NRC.pptx

Pediatrics

1. Janani Shishu Suraksha Karyakram (JSSK) and Nutritional Rehabilitation Centre Dr Rekha Thaddanee

2. JANANI SHISHU SURAKSHA KARYAKRAM Launched on 1 st June, 2011 OBJECTIVES Eliminating out-of-pocket expenses for families of pregnant women, sick newborns and infants in government health facilities Reaching the unreached pregnant women (nearly 75 lakh a year who still deliver at home) Timely access to care for sick newborns

3. JSSK Entitlements for pregnant women Free and cashless delivery Free C-section Free drugs and consumables Free diagnostics Free provision of blood Free diet during stay in health institutions Up to 3 days for normal delivery 7 days for Caesarean sections Free transport Home to health institution Between health institutions in case of referral Drop back home after delivery Exemption from all kinds of user charges, including for seeking hospital care up to 6 weeks post delivery (for post natal complications)

4. JSSK Entitlements for sick neonates and infants Free treatment at the public health institutions Free drugs and consumables Free diagnostics Free provision of blood Exemption from all kinds of user charges

5. Nutritional Rehabilitation Centre

6. Nutrition Rehabilitation Center Nutrition Rehabilitation Center (NRC) is a unit in a health facility where children with Severe Acute Malnutrition (SAM) are admitted and managed. Children are admitted as per the defined admission criteria and provided with medical and nutritional therapeutic care.

7. Objectives of NRC To provide clinical management Reduce mortality among children with severe acute malnutrition , particularly among those with medical complications. To promote physical and psychosocial growth of children with severe acute malnutrition To build the capacity of mothers and other care givers in proper feeding and caring practices for infants and young children To identify the social factors that contributed to the child slipping into severe acute malnutrition .

8. Services provided at the NRC 24 hour care and monitoring of the child Treatment of medical complications Therapeutic feeding Providing sensory stimulation and emotional care Counseling on appropriate feeding, care and hygiene Demonstration and practice- by -doing on the preparation of energy dense child foods Using locally available, culturally acceptable and affordable food items Follow up of children discharged from the facility .

9. Human resources at NRC Requirement for the smooth functioning of a 10 bedded NRC is as follows :- Medical officer - One Nursing staff - Four Nutrition counsellor - One Cook cum Care taker - One Attendant/ cleaners - Two Medical social worker - One

10. The NRC should have the following: Patient area to keep the beds; in NRC adult beds are kept so that the mother can be with the child. Nursing station

11. The NRC should have the following: Play and counselling area with toys; audiovisual equipment like TV , DVD player and IEC material.

12. The NRC should have the following: Kitchen and food storage area attached to ward, or partitioned in the ward, with enough space for cooking, feeding and demonstration .

13. The NRC should have the following: Attached toilet and bathroom facility for mothers and children along with two separate hand washing areas.

14. Admission Indicators in NRC New admission : patient who has never been admitted before in NRC Re-admission: a defaulter who has admitted back to the NRC within 2 months Relapse: a patient who has been discharged as cured from the NRC within the last 2 months but is again eligible for admission to NRC. A large number of relapses are often a sign of food insecurity.

15. Exit Indicators in NRC Exit indicators provide information about the proportion of patients completing the treatment successfully or not successfully (recovered , defaulter, death). They are calculated as a percentage of the total number of exits (discharges ) during the reporting month .

16. Exit Indicators in NRC Recovery (cured) rate: Number of beneficiaries that have reached discharge criteria within the reporting period divided by the total exits Defaulter rate: Number of beneficiaries that defaulted during the reporting period divided by the total exits Defaulter will be a child with SAM admitted to the ward but absent (from the ward) for three consecutive days without been discharged.

17. Exit Indicators in NRC Non-respondent: This exit category includes those beneficiaries who fail to respond to the treatment When the number of cases in this category is high it may indicate underlying problems related to the patient (e.g. chronic disease) or to the programme , and need to be addressed.

