1 Recognition of Malnutrition 2 Use of Z-score in...

1 Recognition of Malnutrition

2 Use of Z-score in community setting

3 Re-feeding

4 Acute management of Malnutrition child in

Shock

Dr Chan Yan Kheong

Paediatric Department

Hospital Raja Permaisuri Bainun Ipoh



3 Re-feeding


Shock

Recognition of Malnutrition

• Malnutrition :

• Refer to any condition in which the body does not receive

enough nutrients for proper function

• Malnutrition is an underlying cause of death of 2-6 million

children each year

• Lancet reports follow the journal's series in 2008

• 6.3 million children under the age of five died in 2013 ( WHO report).

http://www.thelancet.com/series/maternal-and-child-undernutrition

Data : under 5 Mortality

R E. Black The Lancet, Vol 382, Issue 9890, 427 - 451, 3 Aug 2013

Mortality by Districts and Age Group 2012( Perak)

DistrictsInfant

1 - >5 years0 – 6 days 7 – 27 days 28 – 364 days

f rate f rate f rate f rate

Btg Pdg 14 5.75 2 0.82 15 6.17 5 2.06

Hilir Prk 11 4.23 1 0.38 3 1.15 2 0.77

Hulu Prk 4 2.49 5 3.11 3 1.86 19 11.81

Kampar 8 6.01 0 0.00 2 1.50 2 1.50

Kerian 12 5.46 2 0.91 7 3.19 2 0.91

Kinta 43 3.81 9 0.80 19 1.68 9 0.80

KKangsar 10 4.05 2 0.81 6 2.43 7 2.83

LMS 14 3.56 4 1.02 5 1.27 1 0.25

Manjung 20 4.43 2 0.44 11 2.44 10 2.22

Prk Tengah 5 4.28 1 0.86 4 3.42 6 5.14

Total 141 4.20 28 0.83 75 2.24 63 1.88

Percentage 46.0 9.1 24.4 20.5


• Cause of malnutrition :

• 1 insufficient food intake or certain nutrients

• 2 inability of body to :

- absorb nutrients

- use nutrients

- consumption of certain food


• Malnutrition :

Can be serious in children as may :

1 interfere with growth and development

2 predispose to many heath problem

- infection (pneumonia, measles, malaria)

- Persistent diarrhoea


• Malnutrition remain one of the most common underlying

cause of morbidity and mortality among Orang Asli

• Common cause of malnutrition among Orang Asli:

• 1 lack of access to highly nutritious food

• 2 poor feeding practice technique :

– Inadequate breast feeding

– Offering inappropriate food


• How to recognize malnutrition ?

• 1 Anthropometric measurement

technique

• 2 Physical examination ( bilateral pitting oedema)

Kwasyiokor and Marasmus

How to Differentiate?

Kwasyiokor and Marasmus


• Assessment of a child with malnutrition :

• 1 anthropometry measurement

• 2 physical examination

• 3 medical complication :

• - gross oedema

• - temperature instability

• - acute/ prolong respiratory infection

• - Watery diarrhoea / vomiting

• - extensive oral thrush

• - very pale eye and palms ( severe anaemia)

• - irritability / loos of consciousness


• Anthropametric measurement :

• - Z- score (weight for height/ weight for

length , standard deviation chart)

• - mid-upper arm circumference screening (

for children with length > 65 cm)

Equipment's



3 Re-feeding


Shock

Use of Z-score in community setting

• 1 Z score chart

• 2 measure of

• height (> 2 years old and able to stand alone)

• length (< 2 years old and / or unable to stand)

• weight

Use of Z-score in community setting

• Interpretation of severity of malnutrition by

using Z score

• Z score is not reliable in the present of

oedemainterpretation Z score

normal > -2

Moderate malnutrition

-2 to -3

severe malnutrition < -3 orBilateral ankle oedema

Scenario

• 1 measurement of Z-score



3 Re-feeding


Shock

Management Severe Malnutrition

Re-feeding

• Why need re-feeding for a child with acute severe malnutrition ?

• 1 need growth nutrients that are required to build new tissue

• 2 there nutrients aid weight gain after illness, repair damage tissue, help replace the rapid turn-over of cell( intestine and immune cell)

• 3 correct replenishment of nutrient like essential amino acid ( protein), potassium, magnesium, Zinc ( other mineral) is essential for recovery from malnutrition.

