Severe acute malnutrition pediatrics nelson mbbs

Severe Acute Malnutrition Dr. Muhammad Nadeem Chohan

The modules are presented in the following order 1. Introduction 2. Principles of care 3. Initial management 4. Feeding 5. Daily care 6. Monitoring and problem solving 7. Involving mothers in care 8. Outpatient management of severe acute malnutrition

Module 1 Introduction

Infants less than 6 months of age at risk of poor growth and development 2023 guideline process was to produce guidance on the identification and appropriate interventions for infants less than 6 months old who are not growing well, before they meet criteria for wasting and/or nutritional oedema.

Question What do you know about the Infants at risk for SAM based on sequential measures

Answer No weight gain or weight loss from one measurement to the next; or • Downward crossing of weight-for-age centile lines; or • Insufficient weight gain (velocity standards or grams/per specific time period).

Question What do you know about the Infants at risk for SAM based on single measurement?

Infants with poor anthropometry based on a single measure Weight-for-age z-score (WAZ) <-2 SD; or • Weight-for-length z-score (WLZ) <-2 SD; or • Nutritional oedema; or • Mid-upper arm circumference (MUAC) <110mm for infants between 6 weeks to less than 6 months of age.

Question Which are the known risk factors for poor growth in infants?

Answer Neurodevelopmental concerns; or • Infant feeding concerns; or • Maternal risk (physical or mental health problem(s) affecting caring practices); or • History of hospitalization

Infants at risk due to poor birth outcomes Preterm birth; or • Low birth weight; or • Small for gestational age

Question What is the change in Admission criteria for inpatient care for children aged 6 months or older?

Admission criteria for inpatient care for children aged 6 months or older Use of visible severe wasting as a sign of severe acute malnutrition (2009 version)

New version Visible severe wasting is no longer recommended as a sign of severe acute malnutrition, due to its subjective nature

Question Will you Admit all severely malnourished children for inpatient care?

2009 version Admit all severely malnourished children for inpatient care

New version Severely malnourished children with medical complications or failed appetite test should be admitted for inpatient care (or severely malnourished children who have mitigating circumstances such as disability, social issues, or difficulties with access to care

Question Will you admit all children having nutritional edema?

2009 version Oedema of both feet

New version Children with severe acute malnutrition who have severe bilateral oedema (+++) should be admitted for inpatient care, even when they do not present with medical complications and have appetite

Children who have only + or ++ bilateral pitting oedema but present with medical complications or have no appetite, or are wasted, should be admitted for inpatient care

Question What is the Criteria for transfer to outpatient care for children aged 6 months or older?

Criteria for transfer to outpatient care for children aged 6 months or older (New version) medical complications have been treated, and • the child has minimal oedema, and • the child is alert, and • the child eats 75% of the proposed daily amount of ready-to-use therapeutic food (RUTF);

Question What is the Criteria for discharge from all care for children aged 6 months or older?

Criteria for discharge from all care for children aged 6 months or older (New version) weight-for-height/length Z-score is ≥ –2, and no oedema for at least 2 weeks, or • mid-upper arm circumference is ≥ 125 mm, and no oedema for at least 2 weeks

Question What is the dose of commonly used antibiotics in children having SAM?

2009 version Amoxicillin 25 mg/kg/day • Gentamicin 5 mg/kg/day • Ampicillin 50 mg/kg/day

New version The doses of routine antibiotics have been adjusted, for example: amoxicillin 25–40 mg/kg, gentamicin 7.5 mg/kg, to reflect the latest recommendations from the 2013 WHO Pocket book of hospital care for children

Question Should we give Vitamin A to all children having SAM?

Vitamin A (New recommendations) Children with severe acute malnutrition should receive the daily recommended nutrient intake of vitamin A (5000 IU) throughout the treatment period. If the children are receiving F-75, F-100 or RUTF that comply with WHO specifications (and therefore already contain sufficient vitamin A), or vitamin A is part of other daily supplements, the children do not require additional vitamin A

Children with severe acute malnutrition should be given a high dose of vitamin A (50 000 IU, 100 000 IU or 200 000 IU, depending on age) on admission, only if they are given therapeutic foods that are not fortified as recommended in WHO specifications and vitamin A is not part of other daily supplements

Give a high dose (50 000 IU, 100 000 IU or 200 000 IU, depending on age) of vitamin A to children with severe acute malnutrition and eye signs of vitamin A deficiency or recent measles in inpatient care on Days 1, 2, and 15 (or at discharge to outpatient care), irrespective of the type of therapeutic food they are receiving

Question What is the dose of atropine in corneal clouding?

Atropine (2009 version) 1% 3 times a day

New version The concentration of atropine has been adjusted to 0.1% 3 times a day

Question What do you know about the Transition to RUTF?

Transition to RUTF (New version) Start feeding by giving RUTF as prescribed for the transition phase. If the child does not take the prescribed amount, then top up the feed with F-75. Increase the amount of RUTF over 2–3 days until the child takes the appropriate amount of RUTF to meet energy needs

Transition for children with oedema Children with bilateral pitting oedema should transition to RUTF when appetite returns and oedema is reducing

Question What is the next step in Rehabilitation phase for children on F-100

Rehabilitation phase for children on F-100 Children who are taking F-100 and are achieving rapid weight gain during rehabilitation should be changed to RUTF. Ensure that they are finishing up the appropriate amount of RUTF before transferring them for outpatient care

Question What is the Admission criteria for infants aged 0–6 months?

Admission criteria for infants aged 0–6 months (2009 version) Weight-for-height Z-score < –3, and/or • Bilateral oedema

New version Weight-for-length Z-score < –3, or • Presence of bilateral pitting oedema, or • Recent weight loss • Prolonged failure to gain weight • Serious breastfeeding difficulties after mother’s counselling

Question What do you know about Feeding for infants aged 0–6 months?

Feeding for infants aged 0–6 months (2009 version) F-75 as a supplement to breast milk

New version • Infants with severe acute malnutrition but no oedema should be given expressed breast milk. Where this is not possible, commercial (generic) infant formula or F-75 or diluted F-100 may be given, either alone or as the supplementary feed together with breast milk

Infants with severe acute malnutrition and bilateral pitting oedema should be given F-75 as a supplement to breast milk

Question What is the Criteria for transfer to outpatient care for infants aged 0–6 months?

Criteria for transfer to outpatient care for infants aged 0–6 months (New version) all clinical conditions are resolved, and • the infant has good appetite, is clinically well and alert, and • weight gain is satisfactory, and • the infant has been checked for immunizations, and • the mother or caregiver is linked with community-based follow-up and support

Criteria for discharge from all care for infants aged 0–6 months (New version) is breastfeeding effectively or feeding well with replacement feeds, and • has adequate weight gain, and • has a weight-for-length Z-score ≥ –2

Question What do you know about five reference cards?

five reference cards: weight-for-height reference card - F-75 reference card - F-100 reference card - ready-to-use therapeutic food (RUTF) reference card - antibiotics reference card

Question What do you mean by CCP forms?

suitable forms for record keeping CCP forms Initial management Daily care weight charts, Vitals monitoring records • 24-hour food intake charts

Module 2 Principles of care

LEARNING OBJECTIVES weighing and measuring children • determining a Z-score (or standard deviation score) based on the child’s weight and length; • measuring mid-upper arm circumference; • recognizing bilateral pitting oedema

composition of commercial (pre-packaged) therapeutic foods: F-75, F-100 and ready- to-use therapeutic food (RUTF); • important things not to do and why; • recommended admission and discharge criteria.

Question What do you mean by undernutrition?

Undernutrition Undernutrition manifests in four broad forms: wasting, stunting, underweight, and micronutrient deficiencies

Question What do you mean by wasting and stunting?

Answer Wasting is defined as low weight-for-height Stunting is defined as low height-for-age

Question What do you mean by Underweight?

Answer Underweight is defined as low weight-for-age

Question What are the various forms of Wasting?

Answer Wasting can present either as moderate or severe wasting.

Question What do you mean by severe acute malnutrition?

Answer Severe wasting and/or presence of bilateral pitting oedema is known as severe acute malnutrition.

Assessment of severe wasting

Question In which age group MUAC should be measured?

Measuring mid-upper arm circumference MUAC should be measured only for children aged 6 months or older. It should not be used in infants aged less than 6 months.

Children aged 6 months or older with a MUAC less than 115 mm are diagnosed as severely wasted

Question What are the steps of taking MUAC?

Question When will you Weigh the child?

Weighing the child Weigh the child as soon as possible after arrival. After admission, weigh the child once daily, at about the same time each day, one hour before or after a feed.

Question What do you mean by Tared weighing?

Answer “Tared weighing” means that the scale can be reset to zero (“tared”) with the person just weighed still on it. Thus, a mother can stand on the scale, be weighed, and the scale tared. The mother remains on the scale and is given her child to hold; the child’s weight alone appears on the scale If the child is aged under 2 years or is unable to stand, carry out tared weighing.

What are the steps of using this scale?

Answer Remove the child’s clothes but keep the child warm with a blanket or cloth while carrying to the scale. • Put a cloth in the scale pan to prevent chilling the child. • Adjust the scale to zero with the cloth in the pan or bucket. • Place the naked child gently in the pan or bucket. • Wait for the child to settle and the weight to stabilize

Question What do you know about Measuring length or height?

Answer If a child is less than 2 years of age or less than 87 cm tall, recumbent length should be taken. • If the child is 2 years of age or older, or 87 cm tall or more and able to stand, measure standing height. If the child cannot stand, measure recumbent length and subtract 0.7 cm to convert it to height?

Name these scales?

Question How will you interpret Z-score?

To determine Z-score (or standard deviation score) based on child’s weight and length/height The child’s weight may be between two Z-scores. If so, indicate that the weight is between these scores by writing less than (<). For example, if the Z-score is between –1 SD and –2 SD, write < –1 SD (Can we write it >2)?

Various Examples

Question Can you determine severe wasting by using Z scores?

Answer Children aged 6 months or older with a weight-for-length/height Z-score of less than –3 SD are diagnosed as severely wasted

Question What do you know about the nutritional edema?

