulcers or thrush. He has bilateral pitting edema of the lower extremities, and his upper extremities have minimal subcutaneous fat. A soft, vibratory heart murmur is heard on auscultation. The lungs have no adventitious sounds. The abdomen is mildly distended but otherwise soft and nontender. Initial laboratory results are as follows:
| Sodium | 134 mEq/L |
| Potassium | 3.4 mEq/L |
| Chloride | 94 mEq/L |
| Bicarbonate | 22 mEq/L |
| Blood urea nitrogen | 8 mg/dL |
| Creatinine | 0.6 mg/dL |
| Calcium | 10.2 mg/dL |
| Glucose | 70 mg/dL |
| Phosphorus | 3 mg/dL |
Stool occult blood test is negative. Which of the following is the most appropriate initial step in management of this patient?
Severe malnutrition | |
Types |
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Complications of management |
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This patient has severe malnutrition with features of marasmus and kwashiorkor, including a thin, wasted (eg, minimal subcutaneous fat) appearance with pitting edema and fatigue. The patient is also mildly dehydrated (eg, dry mucous membranes) in the setting of an acute diarrheal illness. In a chronically malnourished and dehydrated child who is hemodynamically stable, as in this case, oral rehydration is the preferred method of rehydration. An orogastric or nasogastric tube supplying an oral rehydration solution (glucose and electrolytes) could be considered if oral intake is insufficient.
Intravenous (IV) rehydration (Choice D) should be avoided in a stable, chronically malnourished patient due to risk of fluid overload and heart failure. If the patient is in hypovolemic shock, IV fluid volume is typically less (10 mL/kg) than a normal IV bolus (20 mL/kg) and should be administered over a slower period (eg, 30-60 minutes).
(Choices A, C, and E) Feeding should be started cautiously in chronically malnourished patients to prevent refeeding syndrome (eg, hypophosphatemia, hypokalemia), which can be fatal. This patient already has decreased phosphate and potassium secondary to malnutrition and should therefore not be started initially on a high-calorie diet or total parenteral nutrition. He is also tolerating oral liquids and does not currently require aggressive methods of hydration.
Educational objective:
Oral rehydration is the preferred method of hydration in severe malnutrition. Intravenous rehydration can result in heart failure and should be used cautiously in cases of severe hypovolemia and shock.