Transcript pediatricmalnutrition - Global Emergency Health Medicine

Approach to Pediatric Undernutrition
and Nutritional Deficiencies in the
Emergency Department
Authors: Kiran Talwar MD, FRCP(C)
and Lisa Evered MD, FRCP(C), MSc
Date Created: December 2012
Global Health Emergency Medicine Teaching Modules by GHEM is licensed under
a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License.
Learning Objectives
1. Define and understand contributions of undernutrition
to global child health, including immediate, underlying
and social causes of pediatric undernutrition
2. Discuss clinical presentations of severe acute
undernutrition, including kwashiorkor and marasmus
3. Explore co-morbidities of undernutrition in children
4. Review common vitamin deficiencies
5. Discuss an approach to management of severe acute
undernutrition, including nutritional therapy and
management of common complications
How does undernutrition contribute
to global child health?
Overall, there were 6.9 million children under
the age of 5 years who died in 2011
 This is 21 000 deaths per day or ~15 deaths
every minute
 This is greater than the annual number of
deaths from AIDS, malaria and TB combined
 45% of deaths occur in Africa and 30% in
South-East Asia
Quiz Question 1
 What fraction of childhood mortality worldwide is
attributable to undernutrition?
a)
b)
c)
d)
5%
10%
20%
30%
Quiz Question 1
 What fraction of childhood mortality worldwide is
attributable to undernutrition?
a)
b)
c)
d)
5%
10%
20%
30%
How does undernutrition contribute
to global child health?
 3.5 million children
under 5 years die
every year due to
undernutrition
 Undernutrition is
responsible for 11%
of global disease
burden
 Undernutrition is the
underlying cause of
more than one third
of all child deaths
under the age of five
Quiz Question 2
 What is the number one cause of child mortality
worldwide?
a)
b)
c)
d)
Pneumonia
Diarrhea
Neonatal-related illnesses
Malaria
Quiz Question 2
 What is the number one cause of child mortality
worldwide?
a)
b)
c)
d)
Pneumonia
Diarrhea
Neonatal-related illnesses
Malaria
What are the causes of mortality in
children under 5 years?
Data from 2008,
The Lancet
From: Administrative Committee on Coordination –
Subcommittee on Nutrition (ACC/SCN). How nutrition
improves. ACC/SCN State of the Art Series Nutrition
Policy Discussion Paper No. 15, 1996. Geneva, ACCSCN.
What is the association between
undernutrition and disease?
 Undernutrition may cause death directly or
indirectly
 Increases the fatality rate from other illnesses
 Undernutrition contributes to infection
 Infection contributes to undernutrition
Undernutrition is Preventable!
 There are many contributing factors to
undernutrition
 Undernutrition needs to be addressed in
order to reduce child mortality worldwide
What are the immediate causes of
undernutrition?
 Lack of access to nutrients
 No adequate supply of nutritious food
 Poor absorption of nutrients
 Cycle of ill health and poverty
 Disease – e.g. pneumonia, diarrhea, malaria,
HIV/AIDS, intestinal parasites
What are the social causes of
undernutrition?






Poverty
Poor access to health care
Low levels of education
Gender inequality
Political unrest
Natural disaster/famine
How does undernutrition affect child
health?
