SAM and management of complications.pptx

Sever acute malnutrition and management of complications

1. Severe acute malnutrition (SAM) and management of complications Prepared by Abdulghani Jaafar

2. PART 1 Basic understanding of a malnutrition programme

3. Definitions TFP = Therapeutic Feeding Programme ATFC = Ambulatory Therapeutic Feeding Centre (patients treated as out-patients) ITFC = Inpatient Therapeutic Feeding Centre MUAC = Mid-Upper Arm Circumference RUTF = Ready to Use Therapeutic Food (usually PlumpyNut ) W/H: weight for height (or length in infants).

4. TFP 1-6 months of Age

5. Admission and Discharge Criteria for Children 1-6 months of Ag e

6. Which are the two types of infants (1-6m of age ) seen in TFPs ?

7. Infants who are underweight because they have experience post-natal nutritional deprivation Infants who are underweight because they were born premature or small for gestational age or both.

8. What kind of milk to give in the ITFC?

9. When to Transition from stage to stage?

10. What to do if the patient does not gain weight ?

11. Vitamin D Ferrous Fumarate

12. Systematic Treatment for the Non- Malnourished Lactating Mother

13. TFP 6 to 59 months of Age

14. Admission and discharge criteria to TFP For children 6 months to 5 years

15. ITFC or ATFC??

16. Management of patients in ITFC Establish patient meets criteria for admission Define target weight Therapeutic food Phase 1 Transition Phase 2 Routine tests on admission Routine treatment on admission Treatment of medical complications Discharge from hospital to ATFC to complete treatment

17. Target weight The weight we are aiming for before the patient can be discharged from the TFP Target weight is W/H > -2 The patient does not need to reach this weight in order to be discharged from hospital

18. Weight for height z-score

19. Example 1 8 month old girl Length 64cm Weight 4.2kg MUAC 110 mm No appetite Fever and lethargy Does this child have SAM? Does this child need to be in the TFP? Does this child need to be admitted in ITFC?

20. Example 2 3 year old boy Height 89cm Weight 10.5kg MUAC 112 mm Eating plumpy nut Medically well Does this child have SAM? Does this child need to be in the TFP? Does this child need to be admitted in ITFC?

21. Example 3 18 month old girl Length 72cm Weight 6.5kg MUAC 117 mm High fever, unconscious, history of seizure at home Does this child have SAM? Does this child need to be in the TFP? Does this child need to be admitted in ITFC?

22. Phase 1 – Stabilisation Criteria for moving from Phase 1 to Transition: Medical complications stabilised Appetite has begun to return ( ideally no NGT) Oedema reduced

23. What about breastfeeding ?

24. Transition phase

25. Pg 80

26. Phase 2 - Rehabilitation Criteria for moving from Transition to Phase 2: Good appetite and taking all the RUTF given. Medical complications treated Oedema very reduced but can be ++ if other criteria met. Phase 2 should be done at home Ensure follow-up in ATFC until discharged from TFP

27. Return to Phase 1 Occasionally need to go back to Phase 1 due to deterioration in condition of child Reasons: Anorexia – indicates developing complications Serious medical complication interfering with food intake or appetite Severe re-feeding diarrhoea with weight loss Evidence of overload or excessive weight gain Development of oedema

28. Nasogastric Tubes (NGT) Should be avoided if possible Recommended only if: Complete anorexia Child taking less than 75% of milk in one day Uncontrolled vomiting Child too weak to drink or unable to swallow Impaired conscious level

29. NASOGASTRIC TUBE RULES Explain to the caretaker the need for NGT Verify the position of NGT before EVERY feed Ensure the child is in a good position for using the NGT - half sitting up NOT lying down Use gravity to feed the child – do not push with a syringe Change NGT every 72 hours

30. Examples 1, 2 and 3 What Phase will you start with? What type of milk/food will you give? What quantity of milk/food will you give? When will you change to the next phase? When will he/she be ready for discharge from ITFC?

