1. Global Health Fellowship Nutrition Module
Treatment & Management of severe acute (Protein-Energy) Malnutrition in Children
Global Health Fellowship
Nutrition Module

2. Severe Malnutrition Medical & social disorder
End result of chronic nutritional & emotional deprivation
Management requires medical & social interventions

3. Underlying causes of poor diet & excess disease (UNICEF)
Insufficient access to food
Inadequate maternal & child care
Poor environment
Inadequate or lack of access to health services

4. 3 Phases of Management Initial Treatment Rehabilitation Follow-up
Life threatening problems identified & treated
Specific deficiencies/metabolic abnormities corrected
Feeding begun
Rehabilitation
Intensive feeding
Emotional & physical stimulation
Mother trained
Follow-up
Prevention of relapse
Assure continued development

5. Treatment Facilities Initial treatment & beginning of rehabilitation
SAM with complication (anorexia, infection, dehydration)
Residential care in special nutrition unit
SAM w/out complications, s/p inpt has appetite. gaining weight, stable
Nutritional rehabilitation center:
day hospital,
1ary health center
CTC

6. Evaluation of malnourished child
Nutritional status
WFH, HFA, edema
Moderate (-3<SD<-2) or severe (<3SD)
Hx & PE
Lab tests
Useful: glucose, blood smear (malaria), H/H, urine cx, feces , CXR, PPD
Not useful: serum protein, HIV, electrolytes

7. GENERAL PRINCIPLES FOR ROUTINE CARE There are ten essential steps
(the ‘10 Steps’)
There are ten essential steps
1.Treat/prevent hypoglycemia
2.Treat/prevent hypothermia
3.Treat/prevent dehydration
4.Correct electrolyte imbalance
5.Treat/prevent infection
6.Correct micronutrient deficiencies
7.Start cautious feeding
8.Achieve catch-up growth
9.Provide sensory stimulation and emotional support
10. Prepare for follow-up after recovery
These steps are accomplished in two phases:
# an initial stabilisation phase where the acute medical conditions are managed
# longer rehabilitation phase
Note that treatment procedures are similar for marasmus and kwashiorkor

8. Initial Treatment Hypoglycemia Hypothermia Dehydration Septic shock
Cause death first days
Sign infection: ATB
Sign infrequent feedings
Clinical suspicion, treat
50ml D10%, F75 PO/NG
Never use bottles
Hypothermia
Kangaroo
Warm
Treat for hypoglycemia
Sign of infection, treat
Dehydration
Reliable signs
Diarrhea, thirst, hypoT, eyes, weak pulse
Unreliable signs
MS, mouth/tongue/ tears/skin elasticity
ReSoMal: ml/kg/12h
Breastfeed, F-75
Septic shock
ATB broad spectrum
Tx hypoGly, hypoT
CHF, anemia, Vit K
Seriously ill, wasting, anorexia, infection. Monitor constantly, avoid iv

9. Time frame for management

10. ReSoMal Severely malnourished children Commercially available
K deficient, high Na levels
Mg, Zn, copper deficiency
Commercially available
Dilute 1 packet of standard WHO ORS in 2 l water g of sucrose (25g/l) + 40 ml (20ml/l) mineral mix solution
5ml/kg PO/NG q30min
Cont till thirst & urine

11. Formula diets for severely malnourished children
Impaired liver & intestinal function + infection
Food must be given in small amounts, frequently (PO/NG)
Unable to tolerate usual amounts of dietary protein, fat, Na
Diet low in above, hi in carbohydrates
F-75
75kcal or 315kj/100ml
Initial phase treatment, 130ml/kg/d
Feed q 2-3hr (8 meals/d)
F-100
100kcal or 420kj/100ml
Feed q 4-5 h (5-6 meals/d)
Rehabilitation phase (appetite returned)

12. Composition F-75 and F-100 Dried skimmed milk 25g 80g Sugar 70g 50g
F F-100
Dried skimmed milk 25g g
Sugar 70g g
Cereal flour 35g
Vegetable oil 27g g
Mineral mix 20ml ml
Vitamin mix 140ml ml
Water 1l l
Protein 0.9g g
Lactose 1.3g g
K 3.6mmol mmol
Na 0.6mmol mmol
Mg mmol mmol
Zn 2.0mmol mmol
Copper 0.25mg mg
Osmolarity 333mOsmol/l mOsmol/l
Energy from protein 5% %
Energy from fat 32% %

