Malnutrition-associated inpatient and post-discharge child deaths Tickell KD, Walson JL, Denno DM.

Slides:



Advertisements
Similar presentations
Global Health Fellowship Nutrition Module
Advertisements

Orientation on Community-Based Management of Acute Malnutrition 1.
Page 1 The PepsiCo Foundation Meeting March 31, 2008 International Food Aid Conference Kansas City - April 15, 2008 The Evolving Role of Food Aid in Reducing.
Center for Global Pediatrics Protein Energy Malnutrition Cindy Howard, MD, MPHTM Associate Director Center for Global Pediatrics University of Minnesota.
Moderate Acute Malnutrition (MAM) Contributes to 10% of childhood deaths under five Field Exchange 2007; 31: 3.
1 Impacts of Specialized Food Products on HIV-infected Adults and Malnourished Children: Emerging Evidence from Randomized Trials Tony Castleman International.
Nutrition and Global Health
DIARRHEA and DEHYDRATION
Community Management of Possible Serious Newborn Infections: Simplified Antibiotic Regimens Bina Valsangkar, MD, MPH Saving Newborn Lives/Save the Children.
Lancet Series Update 2013 By Monica Muti
Chapter Ten Child Health.
Interventions to address deaths from childhood Pneumonia and Diarrhoea equitably : what works and at what cost? Zulfiqar A Bhutta, Jai K Das, Neff Walker,
Pneumonia Sapna Bamrah, MD CDC
Performance of Community- based Management of Acute Malnutrition programme and its impact on nutritional status of children under five years of age in.
Address high acute malnutrition among vulnerable populations affected by water logging through CMAM prog. Bangladesh 05 April 2012.
Pediatric HIV Care & Treatment in Uganda A Five-Day Training Course For Health Professionals.
LESSON 13.7: MATERNAL/CHILD HEALTH Module 13: Global Health Obj. 13.7: Explain the risk factors and causes for maternal and child health problems.
Nutritional Status of Children
Pneumonia diagnosis and treatment Prognosis for severe disease.
Child Health Research Project Research Results and Policy Formulation on Nutrition and Micronutrients.
Session 8: Nutrition Care and Support of Adults Living with HIV.
Use Of RUTF in Maradi, Niger 2001 – 2007 From treatment to prevention of acute severe malnutrition.
NUTRITION AND SOCIAL PROTECTION: THE CASE FOR SCHOOL FEEDING S. D. Maruapula, PhD Department of Family & Consumer Sciences University of Botswana.
Community Therapeutic Care for managing severe acute malnutrition- The effect of RUTF By Dr. Paluku Bahwere -Valid International 34 th session of the SCN-
Poverty Population: Challenge and Opportunities
T e c h n i c a l S e m i n a r s Malnutrition Anaemia Generic Guidelines TreatmentTreatment Severe Anaemia Moderate AnaemiaSevere Anaemia Moderate Anaemia.
Effectiveness of Micronutrient-rich Lipid Nutrient Supplements in Delaying Clinical Progression of HIV in Malawian Adults Heidi Sandige, MD.
This presentation was made possible by the American people through the U.S. Agency for International Development (USAID) under Cooperative Agreement No.
Integrated Management of Neonatal and Childhood Illness DR.ARVIND GARG.
Therapeutic Feeding Programs.. Therapeutic Feeding Programs Type of program:Therapeutic feeding program (TFP) Objectives:To provide medical and nutritional.
MALNUTRITION Dr. Godson Lyimo MD. SEVERE MALNUTRITION WHO defines severe malnutrition as the presence of Oedema of both feet, or Severe wasting (
Nutrition/HIV – new developments Increased Evidence Base – e.g. micronutrient supplements, RUTF High Profile Meetings – Durban, Blantyre. Others planned.
Expanded Criteria 24 TH November Background on EC:  The expanded criteria is proposed to reduce mortality associated with malnutrition by ensuring.
Department of International Health Newborn Vitamin A Supplementation and Early Infant Mortality: Current Evidence James Tielsch, Ph.D. Bangkok, March 2010.
Nutrition in Developing Countries Jonathan Gorstein.
Management of Acute severe malnutrition Moderator Presenter Dr.Chetna Maliye Rohan R. Patil.
IMCI This session introduces you to IMCI – Integrated Management of Childhood Illnesses - the strategy introduced in the Philippines in 1995 and known.
Baseline survey was conducted in 92 households covering 6 villages, three each from both the Dhandhar and Jherli village panchayats. Dhandhar Village Panchayat.
Tessa Wardlaw Working Group on Coverage Monitoring Coverage of Key Child Survival Interventions Tessa Wardlaw.
Results Monitoring (B) - Tracking The PepsiCo Foundation Meeting March 31, 2008 The PepsiCo Foundation Community-based Management of Acute Malnutrition.
Theresa Banda. VI Operational Research Advocacy Technical support VN Production and marketing RUF Introduction.
Treatment of severe acute malnutrition Experience from developmental context Jimma, Ethiopia Tsinuel Girma Asst professor of Pediatrics and Child Health.
Nutrition: What’s Working, What Does It Take, & What’s On the Horizon 2002 AFR SOTA Meeting Thursday, June 13.
Stunting Takes Over in 1000 Days Chronic Malnutrition Stunting is Irreversible at 2 years old.
Millennium Development Goal 4:
Severe Acute Malnutrition – what is the best way forward for the region – A panel Discussion Colombo 19 th November 2009.
BACKGROUND METHODS WHAT IS KNOWN   Child malnutrition is a major public health problem in developing countries   New WHO Growth Standards result in.
NUTRITION SUPPORT IN THE PAEDIATRIC SURGICAL PATIENT
Integrated Management of Childhood Illnesses
Nutrition and Global Health
Florence M. Turyashemererwa Lecturer- Makerere University
PAEDIATRIC NURSING 2 10CREDITS.
9TH IBFAN AFRICA REGIONAL CONFERENCE, 1-4 FEB 2016, KAMPALA, UGANDA Monitoring and Evaluation of MIYCN National Policies and Programs: Experiences from.
Maternal and Child Health June 30, Maternal Child Health Different from Women’s Health and Child’s Health – “Maternal” – Health of mothers and children.
Emergency Nutrition Network Technical review: The Relationship between Wasting and Stunting, Policy, Programming and Research implications Tanya Khara.
1 Use of Nutrition Corners to Improve Identification and Nutritional Status of HIV- Infected Infants and Young Children in Lesotho Presented by: Malijane.
SITES & COORDINATING CENTRES
HEALTH MANAGEMENT INFORMATION FOR NUTRITION 2017
Suri S, Sr Resident, LHMC & SSKH, New Delhi
Screening Mid-upper arm circumference (MUAC) MUAC<110mm
HNO/HRP Nutrition sector plan 2018
Caseload Estimations- current practices and limitations
Comparison of the study findings: Male & female
Presentation Outline Overview of CMAM: Components and the Continuum of Care Updates in the 2016 CMAM guidelines.
Presentation Outline History of CMAM in Malawi
Essential Nutrition Concepts for Nutrition-Sensitive Agriculture
Pediatric HIV Case Finding Strategies
Global Updates on Care for Children with Acute Malnutrition
Malnutrition & the Microbiome
Presentation transcript:

