Recent Advances -Severe Acute Malnutrition .pptx

Recent Advances -Severe Acute Malnutrition in Developing world

1. SEVERE ÅCU"BE MALNUTRI4"ION ngh MBBS, MD (Paedîatrics)

2. Introduction Childhood undernt+trition a major global health problem million under- five children in India [1] Nearly o 6 million deaths and z 6 million DALYs Idisability adjusted life years) are attributed to this condition Diarrhea and pneumonia accounts for half the under- five deaths in India, and malnutrition is believed to contribute to 6196 of diarrheal deaths and 53 pneumonia deaths (z). a. TnternationaT lnstltute 'hnr PopuTazion Sciences. National Fam4y Hearth survey , aoo$- zoo6. Mumbai Tnd\B: nternatlonal 1nstltute of Popu on 5c ence; zoo Black RE, Allen LH, Bhutta ZA, de Onis Id, Gzzati k\, Ivlathers C, et at. IVlatemal and Child undernutrition: global and mglonaT exposures and Health consequences, Lancet aooB; § : z§$- 6o

3. Malnutrition encompasses both ends of the nutrition spectru s, from undernutrition to Dverweight. z. bI- Vr- R F ACU i i- MW.I NU T RI I ION without complications Child ren &- Sg months Df age, weight-for- height less than — Z- score of the median of the WHO growth standards, OR Dr clinical signs of bilateral oedema {nutritional origin), OR Presence of visible severe wasting; OR a mid- upper arm circumference less than » s « z. SEVERE ACUTE MALNUTRITION with complications 3• Mon.erato acute n ialnutrition-weight for hei 9 ht between - 2SD tD - 3 SD ; without eden›a, or MUAC is 3z- sz. s • m

4. SAM vs PEM Name protein- energy malnutrition is avoided, as it oversimplifies the complex mvltideficiency etiology.

5. Ca Uses SAM ..î

6. PÅTHÕP- H YSI›ÖLOĞY/

7. ADAPTATION HYPOTHESIS (GOPALAN’5) Kwashiorkar. Adaptation Failure Marasmus: Extreme case of adaptation Jelliffe's Hypothesis mechanisms Interactions and sequelae of dietary imbalances, infections and infestations, emotional trauma and toxins

8. Reductive adaptation Leads to liver makes glucose Iess— Hypoglycemia Heat production less— hypothermia kidneys less excretion of exCess fluid and sodium. Heart- smaller and weaker with reduced output Sodium builds up inside cells- - excess body sodium, fluid retention, and edema. Potassium leaks out of cells (excreted in urine)- - fluid retention, edema, and anorexia.

9. Gut- less 9 astric acid and enzymes, motility reduced- - Digestion and absorption are impaired. Cell replication and repair are reduced Red cell mass is reduced, releasing iron,.

10. INITIAL ASSESSMENT HISTORY The usual diet {before the current illness) Evidence of any chronic illness: presence of diarrhea (duration, watery /bloody) vomiting, loss of appetite, cough Contact with tuberculosis

11. DIETARY HISTORY zg Hour Dietary recall Recall food and drink intake last zg hour. Pre- morbid intake and current intake Freq of cereals/ pulses/ milk and products1 fruits and veg/ meat products. Calc of calorie frDm breast. DO NOT calculate if usual feeding going on{ on demand feeds)

12. Signs of dehydration Shock (cold hands, slow capillary refill, weak and rapid pulse) Severe palmar pallor Eye signs of vitamin A deficiency signs of infections Skin infection or pneumonia, signs of HIV infection, fever. Hypothermia (rectal temperature ‹9s 9°*›

13. ANTHROPOMETRY Height- for- age (or length- for- age for children <z yr)- measure of linear growth, deficit represents cumulative impact of adverse events weight- for- height(wasting)- - acute malnutrition Mid- upper arm circumference- C ommoniy used for screening, found to be relatively stable between the ages z and yr.

14. FaCR lachrymal and salivary glands phy Mouth Moon facR Dry eyes, pale conjunctiva, Bitot spots (vitamin A), periorbital edema Lack of tears and dry mouth. Angular stomatitis, cheilitis, glossitis, spongy bleeding gums (vitamin C),

15. Teeth Hair Nails Enamel mottlin 9, delayed eruption Dull, sparse, brittle hair, hypopigmentation, flag sign {alternating bands of light and nDrmal CDlDr), alopecia Loose and wrinkled {marasmus), shiny and edematous (kwashiorkor), dry, patchy hyper- and hypopigmentation (crazy paving or flaky paint dermatoses), Koilonychia, thin and soft nail plates, fissures.

