Dr. Ibrahim Abdi Hassan IMAM TRAINING.pptx

Consultant of Institutional training

1. IMAM TRAINING Somalia National Guidelines 2024 SC, KISMAYO GENERAL HOSPITAL

2. DAY ONE: 1. INTRODUCTION 2. PRETEST 3. SESSION 1: OVERVIEW OF IMAM 4. SESSION 2: PATHOPHYSIOLOGY AND EFFECTS OF MALNUTRION 5. SESSION 3: ASSESSMENT OF NUTRITIONAL STATUS IN INDIVIDUALS

3. INTRODUCTION

4. SCOPE Focus on the management of SAM in children 0-59 months following the revised Somali IMAM guidelines

5. Agenda, Objectives & Methodology

6. Learning objectives Discuss acute malnutrition and the need for a response Identify the principles of IMAM Describe innovations and evidence making IMAM possible Identify the components of IMAM and how they work together Identify and using national guidelines IMAM

7. Group 1 Group 2 Group 3

8. Methodology Power Point Presentations Group work Q&A Wrap-ups Quiz Daily reflections and feedback Practical exercises …..And lots discussions

9. Administrative Timing Mobile phones Other ………

10. I do not understand Can you explain again? Complaints I want more information on… Requests Questions I did not like ……. I did like …….

11. SESSION ONE: OVERVIEW OF IMAM

12. THE CORE COMPONENTS IMAM Community Mobilization TSFP OTP Stabilization Center THE PRINCIPLE OF IMAM Maximum access and coverage Timeliness Appropriate medical and nutritional care Care as long as needed ADMISSION CRITERIA OTP CHILDREN UNDER 5 YEARS OLD MUAC < 115 mm W/H z-score <-3 Oedema bilateral pitting +/++ WITH Pass appetite test and NO medical complications DISCHARGE CRITERIA TSFP CHILDREN UNDER 5 YEARS OLD MUAC > =125 mm for 2 consecutives visits W/H >= 1.5 Z-score for 2 consecutive visits Defaulter : Absent for two consecutives visits Dead : Died during time registered in TSFP Non-cured : Has not reached the discharge criteria within 4 months Referral to OTP : Has reached the SAM criteira Transfer to another TSFP THERAPEUTIC FOOD FOR SEVERE ACUTE MALNUTRITION MILK F75 MILK F100 PLUMPYNUT/ eeZeePastNUT BP100 ADMISSION CRITERIA TSFP FOR PLW Pregnant women (from the second trimester) WITH MUAC < 210 mm Lactating women whose child is <6months WITH MUAC < 210 mm CORE ACTIVTIES FOR THE COMMUNITY COMPONENT Sensitize communities on acute malnutrition Make treatment of acute malnutrition understandable Promote community case-finding and referral Conduct follow-up home visits for problem cases

13. Acute malnutrition type and classification Undernutrition: which includes stunting, wasting, underweight and micronutrient deficiencies or insufficiencies (a lack of important vitamins and minerals) Overweight: obesity and diet related to non communicable diseases (such as heart disease, stroke, diabetes and cancer) The term malnutrition always makes reference to undernutrition, and more particularly to the syndrome called Acute Malnutrition .

14. Acute malnutrition type and classification Type of acute malnutrition Malnutrition Over-Nutrition Under-Nutrition Obesity Stunting, wasting Underweight, Micronutrient deficiency

15. What is Undernutrition? A consequence of a deficiency in nutrients in the body Types of undernutrition? Acute malnutrition (wasting and bilateral pitting oedema) Stunting Underweight (combined measurement of stunting and wasting) Micronutrient deficiencies Why focus on acute malnutrition?

16. 52.5% of child mortality is associated with underweight Severe wasting is an important cause of these deaths (it is difficult to estimate) Proportion associated with acute malnutrition often grows dramatically in emergency contexts Malnutrition 52.5% Caulfied , LE, M de Onis , M Blossner , and R Black, 2004 Undernutrition and Child Mortality

17. Acute malnutrition type and classification Classification of acute malnutrition: Moderate acute malnutrition (MAM) Severe acute malnutrition (SAM): - Marasmus - Kwashiorkor

18. Causes of Malnutrition The UNICEF conceptual framework of undernutrition is shown. Source: UNICEF. Improving Child Nutrition: The achievable imperative for global progress. United Nations Children’s Fund; 2013

19. Exercise Prepare a cause of malnutrition tree for each sub-delegation (30 minutes):

20. Basic Causes Regional and national level, where strategies and policies that affect the allocation of resources influence what happens at community level. Example of resources; Human Economic Political and Cultural Geographical isolation and lack of access to markets due to poor infrastructure can have a huge negative impact on food security

21. Underlying Causes Food: Limited access or availability of food Health: Limited access to adequate health services and/or inadequate environmental health conditions Care: Inadequate social and care environment in the household and local community

22. Immediate causes Lack of food intake and disease create a vicious cycle in which disease and malnutrition exacerbate each other i.e. the Malnutrition-Infection Complex. Infection Malnutrition Lack of food intake and disease must both be addressed to support recovery from malnutrition.

23. Spiral of infection and malnutrition

24. Infections impair nutritional status by several routes Reduced food intake poor appetite mother/ carer may withhold food Increased utilization by the body energy and nutrients Losses during diarrhoea protein, zinc potassium, magnesium

25. What Is Integrated Management of Acute Malnutrition (IMAM)?

26. WHAT IMAM IS ? IMAM stands for: I - Integrated M - Management A - Acute M – Malnutrition CMAM = Community-based Management of Acute Malnutrition It is a community and health facility based approach to manage acute malnutrition

27. T.S.F.P. Program for MAM ( Moderate acute Malnutrition ) O.T.P. Outpatient for SAM without complication S.C. In-patient for SAM with medical complications Community Nutrition Workers: early detection through screening, referrals & mobilization IMAM Programs to prevent malnutrition (livelihood activities, relief activities- food and cash, water and sanitation)

28. T.S.F.P. Program for MAM ( Moderate acute Malnutrition ) O.T.P. Outpatient for SAM without complication S.C. In-patient for SAM with medical complications Community Nutrition Workers: early detection through screening, referrals & mobilization IMAM Programs to prevent malnutrition (livelihood activities, relief activities- food and cash, water and sanitation) SAM with medical complication SAM without medical complication MAM SAM with medical complication developed during treatment in OTP ICRC EcoSec Activities ICRC EcoSec Activities ICRC EcoSec Activities ICRC HEALTH Activities ICRC HEALTH Activities

29. Core Components of IMAM (1) Community Outreach: Community assessment Community mobilisation and involvement Community outreach workers: Early identification and referral of children with SAM before the onset of serious complications Follow-up home visits for problem cases Community outreach to increase access and coverage

30. Core Components of IMAM (2) 2 . Outpatient care for children 6-59 months with SAM without medical complications at decentralised health facilities and at home Initial medical and anthropometry assessment with the start of medical treatment and nutrition rehabilitation with take home ready-to-use therapeutic food (RUTF) Weekly or bi-weekly medical and anthropometry assessments monitoring treatment progress Continued nutrition rehabilitation with RUTF at home ESSENTIAL: A good referral system to inpatient care, based on Action Protocol

31. Core Components of IMAM (3) 3 . Inpatient care for children 6-59 months with SAM with medical complications or no appetite, and nutritionally vulnerable infants under 6 months. Infant or child is treated in a hospital for stabilisation of the medical complication Infant or child resumes outpatient care when complications are resolved ESSENTIAL: Good referral system to outpatient care

32. Core Components of IMAM (4) 4. Services or programmes for the management of moderate acute malnutrition (MAM) Supplementary Feeding Programme

33. Recent History of IMAM Response to challenges of centre-based care for the management of SAM 2000: 1 st pilot programme in Ethiopia 2002: pilot programme in Malawi Scale up of programmes in Ethiopia (2003-4 Emergency), Malawi (2005-6 Emergency), Niger (2005-6 Emergency) 2006-2009 many agencies and governments involved in IMAM programming in emergencies and non-emergencies E.g., Malawi, Ethiopia, Niger, Democratic Republic of Congo, Sudan, Kenya, Somalia, Sri Lanka Today IMAM is a globally accepted approach for the management of acute malnutrition and implemented in over 70 countries globally

