Dr.Azad A Haleem AL.MezoriUniversity Of Duhok

Faculty of Medical ScienceSchool Of Medicine

Pediatrics Department2015

Malnutrition in children

Definition

• The World Health Organization (WHO) defines malnutrition as the cellular imbalance between the supply of nutrients and energy and the body’s demand

• to ensure growth, maintenance, and specific functions.

Classification of Undernutrition1-Gomez Classification : uses weight-for-age measurements; provide grading as to prognosis

Weight-for-Age% Status 90-100 Normal75-90 1st degree60-75 2nd degree<60 3rd degree

2-Wellcome Classification : simple since based on 2 criteria only - wt loss in terms of wt for age% & presence or absence of edema

Wt-for-Age% Edema No Edema 80-60 Kwashiorkor Undernutrition< 60 Marasmic-kwashiorkor Marasmus

3-Waterlow Classification : adopted by WHO; can distinguish between deficits of weight-for-height% (wasting) & height-for-age% (stunting)

N Mild Mod SevereHt-for-Age% >95 90-95 80-90 <80Wt-for-Ht% >90 80-90 70-80 <70

Identifying the child with malnutrition:

• Weighing the children.• Measure length/height

• If a child is less than 2 years old (or less than 87 cm if the age is not available),

measure recumbent length.

• If the child is aged 2 years or older (or 87 cm or more if the age is not available)

and able to stand, measure standing height.

• In general, standing height is about 0.7 cm less than recumbent

length.

• Determining a standard deviation score (SD-score) based on the

child’s weight and length:

standard deviation score (SD-score)

Mid-upper arm circumference (MUAC)

• Community based screening programs for severe malnutrition usually use MUAC less than 11.5cm to identify severe wasting.

Introduction

• Severe malnutrition is one of the most common causes of morbidity and mortality among children under the age of 5 years worldwide.

• Severely malnourished children often die because doctors unknowingly use practices that are suitable for most children, but highly dangerous for severely malnourished children.

Reductive Adaptation System• The child with severe malnutrition must be

treated differently because his physiology is seriously abnormal due to:

• Reductive Adaptation System

Reductive Adaptation System• The systems of the body begin to “shut down” with

severe malnutrition. • The systems slow down and do less in order to allow

survival on limited calories. • This slowing down is known as reductive adaptation. • As the child is treated, the body's systems must

gradually "learn" to function fully again. • Rapid changes (such as rapid feeding or fluids) would

overwhelm the systems, so feeding must be slowly and cautiously increased.

• Reductive adaptation affects treatment of the child in 3 ways.

• 1- Presume and treat infection• Nearly all children with severe malnutrition

have bacterial infections. • However, as a result of reductive adaptation,

the usual signs of infection may not be apparent, because the body does not use its limited energy to respond in the usual ways, such as inflammation or fever.

2.Iron • Due to reductive adaptation, the severely malnourished child

makes less haemoglobin than usual.• Iron that is not used for making haemoglobin is put into storage. • Giving iron early in treatment can also lead to “free iron” in the

body. • Free iron can cause problems in three ways:• • Free iron is highly reactive and promotes the formation of free

radicals with damaging effects.• • Free iron promotes bacterial growth and can make some

infections worse.• • The body tries to protect itself from free iron by converting it to

ferritin. This conversion requires energy and amino acids and diverts these from other critical activities.

3. Provide potassium and restrict sodium• In reductive adaptation, the “pump” that

usually controls the balance of potassium and sodium runs slower. As a result, the level of sodium in the cells rises and potassium leaks out of the cells and is lost.

• ReSoMal has less sodium and more potassium than regular ORS.

Recognize signs of severe malnutrition

• Severe wasting.• Oedema.• Dermataosis.• Eye signs.

Recognize signs of severe malnutrition

Severe wasting Oedema Dermatosis Eye signs

front view-ribs easily seen-upper arms look loose-thighs look loose

+ mild: both feet

+ mild: discoloration or a few rough patches of skin

Bitot’s spots –

back view-ribs and shoulder bones easily seen- flesh missing from the buttocks

+ + moderate: both feet, plus lower legs, hands, or lower arms

+ + moderate: multiple patches on arms and/or legs

Pus and inflammation (redness) are signs of eye infection.

+ + + severe: generalized oedema including both feet, legs, hands, arms andface

+ + + severe: flaking skin, raw skin, fissures (openings in the skin)

Corneal clouding

Corneal ulceration

Classification of malnutrition:Classification of malnutrition:

Undernutrition is defined as insufficient food intake combined with repeatedoccurrence of infectious diseases (UNICEF, 2007).

Moderate Acute Malnutrition (MAM) is defined by WHO/UNICEF as: Weight-for-Height Z-score <-2 but >-3

Severe Acute Malnutrition (SAM) is defined by WHO/UNICEF as:MUAC (mid-upper arm circumference) <11.5cmWeight-for-Height Z-score <-3Bilateral pitting oedema

Essential components of care:

• WHO recommends that children be kept in the severe malnutrition ward or area until they reach −1 SD (90%) weight-for-height.

Feeding formulas: What are F-75 and F-100?

