Management of malnutrition 2019

Management of Malnutrition in Children 2019

1. Management of Malnutrition in children Prof. Imran Iqbal Prof of Paediatrics (2003-2018) Prof of Pediatrics Emeritus, CHICH Multan, Pakistan

2. In the name of Allah, the most gracious, the most merciful.

3. MALNUTRITION IS A PATHALOGICAL STATE RESULTING FROM DEFICIENCY OF ONE OR MORE ESSENTIAL NUTRIENTS

4. ACUTE COMPLICATIONS Acute infections – Diarrhea, pneumonia, 2. Hypoglycemia 3. Hypothermia 4. Dehydration 5. Electrolyte deficiency – K +

5. CHRONIC COMPLICATIONS Chronic infection e.g T.B Chronic diarrhea Malabsorption Anemia Vitamin Deficiencies Growth retardation Learning disorders ( low IQ)

6. Management of Malnutrition

7. Management of Malnutrition Adequate calories Micronutrients Growth monitoring Follow-up

8. PRINCIPLES of Management Assessment Severity and type of malnutrition Any complications Associated deficiencies Epidemiological factors Hospital treatment Severe and complicated malnutrition Home treatment Severe malnutrition--uncomplicated cases Moderate malnutrition

9. CMAM Community-based Management of Acute Malnutrition

10. CMAM : Four Components:

11. Programme Approach Community-based Management of Acute Malnutrition (CMAM) CMAM has four components: Community mobilization (for early detection & referral of the malnourished, follow up at home, and prevention activities) Supplementary Feeding Program (SFP) to treat moderate acute malnutrition (MAM) - Outpatient Therapeutic Program (OTP) to treat severe acute malnutrition without medical complications Inpatient care or Stabilization Centre (SC) to treat severe acute malnutrition with medical complications

12. Community-based Management of Acute Malnutrition (CMAM) Community mobilization (Lady Health Workers) Early detection Referral of the malnourished child Follow up at home Prevention activities

13. Community-based Management of Acute Malnutrition (CMAM) Supplementary Feeding Program (SFP) (MAM) moderate acute malnutrition Feeding advice Micronutrients

14. Community-based Management of Acute Malnutrition (CMAM) Outpatient Therapeutic Program (OTP) Severe Acute Malnutrition without medical complications Feeding advice RUTF (ready to use therapeutic food)

15. Community-based Management of Acute Malnutrition (CMAM) Stabilization Centre (SC) Inpatient care to treat severe acute malnutrition with Medical complications Anorexia Severe edema Severe wasting and edema

16. Medical Complications extensive infections, severe dehydration, severe anaemia, hypothermia / high fever hypoglycaemia lethargy convulsions severe vomiting

17. Uncomplicated OPD assessment Wt and Ht MUAC Medical Assessment Appetite Assessment

18. Triage for SAM Once the diagnosis of SAM has been made: Assess medical complications : accurate medical history thorough medical examination Appetite test: - able to finish one-third of RUTF sachet 30-Apr-19 19

19. Triage for SAM Decide outpatient or inpatient care : Inpatient treatment (any of the following): Bilateral pitting oedema (+++) A combination of oedema and wasting SAM with poor appetite (failed appetite test) SAM with medical complications 30-Apr-19 20

20. MAM Moderate Acute Malnutrition Wt for Ht 70 – 80 % Supplementary Feeding program (SFP) Feeding advice Micronutrients (Sprinkles sachet)

21. SAM Severe Acute Malnutrition Wt for Ht < 70 % OR MUAC < 11.5 OR Edema (nutritional cause) Outpatient Therapeutic Feeding Program (OTP) RUTF (Ready to use Therapeutic Food)

22. Severe Acute Malnutrition with complications SAM + complications acute illness / poor appetite / severe edema Stabilization Centre (SC) Inpatient care Phase I (Stabilization) Phase II (Rehabilitation)

23. Severe Acute Malnutrition

24. 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

25. 1-2.Treat/prevent hypothermia and hypoglycemia (which are often related) by feeding, keeping warm, and treating infection 3. Treat/prevent dehydration using Rehydration Solution for Malnutrition ( Resomal ). 4. Correct electrolyte imbalance (by giving feeds and ReSoMal prepared with mineral mix or CMV). 5. Presume and treat infections with antibiotics. 6. Correct micronutrient deficiencies (by giving feeds prepared with mineral mix or CMV and by giving extra vitamins and folic acid as needed). 7. Start calculating feeding with F-75 to stabilize the child (usually 2-7 days). 8. Rebuild wasted tissues through higher protein/caloric feeds (F-100). 9. Provide stimulation, play and loving care. 10. Prepare parents to continue proper feeding and stimulation after discharge.

