Date post: | 06-Apr-2018 |
Category: |
Documents |
Upload: | abdu-raheem-fadlulai |
View: | 217 times |
Download: | 0 times |
of 66
8/3/2019 10. Severe Malnutrition
1/66
Dr. Emmanuel AmeyawDepartment of Child Health
Kath, Kumasi
8/3/2019 10. Severe Malnutrition
2/66
INTRODUCTION CLASSIFICATION
SIGNS
HYPOTHESIS REDUCTIVE ADAPTATION
MANAGEMENT
STATISTICS
8/3/2019 10. Severe Malnutrition
3/66
About 20 million children are affected bysevere acute malnutrition globally,
Leading cause of death in children indeveloping countries,
contributes to 5060% of all child deaths,
Mortality rates for children with SAM are 5 to20 times higher compared to well-nourished
children
8/3/2019 10. Severe Malnutrition
4/66
1 million to 2 million preventable child deathseach year
Only about 15% get hospital admission
28% of children under 5 years of age areunderweight.
8/3/2019 10. Severe Malnutrition
5/66
Malnutrition is defined as the failure of cells toperform their physiological functions due toinability receive and use the energy andnutrients needed, (in terms of amounts, mix
and timeliness).Severe malnutrition is characterized by
Severe wasting ( weight for height < 70% or
8/3/2019 10. Severe Malnutrition
6/66
Primary malnutrition refers to malnutritionresulting from inadequate food intake
Secondary malnutrition refers to malnutritionresulting from increased nutrient needs,decreased nutrient absorption, and orincreased nutrient losses.
Micronutrient malnutrition
Macronutrient malnutrition
8/3/2019 10. Severe Malnutrition
7/66
Weight for height of
8/3/2019 10. Severe Malnutrition
8/66
Syndromic classification Kwashiokor
Marasmus
Marasmic Kwashiokor
Gomez 1st degree .. .. Wgt between 90% and 75%
2nd drgree .. .. 75% and 60%
3rddegree.. Below 60%
8/3/2019 10. Severe Malnutrition
9/66
Wellcome Weight between 80% and 60% (expected weight)
EdemaKwashiokor
No edemaundernutrition
Weight below 60% Edema marasmic kwashiokor
No edema marasmus
Jelliffe
1st degree wgt between 90 and 80% (expected wgt) 2nd degree wgt between 80 and 70% (expected wgt)
3rd degree wgt between 70 and 60% (expected wgt)
4th degree below 60% (expected wgt)
8/3/2019 10. Severe Malnutrition
10/66
McLareen Mild: wgt between 90 and 80% (expected)
Moderate: wgt between 80 and 70% (expected)
Severe: wgt below 70% (expected)
Waterloo Acute: wasted but not stunted
Wgt for height is low, height for age is normal
Chronic: wasted and stunted
Wgt for height low, height for age low
8/3/2019 10. Severe Malnutrition
11/66
1. Severe wasting: Loss of fat and muscle (skin and bones)
Front view: ribs easily seen and skin of upperarm and thighs look loose.
Back view: ribs and shoulder bones easily seen,flesh missing from the buttocks, folds of skinson buttocks and thighs (wearing baggy pants)
8/3/2019 10. Severe Malnutrition
12/66
2. Oedema of both feet: The retained addedto the weight therefore weight for height > -3SD.
Rating of oedema:
+ mild: both feet++ moderate: both feet + lower legs + hand
or lower arms
+++ severe: generalised (moderate + face)
8/3/2019 10. Severe Malnutrition
13/66
3. Dermatosis Occurs in oedematous malnutrition than wasted
child.
Range from patches of abnormal pigmented skin
(light and dark) to shedding, ulceration andweeping lesion.
Affects perineum, groin, nappy areas, limbs, behindears, armpit and face
8/3/2019 10. Severe Malnutrition
14/66
4. Eye Signs: Vit. A deficiency
Night blindness Conjunctivitis xerosis
Bitot spot Corneal xerosis Cornea ulceration Cornea scar
Infection Pus
8/3/2019 10. Severe Malnutrition
15/66
8/3/2019 10. Severe Malnutrition
16/66
8/3/2019 10. Severe Malnutrition
17/66
8/3/2019 10. Severe Malnutrition
18/66
In severe malnutrition, the systems almostshut down or slow down in order to allowfor survival on the barest minimum energyrequirements.