34. Principles of IMAM Following these steps ensure maximum public health impact! Maximum access and coverage Timeliness Appropriate medical and nutrition care Care for as long as needed

35. Maximise Impact for Focusing on Public Health Population level impact (coverage) Individual level impact (cure rates) CLINICAL FOCUS Early presentation Access to services Compliance with treatment Efficient diagnosis Effective clinical protocols Effective service delivery SOCIAL FOCUS

36. Key Principles of IMAM Maximum access and coverage

37. N Darfur 2001 El Fasher Um Keddada Mellit Kutum Taweisha El Laeit Malha Tawila & Dar el Saalam Karnoi & Um Barow Koma Korma Serif Kebkabiya Fata Barno Tina Hospital with inpatient care El Sayah Outpatient care site 100 kms Inpatient care site No ICRC nutrition programme

38. Bringing Treatment into the Local Health Facility and the Home

39. Key Principles of IMAM Timeliness

40. Timeliness: Early Versus Late Presentation 41

41. Timeliness (continued) Find children before SAM and medical complications arise Good community outreach is essential Screening and referral by outreach workers (e.g., community health workers [CHWs], volunteers) Screening and referral by mothers and family members

42. 43 Inpatient care Outpatient Care SFP Catching Acute Malnutrition Early NORMAL

43. Key Principles of IMAM Appropriate medical and nutrition care

44. Appropriate Medical Treatment and Nutrition Rehabilitation Based on Need

45. Key Principles of IMAM Care for as long as needed

46. Care For as Long as Needed Care for the management of acute malnutrition is provided as long as needed Services to address acute malnutrition can be integrated into routine health services of health facilities, if supplies are present Additional support to health facilities can be added during certain seasonal peaks or during a crisis

47. Ready-to-Use Therapeutic Food (RUTF) Energy and nutrient dense: 500 kcal/92g Same formula as F100 (except it contains iron) No microbial growth even when opened Safe and easy for home use Is ingested after breast milk Safe drinking water should be provided Well liked by children Can be produced locally Is not given to infants under 6 months

48. RUTF (continued) Producers of RUTF include: Nutriset France produces ‘ PlumpyNut ® ’ and works with partners producing in 10 countries. Valid Nutrition (Malawi) Project Peanut Butter (Malawi, Sierra Leonne and Ghana) Ingredients for lipid-based RUTF: Peanuts (ground into a paste) Vegetable oil Powdered sugar Powdered milk Vitamin and mineral mix (special formula) Additional formulations of RUTF are being researched

49. Old Classification for the Treatment of Malnutrition

50. Classification for the Integrate Treatment of Acute Malnutrition

51. MUAC: Community Referral

52. Mid-Upper Arm Circumference (MUAC) for Assessment, Admission and Discharge A transparent and understandable measurement Can be used by community-based outreach workers (e.g., CHWs, volunteers), mothers and family members for case-finding in the community

53. Check the edema Exercise in couple: Attach the pictures in a paper and write down the grade of edema you see

54. Referral to the SC/OTP Treat in the OTP if good appetite and no complication. IF poor appetite & medical omplications refer to SC TREAT in the TSFP This child is WELL nourished Congratulate the mother

55. THANK YOU ANY QUESTIONS?

56. SESSION TWO PATHOPHYSIOLOGY AND EFFECTS OF MALNUTRION

57. Patho-physiology : Effects of malnutrition

58. Reductive adaptation

59. Definition: reductive adaptation? Is the physiological response of the body to under nutrition. i.e. Systems slow down and do less in severe malnutrition in order to allow survival on limited calories. The most obvious response is a reduction in body mass

60. Provided by Food ENERGY PROVIDED ENERGY EXPENDITURE Energy Reserves MUSCLE FAT Vital Organs Physical Activity Growth in a Child

61. Intergrated management of acute malnutrition- somalia Provided by food ENERGY PROVIDED ENERGY EXPENDITURE Energy Reserves MUSCLE FAT Vital Organs Physical Activity Growth in a Child

62. Malnutrition makes Loosing weight (primary muscle and fat) The body tries to reduce the energy consumption by slowing down a lot of body functions Slowing down vital functions Intergrated management of acute malnutrition- somalia

63. Can you mention some vital functions of the body?

64. Vital functions which are affected by malnutrition Cardio-vascular system Liver Genito-urinary system Gastro-intestinal system Immune system Endocrine system Metabolism and temperature regulation Cellular function Skin, Muscles and glands.

65. How does reductive adaptation affect the Cardiovascular systems?

66. The cardiovascular system The heart is working less strong Result: Blood pressure is low, weak heart What to do: The patient is vulnerable to both an increase and decrease in blood volume. Any decrease will further compromise tissue perfusion; an increase can easily produce acute heart failure. If the patient is definitely dehydrated: follow exactly the rehydration plan to avoid to overload the child. Give ReSoMal or F75 deit ; do not give intravenous fluid unless unconscious with severe shock. just because the child has diarrhea is not good practice and can lead to heart failure.

67. How does reductive adaptation affect the Circulatory systems ? Basic metabolic rate is reduced by about 30%. Energy expenditure due to activity is very low Both heat generation and heat loss are impaired; the child becomes hypothermic in a cold environment and hyperthermic in a hot environment

68. How does reductive adaptation affect the Liver ?

69. The liver has a lot of functions. Synthesis (producing) proteins Sugar producer and storage Metabolize toxins, products, drugs Biliary excretion Result: Reduced functioning of the liver In Kwashiorkor: often Fatty liver which is enlarged Synthesis of proteins is reduced (also transferrin) The liver is working slowlier than normal, so drugs or toxins are staying longer in the body than usual and can cause problems Increased risk of hypoglycemia (low sugar level) To do: The amount of protein given in the food should not exceed the capacity of the liver, but needs to be high quality since we do not give much (F75) Prevent hypoglycemia by regularly feeding Drugs which are harming the liver and the one which are excreted through the liver should be avoided (like Paracetamol, Aspirin) or in reduced dosages. Iron treatment can be dangerous, since the binding protein transferrin, who reduce the toxicity of iron is reduced.

70. How does reductive adaptation affect the Genitourinary systems (Urinary tract)

71. Kidneys are not working very well Result: Getting rid of Sodium in the body is more difficult – The kidney is physiologically unresponsive. Urinary tract infections are more common (estimated 10% of the children) What to do/and not to do: Avoid giving IV infusions, ORS or high sodium deits . Exception: shock treatment or severe dehydration with unconscious child Ensure sufficient water intake (the amount of water in F75 is enough) Aviod nutrients that can give an acid loads. Ex, magnesium chloride, excess proteins.

72. How does reductive adaptation affect the Gastro intestinal systems ?

73. The stomach and the intestines are working slowly, the motility of the whole intestine is reduced Result: Food is less good taken up by the body Absorption is reduced when the load of nutrients is high. Risk of bacterial overgrow (abdominal distension) What to do: Feed the child more often and with small meals (F75) Regularly food intake is important to keep the intestines working. If food is malabsorbed , the first step is to increase the frequency and reduce the size of each feed.

74. How does reductive adaptation affect the Immune system?

75. All activities of the immune system are reduced Result: Lymph gland and tonsils are smaller than usual Bacteria's are not killed efficiently: risk of infection is higher Immune reaction reduced: less sign of inflammation Local: reduced swelling, less redness General: Fever not very common, less signs for localization of the infection To do: Systemic antibiotics at admission Separate Phase I children from transition phase and phase 2 children Aggressive treatment in case of sick children (second line antibiotic) Hypothermia and hypoglycemia are both signs of infection Treatment should continue until weight gain begins because the child is vulnerable to cross-infection.

