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Severe Malnutrition

Severe Malnutrition. Summary of WHO Management Guidelines Children Age 6 Months to 5 Years Blair Thedinger. Severe Malnutrition Mortality. Responsible for 35% of deaths among children under five.

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Severe Malnutrition

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  1. Severe Malnutrition Summary of WHO Management Guidelines Children Age 6 Months to 5 Years Blair Thedinger

  2. Severe Malnutrition Mortality • Responsible for 35% of deaths among children under five. • Median under-five case-fatality rate for severe acute malnutrition typically ranges from 30% to 50% • Management by WHO guidelines in a hospital setting cut mortality by 55%

  3. Diagnosis of Severe Acute Malnutrition Any ONE of the following: • Weight to length <70% of expected • Symmetrical pitting edema of at least the feet (kwashiorkor) • “Visible Severe Wasting”- Specifically: gluteal muscle wasting, and visible rib outlines or other bony prominence on chest wall. • Mid upper arm circumference (MUAC) less than 11.5 cm

  4. Visible Severe Wasting

  5. Symmetrical Edema in Lower Extremities

  6. Mean Upper Arm Circumference

  7. Step 1: Initial Assesment

  8. Important Aspects of History • How acute is the malnutrition? Get the feeding / social history • Is the child more sick right now? How so? • Does the child want to eat? (if yes watch them try to feed) • If caretaker is not the mother, what happened to the mother? • Any siblings deceased? Sick contacts?

  9. Important Points of Physical • Level of Consciousness / Response • Hydration (difficult to assess) • Signs of Anemia • Signs of Infections • Extent of edema • Eye signs • Feces

  10. Step 2: Hypoglycemia • Glucose absorption and production impaired. • Patients have often travelled for long distances with little food to the health center. • Infection / Sepsis • If any one of the following: Unconscious? Limp? Lethargic? Hypothermia? - TREAT IMMEDIATELY • Hypoglycemia = <56 mg/dl or <3mmol/l

  11. Step 2: Hypoglycemia • Child Unconscious / Lethargic / Hypothermic • Immediately give D10 5ml/kg IV if IV is available. Then 50 ml of 10% Glucose or Sucrose per NG. If child regains consciousness start feeding • Conscious – Able to Take PO • Give 50ml of 10% glucose or sucrose or Formula 75 kcal/100ml. Begin frequent feeding q2-3 hours with F-75 to prevent recurrence

  12. Step 2: Hypothermia • Should be taken as sign of sepsis • Axillary temp <35 C or <95 F. If does not register assume hypothermia • Treat for hypoglycemia • Warming efforts (Kangaroo care) • Remove wet clothes and cover • If heat lamps need to monitor closely

  13. Step 3: Dehydration / Shock • Difficult to assess in malnourished children • IV fluids are dangerous, especially in a situation with no effective monitoring • Reliable Signs: Watery Diarrhea; Thirst (absent in severe dehydration); Sunken eyes (only if developed recently); low urine output; • Unreliable Signs in Malnurished Child: Elastic skin and dry mucous membranes are not reliable in severely malnourished children • If Dehydrated: • Give ReSoMal ** orally. NO IV FLUIDS • 5ml/kg q30 x 2 hours. • 5-10 ml/kg q 1 hour for 6 hours • Switch to F-75 after 6 hours still at above dose / frequency until rehydrated then switch to re-feeding protocol. ** ReSoMal =Recommended ORS solution for severely malnourished children

  14. Step 3: Dehydration / Shock • Shock? • Weak or absent radial pulse? Hypothermic? Lethargic or Unconscious? Cold extremities? Decrease urine flow? • Give IV volume • D5LR, D5 ½ NS, or D5 ½ Darrows at 15 ml/kg over 1 hour • Place NG tube and give ReSoMal at same time • Reassess frequently and discontinue IVF if • Increased respiratory rate • Jugluar veins distended