Almost all the major organs are affected
8/3/2019 10. Severe Malnutrition
19/66
HISTORY Frequency of feeding
Recent appetite
Usual diet before current illness When last child ate normally
Breastfeeding history
Birth history
Social/Family history
8/3/2019 10. Severe Malnutrition
20/66
MEDICAL HISTORY Vomiting & diarrhea Episodes of fever Chronic cough Birth weight Birth rank and intervals Immunizations Milestones reached before current illness
8/3/2019 10. Severe Malnutrition
21/66
Typical signs of malnutrition Signs of shock
Signs of infections or heart failure
Temperature, pulse, and respiratory rate Eye signs,
Mouth; sore tongue, thrush etc
Skin lesions
ENT, Chest Organomegaly, especially the liver, spleen
Lymph nodes
8/3/2019 10. Severe Malnutrition
22/66
Blood film for Mps Full blood count
Chest x-ray
Urine RE & Culture Stool RE & Culture
VCT-where the suspicion is there
8/3/2019 10. Severe Malnutrition
23/66
Weight for height of
8/3/2019 10. Severe Malnutrition
24/66
Prevent or Treat Hypoglycemia Prevent or Treat Hypothermia Prevent or Treat Dehydration Correct Electrolyte Imbalance
Treat and Prevent Infections Correct Micronutrient deficiencies Start Cautious feeding Give Catch-up diet Provide TLC and play and stimulation Prepare for Follow-up and discharge
8/3/2019 10. Severe Malnutrition
25/66
Phases Initial phase
Stabilization phase(1-2)
Transition phase (3-7)
Rehabilitation phase(2-6wks)
Follow ups (7-26 wks)
8/3/2019 10. Severe Malnutrition
26/66
MINERALS Potassium 2340mg
Magnesium 146mg
Zinc 40mg Copper 5.6g
Iodine 154mcg
Selenium 94mcg
8/3/2019 10. Severe Malnutrition
27/66
Vitamin A 3000mcg Vitamin D 60mcg
Vitamin E 44mg
Vitamin C 200mg Vitamin B1 1.4mg
Vitamin B2 4mg
Vitamin B6 1.4mg
Vitamin B12 2mcg
8/3/2019 10. Severe Malnutrition
28/66
Vitamin K 80mcg Biotin 0.2mg
Folic acid 700mg
Patothenic acid 6mg Niacin 20mg
8/3/2019 10. Severe Malnutrition
29/66
F 75 F 100
Suji
RUTF
8/3/2019 10. Severe Malnutrition
30/66
Treat infections and other medical problems Provide sufficient energy and nutrients to
stop further loss of muscle and fat
Revive the cells and organs that are almostdormant
8/3/2019 10. Severe Malnutrition
31/66
Provide extra energy and nutrients for rapidweight gain
Start stimulating the child to improve mentaland motor development
Start educating carer on how to continuecaring for the child after discharge
8/3/2019 10. Severe Malnutrition
32/66
Starter formula (F 75 here) Must contain milk, sugar and oil
Must be low in sodium and protein and highin sugar
Must be fed in small amounts every 3 hoursday and night. Feed very ill children 2hrly.
8/3/2019 10. Severe Malnutrition
33/66
Feed by NGT if a child; Is lethargic and refuses to eat
Has refused or vomited the last 2 consecutivefeeds
Is taking
8/3/2019 10. Severe Malnutrition
34/66
Child is active and smiling Edema resolving or resolved
Increased appetite
Continue with F 100 or RUTF
8/3/2019 10. Severe Malnutrition
35/66
Catch-up diets are high in energy and proteinand some micronutrients
It contains more milk and oil and less sugarthan starter formula
Rapid weight gain Give high energy snacks such as bread and
margarine, banana between feeds
Avoid salty foods
Weight gain should be aimed at 10g/kg/day
8/3/2019 10. Severe Malnutrition
36/66
In severe malnutrition, theres delayedbehavioral and mental development.
These can be improved by giving;
TLC
A cheerful stimulating environment
Structured play therapy,15-30min/day
Physical activities as soon as well enough
Maternal involvement as much as possible
8/3/2019 10. Severe Malnutrition
37/66
Counselling Bringing child back for regular follow-up
checks
Ensure they complete immunizationschedules
8/3/2019 10. Severe Malnutrition
38/66
HYPOGLYCAEMIA Blood sugar
8/3/2019 10. Severe Malnutrition
39/66
When axillary temperature
8/3/2019 10. Severe Malnutrition
40/66
Difficult to rely on usual signs to tell severity
of dehydration
Assume all children with watery diarrhea may
have some dehydration No IV fluids except in shock
ReSoMal-ideal solution in malnutrition; giveorally or by NGT.