18. Performance of NRCs may be assessed by these criteria Indicators Acceptable Not Acceptable Recovery rate >75% <50% Death rate <5% >15% Defaulter rate <15% >25% Weight gain(g/kg/d) >=8 gm <8gm Length of stay (weeks) 1-4 <1 or >6

19. NRC Wage Compensation- Rs. 100/day For transport- Rs. 200 Total for 14 days stay- Rs. 1600 For each followup (three visits)- Rs. 300 Total expense on one child- Rs. 2500 Food for mother/care giver also

20. NRC ASHA incentives: Incentives of Rs. 50 can be provided to ASHA for accompanying the child to the NRC and motivating the mother to stay for at least 14 days till the child is stabilized and has started to eat. Additional incentive of Rs. 50 may be given for each follow up visit by the child, up to a maximum of three visits.

21. Criteria for admission in NRC for Children Between 6-59 months age SAM is defined as the presence of Severe wasting Weight for height/length < - 3SD and or MUAC < 11.5 cm and or Presence of bilateral pitting edema Children with SAM have nine times higher risk of death

22. Severe wasting

23. Nutritional bilateral pitting edema

24. MUAC

25. MUAC

26. SAM

27. Criteria for admission in NRC for Children 6-59 months age WITH Any of the following complications: Anorexia (Loss of appetite) Fever or Hypothermia Persistent vomiting Severe dehydration based on history and clinical examination Not alert, very weak, apathetic, unconscious, convulsions Hypoglycemia

28. Criteria for admission in NRC for Children 6-59 months age 7. Severe Anemia (severe palmar pallor) 8. Severe pneumonia 9. Extensive superficial infection requiring IM injections 10. Any other general sign that a clinician thinks requires admission for further assessment or care 11. In addition to above criteria if the caregiver is unable to take care of the child at home, the child should be admitted.

29. Criteria for admission in NRC for Infants < 6 months Infant is too weak or feeble to suckle effectively (independently of his/her weight-for-length). or WfL (weight-for-length) <–3SD (in infants >45 cm) or Visible severe wasting in infants <45 cm or Presence of edema both feet

30. EPIDEMIOLOGY Worldwide, SAM is among leading causes of death among children <5Yrs More common in the developing states Malnutrition causes abt 5.6 to 10 million deaths/yr, with sever malnutrition contributing to abt 1.5 million of these deaths.

31. ETIOLOGY Primary - when the otherwise healthy individual's needs for protein, energy, or both are not met by an adequate diet . (most common cause worldwide) Secondary - result of disease states that may lead to sub-optimal intake , inadequate nutrient absorption or use, and/or increased requirements because of nutrient losses or increased energy expenditure.

32. PRECIPITATING FACTORS Lack of food (poverty) Inadequate breast feeding Wrong concepts about nutrition Diarrhoea & malabsorption Infections (worms, measles, T.B)

33. WHO classification Acute malnutrition (severity) MUAC (cm) WHZ None >13.5 >-1 At risk 12.5 to 13.4 -2 to -1 Moderate 11.5 to 12.4 -3 to -2 Severe <11.5 < -3 Kwashiorkor

34. PATHOPHYSIOLOGY of SYMPTOMS OEDEMA Cause: Protein-deficient, hypoalbuminaemia , reduced plasma oncotic pressure, fluid shift to interstitium Free radical damage of cell membrane, Na+/K+ ATPase malfunction- fluid leaks Hypovolemia , reduced GFR , activation of RAAS, Na+ and water retention. Increase levels of leukotrienes cause uncontrolled vasodilation - hypovolemia -low BP-decrease peritubular hydrostatic pressure – increase tubular reabsorption of salt and water .

35. PATHOPHYSIOLOGY Cont’d WASTING Calorie def – fats and tissue proteins mobilized to supply energy for metabolic processes. Recurrent infections coupled with hypoglycemia cause acute stress response- cortisol released- wasting Effects of associated infections e.g. HIV wasting syndrome

36. PATHOPHYSIOLOGY- Cont’d HAIR CHANGES Keratin synthesis impaired because of cysteine and methionine def , thus brittle hair easily pulled off /breaks Pigment melanin formed from tyrosine so it’s deficiency in kwash . Hair colour changes reddish or grey. Periods of good nutrition alternating with poor nutrition- flag sign . Dullness and lack of lustre due to weathering of the hair cuticle.

