Malnutrition by Nadia Baasher

Port Sudan Teaching HospitalPort Sudan Teaching HospitalDepartment of PediatricsDepartment of Pediatricsunit of Dr. Zeinab Gailyunit of Dr. Zeinab Gaily

Recognizing and Managing Recognizing and Managing severe malnutritionsevere malnutrition

Prepared byPrepared byDr. Nadia KhalidDr. Nadia Khalid BaasherBaasher

► Malnutrition isMalnutrition is the Impairment of the Impairment of physical and/or mental health resulting physical and/or mental health resulting from a failure to fulfill nutrient from a failure to fulfill nutrient requirementsrequirements

Malnutrition may result from :Malnutrition may result from :

1- Consuming too little food. 1- Consuming too little food.

2- A shortage of key nutrients 2- A shortage of key nutrients

3- Impaired absorption or metabolism 3- Impaired absorption or metabolism

due to disease.due to disease.

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

►Many children die at home without Many children die at home without care , but even when hospital care is care , but even when hospital care is provided case fatality rates may be provided case fatality rates may be high.high.

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

►With proper management in With proper management in hospitals and follow up care the lives hospitals and follow up care the lives of many childrenof many children can be savedcan be saved..

Recognizing the signs of Severe Recognizing the signs of Severe MalnutritionMalnutrition

1.1. Severe WastingSevere Wasting

2.2. OedemaOedema

3.3. DermatosisDermatosis

4.4. Eye signsEye signs

5.5. StuntingStunting

1-Severe Wasting:1-Severe Wasting:

► A child with severe wasting has lost fat and A child with severe wasting has lost fat and muscle and appears like muscle and appears like “ skin and bones ““ skin and bones “ (marasmus)(marasmus)

► To look for severe wasting : To look for severe wasting :

Remove the child’s clothesRemove the child’s clothes

Look at the front view of the child : Look at the front view of the child :

11- - is the outline of the child’s ribs easily seen.is the outline of the child’s ribs easily seen.

2- Does the skin of the upper arms look loose.2- Does the skin of the upper arms look loose.

3- Does the skin of the thighs look loose.3- Does the skin of the thighs look loose.

►Look at the back view of the child :Look at the back view of the child : 1- Are the ribs and shoulder bone easily 1- Are the ribs and shoulder bone easily

seen.seen. 2- Is flesh missing from the buttocks.2- Is flesh missing from the buttocks. When wasting is extreme there are folds of When wasting is extreme there are folds of

skin on the buttocks and thighs it looks like skin on the buttocks and thighs it looks like the child is wearing the child is wearing “baggy pants ““baggy pants “

When any of these signs are found in a child he When any of these signs are found in a child he is to be assessed for admition to the is to be assessed for admition to the malnutrition ward.malnutrition ward.

Baggy pants sign:Baggy pants sign:

2-Oedema:2-Oedema:To be considered a sign of severe malnutrition oedema must To be considered a sign of severe malnutrition oedema must

appear in both feet.appear in both feet.The extent of odema is rated as follows :The extent of odema is rated as follows : + mild+ mild :: both feet both feet

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

+++ Severe :+++ Severe : Generalized Odema including both Generalized Odema including both feet,hands,armsfeet,hands,arms

and face.and face. When Oedema is found in a child he is to be assessed for When Oedema is found in a child he is to be assessed for

admition to the malnutrition ward after exclusion of other admition to the malnutrition ward after exclusion of other causes of odema.causes of odema.

3- Dermatosis:3- Dermatosis:

►The extent of Dermatosis is described The extent of Dermatosis is described as follows:as follows:

+ mild :+ mild : discoloration or a few rough discoloration or a few rough

patches of skin.patches of skin.

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

+++ severe :+++ severe : flaking skin , raw skin , flaking skin , raw skin , fissures.fissures.

flaking skin , raw skin , fissuresflaking skin , raw skin , fissures

4- Eye signs:4- Eye signs:► Children with severe malnutrition may have signs of eye Children with severe malnutrition may have signs of eye

infection and/or vitamin A deficiency.infection and/or vitamin A deficiency.► Eye signs are in the form of:Eye signs are in the form of: 1- Pus and Inflammation :1- Pus and Inflammation : eye infectioneye infection

2- 2- Bitot’s spots :Bitot’s spots : superficial foamy white spots on the superficial foamy white spots on the conjunctiva (associated with vit A deficiency)conjunctiva (associated with vit A deficiency)

3- Corneal clouding :3- Corneal clouding :opaque appearance of the opaque appearance of the corneacornea

( sign of vit A deficiency)( sign of vit A deficiency)

4- Corneal ulceration :4- Corneal ulceration : break in the surface of the break in the surface of the corneacornea

this is caused by severe vit A deficiency it requires this is caused by severe vit A deficiency it requires urgent treatment as it may lead to blindnessurgent treatment as it may lead to blindness

::

Bitot’s spotsBitot’s spotsBitot’s spotsBitot’s spots

Corneal Corneal cloudingclouding

Corneal ulcerationCorneal ulceration

5-Stunting:5-Stunting:

►Stunting is unusually low height or Stunting is unusually low height or length for age , often due to chronic length for age , often due to chronic malnutrition.malnutrition.