Malnutrition-associated inpatient and post-discharge child deaths Tickell KD, Walson JL, Denno DM

Inpatient management of malnutrition Food systems Nutrient deficiency Malnutrition & complications Infection WASH Prevention Treatment

Severe acute malnutrition with complications (SAM-C) Severe Acute Malnutrition: ≤ 3 SD WFH, MUAC <115 mm, Bilateral edema With medical complications or no appetite Inpatient treatment Without complications Outpatient treatment

SAM-C case fatality WHO indicates <10% 1 Sub-Saharan centers of excellence: % 2,3,4 Blantyre, Malawi: 42% at 1 year 5 Severe Acute Malnutrition: ≤ 3 SD WFH, MUAC <115 mm, Bilateral edema With medical complications or no appetite Inpatient treatment Without complications Outpatient treatment

Importance of SAM-C guidelines Opportunity We estimate that 100,000/year child deaths averted if 10% target reached Highly accessible population – rapid impact is possible Directly attributable to SAM-C % of diarrhea deaths 12.3% of measles deaths 8.7% of pneumonia deaths

1)Ancestry tracing guideline –2013 WHO update –2003 & 1999 WHO SAM guideline –1981 WHO PEM guideline –Text books: F. Savage-King (1992) “Nutrition in Developing Countries” M. King (1969) “Medical Care in Developing Countries” Methods

Results : Only 1/4 based on RCT evidence

Areas of guidance Feeding & fluids Infection management Discharge & follow-up care

Feeding & fluids ReSoMal, unless cholera High dose vit A: measles, eye signs RUTF for diarrhea Shock/Severe dehydration: IV HS Darrow’s or Ringer’s + 5% Dextrose No Fe until rehabilitation Folic acid, Zn, Cu RCT Observational Indirect <6 mo: breastfeed or relactate F75 -> RUTF: stabilized F100->rapid wgt gain King (1969) WHO (2013) WHO (1999) WHO (2003) WHO PEM (1981) Savage King (1992) Low dose vit A Cholera: standard ORS Monitor every 5-10 mins if on IV Transfusion: unimproved shock/anemia No transfusions after 24 hrs

