Managing the malnourished child - a team approach -

1. Managing the malnourished child - a team approach - Dr E Malek Principal Specialist & Senior Lecturer Witbank Hospital, University of Pretoria

2. Outline • Introduction • Factors affecting growth, extent of problem • Recognition and severity assessment • Managing the “tip” of the ice-berg • WHO management guidelines (10 steps) • Complications, Case studies • Dealing with the “hidden” problem • Short-term, Long-term

3. Framework for the promotion, achievement, and maintenance of optimal nutritional status Growth & development Manifestations Adequate Psychosocial dietary well being Health intake Immediate determinants Household Food Security Health Services Adequate care of children and women Health Underlying determinants EDUCATION Potential resources Source: UNICEF

4. Kwashiorkor… … the child that has lost its peace….

5. Overview of childhood malnutrition in South Africa • One in four (23%) children are stunted (SAVACG study, 1994) • One in ten (9%) children are underweight • One in three (33%) children have a marginal Vitamin A status • One in five (21%) children are anaemic

6. Extent of malnutrition Tip of the ice-berg: severe malnutrition Below the surface: mild to moderate malnutrition

7. Recognising the malnourished child • Risk factors • Growth monitoring: Road to Health Card • Feeding history • Clinical signs: early wasting, anemia, etc. • Identifying early wasting: wall charts, MUAC

8. Assessing the degree of severity (Integrated Management of Childhood Illness) • Visible severe wasting • Oedema of both feet • Severe palmar pallor • Low weight • Weight gain unsatisfactory • Some palmar pallor

9. Malnourished children in hospital (Mpumalanga Audit 2000: 26 hospitals) • Nutrition & feeding practices in wards • no WFA charts/assessment, RTHC not used • breast/f promotion hampered by bottles & teats • no snacks between meals for infants <2 years • no meals at night for malnourished children • inconsistent lodger mother policies, no facilities • Treatment guidelines • National pediatric EDL; IMCI; other (local)

10. Improving the management of malnourished children in hospital • WHO guidelines for management of children with severe malnutrition in district hospitals • Mount Frere Model Integrated Nutrition Project (Prof David Sanders) • Incorporated WHO guidelines above within a policy implementation cycle (hospital nutrition team, record reviews, patient care observations, case fatality rates, staff training, audit, etc.)

11. Potential team members • Doctor • Nurse • Dietician • Mother / care-giver • Social worker • Physio / O.T. • Volunteers • NGO’s

12. Case Study 1 • Themba, 11 month old boy • Swelling of body and face, lethargic • Abandoned by mother, brought in by grandmother ; RTHC not available • Admitted to the ward with kwashiorkor How would you manage this child for the first 72 hours?

13. Case Study 2 • Gugu, 6 month old girl • Admitted to the ward with kwashiorkor • Cold extremitries, subnormal temperature • Doctor prescribes treatment, feeds and orders child to be kept warm • On review next day, chart shows subnormal temperature between 05h00 and 08h00. How can you prevent this problem?

14. Case study 3 • Zandile, 18 month old girl • Admitted to ward with kwashiorkor • Doctor prescribes IV antibiotics, fortified milk feeds, oral potassium and Vitamin A • Dietician is consulted • No weight change over the following 3 days How would you approach this problem?

15. Case Study 4 • Siphiwe, 15 month old girl • Admitted to ward with kwashiorkor & G/E • Had been diagnosed and admitted 1 month prior for kwashiorkor, ?no follow-up date • Doctor prescribes feeds, antibiotics, etc. • Hypoglycemia is noted on chart review How would you manage this patient?

16. Organisation of care Proper triage Stabilisation and rehabilitation Prevent and treat hypoglycemia Prevent and treat hypothermia Treat dehydration Treat electrolyte imbalance Treat micronutrient deficencies Initial refeeding Catch-up growth Stimulation & support Prepare for follow-up Monitor and audit WHO Guidelines: management of severe malnutrition (PEM)

17. WHO: organisation of care • Admit mother/carer • Team involvement • Ward care: hi-care bed • 2-3 hourly monitoring and feeding (72 hours) • Keep warm (KMC, adjust routines eg. bathing time)

18. WHO: triage and resuscitation • Screen children for signs of severe PEM • Assess dehydration in malnourished children using additional signs • Children wth kwashiorkor and marasmus must be given IV fluid with caution