Re-feeding

• Re-feeding can be give in :

• 1 community ( out patient)

• 2 in- patient

• Consider in- patient care:

• 1 acute severe malnutrition ( Z score > -3)

• 2 poor appetite

• 3 major medical complication

Re-feeding

• Re-feeding in ward :

• 1 consider Ryles’ tube feeding

• 2 treat concurrent medical illness

• 3 treat dehydration and replacement of electrolyte

imbalance

• 3 start specialized therapeutic diet

– F 75

– F100

– RUTF ( ready – to use therapeutic formula)

Re-feeding

• The standard treatment given to non- malnourish child can leads to death if given to patient with severe malnutrition due to :

• 1 severe electrolyte imbalance

• 2 fluid over load ( pulmonary oedema and heart failure)

• Examples :

• - standard feeding regimen ( can not tolerate usual amount of protein , Na and Fat)

• - intra –venous fluid

• - blood transfusion

• Severe malnourish child may die with normal standard feeding

Re-feeding

• Principle :

• 1 to provide appropriate energy and protein

needed for stabilization ( F 75) and catch up

growth ( F100)

• 2 breast feeding children should always get

the breast milk before the diet and on

demand

Re-feeding

• Supplements:

• IV Vitamin K

• IV Thiamine

• Oral Vitamin A

• Vitamin

• Folic acid

• Iron supplements (upon discharge)

Re- feeding

Re-feeding

• consider start with low volume if severe oedema /heart failure

F75 F100

volume 100-130ml/kg/Day 150-220ml/kg/Day

interval 2-3 hourly 3-4 hourly

Re-feeding

• Initial feeding ( F- 75) :

Re-feeding

• Monitoring :

• ( risk of fluid overload and heart failure)

• 1 respiratory rate (not > 5 from the base line)

• 2 heart rate ( not > 25 from from the base line)

• 3 urine output

• 4 conscious level

• 5 temperature

Re-feeding

Record:– amounts of feed offered and left over

– vomiting

– stool frequency and consistency

• daily body weight

• children with good appetite and no odema ,

this can be completed in 3 days

Re-feeding

• When to switch from F 75 to F 100 :

• 1 General condition stable

• 2 Return of appetite

• 3 Evidence of lost of oedema

Re-feeding

• Catch-up growth:

• Return of appetite and general condition stable

• ( usually about 3 days -1 week)

• Replace F75 with F100

• Modified porridges or complementary foods

• increase each successive feed by 10 ml until -some feed remains uneaten

• weight gain aim at every 3 days > 10g/kg/day

• If weight gain is less , need full assessment and look for infection

• After a gradual transition, give:

• — frequent feeds, unlimited amounts

• — 150-220 kcal/kg/day

• — 4-6 g/kg/day of protein

Re-feeding

• F 75/F100

• Various preparation

• F75/F100

• Self preparation

• commercial formula

• Compare of F75/F100



3 Re-feeding


Shock

Step 1

• Confirm z score -3 or less

• Vital signs

• Give oxygen

• insert intra venous or intra osseous line

• Blood investigation :

• Blood sugar, FBC, BUSE, Blood culture, BFMP, ABG

Step 2

• Resuscitation for shock

• Give IV/IO fluid 15ml/kg over 1 hour ( 1st bolus)

• Hartmans (if not available use 1/2NS)

• Use 1/2NSD5% if hypoglycaemic(<3.0mmol/l)

Step 3

• Monitor :

• measure pulse and breathing rate every 5-10 minutes

• Start IV antibiotic

• Monitor blood sugar

• prevent hypothermia

If there are signs of improvement

• pulse and breathing rates are falling

• repeat IV/IO 15ml/kg over 1 hour(2nd bolus)

• then initiate ORS (ReSoMal if available) per oral 5ml/kg

every ½ hr for 2 hours

If the child improved

• transferred to Specialist Unit

• ReSoMal per oral 5-10ml/kg/h for the next 4-10 hours

• initiate refeeding with F75

• continue breastfeeding

• 50-100ml ReSoMal after watery stool

If the child deteriorates

• breathing increases by 5 breaths/min

• pulse increases by 25 beats/min or fails to

improve during IV/IO fluid

• stop infusion as this can worsen child’s

condition

• Discuss with paediatrician for further

management

Scenarios

Date post:	18-Mar-2018
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