Assessment of bilateral pitting oedema To be considered a sign of severe acute malnutrition, oedema must appear in both feet. If the swelling is only in one foot, it may just be a sore or infected foot.

Question What are the gradings of nutritional edema?

Answer + mild: both feet ++ moderate: both feet, plus lower legs, hands or lower arms +++ severe: generalized oedema, including both feet, legs, hands, arms and face.

Children with bilateral pitting oedema (of any grade) are considered severely malnourished

Question Which Medical complications might be associated with severe acute malnutrition?

Medical complications associated with severe acute malnutrition Any one of the following medical complications associated with severe acute malnutrition requires immediate medical attention and admission to inpatient care:

central cyanosis, severe respiratory distress, cough with fast breathing and chest indrawing • shock: cold hands with slow capillary refill and weak and fast pulse • anorexia, loss of appetite • intractable vomiting • convulsions • loss of consciousness

• hypoglycaemia • high fever • hypothermia • acute diarrhoea, recent sunken eyes or dehydration • severe anaemia • eye signs of vitamin A deficiency • skin lesions (e.g. severe dermatosis)

Question What are the gradings of dermatosis?

Dermatosis + mild: discoloration or a few rough patches of skin ++ moderate: multiple patches on arms or legs +++ severe: flaking skin, raw skin, fissures (openings in the skin).

Question Which Eye signs may be there due to vitamin A deficiency?

Eye signs Children with severe acute malnutrition may have signs of eye infection or vitamin A deficiency. • Pus and inflammation (redness) are signs of eye infection. • Bitot’s spots are superficial foamy white spots on the conjunctiva (white part of the eye). These are associated with vitamin A deficiency.

Corneal clouding is an opaque appearance of the cornea (the transparent layer that covers the pupil and iris). It is a sign of vitamin A deficiency and can quickly worsen and evolve into corneal ulceration

Corneal ulceration is a break in the surface of the cornea. It is a severe sign of vitamin A deficiency. The eye may be red or bleeding, or the child may keep the eye shut. If not treated, the lens of the eye may push out and cause blindness. Corneal ulceration is urgent and requires immediate treatment with vitamin A and atropine (to relax the eye).

Question What is the Admission criteria for children aged 6 months and older?

Admission criteria for children aged 6 months and older Bilateral pitting oedema +++ or marasmic kwashiorkor: any bilateral pitting oedema with severe wasting or bilateral pitting oedema + or ++ or severe wasting with any of the following danger signs or medical complications: Will you admit the child with grade + edema?

failed appetite test • intractable vomiting • convulsions • semi-consciousness or unconsciousness • inability to drink or breastfeed • shock • severe dehydration • hypoglycaemia • hypothermia

high fever (> 39°C rectal or > 38.5°C axillary ) • acute diarrhoea • severe malaria • severe anaemia • lower respiratory tract infection • eye signs of vitamin A deficiency • severe dermatosis

or referred from outpatient care according to outpatient care action protocol

Question What do you know about Outpatient care for the management of severe acute malnutrition without medical complications?

Outpatient care for the management of severe acute malnutrition without medical complications Bilateral pitting oedema + or ++ or severe wasting and • passed appetite test • clinically well • alert or transferred from inpatient care after medical complications have been treated

Question How will you define Severe wasting?

Answer Severe wasting is defined as MUAC < 115 mm or weight-for-height/length Z-score of < –3 SD.

If the child has a weight-for-height Z-score of < –3 SD or has a MUAC of less than 115 mm, he or she is severely wasted. If there is oedema of both feet (+ oedema or worse) the child is severely malnourished, even though retained fluid may add to the child’s weight, giving a weight-for-height Z-score of > –3 SD

Question What is the Admission criteria for infants aged less than 6 months?

Admission criteria for infants aged less than 6 months Any bilateral pitting oedema (+, ++, or +++) or weight-for-length Z-score < –3 SD with any of the following danger signs or medical complications:

unable to breastfeed • intractable vomiting • convulsions • semi-consciousness or unconsciousness • shock • severe dehydration • hypoglycaemia • hypothermia

high fever (> 39°C rectal or > 38.5°C axillary) • acute diarrhoea • severe anaemia • lower respiratory tract infection • eye signs of vitamin A deficiency • severe dermatosis

or any of the following: • failure to gain weight • any loss of weight that crosses the infant’s growth line • ineffective breastfeeding (attachment, positioning or suckling) directly observed for 15–20 minutes

disability that affects suckling or swallowing, or a developmental problem affecting feeding • any social issue requiring detailed assessment or intensive support (e.g. maternal depression)

Question When will you advise for Outpatient care (< 6 months old infants)?

Outpatient care Weight-for-length Z-score < –3 SD and • no bilateral pitting oedema • clinically well and alert • gaining weight following the growth curve (serial weight measurements follow consistently along a channel on or between the same centiles) • adequate social circumstances and support

Question Which infants aged less than 6 months may become malnourished? (Risk factors)

Infants aged less than 6 months may become malnourished if: they have never been breastfed or have experienced suboptimal breastfeeding practices; • they have received inadequate or unsafe artificial feeds, or complementary feeds are introduced too early; • they have had recurrent infections; • they have had a medical complication

their mothers are dead or absent and no appropriate caregiver is in place; • their mothers are malnourished, traumatized, ill, or unable to respond normally to their infants’ needs; • they have some form of disability that affects their ability to suckle or swallow, or a developmental problem affecting feeding.

Question For infants with a length < 45 cm, the weight-for-length Z-score has not been established, than what will you do?

Answer Note that infants aged less than 6 months are considered as severely malnourished if they have a weight-for-height Z-score of < –3 SD or bilateral pitting oedema. For infants with a length < 45 cm, the weight-for-length Z-score has not been established. The criteria for severe acute malnutrition are based on a weight for-age Z-score of < –3 SD, together with breastfeeding difficulties. They should always be admitted into inpatient care.

Question What about the Low-birth-weight babies?

Answer Note that low-birth-weight babies are not usually severely wasted or edematous and so are unlikely to meet the criteria for severe acute malnutrition. Management of low-birth-weight babies is not taught in this course. Low-birth-weight babies should be breastfed

Integration of inpatient and outpatient services

Question Will you give antibiotics to all children with severe acute malnutrition?

Presume and treat infection Nearly all children with severe acute malnutrition have bacterial infections. However, as a result of reductive adaptation, the usual signs of infection may not be apparent, because the body does not use its limited energy to respond in the usual ways, such as inflammation or fever

Question Give Examples of common infections in the severely malnourished children?

Answer Examples of common infections in the severely malnourished child are ear infection, urinary tract infection and pneumonia. Assume that infection is present and treat all severe acute malnutrition admissions with broad-spectrum antibiotics. If a specific infection is identified (such as Shigella), add specific appropriate antibiotics to those already being given.

Question Why not to give iron early in treatment in case of anemia?

Do not give iron early in treatment Due to reductive adaptation, the severely malnourished child makes less haemoglobin than usual. Iron that is not used for making haemoglobin is put into storage. Thus, there is extra iron stored in the body, even though the child may appear anaemic. Giving iron early in treatment will not cure anaemia, as the child already has a supply of stored iron

Question What about the potassium and sodium supplementation?

Provide potassium and restrict sodium All severely malnourished children should be given potassium to make up for what is lost. (They should also be given magnesium, which is essential for potassium to enter the cells and be retained.) When children are receiving therapeutic foods that comply with WHO specifications, such as commercial (pre-packaged) F-75, F-100, and RUTF, the increased requirements of potassium and magnesium are covered, therefore additional supplements should not be given

Question Will you give regular oral rehydration solution (ORS) in case of diarrhea? (There is a reward if any body answer yes)

Malnourished children already have excess sodium in their cells, so sodium intake should be restricted. If a child has dehydration, a special rehydration solution called rehydration solution for malnutrition (ReSoMal) should be used instead of regular oral rehydration solution (ORS). ReSoMal has less sodium and more potassium than regular ORS.

Question How many calories are present in F-75, F-100 and RUTF?

Therapeutic feeds: what are F-75, F-100 and RUTF? F-75 contains 75 kcal and 0.9 g protein per 100 ml. F-100 contains more calories and protein: 100 kcal and 2.9 g protein per 100 ml.

RUTF is an energy-dense food equivalent to F-100. It is made from peanut butter paste, vegetable oil, skimmed milk, maltodextrin, sugar, and combined minerals and vitamins (CMV) mix. RUTF is similar in composition to F-100, the major difference being the added iron in RUTF

Since no water is added during preparation, bacteria cannot grow on RUTF and it has a shelf-life of 24 months. It is often packaged in a 92 g packet, which contains 500 kcal

Question What is the dose of RUTF?

Answer RUTF is given with clean drinking water. The number of sachets to be consumed per day is based on the severely malnourished child’s weight. As soon as the child is stabilized on F-75, or F-100, RUTF can be used as a “catch-up” formula to rebuild wasted tissues.

RUTF enables severely malnourished children to be transferred from inpatient care early, to continue care from home while attending a weekly outpatient therapeutic Programme. RUTF is given after each weekly nutritional and medical assessment until full recovery and discharge from the programme.

Question What do you know about the Process for successful management of the severely malnourished child (New version of 10 steps)?

Process for successful management of the severely malnourished child 1. treat emergencies, for example shock, dehydration, hypoglycaemia and hypothermia; 2. start cautious feeding with F-75 to stabilize the child; 3. presume infection, and provide routine intravenous antibiotics; 4. correct electrolyte imbalance (by giving WHO-recommended feeds); 5. correct micronutrient deficiencies (by giving WHO-recommended feeds);

6. prevent hypoglycaemia; 7. prevent hypothermia; 8. rebuild wasted tissues through higher protein and calorie feeds (RUTF, F-100); 9. provide stimulation, play and loving care; 10. prepare parents to continue proper feeding and stimulation after discharge.

Question What is Stabilization phase?

Stabilization: acute phase Life-threatening problems are identified and treated in a hospital or a residential care facility, specific deficiencies are corrected, metabolic abnormalities are reversed and feeding is begun

Question What is Transition phase?