►Stunted children should be managed Stunted children should be managed in the community rather than in the in the community rather than in the hospitalhospital

This 5 year old child was severly malnourished althought This 5 year old child was severly malnourished althought recoverd but has stunted growthrecoverd but has stunted growth

Weigh and measure the Weigh and measure the child:child:

► In addition to looking for the visible signs of severe In addition to looking for the visible signs of severe malnutrition it is important to weigh and measure malnutrition it is important to weigh and measure the childthe child

► The child’s weight-for-height is then compared to The child’s weight-for-height is then compared to averages.averages.

► Measure length using measuring board Measure length using measuring board ► Measure height using stadiometerMeasure height using stadiometer► Two people should work together to measure the Two people should work together to measure the

child properly child properly ► Weigh the child on scales after removing clothingWeigh the child on scales after removing clothing► Scales and Stadiometers must be standardized Scales and Stadiometers must be standardized

daily to ensure accuracy .daily to ensure accuracy .

Determine standard deviation score(SD-Determine standard deviation score(SD-score) based on child’s weight and score) based on child’s weight and

height/length :height/length :► SD-score is a way of comparing a measurement, in this SD-score is a way of comparing a measurement, in this

case it compares a child’s weight-for-length to an case it compares a child’s weight-for-length to an ‘average”‘average”

► Average is provided by the WHO normalized reference Average is provided by the WHO normalized reference values for weight-for height and weight for length.values for weight-for height and weight for length.

► SD-score are interpreted as follows :SD-score are interpreted as follows :

-1 SD approximately corresponds to 90% of the median weight-for-height-1 SD approximately corresponds to 90% of the median weight-for-height..

-2SD approximately corresponds to 80% of the median weight-for height.-2SD approximately corresponds to 80% of the median weight-for height.

-3SD approximately corresponds to 90% of the median weight-for height.-3SD approximately corresponds to 90% of the median weight-for height.

Recommended criteria for admission to Recommended criteria for admission to a severe malnutrition ward:a severe malnutrition ward:

Weight – for – Height less than -3SD Weight – for – Height less than -3SD (less than 70%) (less than 70%)

and/ orand/ or

Odema of both feetOdema of both feet

How does the physiology of malnutrition How does the physiology of malnutrition affect the care of the child:affect the care of the child:

► The child with severe malnutrition must be treated The child with severe malnutrition must be treated differently because his physiology is seriously differently because his physiology is seriously

abnormal due to abnormal due to reductive adaptation .reductive adaptation .►What is reductive adaptation ?What is reductive adaptation ?With severe malnutrition the body systems begin to “ shut With severe malnutrition the body systems begin to “ shut

down” and do less in order to allow survival on limited down” and do less in order to allow survival on limited calories. This slowing down is known as reductive adaptation.calories. This slowing down is known as reductive adaptation.

As the child is treated the body systems must gradually “ learn “ As the child is treated the body systems must gradually “ learn “ to function fully againto function fully again

Rapid changes (such as rapid feeding of fluids) will overwhelm Rapid changes (such as rapid feeding of fluids) will overwhelm the systems . So feeding must be slowly and cautiously the systems . So feeding must be slowly and cautiously increased.increased.

Important implications of management Important implications of management based on reductive adaptationbased on reductive adaptation

►1- Presume and treat infection:1- Presume and treat infection: Nearly all children with severe malnutrition have bacterial Nearly all children with severe malnutrition have bacterial

infections.infections.However due to reductive adaptation the usual signs of infection However due to reductive adaptation the usual signs of infection

may be no apparent , because the body does not use the may be no apparent , because the body does not use the limited energy to respond in the usual ways such as limited energy to respond in the usual ways such as inflammation or fever.inflammation or fever.

Examples of common infections in severely malnourished children:Examples of common infections in severely malnourished children:► PneumoniaPneumonia► UTIUTI► Otitis mediaOtitis media

Assume that infection is present and treat all Assume that infection is present and treat all severe malnutrition admissions with broad severe malnutrition admissions with broad spectrum antibiotics.spectrum antibiotics.

2- Don’t give Iron early in treatment:2- Don’t give Iron early in treatment:

►Due to reductive adaptation , the Due to reductive adaptation , the severely malnourished child makes less severely malnourished child makes less hemoglobin .hemoglobin .

► Iron that is not used for making Iron that is not used for making hemoglobin is put into storage.hemoglobin is put into storage.

►Thus there is an Thus there is an ‘extra’‘extra’ iron storage in iron storage in the body even though the child may the body even though the child may appear anemic appear anemic

►Giving iron early in treatment will lead Giving iron early in treatment will lead to to “ Free Iron“ Free Iron ““ in the body . in the body .

► Free iron can cause :Free iron can cause :

1.1. Free iron gives free radicals which Free iron gives free radicals which cause damaging chemical cause damaging chemical reactions.reactions.

2.2. Free iron promotes bacterial growth Free iron promotes bacterial growth making infections worse.making infections worse.

3.3. Body tries to protect itself from free Body tries to protect itself from free iron by converting it to ferritin the iron by converting it to ferritin the energy used in this conversion is energy used in this conversion is diverted from other critical diverted from other critical activities.activities.

