Treatment

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Treatment Management of severe acute
(Protein-Energy) Malnutrition in Children

• Global Health Fellowship
• Nutrition Module

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Severe Malnutrition

• Medical social disorder
• End result of chronic nutritional emotional
  deprivation
• Management requires medical social
  interventions

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Underlying causes of poor diet excess disease
(UNICEF)

• Insufficient access to food
• Inadequate maternal child care
• Poor environment
• Inadequate or lack of access to health services

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3 Phases of Management

• Initial Treatment
• Life threatening problems identified treated
• Specific deficiencies/metabolic abnormities
  corrected
• Feeding begun
• Rehabilitation
• Intensive feeding
• Emotional physical stimulation
• Mother trained
• Follow-up
• Prevention of relapse
• Assure continued development

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Treatment Facilities

• Initial treatment beginning of rehabilitation
• SAM with complication (anorexia, infection,
  dehydration)
• Residential care in special nutrition unit
• SAM w/out complications, s/p inpt has appetite.
  gaining weight, stable
• Nutritional rehabilitation center
• day hospital,
• 1ary health center
• CTC

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Evaluation of malnourished child

• Nutritional status
• WFH, HFA, edema
• Moderate (-3ltSDlt-2) or severe (lt3SD)
• Hx PE
• Lab tests
• Useful glucose, blood smear (malaria), H/H,
  urine cx, feces , CXR, PPD
• Not useful serum protein, HIV, electrolytes

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GENERAL PRINCIPLES FOR ROUTINE CARE (the 10
Steps) There are ten essential
steps 1.Treat/prevent hypoglycemia 2.Treat/preven
t hypothermia 3.Treat/prevent dehydration 4.Correc
t electrolyte imbalance 5.Treat/prevent
infection 6.Correct micronutrient
deficiencies 7.Start cautious feeding 8.Achieve
catch-up growth 9.Provide sensory stimulation and
emotional support 10. Prepare for follow-up after
recovery These steps are accomplished in two
phases an initial stabilisation
phase where the acute medical conditions are
managed longer rehabilitation
phase Note that treatment procedures are similar
for marasmus and kwashiorkor
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Initial Treatment

• Hypoglycemia
• Cause death first days
• Sign infection ATB
• Sign infrequent feedings
• Clinical suspicion, treat
• 50ml D10, F75 PO/NG
• Never use bottles
• Hypothermia
• Kangaroo
• Warm
• Treat for hypoglycemia
• Sign of infection, treat

• Dehydration
• Reliable signs
• Diarrhea, thirst, hypoT, eyes, weak pulse
• Unreliable signs
• MS, mouth/tongue/ tears/skin elasticity
• ReSoMal 70-100ml/kg/12h
• Breastfeed, F-75
• Septic shock
• ATB broad spectrum
• Tx hypoGly, hypoT
• CHF, anemia, Vit K

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Time frame for management
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ReSoMal

• Severely malnourished children
• K deficient, high Na levels
• Mg, Zn, copper deficiency
• Commercially available
• Dilute 1 packet of standard WHO ORS in 2 l water
  50 g of sucrose (25g/l) 40 ml (20ml/l)
  mineral mix solution
• 5ml/kg PO/NG q30min
• Cont till thirst urine

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Formula diets for severely malnourished children

• Impaired liver intestinal function infection
• Food must be given in small amounts, frequently
  (PO/NG)
• Unable to tolerate usual amounts of dietary
  protein, fat, Na
• Diet low in above, hi in carbohydrates
• F-75
• 75kcal or 315kj/100ml
• Initial phase treatment, 130ml/kg/d
• Feed q 2-3hr (8 meals/d)
• F-100
• 100kcal or 420kj/100ml
• Feed q 4-5 h (5-6 meals/d)
• Rehabilitation phase (appetite returned)

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Composition F-75 and F-100

• 
  F-75
  F-100
• Dried skimmed milk 25g 80g
• Sugar 70g 50g
• Cereal flour 35g -
• Vegetable oil 27g 60g
• Mineral mix 20ml 20 ml
• Vitamin mix 140ml 140 ml
• Water 1l 1l
• Protein 0.9g 2.9g
• Lactose 1.3g 4.2g
• K 3.6mmol 5.9mmol
• Na 0.6mmol 1.9mmol
• Mg 0.43mmol 0.73mmol
• Zn 2.0mmol 2.3mmol
• Copper 0.25mg 0.25mg
• Osmolarity 333mOsmol/l 419mOsmol/l
• Energy from protein 5 12
• Energy from fat 32 53