Transition phase Intensive feeding is given to recover most of the lost weight, emotional and physical stimulation is increased, the mother or caregiver is trained to continue care at home, and preparations are made to transfer the child to outpatient care (Rehabilitation phase?)

Question When will you Transfer to outpatient care?

Transfer to outpatient care. After successful transition, the child is transferred to outpatient care to continue rehabilitation on RUTF at home, with weekly follow-up visits at the outpatient care facility

Question Which Important things NOT to do and why?

Important things NOT to do and why Do not give diuretics to treat oedema. The oedema is partly due to potassium and magnesium deficiencies that may take about 2 weeks to correct. The oedema will go away with proper feeding, including a mineral mix containing potassium and magnesium. Giving a diuretic will worsen the child’s electrolyte imbalance and may cause death

Do not give high protein formula (over 1.5 g protein per kg body weight daily). Too much protein in the first days of treatment may be dangerous because the severely malnourished child is unable to deal with the extra metabolic stress involved. Too much protein could overload the liver, heart and kidneys and may cause death

Do not give intravenous (IV) fluids routinely. IV fluids can easily cause fluid overload and heart failure in a severely malnourished child. Only give IV fluids to children with signs of shock

Question When will you TRANSFER TO OUTPATIENT CARE?

TRANSFER TO OUTPATIENT CARE WHO recommends that children be transferred from inpatient care to outpatient care as their condition is stabilized (regained appetite, reduced oedema, and the child has good appetite – the child should finish at least 75% of the proposed daily amount of RUTF during transition).

Question What is the drawback if a child leaves before being stabilized?

Answer If a child leaves before being stabilized, they are likely to get worse and have to return or may die

Question What will you do if a child cannot be transferred to outpatient care?

Answer In special (and rare) cases where a child cannot be transferred to outpatient care, the child should be kept in the severe acute malnutrition ward until the weight for-height/length Z-score is above or equal to –2 SD and the child has had no oedema for at least 2 weeks; or the MUAC is above or equal to 125 mm and the child has had no oedema for at least 2 weeks

Question How will you Treat or prevent hypoglycaemia?

Treat or prevent hypoglycaemia Feed straight away and then every 2–3 hours, day and night

Question Which are the Warning signs (clinical signs) for hypoglycemia?

Warning signs (clinical signs) for hypoglycemia Low temperature (hypothermia) noted on routine check • Lethargy, limpness and loss of consciousness • Child can become drowsy

• Conduct glucose test on admission • If hypoglycaemia is suspected but no tests are available, or if it is not possible to get enough blood for test, assume that the child has hypoglycaemia and give treatment immediately without laboratory confirmation

Question What is the management of hypoglycemia?

If the child is conscious: Give a bolus of 10% glucose (50 ml) or sugar solution (1 rounded teaspoon sugar in 3 tablespoons of water) orally or via nasogastric tube. Bolus of 10% glucose is best, but if not available give sugar solution or F-75 rather than wait for glucose

Start feeding with F-75 immediately after giving glucose and follow the feeding schedule (2-hourly feeds) Recheck blood sugar after 2 hours: if normal, then feed 2-hourly (12 feeds in 24 hours). If blood glucose is still low, verify that F-75 and antibiotics were given correctly

If the child is unconscious: Give glucose intravenously (IV) (5 ml/kg of sterile 10% glucose), followed by 50 ml of 10% glucose or sucrose by nasogastric tube • If the IV dose cannot be given immediately, give the nasogastric dose first

Question What do you mean by hypothermia and how will you manage it?

Treat or prevent hypothermia (defined as a rectal temperature < 35.5ºC or an axillary temperature < 35ºC) Feed straight away and then every 2–3 hours, day and night • Keep warm; use kangaroo technique, cover with a blanket • Let mother sleep with child to keep child warm • Keep room warm, no draughts

Keep bedding and clothes dry • Dry carefully after bathing (do not bathe if very ill) • Avoid exposure during examinations and bathing

Warning signs (clinical signs) for hypothermia Low temperature Note: Hypothermia in malnourished children often indicates coexisting hypoglycaemia and serious infection

Question What do you Monitor during rewarming?

Answer Monitor during rewarming: Take temperature every 30 minutes until it becomes normal and stop rewarming when it rises above 36.5ºC (or 36ºC axillary)

Question What are the warning signs in case of Profuse watery diarrhoea?

Treat dehydration (Warning signs) Profuse watery diarrhoea, thirst, hypothermia, weak or absent radial pulse, cold hands and feet, reduced urine output

In case of profuse watery diarrhoea or cholera, ReSoMal should not be given; instead use low-osmolarity oral rehydration solution (ORS) without changing the amounts and frequency Do not give IV fluids except in shock

Question How will you rehydrate the child with diarrhea?

If dehydrated: Give ReSoMal 5 ml/kg every 30 minutes for 2 hours (orally or by nasogastric tube (omit this step if the child has already received IV fluids for shock and is switching to ReSoMal – continue with next step) • Then give 5–10 ml/kg in alternate hours for up to 10 hours (i.e. give ReSoMal and F-75 formula in alternate hours). Use initial management chart

Question When will you Stop giving ReSoMal?

Stop giving ReSoMal when there are 3 or more hydration signs (less thirsty, less lethargic, slowing of respiratory and pulse rate, passing urine, not thirsty) or if the child has reached the target weight, or any signs of over hydration

Monitor every 30 minutes for the first 2 hours during rehydration for signs of over hydration • Increasing pulse and respiratory rate • Increasing oedema and puffy eyelids Thereafter: Check for signs at least hourly. Stop if pulse increases by 25 beats/ minute or respiratory rate by 5 breaths/minute

Question What are the signs of shock?

Treat shock (Warning signs) A child in shock is semiconscious or unconscious and has cold hands plus either: • Slow capillary refill (longer than 3 seconds) or • Weak fast pulse

Question What is the management of shock?

Monitor closely: use the critical care pathway initial management chart If child is in shock: • Give oxygen • Give sterile 10% glucose (5 ml/kg) by IV • Give IV fluid at 15 ml/kg over 1 hour, using one of the following solutions in order of preference:

Question Which fluids you will give in shock?

Answer -Half-strength Darrow’s solution with 5% glucose (or dextrose) or -Ringer’s lactate with 5% glucose* or -Half-normal saline with 5% glucose*

If there are signs of improvement over a period of 1 hour (pulse and respiration rates fall): Repeat IV 15 ml/kg for 1 more hour • Then give 5−10 ml/kg ReSoMal in alternate hours with F-75 for up to 10 hours

Question What will you do you if there are no signs of improvement after the first hour of IV fluid?

If there are no signs of improvement after the first hour of IV fluid assume child has septic shock. • Give maintenance fluids (4 ml/kg/h) while waiting for blood • Order 10 ml/kg fresh whole blood and when blood is available, stop oral intake and IV fluids • Give a diuretic • Transfuse whole fresh blood (10 ml/kg slowly over 3 hours)

Question What will you do if signs of heart failure are present?

If signs of heart failure: Give packed cells instead of whole blood

Question How will you Correct electrolyte imbalance?

Correct electrolyte imbalance (Too little potassium and magnesium, and too much sodium) In case commercial (prepackaged) F-75 is not available: • For potassium, add combined minerals and vitamins (CMV) or electrolyte/ mineral solution or 10% potassium chloride solution to feeds. If these are unavailable, give crushed Slow-K half a tablet/kg body weight daily • For magnesium, add CMV or electrolyte/mineral solution to feeds

Question What are the Warning signs for infection?

Treat infections (Warning signs) Hypothermia and hypoglycaemia are signs of severe infection

Question How will you treat infections?

Answer Starting on the first day, give broad-spectrum antibiotics to all children: • Gentamicin* IV or intramuscular (IM) 7.5 mg/kg once per day up to 7 days and • Ampicillin: 50 mg/kg IM/IV 6-hourly for 2 days, followed then by oral amoxicillin 25–40 mg/kg every 12 hours for 5 days

If serious complications (e.g. severe sepsis, shock) or resistance to amoxicillin and ampicillin, give: • Cefotaxime for children or infants older than 1 month 50 mg/kg every 8–12 hours plus oral ciprofloxacin 10–20 mg/kg twice per day for 5 days

If staphylococcal infection is suspected add cloxacillin 25–50 mg/kg 4 times per day for 14 to 21 days For parasitic worms (helminthiasis, whipworm), treatment will be given in outpatient care.

Question How will you Correct micronutrient deficiencies?

Correct micronutrient deficiencies Give vitamin A on day 1, day 2 and at the end of rehabilitation if the child has visible signs of vitamin A deficiency, signs of eye infection, or has measles now or has had measles in the past 3 months. For corneal ulceration add atropine drops and bandage Vitamin A, folic acid, multivitamins, zinc and copper are already added in commercial (pre-packaged) F-75, RUTF and F-100

Question Which feed you will give in Stabilization phase?

Begin cautious feeding (Stabilization phase) Give F-75 formula. These provide 130 ml/kg/day • Give 8–12 feeds over 24 hours (day and night) • If the child has oedema +++, reduce the volume to 100 ml/kg/day • Always use starting weight to determine feed amounts

Question What is the indication of nasogastric tube?

If the child has poor appetite, encourage the mother to coax and support the child finishing the feed. If eating 80% or less of the amount offered for 2 consecutive feeds, use a nasogastric tube If the child is breastfed, encourage continued breastfeeding but also give F-75

Question Which feed you will give in transition phase?

Transition phase: Switch to RUTF or F-100 as soon as appetite has returned and oedema is resolving • Weigh daily and plot weight

Prepare to transfer to outpatient care Transfer to outpatient care after successful transition on RUTF • For a few children who may not tolerate RUTF, give F-100, 6 feeds over 24 hours

Question How will you Stimulate emotional and sensorial development?