 Low birth weight
 Wasting
 Underweight
 Micronutrient
deficiencies
 Stunting
Quiz Question 3
 Which of the following is false:
a) A low birth weight infant is 8X more likely to die than a
normal birth weight infant
b) There is no association between maternal
undernutrition and risk of maternal death during
childbirth
c) Almost 60% of newborns in developing countries are
not weighed at birth
d) Low birth weight is defined as < 2.5 kg
Quiz Question 3
 Which of the following is false:
a) A low birth weight infant is 8X more likely to die than a
normal birth weight infant
b) There is no association between maternal
undernutrition and risk of maternal death during
childbirth
c) Almost 60% of newborns in developing countries are
not weighed at birth
d) Low birth weight is defined as < 2.5 kg
Low Birth Weight
 Maternal nutrition is critical for a healthy
pregnancy and delivery
 Lack of adequate nutrition during pregnancy
can result in IUGR or LBW
 This puts newborns at risk of other illnesses
 LBW < 2.5kg
 IUGR is weight < 10th percentile for
gestational age
Quiz Question 4
 Preethy is a 2 year old girl. Her weight for height is 2.5 SD below the mean for her age. This classifies
her as:
a)
b)
c)
d)
e)
Kwashiorkor
Severe stunting
Wasting
Severe acute malnutrition
Underweight
Quiz Question 4
 Preethy is a 2 year old girl. Her weight for height is 2.5 SD below the mean for her age. This classifies
her as:
a)
b)
c)
d)
e)
Kwashiorkor
Severe stunting
Wasting
Severe acute malnutrition
Underweight
Underweight
 Weight for age < -2 SD below the
median
 Severe < -3 SD below
 129 million children under five are
underweight in the developing world
 22% of children in developing countries
Wasting
 Observed weight for height < -2 SD
below the median
 20 million children under age 5y
 10 countries account for 60% of the global
wasting burden
 Carries a markedly increased risk of death
Mid upper arm circumference
(MUAC)
 For a review of how
to measure MUAC
visit
http://www.unicef.or
g/nutrition/training/3.
1.3/1.html
 < 115 mm is severe
acute undernutrition
http://motherchildnutrition.org/early-malnutrition-detection/detection-referralchildren-with-acute-malnutrition/screening-for-acute-malnutrition.html]. Accessed
Dec 29, 2011
Stunting
 Observed height for age < -2 SD below
the median
 Severe stunting < -3 SD below the median
 One third of children in the developing
world are stunted
 178 million children worldwide
 90% of the worlds stunted children live in
Africa and Asia
Percentage of children underweight
and stunted, by region
Region
Children
under 5y
Percent
stunted
Percent
Percent
underweight LBW
(<2.5kg)
Percent
IUGR
Africa
142 million
40.1
21.9
14.3
8.9
Asia
357 million
31.1
22.0
18.3
12.4
Latin
America
(Caribbean,
South and
Central
America)
57 million
16.1
4.8
10.0
5.3
Severe Acute Malnutrition
 20 million children under age 5 years are
affected
 1 million children die every year
 > 9 times more likely to die than a child
who is not undernourished
Severe acute malnutrition:
Diagnostic Criteria
 Weight for height less than -3 SD below the
mean (based on WHO standards) = Severe
Wasting
 Mid upper arm circumference (MUAC)
< 115 mm
 Bilateral edema
Any independent indicator requires urgent
action!
What comprises the protein-energy
undernutrition spectrum?
 Kwashiorkor
 Marasmus
 Micronutrient deficiencies
Quiz Question 5
 Which of the following is false:
a) Kwashiorkor carries a worse prognosis than marasmus
b) Children with kwashiorkor often have a near normal
weight and height for age
c) Kwashiorkor is due to a dietary deficiency of protein in
the presence of adequate caloric intake
d) Kwashiorkor usually affects children older than 18
months of age
Quiz Question 5
 Which of the following is false:
a) Kwashiorkor carries a worse prognosis than marasmus
b) Children with kwashiorkor often have a near normal
weight and height for age
c) Kwashiorkor is due to a dietary deficiency of
protein in the presence of adequate caloric intake
d) Kwashiorkor usually affects children older than 18
months of age
Kwashiorkor
 Interaction of
nutritional deficits
and infection/injury
 Worse prognosis
than marasmus
 Often near normal
weight and height
for age
 Usually affects
children >18 months
old
What are the clinical features of
kwashiorkor?
 Severe generalized
edema
 Pitting edema in
lower extremities
and periorbitally
 Rounded cheeks
“moon face”
 Pursed mouth
 Anorexia
 Irritability or apathy
 Hepatomegaly
 Fatty infiltrates
 Dry, hypopigmented
hair
 Falls out easily or
easily plucked
 Distended abdomen
 Dilated intestinal
loops
What are skin changes associated
with kwashiorkor?