76. Endocrine system Insulin is reduced and there is glucose intolerance. Result: IGF-I is very low, although growth hormones is high. To do: The endocrine system may not be able to respond appropriately to large meals. Give small frequent meals. Do not give steroids (Anti-inflammation medicines.

77. Reductive effects Temperature regulations Internal heat production is limited. Temperature regulation is disturbed. The body takes the temperature of surroundings. Result: The children became hypothermic in a cold environment and feverish in a hot one To do: Cover the child with clothes and blankets. Keep windows closed at the night. Keep room temperature at 28-32C. Dry the child quickly after washing. Cool a febrile child with (not cold) water. Never use alcohol rubs to cool Avoid use Paracetamol

78. How does reductive adaptation affect the Cellular Function ? The whole body consists of cells Every cell has a pump which is regulating electrolytes in and outside of the cell (potassium, sodium, magnesium) These pumps needs a lot of energy so in malnutrition while trying to reduce the energy need, they are not working this leads to increase of sodium in the cells Decrease of potassium in the cells Result: During the Phase I the child needs high amount of potassium, magnesium and little sodium what to do: F75 has exactly right amount of sodium, potassium and magnesium Resomal also… So no other products like water, porridge, PN should be used in the stabilization phase. Potassium is low Magnesium is low Sodium is high

79. Intergrated management of acute malnutrition- somalia The Sodium- Potassium Pump Potassium Sodium Marasmus Healthy Child Sodium Potassium Kwashiorkor

80. Effects on Potassium/Sodium Homeostasis (balance) The potassium/sodium pump runs slower. This leads to accumulation of sodium in the cells and leakage of potassium out of cells followed by its loss in urine, stools etc Fluid then accumulates outside the cells (as in odema ) instead of being properly distributed throughout the body Severely malnourished children should be given potassium to make up for what is lost They also need magnesium essential for potassium to enter the cells and be retained. Sodium should be restricted. Special ORS, ( ReSoMal ) should be used instead of regular ORS for rehydration. This has less sodium and more potassium.

81. Skin, Muscles and glands.

82. How does reductive adaptation affect the skin, muscles and glands systems? Atrophy of the muscles, skin and subcutaneous fat. Atrophy of glands, inclusive tear glands, salivary glands and sweat glands Result: Signs of dehydration are unreliable: Sunken eyes may be due to reduced orbital fat Skin atrophy leads to skin folds and positive skin pitch Mouth and eyes are dry The respiratory muscles are very easily fatigued To do: Dehydration has to be judged by history of recent and frequent watery diarrhea , recent changes of sunken eyes, recent loss of skin elasticity and recent weight loss Never use the WHO definition for dehydration

83. Risk of overloading with Iron Less haemoglobin than normal is made. Iron that is not used is put in storage hence extra iron stored is in the body though child may appear anaemic. Early iron supplementation will not cure anaemia. Giving iron early can also lead to ‘free iron’ in the body, which can cause problems in 3 ways: Free iron promotes free radicals leading to uncontrolled chemical reactions with damaging effects. Promotes bacterial growth leading to worsening of infection. Body tries to protect itself by converting free iron to ferritin. This uses energy and amino acids and diverts these from other critical activities. As child recovers and starts using iron to form red blood cells, the iron in storage will be used and supplements will be needed.

84. Implication on Management of Severe Acute Malnutrition As child is treated, the body systems must gradually ‘learn’ to function fully again. Hence strict follow-up of treatment guidelines is required. Rapid changes e.g. rapid feeding and fluids would overwhelm the systems hence feeding must be slowly and cautiously introduced. Refer to the feeding guideline.

85. Nutritional Treatment Muscular degeneration Multiple mineral and vitamin deficiencies Energy diet with vitamins and minerals Low glycogen reserves Meals at night Excess sodium --- risk of cardiac failure Low-sodium diet Decrease in total potassium High potassium diet Poor utilization and elimination of amino acids or proteins Low protein diet

86. Nutritional treatment Low fat absorption Limited lipid content of diet Intestinal absorption reduced Small frequent meals Gradual increase in quantity of meals Reduced ability to synthesize iron-binding proteins: free iron in the blood, stimulating bacterial growth Low-iron diet at start of treatment Do not give iron tablets

87. Intergrated management of acute malnutrition- somalia Systematic Medical Treatment Diminished immunocompetence Broad-spectrum antibiotic treatment Anti-malarial treatment Measles vaccination Dehydration Low-sodium high potassium ReSoMal Poor regulation of body temperature Keep child warm and watch temp closely

88. Thank You Questions?

89. SESSION THREE: Assessment of Nutritional Status in Individuals

90. Assessment of Nutritional Status in Individuals In situations of conflict or violence, acute malnutrition appears quickly after the initial shock, when food and health conditions are deteriorating. Malnutrition is measured because it is linked to a high risk of mortality, and it can be treated. Chronic malnutrition takes longer to appear, and changes caused by the conflict are not immediately visible. However, it is important to collect information on chronic malnutrition, because it is a good indicator of poverty and of the shortages of services and essential infrastructure that existed before the crisis. In the general population, anthropometric measurements (measurements of body proportions) and assessments of oedema are performed on children aged 6 to 59 months. Always the measurements should be taken among pregnant and lactating women. Anthropometric data   To assess growth in children you can use several different measurements including length or height, weight, MUAC and oedema and to assess PLW you use the MUAC.

91. 1. MEASURING WEIGHT/HEIGHT or LENGTH If a child’s weight falls within the range considered normal for his/her height, the child is found to be well-nourished. If the weight is less than the international standards, the child is considered acutely malnourished or wasted. WHO has created cut-off points to indicate the severity of the undernutrition.   If a child’s weight-for-height is between -3 z-scores and -2 z-scores (or standard deviations) of normal children, s/he is considered to suffer from moderate acute malnutrition (MAM).   If the child’s weight-for-height is less than -3 z-scores (standard deviations) of normal children s/he suffers from severe acute malnutrition (SAM) and is considered to be severely wasted.

92. 2. MUAC ( Mid-Upper Arm Circumference ) MUAC measurements require a simple, colour-coded measuring band rather than weighing scales and height boards, they are often used during crisis situations. Mid-upper arm circumference, often shortened to MUAC, is a measurement that allows health workers to quickly determine if a patient is acutely malnourished. MUAC provides a fast and effective first-line screening method. MUAC measurement is expressed in millimeters (mm) RED ZONE –Severe Acutely malnourished ORANGE ZONE – Moderately malnourished GREEN ZONE – Properly nourished

93. 2. MUAC ( Mid-Upper Arm Circumference ) Useful for PLW, a MUAC measurement under 230 mm indicates that a PLW is suffering from malnutrition. MUAC measurement is expressed in millimeters (mm) UNDER 230 mm. Acute malnutrition

94. 3. OEDEMA Oedema is the retention of water in the tissues of the body. Pitting- bilateral oedema is a sign of kwashiorkor, a form of severe acute malnutrition. In this form of severe acute malnutrition, oedema is present on the lower limbs, and is verified when thumb pressure is applied on top of both feet for three seconds and leaves a pit or indentation in the foot, after the thumb is lifted. The oedema may eventually spread to the legs and face, and the child appears puffy, and is usually irritable, weak and lethargic.