Stimulate emotional and sensorial development Teach the mothers how to provide tender loving care • Help and encourage mothers to comfort, feed, and play with their children • Give structured play when the child is well enough. Teach the mothers how to continue play and stimulation at home

Transfer to outpatient care Inform the mother of the closest outpatient care facility to her home and give the mother a weekly ration of RUTF. Instruct the mother to report to the outpatient care facility a week later for follow-up

Module 3 Initial Management

Question What will you do When a child with severe acute malnutrition is seen in the emergency department?

Answer When a child with severe acute malnutrition is seen in the emergency department, assess for general danger signs or emergency signs and take a history:

Question What about the relevant history taking?

Answer recent intake of food and fluids • usual diet before the current illness • breastfeeding • duration and frequency of diarrhoea and vomiting • type of diarrhoea (watery, bloody) • loss of appetite • family circumstances

cough for more than 2 weeks • contact with tuberculosis • recent contact with measles • known or suspected HIV infection or exposure

Question Which relevant examination will you perform?

On examination, look for shock: semi-conscious or unconscious, with cold hands, slow capillary refill (over 3 seconds) or weak (low volume), rapid pulse and low blood pressure • signs of dehydration • severe palmar pallor • bilateral pitting oedema

eye signs of vitamin A deficiency: - dry conjunctiva or cornea, Bitot’s spots - corneal ulceration - corneal clouding • localizing signs of infection, including ear and throat infections, skin infection or pneumonia

fever (temperature ≥ 37.5°C) or hypothermia (rectal temperature < 35.5°C) • mouth ulcers • skin changes: - hypo- or hyperpigmentation - desquamation - ulceration (spreading over limbs, thighs, genitalia, groin and behind the ears) - exudative lesions (resembling severe burns), often with secondary infection (including Candida)

• conduct an appetite test: - check if the child has appetite by providing ready-to-use therapeutic food (RUTF) • conduct necessary laboratory investigations.

Question What are the signs of hypoglycemia?

MANAGE HYPOGLYCAEMIA Hypoglycaemia is a low level of glucose in the blood. In severely malnourished children, the level considered low is less than (<) 3 mmol/L (or < 54 mg/dl). The hypoglycaemic child is often hypothermic (low temperature) as well. Other signs of hypoglycaemia include limpness, loss of consciousness and sometimes eyelid retraction (sleeping with eyes open, which may also be due to dehydration).

Sweating and pallor are uncommon in malnourished children with hypoglycaemia. Often the only sign before death is drowsiness.

Question What is the management of hypoglycemia?

Answer give all severely malnourished children a drink of sugar water (10%) on arrival at the health facility; followed by NG feed

Note: If the child is being given IV fluids for shock, there is no need to follow the 10% IV glucose with an NG bolus, as the child will continue to receive glucose in the IV fluids. The treatment of significant hypoglycaemia is dramatic; the child usually wakes up in 2 or 3 minutes. If the child does not regain consciousness within this period, look for other causes of unconsciousness

Question How to MANAGE A SEVERELY MALNOURISHED CHILD WHO IS IN SHOCK?

MANAGE A SEVERELY MALNOURISHED CHILD WHO IS IN SHOCK • give sterile 10% glucose 5 ml/kg by IV • give oxygen • give IV fluids • keep the child warm

Giving oxygen If available, provide oxygen flow at 1–2 L per minute (0.5 L per minute for young infants) to aim for an oxygen saturation > 90%. Care should be taken to keep the nostrils clear of mucus, which could block the flow of oxygen

To give IV fluids Check the starting weight, respiratory and pulse rates and record them on the CCP. Also record the starting time. • Infuse IV fluid at 15 ml/kg over 1 hour. Use one of the following solutions, listed in order of preference 1. half-strength Darrow’s solution with 5% dextrose 2. Ringer’s lactate solution with 5% glucose 3. 0.45% (half-normal) saline with 5% glucose

Observe the child and check respiratory and pulse rates every 5–10 minutes. • If there are signs of improvement (pulse rate and respiratory rate are slower) and no evidence of pulmonary oedema: - repeat IV infusion at 15 ml/kg over 1 hour; then

switch to oral or NG rehydration with ReSoMal at 5–10 ml/kg in alternate hours with F-75 for up to 10 hours; - initiate re-feeding with F-75; - leave the IV line in place in case it is needed again; - continue to check respiratory and pulse rates every 5–10 minutes; - continue to monitor weight changes

If the child fails to improve after 1 hour on IV fluids, then treat for septic shock: - give maintenance IV fluid (4 ml/kg per hour) while waiting for blood; - when blood is available, transfuse fresh whole blood at 10 ml/kg slowly over 3 hours (use packed cells if the child is in cardiac failure); then - initiate re-feeding with F-75

Note: Children in shock who respond partially or not at all to fluid resuscitation require a differentiated response, depending on the cause. A careful history should be taken, with a clinical examination, investigations and treatment. In addition to septic shock, other causes of shock, such as toxic shock or cardiogenic shock, should be considered

Question How will you manage dehydration?

MANAGE DEHYDRATION Children with severe acute malnutrition who present with some dehydration or severe dehydration but who are not shocked should be rehydrated slowly, either orally or by NG tube, using ReSoMal. Do not give IV fluids

Is this composition ok?

In some countries, sachets are available that are designed to make 500 ml of standard WHO low-osmolarity ORS. In this situation, dilution can be revised to add 1 L

Children with severe acute malnutrition and who have some or severe dehydration but no shock should receive 5 ml/kg ReSoMal every 30 minutes for the first 2 hours. Then, if the child is still dehydrated, 5–10 ml/kg/hour ReSoMal should be given in alternate hours with F-75, up to a maximum of 10 hours.

If the child has already received IV fluids for shock and is switching to ReSoMal, omit the first 2-hour treatment and start with the amount for the next period of up to 10 hours

Question When will you stop ReSoMal?

• If pre- diarrhoeal weight is not known, presume a 5% loss of body weight and determine the target weight before giving the ReSoMal It is essential to stop giving ReSoMal when the child reaches the target weight

Question How frequently you will monitor the child who is taking ReSoMal?

Monitoring the child who is taking ReSoMal Monitor the child’s progress every half hour for the first 2 hours. It is important to make a major reassessment of the child’s condition after the first 2 hours. Then monitor hourly, i.e. every time the child takes F-75 or ReSoMal. Continue monitoring even after improved hydration status and discontinuation of ReSoMal.

Question What about the Signs to check during rehydration?

Signs to check attainment of target weight: stop giving ReSoMal when the child has reached the target weight • clinical signs of improvement • clinical signs of over hydration • respiratory rate: count for a full minute

• pulse rate: count for 30 seconds and multiply by 2 • urine frequency: has the child urinated since last checked? • stool or vomit frequency: has the child had a stool or vomited since last checked? • respiratory and pulse rates in normal ranges • passing urine

Question Which are the Signs of over hydration?

Signs of over hydration Stop ReSoMal immediately if any of the following signs appear: • child’s weight exceeds the target weight • increased respiratory rate or pulse rate • jugular veins engorged (pulse wave can be seen in the neck) • increasing oedema (e.g. puffy eyelids).

Question What to do in Children with profuse (acute) watery diarrhoea?

Children with profuse (acute) watery diarrhoea In cases of profuse (acute) watery diarrhoea (e.g. cases of cholera), ReSoMal should not be given. This is because ReSoMal is not adapted to provide the amount of sodium needed to correct losses in cholera. Such children should be managed with standard WHO low-osmolarity ORS that is normally made, without further dilution.

Question What do you know about osmotic diarrhoea?

Children with osmotic diarrhoea Osmotic diarrhoea is common in malnourished children when they start taking therapeutic feeds, due to carbohydrate intolerance. It is generally due to villous atrophy and challenge to the gut from the sugars in diets and rehydration fluids, resulting in increased fluid losses from the gut.

Question Will you prescribe ReSoMal in Osmotic diarrhoea?

Answer Osmotic diarrhoea does not require ReSoMal unless there is significant weight loss (indicating dehydration). Continue giving the feeds and closely monitor weight changes.

Question What do know about persistent diarrhoea?

Children with persistent diarrhoea Persistent diarrhoea is defined as three or more loose or watery stools in a day for more than 14 days. Persistent diarrhoea may be due to carbohydrate intolerance or small bowel bacterial overgrowth, though it may also be associated with enteric infections such as cryptosporidiosis, or Giardia, Shigella or Salmonella infection

Question What is the Management of persistent diarrhoea?

Answer Management of persistent diarrhoea in such situations generally involves nutritional interventions (including diets that are rich in essential nutrients, particularly zinc), restricting disaccharides (for example, by giving low-lactose feeds), treating bacterial overgrowth, and, when appropriate, excluding enteric or other systemic infections.

Question Will you give ReSoMal in persistent diarrhea?

Answer Do not give ReSoMal in children with persistent diarrhoea unless there are signs of dehydration

Question When will you label severe anemia?

MANAGE VERY SEVERE ANAEMIA Anaemia is a low concentration of haemoglobin (Hb) in the blood. Very severe anaemia is a Hb concentration of < 4%). As malnutrition is usually not the cause of very severe anaemia, it is important to investigate other possible causes such as severe malaria

Question What are the indications for Blood transfusion?

Blood transfusion for very severe anaemia Children with severe acute malnutrition should be given blood if they present with very severe anaemia (Hb < 40 g/L) or if Hb < 60 g/L with signs of respiratory distress. Care should be taken because respiratory distress can also be a sign of cardiac failure, and inappropriate blood transfusion can exacerbate heart failure, resulting in death.

Question What caution should be taken for blood transfusion?

Children with severe acute malnutrition should only receive blood if the diagnosis of very severe anaemia is made within the first 24 hours of admission. Do not give a transfusion when the child has been admitted to inpatient care and receiving feeds for more than 24 hours

Stop all oral intake and IV fluids during the transfusion. Look for signs of congestive heart failure, such as fast breathing, respiratory distress, rapid pulse, engorgement of the jugular vein, cold hands and feet, and cyanosis of the fingertips and under the tongue

Question How much blood should be transfused?