8/3/2019 10. Severe Malnutrition
41/66
ReSoMal: 5ml/kg every 30mins for the 1st 2hours, then 5-10ml/kg/hr for the next 4-10hours
Start starter feeds after 4 hours
Continue breastfeeding
8/3/2019 10. Severe Malnutrition
42/66
Look out for signs of over hydration Puffy face
Engorged jugular vein
Pulse
Respiratory rate
HR
Crackles
8/3/2019 10. Severe Malnutrition
43/66
Assume all malnourished children have aninfection
Hypoglycemia & hypothermia are signs ofsevere infections
Give broad-spectrum antibiotics Keep warm Check RTHC for at least measles vaccine,
8/3/2019 10. Severe Malnutrition
44/66
All severely malnourished children have vitamin& mineral deficiencies
Do not give iron within the first 2 weeks Give;
Vitamin A Multivitamin supplement
Folic acid Zinc
Copper
8/3/2019 10. Severe Malnutrition
45/66
Haemotransfusion required if Hb
8/3/2019 10. Severe Malnutrition
46/66
Common causes Misdiagnosis of dehydration with consequent
inappropriate hydration
Very severe anemia
Overloading due to blood transfusion High Na diet using conventional ORS or
excess ReSoMal
Inappropriate treatment of refeeding
diarrhea with rehydration solutions
8/3/2019 10. Severe Malnutrition
47/66
First fast breathing 2-12 months: RR>50 cpm
1-5years: RR>40cpm
Later
Cyanosis or pulse oximetry,SaO2 2cm
Engorged jugular veins
Increased pulse rate
Lung crepitations
Respiratory distress
8/3/2019 10. Severe Malnutrition
48/66
Stop all oral intake and IV fluid No fluid should be given until cardiac
function improves
A diuretic-IV lasix,1mg/kg stat
8/3/2019 10. Severe Malnutrition
49/66
TB can be a cause of failure to gain weight Signs are often non-specific
Asymmetric chest signs or lymph nodes areusually TB
The mantoux test can be negative Take a chest x-ray
To treat as soon as the suspicion is there
8/3/2019 10. Severe Malnutrition
50/66
Nutritional treatment of HIV/HIV-suspectedpatients is the same as for any severelymalnourished patient
They require the same dietary and medical
treatment HIV-positive patients usually respond well to
the nutritional treatment and gain weight
8/3/2019 10. Severe Malnutrition
51/66
Children can be allowed to go home if they; Have completed the transition to catch-up diets and are
eating well
Have no edema
Have completed antibiotic treatment
Have received extra electrolytes and micronutrients for atleast 2 weeks
Have been gaining weight well for at least 1week
Are up to date with their immunizations
W-f-h of >85%,if theres good follow-up services; w-f-h
of >95% without good follow-up services
8/3/2019 10. Severe Malnutrition
52/66
MONTH KWASHIOKOR MARASMUS MK TOTAL FATALITY
January 7 15 2 24 2
February 0 15 2 17 3
March 1 13 1 15 4
April 1 20 3 24 0
May 5 20 4 29 5
June 2 18 3 23 1
July 0 15 4 19 4
August 3 16 3 22 4
September 4 12 0 16 2
October 1 14 3 18 3
November 10 20 8 38 9
December 10 17 4 31 2
TOTAL 44 195 37 276 39
8/3/2019 10. Severe Malnutrition
53/66
MONTH KWASHIOKOR MARASMUS MK TOTAL FATALITY
January 2 24 4 30 1
February 3 35 6 44 3
March 5 30 1 37 6
April 9 24 1 34 4
May 1 17 0 18 3
June 3 15 2 20 5
July 4 19 2 25 1
TOTAL 27 164 16 207 23
8/3/2019 10. Severe Malnutrition
54/66
14.13% for 2008 11.11% for 2009
Both primary and secondary
WHO accepts between 5-10%
Resources available: 1-5%
8/3/2019 10. Severe Malnutrition
55/66
Part of Ward B4 Four nutritionist
3 pediatricians
1 resident
3/4 house officers
Nurses
Health care assistants
8/3/2019 10. Severe Malnutrition
56/66
Over crowding Nocturnal feedings
No office and store for feeds
Funds for alternate feeds
Hospital bill
8/3/2019 10. Severe Malnutrition
57/66
Case management practices suitable for the
non malnourished child may be highlydangerous for the PEM child
A malnourished child can be likened to apremature neonate
Very delicate and fragile, but when given thenecessary care and treatment, can surpriseeven you
8/3/2019 10. Severe Malnutrition
58/66
1. ScienceDirect - The Lancet : Managementof severe acute malnutrition in children.Available at: http://hinari-gw.who.int/whalecomwww.sciencedirect.com
/whalecom0/science?_ob=ArticleURL&_udi=B6T1B-4M0BHJ3-2&_user=2778664&_coverDate=12%2F08%2F2006&_rdoc=34&_fmt=high&_orig=browse&
_srch=doc-info(%23toc%234886%232006%23996310448%23638508%23FLA%23display%23Volume)&_cdi=4886&_sort=d&_docanchor=&_ct=38&_a
cct=C000049744&_version=1&_urlVersion=0
8/3/2019 10. Severe Malnutrition
59/66
2. Community Based Management of
Malnutrition. A Proposal for Pakistan Initiativefor Mothers and Newborns - Full Text View -
ClinicalTrials.gov. Available at:http://clinicaltrials.gov/ct2/show/NCT00941434 [Accessed October 5, 2009].