• F-75 is the "starter" formula to use during initial management, beginning as soon as possible and continuing for 2−7 days until the child is stabilized.

• F 75 a diet that is low in protein and sodium and high in carbohydrate. F-75 contains 75 kcal and 0.9 g protein per 100 ml.

• As soon as the child is stabilized on F-75, F-100 is used as a "catch-up" formula to rebuild wasted tissues.

• F-100 contains more calories and protein: 100 kcal and 2.9 g protein per 100 ml.

Important things NOT to do

• Do not give diuretics to treat oedema. • Do not give iron during the initial feeding

phase• Do not give high protein formula• Do not give IV fluids routinely.

The 10 StepsThere are ten essential steps:1.Treat/prevent hypoglycaemia2.Treat/prevent hypothermia3.Treat/prevent dehydration4.Correct electrolyte imbalance5.Treat/prevent infection6.Correct micronutrient deficiencies7.Start cautious feeding8.Achieve catch-up growth9.Provide sensory stimulation and emotional support10. Prepare for follow-up after recovery

Initial Management

• Manage hypoglycaemia• In severely malnourished children, the level

considered low is less than (<) 3 mmol/litre (or <54 mg/dl).

• If the child can drink, give the 50 ml bolus of 10% glucose orally. If the child is alert but not drinking, give the 50 ml by NG tube.

Treat hypoglycaemia:

• If the child is lethargic, unconscious, or convulsing, give 5 ml/kg body weight of sterile 10% glucose by IV, followed by 50 ml of 10% glucose by NG tube. If the IV dose cannot be given immediately, give the NG dose first.

• Start feeding F-75 half an hour after giving glucose , during the first 2 hours.

• If the child’s blood glucose is not low, begin feeding the child with F-75 right away. Feed the child every 2 hours, even during the night.

Manage hypothermia

• Actively re-warm the hypothermic child:• keeping the child covered and • keeping the room warm, • Have the mother hold the child with his skin

next to her skin when possible (kangaroo technique), and cover both of them.

• Keep the child’s head covered.

Manage Shock:• The severely malnourished child is considered

to have shock if he/she:• is lethargic or unconscious and• has cold hands • plus either:• slow capillary refill (longer than 3 seconds),or• weak or fast pulse.

• Give oxygen, IV glucose, and IV fluids for shock

• Give sterile 10% glucose 5 ml/kg by IV • then infuse IV fluid at 15ml/kg over 1 hour.• Use 0.45% (half-normal) saline with 5%

glucose).• Observe the child and check respiratory and

pulse rates every 10 minutes.

• If respiratory rate and pulse rate are slower after 1 hour, the child is improving. stop the IV.

• If the respiratory rate and pulse rate increase Repeat the same amount of IV fluids for another hour.

• Continue to check respiratory and pulse rates every 10 minutes.

• After 2 hours of IV fluids, switch to oral or nasogastric rehydration with ReSoMal (special rehydration solution for children with severe malnutrition).

• Give 5 − 10 ml/kg ReSoMal in alternate hours with F-75 for up to 10 hours.

• Leave the IV line in place in case it is needed again. • If the child fails to improve after the Second hour of

IV fluids, then assume that the child has septic shock. • Give maintenance IV fluids (4 ml/kg/hour) while

waiting for blood. • When blood is available, stop all oral intake and IV

fluids, give a diuretic to make room for the blood, and then transfuse whole fresh blood at 10 ml/kg slowly over 3 hours.

Manage anemia:• Mild or moderate anaemia is very common in severely

malnourished children and should be treated later with iron, after the child has stabilized.

• Very severe anaemia • If haemoglobin is less than 40 g/l, (or packed cell volume is less than

12 %), give a blood transfusion. • If there are no signs of congestive heart failure, transfuse whole fresh

blood at 10 ml/kg slowly over 3 hours.• If there are signs of heart failure, give 5 – 7 ml/kg packed cells over 3

hours instead of whole blood. Give a diuretic; Furosemide (1 mg/kg, given by IV)

Corneal ulceration • All severely malnourished children need

vitamin A on Day 1.• Additional doses are given if:• the child has signs of eye infection, measles ,

clinical signs of vitamin A deficiency.• The additional doses are given on Day 2 and

at least 2 weeks later, preferably on Day 15.

Child's age

Vitamin A Oral Dose < 6 months 50 000 IU

6 − 12 months

100 000 IU >12 months 200 000 IU

Manage watery diarrhoea and/or vomiting with ReSoMal:

• ReSoMal is Rehydration Solution for Malnutrition. It is a modification of the standard Oral Rehydration Solution (ORS) recommended by WHO.

• ReSoMal contains less sodium, more sugar, and more potassium than standard ORS

• For children < 2 years, give 50 − 100 ml after each loose stool. For children 2 years and older, give 100 − 200 ml after each loose stool.

• It should be given by mouth or by nasogastric tube.• If the child develops a hard distended abdomen with very little

bowel sound, give 2 ml of a 50% solution of magnesium sulphate IM.

