Transcript Managing the malnourished child

Managing the malnourished
child - a team approach Dr E Malek
Principal Specialist & Senior Lecturer
Witbank Hospital, University of Pretoria
Outline
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Introduction
– Factors affecting growth, extent of problem

Recognition and severity assessment
 Managing the “tip” of the ice-berg
– WHO management guidelines (10 steps)
– Complications, Case studies
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Dealing with the “hidden” problem
– Short-term, Long-term
Growth &
Manifestations
development
Adequate Psychosocial
dietary
Immediate
well being
Health
Adequate
Health
care
Services
determinants
intake
Household
Food
Security
of children
and women
Health
Underlying
determinants
EDUCATION
Potential
resources
Source: UNICEF
Kwashiorkor…
… the child that
has lost its
peace….
Overview of childhood
malnutrition in South Africa
• One in four (23%) children are stunted
(SAVACG study, 1994)
• One in ten (9%) children are underweight
• One in three (33%) children have a
marginal Vitamin A status
• One in five (21%) children are anaemic
Extent of malnutrition
Tip of the ice-berg:
severe malnutrition
Below the surface:
mild to moderate
malnutrition
Recognising the malnourished
child
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Risk factors
Growth monitoring:
Road to Health Card
Feeding history
Clinical signs: early
wasting, anemia, etc.
Identifying early
wasting: wall charts,
MUAC
Assessing the degree of
severity (Integrated Management of
Childhood Illness)
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Visible severe wasting
 Oedema of both feet
 Severe palmar pallor