 Hypo- or hyperpigmentation
 Desquamation
 Ulceration
 Limbs, genitalia,
thighs, groin and
behind ears
 Exudative lesions
 Resemble severe
burns
 Often are infected
Pocket Book of Hospital Care for Children: Guidelines for the
Management of Common Illnesses with Limited Resources. China:
World Health Organization, 2005.
What is Marasmus?
Pocket Book of
Hospital Care for
Children:
Guidelines for the
Management of
Common Illnesses
with Limited
Resources. China:
World Health
Organization,
2005
.
 The most common
form of protein
energy
undernutrition
 Caused by
inadequate intake of
all nutrients
 Especially total
calories
What are the clinical features of
Marasmus?
 Emaciated and
weak appearance
 Bradycardia,
hypotension,
hypothermia
 Thin, dry skin
 Thin, sparse hair
 Redundant skin
folds (loss of
subcutaneous fat)
Mixed kwashiorkor-marasmus
 Particularly high morbidity and mortality
 Associated with acute infection
 Acute loss of nutrients associated with an
inflammatory response
 Superimposed on chronic undernutrition
 Less adapted metabolically than pure
marasmus
What are key questions to ask about
on history?
 Recent intake of
fluid and food
 Usual diet/
breastfeeding
 Vomiting and
diarrhea (frequency,
duration, blood etc.)
 Loss of appetite
 Chronic cough?
 Contact with
tuberculosis or
measles?
 Known/suspected
HIV infection
 Social history
What are the key physical exam
features to look for?







Dehydration or shock
Palmar pallor
Signs of vitamin A deficiency
Localized infections (ear, throat etc.)
Signs of HIV/AIDS
Mouth ulcers
Kwashiorkor skin changes
What are common co-morbidities of
undernutrition?
 Shock
 Dehydration
 Infection
 Pneumonia, diarrhea, measles
 TB, Malaria, Parasites, HIV/AIDS
 Anemia
 Dermatosis
 Micronutrient deficiencies
Common micronutrient deficiencies
in undernutrition
 Vitamin A
 Folic acid
 B vitamins
 Zinc
 Vitamin C
 Iron
 Vitamin D
 Iodine
Quiz Question 6
 Sonkwe is a 6 month old boy. He presents to the local health
station and is found to be irritable and pale with a weak cry. He
looks wasted and is very tachypneic with crackles audible
bilaterally and a loud murmer. This presentation is most
consistent with:
a)
b)
c)
d)
e)
Infantile scurvy
Thiamine deficiency
Pellagra
Zinc deficiency
Folic acid deficiency
Quiz Question 6
 Sonkwe is a 6 month old boy. He presents to the local health
station and is found to be irritable and pale with a weak cry. He
looks wasted and is very tachypneic with crackles audible
bilaterally and a loud murmer. This presentation is most
consistent with:
a)
b)
c)
d)
e)
Infantile scurvy
Thiamine deficiency
Pellagra
Zinc deficiency
Folic acid deficiency
Vitamin A deficiency
 The leading cause of preventable blindness
in children
 250 000 - 500 000 vitamin A deficient children
become blind every year
 Half die within one year of losing their sight
 Increases the risk of illness and death from
infections
 Especially diarrhea and measles
 Contributes to anemia
What are the eye findings in
vitamin A deficiency?
 Xeropthalmia
 Clinical spectrum:
Bitot’s spots = superficial keratin
build up on conjunctiva
http://www.oculist.net/downaton502/prof/ebook/duanes/pages/v5/v5
c059.html




Night blindness
Photophobia
Bitot’s spots
Corneal ulceration
and scarring
How should we treat vitamin A
deficiency?
 Periodic supplementation with high dose
vitamin A
 Reduces overall mortality by 23%
 Reduces mortality by 50% in acute measles
 Reduces xeropthalmia by 90%
 Long-term interventions
 Improved dietary diversity and availability of
vitamin A rich foods
 Fortified foods (eg. sugar, wheat flour, rice)
What are the clinical findings of
vitamin B1 (thiamine) deficiency?
