5.8 Cholera and acute malnutrition

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    Typically, in a cholera treatment facility, two situations will be encountered:

    1 - Malnutrition is certain

    • Either severe acute malnutrition has been already diagnosed by a feeding centre that subsequently refers the child for cholera care;


    • The child presents with bilateral leg oedema typical of severe acute malnutrition that is detected on admission a Citation a. The diagnosis is to be confirmed by a doctor who must exclude other causes of oedema.  .


    Children referred from a feeding centre with a diagnosis of moderate malnutrition receive the standard protocol for rehydration based on the degree of dehydration, as for non-malnourished children (Section 5.4).


    Children suffering from severe acute malnutrition, diagnosed by a feeding centre or determined on admission by the detection of nutritional oedema, are treated using the protocols below.

    2 - Malnutrition is suspected

    The child presents with signs and symptoms that are common to both cholera with dehydration and severe malnutrition (diarrhoea, persistent skin fold, sunken eyes, lethargy, and shock) where it is difficult to distinguish the two conditions, particularly as they can be present simultaneously in the same patient.


    Since weight is significantly affected by hydration status, weight-for-height (W/H) cannot be measured on admission but only once the dehydration has been corrected.


    MUAC is less affected by dehydration and can be used to identify children with possible malnutrition. Children with MUAC < 115 mm on admission should be treated according to the protocols below. Once the child has been fully rehydrated, MUAC should be reassessed in order to confirm the diagnosis of malnutrition.

    5.8.1 Management of cholera in severe acute malnutrition

    Initial clinical assessment

    Altered consciousness (lethargy, coma)


    Very rapid or very slow pulse
    or difficult to palpate or absent



    Cold extremities (hands/feet)
    Capillary refill time > 3 seconds



    Very rapid breathing
    or gasping or cyanosis 



      Agitated, irritable



    Palpable pulse,
    may be rapid

    Sunken eyes

    Skin pinch
    disappears slowly



      Awake, not agitated

    Pulse easily

    Normal eyes

    Skin pinch
    disappears immediately





    • The clinical assessment of dehydration in severely malnourished children may be difficult. In particular, skin pinch and recently sunken eyes should be interpreted with caution as they may occur with malnutrition even if no dehydration is present.
    • Children referred from a feeding centre may have weight data that pre-dates the onset of diarrhoea. The severity of dehydration can be estimated by comparing this weight from that measured on admission to the cholera facility (this does not apply to children with nutritional oedema).

    If the weight lost is ≥ 10% of the pre-cholera weight, the patient has severe dehydration. Weight loss between 5-9% indicates some dehydration, weight loss of < 5% means mild or no dehydration.
    This method of estimation is complementary to the clinical evaluation, particularly if the signs of dehydration are ambiguous, but it does not replace the clinical evaluation. In addition, it is accurate only if the child was weighed daily prior to the onset of cholera.

    Severe dehydration or shock

    Severely malnourished children receive the same volume of RL as non-malnourished children with an equivalent degree of dehydration, but the rate of administration is slower (twice as slow). The child should be closely monitored during rehydration.


    Given the lack of data on optimal treatment of severe dehydration in severely malnourished children, until robust data becomes available, this recommendation aims to avoid complications related to excessive or insufficient rehydration.


    20 ml/kg of RL over 30 minutes
    If danger signs still present, repeat the bolus up to 2 times
    70 ml/kg of RL over 6 hours


    Immediate therapy:

    • Rehydration begins with a rapid bolus infusion of RL in 30 minutes.

    For volumes to prescribe to severely malnourished children, see Appendix 5.

    • Once the IV infusion is in place, measure the blood glucose and administer glucose if blood glucose level is < 60 mg/dl (< 3.3 mmol/litre) or give glucose empirically (Section 5.10.1).
    • During the first 30 minutes:
      • Closely monitor the child until the danger signs resolve, with a clinical assessment every 10 to 15 minutes.
      • Observe the volume infused, making sure that the rate of infusion is sufficient to deliver the prescribed volume in the appropriate time.
      • If there is no improvement, repeat the bolus of RL up to 2 times.


    If the clinical state has improved (danger signs resolved after 1 to 3 boluses of RL):

    • Begin the continuous infusion (70 ml/kg of RL) over 6 hours.
    • Continue glucose by adding 100 ml of 50% glucose to each litre of RL.
    • Repeat the clinical examination every 30 minutes and verify that signs of dehydration are regressing. Note the quantity of on-going fluid losses (diarrhoea and vomiting) and volume of fluid intake (RL and ORS), while ensuring that the IV rate will allow the prescribed volume be infused over the duration prescribed.
    • If danger signs reappear, re-administer a bolus of RL, repeating up to 2 times as necessary.
    • If during rehydration the respiratory rate begins to increase, pulmonary crepitations are heard on auscultation, or lower extremity or peri-orbital oedema appear or worsen, suspect that over-hydration has occurred.
    • As soon as the child is haemodynamically stable and can drink without excessive vomiting:
      • Use standard hypo-osmolar ORS to compensate for on-going fluid losses. Do not use ReSoMal, as its sodium content is not sufficient to replace that lost in cholera.
      • Give an antibiotic as a single dose (Appendix 7).
      • Start therapeutic feeding as soon as possible (within 4 hours).
      • Give zinc sulfate to children under 5 years.
    • At the end of the rehydration phase, re-evaluate the clinical degree of rehydration:
      • If there are no longer signs of dehydration, start the maintenance phase (Section 5.5.1). Stop the infusion but leave the catheter in place.
      • If there are signs of some dehydration, then start treatment for some dehydration (see below). Stop the infusion but leave the catheter in place.


    If the clinical state does not improve after the 3rd bolus of RL, consider sepsis:

    • Administer a broad-spectrum antibiotic (ceftriaxone IV: 50-80 mg/kg once daily + cloxacillin IV infusion 25-50 mg/kg every 6 hours).
    • Administer maintenance fluid of continuous RL using the Holliday-Segar method:
      For the first 10 kg 4 ml/kg/hour
      For each kg between 11-20 kg 2 ml/kg/hour
      For each kg above 20 kg 1 ml/kg/hour



    For example, to calculate the hourly maintenance fluid rate for a child weighing 14 kg: (4 ml x 10 kg) + (2 ml x 4 kg) = hourly rate: 40 ml + 8 ml = 48 ml per hour.

    • Administer therapeutic milk by nasogastric tube.


    Note: during the treatment for cholera, monitor temperature. Co-infections are common in severely malnourished children and can be manifested as hypothermia as well as fever.

    Some dehydration

    The total volume of ORS to administer is 75 ml/kg over 4 hours. Use standard ORS. Do not use ReSoMal as its sodium content is too low to replace that lost in cholera.


    If the child is unable to drink, use a nasogastric tube (under strict surveillance, avoiding improper tube placement),
    + Surveillance and compensation of on-going fluid losses,
    + Antibiotic as a single dose (Appendix 7),
    + Therapeutic feeding as soon as possible (within 4 hours),
    + Zinc sulfate for children under 5 years.


    Once dehydration has been corrected, administer ORS after each liquid stool until diarrhoea ceases, as for other children.

    No dehydration

    See the standard protocol (Section 5.5.1). Use standard hypo-osmolar ORS. Do not use ReSoMal.
    Give zinc sulfate to children under 5 years.

    5.8.2 Approach to suspected malnutrition in cholera patients

    If, once the dehydration has been corrected, the child fills the anthropometric criteria for malnutrition, start therapeutic food and refer the child to a feeding centre once discharged from the CTC.


    • (a)The diagnosis is to be confirmed by a doctor who must exclude other causes of oedema.