95. 1. How to measure weight and height/length Measuring Weight : Electronic Scale Weight should be measured to the nearest 100 g (0.1 kg)

96. 1. How to measure weight and height/length Measuring Weight : Electronic Scale Two methods of measuring a child using an electronic scale: Direct : Measure the child by themselves. Children able to stand up can be weighed by standing on the scale. Indirect : Measuring the child in the arms of a caretaker (aka “double weighing”) Babies/young children unable to stand on their own Children who are too weak to stand on their own Children who are disabled Children who are restless and can’t stand still Weight should be measured to the nearest 100 g (0.1 kg)

97. 1. How to measure weight and height/length Electronic Scale setup Place the scale on a hard and flat surface, if possible E.g., concrete, solid ground, wooden board, but NOT on the height board Place the scale in the shade or indoors, if possible If the scale overheats and does not work properly, move it to a cooler place and wait 15 minutes before trying again Handle the scale with care and protect it from excess humidity Ensure that the batteries are working before going to the field and carry a spare set

98. 1. How to measure weight and height/length Indirect (Double) Weighing Explain the procedure to the child’s mother or caretaker Take off the child’s clothes Place the scale on a flat surface. Turn on the scale Ask the caretaker (mother) or the assistant to stand on the scale After their weight appears, the caretaker stays on the scale The measurer presses the hold/tare button (to “zero” the scale) Wait until the 0.0 must appears Hand the child to the caretaker. The child must be held facing the caretaker, and should keep still. Note: The person whose weight was used to zero the scale must hold the child to be weighed The weight displayed will be the child’s weight Measurer reads the weight out loud. Assistant repeats the weight out loud to confirm, and writes the weight on the data sheet

99. 1. How to measure weight and height/length Electronic Scale: Roles Measurer: Takes the reading Assistant: Kneels in front of child. Ensures that the child’s feet are entirely on the scale and that they are looking straight ahead (not down). If double weighing, assistant ensures that the child is held tight and facing the caregiver

100. 1. How to measure weight and height/length Salter Scale

101. 1. How to measure weight and height/length Salter Scale Setup Weight should be measured to the nearest 100 g (0.1 kg). Attach the weighing pants, basket or basin and confirm the scale is set at zero. Involve the caregiver in calming the child. Have her remain close to the child.

102. 1. How to measure weight and height/length Salter Scale : Roles Measurer: Wait until pointer stops before taking the exact reading. Take the reading at eye level. Do not round the weight measurement. Assistant: Help place the child in the weighing pants. Help calm down the child, if necessary.

103. 1. How to measure weight and height/length General recommendations Always calibrated scale EVERY DAY in the morning Always measure weight before height If there is more than 1 eligible child in a household, always weigh the ‘less fussy’ one first Try and obtain scales that are sturdy but light enough to be carried easily by the team Measure weight without clothes

104. 1. How to measure weight and height/length Measuring Height and Length Measure Length when child is < 2 years of age or <87cm. Measure Height when child is ≥ 2 years of age or ≥87cm. Use ONE inclusion criteria (Age OR Height)

105. 1. How to measure weight and height/length Measuring Length

106. Measuring Length Correct position view perpendicular to the base of the board

107. 1. How to measure weight and height/length Measuring Length: Roles Measurer: Kneels beside child’s feet on the child’s right Left hand on child’s knees or shins to ensure straight legs Ensures that feet are FLAT against the cursor Takes the reading Assistant: Kneels at top of child’s head Gently but firmly holds both sides of child’s head and ensures child is looking straight up towards the sky Records the reading

108. 1. How to measure weight and height/length Measuring Height

109. 1. How to measure weight and height/length Standing height measurement

110. 1. How to measure weight and height/length Measuring Height: Roles Measurer: Kneels on child’s left. Gently but firmly presses on both sides of chin with the left hand (making sure not to touch the neck) so that the back of the head and shoulder blades touch the board and child is looking straight ahead. Holding the cursor with the right hand, takes the height reading at eye level . Assistant: Kneels on child’s right (opposite measurer). Ensures child’s heels, calves and buttocks touch the board and their arms are by their side. Does not look up to read height. Records the reading.

111. 2. How to measure MUAC Measuring MUAC

112. 2. How to measure MUAC Key Points Measuring Midpoint Arm is 90 degrees. Ensure MUAC tape window (0 cm) is placed over AC joint and make an imaginary line through the tip of the elbow Keep top hand planted over AC joint when marking mid point

113. 2. How to measure MUAC Common MUAC mistakes Measuring MUAC on the right arm. Estimating (rather than measuring) the mid-point of the upper arm. Bending the MUAC tape when measuring the midpoint. Not measuring the midpoint from the tip of the shoulder to the elbow bend. Pulling the MUAC tape too tight. Not pulling the MUAC tape tight enough (too slack). Not reading the tape accurately (to nearest mm). Ensure MUAC tape window (0 cm) is placed over AC joint and make an imaginary line through the tip of the elbow Keep top hand planted over AC joint when marking mid point

114. 3. Diagnosis of bilateral OEDEMA Count to 3 when administering the test for Oedema “One thousand and one , two thousand and one, three thousand and one”. Oe dema must be bilateral (both feet) . Tested after weight and height/length measurements. Hard pressure is not required to test for oedema.

115. 3. Diagnosis of bilateral oedema Thumb Pressure Test

116. 3. Diagnosis of bilateral oedema Thumb Pressure Test

117. Common errors Why? Look the pictures and find the mistake

118. THANK YOU QUESTIONS ?

119. DAY TWO: REVIEW OF DAY ONE SESSION ONE: STABILIZATION CENTER SESSION TWO: INFANTS LESS THAN 6 MONTHS SESSION THREE: ROUTINE MEDICINES

120. SESSION ONE: STABILIZATION CENTER

121. DECISION MAKING for SC or OTP

122. . STABILIZATION CENTER Acute-phase or Phase 1 Patients with an inadequate appetite and/or an acute major medical complication are initially admitted to an SC for acute-phase treatment. The formula used during this phase (F75) promotes repair of physiological and metabolic functions and electrolyte imbalance. Rapid weight gain at this stage can be dangerous, that is why F75 is formulated so that patients do not gain weight

123. . STABILIZATION CENTER Transition Phase A transition phase is then introduced because a sudden change to large amounts of diet before physiological functions are fully restored can be dangerous and lead to electrolyte disequilibrium and “refeeding syndrome”. During this phase the patients start to gain weight. The diet is changed to RUTF or F100 and the amount given increases the energy intake by about 30%. The increase in energy intake should give a weight gain of around 6g/kg/d ; this is less than the quantity given and rate of weight gain expected in the recovery phase

124. . STABILIZATION CENTER Transfer/return to OTP for the recovery phase Whenever patients have a good appetite and no acute major medical complication, they are given RUTF and transferred to OTP. These formulae are designed for patients to rapidly gain weight (more than 8 g/ kg/ day).

125. STABILIZATION CENTER The structures There are different possibilities: • SC on a 24/24 hour basis SC on a Day Care system (receiving 5 or 6 meals during the day) Those from far away sleep in the facility in a separate room or a separate local structure, on beds or (preferably) mattresses on the floor. 24h care is not required for many in-patients. Patients who live or are hosted by family or friends in the immediate neighbourhood of the facility can come each morning and remain in the facility during the day and then return home at night (non-residential day-care) .

126. . STABILIZATION CENTER Organisation of the SC A space to take the anthropometric measurements, examine the patients, prepare the therapeutic milk (F75), the drugs to deliver to the patients, toilet and washing facilities, provision for the caretakers to cook (and where possible food given to the caretakers), and storage facility for drugs and F75/F100/RUTF The patients should always be treated together in a separate room or dedicated section of the ward and NOT mixed with other patients Mothers should sleep with their children to avoid hypothermia, emotional stress, and interruption of breast feeding, and so that the mothers themselves do not get exhausted, are able to make rational decisions, and are less likely to default

127. . STABILIZATION CENTER Admission NEW ADMISSION Applies the procedure of triage and admits the SAM patients with complications to the SC and transfers those with a good appetite and without medical complications directly to the OTP

128. . STABILIZATION CENTER Admission From OTP (Internal transfer) Register the patient using his/her SAM N° given by the OTP (if the SAM patient is referred by other health facilities or the Emergency Room, the SAM-number is given by the facility) Ask the doctor in charge to examine the patient when s/he is available but do not wait before starting treatment according to the protocol Give a phone call to the OTP transferring the patient to inform them of arrival and discuss any details that are not recorded on the transfer from the doctor in charge to examine the patient when s/he is available but do not wait before starting treatment according to the protocol . Start treatment of the acute-phase and treat the complications according to the protocol

129. STABILIZATION CENTER To OTP As soon as possible, move to Transition phase and prepare for transfer to the OTP

130. STABILIZATION CENTER Records The registration book It contains all the information necessary to complete the monthly and other reports The Multi-chart It is the primary tool used for in-patient treatment of malnourished patients. Other charts should not be used. All the staff use the same multi-chart to record all the information needed to manage the malnourished patient – separate charts are not used by different categories of staff The Critical-Care chart It is used for patients with complications who require more intensive monitoring during the acute treatment of the complication

131. .