 Infantile beriberi
 Wet beriberi
 Anorexia, vomiting, restlessness, pallor
 Dyspnea, heart failure, generalized edema,
pulmonary edema
 Dry beriberi
 Peripheral neuropathy, paraesthesias, muscle
weakness, aphonic cry, encephalopathy
What are the clinical findings of
vitamin B2 (riboflavin) deficiency?
Ariboflavinosis
 Angular stomatits, glossitis, cheilosis
 Weakness, fatigue, anemia
 Seborrheic dermatitis (nose and around mouth)
 Eye changes (tearing, photophobia), cataracts
What are the clinical findings of
vitamin B3 (niacin) deficiency?
Pellagra
 Dermatitis
 T-shirt distribution (affects light-exposed areas)
 Diarrhea
 Dementia
What are the clinical findings of
vitamin B12 deficiency?
 Pernicious anemia
 Macrocytic anemia and hypersegmented
neutrophils
 Failure to thrive
 Neurologic signs
 Depression, peripheral neuropathy, posterior
spinal column signs, dementia
What are the clinical findings of
vitamin C deficiency (scurvy)?
 Infantile scurvy
 Irritability, bony tenderness/swelling,
pseudoparalysis of legs
 Early signs
 Perifollicular hemorrhages, petechiae,
ecchymosis, bleeding gums, abdominal curly
hairs
 Late signs
 Swollen gums, subperiosteal hemorrhage,
anemia, depression, hysteria
What are the clinical findings of
vitamin D deficiency?
 Rickets (children)
 Craniotabes, enlarged fontanel with delayed
closure
 Rachitic rosary
 Thickening of wrists and ankles
 Bowed legs or knocked knees
 Osteomalacia (postpubertal adolescents)
 Increased risk of infection (TB, pneumonia)
Rachitic Rosary
http://www.thachers.org/rickets_photos.htm
CXR Rachitic Rosary
http://www.pediatriceducation.org/2004/12/06/
Classic XR changes of distal ulna and radius:
cupping and frayed, poorly demarcated ends,
widened metaphysis – Leads to thickening of wrists
http://www.pediatriceducation.org/2004/12/06/
What are the clinical findings of
folic acid deficiency?
 Macrocytic anemia
 Hypersegmented neutrophils
 Glossitis
 Neural tube defects in offspring
What are the clinical findings of zinc
deficiency?
 Stunting
 Immune impairment
 Increased incidence and severity of diarrheal
and respiratory infections
 Higher maternal mortality/obstetric
complications
 Severe deficiency
 Alopecia, dermatitis, delayed sexual
maturation, hepatosplenomegaly
What are the WHO/UNICEF
recommendations for treating zinc deficiency?
In treatment of acute diarrhea:
 Low osmolarity oral rehydration solution
 Zinc supplements
 20mg per day (> 6 months old)
 10mg per day (< 6 months old)
 Treat for 10-14 days
 Continue feeding
What are the clinical findings of iron
deficiency?
 Pallor
 Hypochromic microcytic anemia
 Lethargy
 Impaired neurocognitive development
 Temperament change
 Higher maternal mortality
What are the clinical manifestations
of iodine deficiency?
 Goitre
 Over 1 billion people worldwide




Hypothyroidism
Stunting
Cretinism
Intellectual disability
 Single most common preventable cause of
brain damage
What is associated with iodine
deficiency?
 Low birth weight
 Increased infant mortality
 Hearing impairment
 Impaired motor skills
 Neurologic dysfunction
Treatment of Undernutrition
Community
Integrated management of
childhood illness (IMCI) guidelines
 Standardized protocols for simple and
effective management of leading causes of
childhood illness and death
 World Health Organization
 UNICEF
 Evidence-based assessment and treatment
treatment
 To continue adding slides, copy and paste
this slide
Handbook: Integrated Management of Childhood Illness. World Health Organization, 2000.
treatment
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this slide
Should an undernourished child be
treated as an inpatient or outpatient?
