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TREATMENT &MANAGEMENT OF SEVERE ACUTE (PROTEIN-ENERGY) MALNUTRITION IN CHILDREN
Global Health FellowshipNutrition Module
Severe Malnutrition
Medical & social disorder
End result of chronic nutritional & emotional deprivation
Management requires medical & social interventions
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
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
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
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
GENERAL PRINCIPLES FOR ROUTINE CARE(the ‘10 Steps’)
There are ten essential steps
1.Treat/prevent hypoglycemia2.Treat/prevent hypothermia3.Treat/prevent dehydration4.Correct electrolyte imbalance5.Treat/prevent infection6.Correct micronutrient deficiencies7.Start cautious feeding8.Achieve catch-up growth9.Provide sensory stimulation and emotional support10. 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
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: 70-100ml/kg/12h Breastfeed, F-75
Septic shock ATB broad spectrum Tx hypoGly, hypoT CHF, anemia, Vit K
Time frame for management
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
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)
Composition F-75 and F-100
F-75 F-100
Dried skimmed milk 25g 80g Sugar 70g 50g Cereal flour 35g - Vegetable oil 27g 60g Mineral mix 20ml 20 ml Vitamin mix 140ml 140 ml Water 1l 1l Protein 0.9g 2.9g Lactose 1.3g 4.2g K 3.6mmol 5.9mmol Na 0.6mmol 1.9mmol Mg 0.43mmol 0.73mmol Zn 2.0mmol 2.3mmol Copper 0.25mg 0.25mg Osmolarity 333mOsmol/l 419mOsmol/l Energy from protein 5% 12% Energy from fat 32% 53%
Continue Breastfeeding
Initial Treatment
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
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
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)
Nutrition for children < 24 mo
F-100 diet q 4 hr (day & night) ↑each feed by 10ml 150-220 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
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)
Emotional & physical stimulation
1ary/2ary prevention DD, MR, ED Start during rehabilitation Avoid sensory deprivation Maternal presence Environment Play activities, peer interactions Physical activities
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
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
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
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
Failure to respond
Problems with treatment facilities Poor environments Insufficient or inadequately trained staff Inaccurate weighing machines Food prepared or given incorrectly
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
Fight Malnutrition
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