132. ACUTE PHASE 1 Diet : F75 It is designed for patients with severe complicated malnutrition who have impaired liver and kidney function with infection. Patients should not gain weight on F75. The diet allows their biochemical, physiological, and immunological functions to start to recover before they have the additional stress of making new tissues

133. . ACUTE PHASE 1 Diet : F75 Half an hour before the scheduled time for giving the feed, ask the mothers to breast-feed their children • Calculate the total quantity of F75 to prepare according to the number of patients, their weight, and the number of feeds • Prepare the quantity of water and F75 for the feeds • Ask the mother to wash her own and her children’s hands Give eight feeds per day over 24h (night as well as daytime) Make out a time schedule and post it on the wall

134. Diet : F75 Give eight (or more) feeds per day over 24h (night as well as daytime) for the few children who cannot tolerate the increased volumes when 5 or 6 feeds, quite closely spaced during the day, are given. This includes those who: are very severely ill, develop re-feeding diarrhea on the routine schedule, have had very little during the day (e.g. new arrivals), have vomited some or all of their feeds during the day, have had an episode of hypoglycemia, have had hypothermia, and in places where there are sufficient staff to prepare and distribute the feeds at night (unusual).

135. .

136. . Naso-gastric feeding Naso -gastric tube (NGT) feeding is used when a patient is not taking sufficient diet by mouth The reasons for use of an NG tube are: o Taking less than 75% of prescribed diet per 24 hours o Pneumonia with a rapid respiration rate o Painful lesions of the mouth o Cleft palate or other physical deformity o Disturbances of consciousness Every day, try patiently to give the F75 by mouth before using the NGT. The use of the NGT should not normally exceed 3 days and should only be used in the Acute- phase

137. Feeding technique

138. Feeding technique Why is it important? The muscle weakness, slow swallowing, and poor peristalsis of these children makes aspiration pneumonia very common Tell the mother to put the child on the mother’s lap against her chest, with one arm behind her back. The mother’s arm encircles the child and holds a saucer under the child’s chin. The child should be sitting straight (vertical) Give the F75 in a cup, any dribbles that fall into the saucer are returned to the cup If a child “splutters” or coughs during feeding, tell the mother that it is probably due to incorrect feeding- technique

139. Feeding technique Tell the mother not to force fed the child and never to pinch his/her nose, squeeze the cheeks to force the mouth open, or lie back and have the milk poured into the mouth The meals of the caretakers should never be taken beside the patient

140. Feeding technique The only food apart from F75 that the child should receive is breast milk

141. Failure-to-respond for In-Patients

142. Investigation on the Causes of failure to respond (In-patients) PROBLEMS WITH THE TREATMENT FACILITY: • Failure to apply the protocol appropriately • Poor environment for malnourished children • Excessively intimidating, strict, or cross staff • Failure to treat the children in a separate, dedicated area • Failure to complete the multi-chart correctly (or use of traditional hospital records only) • Insufficient staff (particularly at night) • Poorly trained staff – excessive staff turnover or untrained senior medical staff • Inaccurate weighing machines (or failure to take and plot the weight change routinely) • F75 not prepared or given correctly PROBLEMS OF INDIVIDUAL CHILDREN: • A severe medical complication (see section on complications) • Drug toxicity (see section on drugs) • Insufficient food given (criteria for NGT not applied) • Food taken by siblings or caretaker • Sharing of caretaker’s food • Malabsorption • Psychological trauma • Rumination (and other types of severe psychosocial deprivation ) • Infection, especially : viral, bacteria resistant to the antibiotics being used , fungal , diarrhoea , dysentery , pneumonia , TB, urinary infection/ Otitis media, malaria, HIV/AIDS, Schistosomiasis / Leishmaniosis , Hepatitis / cirrhosis • Other serious underlying disease : congenital abnormalities (e.g. Down’s syndrome), neurological damage (e.g. cerebral palsy ), inborn errors of metabolism

143. Criteria to Progress from Acute-Phase to Transition Phase There is no “fixed” time that a child should remain in the acute phase – individual children differ Transfer a patient from Acute-phase to Transition Phase when all the following are present: Return of appetite and Beginning of loss of oedema (Normally judged by an appropriate and proportionate weight loss as the oedema starts to subside) and The patient appears to be clinically recovering. Patients with gross oedema (+++) should wait in Acute-phase at least until their oedema has reduced to moderate (++) oedema . These patients are particularly vulnerable

144. TRANSITION PHASE Transition Phase prepares the patient for Recovery-phase as an out-patient The transition phase usually lasts between 1 and 5 days

145. TRANSITION PHASE DIET ATTENTION! The ONLY change that is made to the treatment on moving from Acute-phase to Transition-Phase is a change in the diet from F75 to RUTF, or to F100

146. TRANSITION PHASE It is preferable to use RUTF in the Transition Phase DIET Those children who have been very ill and are going to continue treatment as out-patients with take-home treatment should become habituated to RUTF before they go home

147. TRANSITION PHASE Give the total amount of RUTF that should be taken during the day according to the table • Advise the mother to breastfed the child 30 min before giving the RUTF • Tell the mother to wash hands before giving the sachet of RUTF to the child • Tell the mother to offer plenty of water to the child • Advise the mother to put the sachet in a box (insect and rodent proof) when the child has finished each session of eating • CHECK five times during the day the amount given by the mother. It is important for the assistant to check regularly and counsel the mother and not assume that the mother will give all the RUTF to the child. It is useful to have regular “meal times” for the children where the mothers all gather together in one place to feed their children. DIET

148. TRANSITION PHASE DIET for children that are not taking sufficient RUTF (not gaining any weight)

149. TRANSITION PHASE DIET Either give F100 for a few days and then re-introduce RUTF • Or return the child to the acute-phase for a day or so and give F75 • Do NOT give any other food to the patient during this period • Do NOT let the caretaker eat in the same room as the malnourished children Check that the caretaker or other children do not consume the patients’ RUTF • Make drinking water available both in the ward and also to individual children. The mother must offer as much water to drink as they will take during and after they have taken some of the RUTF

150. TRANSITION PHASE DIET Table for RUTF in Transition Phase per 24h

151. TRANSITION PHASE DIET Table for on the amounts of f100 to give for 6 – 5 feeds per day (24 hours)

152. TRANSITION PHASE DIET WHAT TO DO? 20 MINUTES OF DISCUSSION TO DECIDE HOW TO PROCEED WITH THE DIET IN ICRC S.C. (TRANSITION PHASE)

153. Criteria to move back from transition phase to the acute phase • If there is a rapid increase in the size of the liver • If any other signs of fluid overload develop (increased respiratory rate) • If the patient gains weight more rapidly than 10g/kg/d (this indicated excess fluid retention) • If tense abdominal distension develops (indicates abnormal peristalsis, small bowel overgrowth and perhaps excess carbohydrate intake) • If the patient gets significant re-feeding diarrhoea so that there is weight loss (see separate section) • If a complication arises that necessitates an intravenous infusion (e.g. malaria, dehydration, etc.) • If there is any deterioration in the child’s condition (see section on refeeding syndrome) • If there is increasing oedema

154. Criteria to progress from transition phase to OTP • If s/he has a good appetite - this means taking at least 90% of the RUTF (or F100) prescribed for transition phase • For oedematous patients (kwashiorkor), if there is a definite and steady reduction in oedema • If there is a capable caretaker • If the caretaker agrees to out-patient treatment • If there are reasonable home circumstances • If there is a sustained supply of RUTF • If an OTP program is in operation in the area close to the patient’s home