  15. Step 4 - Infection Severely Malnourished Children Should be Considered Immunocompromised • Lymph glands, tonsils and the thymus are atrophied • Cell-mediated immunity is severely depressed • IgA levels in secretions are reduced • Complement components are low • Phagocytes do not kill ingested bacteria efficiently • Tissue damage does not result in inflammation or migration of white cells to the affected area • Acute phase immune response is diminished • Typical signs of infection, such as an increased white cell count and fever, are frequently absent

  16. Step #4 Infection • BACTERIAL: ALL severely malnourished children get treatment • If no hypoglycemia, hypothermia, or shock give: • Cotrimoxazole 4mg/20mg PO BID x 5 days • If these are present give: • Ampicillin 50 mg/kg IM/IV q6 x 7 days • Gentamycin 7.5 mg/kg IM/IV qDayx 7days • If not improving after 48 hours or suspect meningitis give in addition: • Chloramphenicol 25mg/kg q6 hours IV / IM – switch to PO at q8 ASAP.

  17. Step #4 Infection • MALARIA: Blood smear on every child as available. If positive treat based on severity. • Severe: • Quinine 20 mg/kg IV/IM loading dose in dextrose over 4 hours • Then 12 hours after start of loading dose 10 mg/kg over 2 hours Q8 (Switch to PO when able) • Non-severe: • Artemether/Lumefantrine 3 day pack, Other Artemenisin based combination, or Sulfadoxine/Pyrimethamine 25/1.5 mg/kg as a single dose (Much less effective and can contribute to resistance development)

  18. Step #4 Infection • TB: Common but should not give treatment until you have a diagnosis or is very strongly suspected clinically • HIV: If signs of opportunistic infection then test. If mother HIV positive and child untested then test. • MEASLES: Give vaccine to all children at admission unless proof of recent vaccine. • GI: If able to send stool for analysis • If Helminlithiasis give mebendazole 100 mg PO BID for 3 days or if in area with high infection rate give to everyone once improving. • If bloody diarrhea assume Shigella infection and treat: Nalidixic acid (15mg/kg four times daily for 5 days) • If Giardia give Metronidazole 7.5 mg/kg PO q8 hours for 7 days

  19. Step #5 Feeding • What food do you give? • F-75 for initial re-feeding – for F-75 recipe see WHO pediatric Handbook. Alternatives are listed if milk is unavailable • How much do you give? • For 1st 2 days give 11 ml/kg/feed, then 16ml/kg/feed on days 3-5, then 22ml/kg/feed on days 6 onwards • How often do you give feedings? • Days 1-2 = q2 hours. Days 3-5 = q3hours. Days 6 onwards q4hours. This includes throughout the night. • When documented weight gain you transition to F-100 or other “catch up” formula and then increase feeds by 10ml per day.

  20. Step #6 Micronutrients ALL severely malnourished children need at least 2 weeks of daily vitamins. All children should be getting either ReSoMal or F-75 that is fortified with Electrolyte and Mineral Powder Mix. In addition: 1. Vitamin A as below 2. Folic acid 5mg on day 1 and then 1mg/day 3. Iron 3 mg Fe/kg/day – start AFTER the child starts gaining weight

  21. Step #6 Micronutrient • Eyes and Vitamin A • An estimated 250 000 to 500 000 vitamin A-deficient children become blind every year, half of them dying within 12 months of losing their sight. (WHO)

  22. Step #6 Micronutrient Severe Anemia: Determine by clinical exam or Hbg < 4 g/dl or <6g/dl if child has respiratory distress) Whole blood or pRBCs at 10 ml/kg slowly over 3 hours Lasix at 1mg/kg with transfusion

  23. Ready for Rehab? • ( ) Hungry, and feeding without an NG tube? • ( ) Mental status normal (interactive)? • ( ) Sits, crawls, walks as normal? • ( ) Temperature normal? • ( ) No Vomiting or Diarrhea? • ( ) No Edema? • ( ) GAINING WEIGHT ( >5 g/kg or body weight for 3 successive days)

  24. Malnutrition is not Natural

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