Answer If there are no signs of congestive heart failure, transfuse whole fresh blood at 10 ml/kg slowly over 3 hours. If there are signs of heart failure, give 5–7 ml/kg packed cells over 3 hours instead of whole blood. 4. Give a diuretic at the start of the transfusion to make room for the blood. Furosemide (1 mg/kg, given by IV) is the most appropriate choice.

Question What about Monitoring during transfusion?

Monitoring during transfusion Monitor the respiratory and pulse rates, listen to the lung fields, examine the abdomen for liver size and check the jugular venous pressure every 15 minutes during the transfusion. If either respiratory or pulse rate increases (breathing by 5 breaths per minute or pulse by 25 beats per minute), transfuse more slowly. If there are basal lung crepitations or an enlarging liver, stop the transfusion and give furosemide at 1 mg/kg IV

Question When will you give the GIVE EMERGENCY EYE CARE?

GIVE EMERGENCY EYE CARE If any of the following eye signs are present in one or both eyes, emergency eye care is needed: • dry conjunctiva or cornea • Bitot’s spots • corneal clouding • corneal ulceration

Give vitamin A and atropine eye drops for children with eye signs Oral treatment with an oil-based vitamin A formulation should be given immediately if the child has any of the eye signs. The following treatment dose should be given on Day 1, Day 2, and Day 15

Question What is the dose of atropine eye drops?

Install one drop atropine (0.1%) into the affected eye(s) to relax the eye and prevent the lens from pushing out. Tetracycline or chloramphenicol eye drops and bandaging are needed

Question Which antibiotics should be given?

GIVE ANTIBIOTICS start on IV gentamicin, plus IV ampicillin followed by oral amoxicillin; • if severe complications (e.g. shock, sepsis, severe infections), or the context indicates a resistance to the first-line antibiotics, consider other antibiotics

In the case of sepsis or septic shock: • IV or intramuscular (IM) cefotaxime 50 mg/kg every 8 to 12 hours + oral ciprofloxacin 10–20 mg/kg, 2 times per day for 5 days).

If specific infections are identified that require a specific antibiotic not already being given, give an additional antibiotic to address that infection. For example, dysentery and pneumonia may require additional antibiotics. Certain skin infections such as candidiasis require specific antibiotics

Module 4 Feeding

Question What do you know about 2, 3 and 4 hourly feeds?

a Volumes in these columns are rounded to the nearest 5 ml. b Feed 2-hourly for at least the first day. Then, when little or no vomiting, modest diarrhoea (< 5 watery stools per day), and finishing most feeds, change to 3-hourly feeds. c After a day on 3-hourly feeds: if no vomiting, less diarrhoea, and finishing most feeds, change to 4-hourly feeds

Question What do you know about Ready‑to‑use therapeutic food?

Ready‑to‑use therapeutic food For young children, continue breastfeeding on demand. Always breastfeed fully before giving the child RUTF. • Always give the child RUTF after breastfeeding but before other food, including corn-soy blend

Question What do you know about the FEED THE CHILD WITH F-75 DURING STABILIZATION

FEED THE CHILD WITH F-75 DURING STABILIZATION On the first day, feed the child a small amount of F-75 every 2 hours (12 feeds in 24 hours, including through the night). During the stabilization (acute) phase there is a set amount of daily feeds for each child, which should not be changed

On the front side of the card, notice that the amounts per feed ensure that the child will be offered a total of 130 ml/kg/day of F-75. This amount of F-75 will give the child 100 kcal/kg/day and 1–1.5 g protein/kg/day. This amount is appropriate until the child is stabilized

If the child has severe (+++) oedema, their weight will not be a true weight; the child’s weight may be 30% higher due to excess fluid. To compensate, the child with severe oedema should be given only 100 ml/kg/day of F-75. Amounts per feed for the child with severe oedema are shown on the reverse side of the F-75 reference card

Question How much F-75 you will give to 2.1 kg weight child?

• Note that children’s weights listed on the F-75 reference card are all in even digits (2.0 kg, 2.2 kg, 2.4 kg, etc.). If a child’s weight is between these (for example, if the weight is 2.1 kg or 2.3 kg), use the amount of F-75 given for the lower weight.

While the child is on F-75, keep using the starting weight to determine feeding amounts even if the child’s weight changes. The child’s weight should not increase on F-75

If the child starts with severe oedema, continue using the F-75 table for severe oedema for the entire time that the child is on F-75. Also, continue using the child’s starting weight to determine the amount of F-75, even when the oedema (and weight) decrease. The volume per feed on the chart is already based on the child’s estimated true weight.

Feed the child F-75 orally, or by nasogastric tube if necessary It is best to feed the child with a cup and a saucer (and spoon, if needed). Encourage the child to finish the feed. It may be necessary to feed a very weak child with a dropper or syringe. Do not use a feeding bottle.

Question Will you give breastfeeding, if the child is on F-75?

Answer Encourage breastfeeding on demand between therapeutic milk feeds. Ensure that the child still gets the required feeds of F-75 even if breastfeeding.

Question What about the Feeding children who have diarrhoea and vomiting?

Feeding children who have vomiting If the child vomits during or after a feed, estimate the amount vomited and offer that amount of feed again. If the child keeps vomiting, offer half the amount of feed twice as often. For example, if the child is supposed to take 40 ml of F-75 every 2 hours, offer half that amount (20 ml) every hour until vomiting stops

diarrhoea Diarrhoea after initiation of feeds may be due to malabsorption. In such cases do not give ReSoMal for each loose stool unless there is significant weight loss (indicating severe dehydration)

Question What are the indications of Nasogastric feeding?

Nasogastric feeding It may be necessary to use a nasogastric (NG) tube if the child is very weak, has mouth ulcers that prevent drinking, or cannot take enough F-75 by mouth. The minimum acceptable amount for the child to take is 80% of the amount offered. At each feed, offer the F-75 orally first. Use an NG tube if the child does not take 80% of the feed (i.e., leaves more than 20%) for two or three consecutive feeds.

Other indications for NG tube feeding are: • cleft palate • unconsciousness • rapid respiratory rate • painful mouth lesions or ulcers.

Question What will you do if Abdominal distension occur with oral or NG feeding?

Answer Abdominal distension can occur with oral or NG feeding, but it is more likely with NG feeding. If the child develops a hard, distended abdomen with very little bowel sound, give 2 ml of a 50% solution of magnesium Sulphate by intramuscular (IM) route

Question When will you Remove the NG tube?

Remove the NG tube when the child takes: 80% of the day’s amount orally; or • two consecutive feeds fully by mouth.

Children who do not have very serious medical complications may require less frequent feeds after admission (but the same daily amount of feeds). Each day review the child’s 24-hour food intake chart to determine if the child is ready for larger but less frequent feeds

Question What is the Criteria for increasing volume and decreasing frequency of feeds?

Criteria for increasing volume and decreasing frequency of feeds: if vomiting, lots of diarrhoea, or poor appetite, continue 2-hourly feeds; • if little or no vomiting, modest diarrhoea (for example, less than five watery stools per day), and finishing most feeds, change to 3-hourly feeds; • after a day on 3-hourly feeds: if no vomiting, less diarrhoea, and finishing most feeds, change to 4-hourly feeds.

Compare the total amount of F-75 taken for the day to the 80% column on the F-75 reference card to confirm that the child has taken enough feeds. If not, NG feeding may be needed. Continue to offer each feed orally first; then use an NG tube to complete the feed if the child does not take at least 80% orally.

Question What do you know about FEEDING THE CHILD IN TRANSITION?

FEEDING THE CHILD IN TRANSITION It may take up to 7 days, or even longer, for the child to stabilize on F-75. Once the child is stable, has increased appetite and has reduced oedema, and is therefore ready to move into the rehabilitation phase, the child should transition from F-75 to ready-to-use therapeutic food (RUTF) The child will have to tolerate RUTF before being referred to outpatient care.

Question How will you Recognize readiness for transition?

Recognize readiness for transition return of appetite (easily finishes four feeds of F-75) • reduced oedema or minimal oedema.

Question What do you know about the RUTF appetite test?

Perform RUTF appetite test The RUTF is considered acceptable if the child has eaten at least 30 g (one third of a sachet of 92 g). Observe the child for 30 minutes.

If the child accepts RUTF, two options for transitioning children from F-75 to RUTF are suggested Start feeding by giving RUTF as prescribed for the transition phase. Let the child drink water freely. If the child does not take the prescribed amount of RUTF, then top up the feed with F-75. Increase the amount of RUTF over 2–3 days until the child takes the full requirement of RUTF.

Or Give the child the prescribed amount of RUTF for the transition phase. Let the child drink water freely. If the child does not take at least half the prescribed amount of RUTF in the first 12 hours, then stop giving the RUTF and give F-75 again. Retry the same approach after another 1–2 days until the child takes the appropriate amount of RUTF to meet energy needs.

Question What will you do If RUTF is not available or if the child does not accept it?

If RUTF is not available or if the child does not accept it, give F-100 If the child does not accept RUTF after all the procedures above, administer F-100 every 4 hours according to the recommended amounts Encourage mothers to breastfeed between the F-100 feeds. Important point: F-100 should never be given to take home.

Example of feeding programme during transition for a child who passes appetite test for RUTF Ryan is 10 months old, and severely wasted. His admission weight is 5.5 kg and his length is 65 cm. He started taking 45 ml of F-75 every 2 hours. He continued to eat well for the next 2 days. On Day 2, he took 70 ml of F-75 every 3 hours.

On Day 3, he took 95 ml of F-75 every 4 hours and easily completed all his meals. Therefore, on Day 4, the child is ready for transition. During the transition phase, the feeding programme of Ryan will be:

155 g (1.75 sachet) of RUTF to be given to the mother early in the day. The RUTF will be given regularly to the child throughout the day, and additional F-75 to top up if needed. Ryan will also receive water freely and breastfeed between rations.

Example of feeding schedule during transition for a child who does not accept the RUTF On Day 3 Delroy easily finished all of his 4-hourly feeds. Thus, on Day 4 Delroy is ready for transition. Delroy’s feeding schedule during transition will be as follows: Day 4: 85 ml of F-100 every 4 hours (same amount and frequency as he previously took F-75). Day 5: 85 ml of F-100 every 4 hours (same as Day 4).