155. EXERCISE Referral from Impatient to Outpatient Care

156. THANK YOU QUESTIONS?

157. SESSION TWO: INFANTS LESS THAN 6 MONTHS

158. INFANTS LESS THAN 6 MONTHS OLD WITH A FEMALE CARETAKER

159. INFANTS LESS THAN 6 MONTHS OLD WITH A FEMALECARETAKER The objective of treatment of these patients is to return them to full exclusive breast-feeding. This is achieved by stimulating breast-feeding at the same time as supplementing the child during breast feeding until the infant becomes stronger and breast milk production is sufficient to allow the child to grow properly

160. INFANTS LESS THAN 6 MONTHS OLD WITH A FEMALE CARETAKER

161. INFANTS LESS THAN 6 MONTHS OLD WITH A FEMALE CARETAKER Diet The SS-milk can be made by diluting F100 to make F100 dilute. Note: Full strength F100 should NEVER be used for small infants of children less than 3kg. The renal solute load is too high for this category of child and could provoke hypernatraemic dehydration

162. INFANTS LESS THAN 6 MONTHS OLD WITH A FEMALE CARETAKER

163. INFANTS LESS THAN 6 MONTHS OLD WITH A FEMALE CARETAKER Supplemental Suckling (SS) technique

164. INFANTS LESS THAN 6 MONTHS OLD WITH A FEMALE CARETAKER At the beginning of the SST technique • Use a tube the same size as n°8 NGT • Put the appropriate amount of SS-milk in a cup and hold it • Put the end of the tube in the cup • Put the tip of the tube on the breast at the nipple • Tell the mother to offer the breast in the normal way so that the infant attaches properly • When the infant suckles on the breast, with the tube in his mouth, the milk from the cup is sucked up through the tube and taken by the infant. It is like taking a drink through a straw • Help the mother at first by holding the cup and the tube in place Place the cup at first about 5 cm to 10 cm below the level of the nipple so the SS-milk can be taken with little effort by a weak infant NEVER place the cup above the level of the nipple, or it will flow quickly into the infant’s mouth by siphonage with a major risk of inhalation

165. INFANTS LESS THAN 6 MONTHS OLD WITH A FEMALE CARETAKER

166. CARE FOR THE FEMALE CARETAKER As the aim is to increase breast milk, the mother’s health and nutritional status are critical for the nutritional repletion of the infant

167. CARE FOR THE FEMALE CARETAKER Check mother’s MUAC and the presence of oedema • Explain to the mother what the aim of treatment is and what is expected of her • Do not make the mother feel guilty for the state of her child or blame her for giving other foods Tell her and encourage her to drink at least 3 litres per day • Make the necessary arrangement for the mother so she can eat about 2500kcal/day of a high-quality diet • Give the mother Vitamin A: 1) If the child is below 2 months or if the mother is menstruating: 200.000UI (there should be no risk of pregnancy), 2) If the child is above 2 months: 25.000UI once a week • Give Micronutrient supplementation • Decrease as much as possible the length of stay in the facility • If needed, give drugs which help with lactation (ICRC ???)

168. INFANTS LESS THAN 6 MONTHS OLD WITH A FEMALE CARETAKER • Monitor the progress of the infant by the daily weight with a scale graduated within 10g (or 20g) and record the information on the on the infant chart. If the child loses weight over 3 consecutive days yet seems hungry and is taking all his F100 dilute/infant formula, • Add 5ml to each feed The Supplemental Suckling feed is giving maintenance amounts. If it is being taken and there is weight loss, either the maintenance requirement is higher than calculated or there is significant malabsorption. If the child grows regularly with the same quantity of milk, Tell the mother that the quantity of breast milk is increasing and she is “responsible” for recovery

169. INFANTS LESS THAN 6 MONTHS OLD WITH A FEMALE CARETAKER If after some days, the child does not finish all the supplemental food, but continues to gain weight : • Tell the mother that the breast milk is increasing and that the infant is getting enough to fully recover • Reduce the amount of SS-milk given at each feed by the amount not taken. For example, if the child is supposed to take 10ml, but only manages to take 7ml in the current feed, then the next feed should be 7ml not 10ml. This means that the treatment is working, as the idea is to gradually reduce the SS-Milk and increase the breast milk taken.

170. INFANTS LESS THAN 6 MONTHS OLD WITH A FEMALE CARETAKER When a baby is gaining weight at 20g per day for 2 consecutive days (whatever her/his weight) • Decrease the quantity of SS-milk given at each feed to one half of the maintenance intake If, on half the SS-intake, the weight gain is maintained at 10g per day (whatever her/his weight) • Then stop supplement suckling completely. Tell the mother that she is doing this all by herself If the weight gain is not maintained when the SS-milk intake is cut in half • Then change the amount given to 75% of the maintenance amount for 2 days and then reduce it again if weight gain is maintained.

171. INFANTS LESS THAN 6 MONTHS OLD WITH A FEMALE CARETAKER If the mother wishes to go home as soon as the child is taking the breast milk greedily and gaining weight, they should be discharged If the mother is agreeable, keep in the centre for a further 2 days on breast milk alone to confirm that her infant continues to gain weight on breast milk alone Then discharge the infant, no matter what his current weight for age or weight for length

172. INFANTS LESS THAN 6 MONTHS OLD WITH A FEMALE CARETAKER

173. INFANTS WITHOUT ANY PROSPECT OF BEING BREAST-FED These young infants are particularly vulnerable because they have neither a mother nor the protection of breast milk

174. INFANTS WITHOUT ANY PROSPECT OF BEING BREAST-FED

175. INFANTS WITHOUT ANY PROSPECT OF BEING BREAST-FED The infants must have antibiotics routinely and the management of complications is the same as for older infants and children The diet should normally be based upon Generic Infant Formula except for those with oedema when F75 is used in the acute phase Generic Infant Formula is preferred, however, F100diluted can be used, but full strength F100 must never be used ACUTE PHASE

176. INFANTS WITHOUT ANY PROSPECT OF BEING BREAST-FED During recovery phase, twice the volume of Generic Infant Formula (or F100diluted) is OFFERED to the infants This is a large amount to encourage rapid catch up growth - they must NEVER be force fed The frequency of feeding can be reduced to 6 times per day RECOVERY PHASE

177. When the infant reaches -1.5Z score weight-for-height and is gaining weight at 20g/d, s/he can be discharged. He/she should be followed at the MCH clinic every week in addition to home visit by an outreach worker and community volunteer The infant is discharged from the SC as “cured” The infants will be discharged on Generic Infant Formula The caretaker (father/siblings) must have the knowledge and facilities to prepare the formula milk safely Follow-up for these infants and their caretakers is very important and should be organised by the outreach worker in conjunction with the community volunteers CRITERIA DISCHARGE

178. QUESTIONS?

179. SESSION THREE: ROUTINE MEDICINES

180. ROUTINE MEDICINES Antibiotics should be given to every severely malnourished in-patient, even if they do not have clinical signs of systemic infection. Despite the absence of clinical signs, they are all infected.

181. ROUTINE MEDICINES ANNEX 25 – Pages 179-180-181-182 First line treatment for patients without apparent signs of infection: give oral Amoxicillin OR cefotaxime IM or amoxicillin-clavulanic acid combination and/or metronidazole

182. ROUTINE MEDICINES Second line treatment for patients with any apparent signs of systemic infection: add gentamicin IM OR change to cefotaxime IM injection plus ciprofloxacin orally If suspicion of Staphylococcus infection add cloxacillin

183. ROUTINE MEDICINES Third line : individual medical decision Anti-fungal treatment: Nystatin fluconazole Medications should be administered orally preferably, only in special cases they could be administered via parenteral (IM), no infusions and rarely if never indwelling cannula.