Give antibiotics:• Give all severely malnourished children

antibiotics for presumed infection. IF: GIVE: NO COMPLICATIONS Amoxil Oral

Cotrimoxazole Oral (25 mg sulfamethoxazole + 5 mg trimethoprim / kg) every 12 hours for 5 days

COMPLlCATIONS(shock, hypoglycaemia, hypothermia, dermatosis with raw skin/fissures, respiratory or urinary tract infections, or lethargic/sickly appearance)

Gentamicin IV or IM (7.5 mg/kg), once daily for 7 days, plus: Ampicillin IV or IM (50 mg/kg), every 6 hours for 2 days Followed by: Amoxicillin Oral (15 mg/kg), every 8 hours for 5 days

Feeding F-75 and F-100?

•

Determine frequency & Amount of feeds

• Feed orally .• Use an NG tube if the child :• does not take 80% of the feed (i.e., leaves

more than 20%) for 2 or 3 consecutive feeds.• Remove the NG tube when the child takes:

80% of the day’s amount orally; or two consecutive feeds fully by mouth.

Determine frequency of feeds: • On the first day, feed the child a small amount of F-75

every 2 hours (12 feeds in 24 hours, including through the night).

• If the child is hypoglycaemic, give ¼ of the 2-hourly amount every half-hour for the first 2 hours or until the child’s blood glucose is at least 3 mmol/l.

• After the first day, increase the volume per feed gradually so that the child's system is not overwhelmed.

• The child will gradually be able to take larger, less frequent feeds (every 3 hours or every 4 hours).

Determine amount of F-75 needed per feed:

• Criteria for increasing volume/decreasing frequency of feeds:

• If little or no vomiting, modest diarrhoea (for example, less than 5 watery stools per day), and finishing most feeds, change to 3-hourly feeds.

• After a day on 3-hourly feeds: If no vomiting, less diarrhoea, and finishing most feeds, change to 4-hourly feeds.

Adjusting to F-100 during transition, or feeding freely on F-100:

• Look for the following signs of readiness usually after 2 − 7 days:

• Return of appetite (easily finishes 4-hourly feeds of F 75)

• Reduced oedema or minimal oedema• The child may also smile at this stage.

• Begin giving F-100 slowly and gradually:• Transition takes 3 days.

• First 48 hours (2 days): Give F-100 every 4 hours in the same amount as you last gave F-75. Do not increase this amount for 2 days.

• Then, on the 3rd day: Increase each feed by 10 ml as long as the child is finishing feeds.

• Continue increasing the amount until some food is left after most feeds (usually when amount reaches about 30 ml/kg per feed).

• If the child is breastfeeding, encourage the mother to breastfeed between feeds of F-100.

Rehabilitation" phase

• After transition, the child is in the "rehabilitation" phase and can feed freely on F-100 to an upper limit of 220 kcal/kg/day.

• (This is equal to 220 ml/kg/day.)

Others??

• Folic acid: Each child should be given a large dose (5mg) on Day 1 and a smaller dose (1mg) on subsequent days.

• Multivitamin: daily (not including iron).• Iron: • After two days on F-100, give iron daily, Calculate

and administer the amount needed: Give 3 mg elemental Fe/kg/day in 2 divided doses. Always give iron orally, never by injection. Preferably give iron between meals using a liquid preparation.

Monitor individual patient progress and care:

• Good weight gain: 10 g/kg/day or more• Moderate weight gain: 5 up to10 g/kg/day• Poor weight gain: Less than 5 g/kg/day

Criteria for failure to respond to treatmentCriteria Time after admissionPrimary failure to respond:

Failure to regain appetite Day 4

Failure to start to lose oedema Day 4 Oedema still present Day

10 Failure to gain at least 5 g/kg Day

10 of body weight per day

Secondary failure to respond: Failure to gain at least 5 g/kg During

rehabilitation of body weight per dayfor 3 successive days

Failure to respond to treatment

• Problems with the treatment facility:

• Poor environment for malnourished children.

• Insufficient or inadequately trained staff.

• Inaccurate weighing machines.• Food prepared or given incorrectly.

Review patient records for common factors in adverse outcomes:

• Deaths that occur within the first 2 days are often due to:

Hypoglycaemia.Overhydration. Unrecognized or mismanaged septic shock, or

other serious infection.• Deaths that occur after 2 days are often due to:• Heart failure.

Discharge • WHO recommends that children be kept in the severe

malnutrition ward or area until they reach −1 SD weight-for-height. It usually requires about 2 – 6 weeks .

• If a child leaves before being achieving -1 SD, he is likely to get worse and have to return. 

• WHO recommends that children be kept in the severe

malnutrition ward or area until their condition is

stabilized( regained appetite, reduced edema and good

acceptance of RUTF during transition phase.

Give general discharge instructions:

• In addition to feeding instructions, mothers will need to be taught:

• The mother has been thoroughly trained in how to feed the child at home and give supplements.

• how to continue any needed medications, vitamins , folic acid (for 1 − 2 weeks),

• and iron (for 1 month) at home

•when and where to go for planned follow-up:• at 1 week, 2 weeks, 1 month, 3 months, and

6 months;• then twice yearly visits until the child is at

least 3 years old.

THANKS FOR YOUR PATIENCE….