Later as the child recovers and begins to build new Later as the child recovers and begins to build new tissue and form more RBCs , the iron in storage tissue and form more RBCs , the iron in storage will be used and supplements will be neededwill be used and supplements will be needed

3-Provide K+ and restrict Na+:3-Provide K+ and restrict Na+:

► Due to reductive adaptation Na+ - K+ pump becomes slower Due to reductive adaptation Na+ - K+ pump becomes slower as a result the level of Na+ in cells increases and K+ leaks out as a result the level of Na+ in cells increases and K+ leaks out of the cells and is lost .of the cells and is lost .

► Fluid may accumulate outside of the cells (odema)Fluid may accumulate outside of the cells (odema)► All severely malnourished children should be given K+ to All severely malnourished children should be given K+ to

make up for what is lost make up for what is lost ► They should also be given Magnesium which is essential for They should also be given Magnesium which is essential for

potassium to enter the cells and be retainedpotassium to enter the cells and be retained► Sodium should be restricted.Sodium should be restricted.► If there diarrhea a special rehydration fluid called ReSoMal If there diarrhea a special rehydration fluid called ReSoMal

should be used instead of ORS it has less sodium and more should be used instead of ORS it has less sodium and more potassium than ORS.potassium than ORS.

Initial care of the severely Initial care of the severely malnourished child:malnourished child:

► This includesThis includes : :

1.1. Management of hypoglycemia.Management of hypoglycemia.2.2. Management of hypothermia.Management of hypothermia.3.3. Management of shock in the severely malnourished child.Management of shock in the severely malnourished child.4.4. Management very severe anaemia.Management very severe anaemia.5.5. Management of watery diarrhea and vomiting with ReSoMalManagement of watery diarrhea and vomiting with ReSoMal6.6. Management of corneal ulcerationManagement of corneal ulceration7.7. Selecting antibiotics .Selecting antibiotics .

The focus of initial management is to prevent death The focus of initial management is to prevent death while stabilizing the child.while stabilizing the child.

1-Manegment of hypoglycemia:1-Manegment of hypoglycemia:

► Hypoglycemia is low level of blood glucose. Hypoglycemia is low level of blood glucose. ► In severely malnourished children the level In severely malnourished children the level

considered low is considered low is <3mmol/L (<54mg/dl) <3mmol/L (<54mg/dl) ► Signs of hypoglycemia include :Signs of hypoglycemia include :

LethargyLethargy

LimpnessLimpness

Loss of consciousnessLoss of consciousness

Sweating and pallor may not occur Sweating and pallor may not occur

Often the only sign before death is drowsinessOften the only sign before death is drowsiness

The hypoglycemic child is usually hypothermic.The hypoglycemic child is usually hypothermic.

Test blood glucose

If not low> Or = 54mg/dl

If low< 54md/dl

Start F75 immediately To prevent hypoglycemia

Give glucose to treathypoglycemia

Treatment of hypoglycemia:Treatment of hypoglycemia:

If blood glucose is low or hypoglycemia is suspected immediately If blood glucose is low or hypoglycemia is suspected immediately give a 50 ml bolus of Glucose 10%give a 50 ml bolus of Glucose 10%

If the child can drinkIf the child can drink give the 50 ml bolus orally if the child is give the 50 ml bolus orally if the child is alert but is not drinking give the 50 ml bolus by NG tube.alert but is not drinking give the 50 ml bolus by NG tube.

If the child is lethargic, unconscious or convulsingIf the child is lethargic, unconscious or convulsing give give 5ml/kg body weight of glucose 10% I.V followed by 50 ml by 5ml/kg body weight of glucose 10% I.V followed by 50 ml by NG tube.NG tube.

if the child is going to be given I.V fluids for shock there is no need if the child is going to be given I.V fluids for shock there is no need for the NG bolus.for the NG bolus.

Start feeding with F75 half an hour after giving Glucose and give it Start feeding with F75 half an hour after giving Glucose and give it every half an hour for the first 2 hoursevery half an hour for the first 2 hours

The amount of F75 for a hypoglycemic child is ¼ of the 2 hourly The amount of F75 for a hypoglycemic child is ¼ of the 2 hourly amount shown on the table.amount shown on the table.

2- Management of hypothermia:2- Management of hypothermia:

► Hypothermia is low body temperatureHypothermia is low body temperature► The severely malnourished child is hypothermic if rectal The severely malnourished child is hypothermic if rectal

temperature is <35.5 C or if the axillary temperature is < temperature is <35.5 C or if the axillary temperature is < 35C35C

► Hypothermia is very dangerous and rewarming is essential.Hypothermia is very dangerous and rewarming is essential.► The following measures are essential for all malnourished The following measures are essential for all malnourished

children to prevent hypothermia :children to prevent hypothermia :

1.1. cover the child including the head.cover the child including the head.2.2. Move the child away from the windowMove the child away from the window3.3. Maintain a room temperature of 25-30 C Maintain a room temperature of 25-30 C 4.4. Warm hands before touching the childWarm hands before touching the child5.5. Promptly change wet clothes of beddingPromptly change wet clothes of bedding6.6. Dry the child well after bathingDry the child well after bathing

Active re-warming of the Active re-warming of the hypothermic child:hypothermic child:

► Re-warming techniques include:Re-warming techniques include:► Kangaroo techniqueKangaroo technique : in which the mother : in which the mother

holds the child with his skin next to her skin and holds the child with his skin next to her skin and cover the child, keep the child’s head cover.cover the child, keep the child’s head cover.