184. ROUTINE MEDICINES THE DISADVANTAGES OF INDWELLING CANNULA

185. ROUTINE MEDICINES THE DISADVANTAGES OF INDWELLING CANNULA They give access to the circulation for antibiotic- resistant bacteria in these immuno-compromised patients. • The dressings quickly become dirty in conventional hospital settings. • They often become colonised with Candida and can give rise to fungal septicaemia . • They require fluid or anticoagulants to keep the vein open – but these children have impaired liver function (bleeding tendency) and are very sensitive to fluid overload. • They require skilled health persons to insert, re-site, and maintain the cannula - staff time is the limiting factor in most resource poor settings.

186. ROUTINE MEDICINES THE DISADVANTAGES OF INDWELLING CANNULA • The administration of IV drugs takes more time, from higher grades of staff, than giving oral drugs. • IV preparations are much more expensive than oral preparations and the cannula itself is expensive. • Insertion of the cannula is painful and distressing for the child and they frequently need to be re-inserted. • The cannula restricts the movements of the child and impairs feeding, washing, play, and care. • Extravasations into the tissue can cause skin necrosis and other complications.

187. ROUTINE MEDICINES MALARIA asymptomatic malaria should be followed in OTP, cases with symptomatic malaria are admitted to SC 1st line: artemether+lumefantrine (AL) For complicated Malaria, high dose artemether or artesunate suppositories; When diarrhoea , disturbance of consciousness, or where suppositories are not available, give IM artesunate or IV artemether. Once responding, change to oral AL 2nd line: Dihydroartemesinin – Piperaquine No Quinine or Amodiaquine in SAM patients.

188. ROUTINE MEDICINES

189. ROUTINE MEDICINES Give all children from 6 months, without a vaccination card, measles vaccine on admission (and a second dose at week 4 as an outpatient in OTP. Young children should also get a further dose at 9 months according to the national protocol) Measles

190. MEDICINES given under specific circumstances only There is sufficient vitamin A in F75, F100, and RUTF to correct mild vitamin A deficiency Vitamine A Folic Acid There is sufficient Folic Acid in F75, F100, and RUTF to treat the mild folate deficiency

191. THANK YOU FOR YOUR ATTENTION

192. DAY THREE: REVIEW OF DAY TWO SESSION ONE: TREATMENT OF COMPLICATIONS POST TEST AND CLOSING CEREMONY

193. SESSION ONE TREATMENT OF COMPLICATIONS IN SAM

194. HYPOGLYCEMIA Definition: Hypoglycemia is a condition in which the blood sugar(glucose) is lower than normal. ( hypo means low and glycemia means blood sugar).

195. Conti… Hypoglycemia is said when the blood glucose level is: <54mg/ dL or <3mmol/L

196. What is the normal range of blood sugar?

197. What causes hypoglycemia Hypoglycemia can be caused by may factors but Severely acute malnourished children the most common cause is lack of oral intake or fasting for several hours. Sepsis is also a common cause of recurrent hypoglycemia in SAM patients.

198. Clinical signs and Pathophysiology Glucose is the cells preferred fuel molecule and most important thing for production of ATP. when the levels of blood glucose fall all the normal physiological processes in our body are disrupted and the clinical signs of hypoglycemia start to develop.

199. Conti… The body normally defends against hypoglycemia by decreasing insulin secretion and increasing glucagon, epinephrine, growth hormone and cortisol secretion. These hormonal changes combine to increase hepatic glucose output, increase alternative fuel availability and decrease glucose use.

200. Conti… The signs and symptoms of hypoglycemia develop as a result of these compensatory mechanisms by the body

201. Conti… There are often no signs at all of hypoglycemia. Most hypoglycemic malnourished children do not sweat, have raised hair on their arms, or go pale. They simply become less responsive and slip into coma and often present with hypothermia. One sign of the overactive sympathetic nervous system which starts before actual hypoglycemia develops and is seen in the malnourished child, is eye-lid retraction. If a patient sleeps with his/her eyes slightly open, then s/he should be woken up and given sugar-water or F75 to drink. The mothers and staff should be taught to look for this sign during the night.

202. Complications of hypoglycemia In severe, prolonged and untreated hypoglycemia lead to seizures that can cause life-threatening and permanent brain tissue damage, coma and ultimately death.

203. Prevention Give sugar-water to all children that have travelled for long distances as soon as they arrive at the centre. As it is normally unknown when a new admission last had food all new arrivals should be given sugar-water routinely while they are waiting to be measured and assessed. Give extra sugar to all children who get hypothermia or have septic shock, whether or not they have low blood glucose. The children who develop hypoglycemia are those that have not taken food (carbohydrate) for at least 12 hours. Any child that has not taken food during the day needs at least one feed during the night.

204. Quantity of Water Quantity of Sugar 100 ml 10 g 2 heaped teaspoons 200 ml 20 g 4 heaped teaspoons 500 ml 50 g 10 heaped teaspoons 1 Litre 100 g 20 heaped teaspoons

205. Treatment For Patients who are conscious and able to drink, give about 50 ml (approximately 5 to 10ml/kg) of sugar-water (about 10% ordinary sugar in water), or F75 by mouth. The actual amount given is not critical. For Patients losing consciousness, give 50 ml of sugar- water by NGT immediately. When consciousness is regained, give F75 feeds frequently. For semi-conscious and unconscious patients, give sugar-water by NGT immediately. They should then be given glucose as a single intravenous injection (approximately 5ml/kg of a sterile 10% glucose solution).

206. Conti… Treat all malnourished patients with hypoglycemia with second-line antibiotics. The response to treatment is dramatic and rapid. If a very lethargic or unconscious patient does not respond in this way. then it is urgent that another cause for the clinical condition is considered, found, and treated (e.g. cerebral malaria, meningitis, hypoxia, hypernatremia, shock, etc.)

207. HYPOTHERMIA Hypothermia is a condition in which the body’s temperature is lower than normal Derived from two words: hypo which means low and thermo which means heat or temperature.

208. Conti… Hypothermia is said when the body’s temperature is B elow 35.5oC in Rectal temperature or B elow 35oC in under- arm temperature

209. What is the normal range of body temperature?

210. Severely malnourished patients are highly susceptible to hypothermia Why?

211. What causes hypothermia Prolonged exposure to cold temperatures may become the main cause of hypothermia in SAM patients. Hypoglycemia can also be a concurrent problem. Infection also can become the underlying cause of hypothermia.

212. Complications Cardiac arrhythmias Aspiration pneumonia Pulmonary edema Pancreatitis bleeding diathesis Bladder atony Frostbite

213. Prevention of hy p othermia Keep the room warm, especially at night (the thermo- neutral temperature for malnourished is from 28oC and 32oC). Keep windows and doors closed at night. Monitor the temperature with a maximum-minimum thermometer on the wall. Use adult beds so the children sleep with their mothers. There should be adequate blankets. Do not wash severely ill children!

214. Treatment Use the “kangaroo technique”. The child is placed on the chest of the mother skin-to-skin and the mother’s clothes wrapped around the child. Put a hat on the child. Check the blood glucose level and treat if the child is hypoglycemic.

215. kangaroo technique

216. FEVER Fever or hyperthermia is a condition in which the body’s temperature raised from it’s normal ranges.

217. Conti… Severely malnourished children do not respond to anti- pyretics. Because they fail to work, caretakers and staff often repeat the dosage inappropriately, frequently leading to toxicity. Antipyretics are much more likely to be toxic in the malnourished than a normal child.

218. Do not give aspirin or paracetamol to SAM children in SC.

219. Management For moderate fevers, up to 38.5°C rectal Do not treat moderate fevers (up to 38.5°C rectal or 38.0°C underarm). Maintain routine treatment. Remove blankets, hat, and most clothes and keep in the shade in a well-ventilated area. Give water to drink. Check for malarial parasites and examine for infection.

220. Conti… Fevers of over 39°C rectal or 38.5°C underarm, where there is the possibility of hyperpyrexia developing In addition to the above, also: Place a damp/wet room-temperature cloth over the child’s scalp and re-dampen the cloth whenever it is dry. Monitor the rate of fall of body temperature. Give the child abundant water to drink. If the temperature does not decline, the damp/wet cloth can be extended to cover a larger area of the body. When the temperature falls below 38°C rectal, stop active cooling. There is a danger of inducing hypothermia with aggressive cooling.