Independent
additional criteria
-No appetite
-Medical
complications
-Appetite
-No medical
complications
Type of therapeutic
feeding
Facility-based
Community-based
Intervention
F75 to F100/RUTF
and 24h medical
care
RUTF, basic medical
care
Discharge criteria
-Reduced edema
-Good appetite with
acceptable intake
15-20% weight gain
What happens in community-based
treatment?
 Early identification is key!
 Community health care workers can be
trained to identify MUAC <115 and edema
 Then referral to health care worker who can
identify them with IMCI approach
 Further referral to community vs. inpatient
treatment
Community-based Treatment
 Uncomplicated forms of  80% of children
SAM should be treated
identified through
in the community
active case finding
can be treated at
home
 Weekly follow up in a
local clinic
Ready to Use Therapeutic Foods
(RUTF)
 Safe palatable food
 High energy content
 Adequate vitamins
and minerals
 Does not require
water or
refrigeration
 Costs US$3/kg
Treatment of Undernutrition
Hospital Based
What about patients who need
inpatient treatment?
 30-50% case fatality rate
 Children severely undernourished and
admitted to hospital
 This can be reduced to < 5% with
appropriate treatment!
 WHO inpatient treatment protocol
What are the WHO ten 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
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Stabilization Starts in the
Emergency Department (or
Outpatient Department)
Stabilization phase – (In the ER)
 General stabilization
of the child (ABCs)
 Treat/prevent
hypothermia
 Treat/prevent
hypoglycemia
 Treat/prevent
dehydration
Step 1: Treat/Prevent Hypoglycemia
 Hypoglycemia and
hypothermia usually
occur together
 Signs of infection
 Frequent feeding is
needed for both
conditions
 Check blood glucose
whenever hypothermia
is found
 If unable to assess a child’s
temperature assume
hypothermia is present
 If unable to test blood
glucose assume all children
with SAM are hypoglycemic
and treat empirically
Quiz Question 7
 Maya is a 9 month old girl. She is presenting to the hospital
with severe acute malnutrition and diarrhea. She is alert,
mildly dehydrated and her glucose is 2.4mmol/L. Her initial
management should include everything except:
a)
b)
c)
d)
e)
Vitamin A supplementation
Measles vaccination
IV glucose bolus of 5ml/kg 10% glucose solution
Zinc supplementation
Immediate oral feeds
Quiz Question 7
 Maya is a 9 month old girl. She is presenting to the hospital
with severe acute malnutrition and diarrhea. She is alert,
mildly dehydrated and her glucose is 2.4mmol/L. Her initial
management should include everything except:
a)
b)
c)
d)
e)
Vitamin A supplementation
Measles vaccination
IV glucose bolus of 5ml/kg 10% glucose solution
Zinc supplementation
Immediate oral feeds
How should we treat hypoglycemia?
 Definition: Dextrostix < 3mmol/L or 54mg/dL
 If the child is unconscious or convulsing:
 IV bolus of 5mL/kg of 10% glucose solution, followed by
50mL of 10% glucose/sucrose solution NG
 Then begin starter F75 feeds every 30 min for 2 hours
 If the child is conscious:
 50mL bolus of 10% glucose/sucrose solution orally or
NG, followed by starter F75 feeds
How should we treat hypothermia?
 Temp <35.0 C axillary or 35.5 °C rectally
 Feed immediately!
 Rewarm the child
 Skin to skin contact on mother’s chest
 Warm blankets/clothes
 Heater or lamp
 Give antibiotics for infection
Quiz Question 8
 Champei is an 11 month old girl. She is brought to the
hospital for irritability and diarrhea. On exam she has
tachycardia, strong pulses, bilateral pedal edema and
looks moderately dehydrated. Her hemoglobin is 70
mg/dL. What should we do?
a)
b)
c)
d)
e)
Bolus 20cc/kg of normal saline
Start a blood transfusion now
Start iron supplementation now
Start oral rehydration solution now
Start a diuretic to help with the edema
Quiz Question 8
 Champei is an 11 month old girl. She is brought to the
hospital for irritability and diarrhea. On exam she has
tachycardia, strong pulses, bilateral pedal edema and
looks moderately dehydrated. Her hemoglobin is 70
mg/dL. What should we do?
a)
b)
c)
d)
e)
Bolus 20cc/kg of normal saline
Start a blood transfusion now
Start iron supplementation now
Start oral rehydration solution now
Start a diuretic to help with the edema
How should we treat dehydration?
