Transcript Treatment & Management of severe Protein

TREATMENT &
MANAGEMENT OF
SEVERE ACUTE (PROTEIN-ENERGY)
MALNUTRITION IN CHILDREN
Global Health Fellowship
Nutrition 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 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
Initial Treatment

Hypoglycemia








Cause death first days
Sign infection: ATB
Sign infrequent feedings
Clinical suspicion, treat
50ml D10%, F75 PO/NG
Never use bottles




Kangaroo
Warm
Treat for hypoglycemia
Sign of infection, treat
Reliable signs
 Diarrhea,

thirst, hypoT, eyes,
weak pulse
Unreliable signs
 MS, mouth/tongue/
tears/skin elasticity
ReSoMal: 70-100ml/kg/12h

Breastfeed, F-75

Hypothermia

Dehydration

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


Unable to tolerate usual amounts of dietary protein, fat, Na


Diet low in above, hi in carbohydrates
F-75




Food must be given in small amounts, frequently (PO/NG)
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

















Dried skimmed milk
Sugar
Cereal flour
Vegetable oil
Mineral mix
Vitamin mix
Water
Protein
0.9g
Lactose
1.3g
K
Na
Mg
Zn
Copper
0.25mg
Osmolarity
Energy from protein
Energy from fat
F-100
25g
70g
35g
27g
20ml
140ml
1l
80g
50g
60g
20 ml
140 ml
1l
2.9g
4.2g
3.6mmol
0.6mmol
0.43mmol
2.0mmol
5.9mmol
1.9mmol
0.73mmol
2.3mmol
0.25mg
333mOsmol/l
5%
32%
419mOsmol/l
12%
53%
Continue Breastfeeding
Initial Treatment

Infections



↓ fever, inflammation
Measles vaccine
1st line, all children






Cotrimoxazole
Complications: ampi + gent
+ chloramphenicol
Malaria, candidiasis
Helminthiasis
TB
Dermatosis Kwashiorkor



Vitamin deficiencies

Folic acid

Vit mix:

Vit A PO or IM
1% K permanganate soaks
Nystatin
Zinc + castor oil
riboflavin, ascorbic acid,
pyridoxine, thiamine, fat soluble vit D, E, K


2nd line, > 48 hr ATB





Severe Anemia



Eye pads NS solution
Tetracycline + atropine eye drops
Bandage eyes
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







Mother





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
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