Low weight
 Weight gain
unsatisfactory
 Some palmar pallor
Malnourished children in hospital
(Mpumalanga Audit 2000: 26 hospitals)
• Nutrition & feeding practices in wards
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no WFA charts/assessment, RTHC not used
breast/f promotion hampered by bottles & teats
no snacks between meals for infants <2 years
no meals at night for malnourished children
inconsistent lodger mother policies, no facilities
• Treatment guidelines
– National pediatric EDL; IMCI; other (local)
Improving the management of
malnourished children in
hospital
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WHO guidelines for management of
children with severe malnutrition in district
hospitals
 Mount Frere Model Integrated Nutrition
Project (Prof David Sanders)
– Incorporated WHO guidelines above within a
policy implementation cycle (hospital nutrition
team, record reviews, patient care observations,
case fatality rates, staff training, audit, etc.)
Potential team members
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Doctor
Nurse
Dietician
Mother / care-giver
Social worker
Physio / O.T.
Volunteers
NGO’s
Case Study 1
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Themba, 11 month old boy
 Swelling of body and face, lethargic
 Abandoned by mother, brought in by
grandmother ; RTHC not available
 Admitted to the ward with kwashiorkor
How would you manage this child for the first
72 hours?
Case Study 2
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Gugu, 6 month old girl
Admitted to the ward with kwashiorkor
Cold extremitries, subnormal temperature
Doctor prescribes treatment, feeds and
orders child to be kept warm
On review next day, chart shows subnormal
temperature between 05h00 and 08h00.
How can you prevent this problem?
Case study 3
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Zandile, 18 month old girl
 Admitted to ward with kwashiorkor
 Doctor prescribes IV antibiotics, fortified
milk feeds, oral potassium and Vitamin A
 Dietician is consulted
 No weight change over the following 3 days
How would you approach this problem?
Case Study 4
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Siphiwe, 15 month old girl
 Admitted to ward with kwashiorkor & G/E
 Had been diagnosed and admitted 1 month
prior for kwashiorkor, ?no follow-up date
 Doctor prescribes feeds, antibiotics, etc.
 Hypoglycemia is noted on chart review
How would you manage this patient?
WHO Guidelines:
management of severe
malnutrition (PEM)
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Organisation of care
Proper triage
Stabilisation and
rehabilitation
Prevent and treat
hypoglycemia
Prevent and treat
hypothermia
Treat dehydration
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Treat electrolyte
imbalance
Treat micronutrient
deficencies
Initial refeeding
Catch-up growth
Stimulation & support
Prepare for follow-up
Monitor and audit
WHO: organisation of care
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Admit mother/carer
Team involvement
Ward care: hi-care bed
2-3 hourly monitoring
and feeding (72 hours)
Keep warm (KMC,
adjust routines eg.
bathing time)
WHO: triage and resuscitation
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Screen children for
signs of severe PEM
 Assess dehydration in
malnourished children
using additional signs
 Children wth
kwashiorkor and
marasmus must be
given IV fluid with
caution
WHO: Stabilisation phase
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Hypoglycaemia (prevent, monitor & treat):
– 2-3 hourly fortified milk feeds (60-130ml/kg/d)
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Hypothermia (prevent, monitor and treat):
– 3 hly temp, warm skin-to-skin, use hat, no baths
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Dehydration: (prevent and treat):
– Treat shock cautiously, rehydrate orally
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Suspect and treat infection:
– Assume infection, give broad spectrum antibiotics
– Monitor appetite, weight: if not better, change
antibiotics after 48 hours
WHO: Stabilisation phase
(cont.)
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Correct electrolyte imbalances:
– Hypokalemia: oral K, if K<2.5, add IV KCl (!)
– Hyponatremia: do not give Na supplements
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Treat micronutrient deficiencies:
– Vit A stat – reduces morbidity and mortality
– Multivitamins, Zink sulphate, Phosphate, Folic
acid, copper
– Give Fe later – once infection is controlled
WHO: Stabilisation phase
(cont.)
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Initial Refeeding:
– Frequent small feeds orally/nasogastrically
– 100 kcal/kg/day; protein: 101.5g/kg/day; liquid:100-
130ml/kg/day
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Monitor:
– 3 hourly temperature and dextrostix for first 72 hours
– Daily weight (same conditions)
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Audit outcome
– Weight gain (good: >10g/kg/day), mortality ( <5% )
WHO: Rehabilitation phase
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Catch-up growth:
– Return of appetite then gradual transition
– Frequent feeds, up to 200ml/kg/day (!)
– 150-200 kcal/kg/day; protein 4-6 gram/kg/day
Stimulation and support
– Visual and emotional stimulation
– Social support: child care grant application, etc.
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Prepare for follow-up
– Follow IMCI feeding recommendations
Time frame for the management of
a child with severe malnutrition
Stabilization
Days 1-2
Days 3-7
Rehabilitation
Weeks 2-6
1. Hypoglycaemia
2. Hypothermia
3. Dehydration
4. Electrolytes
5. Infection
6. Micronutrients
no iron
with iron
7. Initiate feeding
8. Catch up growth
9. Sensory stimulation
10. Prepare for follow-up
Source: WHO
Extent of malnutrition
Tip of the ice-berg:
severe malnutrition
Below the surface:
mild to moderate
malnutrition
Dealing with the ice-berg
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Underlying issues: poverty, female literacy
 Public health education: feeding rec.’s
 Disease prevention/early intervention (HIV)
Timely treatment of illness (IMCI), regular
growth assessment (RTHC), nutrit. counselling
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Health worker access, skill and attitude *
 Support: household food security/grants/etc
 Advocacy: eg. BFHI, Code of Conduct, etc.
Dealing with the ice-berg
(cont.)
Short term programs:
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Long term initiatives
Relief feeding : PEM
 Multi-secoral
Scheme? food parcels?
approach: ?NPA; PPA
(National and Prov Identifying those most
incial Programs of
in need - WFH vs
Action for Children)
WFA
 Community upliftment
Evaluating the PEM Scheme
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To review the PEM Scheme in relation to
the Integrated Nutrition Programme, with
special emphasis on:
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a) its potential for impacting on
anthropometric measurements
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b) current implementation in the
Mitchells Plain district
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c) implications for nutrition policy
Methods
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Clinic record review (3/95-3/96)
Analysis of anthropometric data
Staff interviews and observation
Policy review
Results (n= 831)
Weight for Age at Entry (%)
60%
50%
40%
30%
20%
10%
0%
UWFA
< 3rd
centile
Weight
=>3rd
centile
3-D
Column 1
3-D
Column 2
Duration of Attendance (months)
60%
50%
40%
30%
20%
3-D
Column 1
10%
0%
Only came < 6 mnths
once
=> 6
mnths
Catch-up Growth at Outcome(%)
40%
35%
30%
25%
20%
15%
10%
5%
0%
Only came Improv-ed
once
Deteriorated
3-D Column
1
3-D Column
2
3-D Column
3
Degree of Change (WAZ-score)
25%
20%
15%
10%
3-D
Column 1
5%
0%
>1.0
>0.5
>0
<-0.5
<-1.0
>-1.0
The PEM Scheme for children:
problems
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limited human resource capacity
lack of nutrition education
no links to community-based programmes
poor monitoring and evaluation
Outcome of PEM Scheme
• Can effect catch-up growth
• Restructuring of the PEM Scheme is
essential
• Recommendations for policy review
• Practical strategies have been recommended
to implement revised policy
Growth &
Manifestations
development
Adequate Psychosocial
dietary
Immediate
well being
Health
Adequate
Health
care
Services
determinants
intake
Household
Food
Security
of children
and women
Health
Underlying
determinants
EDUCATION
Potential
resources
Source: UNICEF
Severe Malnutrition:
Before and After
Conclusion
“Many things we need can wait.
The Child cannot.
Right now is the time his
bones are being formed, his
blood is being made and his
senses are being developed.
To him we cannot answer
“Tomorrow”.
His name is “Today”.”
- Gabriela Mistral -
Useful Resources

WHO IMCI Manual: Management of the
child with a serious infection or severe
malnutrition
 WHO Website (IMCI):
http:/www.who.int/child-adolescent-health
 IMCI charts also available on UP Intranet
(www.ais.up.ac.za) at UpeXplore
(Academic Info Services – Course: IMCI)