 Do not use IV rehydration except in shock!
 It is difficult to estimate dehydration status in a
severely malnourished child
 Assume all children with watery diarrhea may be
dehydrated
 Use low sodium oral rehydration solution
 ReSoMal (WHO solution)
 Reassess frequently
 Watch for signs of fluid overload
Stabilization phase (ER & day 1-7)
 Correct electrolyte
imbalances
 Correct
micronutrient
deficiencies
 Treat/prevent
infections
 Start cautious
feeding
Step 4: Correct electrolyte
imbalances
 All children with SAM are relatively
hypernatremic, hypokalemic and
hypomagnesemic
 To treat:




Use low sodium rehydration fluid
Supplement potassium and magnesium
Prepare food without salt
Do not treat edema with a diuretic!
Step 5: Treat/prevent infection
 The usual signs of infection are often absent
(ie. fever)
 Routinely give:
 Broad spectrum antibiotics
 Measles vaccine if child is >6m and unimmunized
 If a specific infection is present, treat with the
appropriate antibiotics
 Consider antimalarials or antiparasitics
Step 6: Correct micronutrient
deficiencies
 Do not give iron initially as it may make
infections worse
 Give vitamin A orally on day 1
 Also give the following supplements:





Multivitamin
Folic acid
Zinc
Copper
Iron – only start after the child is gaining weight
Step 7: Start cautious feeding
 Small frequent feeds should be started as
soon as possible
 Calories: 100 kcal/kg/day
 Fluid: 130 mL/kg/d
 F75 is starter formula (75kcal/100mL)
 Feeds should be given orally or NG (not IV)
 Continue breastfeeding in addition to
formula supplementation
Feeding schedule
Days
Frequency
Vol/kg/feed
Vol/kg/d
1-2
q2h
11mL
130mL
3-5
q3h
16mL
130mL
6-7+
q4h
22mL
130mL
Treatment of associated conditions:
 Emergency
treatment of shock
 Parasitic worms
 Ongoing diarrhea
 Emergency
treatment of severe
anemia
 Dermatosis
 Tuberculosis
What is the emergency treatment of
shock?
 Shock from dehydration and sepsis are
likely to coexist in SAM
 Difficult to differentiate based on clinical signs
 Give oxygen, record vital signs q10min
 Give 5 mL/kg 10% glucose IV
 Give 15 mL/kg IV fluid over 1 hour
 D51/2 NS or Ringer’s lactate with 5% dextrose
 Give antibiotics
What is the emergency treatment of
severe anemia in SAM?
 Blood transfusion criteria:
 Hemoglobin (Hb) less than 4 g/dL
 Respiratory distress and Hb 4-6 g/dL
 Treatment
 Whole blood 10 mL/kg slowly over 3 hours
 Furosemide 1 mg/kg IV at the start of the
transfusion
 Monitor vital signs closely
How should dermatosis be treated?
 Zinc deficiency is common
 Skin improves quickly with zinc
supplementation
 Apply barrier cream to raw areas
 Zinc and castor oil ointment
 Petroleum jelly
 Paraffin guaze
 Omit diapers so perineum can dry
How should we treat vitamin A
deficiency in SAM?
 If the child has eye findings:
 Give oral vitamin A on days 1, 2 and 14
 If there is corneal clouding or ulceration:
 Instill chloramphenicol or tetracycline eye
drops (1%) every 2-3 hours for 7-10 days
 Instill atropine eye drops (1%) TID for 3-5 days
 Cover with eye pads soaked in saline and
bandage
How should we treat parasitic
worms?