► Use a heater or incandescent lamp Use a heater or incandescent lamp cautioncaution..

► Monitor rectal temperature every 30 mins to Monitor rectal temperature every 30 mins to make sure the child does not get too hot.make sure the child does not get too hot.

► Do Do NOTNOT use hot water bottles due to danger of use hot water bottles due to danger of burning fragile skin.burning fragile skin.

Kangaroo technique:Kangaroo technique:

Managing the severely malnourished Managing the severely malnourished childchild withwith shock :shock :

► The severely malnourished child is considered in The severely malnourished child is considered in shock if he/she is :shock if he/she is :

Is lethargic or unconsciousHas cold extremities

Has slow capillary refill (longer than 3 seconds)Weak rapid pulse

Hypovolemic shock and septic shock usually coexist in severelyMalnourished children

They may be difficult to differentiateHypovolemic shock will respond to fluid replacement septic shock will not

If the child is in shock :If the child is in shock :

Give Oxygen immediately

Quickly insert an I.V line

Give Dextrose 10% 5 ml/kg i.v

Give i.v fluids

Keep the child warm

Fluid replacement in the shocked Fluid replacement in the shocked severely malnourished child:severely malnourished child:

► To give I.V fluids :To give I.V fluids :► Check the starting RR and Pulse .Check the starting RR and Pulse .► Infuse 15ml/kg over one hour of Ringer’s LactateInfuse 15ml/kg over one hour of Ringer’s Lactate► Monitor RR and Pulse every 10 minutesMonitor RR and Pulse every 10 minutes► If RR and Pulse rate increase stop the i.v fluidsIf RR and Pulse rate increase stop the i.v fluids► If RR and Pulse are slower after one hour are slower If RR and Pulse are slower after one hour are slower

and the child is improving repeat the same amount and the child is improving repeat the same amount of i.v fluids for another hour with Monitoring of RR of i.v fluids for another hour with Monitoring of RR and Pulse every 10 minutes.and Pulse every 10 minutes.

► After 2 hours of i.v fluids switch to oral or NG After 2 hours of i.v fluids switch to oral or NG rehydration with ReSoMal give 5-10 ml /kg in rehydration with ReSoMal give 5-10 ml /kg in alternate hours with F75 up to 10 hours.alternate hours with F75 up to 10 hours.

If no improvement with i.v fluids give blood If no improvement with i.v fluids give blood transfusion:transfusion:

►Blood transfusion in severely Blood transfusion in severely malnourished children is can only be malnourished children is can only be given on day 1 of admission and then given on day 1 of admission and then not until day 14not until day 14

► If the child fails to improve after i.v If the child fails to improve after i.v fluids for one hour then assume septic fluids for one hour then assume septic shockshock

Give maintenance i.v fluids 4ml/kg/hour Give maintenance i.v fluids 4ml/kg/hour while waiting for the bloodwhile waiting for the blood

If there are NO If there are NO signs of heart failuresigns of heart failure

If there are signs If there are signs of heart failureof heart failure

give whole blood 10 ml/kggive whole blood 10 ml/kg

slowly over 3 hoursslowly over 3 hours give packed cells 10 ml/kg give packed cells 10 ml/kg slowly over 3 hoursslowly over 3 hours

diuretics should be given to make diuretics should be given to make

room for the blood 1 mg/kg i.v room for the blood 1 mg/kg i.v

before and after transfusionbefore and after transfusion

no diuretic is given.no diuretic is given.

If there are NO If there are NO signs of heart failuresigns of heart failure

give whole blood 10 ml/kggive whole blood 10 ml/kg

slowly over 3 hoursslowly over 3 hours

If there are NO If there are NO signs of heart failuresigns of heart failure

diuretics should be given to make diuretics should be given to make

room for the blood 1 mg/kg i.v room for the blood 1 mg/kg i.v

before and after transfusionbefore and after transfusion

give whole blood 10 ml/kggive whole blood 10 ml/kg

slowly over 3 hoursslowly over 3 hours

If there are NO If there are NO signs of heart failuresigns of heart failure

Emergency eye care:Emergency eye care:

1- Examine the eyes :1- Examine the eyes :

Wash your hands , touch the Wash your hands , touch the eyes extremely gently and as eyes extremely gently and as little as possible , wash your little as possible , wash your hands again after examining hands again after examining eyes.eyes.

2- Give vitamin A and atropine 2- Give vitamin A and atropine drops immediately for corneal drops immediately for corneal ulceration:ulceration:

Vit AVit AChild’s ageChild’s age Vit A Oral doseVit A Oral dose

< 6 months< 6 months 50.000 IU50.000 IU

6 – 12 months6 – 12 months 100 000 IU100 000 IU

> 12 months> 12 months 200 000 IU200 000 IU

► If the child is severely ill and anorexic and cannot If the child is severely ill and anorexic and cannot take orally give vit A I.M the dosage is 100.000 IU take orally give vit A I.M the dosage is 100.000 IU except for children under 6 months give 50.000 IU.except for children under 6 months give 50.000 IU.

