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Management of Severe Malnutrition

Time frame for the management of the child with severe malnutrition
Stabilization 10 STEPS Days 1-2 Days 3-7 Weeks 2-6 Rehabilitation

1. Hypoglycemia 2. Hypothermia 3. Dehydration 4. Electrolytes 5. Infection 6. Micronutrients 7. Initial feeding 8. Catch-up growth 9. Sensory stimulation 10. Prepare for follow-up

no iron

with iron

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STEP 1

HYPOGLYCEMIA
Is quick blood glucose test (e.g. Dextrostix) available? YES NO Hypoglycemia* Assume that the child has hypoglycemia

Blood glucose normal

* < 3 mmol/l or < 54 mg/dl ** 1 teaspoon of sugar in 31/2 tablespoons water

Is the child conscious? YES Give: First feed of F-75 or: 50 ml of 10% glucose orally or: 50 ml of sucrose solution** NO (unconscious)

Give: i.v. 10% glucose 5ml/kg or: 50 ml of 10% glucose by NGT or: 50 ml of sucrose solution by NGT REPEAT TEST AFTER 30 MINUTES

STEP 2

HYPOTHERMIA
Is thermometer available? YES NO HYPOTHERMIA* Assume the child has hypothermia

NORMAL

* Axillar temperature < 35C or: Rectal temperature < 35,5C

Child clothed (including head) - Warm blanket Place a heater or lamp nearby or: Put the child on bare chest or abdomen of the mother (skin-to-skin) cover them with warm blanket and/or warm clothing Monitor temperature every 2 hour until it increases more than 36.5C or: Every hour if a heater is being used

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STEP 3

DEHYDRATION

It is difficult to estimate dehydration status accurately in a severely malnourished child

Is the child suffering from watery diarrhea? YES Assume the child may has some dehydration Give: ReSoMal by oral or NGT - 5 ml/kg/30 minutes for first 2 hours - 5-10 ml/kg/hour for the next 4-10 hours Rehydration is still occurring at 6 and 10 hours Give: F-75 instead of ReSoMal use the same volume of F-75 as for ReSoMal NOTE: Do not use i.v. route for rehydration EXCEPT in cases of shock Overhydration may lead to heart failure check: - respiratory rate increases by 5/minute - pulse rate increases by 15/minute Stop ReSoMal immediately and reasses after 1 hour NO

STEP 4

ELECTROLYTES

All severely malnourished children have deficiencies of potassium and magnesium takes 2 weeks or more to correct Do not treat edema with a diuretics Excess body sodium exists even though the plasma sodium may be low GIVING HIGH SODIUM LOADS COULD KILL THE CHILD! Give: -Extra potassium (3-4 mmol/kg/daily) -Extra magnesium (0.4-0.6 mmol/kg/daily) The extra potassium and magnesium should be added to the feeds during their preparation

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STEP 5

INFECTION

All severely malnourished children should be assumed have infection during their arrival in hospital

Are there complications (hypoglycemia, hypothermia or the child looks lethargic or sickly)? NO YES Ampicillin 50 mg/kg/i.m./i.v. 6 hourly 2 days + gentamicin 7.5 mg/kg/i.m./i.iv. once daily 2 days Improvement? YES NO Continue ampicillin and Gentamicin until 7 days Add: Chloramphenicol: 25 mg/kg/i.m./i.v. 8 hourly 5 days

Cotrimoxazole: 4 mg TMP + 20 mg SMX/kg 2 times/daily - 5 days

NOTE Check for meningitis, malaria, tuberculosis pneumonia, dysentery, skin infection

Terapi diet gizi buruk

Gangguan organ-organ (hati, usus, ginjal) Infeksi, bakteri tumbuh lampau di usus Anoreksia Makanan dengan kandungan protein, besi, dan natrium rendah Mudah dicerna Kaya kalium dan magnesium Bukan untuk pertumbuhan

Resintesis enzim Metabolisme membaik Edema menghilang Proses fisiologis mulai normal Nafsu makan membaik Energi dan protein lebih padat Fortifikasi vitamin dan mineral Promosi pertumbuhan

F-75

F-100

Golden MH. Evolution of nutritional management of acute malnutrition. Indian Pediatr 2010;47:667-78.

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Terapi diet gizi buruk

F-100

Sebenarnya ada masalah fungsi tubuh yang tidak disadari oleh dokter: Kemampuan ginjal belum baik Intoleransi glukose Sekresi insulin belum normal Fungsi imunitas masih jelek Pompa natrium belum baik Konsentrasi elektrolit intraselular belum terkoreksi Komposisi tubuh masih belum ideal terutama pertumbuhan otot

Berat badan bertambah Panjang/ tinggi badan bertambah

Dokter puas

Zinc
Golden MH. Evolution of nutritional management of acute malnutrition. Indian Pediatr 2010;47:667-78.