37. Flag sign

38. PATHOPHYSIOLOGY- Cont’d SKIN CHANGES Ulcerations and flaky paint rash due to Zn def. Atrophy of sweat and sebaceous glands leads to excessive dryness of the skin . Hyperpigmentation, erythema, duskiness of exposed areas – niacin def Cracking and fissuring of hyper pigmented Generalized hypopigmentation due to stretching of the skin by the edema.

39. Ulcerations and flaky paint rash due to Zn deficiency

40. PATHOPHYSIOLOGY- Cont’d HEPATOMEGALY/ FATTY LIVER Free radicals damage mitochondrial enzymes in the liver causing reduced synthesis of proteins. Beta LP def – accumulation of TG in the liver – fatty liver –Hepatomegally.

41. PATHOPHYSIOLOGY- Cont’d POT BELLY Hypotonic muscles of abdominal wall resulting from muscle wasting. Overgrowth of bacteria in the gut due to reduced immunity- Paralytic ileus due to hypokalemia Hepatomegally because of fatty liver

42. PATHOPHYSIOLOGY- Cont’d DIARRHOEA Caused by recurrent infections due to reduced immunity- low secretary IgA and reduced secretion of acid in stomach. Malabsorption – deficiency of pancreatic enzymes resulting from pancreatic atrophy/protein deficiency. Villous atrophy- reduced absorptive surface

43. PATHOPHYSIOLOGY- Cont’d Recurrent infections Atrophy of thymo -lymphatic glands cause depletion of T lymphocytes and depressed CMI thus infections like Herpes, candidiasis common. Reduced phagocytic and bactericidal activity of leucocytes- NADPH oxidase and lysozyme def C3,C5, and factor b levels reduced – opsonization and phagocytosis reduced. I mmune response reduced due to inability to synthesis IL-1,IL-6, TNF alpha due to lack of supply of essential AA.

44. PATHOPHYSIOLOGY- Cont’d The “Vicious Cycle”of Undernutrition & Infection

45. PATHOPHYSIOLOGY- Cont’d ANAEMIA Due to dietary deficiency of iron and folate Parasitic infections e.g. hookworm. Malabsorption due to recurrent diarrhea . Reduced protein intake and synthesis.

46. PATHOPHYSIOLOGY- Cont’d APATHY Hypokalemia- muscle weakness and easy fatigability of muscles-child lacks in energy Lack of stimulation and deprivation causes reduced growth of brain and nerve thus mental slowing. Reduced BMR Apathy also attributed to Zinc deficiency.

47. PATHOPHYSIOLOGY- Cont’d ELECTROLYTE/ MINERAL DEFICIENCIES – Magnesium Good evidence that magnesium deficiency is common in severe malnutrition Consequences: Muscular twitching Arrhythmias Convulsions Predisposes to K + deficiency

48. PATHOPHYSIOLOGY- Cont’d sodium Plasma sodium can be low and on occasions is extremely low in children with marasmic kwashiorkor. However total body sodium is often increased

49. PATHOPHYSIOLOGY- Cont’d Consequences of Zinc deficiency Reduced appetite Reduced immunity Reduced gastrointestinal function – longer period of diarrhoea Reduced ability to gain weight even when there is adequate feeding Skin changes Acrodermatitis Enteropathica

50. Zinc deficiency

51. PATHOPHYSIOLOGY- Cont’d Consequences of Copper and Selenium deficiency Copper is required for adequate tissue growth and repair, anaemia and poor bone growth may be associated with inadequate copper (it is very little in milk). Selenium deficiency may be associated with reduced cardiac muscle function.

52. PHYSICAL EXAMINATION Shock: lethargic or unconscious; with cold peripheries, slow cap refill (>3sc) or weak rapid pulse or low BP Signs of Dehydration Severe pallor Bilateral pitting edema

53. PHYSICAL EXAMINATION Eye signs of vitamin A deficiency Dry conjuctival or cornea, Bitot spots Corneal ulceration Keratomalacia In Vitamin A deficiency- pt likely to be photophobic, keep eyes closed. Examine eyes gently to avoid corneal rupture.

