Global Health Fellowship Nutrition Module Treatment & Management of severe acute (Protein-Energy) Malnutrition in Children Global Health Fellowship Nutrition Module

Severe Malnutrition Medical & social disorder End result of chronic nutritional & emotional deprivation Management requires medical & social interventions

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

3 Phases of Management Initial Treatment Rehabilitation Follow-up 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

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

Evaluation of malnourished child Nutritional status WFH, HFA, edema Moderate (-3<SD<-2) or severe (<3SD) Hx & PE Lab tests Useful: glucose, blood smear (malaria), H/H, urine cx, feces , CXR, PPD Not useful: serum protein, HIV, electrolytes

GENERAL PRINCIPLES FOR ROUTINE CARE There are ten essential steps (the ‘10 Steps’) There are ten essential steps 1.Treat/prevent hypoglycemia 2.Treat/prevent hypothermia 3.Treat/prevent dehydration 4.Correct 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

Initial Treatment Hypoglycemia Hypothermia Dehydration Septic shock 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 Seriously ill, wasting, anorexia, infection. Monitor constantly, avoid iv

Time frame for management

ReSoMal Severely malnourished children Commercially available 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

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)

Composition F-75 and F-100 Dried skimmed milk 25g 80g Sugar 70g 50g 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%

Continue Breastfeeding

Initial Treatment Vitamin deficiencies Infections Severe Anemia CHF 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 (>48hr) Stop feeds. Give furosemide Infections ↓ fever, inflammation Measles vaccine 1st line, all children Cotrimoxazole Complications: ampi + gent 2nd line, > 48 hr ATB + chloramphenicol Malaria, candidiasis Helminthiasis TB Dermatosis Kwashiorkor 1% K permanganate soaks Nystatin Zinc + castor oil Iron toxic and reduces resistance to infection

Rehabilitation Principles & criteria Eating well MS improved: smiles, responds to stimuli Dev appropriate behavior Nl temperature No V/D No edema Gaining Wt: > 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)

Nutrition for children < 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

Nutrition for children > 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)

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

Rehabilitation Parental teaching Preparation for D/C 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

Criteria for D/C Child Mother Health worker 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

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

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

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

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

Fight Malnutrition