The IAP Guidelines 2006 on Hospital Based Management of Severely Malnourished Children(1) makes excellent practical reading and would serve as a brilliant ready reckoner for practising pediatricians. A few points need further clarification.

1. In Step 10: Prepare follow-up after recovery, adequate emphasis has not been placed on the edematous child with malnutrition which is easily the more tricky case to manage than the purely malnourished child without edema. During hospital rounds, our seniors always taught us to look for the Brian Wharton's tick sign. By that they implied the initial weight loss that is seen in the edematous malnourished child when he loses fluid weight in the initial stages of improvement. The uptick of the tick sign after the initial few days is the actual dry weight that the child begins to gain after losing the edematous weight initially. I still distinctly remember my days as a resident doctor when every morning and evening we used to check for weight loss. Infact, early weight gain was considered an ominous sign in the presence of edema. Therefore, in this section, we need to incorporate this fact as a possible cause of poor weight gain!

2. Do we need to titrate the dose of vitamin A by weight too? We may have a 2 year old severely malnourished child with a weight of say 7 kg for whom a vitamin A dose of 2,00,000 I.U. may be an overdose. Would a cut-off of 8 or 10 kgs to decide whether to give 1,00,000 or 2,00,000 I.U. of vitamin A be useful?

3. No mention has been made about the mood of the child in the entire article. The malnourished child with edema is typically listless, anorexic and apathetic unlike the malnourished child without edema. Not only is it a diagnostic clue, it is also a useful indicator of the trend towards recovery as also one of the useful guides for "criteria for discharge" when the child starts smiling and becomes interested and curious about his surroundings.

M . Sanklecha,
Consultant Pediatrician,
Bombay Hospital,
Mumbai, India.
E-mail : [email protected]