Clinical Scenario:
A 15-month-old boy is admitted with lethargy and poor feeding. He has had diarrhea for 5 days. His weight-for-length is −3.5 Z-scores, and MUAC is 10.8 cm. He has bilateral pitting edema of the feet. His temperature is 35.2°C, pulse 138/min and respiratory rate 42/min. Blood glucose is 2.3 mmol/L. He is conscious but weak and refuses oral feeds.
Which of the following should be addressed first?
A. Begin high-protein therapeutic feeding
B. Correct hypoglycemia
C. Give intravenous fluids rapidly
D. Start iron supplementation
E. Treat edema with diuretics
Correct answer & Explanation:
Correct answer: B. Correct hypoglycemia
This child has severe acute malnutrition (SAM), demonstrated by weight-for-length below −3 Z-scores and MUAC <11 cm, with bilateral nutritional edema. However, the question asks for the first management priority, not the diagnosis.
The blood glucose is 2.3 mmol/L, and the child is lethargic and unable to feed. Hypoglycemia is an immediate life-threatening complication of SAM and must be treated promptly. If the child is conscious and able to drink, oral/NG glucose or feeding can be given; in a child who is unable to feed, IV glucose should be administered, followed by frequent feeding to prevent recurrence.
The associated hypothermia (35.2°C) is another important danger sign. The child should be kept warm and monitored closely because hypothermia and hypoglycemia frequently occur together in severely malnourished children and may indicate serious infection.
Why the other options are incorrect:
- A. High-protein feeding: Feeding is essential, but immediate correction of hypoglycemia takes priority. Initial therapeutic feeds should also be appropriate for SAM rather than simply being high-protein.
- C. Rapid IV fluids: Children with SAM have a high risk of fluid overload and heart failure. IV fluids are reserved for carefully selected children with shock and must be given cautiously.
- D. Iron supplementation: Iron is generally not started during the initial stabilization phase; it is introduced later when the child is clinically stabilizing and gaining weight.
- E. Diuretics: Nutritional edema is not treated with diuretics. Diuretics can worsen dehydration and electrolyte disturbances.
Key postgraduate point: In SAM, remember the stabilization priorities—hypoglycemia, hypothermia, dehydration/shock, electrolyte abnormalities and infection—before focusing on nutritional rehabilitation.