13. Continue Breastfeeding

14. Initial Treatment Vitamin deficiencies Infections Severe Anemia CHF
Folic acid
Vit mix: riboflavin, ascorbic acid, pyridoxine, thiamine, fat soluble vit D, E, K
Vit A PO or IM
Eye pads NS solution
Tetracycline + atropine eye drops
Bandage eyes
Severe Anemia
Transfusion PRC/WB (CHF)
No Iron at this stage
CHF
Overhydration (>48hr)
Stop feeds. Give furosemide
Infections
↓ fever, inflammation
Measles vaccine
1st line, all children
Cotrimoxazole
Complications: ampi + gent
2nd line, > 48 hr ATB
+ chloramphenicol
Malaria, candidiasis
Helminthiasis TB
Dermatosis Kwashiorkor
1% K permanganate soaks
Nystatin
Zinc + castor oil
Iron toxic and reduces resistance to infection

16. Rehabilitation Principles & criteria
Eating well
MS improved: smiles, responds to stimuli
Dev appropriate behavior
Nl temperature
No V/D
No edema
Gaining Wt: > 5g/kg of body wt/d x 3 days
Most important determinant of recovery:
Amount of energy consumed: calories, protein, micronutrients (K, Mg, I, Zn)

17. Nutrition for children < 24 mo
F-100 diet q 4 hr (day & night)
↑each feed by 10ml
kcal/kg/d
Folic acid + Iron, Vit & Mineral mix
Attitude of care giver crucial
Decreasing edema
F-100 continued till Target Wt (-1 SD/ 90% of median NCHS/WHO reference value for WFH)
Wt daily plotted on graph
Target wt usually reached 2-4 wks

18. Nutrition for children > 24 mos
↑ amounts F-100 (practical value in refugee camps, # different diets )
Introduce solid foods
Local foods should be fortified
↑ content of Energy (oil), minerals &Vitamins (mixes)
Milk added (protein)
Energy content of mixed diets: 1kcal or 4/2kj/g
F-100 given between feeds of mixed diet
5-6 feeds /d
Folic acid (5mg on day 1, 1mg/d) + Iron ( 3mg/kg elemental iron/d x 3mo)

19. Emotional & physical stimulation
1ary/2ary prevention DD, MR, ED
Start during rehabilitation
Avoid sensory deprivation
Maternal presence
Environment
Play activities, peer interactions
Physical activities

20. Rehabilitation Parental teaching Preparation for D/C
Correct feeding/food preparation practices,
Stimulation, play, hygiene
Treatment diarrhea, infections
When to seek medical care
Preparation for D/C
Reintegration into family & community
Prevent malnutrition recurrence

21. Criteria for D/C Child Mother Health worker WFH reached -1SD
Eating appropriate amount of diet that mother can prepare at home
Gaining wt at normal or ↑rate
Vit/mineral deficiencies treated/corrected
Infections treated
Full immunizations
Mother
Able & willing to care for child
Knows proper food preparation
Knows appropriate toys & play for child
Knows home treatment fever, diarrhea, ARI
Health worker
Able to ensure F/U child & support for mother

22. Follow up Child usually remains stunted w/ DD
Prevention of recurrence severe malnutrition
Strategy for tracing children
F/U: 1,2, 4 weeks, then 3 & 6 mos, then 2x/yr till age 3yrs
WFH no less than -1SD
Assess overall health, feeding, play
Immunizations, treatments, vitamin/minerals
Record progress

24. Failure to respond Criteria
1ary failure to respond
Failure to regain appetite by day 4
Failure to start to lose edema by day 4
Edema still present by day 10
Failure to gain at least 5g/kg/d by day 10
2ary failure to respond
Failure to gain at least 5g/kg/d during rehabilitation

25. Failure to respond Problems with treatment facilities
Poor environments
Insufficient or inadequately trained staff
Inaccurate weighing machines
Food prepared or given incorrectly

26. Failure to respond Problems w/ individual children
Insufficient food given
Vitamin or mineral deficiency
Malabsorption of nutrients
Rumination
Infections
Diarrhea, dysentery, OM, LRI, TB, UTI, malaria, intestinal helminthiasis, HIV/AIDS
Serious underlying disease
Congenital abnormalities, inborn errors metabolism, malignancies, immunological diseases

27. Fight Malnutrition