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THE ROAD TO CHILD HEALTH

The Steps Yet To Be Taken. THE ROAD TO CHILD HEALTH. INVOLVES. IN PATIENT CARE. COMMUNITY MANAGEMENT OF MALNUTRITION. RCH CLINIC. M.R. 1 yr 9 months old Female Admitted on 14/03/2016 Referral from Gonja Lutheran Hospital. M/C. Skin rashes for 3/12 Mouth ulcers for 2/12

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THE ROAD TO CHILD HEALTH

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  1. The Steps Yet To Be Taken THE ROAD TO CHILD HEALTH

  2. INVOLVES IN PATIENT CARE COMMUNITY MANAGEMENT OF MALNUTRITION RCH CLINIC

  3. M.R • 1 yr 9 months old • Female • Admitted on 14/03/2016 • Referral from Gonja Lutheran Hospital

  4. M/C • Skin rashes for 3/12 • Mouth ulcers for 2/12 • Swollen lower limbs for 1/12 • Right eye discharge for 2/7 • Diarrhea for 2/7

  5. HPI • Seen as outpatient and given symptomatic treatment • Admitted with anasarca and treated for 3/52 • While in ward developed pus discharge right eye and wound in peri anal region

  6. Other history • Natal hx: Born via C/S weighed 3.9kg. • Post-natal hx: exclusively breastfed for 6 months • Immunization: up to date • Developmental milestones: normal

  7. Nutritional history • Positive history of poor appetite from 8 months of age • Weight loss since 1 year of age.

  8. Clinically

  9. Anasarca Flaky paint dermatitis

  10. Anthropometric measurements • MUAC – 13cm • Length – 68.5cm • Weight – 7kg • Weight for length -1 and -2 SD

  11. Systems

  12. Local Examination

  13. Provisional diagnosis

  14. Investigations

  15. Medical Treatment • IV Antibiotics • Cloxacillin • Metronidazole • Ceftriaxone • Management for malnutrition • Vitamin A • Ped Zinc • Cod Liver Oil • Multivitamins • 140mls of whole blood

  16. Nutritional support • Feeding: via NGT • F75 125mls PO 2hourly • ReSoMal 50mls PO after each loose motion

  17. Supportive • Kept warm • Regular skin care with potassium permanganate soaks • Sitz baths with Dettol • 2 hourly turning

  18. Multidisciplinary team • Ophthalmology review • Recommended evisceration RE when stable • Added • Ciprofloxacin eye drops QID • Chloramphenicol eye drops TDS • Normal Saline eye irrigation 4 hourly • Surgical review • Recommended fecal diversion as soon as possible • Anaesthesia review • ASA Grade IV, prepare for surgery

  19. Progress in the ward

  20. So what went wrong in general • Child wasn’t picked up early in clinic • RCH card failed • Management pitfalls • CMAM in place but failed • Plumpy nut isolated to hospitals only • Delayed referral

  21. Where the story started

  22. Undernutrition • Consequence of deficiency of nutrients in the body • Types of undernutrition: • Acute malnutrition (wasting and bilateral pitting oedema) • Stunting • Underweight (combined measurement of stunting and wasting) • Micronutrient deficiencies

  23. Epidemiology • Under nutrition • Causes > 50% of all childhood mortality in resource-poor settings • Major contributor of morbidity • Late diagnosis, untimely and improper treatment can be fatal

  24. Risk factors • Food insecurity • Maternal undernutrition • Low birth weight,prematurity • Deficiencies of specific nutrients (iodine, vitamin A, iron, zinc) • Infection and duration of breastfeeding WHO 2005, Victora et al 2016

  25. Initially starts here Healthy baby Failure to thrive

  26. Community Management of Malnutrition (CMAM)

  27. CMAM • One of World Vision’s core project models in nutrition • Used as a methodology for treating acute malnutrition in young children using a case-finding and triage approach. • Enables community volunteers to • Identify • Initiate treatment for children with acute malnutrition using Ready-to-Use-Therapeutic Foods (RUTF) and routine medical care.

  28. Key components CMAM approach

  29. Community Mobilisation Supplementary Feeding Programme

  30. Outpatient Therapeutic Programme

  31. Key Principles of CMAM • Maximum access and coverage • Timeliness • Appropriate medical and nutrition care • Care for as long as needed Following these steps can ensure maximum public health impact!

  32. Treatment guidelines • Mainly focus on in-patient management through 10 steps for malnutrition • Very little on CMAM • All treatments centralised to certain centres • Peripheral sites have none

  33. WHO 10 Steps • Prevent/treat hypoglycemia • Prevent/treat hypothermia • Prevent/treat dehydration • Correct electrolyte imbalances • Treat/prevent infections • Correct micronutrient deficiencies • Start cautious feeding • Give catch-up diet • Sensory stimulation • Discharge and follow-up

  34. Micronutrient deficiencies Pellagra

  35. Feeds

  36. Opposite end of spectrum OBESITY

  37. Statistics • Globally • Increased from 32 million in 1990 to 42 million in 2013 • WHO African Region • Increased from 4 to 9 million over the same period. • Majority live in developing countries • Current trends • Estimate globally will increase to 70 million by 2025

  38. Both spectrums fall under malnutrition

  39. CMAM & KCMC • 3 components • RCH clinic • Regular nutrition counselling and teaching to mothers • Outreach programmes by Paediatric department

  40. Take home message • Strengthening of CMAM programs • Clinicians • Always assess the RCH card of every child <5years • Always take a good, detailed history and examination • Emphasis on good nutrition • Educate peripheral health centres on the importance of early referrals

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