Day 6: Continue 4-hourly feeds, increasing amount by 10 ml each time: 95 ml, 105 ml, 115 ml, etc. If Delroy does not finish a feed, give the same amount at the next feed. Continue increasing the amount until some food is left after most feeds

Question What do you know about Monitor the child carefully during transition?

Monitor the child carefully during transition Every 4 hours check the child’s respiratory and pulse rates. If RUTF or F-100 is introduced carefully and gradually, problems are unlikely; however, increasing respiratory rate and pulse rate may signal heart failure. Call a physician for help.

Question What do you know about PREPARING FOR TRANSFER TO OUTPATIENT CARE?

PREPARING FOR TRANSFER TO OUTPATIENT CARE When the child is taking the entire amount of RUTF provided during transition, the child should be transferred to continue treatment in outpatient care. Before leaving, the mother should be given a ration of RUTF covering the needs of the child for a week and should be informed to attend outpatient care services the following week. In outpatient care, the child will continue taking the RUTF at home and visit the health facility once a week, where progress is monitored and RUTF prescribed according to the child’s body weight

Question What will you do If the child does not accept RUTF or RUTF is not available?

If the child does not accept RUTF or RUTF is not available, the child should remain in hospital and receive F-100

USING F-100 DURING REHABILITATION (IF CHILD DOES NOT TOLERATE RUTF) In such cases, after transition, provide F-100 to an upper limit of 220 kcal/kg/day (equal to 220 ml/kg/day). Most children will consume at least 150 kcal/kg/day

If you need to calculate the acceptable range yourself (for example, if the child weighs more than 10.0 kg), multiply the child’s weight by 150 ml (minimum) and 220 ml (maximum); then divide each result by 6 (for six feeds per day).

FEEDING SEVERELY MALNOURISHED INFANTS AGED LESS THAN 6 MONTHS

The development of severe acute malnutrition in infants aged less than 6 months commonly reflects suboptimal feeding practices, especially breastfeeding practices. Feeding approaches for infants aged less than 6 months with severe acute malnutrition should prioritize establishing, or re-establishing, effective exclusive breastfeeding by the mother

Question Which feeds should be given to infants?

- For infants with severe acute malnutrition but no oedema, expressed breast milk should be given and, where this is not possible, commercial (generic) infant formula or F-75 or diluted F-100 may be given, either alone or as the supplementary feed together with breast milk

Question How will you make diluted F-100?

To make diluted F-100, add water to F-100 formula up to 1.5 litres instead of 1 litre. Undiluted F-100 should never be given to infants aged less than 6 months or with severe acute malnutrition because of high renal solute load and risk of hypernatraemic dehydration.

- For infants with severe acute malnutrition and oedema, infant formula or F-75 should be given as a supplement to breast milk.

• If there is no realistic prospect of being breastfed, provide appropriate and adequate replacement feeds such as commercial (generic) infant formula, with relevant support to enable safe preparation and use, including at home when discharged

rehabilitation phase breast milk (if available in sufficient quantity) • commercial infant formula.

Transfer to outpatient care all clinical conditions or medical complications including oedema are resolved and the child is clinically well and alert; • the child is breastfeeding effectively and gaining weight on breast milk alone

RUTF should not be used in the management of severe acute malnutrition in infants aged < 6 months

Criteria for discharge from all care is breastfeeding effectively or feeding well with replacement feeds, and; • has an adequate weight gain, and/or; • has a weight-for-length Z-score of ≥ –2 SD.

Feeding during stabilization • Give infant formula or diluted F-100 (or F-75 in case of oedema) at 130 ml/ kg/day, distributed across 12 or 8 feeds per day (every 2–3 hours), providing 100 kcal/kg/day

Two-hourly feeds are best for at least the first day. Then, when the infant has little or no vomiting and modest diarrhoea, change to 3-hourly feeds. After a day on 3-hourly feeds, and no vomiting and no diarrhoea, change the infant to 4-hourly feeds Once there is a return of appetite and oedema starts resolving the infant can enter a transition period before the rehabilitation phase.

Feeding during transition Give infant formula or diluted F-100 at 150–170 ml/kg/day or increased by one third over the amount given in the stabilization phase, providing 110–130 kcal/ kg/day

Criteria for discharge from hospital and progress to outpatient care Medical complication has resolved, and • Oedema has resolved, and • Good weight has been gained on breast milk substitute, or a weight gain of at least 20 g per day for 3 consecutive days has been achieved, and • Infant is clinically well and alert, and • Health worker is confident that the mother prepares infant formula well and gives it correctly, and • Access to adequate infant formula is secured

Feeding during rehabilitation in case the infant remains in hospital • Give infant formula milk or diluted F-100 providing 200 ml/kg/day, or twice the volume given in the stabilization phase, providing 150 kcal/kg/day.

PREPARING FEEDS IF COMMERCIAL F-75 OR F-100 IS NOT AVAILABLE

Where pre-prepared CMV is not available, a mineral mix should be used (20 ml for 1 L of preparation).

Therapeutic milk feeds in stabilization for infants aged less than 6 months who are breastfed or not breastfed

How total feed volumes are calculated for initial feeding

Therapeutic milk feeds in transition for infants aged less than 6 months who are not breastfed

How total feed volumes are calculated for initial feeding

Therapeutic milk feeds in the recovery phase for infants aged less than 6 months who are not breastfed

How total feed volumes are calculated for catch-up/rehabilitation (nonbreastfed infants)

Module 5 Daily Care

Monitoring danger signs during inpatient management of severe acute malnutrition

As the child recovers, stimulation of the child should increase. Play, physical activities, and mental and emotional stimulation become very important to the child’s complete recovery

CARE FOR SKIN AND BATHE THE CHILD Bathe children daily unless they are very sick. If a child is very sick, wait until the child is recovering before bathing. If the child does not have skin problems, or has only mild or moderate dermatosis, use regular soap for bathing

If the child has severe (+++) dermatosis, apply zinc oxide 10% ointment to the skin lesions. Record it on the daily care page of the CCP

Other useful medications include castor oil ointment if available, petroleum jelly, gentian violet, silver sulphadiazine and paraffin gauze dressing. These help to relieve pain and prevent infection.

Folic acid Commercial (pre-packaged) therapeutic feeds (F-75, F-100, and RUTF) already contain folic acid. Do not give folic acid if the child is receiving therapeutic feeds that follow WHO specifications, unless the child has very severe anaemia

Vitamin A Commercial (pre-packaged) therapeutic foods (F-75, F-100, and RUTF) already contain vitamin A. Do not give additional vitamin A unless: • the child has visible clinical signs of vitamin A deficiency (Bitot’s spots, corneal clouding, or corneal ulceration); • the child has signs of eye infection (pus, inflammation); • the child has measles now or has had measles in the past 3 months. In such cases, give vitamin A on Day 1, Day 2 and Day 15

On the CCP shade out the boxes for Day 1, Day 2 and Day 15 for vitamin A if these doses are not needed (child has no eye signs and no recent measles).

If the child has worms, give appropriate drugs Worms are common in older children who play outside, and they can be a problem in severely malnourished children. They can cause dysentery and anaemia. Ask the mother if the child has worms. If so, give an appropriate drug for worms if the child has not already recently received deworming drugs.

Treatment should be delayed until the rehabilitation phase, to be given on transfer to outpatient care (if the child is receiving RUTF) or before discharge from the hospital (if the child is receiving F-100). However, treatment may be started earlier if necessary (e.g. in the case of very severe infection with worms).

Register on the daily care page the type of worm and the drug(s) given. Record when drugs for worms are given. If no worms are reported, write “none” or shade out the spaces for these drugs

Iron Iron should not be given in the stabilization (acute) phase (iron can have toxic effects and reduce resistance to infection). In the rehabilitation phase, do not give iron if the child is receiving RUTF. RUTF already contains iron.

If the child is still in hospital after about 10–14 days and is taking F-100, iron should be given Give 3 mg of elemental iron per kg of body weight per day. • Write the dose on the daily care page of the CCP in the left column. Register each time when the dose is given (twice a day). Continue giving iron for the rest of the hospital stay if the child is on F-100

CARE FOR THE EYES Tetracycline or chloramphenicol eye drops or tetracycline eye ointment should be given for eye infection or possible eye infection. Atropine eye drops are used to relax the eye when there is corneal involvement (i.e., corneal clouding or ulceration).

If the child has Bitot’s spots only (no other eye signs): No eye drops needed.

If the child has pus or inflammation: • Give tetracycline or chloramphenicol eye drops 4 times a day

If the child has corneal clouding or corneal ulceration: Give both: Ʊ tetracycline or chloramphenicol eye drops 4 times a day Ʊ atropine eye drops, one drop 3 times a day.

If both types of drops are needed, give them both at the same time for convenience (i.e., give tetracycline 4 times daily, and at 3 of those times also give atropine). Continue drops for at least 7 days and until all eye signs disappear.

The affected eye(s) should also be bandaged for 3–5 days until inflammation and irritation subside. Use eye pads soaked in 0.9% saline solution, held in place with gauze bandages. The damp pads and bandages will cool the soreness, prevent the child scratching the eyes, and promote healing. Change pads and bandages whenever drops are given

To bandage the eyes: 1. wash hands 2. soak eye pads with 0.9% saline solution 3. place a pad over each affected eye 4. wrap a gauze bandage over the pads and around the head (not too tight, just tightly enough to hold in place).

Measure pulse rate

Count pulses (beats) per minute, or count pulses per 30 seconds and multiply by 2. Record pulses (beats) per minute on the monitoring record in the CCP.