STEP 6

MICRONUTRIENTS INITIAL FEEDING

Give daily for at least two weeks: a multivitamin supplement folic acid 5 mg on day 1, then 1 mg/day zinc 2 mg Zn/kg/day copper 0.3 mg/kg/day once gaining weight, ferrous sulfate 3 mg/kg/day vitamin A orally (aged < 6 mo: 50000 IU, aged 6 mo 12 months: 100.000 IU, older children 200.000 UI 20,.000 daily) on day 1

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STEP 7

INITIAL FEEDING

All severely malnourished children have vitamin and mineral deficiencies

Essential features of initial feeding are: 1. Frequent small feeds 2. Oral or nasogastric tube (never parenteral preparation ) 3. 100 kcal/kg/day 4. Protein 1-1.5 g/kg/day 5. Liquid: 130 ml/kg/day (100 ml/kg/day if the child has severe edema) 6. If the child is breastfed, continue with this, but make sure the prescribed amounts of starter formula are given Days 1-2 3-5 6 onwards Frequency 2-hourly 3-hourly 4-hourly Vol/kg/feed 11 ml 16 ml 22 ml Vol/kg/day 130 ml 130 ml 130 ml

STEP 8

CATCH-UP GROWTH

Signs that a child has reached this phase are: return of appetite most/all of the edema has gone

Replace F-75 with an equal amount of catch-up F-100 for 2 days The increase each successive feed by 10 ml until some feed remains uneaten After a gradual transition give: frequent feeds, unlimited amounts 150-220 kcal/kg/day 4-6 g of protein/kg/day Assess progress: poor: < 5 g/kg/day requires a full re-assessment moderate: 5-10 g/kg/day check whether the intake targets are being met, or infection has been overlooked good: > 10 g/kg/day

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STEP 9

SENSORY STIMULATION

Provide: tender loving care a cheerful stimulating environment structured play therapy for 15-30 minutes a day physical activity as soon as the child is well enough maternal involvement as much as possible (e.g. comforting, feeding, bathing, play)

STEP 10

PREPARE FOR FOLLOW-UP

A child who is 90% weight for length (equivalent to 1 SD) can be considered to have recovered The child is still likely to have a low weight for age because of stunting

Show the parents how to: feed frequently with energy-rich and nutrient-dense foods give structured play therapy ask the parents to bring the child back for regular follow-up (at 1, 2 and 4 weeks, then monthly for 6 months) and make sure the child receives booster immunizations and 6-monthly vitamin A

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TREATMENT OF ASSOCIATED CONDITION: EYE PROBLEM

VITAMIN A DEFICIENCY Vitamin A on days 1, 2, and 14 CORNEAL CLOUDING or ULCERATION Chloramphenicol or Tetracycline eye drops 4 times a day 7-10 days Atropine eye drops 1 drop 3 times a day 3-5 days Cover with saline-soaked eye pads Bandage Note Examine the eyes gently to prevent rupture

TREATMENT OF ASSOCIATED CONDITION: SEVERE ANEMIA

BLOOD TRANSFUSION Hb is <4g/dl or 4-6 g/dl and the child with repiratory distress Whole blood 10 ml/kg slowly over 3 hours Furosemide 1 mg/kg iv at the start of transfusion

Pack red cell 10 ml/kg if child has hart failure Monitor pulse and breathing rate every 15 minutes during transfusion If breathing increases by 5 breath/minute or pulse by 25 beats/minute transfuse more slowly
Note If Hb is still low do not repeat the transfusion within 4 days Kwashiorkor may indicate redistribution of fluid leading to apparent low Hb which does not require transfusion

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TREATMENT OF ASSOCIATED CONDITION: SKIN LESION

Bath or soak the affected areas for 10 minutes/day in 0.01% potassium permanganat solution Apply barrier cream (zinc and castor oil ointment or petroleum jelly or tulle gras) to the aw areas Apply gentian violet or nystatin cream to the skin sores Omit using nappies/diapers so that the perineum can stay dry

TREATMENT OF ASSOCIATED CONDITION: CONTINUING DIARRHEA

GIARDIASIS Metronidazole 7.5 mg/kg 8 hourly for 7 days LACTOSE INTOLERANCE Substitute milk feeds with yoghurt or lactose free infant formula Reintroduce milk feeds gradually in the rehabilitation phase OSMOTIC DIARRHEA Use a lower osmolar cereal-based starter F-75 Introduce catch-up F-100 gradually