► Instill one drop of 1% of atropine drops to relax the Instill one drop of 1% of atropine drops to relax the eyes.eyes.

► Tetracycline eye drops and bandaging are also Tetracycline eye drops and bandaging are also needed.needed.

► To bandage eyes :To bandage eyes : 1- Wash hands.1- Wash hands. 2- Soak eye pads with saline.2- Soak eye pads with saline. 3- Place a pad over each affected eye.3- Place a pad over each affected eye. 4- Wrap gauze bandage over the pads.4- Wrap gauze bandage over the pads.

Managing watery diarrhea and or vomiting with Managing watery diarrhea and or vomiting with ReSoMal:ReSoMal:

► ReSoMal ( Rehydration Solution for Malnutrition)ReSoMal ( Rehydration Solution for Malnutrition)► ReSoMal is a modification of ORSReSoMal is a modification of ORS► ReSoMal contains less sodium , more sugar and more ReSoMal contains less sodium , more sugar and more

potassium.potassium.► It should be given by mouth of NG tube.It should be given by mouth of NG tube.► Do NOT ORS to a severely malnourished child.Do NOT ORS to a severely malnourished child.

Contents of ReSoMal as prepared from standard ORS

Water 2 litersWHO- ORS one packetSugar 50 gMineral mix solution 40 ml

Signs of Dehydration:Signs of Dehydration:

1- Lethargy

2- Restlessness and irritability

3- Absence of tears

4- Sunken eyes

5- Dry mouth and tongue

6- Thirst

7- Skin pinch goes back slowly

Calculating the amount of ReSoMal:Calculating the amount of ReSoMal:

How often to give ReSoMalHow often to give ReSoMal Amount to giveAmount to give

Every 30 mins for the first 2 Every 30 mins for the first 2 hourshours

5 ml/kg5 ml/kg

Alternate hours for up to 10 Alternate hours for up to 10 hourshours

5 – 10 ml/kg5 – 10 ml/kg

F75 is given in alternate hours until the child is rehydrated then the ReSoMal is stopped alternatively and given after each loose stool

For children < 2 years give 50 – 100 ml after each loose stoolFor children 2 years and older give 100 – 200 ml after each loose stool

Monitoring the child who is taking ReSoMal:Monitoring the child who is taking ReSoMal:

► ReSoMal should be given slowly orally or by NG tube.ReSoMal should be given slowly orally or by NG tube.► Signs to check when monitoring the child :Signs to check when monitoring the child :

Respiratory rate

Pulse rate

Urine output

Stool and vomit frequency

Signs of hydration

Signs of overhydration:Signs of overhydration:

Rapid and marked increase in Pulse rate and RR

Jugular vein engorgement

Increasing edema

Important thing NOT to do in the initial management Important thing NOT to do in the initial management of a severely malnourished child:of a severely malnourished child:

1.1. Do not give diuretics to treat odemaDo not give diuretics to treat odema

2.2. Do not give iron during the initial Do not give iron during the initial phasephase

3.3. Do not give high protein formulaDo not give high protein formula

4.4. Do not give I.V fluids routinelyDo not give I.V fluids routinely

Selecting antibiotics:Selecting antibiotics:

IF:IF: GIVE:GIVE:

No ComplicationsNo Complications Cotrimoxazole orally(25 mg Cotrimoxazole orally(25 mg sulfamethoxazole + 5mg trimethoprim/ sulfamethoxazole + 5mg trimethoprim/ kg)kg)

Every 12 hours for 5 days orallyEvery 12 hours for 5 days orally

ComplicationsComplications( shock . ( shock . Hypoglycemia , dermatosis +++ , Hypoglycemia , dermatosis +++ , respiratory or urinary tract infection )respiratory or urinary tract infection )

Gentamicin i.v or i.m (7.5mg/kg) Gentamicin i.v or i.m (7.5mg/kg) once daily for 7 days + Ampicillin i.v once daily for 7 days + Ampicillin i.v or i.m(25mg/kg) every 6 hours for 2 or i.m(25mg/kg) every 6 hours for 2 daysdays

followed byfollowed by

Amoxicillin orally 15mg/kg every 8 Amoxicillin orally 15mg/kg every 8 hours for 5 dayshours for 5 days

If the child fails to If the child fails to improve within 48 hrs improve within 48 hrs addadd

Chloramphenicol i.v or i.m 25mg/kg Chloramphenicol i.v or i.m 25mg/kg every 8 hours for 5 days.every 8 hours for 5 days.