Measure respiratory rate

Watch the child’s chest while the child is quiet. • Count breaths per minute. Count for a full minute, as breathing may be irregular

Look for breathing movement anywhere on the child’s chest or abdomen. Usually you can see breathing movement even when a child is dressed. If you cannot see the movement easily, ask the mother to lift the child’s shirt. • If the child starts to cry, ask the mother to calm the child before you start counting. Record breaths per minute on the monitoring record of the CCP

Take temperature Monitoring the temperature can be done at 4-hour intervals. Along the bottom of the graph, enter the times at which monitoring is done. When a temperature is taken, write an X or large dot on the line above the time and across from the temperature. You may connect the points with a line

Recognize danger signs (Changes in pulse, respiration or temperature) • if pulse increases by 25 or more beats per minute, confirm in 30 minutes • if respiratory rate increases by 5 or more breaths per minute, confirm in 30 minutes

If the above increases in pulse and respiratory rates are both confirmed, they are a danger sign. Together, these increases suggest an infection, or heart failure from over hydration due to feeding or rehydrating too fast. Stop feeds and rehydration solution for malnutrition (ReSoMal), and slow fluids. Call the physician for immediate review

If just the respiratory rate increases, determine if the child has fast breathing, which may indicate pneumonia. If the child is from 2 up to 11 months old, a rate of 50 breaths per minute or more is considered fast. If the child is 12 months up to 5 years old, a rate of 40 breaths per minute or more is considered fast.

If just the pulse increases, there is no cause for concern, as the pulse may increase for many reasons, such as fear or crying.

If a child’s rectal temperature drops below 35.5°C, or the axillary temperature drops below 35°C, the child is hypothermic and needs rewarming. Have the mother hold the child next to her skin or use a heater or lamp with caution. Be sure the room is warm (28–32°C if possible) and the child is covered. Hypothermia may be a sign of infection. If the temperature drops suddenly, call the physician for immediate review

Increases in temperature can also indicate infection. If there is a sudden increase or decrease in temperature, call the physician for immediate review. Monitor and record temperature in the monitoring record of the CCP to visualize changes in temperature more easily

In addition to watching for increasing pulse or respiration rates and changes in temperature, watch for other danger signs such as anorexia (loss of appetite) • change in mental state (e.g. becomes semi-conscious or unconscious) • jaundice (yellowish skin or eyes) • cyanosis (tongue/lips turning blue from lack of oxygen) • difficulty breathing

difficulty feeding or waking (drowsy) • abdominal distension • new oedema • large weight changes • increased vomiting • petechiae (bruising).

Night staff must: keep each child covered to prevent hypothermia; • provide hats – most of the heat is lost from the head; • feed each child according to schedule during the night (at first this will be every 2 hours) – this will involve gently waking the child to feed; • take 4-hourly measurements of pulse, respiration and temperature; • watch carefully for danger signs and call a physician if necessary.

WEIGH THE CHILD DAILY AND MAINTAIN WEIGHT CHART Remember to weigh the child at about the same time each day, about 1 hour before or after a feed.

The weight chart will visually show: • the child’s progress in weight gain; • any loss of weight due to oedema; • failure to improve (in the stabilization phase, the child is not expected to gain weight – weight monitoring in this phase is crucial to monitor fluid balance).

Example of weight chart for a girl with mild oedema (+)

Module 6 Monitoring and problem solving

This module teaches a process for identifying and solving problems that may occur on the ward. The process includes • identifying problems through monitoring • investigating causes of problems • determining solutions • implementing solutions.

By monitoring individual patient progress, weight gain and care, you may identify problems such as the following The patient’s appetite has not returned. • The patient has failed to gain weight for several days while taking RUTF or F-100. • The mother wants to take her child home before the child’s medical complication has resolved. • The child seems to have an unrecognized infection.

By monitoring overall weight gain on the ward, patient outcomes, and the case fatality rate, you may identify problems such as the following 20% of children on the ward have poor weight gain. • 75% of mothers leave with their children before the children’s medical complications have resolved. • The case-fatality rate in the ward was 15% during the months of June through August.

For example, you may identify problems such as the following IV fluids are given routinely by certain physicians. • Children are not fed every 2 hours through the night. • Staff do not consistently wash their hands with soap.

Determine solutions Solutions will depend on the causes of the problems. For example, if staff do not know how to do a new procedure, a solution may be training. On the other hand, if the cause is a lack of equipment or supplies, a different solution is needed.

remove the cause of the problem (or reduce its effects) • be feasible (affordable, practical, realistic) • not create another problem

Example of problem-solving process Problem: Weight gain on a severe acute malnutrition ward is not as good as it was several months ago. Instead of good weight gain for most children on ready-to-use therapeutic food (RUTF) or F-100 (that is, 10 g/kg/day or more), the typical weight gain is now less than 10 g/kg/day.

The senior nurse decides to investigate by monitoring ward procedures and food preparation. Following are some possible causes that she might find, along with an appropriate solution for each

Problem The type of milk available for making feeds has changed and the recipes have not been adjusted appropriately. Solution Adjust the feed recipes appropiately to use milk that is available. Post the new recipes and teach them to staff

Problem • Staff add too much water when making F-100. They add 1000 ml instead of just enough water to make 1000 ml of formula Solution Explain the recipe to staff. Be sure that 1000 ml is clearly marked on mixing containers. Demonstrate how to add water to the mark

Problem • Measuring scoops have been lost and staff are estimating amounts of ingredients for feeds. Solution Obtain new scoops.

Problem • There are more children on the ward and staff numbers have not increased. Nurses cannot spend as much time feeding each child. Solution • Invest time in teaching mothers to feed and care for the children

It is clear that buying new scoops will not solve the problem if the cause is really lack of an appropriate recipe. By investigating the cause of a problem, one can avoid wasting money and time on the wrong solutions.

Clinicians should do a ward round at least once every day. During rounds, a clinician should do the following. Observe the child and question the mother and nurse. - Is the child more alert? Smiling? Sitting up? Able to play? - Has the child lost oedema? - Is there less diarrhoea? - Has dermatosis improved? - How is the child’s appetite?

Review the child’s weight chart. - Is the child gaining weight according to the weight chart? - If there is a loss, is it due to decreasing oedema?

• Review the CCP and food intake chart. - Is the child getting the recommended feeds? - Is prescribed care (such as antibiotics) being given? - Are there any danger signs recorded on the CCP (increased pulse rate, respiratory rate, or temperature)?

Daily, during transition and rehabilitation, a clinician should calculate the child’s weight gain in grams per kilogram body weight (g/kg/day) and judge whether weight gain is sufficient.

Good weight gain: 10 g/kg/day or more Moderate weight gain: 5 up to 10 g/kg/day Poor weight gain: less than 5 g/kg/day

Note: This calculation is not useful until the child is on RUTF or F-100, as the child is not expected to gain weight on F-75. In fact, weight may be lost on F-75 due to decreasing oedema. Remember that this calculation will be most useful if the child is weighed at about the same time each day

Example Kofi began taking F-100 on Day 4 in the severe acute malnutrition ward. By Day 6 he began to gain weight. On Day 6 Kofi weighed 7.32 kg. On Day 7 he weighed 7.4 kg. His weight gain in g/kg/day can be calculated as follows: 1. 7.4 kg – 7.32 kg = 0.08 kg; 0.08 kg x 1000 = 80 grams gained 2. 80 grams ÷ 7.32 = 10.9 g/kg/day A gain of 10.9 g/kg/day is considered a good weight gain.

Identify the child who is failing to respond

Determine cause(s) of failure to respond • Insufficient food given: - Has the feeding plan been adjusted as the child gains weight? - Is the correct feed being given? - Is the correct amount offered at the required times? - Is the child being fed adequately at night? - Is the child being held and encouraged to eat? - Are leftovers recorded so the child’s recorded intake is accurate?

• Insufficient attention given to child: - Do staff pay less attention to this child for some reason (for example, because they believe the child is “beyond help”)? - Is the mother present to assist in feeding and care of the child?

Rumination: The child regurgitates food from the stomach to the mouth, then vomits part of it and swallows the rest. This usually happens when the child is not observed. - Is the child eating well but failing to gain weight? - Does the child smell of vomit or have vomit-stained clothes or bedding? - Does the child seem unusually alert and suspicious? - Does the child make stereotyped chewing movements?

Unrecognized infection : Infections most commonly overlooked include pneumonia, urinary tract infection, ear infection, and tuberculosis. Others include malaria, dengue, viral hepatitis B, and HIV infection

Example weight gain tally sheet for the ward

Determine if there is a problem with weight gain on the ward If the weight gain of 10% or more of the children on RUTF or F-100 is poor, there is a problem that must be investigated. If there is a negative change as compared to previous months, there may also be a problem. For example, if the percentage of children in the “moderate” column increases and the percentage in the “excellent” column decreases, investigate the reasons for this change.

Record each patient’s outcome on the CCP The last page of the CCP has a space for recording patient outcomes. Record the outcome for the patient whether it is successful or not. Also record any relevant comments, such as circumstances and causes of adverse outcomes, and follow up closely or refer to supplementary feeding programmes

Example from CCP

Calculate a case-fatality rate for the ward In a big ward (for example, with 100 admissions per month), calculate the case-fatality rate once each month if possible. Also calculate the case-fatality rate monthly in any ward where the current rate is poor or unacceptable. This will allow improvements to be seen rapidly.

In a small ward (for example, 10 cases per month), or in a ward where the case fatality rate is moderate or better, the case-fatality rate may be calculated less often (for example, every 3 months).

To calculate the case-fatality rate: 1. Determine the number of patients admitted to the severe acute malnutrition ward in the past month(s). 2. Determine the number of those patients who died. (Wait to count deaths until the outcomes for the patients are known. For example, wait until mid November to count deaths among patients admitted in October.) 3. Divide the number of deaths by the number of patients and express the result as a percentage

For the purposes of this training course, a case-fatality rate of > 20% is unacceptable 11–20% is poor 5–10% is moderate < 5% is acceptable

Weighing

Handwashing Are there working handwashing facilities in the ward? • Do staff consistently wash hands thoroughly with soap? • Are their nails clean? • Do they wash hands before handling food? • Do they wash hands between each patient?

Module 7 Involve mother in care

• prepare food • feed children • bathe and change children • play with children, supervise play sessions • make toys

The staff must be friendly and treat mothers as partners in the care of the children. A mother should never be scolded or blamed for her child’s problems or made to feel unwelcome. Teaching, counselling and befriending the mother are essential to long-term treatment of the child

Mothers should have a place to sit and sleep on the ward. They also need washing facilities and a toilet, and a way to obtain food for themselves. Some mothers may need medical attention themselves if they are sick or anaemic.

