Adapted IMNCI malnutrition 2020

Diagnosis and Management of children with Malnutrition with reference to IMNCI (Integrated Management of Neonatal and Childhood Illness)

1. Adapted
A practical approach to the child with
Malnutrition
Background, Assessment and Management
Prof. Imran Iqbal
Prof of Paediatrics(2003-2018)
Prof of Pediatrics Emeritus, CHICH
Prof of Pediatrics, CIMS
Multan, Pakistan

3. IMNCI
A Strategy for
Outpatient Case Management
of Children
under five years of age

4. Step 1
General Danger Signs
Check for General Danger Signs in all Children
General Danger Signs indicate severe disease
Presence of any one of the General Danger Signs
means that the child needs to be
referred / admitted to the emergency

5. Check for General Danger Signs
•Unable to drink or breastfeed
•Vomiting everything
•Lethargic or unconscious
•Convulsions
•General Danger Signs indicate severity of illness
•Not diagnostic but suggests acuity of situation

6. Step 2
Assess for
Cough or Difficult Breathing
Ask the mother: Does the Child have Cough

7. Step 3
Assess for
Diarrhoea
Ask the mother: Does the Child have Diarrhea

8. Step 4
Assess for
Sore Throat
Ask the mother: Does the Child have Sore Throat

9. Step 5
Assess for
Ear Problem
Ask the mother: Does the Child have Ear Problem

10. Step 6
Assess for
Fever
Ask the mother: Does the Child have Fever

11. Step 7
Assess for
Malnutrition
Assess all children for Malnutrition

12. What is Malnutrition ?

13. Nutritional status
Nutritional status is determined by balance of
Nutritional Intake and Nutritional Expenditure
NUTRITIONAL INTAKE
NUTRITIONAL EXPENDITURE
NUTRITIONAL STATUS

14. What is Malnutrition ?
•Malnutrition is a Pathological State resulting from Deficiency of One or More
Essential Nutrients
•Protein –Calorie Malnutrition (PCM / PEM)
•Severe Acute Malnutrition (SAM)
•Specific Micronutrient deficiency
-VitA deficiency immunodeficiency
-VitD deficiency Rickets
-Iron deficiency anemia
-Iodine deficiency goitre

15. Clinical Types of Malnutrition
Previous terminology
(clinical picture)
•Marasmus
•Kwashiorkor
•MarasmicKwashiorkor
New terminology
(Weight, Height, MUAC measurements)
•Low weight
•Stunting
•Wasting
•MAM (moderate acute malnutrition)
•SAM (severe acute malnutrition)

16. Growth Charts (Weight for Age)

17. Growth Charts (Weight for Length / Height)

18. Weight for Height Reference Tables

19. Normal Anthropometric Measurements
•Weight –more than –2 z-score
(> 80 % of mean or expected for age)
•Length / Height –more than –2 z-score
(> 80 % of mean or expected for age)
•Mid arm circumference (MUAC) –125 mm to 160 mm
(at 6 months to 5 years of age)

20. Clinical types of Malnutrition
•Underweight child –Weight for Age lessthan –2 z-score
(< 80 % of mean or expected for age)
•Wasting –Low Weight for Height (indicates acute malnutrition)
•Stunting –Low Height for Age (indicates chronic malnutrition)

21. Stunting and Wasting

22. Moderate Acute Malnutrition (MAM)
(Presence of anyof the following)
•Weight for Height < -2 z-score (< 80 %)
•MUAC < 125 mm

23. Severe Acute Malnutrition (SAM)
(Presence of anyof the following)
•Weight for Height < -3 z-score (< 70 %)
•MUAC < 115 mm
•Edema

24. Severe Acute Malnutrition
•Age = 11 months
•Length = 70 cm
•Weight = 5.5 kg ( -4 SD)

25. Epidemiology

26. Prevalence of Malnutrition under 5 years of age
National Nutrition Survey –2018

27. Contribution of Malnutrition in Child Deaths

28. Causes of
Malnutrition in Pakistan

29. Nutrition Causal Framework
Adapted from Unicef
Outcome
Under-Nutrition
Immediate
Causes
Inadequate
Dietary Intake
Disease
Underlying
Health /
Nutrition
Causes
Inadequate
Care for Mothers
and Children
Insufficient
Access to Food
Lack of health services &
unhealthy environment

30. Causes of Malnutrition in Pakistan
LOW INTAKE (underfeeding)
+
RECURRENT INFECTIONS

31. Patho-physiology of
Malnutrition

32. Reductive adaptation
•Smaller size
•Thinness
•Smaller organs
•Reduced immunity

33. Physiological Effects of
Malnutrition
•Cardiovascular -↓ cardiac output and stroke volume
•GI -↓ absorption of nutrients
•Renal -↓ glomerular filtration
•Immune -↓ immunoglobulins, ↓ cell-mediated immunity
•Liver -↓ glycogen, Hypoglycemia
•Endocrine -↓ insulin levels
•Cellular function -↑ permeability of cell membranes
•Temperature regulation -↓ BMR, Hypothermia
•Skin, muscles, glands –atrophy, muscle fatigue