54. Bitot spot

55. K eratomalacia

56. PHYSICAL EXAMINATION Localizing signs of infection: ear discharge, throat infections, skin infections or pneumonia Signs of HIV infection Fever : >37.5 c or Hypothermia (rectal: <35.5c) Mouth ulcers

57. PHYSICAL EXAMINATION Skin changes Hypo/hyperpigmentation Desquamation Ulceration Exudative lesion

58. Features of Kwashiorkor 1.Always present Generalized edema, Pitting edema over the lower limbs Growth failure: wasting (may be masked by edema). Psychomotor changes: apathy, irritability

59. Features of Kwashiorkor 2.Usually present Hair changes: fine but coarse in chronic d’se , easy pluckability , discoloured , light-colored hair streaky red/gray, sparseness (areas of alopecia),Alternate areas of hypo and normal pigmentation-flag sign Anemia Loose stools

60. Features of Kwashiorkor 3.Occasionaly present Hepatomegaly Signs of vitamin deficiencies Skin changes Diffuse/patchy areas of hypo/ hyperpigmentn Thin, shiny, taut skin over edematous areas Moist ulcerations over flexural/pressure points

61. Features of Kwashiorkor Classical skin lesions Flaky paint dermatosis : hyper pigmented, desqumation area (flake) over raw skin. Crazy pavement dermatosis : dry, hyperkeratotic ,fissured skin with alternate areas of hyper/hypo pigmentation Mosaic dermatosis : mixed lesions in mosaic form

62. Flaky paint dermatosis

63. Mosaic d ermatosis ↓

64. Features of Marasmus 1.Always present Extreme growth failure, <50% WA Marked muscle wasting, loss of subcut fat Alert, with good appetite

65. Features of Marasmus Face is shriveled like ‘little old man, monkey like- Relatively larger head, wrinkled skin, loose skin folds over buttocks, thighs, axilla

66. Features of Marasmus 2.Occasionaly present Anemia Diarrhea with signs of dehydration Vit deficiencies: cheilosis , dermatosis , rickets Infections: TB, measles

67. Laboratory Tests Blood glucose Haemoglobin Serum electrolytes eg ; (sodium, potassium, and calcium whenever possible) Screening for infections: Total and differential leukocyte count, blood culture Urine routine examination and Urine culture Chest x-ray Mantoux test Screening for HIV after counseling Any other specific test required based on geographical location or clinical presentation e.g. Celiac Disease, malaria etc.

68. SAM Principles of management of SAM are based on 3 phases: Stabilization Phase Transition Phase Rehabilitative Phase

69. Stabilisation Phase Children with SAM without an adequate appetite and/or a major medical complication are stabilized in an in-patient facility This phase usually lasts for 1–2 days The feeding formula (F-75) used during this phase is Starter diet which promotes recovery of normal metabolic function and nutrition-electrolytic balance All children must be carefully monitored for signs of overfeeding or over hydration in this phase.

70. Transition Phase This phase is the subsequent part of the stabilization phase and usually lasts for 2-3 days. The transition phase is intended to ensure that the child is clinically stable and can tolerate an increased energy and protein intake The child moves to the Transition Phase from Stabilization Phase when there is: At least the beginning of loss of oedema AND Return of appetite AND No nasogastric tube, infusions, no severe medical problems AND Is alert and active

71. Transition Phase The ONLY difference in management of the child in transition phase is the change in type of diet. There is gradual transition from Starter diet (F-75) to Catch up diet (F 100). The quantity of Catch up diet (F100) given is equal to the quantity of Starter diet given in stabilization Phase.