26. Initial Management Hypoglycemia Hypothermia Shock Very severe anaemia Corneal ulceration Watery diarrhea and /or vomiting Prepare Re So Mal Appropriate antibiotics Record initial findings and treatments

27. HYPOGLYCEMIA RBS less than 54mg/dl (< 3 mmol / L) is hypoglycemia Signs of hypoglycemia Lethargy Hypothermia Loss of consciousness

28. Hypoglycemia is a sign of infection Hypoglycemia is due to: Infrequent feeding Vomiting Reluctance to feed due to infection If no glucometer available presume hypoglycemia and treat

29. MANAGEMENT of HYPOGLYCEMIA Check blood sugar If blood sugar is < 54mg.dl (< 3 mmol / L) give 50 ml of 10% glucose orally Give by N-G if cannot take orally If child drowsy give 5 ml/kg of 10% glucose by IV followed by 50 ml of 10% glucose by N-G. START FEEDING f-75 every half hour for 2 hours Give ¼ of the 2 hourly feed every half hour. Check blood sugar after 2 hours If >54 mg/dl (> 3 mmol / L) give F-75 every 2 hours If < 54 mg/dl (< 3 mmol / L) keep giving F-75 every half hour for 2 hours

30. HYPOTHERMIA Rectal temperature <35.5 °C or 95.9 °F or Axillary temperature <35 °C or 95.0 °F Hypothermia is a sign of serious infection Hypothermic children should be treated for infection and hypoglycemia

31. MANAGEMENT OF HYPOTHERMIA Cover the child including his head Keep windows closed Maintain room temperature of 25-30 °C Change wet clothes immediately Avoid leaving child uncovered during examination and weighing Warm your hands before examining the child Monitor temperature ½ hourly till normal

32. Rewarming the hypothermic child Heater or warmer can be used Skin to skin contact with mother Blankets to cover the child Head covered with a cap Do not use hot water bottles

33. SHOCK Lethargic or unconscious Cold hands Slow capillary refill (>3 seconds) Weak or fast pulse Shock can be due to dehydration or sepsis Difficult to differentiate Children with dehydration respond to IV fluids Those with sepsis and no dehydration do not respond to IV fluids

34. Treatment of shock Give oxygen Give 5 ml/kg of 10% glucose IV Keep child warm Give IV fluids

35. IV FLUIDS for SHOCK Check respiratory and heart rate and record Give D-Ringer’s lactate or 5% ½ strength normal saline 15 ml/kg over 1 hour Monitor heart rate & respiratory rate every 10 minutes Stop IV if RR & HR increase At the end of 1 hour if RR & HR decreased, repeat 15 ml/kg over next 1 hour with monitoring of HR & RR At the end of 2 hrs start Resomal If child fails to improve after 1 hour give 10 ml/kg of fresh blood over 2 hours Give lasix with blood Give IV fluids 4 ml/kg/hr while blood is being arranged At the end of blood transfusion start oral fluids i.e. Resomal as above

36. ANAEMIA Haemoglobin < 4 mg/dl is very severe anaemia Very severe anaemia leads to heart failure It requires a transfusion Mild to moderate anaemia should be treated after the 1st week with Iron

37. Treatment of Very Severe Anaemia Stop oral intake and IV fluids Look for signs of heart failure If there are signs of heart failure give 5-7 ml/kg of packed cells in 3 hours If no heart failure give 10 ml/kg of fresh blood in 3 hours Give diuretic lasix 1 mg/kg by IV

38. CORNEAL ULCERATION It is a break in the surface of the cornea Can lead to extrusion of lens and blindness Child has photophobia

39. CORNEAL ULCERATION Give first dose of vitamin A immediately Oral dose is 50,000 IU for <6 months 100,000 IU for children 6-12 month 200,000 IU for <12 months Instill one drop of 1% atropine to relax the eye It prevents extrusion of lens Put tetracycline eye drops and bandage the eye

40. DIARRHOEA AND DEHYDRATION Difficult to assess dehydration in a malnourished child History of vomiting diarrhea if present, assume dehydration Assess for dehydration even through signs are misleading Disappearance of these signs on dehydration indicate improvement

41. Signs of dehydration Lethargy Restlessness, irritability Sunken eyes Absent tears Dry mouth & tongue Thirst Skin pinch goes back slowly

42. RE SO MAL Modified oral rehydration solution for severely malnourished children Has less sodium, more sugar and more potassium Standard ORS should not be used in severely malnourished If Re So Mal not available prepare from standard ORS

43. 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

44. ORS, low osmolar ORS and ReSoMal Amount i n 1 litre ORS Low Osmolality ORS ReSoMal Sodium Chloride 3.5 gm 2.6 gm 1.75 gm Sodium Citrate 2.9 gm 2.9 gm 1.45 gm Potassium Chloride 1.5 gm 1.5 gm 2.54 gm Potassium Citrate 0.65 gm Magnesium Chloride 0.61 gm Zinc Acetate 0.656 gm Copper Sulphate 0.0112gm Glucose 20 gm 13.5 gm 10 gm Sucrose 25 gm Osmolality 311 245 300

45. ORS, low osmolar ORS and ReSoMal mmol / litre ORS Low Osmolality ORS ReSoMal Sodium 90 75 45 Potassium 20 20 40 Chloride 80 65 70 Citrate 10 10 7 Magnesium 3 Zinc 0.3 Copper 0.045 Glucose 111 75 125 Osmolality 311 245 300