16. Fłaky pa*nt D erm atosis Koilonychia

17. Muscle Abdomen Neurologic Hematologic Wasting, Chvostek or Irousseau si 9 n (hypocalcemia) Distended: hepatomegaTy with fatty liver Global developmental delay, loss of knee and ankle reflexes, impaired memory Pallor, petechiae, bleeding diathesis Behavior Letharpic, apathetic, irritable on handIin 9

18. Indications for inpatient care Presence of a medical complication Reduced a Apetite Presence of bilateral pit ting edema

19. APPETITETEST 7#.9 Differentiate a complicated from an uncomplicated tase (if require in- patient care} TABLB T: Certcaic rrie Prima A›eczilz' Ttsr 35 If appetite- oood, still rate of weight gain at home is poor - may indicate a social ptdblem at household level or extensive sharing of the medical nutrition therapy.

20. RUTF RUTF- mixture of milk powder, vegetable oil, sugar, peanut butter, and powdered am d m nera Powdered ingredients embedded in lipid rich paste..-energy dense Resists microbial contamination ..(very low water activity). Stored at room temp and tropical conditiO05 fO£ 3- 4 months is energy- dense food providing s s^«•!/s Equivalent in formulation to F zoo Practical to use- where cooking fuel and facilities are limiting Continue to receive other foods and brestfeeding during medical nutrition therapy with RUTF

21. Daily amount of RUTF to be consumed e6o- too g and zo- a 4 9 *9: too- §6o g. To given along with p|enty of water in *-3 hourly feeds

22. A typical re g e for R Full fat mi|k powder Sugar Peanut butter °S se TheLa ie -ood Oxidation of the fatty acids, vitamin A and C, is the main factor iimitinq the storage life of RUTH

23. An example of- - Ready- to-use therapeutic spread produced by Nutriset

24. I iN.P°ÅTI I NT M/UAN é G É ‹MIENT

25. P ri nc i pIes of Treat sent 6 Pre\ent'’lreat h#QO 0i yceniin Prevenl/treal hypolhermin Treat'p e 'em dehydration Correct imbalance of eleciro1yles Treal elections Correcl rleficiencies of micronHlrients Fla 1 caul ous feec›ng Rebuild •asied Issue I catch up gro'.›'Ih) Prcv‹rle losing care and pla'y Prepare lor lolfo '- up Rehabilitation Week 2— 6

26. PHASES Stabilization phase rehabilitation phase{catch- up groMh). *Pushing ahead too quickly risk- - “refeeding syndrome. ^ Don't treat edema with diuretic *Don't g ve high- protein diet ‹n early phase of treatment.

27. Emergency Management SHOCK (Lethargic/ unconscious/ cold hands/ slow capillary refill/ weak fast pulse) IV fluid(Ringer lactate with $% dextrose, lN /z) with 5 dextrose or Ringer lactate alone at z$ mL/kg over a hr If signs of Improvement, repeat IV t$ mL/kg for z more hr. Then oral or nasogastric rehydration If does not improve after z h of intravenous therapy, a bJood transfusion (zo mL/kg slowly over atleast 3 ^› given

28. Emergency treatment of severe anemia Hb <§ g/ dl or between g and 6 9/ dl with respi‹’atory distress Give BT with whole l›lou‹J o n I/kg over 3 hr Lasik given at starting uf BT

29. Hypoglycemia ' zoD($o nJL), or a feed, or z teaspoon su 9 a r under the tongue- whichever is ğUic kest I I Unconscius(symptomatic) Fee‹J eve y 2 hr for at least the first day Keep warm Start broad-spectrum a ntihioi iC s

30. Hypothermia- - ‹Hillary ‹ 3 s° C tgs°* ); rectal ‹ 3 s s° C ( 9 s s O F ) Feed Skin- to- skin conta ct l dress warmed clothes, cover head, wrap in warmed blanket In case of severe hypothermia (rectal temperature warm humidified osygen followed immediately by S ml/kg of 1o% dextrose IV or o m I of 1o96 dextrose by naso 9 6Stric route Stop rewarnain9 rectal temperature 3 6

31. Dehydration Do not give IV fluids unless in shock Give ReSoMal $ mL/kg ever y 3• mi n fDr first a hr orally or NG tube s- a mL/kg in alternate hours for up to zo hr. STOP- - signs of overload (pulse rate increases by s beats/min and respiratory rate by s breaths/min, increasing edema, engorged jugular veins) StDp when dehydrated.

32. Standard WHO IDW- Osrnolarity oral rehydration solutio n (75 ^^ oI/L sodium) should not - - used for oral pr nasogastric rehydration in severe acute malnutrition in dehydration or severe dehydration Re SoMal or half- strength standarcl WHO low- osmoIarity oral rehydration solution should be given WHO The lrealmenl of diarrhoea: manual for physicians and olher senior heallh vo/4‹ers. Geneva. World Heallh Organization; 2005 ( htlp://www.who.int/maiernat d Ild adolescenVdocumenis/9241583180/en/).