72. Rehabilitation Phase Once children with SAM have recovered their appetite and received treatment for medical complications they enter Rehabilitation Phase. The aim is to promote rapid weight gain, stimulate emotional and physical development and prepare the child for normal feeding at home The child progresses from Transition Phase to Rehabilitation Phase when: has reasonable appetite; finishes > 90% of the feed that is given, without a significant pause Major reduction or loss of oedema No other medical problem

73. Management Those who pass appetite test: phase 2 treatment in NRC using F 100 and locally made special feed for uncomplicated SAM. Those who fail appetite test and with one or more danger signs or with medical conditions requiring admission- phase 1 treatment in NRC

74. APPETITE TEST FEED (EPD) Roasted ground nuts 1000 gm Milk powder 1200 gm Sugar 1120 gm Coconut oil 600 gm How to prepare :- ------------

75. How to prepare EPD Take roasted ground nuts and grind them in mixer Grind sugar separately or with roasted ground nut Mix ground nut, sugar, milk powder and coconut oil Store them in air tight container Prepare only for one week to ensure the quality of feed Store in refrigerato r

76. How to do appetite test? Do the test in a separate quiet area Explain to the mother/caregiver how the test will be done The mother/caregiver should wash her hands The mother sits comfortably with the child on her lap and offers therapeutic food

77. How to do appetite test The child should not have taken any food for the last 2 hrs The test usually takes a short time but may take up to one hour The child must not be forced to take the food offered When the child has finished, the amount taken is judged/ measured

78. APPETITE TEST Appetite test is fail if baby is not eating that much amount of EPD according to weight---- BW(Kg) EPD 3-3.9 <15gm 4-6.9 <20gm 7-7.9 <25gm 8-9.9 <30gm 10-11.9 <35gm 12-14.9 <40gm

79. 10 step management of SAM Hypoglycemia Hypothermia Dehydration Electrolyte imbalance Infections 6. Micronutrient def.s 7. Initial feeding 8. Catch up growth 9. Sensory stimulation 10. Follow up

80. 10 step approach STABILIZATION REHABILITATION DAY 1-2 DAY 3-7 WEEKS 2-6 Hypoglycemia ------------- Hypothermia -------------  Dehydration -------------  Electrolyte imbalance ---------------------------------------------------------------------  Infections ----------------------------------  Micronutrient ------NO IRON-----------------------WITH IRON------------  Initiate feeding -----------------------------------  Catch up growth ---------------------------  Sensory stimulation --------------------------------------------------------------------  Prepare for follow-up --------------------------- 

81. Hypoglycemia Dx: blood glucose < 54mg% Rx: if conscious child 50mls of 10% glucose or sucrose sol (1 rounded teaspoon of sugar in 3.5 tsf of water) orally or by NGT, followed by 1 st feed. Give 1 st feed of F75 therapeutic milk every 30 min for first 2 hours then F75 feeds 2hrly day and night.

82. Hypoglycemia If unconscious child: Rx with IV 10% glucose at 5mls/kg or if no IV access then 10% glucose by NGT Monitoring: after 30 mins. If BG still <54mg% repeat 10% dextrose bolus. Then repeat 2 hourly.

83. Hypoglycemia Keep child warm as hypoglycemia and hypothermia coexist Administer antibiotics as hypoglycemia may be a feature of underlying infection

84. Hypothermia Often indicates coexisting hypoglycemia or serious infection Dx: Axillary temp <35 o c rectal < 35.5 o c Rx: Feed immediately and then 2hrly unless with abd distension Dress warmly-cover with a warmed blanket Keep dry, away from draught Heaters or lamp Put child on mothers bare chest or abdomen(KMC) Avoid exposure to cold during procedures, bathing

85. Hypothermia Monitoring: Monitor temp 2hrly- rectal till rises to 36.5 o c,half hourly if heater is being used . Ensure child is covered at all times Check for hypoglycemia Prevention Feed 2-3hrly Kangaroo technique Avoid child exposure to cold Don’t use hot water bottle of fluorescent lamp Change wet nappies

86. Severe Hypothermia If rectal temperature < 32°C Give warm humidified oxygen. Give 5 mL /kg of 10% dextrose IV immediately or 50 ml of 10% dextrose by nasogastric route (if intravenous access is difficult). Provide heat using radiation (overhead warmer), or conduction (skin contact) or convection (heat convector). Avoid rapid rewarming , monitor temperature every 30 minutes

87. Severe Hypothermia Give warm feeds immediately, if clinical condition allows the child to take orally, else administer the feeds through a nasogastric tube. Start maintenance IV fluids ( prewarmed ), if there is feed intolerance/contraindication for nasogastric feeding. Rehydrate using warm fluids immediately, when there is a history of diarrhea or there is evidence of dehydration. Start intravenous antibiotics Do not use hot water bottles due to danger of burning fragile skin.