46. Preparation of Re So Mal take 1 packet of standard ORS packet pour into a container that holds more than 2 liters Add 40 meq of kcl measure and add 50 gms of sugar measure and add 2 liters cooled boiled water stir use within 24 hours

47. How often and how much to give? 5 ml/kg of Re So Mal every 30 minutes for 2 hours, 5-10 ml/kg every alternate hour for 10 hours (if child not in shock) Omit first 2 hours treatment if patient has received treatment for shock If child too sick feed through N-G feed

48. Monitoring when taking Re So Mal Check respiratory rate Check pulse rate Ask about urine frequency Number of vomiting Ask about stool frequency Assess signs of dehydration

49. Phases of Treatment Stabilization Phase Day 1 – 2 Transition Phase Day 3 – 7 Rehabilitation Phase Week 2 – 6 It may take up to 7 or more days for the child to stabilize. Weight gain is not expected during stabilization

50. Stabilization Phase Day 1-2 Treat Acute Complications Give micronutrients Initiate feeding Provide love and nursing care

51. TREAT ACUTE COMPLICATIONS Respiratory distress – Oxygen Hypothermia – warm environment Hypoglycemia – IV / NG / oral dextrose Hypokalemia – ReSoMal Dehydration – ReSoMal Severe anaemia – blood transfusion -

52. Treat acute infections Pneumonia Diarrhoea Skin infections ENT infections Note: signs of acute infection may be masked due to severe malnutrition

53. Micronutrients Vitamin A 1-2 lac units once Zinc 1-2 mg per kg daily Folic Acid 5 mg per day Vitamin D 400 IU daily Iron 1-2 mg per kg daily (start when gaining weight)

54. Start Feeding Start gradual feeds Give NG / oral feeds Target calories 100 calories/kg/day Proteins 1-1.5 gm /kg/day Prepare feeds with a base of milk

55. Therapeutic diets F – 75 Start from Day 1 F – 100 Start during transition RUTF / RUSF when gaining weight

56. 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 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

57. Cereal based F-75 F – 75 contains 100 gm sugar /1000 ml 30 gm sugar can be replaced by cooked Rice flour 35 gm It reduces diarhoea quickly

58. Modified Rice based F-75 Milk 300ml Rice flour 75 gm is cooked and added Sugar 35 gm is added Cooking oil 20 ml Potassium Chloride 20 ml Water to make 1000 ml Blended and given

59. Smoothie diet Rice flour half cup is cooked Potato boiled one small Banana one small Egg white boiled one Blended and given with spoon

60. 61 RUTF - 500 kcal / 92 gm Peanuts (ground into a paste) Vegetable oil Powdered sugar Powdered milk Vitamin and mineral mix (special formula)

61. Feeding in STABLIZATION PHASE Start feed with F-75 , initially give 2 hourly feed, than shift to 3 hourly feed transfer to 4 hourly feed Volume of feed 130 ml /kg/day Change guided by condition of the patient

62. Start Nasogastric Feeding Very weak child Mouth ulcers Unable to take at least 80% of the amount offered Do not force the feed down the NG tube

63. Stop Nasogastric Feeding Remove N.G tube when ……….. 80% of the daily amount is taken orally. Two consecutive feeds taken fully by mouth Remove the tube in the day time

64. Signs of Improvement Transition Phase Smile of child Loss of edema Improved appetite This phase should continue for 4-5 days

65. FEEDING DURING TRANSITION (2 – 7 days) F – 75 decrease gradually and stop F – 100 Start 130 ml / kg / day and increase gradually after 2 days RUTF 500 kcal / sachet RUSF as liked by child

66. Feeding in Rehabilitation Phase Increse feeding by 10 ml per feed slowly The child can be fed freely on F-100 to an upper limit of 220 ml/kg/day. In rehabilitation phase encourage the child to eat as much as he wants

67. Daily Follow-up History (appetite, vomits, diarrhoea ) Physical examination (smile, edema, diarrhoea , skin ) Vitals Medications Amounts of Feeds taken Weight Growth chart

68. RECOVERY WEIGHT GAIN should be 10 gm / kg / day Child is considered to be recovered when Weight for length / height is more than -1 SD or 90 % of expected

69. Catch-up growth Catch-up growth occurs during the period of recovery from malnutrition During this period child grows at above the normal growth rate Gain in height and weight is more than expected for that age period This above normal growth allows the child to catch-up with other children of his age

70. When catch-up growth will occour ? After acute complications have been managed When the child is free of infection When calories intake is 100 – 200 Cal / kg of actual weight

71. RECOVERY WEIGHT GAIN should be 10 gm / kg / day Child is considered to be recovered when 90 % of expected weight for length has been achieved

72. Hifsa’s journey from malnutrition to health

73. ?

74. Professional Ethics in Medicine

75. Core Values in Institution

76. Basic Principles in Work

77. Thankyou