33. Electrolytes ÑKtFô Ot6SSİU‹Tł ăt 3-4 ^NEq /kg/ day for(min z weeks) On day +. 5 D9'3 magnesium sulphate (\ mEq/ml) IM once (o. /k of a.8- t.z mE 9/* g daily Excess body sodium exists(even though the plasma sodium may low)- - decrease salt in diet

34. Infections If no CO Tlplications- - Oral cotrimoxazole (s mg/kg z2 hourly of trimethoprim) or oral amoxiciltin for g days If compIicatiOns- Gentamicin ‹7,S 9 /kg IV or IM) or amikacin (i - zo mg/kg IV or IM) once daily for y days Ampicillin s• mg/kg/dose IV or IM) every 6 hF for 2 days, oral amoxicillin (2y - k mg/kg) every 8 hr for s days. If no improvement within g8 hr- - !V cefotaxime (zoo- s o mg/kg/day 6- 8 hourly) or ceftriaxOne (to-yg mg/kg/day zz hourly).

35. Correct micronutrient deficiencies Twice RDA - vitamins and minerals be used. Iron avoided, promoting free radical generation and bacterial proliferation.. Added— gaining weight and good appetite. Vitamin A, given to all severely malnourished.. day a at s• ,ooo IU, zoo,ooo IU and zoo,ooo IU for infants o- s month, 6- zz months and children > a yr On day z and zg..IF SIGNS of xerophthalmia.

36. Thiamine Bz single dose ohm.$ mg i/m •s g oookca 6.6 mg/ ooo kcal y mg/kg/ day...(LATER)

37. Initiate Re- feeding Milk- based feeds- Fy$ in stabilization phase and Fzoo- rehabilitation phase ' Started as soon as possible (frequent small feeds) Breastfeeding- - continued ad libitum Begin with 8o kcal/kgl day and gradually increase to zoo kcalJkg/ day

38. Catch- up growth Oi 1 c g' A pp e tite returns in - 3 days me i'ease vulume feed Gradual transition front F- y$ ro F- zoo diet {calorie d+nsity (zoo kCEl/100 TT)l} ZICII have at least z $-$.o g protein/\oo ml Increase calories to z S o- zoo kcaI/k 9/ day, add proteins to g- 6 g)kg| day

39. Starter diets

40. com milk/‹wned dai y milk ‹m)) 9s (Approxiznale measure of one lcalori) (3/4) 1/2 ñiugar (g) 2.5 (Approximate measure of one evel tc n) (Approximate measure of one evel teaspoon) Water tb make (ml) fkcat)

41. Inpatient care Weighed each morning Lengih/height are measured on admission and discharge If good weight gain › zo g/kg/ day- - same treatment Moderate weight gain s zo g/kg/rlay— check food intake screened for systemic infection Poor weight gain <$ g/kq/ day - inadequate feeding, vntreared infection, ps yc IJoloqical probJems and coexisting infections

42. Criteria for discharge Alert and active, eating at least z - 3 * C ¿l l/kg/ day consistent weight gain (of at least g/kg/ day for 3 consecutive days) on exclusive ora! feeding Receiving adequate micronutrients Completed immunization appropriate for age aretaker has been sensitized to home care.

43. Failure of treatment Failure regain appetite by day § Failure start losing edema by day § Presence of edema on day to Failure gain at least s g/ kg/day-by- day o Secondary failure Failure gain at least $ g1kg/day for consecutive days during the rehabilitation phase

44. Refeeding syndrome Can complicate the acute nutritiona( rehabilitation May follow overly aggressive enteral or parenteral nutrition Excessive carbohydrates Increase in serum insulin levels Hypokalemia, hypophosphatemia(ts hallmark), hypomagnesemia. Phosphate o s mmol/L- - weakness, rhabdomyolysis, neutrophil dysf u n ct ” ion, ca r d ' iorespir a t or y f a ilure, arrhythmias, seizures, altered level of consciousness, or sudden death.

45. Pseudotumor cerebri transient rise of intracrania! tension beni 9^ and self limiting.

46. Nutritional recovery syndrome Sequence of events due high quantity of proteins during rehabilitation, possibly due- - endocrine disturbance(ex estrogen) produced by the recovering pituitary gland Presents as (ij abdominal distention, Increasing hepatomegaly ( ) Ascites Gv› Hypertrichosis (v› Parotid swelling ‹vi› Gynecomastia Eosinophilia sp1enomegaly.

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