8/3/2019 10. Severe Malnutrition
60/66
3. WHO guidelines for severe malnutrition:are they feasible in rural African hospitals? --Karaolis et al. 92 (3): 198 -- Archives ofDisease in Childhood. Available at:
http://hinari-gw.who.int/whalecomadc.bmj.com/whalecom0/cgi/content/full/92/3/198 [AccessedOctober 7, 2009].
4. a57361.pdf (application/pdf Object).Available at:http://whqlibdoc.who.int/hq/1999/a57361.pdf Accessed ctober 2 .
8/3/2019 10. Severe Malnutrition
61/66
5. ScienceDirect - The Lancet : Addressingsevere acute malnutrition where it matters.Available at: http://hinari-gw.who.int/whalecomwww.sciencedirect.com
/whalecom0/science?_ob=ArticleURL&_udi=B6T1B-4WR1DM6-3&_user=2778664&_coverDate=07%2F17%2F2009&_rdoc=5&_fmt=high&_orig=browse&_s
rch=doc-info(%23toc%234886%232009%23996250315%231294049%23FLA%23display%23Volume)&_cdi=4886&_sort=d&_docanchor=&_ct=38&_
acct=C000049744&_version=1&_urlVersion=
8/3/2019 10. Severe Malnutrition
62/66
6. USAID Health: Nutrition, Technical Areas,
Management of Malnutrition. Available at:http://www.usaid.gov/our_work/global_healt
h/nut/techareas/mal_children.html [AccessedOctober 5, 2009].
7. Community care: addressing themanagement of severe malnutrition. Availableat:http://fex.ennonline.net/14/community.aspx
[Accessed October 5, 2009].
8/3/2019 10. Severe Malnutrition
63/66
8. How Can We Improve the Care of SeverelyMalnourished Children in Africa? Available at:http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1783670 [Accessed October 5,
2009]. 9. Nick AEA.Jolly's Diseases of Children. sixth
edition. Black Well Scientific Publications;2009:531-546.
8/3/2019 10. Severe Malnutrition
64/66
10.Statement_community_based_man_sev_acute_mal_eng.pdf (application/pdf Object).Available at:
http://www.who.int/nutrition/topics/Statement_community_based_man_sev_acute_mal_eng.pdf [Accessed October 5, 2009].
11. SG. The Short textbook of Pediatrics.
Seventh Edition. New Delhi, India: jaypeeBrothers Medical Publishers Ltd; 2009:107-138.
8/3/2019 10. Severe Malnutrition
65/66
12. Improving Children's Nutritional Status IsImperative-Minister | Ghana Official Portal.Available at:http://www.ghana.gov.gh/ghana/improving_
childrens_nutritional_status_imperative_minister.jsp [Accessed October 7, 2009].
13. Management of Malnutrition in Childrenunder five years - Mother, Infant and Young
Child Nutrition & Malnutrition - Feedingpractices including micronutrient deficienciesprevention, control of wasting, stunting andunderweight. Available at:htt ://motherchildnutrition.or /malnutrition
8/3/2019 10. Severe Malnutrition
66/66
14. Nutrition in Ghana: Investing now for theyear 2020. Available at:http://www.geocities.com/cspslibrary/nutrition.html [Accessed October 7, 2009].