Kwashiorkor — DTM&H MCQ

Correct answer: D — Stabilisation with cautious F-75 feeds and treatment of infection

The correct answer is D, stabilisation with cautious F-75 feeds and treatment of infection. Bilateral pitting oedema with a flaky-paint dermatosis and apathy in a 2 year old is classic for oedematous severe acute malnutrition (kwashiorkor), and hypothermia plus poor appetite confirm he is in the unstable stabilisation phase rather than the rehabilitation phase. WHO protocols mandate low-protein, low-sodium, low-volume F-75 feeds given frequently, alongside warming, glucose monitoring and empirical broad-spectrum antibiotics, because these children have impaired homeostatic reserve, sub-clinical infection is almost universal, and their liver and kidneys cannot handle a protein or sodium load. Only once oedema resolves and appetite returns does the child progress to energy-dense catch-up feeding (F-100) in the rehabilitation phase. Why the other options are wrong: E. Rapid diuresis with furosemide: the oedema of kwashiorkor is due to hypoalbuminaemia and capillary leak, not fluid overload or heart failure, so diuretics do not correct it and risk dangerous electrolyte depletion and cardiovascular collapse. B. Immediate high-protein catch-up feeding: giving high-protein, high-osmolar feeds before stabilisation overwhelms a compromised liver and kidneys, precipitating refeeding syndrome, heart failure and death. C. Weight-loss diet with vitamin tablets: this child is severely malnourished, not obese; restricting intake further would worsen his catabolic state and is clinically inappropriate. A. Oral iron on the first day of admission: iron is withheld during the stabilisation phase because it promotes free-radical damage and can feed occult infection; it is only added once the child is on F-100 and gaining weight. Key point: oedematous severe acute malnutrition is a medical emergency requiring cautious, low-protein F-75 stabilisation and antibiotics before any catch-up feeding or iron is started.

Reference: WHO, Pocket Book of Hospital Care for Children: Guidelines for the Management of Common Childhood Illnesses, Section on Severe Acute Malnutrition (stabilisation phase, F-75, antibiotics, deferred iron) - https://www.ncbi.nlm.nih.gov/books/NBK154454/