Feeding formulas and feeding phases:Feeding formulas and feeding phases:

► Types of Feeding formulas :Types of Feeding formulas :

These are F-75 and F-100These are F-75 and F-100

F-75F-75 F-100F-100

Starter formula used during Starter formula used during the stabilizing phase 2-7 daysthe stabilizing phase 2-7 days

Catch-up formula used to rebuild Catch-up formula used to rebuild wasted tissues. Given starting wasted tissues. Given starting from transitional phasefrom transitional phase

It contains 75 kcal and 0.9 g It contains 75 kcal and 0.9 g protein per 100 mlprotein per 100 ml

It contains 100 kacl and 2.9 g It contains 100 kacl and 2.9 g protein per 100 mlprotein per 100 ml

Given because severely Given because severely malnourished children can not malnourished children can not tolerate high amounts of protein tolerate high amounts of protein and fat at this stage.and fat at this stage.

► If you have cereal flour and cooking facilities, use one of ► the top three recipes for F-75: ► Alternatives Ingredient Amount for F-75 ► Dried skimmed milk 25 g ► If you have Sugar 70 g ► dried skimmed Cereal flour 35 g ► Milk Vegetable oil 30 g ► Mineral mix* 20ml ► Watertomake 1000 ml 1000 ml** ► Dried whole milk 35 g ► If you have Sugar 70 g ► dried whole Cereal flour 35 g ► milk Vegetable oil 20 g ► Mineral mix* 20 ml ► Watertomake 1000 ml 1000 m/** ► Fresh cow's milk, or full- 300ml ► If you have Cream (whole) long life milk ► fresh cow's Sugar 70 g ► milk, or full- Cereal flour 35 g ► cream (whole) Vegetable oil 20 g ► long life milk Mineral mix* 20 ml ► Watertomake 1000 ml 1000 ml** ► If you do not have cereal flour, or there are no cooking No cooking is ► facilities, use one of the following recipes for F-75: required for F-100: ► Alternatives Ingredient Amount for F-75 Amount for F-100 ► Dried skimmed milk 25 g 80 g ► If you have Sugar 100 g 50 g ► dried skimmed Vegetable oil 30 g 60 g ► milk Mineral mix* 20 ml 20 ml ► Watertomake 1000 ml 1000 ml** 1000 ml** ► Dried whole milk 35 g 110 g ► If you have Sugar 100 g 50 g ► dried whole Vegetable oil 20 g 30 g ► milk Mineral mix* 20 ml 20 ml ► Watertomake 1000 ml 1000 ml** 1000 ml** ► Fresh cow's milk, or full- 300 ml 880 ml ► If you have Cream (whole) long life milk ► fresh cow's Sugar 100 g 75 g ► milk, or full- Vegetable oil 20 g 20 g ► cream (whole) Mineral mix* 20ml 20ml ► long life milk Watertomake 1000 ml 1000 ml** 1000 ml**

Feeding phases:Feeding phases:

► Stabilizing phaseStabilizing phase ► this phase is from admission until the child is stable this phase is from admission until the child is stable

usually takes from 2-7 days .usually takes from 2-7 days .► If the child has oedema in this stage the child should If the child has oedema in this stage the child should

first drop in weight and then gradually rise after the first drop in weight and then gradually rise after the odema has begun to subside.odema has begun to subside.

► F-75 is given in this stageF-75 is given in this stage► Feeding is orally or by NG tube if the child cannot Feeding is orally or by NG tube if the child cannot

drinkdrink► Intake and output are recorded on a 24-hour food Intake and output are recorded on a 24-hour food

intake chart.intake chart.► Amount to give of F-75 is taken from WHO reference Amount to give of F-75 is taken from WHO reference

card.card.

► Transitional phase :Transitional phase :► This phase begins after the child is stabilized on F-75This phase begins after the child is stabilized on F-75► In this phase F-100 is startedIn this phase F-100 is started► Child is ready for transition when :Child is ready for transition when :

1- appetite returns ( easily finishes his feeds) 1- appetite returns ( easily finishes his feeds)

2- Reduced or minimal oedema2- Reduced or minimal oedema

In order to be moved to transitional stage the child must be In order to be moved to transitional stage the child must be stable taking orally without an NG tube and no I.V line.stable taking orally without an NG tube and no I.V line.

Transitional phase takes 3 days and weight is usually staticTransitional phase takes 3 days and weight is usually static

F-100 must be given slowly and gradually as follows :F-100 must be given slowly and gradually as follows :

For the first 48 hours give F-100 4 hourly in the same amount as For the first 48 hours give F-100 4 hourly in the same amount as you last you last

F-100 must be given slowly and gradually as follows :F-100 must be given slowly and gradually as follows :

For the first 48 hours give F-100 4 hourly in the same amount as For the first 48 hours give F-100 4 hourly in the same amount as you last gave F-75 you last gave F-75

Do not increase the amount for 2 daysDo not increase the amount for 2 days

Then on the 3Then on the 3rdrd day increase each feed by 10 ml as long as the day increase each feed by 10 ml as long as the child finishes his feeds continue to increase until some milk is child finishes his feeds continue to increase until some milk is left after most feeds.left after most feeds.

If the child is breastfeeding encourage breastfeeding between If the child is breastfeeding encourage breastfeeding between feedsfeeds

Monitor child carefully during transitionMonitor child carefully during transition

Record intake and output and plan feeding for next 24 hours.Record intake and output and plan feeding for next 24 hours.