88. D ehydration Dx: assume that all children with watery diarrhea or reduced urine output have some dehydration. Only h/o fluid loss and very recent change in appearance can be used. Treatment of dehydration is different in SAM child from normally nourished child.

89. Dehydration All star signs of dehydration are unreliable in marasmic child .

90. Dehydration Rx: if conscious- No IV route unless in shock If Resomal is not available: - Reduced osmolarity ORS is used ; add 15 ml of potassium chloride to one litre ORS (15 ml contains 20 mmol /L of potassium)

91. Dehydration How often to give ORS Amount to give Every 30 minutes for first 2 hours 5 ml/kg weight Alternate hours for up to 10 hours* 5-10 ml/kg * *Then 10 mls /kg/hr each for the next 10-12 hrs on alternate hrs, with F75 formula *The exact amt depends on how much the child wants, vol of stool loss and whether the child is vomiting. If rehydration is still required at 10hrs, give starter F75 instead of Resomal , at the same times. Use same vol of F75 as of Resomal

92. Signs to check Every half hour for the first two hours, then hourly: Respiratory rate Pulse rate Urine frequency Stool or vomit frequency Signs of hydration

93. Signs of over hydration Increased respiratory rate and pulse. (Both must increase to consider it a problem –increase of pulse by 15 & respiratory rate by 5) Jugular veins engorged Puffiness of eye Liver size increased Stop ORS if any of the above mentioned signs appear.

94. Dehydration A severely malnourished child is considered in shock if s/he is: Lethargic or unconscious and Has cold hands Plus either: Slow capillary refill (more than 3 seconds) Or Weak or fast pulse

95. If in shock or severe dehydration (unconscious) Weigh the child. Estimate the weight if child cannot be weighed or weight not known Give oxygen Make sure child is warm Insert an IV line & draw blood for emergency laboratory investigations Give IV 10% Glucose (5 ml/kg)

96. Dehydration If in shock or severe dehydration (unconscious) cannot be rehydrated orally or by NGT, give IVF, either RL & 5% dextose at 15 ml/kg in first hour. Reassess, if improving give 15 ml/kg in 2 nd hr. If not improving- dx is septic shock

97. Septic shock treatment Give maintenance IV fluid (4 ml/kg/hr) Review antibiotic treatment Start dopamine Initiate re-feeding as soon as possible

98. Dehydration Monitoring: Expect RR, PR to fall Urine to be passed Return of tears, moist mouth, less sunken eyes and frontanelle and improved skin tugor Wt of child Liver size Monitor every 30 mins for 2hrs then hrly for the next 4-10 hrs

99. Dehydration Prevention of dehydration: CT breastfeeding Initiate re-feeding with starter F75 Give 50-100mls Resomal per loose motion

100. Continuing diarrhoea Replacement fluids CT Stool m/c/s and treat accordingly. giardia ; metronidazole 7.5mg/kg TID x 7d Osmotic diarrhoea: Diarrhea worsens with hyperosmolar F75 and ceases when sugar content and osmolarity are reduced.Rx -lower osmolar feeds

101. Electrolyte imbalance All severely malnourished children have deficiencies in K+ & Mg2+ and excess sodium May take 2 weeks to correct Ideally should receive Mg, Zn, Cu and Se as part of mineral mix – added to milk feed. Rx: Extra K + 3- 4 mmol/kg daily Extra Mg2+ 0.4 – 0.6mmol/daily

102. Infection Signs like fever may be absent but still infection present, assume all malnourished children have an infection Rx: S tart BS ab , measles vaccine if >6mths or unimmunized , albendazole No complications: PO amoxicillin(45mg/kg/d BD) X5 days Complications( hypogly , hypotherm , lethargy): Im /iv xpen (50000IU QID) or ampicillin(50mg/kg BD) X2 days, then oral amoxicillin( 30-40 mg/kg/day TID) X 5 days Plus Genta (7.5mg/kg OD) X7 days.

