Children with severe acute malnutrition have profound disturbances of normal physiology, including electrolyte imbalances and altered fluid distribution. Children with bilateral pitting oedema typically have high intracellular sodium and are therefore inclined to retain fluids. These changes at cellular level are part of the overall adaptive responses to repeated infections and damage to cell membranes by free radicals. Children with severe wasting but without oedema also have depleted intracellular and total body potassium. As a result, they are prone to fluid retention and susceptible to fluid changes and, in particular, have reduced tolerance to rapid changes in circulating blood volume. For these reasons, fluid management is complex in all children with severe acute malnutrition. WHO recommends a cautious approach to fluid management, especially if children have diarrhoea. It is frequently very difficult to assess and determine the hydration status and circulating volume.
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