31. Routine tests and treatment

32. PART 2 Medical complications in malnutrition

33. Diarrhoea Diarrhoea common in malnutrition: Atrophy of lining of gut Reduced gastric acid Reduced digestive enzyme production Can become worse when milk treatment starts Most of the time, diarrhoea does not need treatment Zinc not necessary as there is enough in F75, F100 and RUTF Pay attention to hydration status of child

34. Diarrhoea Bloody diarrhoea: Azithromycin or ciprofloxacin for 3 days Ceftriaxone IV for 3 days if severe Persistent watery diarrhoea (more than 2 weeks): Tinidazole one dose (Giardia) If no improvement, azithromycin or ciprofloxacin for 3 days If no improvement, erythromycin for 5 days (Campylobacter) Albendazole for 3 days (Whip worm) Metronidazole 3 days (Giardia) Shigella

35. Dehydration Difficult to diagnose!! Usual signs not reliable: Skin turgor Sunken eyes Sunken fontanelle Assessment based on: History – number and quantity of loose stools Change in appearance (ask the mother!) Ability to drink (thirsty vs too tired to drink) Conscious level (irritable vs lethargic) Urine output

36. Degree of dehydration

37. Rehydration weight Use weight to guide rehydration Patient should return to weight they were before diarrhoea started If weight before diarrhoea unknown, we can calculate based on percentage (%) dehydration: Mild dehydration = 3-5% Moderate dehydration = 6-9% Severe dehydration = >10% Find rehydration weight by adding this % to current weight

38. Calculating rehydration weight 6kg child with moderate dehydration (7%): Weight + weight x % dehydration 100 6 + (6 x 7%) = 6 + ( 6 x 7 ) = 6 + 0.42 = 6.4kg 100 ( )

39. Example 1 2 year old female with SAM Weight 8kg Diarrhoea past 3 days, 8 times/day Mother says eyes sunken Lethargy, unable to drink, not passed urine since yesterday morning What is the level of dehydration? What percentage does this correspond to? What is the rehydration weight?

40. Example 2 9 month old boy with SAM Weight 4kg Diarrhoea since yesterday, watery Irritable, thirsty, passed a little urine this morning What is the level of dehydration? What percentage does this correspond to? What is the rehydration weight?

41. No or Mild dehydration Mild dehydration: Plan A ORS If outpatient, Resomal if inpatient after loose stool: Weigh child twice/day

42. ORS vs ReSoMal

43. Moderate dehydration Calculate rehydration weight Aim to reach this weight in 8-12 hours Give ReSoMal : Ensure vital signs checked hourly Ensure weight checked every 2 hours Give milk as well as ReSoMal at feeding times Give water in between ReSoMal if child still thirsty Reevaluate every 2 hours at least to check evolution and decide need for ongoing rehydration

44. Severe dehydration Treat as moderate dehydration if tolerated (consider NGT before IV treatment). If not tolerated, give a 200% maintenance or even more if needed, for at least 2 hours

45. Example 2 (continued) 9 month old boy with SAM Weight 4kg Diarrhoea since yesterday, watery Irritable, thirsty, passed a little urine this morning Prescribe the ReSoMal for this child When will you reweight this child? When will you reevaluate this child? When will you stop ReSoMal ?

46. Severe pneumonia Check for signs of severity Oxygen if necessary Consider NGT if respiratory distress prevents feeding Ceftriaxone 80mg/kg once daily (minimum 3 days) If improving after 3 days: Change to amoxiciline Total 10 days treatment If no improvement after 48 hours: Add IV cloxacillin 100mg/kg/day divided in 4 doses In this case the oral continuation should be done with amoxiciline plus clavulanic acid .

47. Sepsis or severe infection Signs of illness with no clear focus of infection: Fever or hypothermia Lethargy, reduced consciousness Tachycardia Tachypnoea Hypoglycaemia Suspect a severe infection if the above signs are present and treat with high dose antibiotics: Ceftriaxone 100mg/kg once daily PLUS Cloxacillin 200mg/kg/day every 6 hrs Change to oral treatment with co- amoxiclav after 3-5 days IV treatment if improving

48. Diagnosis of TB Clinical diagnosis No sputum Use algorithm Crofton (less used) Think carefully: High suspicion of TB? Contacts? 6 months of treatment… Co-infected with HIV?

49. Thank you