103. Infection metronidazole 7.5mg/kg TID X7 days may be added to the BS Abx . Rx for other infections as appropriate: meningitis, pneumonia, dysentery, skin infxns , malaria and TB) Parasitic worms: delay until rehab period. Give ABZ STAT .

104. Micronutrients Give daily for at least two weeks Multivitamins supplement Folic acid- 5 mg on day 1 then 1 mg/day Zinc – 2mg/kg/day Copper - 0.3 mg/kg/day

105. Dermatitis of kwashiokor Due to zinc deficiency – give Zn. Soak/bathe areas in 0.01% potassium permanganate sol. For 10min/day Apply barrier cream zinc and castor oil ointments, petroleum jelly to raw areas, GV or nystatin cream to skin sores Omit nappies/diapers, perineum can stay dry.

106. Micronutrients Vitamin A- < 6 months- 50,000 iu 6 month-1yr-100,000 iu > 1 yr- 200,000 iu ) on day 1, 2 and 14 – only if child has signs of def eg corneal ulceration or Hx of measles Children more than twelve months but having weight less than 8 kg should be given 100,000 IU orally irrespective of age.

107. Micronutrients Once gaining weight and good appetite, ferrous sulphate 3mg/kg/day. From the second week Severe Anaemia Transfuse: Hb < 4gldl,4-6g/dl in resp distress PCV – 10 ml/kg slowly for 3hrs + frusemide 1mg/kg iv at the start of transfusion

108. Initial feeding Essential features Frequent small 2-3 hrly feeds of low osmolality ,low lactose Oral/NGT feeds Never parenteral 100 kcal/kg/d Protein @ 1-1.5g/kg/d Liquid @ 130ml/kg/d (100 if with severe edema) If child is breastfeeding continue it but still give feeds Starter F75(75kcal/100ml and 0.9g protein/100ml)

109. Initial feeding Monitoring: amount of feed and left over, vomiting ,diarrhea, daily body wt. If the child has poor appetite, encourage the child to finish the feed. If eating 80% or less of the amount offered, use a nasogastric tube. If in doubt, see feed chart for intakes below which tube feeding is needed

110. Catch up growth Signs that a child has reached this phase: return of appetite, edema gone and no episodes of hypoglycemia

111. Feeding for catch up growth Treatment: Gradual transition from starter to catch up Replace F75 with an equal amount of F100 (100kcal/100ml and 2.9g protein/100ml) On day 3 increase each successive feed by 10 ml till some remains uneaten at abt 200ml/kg/d After gradual transition give frequent feeds unlimited amouts , 150-220kcal/kg/d, 4-6g of protein/d

112. Feeding for catch up growth Start with small but regular meals and encourage child to eat often 8 meals/day. Monitor for signs of heart failure due to fluid overload. Assess progress: daily wt gain

113. Sensory stimulation Tender, loving care Structured play therapy for 15- 30 mins /d Physical activity as soon as the child is well enough. A cheerful, stimulating environment. Encourage mother’s involvement e.g. comforting, feeding, bathing, play Provide suitable toys for the children.

114. Rehabilitation Appetite has returned Principles: encourage child to eat as much as possible, breastfeeding, emotional care, prepare diet for continued care Criteria for Discharge :, gaining weight >5g/kg/d for 3consecutive days. Continue monitoring progress.