Feeding & fluids ReSoMal, unless cholera High dose vit A: measles, eye signs RUTF for diarrhea Shock/Severe dehydration: IV HS Darrow’s or Ringer’s + 5% Dextrose No Fe until rehabilitation Folic acid, Zn, Cu RCT Observational Indirect <6 mo: breastfeed or relactate F75 -> RUTF: stabilized F100->rapid wgt gain King (1969) WHO (2013) WHO (1999) WHO (2003) WHO PEM (1981) Savage King (1992) Low dose vit A Cholera: standard ORS Monitor every 5-10 mins if on IV Transfusion: unimproved shock/anemia No transfusions after 24 hrs

Infection Ampicillin & gentamicin on admission ART when stable if HIV+ Measles vaccine if not immunized Conscious & hypoglycemic: IV + oral dose glucose Unconcious & hypoglycemic: IV + oral dose HIV+ & >24 months: ART based on CD4 HIV+ & <24 months: ART for life RCT Observational Indirect Zn for diarrhea HIV+ no difference for zn & vit A HIV+ no difference for feeding < 6mo same ABX as older King (1969) WHO (2013) WHO (1999) WHO (2003) WHO PEM (1981) Savage King (1992)

Infection Ampicillin & gentamicin on admission ART when stable if HIV+ Measles vaccine if not immunized Conscious & hypoglycemic: IV + oral dose glucose Unconcious & hypoglycemic: IV + oral dose HIV+ & >24 months: ART based on CD4 HIV+ & <24 months: ART for life RCT Observational Indirect Zn for diarrhea HIV+ no difference for zn & vit A HIV+ no difference for feeding < 6mo same ABX as older King (1969) WHO (2013) WHO (1999) WHO (2003) WHO PEM (1981) Savage King (1992)

Discharge & follow-up care Do not use %weight gain Follow-up care d/c: WHZ >-2 & no edema x 2 weeks Provide emotional and sensory support Hospital d/c: no complications, alert, appetite not anthropometry 5g/kg/day RCT Observational Indirect Assess progress using the anthropometric measure which qualified the child for admission If edema only complication normal anthropmetirc used for F/U King (1969) WHO (2013) WHO (1999) WHO (2003) WHO PEM (1981) Savage King (1992)

WHO 2013 update: “Major research gaps were identified in each of the sections covered.” Two key populations: 7 “No randomized controlled trials in HIV-infected children with SAM were identified that directly addressed any of the prioritized questions.” “No studies were found in the peer-reviewed literature that reported outcomes when WHO therapeutic feeding recommendations…are applied to SAM infants who are less than 6 months of age.”

Weak evidence & high mortality 42% of SAM inpatients die within 1 year o 62% of HIV+ children died o 67% of infants died Post-discharge mortality o 44% of deaths Queen Elizabeth hospital: “the biggest and one of the best” (The Guardian 2005) Data from Kerac, et al

Timing of deaths No data on causes of death

Guidelines Useful clinical tool & synthesis of evidence/opinion Evidence Weak or non-existent for most elements Systematic search of trials registries Limited potential for impact SAM-C Underlying cause: We don’t know why these children die

Beyond SAM-C No guidelines for MAM 34% of diarrhea deaths attributable to MAM 32% of pneumonia deaths attributable to MAM 6 No guidelines for stunting 45% of diarrhea deaths attributable to stunting 43% of pneumonia deaths attributable to stunting 6

Judd Walson Co-director Donna Denno Investigator Kirk Tickell Coordinator Bangladesh Pakistan Kenya Malawi Uganda Next steps: The CHAIN network Jay Berkley Director

Opportunities for intervention Hospital & post-discharge Intervene on modifiable pathways to death

References 1: WHO. Guidelines for the Inpatient Management of Severely Malnourished Children. Geneva: WHO, : Personal communication between Kirk Tickell and Jay Berkley (12/8/14) 3: Fergusson, P. "HIV Prevalence and Mortality Among Children Undergoing Treatment for Severe Acute Malnutrition in Sub-Saharan Africa: a Systematic Review and Meta-analysis.” R Soc Tropl Med (2009) 103, 541—548 4: Personal communication between Donna Denno and Maurice Kelly (6/6/14) 5: Kerac, MH. Et al. "Follow-Up of Post-Discharge Growth and Mortality After Treatment for Severe Acute Malnutrition (FuSAM Study): a Prospective Cohort Study." PLOS One 9.6 (2014): E : Black RE, et al. (2013) Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet, Aug 3; 382: : WHO. Updates on the Management of Severe Acute Malnutrition in Infants and Children. Geneva: WHO, 2013.