34. Acute Complications
•Acute infections –Diarrhea, pneumonia,
•Hypoglycemia
•Hypothermia
•Dehydration
•Electrolyte deficiency –K
+

35. Chronic Complications
•Chronic infection e.gT.B
•Malabsorption / Chronic diarrhea
•Anemia
•Vitamin Deficiencies
•Growth retardation
•Learning disorders ( low IQ)

36. Management of Malnutrition

37. WHO IMNCI Assessment and Management

38. Assess and Classify Malnutrition
•Edema feet
•Weight for Height / Length (determine z-score as per chart or table)
•MUAC (age > 6 months)
•Medical complications (extensive infections, severe dehydration,
severe anemia, hypothermia / high fever, hypoglycemia, lethargy,
convulsions, severe vomiting
•Anorexia

39. No Acute Malnutrition
•Wtfor Ht> -2 z-score (> 80 % )
•MUAC > 125 mm
•Compliment the mother
•Give Feeding advice
•Micronutrients if needed

40. MAM -Moderate Acute Malnutrition
•Wtfor Htbetween –3 and –2 z-score (70 -80 % )
•MUAC = 115 -125 mm
•Assess the Child Feeding
•Give Feeding advice
•Micronutrients

41. SAM -Severe Acute Malnutrition
•Wtfor Htless than –3 z-score (less than 70 % )
•MUAC = less than 115 mm
•Edema (nutritional cause)
•No Medical Complications
•No Anorexia -Able to feed adequately
•Assess the Child Feeding
•Give Feeding advice
•Micronutrients
•Give Therapeutic Feeds (RUTF)

42. Severe Acute Malnutrition with complications
•SAM + Medical complications (acute illness / poor appetite /
severe edema)
•Admit / Refer for Inpatient care
•Admit in Stabilization Centre (SC)
•Manage according to Guidelines
•Phase I (Stabilization)
•Phase II (Rehabilitation)

43. Principles in Management of Malnutrition
•Treat Acute complications -hypothermia, hypoglycemia, dehydration,
diarrhea, infection
•Adequate diet which the child can digest (150 –200 calories / kg / day)
•Micronutrients ( Vitamin A )
•Growth monitoring (assess weight daily or weekly)
•Follow-up (monthly to prevent relapse)

44. Time frame for the management of
a child with severe malnutrition
Stabilization Rehabilitation
Days 1-2 Days 3-7 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

45. ReSoMal
(Rehydration Solution for Malnutrition)
•Sodium Chloride 1.75 gm
•Sodium Citrate 1.45 gm
•Potassium Chloride 2.54 gm
•Potassium Citrate 0.65 gm
•Magnesium Chloride 0.61 gm
•Zinc Acetate 0.0656 gm
•Copper Sulphate 0.0112 gm
•Glucose 10 gm
•Sucrose 25 gm

46. Therapeutic diets given in SAM
•Mother milk
•F –75 diet (milk, sugar, vegetable oil, water) -75 calories / 100ml
•F –100 diet (milk, sugar, vegetable oil, water) -100 calories / 100ml
•RUTF (Ready to use therapeutic food)
•Semisolidand solid home foods which the child can take easily (e.g.
blended egg, rice, banana, potato)

47. Recipe for F-75 and F-100
Alternatives Ingredient Amount for F-75 Amount for F-100
Dried whole Milk Dried whole milk
sugar
vegetable oil Mineral
mix* water to
make 1000ml
35 g
100 g
20 g
20 ml
1000 ml**
110 g
50 g
30 g
20 ml
1000 ml**
Fresh cow’s Milk Fresh Cow’s milk, or
full cream (whole)
long life milk
sugar
vegetable oil Mineral
mix* water to
make 1000 ml
300 ml
100 g
20 g
20 ml
1000 ml**
880 ml
75 g
20 g
20 ml
1000 ml**

48. 48
Composition of RUTF (supplied by Unicef)
•Peanuts (ground into a paste)
•Vegetable oil
•Powdered sugar
•Powdered milk
•Vitamin and mineral mix (special formula)

49. Recovery from SAM
•WEIGHT GAIN should be 5 –10 gm / kg / day
•Child is considered to be recovered when
–1 SD weight for length / height
(90 % of expected weight for length / height)
has been achieved

50. Hifsa’s journey from malnutrition to health

51. Prevention of Malnutrition

52. PREVENTION OF MALNUTRITION
•Nutrition education
•Adequate feeding and diet
•Growth monitoring
•Protection against infections

53. Adequate feeding and diet
•Breast feeding for 2 Yrs
•Weaning at 4 –6 months
•Adequate diet for children
•Feeding during illness

54. Growth Monitoring
•Weigh the baby/ child every month uptofive years of age
•Plot the weight on the Growth chart
•Ensure that the weight is increasing normally

55. Protection against Infections
•Vaccination
•Handwashing
•Use Masks
•Social distancing
•Breastfeeding
•Adequate Nutrition
•Micronutrients
•Safe water
•Clean food