115. Discharge Criteria Child Oedema has resolved Achieved weight gain of >15% or gaining weight >5g/kg/d for 3consecutive days . Child is eating an adequate amount of nutritious food that the mother can prepare at home All infections and other medical complications have been treated Child is provided with micronutrients Immunization is updated

116. Discharge Criteria Mother/caregiver Knows how to prepare appropriate foods and to feed the child Knows how to give prescribed medications, vitamins, folic acid and iron at home Knows how to make appropriate toys and play with the child Knows how to give home treatment for diarrhoea , fever and acute respiratory infections and how to recognise the signs for which medical assistance must be sought Follow-up plan is discussed and understood

117. Weight Gain (g/kg/d) calculation Weight gain = {discharge weight in gms – minimum weight in gms } * 1000/{ minimum weight in kg x number of days between date of minimum weight and discharge day} The rate of weight gain for an individual is calculated as the discharge weight minus the minimum weight multiplied by 1000 to convert the weight gain to grams. This is then divided by the admission weight to give grams of weight gained per kilo body weight. Lastly, this total weight gain is divided by the number of days from the date of minimum weight to the date of discharge, to give g/kg/d.

118. Weight Gain (g/kg/d) calculation e.g. Ramu a two year boy was admitted and weighed 7.3 kg at admission and 8.4 kg at discharge; Ramu stayed for 17 days at the NRC. Weight gain for Ramu = (8.4 – 7.3) x 1000/7.3 x 17 = 8.8 gm/kg/day. Ramu’s weight gain is 9 gm/kg/day

119. Failure to respond criteria Failure to regain appetite-------on 4 th day after admission. Failure to start to lose oedema ------on day 4 th . Oedema still present---------on 10 th day. Failure to gain at least 5 gm/kg/day for 3 successive days after feeding on catch up diet.

120. Follow up Planned and regular, nutrition clinic Risk of relapse greatest after discharge Should be seen after 2wks,1mth,3mths If a problem is identified more frequent visits Aft 6mths,do yearly visits till 3yrs of age.

121. Follow up Regular check-ups should be made at 2 weeks in first month and then monthly thereafter until weight for height reaches -1 SD or above. If a problem is detected or suspected, visit/s can be made earlier or more frequently until the problem is resolved.

122. Follow up Before discharge, inform the ANM posted at the nearest PHC or sub-centre in order to ensure follow up. ASHAs and AWWs are an important link in community based follow up of the child till full recovery takesplace . All SAM children should be followed up by health providers in the program till s/he reaches weight-for-height of – 1SD.

123. PROGNOSIS Good if picked early before complications have set in. Long-term effects include failure to thrive, behavioral and cognitive dysfunction, Small stature, Obstructed labour, Low birth wgt infants

124. Management of SAM children less than 6 months of age Initial steps of management i.e. hypoglycemia, hypothermia, dehydration, infection, septic shock are same as for older children. Feed the infant with appropriate milk feeds for initial recovery and metabolic stabilization. Wherever possible breastfeeding or expressed milk is preferred in place of Starter diet. If the production of breastmilk is insufficient initially, combine expressed breast milk and non-cereal Starter diet initially. For nonbreastfed babies, give Starter diet feed prepared without cereals

125. Management of SAM children less than 6 months of age Provide support to re-establish breastfeeding as soon as possible. Support and help to express breast milk if the infant is too weak to suckle. Give supplementary milk feeds if breast milk is not enough or if breastfeeding is not possible or mother is HIV + ve and has opted for replacement feeds.

126. Management of SAM children less than 6 months of age Give good diet and micronutrient supplements to the mother. In the rehabilitation phase, provide support to mother to give frequent feeds and try to establish exclusive breast feeding. In artificially fed without any prospects of breastfeeds, the infant should be given diluted Catch-up diet. [ Catch-up diet diluted by one third extra water to make volume 135 ml in place of 100ml].

127. Management of SAM children less than 6 months of age On discharge the non-breastfed infants should be given locally available animal milk with cup and spoon The infant formulas are very expensive and should only be advised if the parents can afford this Discharge the infant from the facility when gaining weight for 5 days and has no medical complications.

128. Supplementary Suckling Technique (SST) Relactation through Supplementary Suckling Technique – Supplementary Suckling Technique (SST) is a technique which can be used as a strategy to initiate relactation in mothers who have developed lactation failure

129. Supplementary Suckling Technique (SST)

130. THANK YOU