19. WHO: Stabilisation phase • Hypoglycaemia (prevent, monitor & treat): • 2-3 hourly fortified milk feeds (60-130ml/kg/d) • Hypothermia (prevent, monitor and treat): • 3 hly temp, warm skin-to-skin, use hat, no baths • Dehydration: (prevent and treat): • Treat shock cautiously, rehydrate orally • Suspect and treat infection: • Assume infection, give broad spectrum antibiotics • Monitor appetite, weight: if not better, change antibiotics after 48 hours

20. WHO: Stabilisation phase (cont.) • Correct electrolyte imbalances: • Hypokalemia: oral K, if K<2.5, add IV KCl (!) • Hyponatremia: do not give Na supplements • Treat micronutrient deficiencies: • Vit A stat – reduces morbidity and mortality • Multivitamins, Zink sulphate, Phosphate, Folic acid, copper • Give Fe later – once infection is controlled

21. WHO: Stabilisation phase (cont.) • Initial Refeeding: • Frequent small feeds orally/nasogastrically • 100 kcal/kg/day; protein: 101.5g/kg/day; liquid:100- 130ml/kg/day • Monitor: • 3 hourly temperature and dextrostix for first 72 hours • Daily weight (same conditions) • Audit outcome • Weight gain (good: >10g/kg/day), mortality ( <5% )

22. WHO: Rehabilitation phase • Catch-up growth: • Return of appetite then gradual transition • Frequent feeds, up to 200ml/kg/day (!) • 150-200 kcal/kg/day; protein 4-6 gram/kg/day Stimulation and support • Visual and emotional stimulation • Social support: child care grant application, etc. • Prepare for follow-up • Follow IMCI feeding recommendations

23. Time frame for the management of a child with severe malnutrition Stabilization Rehabilitation Days 1-2 Days 3-7 Weeks 2-6 1. Hypoglycaemia 2. Hypothermia 3. Dehydration 4. Electrolytes 5. Infection 6. Micronutrients no iron with iron 7. Initiate feeding 8. Catch up growth 9. Sensory stimulation 10. Prepare for follow-up Source: WHO

24. Extent of malnutrition Tip of the ice-berg: severe malnutrition Below the surface: mild to moderate malnutrition

25. Dealing with the ice-berg • Underlying issues: poverty, female literacy • Public health education: feeding rec.’s • Disease prevention/early intervention (HIV) Timely treatment of illness (IMCI), regular growth assessment (RTHC), nutrit. counselling • Health worker access, skill and attitude * • Support: household food security/grants/etc • Advocacy: eg. BFHI, Code of Conduct, etc.

26. Short term programs: Relief feeding : PEM Scheme? food parcels? Identifying those most in need - WFH vs WFA Long term initiatives Multi-secoral approach: ?NPA; PPA (National and Prov-incial Programs of Action for Children) Community upliftment Dealing with the ice-berg (cont.)

27. Evaluating the PEM Scheme • To review the PEM Scheme in relation to the Integrated Nutrition Programme, with special emphasis on: • a) its potential for impacting on anthropometric measurements • b) current implementation in the Mitchells Plain district • c) implications for nutrition policy

28. Methods • Clinic record review (3/95-3/96) • Analysis of anthropometric data • Staff interviews and observation • Policy review

29. Results (n= 831) Weight for Age at Entry (%)

30. Duration of Attendance (months)

31. Catch-up Growth at Outcome(%)

32. Degree of Change (WAZ-score)

33. The PEM Scheme for children: problems • limited human resource capacity • lack of nutrition education • no links to community-based programmes • poor monitoring and evaluation

34. Outcome of PEM Scheme • Can effect catch-up growth • Restructuring of the PEM Scheme is essential • Recommendations for policy review • Practical strategies have been recommended to implement revised policy

35. Managing the malnourished child: a team approach... Growth & development Manifestations Adequate Psychosocial dietary well being Health intake Immediate determinants Household Food Security Health Services Adequate care of children and women Health Underlying determinants EDUCATION Potential resources Source: UNICEF

36. Severe Malnutrition:Before and After

37. Conclusion “Many things we need can wait. The Child cannot. Right now is the time his bones are being formed, his blood is being made and his senses are being developed. To him we cannot answer “Tomorrow”. His name is “Today”.” - Gabriela Mistral -

38. Useful Resources • WHO IMCI Manual: Management of the child with a serious infection or severe malnutrition • WHO Website (IMCI): http:/www.who.int/child-adolescent-health • IMCI charts also available on UP Intranet (www.ais.up.ac.za) at UpeXplore (Academic Info Services – Course: IMCI)