► Rehabilitation phase :Rehabilitation phase : ( feed freely with F- ( feed freely with F-100)100)

► In this phase child can feed freely with F-100 In this phase child can feed freely with F-100 with an upper limit of 220 kcal/kg/day.with an upper limit of 220 kcal/kg/day.

► amount , minimums and maximums are amount , minimums and maximums are taken from the WHO- reference card for F-taken from the WHO- reference card for F-100.100.

► Use input/output 24 hour chart.Use input/output 24 hour chart.

Daily care of the malnourished child on Daily care of the malnourished child on the malnutrition ward:the malnutrition ward:

► This includes :This includes :► 1- Preparing and maintaing a weight chart1- Preparing and maintaing a weight chart► 2- Caring for the skin and bathing .2- Caring for the skin and bathing .► 3- Giving prescribed antibiotics and other 3- Giving prescribed antibiotics and other

medications and supplementsmedications and supplements► 4- Caring for eyes4- Caring for eyes► 5- Monitoring pulse,RR,Temp and watching 5- Monitoring pulse,RR,Temp and watching

for danger signsfor danger signs

Care for skin and bathingCare for skin and bathing::

► Bath children daily unless the are very ill.Bath children daily unless the are very ill.► If the child has severe (+++) dermatosis bath for 10 If the child has severe (+++) dermatosis bath for 10

-15 min/day in 1% potassium permanganate solution.-15 min/day in 1% potassium permanganate solution.► If the child has severe (+++) dermatosis but is to If the child has severe (+++) dermatosis but is to

sick to be bathed dab 1% potassium permanganate sick to be bathed dab 1% potassium permanganate solution on the bad spots and dress oozing areas solution on the bad spots and dress oozing areas with gauze to keep clean.with gauze to keep clean.

► If potassium permanganate is not available gentian If potassium permanganate is not available gentian violet can be used.violet can be used.

► Napkin dermatitis is treated with nyastatin oinment Napkin dermatitis is treated with nyastatin oinment and diapers left off and area kept dry.and diapers left off and area kept dry.

► Always dry child after bath and keep warm.Always dry child after bath and keep warm.

Supplements:Supplements:

► Folic acid: Folic acid: ► it is given as one single it is given as one single

dose on the day of admission 5 dose on the day of admission 5 mg and then on discharge.mg and then on discharge.

► Vitamin A:Vitamin A:

timingtiming ageage DosageDosageAll childrenAll children Day 1Day 1 <6 months<6 months

6-12 months6-12 months

> 12 months> 12 months

50.000 IU50.000 IU

100.000 IU100.000 IU

200.000 IU200.000 IU

Only children Only children with eyes signs with eyes signs or recent or recent measlesmeasles

Day 2 and Day 2 and

DAY 15DAY 15SAMESAME SAMESAME

► First dose of vitamin A is given by I.M and the rest orally.First dose of vitamin A is given by I.M and the rest orally.► Multivitamins:Multivitamins:► if CMV is used in preparing feeds then there will be no if CMV is used in preparing feeds then there will be no

need for multivitamins if not give multivitamin drops daily (not need for multivitamins if not give multivitamin drops daily (not including iron)including iron)

If the child has worms give the appropriate drugsIf the child has worms give the appropriate drugs

After two days of F-100 give iron daily.After two days of F-100 give iron daily. Weight of childWeight of child Dose of ferrous sulphateDose of ferrous sulphate

3 – 6 kg3 – 6 kg 0.5 ml0.5 ml

6-10 kg6-10 kg 0.75 ml0.75 ml

10 -15 kg10 -15 kg 1 ml1 ml

► Care for the eyes:Care for the eyes:

If the child hasIf the child has thenthen

Bitot’s spots onlyBitot’s spots only No eye drops neededNo eye drops needed

Pus or inflammationPus or inflammation Give chloramphenicol or Give chloramphenicol or tetracycline eye dropstetracycline eye drops

Corneal clouding orCorneal clouding or

Corneal ulcerationCorneal ulcerationGive bothGive both

Chloramphenicol or tetracycline aChloramphenicol or tetracycline a

andand

Atropine eye dropsAtropine eye drops

Doses:Chloramphenicol or tetracycline: 1 drop 4 times dailyAtropine : I drop 3 times daily.

On the ward monitor pulse, RR, temperature and On the ward monitor pulse, RR, temperature and WATCH for danger signs:WATCH for danger signs:

Danger signDanger sign suggestssuggests

Pulse and RRPulse and RR Confirmed increase in Confirmed increase in pulse rate of 25 or pulse rate of 25 or more per minute + more per minute + increase in RR of 5 increase in RR of 5 breaths per minute.breaths per minute.

Infection Infection

oror

Heart failure( possibly Heart failure( possibly from overhydration from overhydration due to feeding or due to feeding or rehydrating too fast)rehydrating too fast)

RR onlyRR only Fast breathing :Fast breathing :

50 /min or more in a 2 50 /min or more in a 2 month child up to 12 month child up to 12 monthsmonths

40 /min or more in a child 40 /min or more in a child 12 months up 5 years12 months up 5 years

PneumoniaPneumonia

TemperatureTemperature Any sudden increase Any sudden increase or decreaseor decrease

Rectal temp 35.5 CRectal temp 35.5 C

InfectionInfection

oror

HypothermiaHypothermia

Other Danger signs:Other Danger signs:

► Loss of appetiteLoss of appetite► Change in mental stateChange in mental state► JaundiceJaundice► CyanosisCyanosis► Difficult breathingDifficult breathing► Abdominal distentionAbdominal distention► New oedemaNew oedema► Increased vomitingIncreased vomiting► petechiaepetechiae

Providing continuing care at night:Providing continuing care at night:

► Night staff must :Night staff must :

keep each child covered to prevent hypothermia.keep each child covered to prevent hypothermia.

