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Presentation on theme: "TREATMENT & MANAGEMENT OF SEVERE ACUTE (PROTEIN-ENERGY) MALNUTRITION IN CHILDREN Global Health Fellowship Nutrition Module."— Presentation transcript:


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 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

7 GENERAL PRINCIPLES FOR ROUTINE CARE (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 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

9 Time frame for management

10 ReSoMal Severely malnourished children K deficient, high Na levels Mg, Zn, copper deficiency Commercially available Dilute 1 packet of standard WHO ORS in 2 l water + 50 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 kcal or 420kj/100ml Feed q 4-5 h (5-6 meals/d) Rehabilitation phase (appetite returned)

12 Composition F-75 and F-100 F-75 F-100 Dried skimmed milk25g 80g Sugar70g 50g Cereal flour35g - Vegetable oil27g 60g Mineral mix20ml 20 ml Vitamin mix140ml 140 ml Water1l 1l Protein0.9g 2.9g Lactose1.3g 4.2g K3.6mmol 5.9mmol Na0.6mmol 1.9mmol Mg0.43mmol 0.73mmol Zn2.0mmol 2.3mmol Copper0.25mg 0.25mg Osmolarity333mOsmol/l 419mOsmol/l Energy from protein5% 12% Energy from fat32% 53%

13 Continue Breastfeeding

14 Initial Treatment Infections fever, inflammation Measles vaccine 1 st line, all children Cotrimoxazole Complications: ampi + gent 2 nd line, > 48 hr ATB + chloramphenicol Malaria, candidiasis Helminthiasis TB Dermatosis Kwashiorkor 1% K permanganate soaks Nystatin Zinc + castor oil Vitamin deficiencies 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


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 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 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 C ongenital abnormalities, inborn errors metabolism, malignancies, immunological diseases

27 Fight Malnutrition


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