221. DEHYDRATION Misdiagnosis and inappropriate treatment for dehydration is the most common cause of death in SAM patients. Diagnosis Do NOT use the classical signs of dehydration to make diagnosis, they are unreliable. Do NOT use the skin pinch test to diagnose dehydration in severely malnourished children. Do NOT diagnose dehydration in malnourished patients because they have sunken eyes. Do NOT make a definitive diagnosis of dehydration The main diagnosis comes from the HISTORY rather than from the examination.

222. DEHYDRATION Misdiagnosis and inappropriate treatment for dehydration is the most common cause of death in SAM patients. Diagnosis The main diagnosis comes from the HISTORY significant recent fluid loss - usually watery diarrhoea (not just soft or mucus) and frequent with a sudden onset. HISTORY of a recent CHANGE in the child’s appearance. If the eyes are sunken then the mother must say that the eyes have changed to become sunken since the diarrhoea started. Absence of visible “full” superficial veins (look at the head, neck, and limbs). The child must not have any oedema.

223. DEHYDRATION Misdiagnosis and inappropriate treatment for dehydration is the most common cause of death in SAM patients. Treatment: Do NOT make ORS or ReSoMal freely available for the caretakers to give to their SAM children. This leads directly to heart failure. Diarrhoea is not treated with rehydration fluids to “prevent” the onset of dehydration in SAM children. This again leads to over-hydration and heart failure. Rehydration fluids are never given “routinely”. IV infusions are rarely used. The standard instructions to give 50-100ml for each stool should not be applied – it is dangerous.

224. Treatment BEFORE starting any rehydration treatment: WEIGH the child MARK the edge of the liver and the costal margin on the skin with an indelible marker pen; RECORD the respiration rate; RECORD the pulse rate; and RECORD the capillary refill time (of the nail bed) in seconds Normally much less ReSoMal is sufficient to restore adequate hydration in malnourished than normally nourished children (e.g. a total of 50ml per kg body weight = 5% body weight).

225. Conti… Make a major reassessment at two hours. Start with 10ml/kg/h for the first two hours orally or by naso -gastric tube and then adjust according to the weight changes observed. Weigh the child each hour and assess his/her liver size, respiration rate, capillary refill time, and pulse

226. Conti… If there is continued weight loss then: Increase the rate of administration of ReSoMal by 10ml/ kg/hour (to 20ml/kg/hr) and Formally reassess in one hour. If there is no weight gain then: Increase the rate of administration of ReSoMal by 5ml/ kg/hour (to 15ml/kg/hr) and Formally reassess in one hour. If there is weight gain and: Deterioration of the child’s condition with the rehydration therapy, the diagnosis of dehydration was definitely wrong. Stop the rehabilitation therapy and start the child on F75 diet. No improvement in the mood and look of the child or reversal of the clinical signs, then the diagnosis of dehydration was probably wrong, therefore o either change to F75 or alternate F75 and ReSoMal. Clinical improvement, but there are still signs of dehydration, continue cautiously with the treatment until the appropriate weight gain has been achieved and Either alternate F75 and ReSoMal or continue with ReSoMal alone. Resolution of the signs of dehydration, o stop all re-hydration treatment and start the child on F75 diet.

227. Diagnosis of shock from dehydration The patient is in shock if: there is definite dehydration from both the history and examination; and a weak or absent radial or femoral pulse; and cool or cold hands and feet; and poor capillary refill in the nail beds (more than 3 seconds). When, in addition to the above signs there is also: 5. decrease in level of consciousness so that the patient is semi-conscious or cannot be roused Then this is severe shock.

228. Conti… Treat the patient with intravenous fluids. The amounts given should be half that used in normally nourished children. Use one of the following solutions that are used in normally nourished children: o Half-strength Ringer-Lactate with 5% dextrose o Half-strength Saline with 5%dextrose Give 15 ml/kg IV over the first hour and then reassess the child If there is continued weight loss or the weight is stable, repeat the 15ml/kg IV over the next hour. Continue until there is weight gain with the infusion. (15mg/kg is 1.5% of body weight, so the expected weight gain after 2 hours is from 0% up to 3% of body weight.) If there is no improvement and the child has gained weight, then assume that the child has toxic, septic, or cardiogenic shock, or liver failure. Stop rehydration treatment. Search for other causes of loss of consciousness As soon as the child regains consciousness and th pulse rate drops towards a normal level, then stop the drip and treat the child orally or by NG-Tube with 10ml/ kg/hour of ReSoMal. Continue with the protocol (above) for re-hydration of the child orally. Continue to use weight change as the main indicator of progress.

229. SEPTIC (OR Toxic) Shock Remember Keep warm Disturb as least as possible transfer unless with a safe mean to a safe facility

230. Absent Bowel Sounds, Gastric Dilatation, and Intestinal Splash With Abdominal Distension Remember: Very serious condition, not a good prognosis. Keep warm.

231. Heart Failure When : Physical deterioration and GAIN of WEIGHT or Increase in respiration rate and GAIN of WEIGHT C hildren with oedema don’t gain weight …. Attention U sually after admission, due to Na overload >> fluid overload >> dilutional anemia , DON’T TRANSFUSE . S top any kind of fluid intake till improvement ( even 24-48 hours )

232. Severe Anemia Remember: Anemia is treated in the first 48 hours after admission only. Only when very severe Hb <4g/100ml or cell volume <12% No treatment of anemia in Heart Failure. If deemed necessary after 48hourse, transfer to neonatal unit for exchange transfusion.

233. Persistent or chronic diarrhea Diagnosis: persistent or chronic diarrhea with no acute watery exacerbation. Children with the above do not need to be rehydrated. The appropriate treatment is nutritional as the condition is mostly due to nutritional deficiency and is often resolved quickly once product F75 is given. If persistent, Metronidazole can be given

234. Re-feeding diarrhea after admission The intestine of the malnourished child has lost its capacity to absorb carbohydrate and the pancreas has also lost its ability to absorb carbs protein and fat. Diagnosis : no weight loss; loose stools and increased frequency of stools. Treatment : when the F75 is started, there is no weight loss so the child is not dehydrated and the treatment should continue. After a few days the intestine repairs itself.

235. Hypernatraemic ( HnD ) Dehydration Prevention is the best approach by frequent fluids and sugared water on arrival at the clinic. Diagnosis: sunken eyes; change in level of consciousness – drowsy, unconscious,, convulsions, death. If convulsions do not respond to normal anti convulsants often its an indication of HnD . Treatment: Mild : breast feeding and fluids. Severe; allow 48 hrs to correct the Na by the use of Normal Saline – 0.9% Requires strict medical supervision.

236. Skin Lesions: Kwashiorkor lesions: skin has split, burn like with weeping lesions Infections are common; treat with antibiotics and fluconazole. Dressings as required. Perineal excoriation : caused by sweat etc when the area is covered in plastic, Treatment ; keep clean, no plastic, expose to the air and antibiotics if 2 nd infection. Scabies: apply permethrin to all members of the family and treat clothing and bedding.

237. Complications: SKIN – cont`d Bacterial infection – Impetigo –mosquito bite Treatment : keep clean, dressings if needed, if child is well topical antibiotic cream can be used. However if malnourished systemic antibiotics are recommended. Fungal Infections : ringworm, topical miconazole cream

238. Cholera in SAM conscious Difficult to treat as risk of overload versus risk of death by dehydration. Diagnosis: normal signs of dehydration are all unreliable Stool observation ( clear like rice water) and history. Maybe other cases. Treatment: Isolation as very infectious; ORS, and as renal function is not normal check changes in body weight. Risk of overhydration: check respiratory rate, distension of neck veins; continue with Nutrition treatment as able.

239. ANY QUESTIONS ?

240. THE END THANKS FOR YOUR PARTICIPATION