 Mebendazole 100 mg orally BID for 3 days
 or equivalent in your local area
 eg. Albendazole
What are the causes of ongoing
diarrhea?
 Diarrhea should improve during the first
week of treatment
 Ongoing diarrhea:




Mucosal damage
Giardia
Lactose intolerance
Osmotic diarrhea
What about tuberculosis?
 If significant TB contact or clinical findings
 Perform Mantoux test
 CXR
 If positive result or strong clinical suspicion
 Treat according to national TB guidelines
Summary
 Undernutrition contributes to 1/3 of all childhood
deaths worldwide
 Undernutrition is preventable
 Immediate, underlying and social causes must
be addressed
 Micronutrient deficiencies are an important
comorbidity of undernutrition
 Mortality can be reduced by following standard
protocols for assessment and management of
undernutrition
Thank you!!!
Addendum: Treatment of
Undernutrition beyond the
Emergency Room
Rehabilitation phase (weeks 2-6)
 Achieve catch-up
growth
 Provide sensory
stimulation &
emotional
support
 Prepare for followup after recovery
Step 8: Achieve catch-up growth
 Readiness to enter this phase is signaled
by a return of appetite
 Gradually replace F75 with F100
 100 kcal/100 mL and 2.9 g protein/100 mL
 Monitor closely for signs of heart failure
 Aim for weight gain >10 g/kg/day
Step 9: Provide sensory stimulation
and emotional support
 Children are often developmentally delayed
in the setting of severe undernutrition
 Encourage:
 A happy and stimulating environment
 Structured play time
 Physical activity when well enough to
participate
 Encourage parental involvement and counsel
around development
Step 10: Prepare for follow-up after
recovery
 Recovery occurs when weight for length is
-1SD below the mean
 Counsel the parents on feeding practices
and sensory stimulation prior to discharge
 Follow-up:
 Regular check-ups
 Ensure booster immunizations are given
 Give vitamin A every 6 months
What if the child does not gain
weight as expected?
 Inadequate feeding
 HIV/AIDS
 Specific nutrient
deficiency
 Psychological/devel
opmental problems
 Untreated infection
When should we discharge from
facility-based treatment?
 Recovery when child reaches -1 SD weight
for length
 Transfer to community-based program
when:
 Good appetite
 Acceptable intake of RUTF (>75% or target)
 Reduced edema
However…
 We must address the underlying causes of
undernutrition
 It is also a social disorder
 If viewed as only a medical disorder than
the child is likely to relapse when he goes
home
 Other children in the family are also at risk
Community follow-up plans are
crucial…
 Evidence-based strategies that work:
 Exclusive breastfeeding for first 6m of life
 Complementary feeding /weaning education
 Improving water sanitation and hygiene
Prevention first…
 Improve access to high quality foods
 Improve access to health care
 Improve nutrition and health knowledge
Quiz Question 9
 Which of the following is true:
a) An undernourished child is more likely to have a
reduced income as an adult
b) The effects of undernutrition on cognitive development
are reversible with proper nutrition
c) More than half of all countries are on track to
accomplish the Millennium Development Goals
d) The effects of undernutrition on growth stunting are
reversible with proper nutrition
Quiz Question 9
 Which of the following is true:
a) An undernourished child is more likely to have a
reduced income as an adult
b) The effects of undernutrition on cognitive development
are reversible with proper nutrition
c) More than half of all countries are on track to
accomplish the Millennium Development Goals
d) The effects of undernutrition on growth stunting are
reversible with proper nutrition
What are the long-term morbidities
associated with undernutrition?
 Cognitive disability
 Affects in the first 2 years of life are irreversible
 Limited academic achievement
 Stunted growth
What are the long-term morbidities
associated with undernutrition?
 Poorly developed immune systems
 Increased risk of childhood infectious diseases
 Chronic diseases in adulthood
 Reduced adult income
 Lower birth weight of their children