Feed each child according to schedule the night. Feed each child according to schedule the night.

this will involve gently waking the child to feed.this will involve gently waking the child to feed.

Take 4-hourly measurements of pulse , respirations Take 4-hourly measurements of pulse , respirations

and temperature.and temperature.

Watch carefully for danger signs and call a physician.Watch carefully for danger signs and call a physician.

Weigh the child daily and maintain weight Weigh the child daily and maintain weight chart:chart:

► Label the vertical axis of the graph with range of weights that Label the vertical axis of the graph with range of weights that includes the child’s starting weight and desired discharge includes the child’s starting weight and desired discharge weight.weight.

► Each horizontal line on the graph should represent a Each horizontal line on the graph should represent a difference of 0.1 kgdifference of 0.1 kg

► If the child has oedema label the axis so that the starting If the child has oedema label the axis so that the starting weight will be near the bottum but allow a little space for weight will be near the bottum but allow a little space for possible weight loss.possible weight loss.

► If the child has oedema allow more space for wegiht loss.If the child has oedema allow more space for wegiht loss.► Allow for up to :Allow for up to :

1 kg weight loss of mild(+) or moderate oedema (++)1 kg weight loss of mild(+) or moderate oedema (++)

2 kg weight loss if severe (+++) oedema (child <7kg)2 kg weight loss if severe (+++) oedema (child <7kg)

3 kg weight loss if severe (+++) oedema (child >7kg)3 kg weight loss if severe (+++) oedema (child >7kg)

► Mark the desired discharge weight with a horizontal line Mark the desired discharge weight with a horizontal line across the chart.across the chart.

► Each day , plot the child’s weight on the chart plot the starting Each day , plot the child’s weight on the chart plot the starting weight on day 1 then day 2 day 3 e.t.cweight on day 1 then day 2 day 3 e.t.c

► Connect the points for the daily weights to see the child’s Connect the points for the daily weights to see the child’s progressprogress

► Highlight the day of beginning F100 ( first day of transition)Highlight the day of beginning F100 ( first day of transition)

Mental stimulation:Mental stimulation:

► Malnourished children have a depressed mood and Malnourished children have a depressed mood and many of them may suffer from maternal deprivation many of them may suffer from maternal deprivation due to death or birth of a younger sibling.due to death or birth of a younger sibling.

► Emotional stimulation is very important after the Emotional stimulation is very important after the child is stabalized child is stabalized

► Playing sessions should be arranged to stimulate Playing sessions should be arranged to stimulate mental and emotional developmentmental and emotional development

► Mothers should join in this effortMothers should join in this effort► Involving the father is also very important as he Involving the father is also very important as he

plays a big role in the encoragement of the child plays a big role in the encoragement of the child and mother .and mother .

Educating mothers:Educating mothers:

► During the stay on the ward it is a chance to educate During the stay on the ward it is a chance to educate mothers on :mothers on :

► how to continue good care at home how to continue good care at home ► and how top prepare nourishing food from simple , affordable and how top prepare nourishing food from simple , affordable

and available ingredients and available ingredients ► importance of stimulating the child and improving their importance of stimulating the child and improving their

mental development by talking to and playing with the childmental development by talking to and playing with the child► Teaching the mother how to bath and feed the childTeaching the mother how to bath and feed the child► The importance of the routine vaccinations. The importance of the routine vaccinations. ► It is also recommended that nurses allow mother to help and It is also recommended that nurses allow mother to help and

participate in caring for the children on the wardparticipate in caring for the children on the ward

Discharge criteria:Discharge criteria:

► Child has reached his ideal weightChild has reached his ideal weight► Antibiotic treatment is finishedAntibiotic treatment is finished► The child is eating wellThe child is eating well► No signs of malnutritionNo signs of malnutrition► Mother has been trained on how to feed the child at home and Mother has been trained on how to feed the child at home and

give supplementsgive supplements► Danger signs have been explained to mother and she knows to Danger signs have been explained to mother and she knows to

return immediately if any appear.return immediately if any appear.► Arrangemnts have been made for support and follow-up.Arrangemnts have been made for support and follow-up.

A discharge card is given in which all information is A discharge card is given in which all information is recorded and child return for frequent visits to be recorded and child return for frequent visits to be checkedchecked..

Before and afterBefore and after

الحمدالله الحمدالله الحمدالله الحمدالله الحمدالله الحمداللهبه ابتالك مما عافانا الذى به الحمدالله ابتالك مما عافانا الذى الحمدالله

تفضيال عليك تفضيال وفضلنى عليك وفضلنى

►THANKYOUTHANKYOU