The staff should also make other family members feel welcome. All family members are important to the health and well-being of the child. When possible, fathers should be involved in discussions of the child’s treatment and how it should be continued at home. Fathers must be kept informed and encouraged to support mothers’ efforts in care of the children.

When teaching tasks such as feeding or bathing, staff should: Show the mother how to do the task, explaining each step. 2. Let the mother try the task, assisting and encouraging her as she tries. 3. Ask checking questions to make sure the mother understands what to do. For example, if you have just explained how to feed the child, ask the mother such questions as: - What will you feed your child? - How often will you feed the child? - How much will you give the child for a serving?

Observe when the mother does the task independently for the first time. 5. Give positive feedback, that is, tell the mother what she did well. Make suggestions for improvements without discouraging the mother. For example, say: “Let’s try together to do it this way.”

Value of group teaching and learning sessions There are many topics that can efficiently be presented to groups of mothers and other interested family members. Group teaching sessions may be held on topics such as nutrition and feeding, hygiene, making oral rehydration solution (ORS) to treat diarrhoea, and family planning.

Preparing khichuri (home-based food)

This recipe is appropriate for children aged 6 to 24 months when they have recovered and are eating at home. The quantity prepared makes 589 g of cooked food (cooked soft). The recipe provides 115 kcal and 2.9 g protein per 100 g.

oil and rice (or other staples such as potatoes) are needed to give energy; • dal is needed to build and grow the body; • leafy green and orange- coloured vegetables are needed to give strength and good health and also to prevent blindness.

Children transferred to outpatient care during rehabilitation • the child eats 75% of the proposed daily amount of ready-to-use therapeutic food (RUTF); • medical complications have been treated; • the child has minimal oedema; • the child is alert

Food at home during rehabilitation will consist of RUTF at first and then, as a second step, RUTF is alternated with meals based on locally available foods that are nutrient rich and varied

Children who remain as inpatients (severe acute malnutrition ward) during rehabilitation During rehabilitation, while the child is on the ward, gradually reduce and eventually stop the feeds of RUTF or F-100, while adding or increasing the mixed diet of home foods, until the child is eating as they will eat at home. Before returning home, the child must become accustomed to eating family meals based on locally available foods

Appropriate diets for children recovering from severe acute malnutrition Appropriate mixed diets are the same as those recommended for a healthy child. They should provide enough calories, vitamins, and minerals to support continued growth. Home foods should be consistent with the following guidelines.

The mother should continue breastfeeding as often as the child wants. • If the child is no longer breastfeeding, animal milk is an important source of energy, protein, minerals and vitamins

Solid foods should include a well cooked staple cereal. To enrich the energy content, add vegetable oil (5–10 ml for each 100 g serving) or margarine, ghee, or groundnut paste. The cereal should be soft and mashed; for infants use a thick pap

Give a variety of well cooked vegetables, including orange and dark green leafy vegetables. If possible, include fruit in the diet as well. • If possible, include meat, fish, or eggs in the diet. Pulses (such as lentils or chickpeas) and beans are also good sources of protein.

• Give extra food between meals (healthy snacks). • Give an adequate serving size (large enough that the child leaves some).

Examples of healthy snacks that are high in energy and nutrients include: bread, tortilla, or chapati with butter, margarine, or groundnut paste (peanut butter) • biscuits, crackers • bean cakes • yoghurt, milk, cheese • ripe banana, papaya, avocado, mango, other fruits • cooked potatoes, boiled or fried plantain

TEACH MOTHERS THE IMPORTANCE OF STIMULATION AND HOW TO MAKE AND USE TOYS

Mothers should be taught to play with their children using simple, home-made toys. It is important to play with each child individually at least 15–30 minutes per day, in addition to informal group play

GIVE GENERAL INSTRUCTIONS FOR TRANSFER TO OUTPATIENT CARE how to continue any needed medications (except the antibiotic treatment that will be fully given in the severe acute malnutrition ward), vitamins (if available), folic acid (for 1–2 weeks), and iron (for 1 month) at home if RUTF is not provided to the child;

signs to bring the child back for immediate care: - not able to drink or breastfeed - stops feeding - develops a fever - has fast or difficult breathing - has a convulsion - has diarrhoea for more than a day, or blood in stool - has oedema (swelling in feet, legs, hands or arms);

when and where to go for planned follow-up: - at 1 week, 2 weeks, 1 month, 3 months, and 6 months - then twice yearly visits until the child is at least 3 years old;

In no case should a child be discharged until the following conditions are met The child is through transition to F-100 (is feeding freely on F-100) or RUTF. • Antibiotic treatment is finished. • The child is eating well, has appetite. • The child is gaining weight. • The mother has been thoroughly trained in how to feed the child at home and give the remaining basic medication and supplements. • Arrangements have been made for support and follow-up (for example, home visits, or visits to an outpatient facility).

KEY MESSAGES ABOUT THE USE OF READY-TO-USE THERAPEUTIC FOOD (RUTF) RUTF is both a food and medicine for malnourished children only. It should not be shared. • Give small regular meals of RUTF and encourage the child to eat often (if possible eight meals a day)

During the first week of treatment at home, give mainly RUTF to the child. Over the following weeks, the child will need to receive, alternately with RUTF, locally available foods, nutrient rich and varied. The health centre will instruct the mother how to feed the child with food available locally.

For young children, continue to breastfeed regularly. • Always offer the child plenty of clean water to drink or breast milk when the child takes RUTF. • Wash the child’s hands and face with soap before eating, if possible.

Keep food clean and covered, including sachets of RUTF, which should be kept closed and covered. • Always keep the baby covered and warm. • When a child has diarrhoea, continue to feed the child. Offer frequent meals in small quantities if the child’s appetite is reduced. • Return to the health facility whenever the child’s condition deteriorates or if the child is not eating sufficiently.

Module 8 Outpatient management of severe acute malnutrition

Outpatient care for the management of severe acute malnutrition without medical complications Bilateral pitting oedema + or ++ or severe wasting and • passed appetite test • clinically well • alert or transferred from inpatient care after medical complications have been treated

Appetite test Passed appetite test: the child eats at least one third of a packet of RUTF (92 g) or three teaspoons from a pot – child should be managed in outpatient care. Failed appetite test: the child does not eat one third of a packet of RUTF (92 g) or three teaspoons from a pot – child should be managed in inpatient care

It is not necessary to conduct the appetite test if the child is very ill, for example with pneumonia, acute diarrhoea, dysentery, measles or severe malaria, or any of the general danger signs. This child should be immediately referred to inpatient care.

MEDICAL MANAGEMENT IN OUTPATIENT CARE Antibiotics Routine antibiotics are given to all children, due to the high prevalence of infections in severe acute malnutrition. Amoxicillin should be used as a broad-spectrum antibiotic. If the child fails to respond to treatment, they should be referred for inpatient care

The recommended dosage for amoxicillin is 25–40 mg per kg of body weight every 12 hours for 5–7 days.

Antimalarial treatment Systematically screen all children for malaria in endemic areas on admission, regardless of their body temperature. A child with severe acute malnutrition cannot autoregulate its body temperature well and tends to adopt the temperature of the environment. If in clinical doubt, repeat the malaria test in the weeks following the initial test

Deworming Hookworm infections can cause severe anaemia. Treatment should commence on the fourth visit to outpatient therapeutic care, though it may be started earlier if necessary (for example, in case of severe infection with worms).

Albendazole (400 mg in a single dose) or mebendazole (500 mg in a single dose for outpatient treatment) is effective in children aged over 2 years. If these drugs are not available or the child is aged under 2 years, hookworm and ascariasis can be treated with pyrantel (10 mg/kg in a single dose).

Vitamin A Children with severe acute malnutrition admitted directly to the outpatient therapeutic programme without eye signs and who have been prescribed RUTF should not receive a high dose of vitamin A.

Immunization Always check the immunization status of the child at each visit and provide the required immunizations according to the standard immunization schedule

Anaemia Children with severe acute malnutrition are often anaemic. Iron supplementation, however, may be harmful to them because iron promotes growth of infectious agents and causes oxidative stress. RUTF contains adequate amounts of iron; there is therefore no need to provide iron supplements

Vitamin A deficiency Children with eye signs of vitamin A deficiency should be referred for inpatient care, as the condition of the eyes can deteriorate very rapidly, and the risk of blindness is high. Children without eye signs and who are taking RUTF do not need additional vitamin A supplementation.

Diarrhoea Children who have severe acute malnutrition and acute watery diarrhoea but no signs of dehydration or other medical complications, and are clinically well and alert, should be treated as outpatients.

Children can be fed RUTF, and rehydration solution for malnutrition (ReSoMal) can be given at the outpatient facility, alongside continued breastfeeding. However, ReSoMal should not be provided for home preparation.

RUTF that complies with WHO specifications provides a daily supplementation of zinc. However, if the therapeutic foods do not comply with WHO specifications and are not fortified, give zinc supplementation (to reduce the duration and severity of the diarrhoea episode and the risk of a new episode in the following 2−3 months). For children aged 6–59 months, the recommended zinc supplementation is 20 mg/ day for 10−14 days

Ready-to-use therapeutic food (RUTF) The dietary management of cases in outpatient care is based on RUTF feeds. RUTF is provided at between 150 and 220 kcal/kg/day. A commonly used dosage is 200 kcal/kg/day.

FOLLOW-UP DURING TREATMENT IN OUTPATIENT CARE During outpatient care, the child is seen at the health facility every week. Only for specific reasons (harvesting time, distance, etc.), and when the child is recovering well and the mother is compliant, can fortnightly visits be scheduled later during the treatment.

If the child is not responding to the treatment a home visit can be required or, if IMCI danger signs are observed, the child should be referred to inpatient care for further medical investigation.

DISCHARGE FROM OUTPATIENT CARE

Severe acute malnutrition pediatrics nelson mbbs

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