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

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

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

3. 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

4. 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

5. 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

6. 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

7. GENERAL PRINCIPLES FOR ROUTINE CARE (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

8. 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 • TxhypoGly, hypoT • CHF, anemia, Vit K

9. Time frame for management

10. 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

11. 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)

12. 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%

13. Continue Breastfeeding

14. Initial Treatment • 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 • 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 (>48hr) • Stop feeds. Give furosemide

16. 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)

17. 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

18. 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)

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

20. 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

21. 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

22. 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

24. 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

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

26. 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

27. Fight Malnutrition