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Continue Breastfeeding
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Initial Treatment

• Vitamin deficiencies
• Folic acid
• Vit mix riboflavin, ascorbic acid, pyridoxine,
  thiamine, fat soluble vit D, E, K
• Vit A PO or IM
• Eye pads NS solution
• Tetracycline atropine eye drops
• Bandage eyes
• Severe Anemia
• Transfusion PRC/WB (CHF)
• No Iron at this stage
• CHF
• Overhydration (gt48hr)
• Stop feeds. Give furosemide

• Infections
• ? fever, inflammation
• Measles vaccine
• 1st line, all children
• Cotrimoxazole
• Complications ampi gent
• 2nd line, gt 48 hr ATB
• chloramphenicol
• Malaria, candidiasis
• Helminthiasis
• TB
• Dermatosis Kwashiorkor
• 1 K permanganate soaks
• Nystatin
• Zinc castor oil

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Rehabilitation

• Principles criteria
• Eating well
• MS improved smiles, responds to stimuli
• Dev appropriate behavior
• Nl temperature
• No V/D
• No edema
• Gaining Wt gt 5g/kg of body wt/d x 3 days
• Most important determinant of recovery
• Amount of energy consumed calories, protein,
  micronutrients (K, Mg, I, Zn)

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Nutrition for children lt 24 mo

• F-100 diet q 4 hr (day night)
• ?each feed by 10ml
• 150-220 kcal/kg/d
• Folic acid Iron, Vit Mineral mix
• Attitude of care giver crucial
• Decreasing edema
• F-100 continued till Target Wt (-1 SD/ 90 of
  median NCHS/WHO reference value for WFH)
• Wt daily plotted on graph
• Target wt usually reached 2-4 wks

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Nutrition for children gt 24 mos

• ? amounts F-100 (practical value in refugee
  camps, different diets )
• Introduce solid foods
• Local foods should be fortified
• ? content of Energy (oil), minerals Vitamins
  (mixes)
• Milk added (protein)
• Energy content of mixed diets 1kcal or 4/2kj/g
• F-100 given between feeds of mixed diet
• 5-6 feeds /d
• Folic acid (5mg on day 1, 1mg/d) Iron ( 3mg/kg
  elemental iron/d x 3mo)

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Emotional physical stimulation

• 1ary/2ary prevention DD, MR, ED
• Start during rehabilitation
• Avoid sensory deprivation
• Maternal presence
• Environment
• Play activities, peer interactions
• Physical activities

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Rehabilitation

• Parental teaching
• Correct feeding/food preparation practices,
• Stimulation, play, hygiene
• Treatment diarrhea, infections
• When to seek medical care
• Preparation for D/C
• Reintegration into family community
• Prevent malnutrition recurrence

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Criteria for D/C

• Child
• WFH reached -1SD
• Eating appropriate amount of diet that mother can
  prepare at home
• Gaining wt at normal or ?rate
• Vit/mineral deficiencies treated/corrected
• Infections treated
• Full immunizations
• Mother
• Able willing to care for child
• Knows proper food preparation
• Knows appropriate toys play for child
• Knows home treatment fever, diarrhea, ARI
• Health worker
• Able to ensure F/U child support for mother

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Follow up

• Child usually remains stunted w/ DD
• Prevention of recurrence severe malnutrition
• Strategy for tracing children
• F/U 1,2, 4 weeks, then 3 6 mos, then 2x/yr
  till age 3yrs
• WFH no less than -1SD
• Assess overall health, feeding, play
• Immunizations, treatments, vitamin/minerals
• Record progress

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Failure to respond Criteria

• 1ary failure to respond
• Failure to regain appetite by day 4
• Failure to start to lose edema by day 4
• Edema still present by day 10
• Failure to gain at least 5g/kg/d by day 10
• 2ary failure to respond
• Failure to gain at least 5g/kg/d during
  rehabilitation

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Failure to respond

• Problems with treatment facilities
• Poor environments
• Insufficient or inadequately trained staff
• Inaccurate weighing machines
• Food prepared or given incorrectly

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Failure to respond

• Problems w/ individual children
• Insufficient food given
• Vitamin or mineral deficiency
• Malabsorption of nutrients
• Rumination
• Infections
• Diarrhea, dysentery, OM, LRI, TB, UTI, malaria,
  intestinal helminthiasis, HIV/AIDS
• Serious underlying disease
• Congenital abnormalities, inborn errors
  metabolism, malignancies, immunological diseases

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Fight Malnutrition