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Managing the malnourished child - a team approach -

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Factors affecting growth, extent of problem. Recognition and severity assessment. Managing the 'tip' of the ice-berg ... Gabriela Mistral - Useful Resources ... – PowerPoint PPT presentation

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Title: Managing the malnourished child - a team approach -


1
Managing the malnourished child - a team approach
-
  • Dr E Malek
  • Principal Specialist Senior Lecturer
  • Witbank Hospital, University of Pretoria

2
Outline
  • Introduction
  • Factors affecting growth, extent of problem
  • Recognition and severity assessment
  • Managing the tip of the ice-berg
  • WHO management guidelines (10 steps)
  • Complications, Case studies
  • Dealing with the hidden problem
  • Short-term, Long-term

3
Framework for the promotion, achievement,
and maintenance of optimal nutritional status
Growth development
Manifestations
Adequate Psychosocial dietary well
being Health intake
Immediate determinants
Household Food Security
Health Services
Adequate care of children and women
Health
Underlying determinants
EDUCATION
Potential resources
Source UNICEF
4

Kwashiorkor
  • the child that has lost its peace.

5
Overview of childhood malnutrition in South
Africa
  • One in four (23) children are stunted (SAVACG
    study, 1994)
  • One in ten (9) children are underweight
  • One in three (33) children have a marginal
    Vitamin A status
  • One in five (21) children are anaemic

6
Extent of malnutrition
Tip of the ice-berg severe malnutrition Below
the surface mild to moderate malnutrition

7
Recognising the malnourished child
  • Risk factors
  • Growth monitoring Road to Health Card
  • Feeding history
  • Clinical signs early wasting, anemia, etc.
  • Identifying early wasting wall charts, MUAC

8
Assessing the degree of severity (Integrated
Management of Childhood Illness)
  • Visible severe wasting
  • Oedema of both feet
  • Severe palmar pallor
  • Low weight
  • Weight gain unsatisfactory
  • Some palmar pallor

9
Malnourished children in hospital (Mpumalanga
Audit 2000 26 hospitals)
  • Nutrition feeding practices in wards
  • no WFA charts/assessment, RTHC not used
  • breast/f promotion hampered by bottles teats
  • no snacks between meals for infants lt2 years
  • no meals at night for malnourished children
  • inconsistent lodger mother policies, no
    facilities
  • Treatment guidelines
  • National pediatric EDL IMCI other (local)

10
Improving the management of malnourished children
in hospital
  • WHO guidelines for management of children with
    severe malnutrition in district hospitals
  • Mount Frere Model Integrated Nutrition Project
    (Prof David Sanders)
  • Incorporated WHO guidelines above within a policy
    implementation cycle (hospital nutrition team,
    record reviews, patient care observations, case
    fatality rates, staff training, audit, etc.)

11
Potential team members
  • Doctor
  • Nurse
  • Dietician
  • Mother / care-giver
  • Social worker
  • Physio / O.T.
  • Volunteers
  • NGOs

12
Case Study 1
  • Themba, 11 month old boy
  • Swelling of body and face, lethargic
  • Abandoned by mother, brought in by grandmother
    RTHC not available
  • Admitted to the ward with kwashiorkor
  • How would you manage this child for the first 72
    hours?

13
Case Study 2
  • Gugu, 6 month old girl
  • Admitted to the ward with kwashiorkor
  • Cold extremitries, subnormal temperature
  • Doctor prescribes treatment, feeds and orders
    child to be kept warm
  • On review next day, chart shows subnormal
    temperature between 05h00 and 08h00.
  • How can you prevent this problem?

14
Case study 3
  • Zandile, 18 month old girl
  • Admitted to ward with kwashiorkor
  • Doctor prescribes IV antibiotics, fortified milk
    feeds, oral potassium and Vitamin A
  • Dietician is consulted
  • No weight change over the following 3 days
  • How would you approach this problem?

15
Case Study 4
  • Siphiwe, 15 month old girl
  • Admitted to ward with kwashiorkor G/E
  • Had been diagnosed and admitted 1 month prior for
    kwashiorkor, ?no follow-up date
  • Doctor prescribes feeds, antibiotics, etc.
  • Hypoglycemia is noted on chart review
  • How would you manage this patient?

16
WHO Guidelines management of severe malnutrition
(PEM)
  • Organisation of care
  • Proper triage
  • Stabilisation and rehabilitation
  • Prevent and treat hypoglycemia
  • Prevent and treat hypothermia
  • Treat dehydration
  • Treat electrolyte imbalance
  • Treat micronutrient deficencies
  • Initial refeeding
  • Catch-up growth
  • Stimulation support
  • Prepare for follow-up
  • Monitor and audit

17
WHO organisation of care
  • Admit mother/carer
  • Team involvement
  • Ward care hi-care bed
  • 2-3 hourly monitoring and feeding (72 hours)
  • Keep warm (KMC, adjust routines eg. bathing time)

18
WHO triage and resuscitation
  • Screen children for signs of severe PEM
  • Assess dehydration in malnourished children using
    additional signs
  • Children wth kwashiorkor and marasmus must be
    given IV fluid with caution

19
WHO Stabilisation phase
  • Hypoglycaemia (prevent, monitor treat)
  • 2-3 hourly fortified milk feeds (60-130ml/kg/d)
  • Hypothermia (prevent, monitor and treat)
  • 3 hly temp, warm skin-to-skin, use hat, no baths
  • Dehydration (prevent and treat)
  • Treat shock cautiously, rehydrate orally
  • Suspect and treat infection
  • Assume infection, give broad spectrum antibiotics
  • Monitor appetite, weight if not better, change
    antibiotics after 48 hours

20
WHO Stabilisation phase (cont.)
  • Correct electrolyte imbalances
  • Hypokalemia oral K, if Klt2.5, add IV KCl (!)
  • Hyponatremia do not give Na supplements
  • Treat micronutrient deficiencies
  • Vit A stat reduces morbidity and mortality
  • Multivitamins, Zink sulphate, Phosphate, Folic
    acid, copper
  • Give Fe later once infection is controlled

21
WHO Stabilisation phase (cont.)
  • Initial Refeeding
  • Frequent small feeds orally/nasogastrically
  • 100 kcal/kg/day protein 101.5g/kg/day
    liquid100- 130ml/kg/day
  • Monitor
  • 3 hourly temperature and dextrostix for first 72
    hours
  • Daily weight (same conditions)
  • Audit outcome
  • Weight gain (good gt10g/kg/day), mortality ( lt5 )

22
WHO Rehabilitation phase
  • Catch-up growth
  • Return of appetite then gradual transition
  • Frequent feeds, up to 200ml/kg/day (!)
  • 150-200 kcal/kg/day protein 4-6 gram/kg/day
  • Stimulation and support
  • Visual and emotional stimulation
  • Social support child care grant application,
    etc.
  • Prepare for follow-up
  • Follow IMCI feeding recommendations

23
Time frame for the management of a child with
severe malnutrition Stabilization Rehabilitat
ion Days 1-2 Days 3-7 Weeks 2-6 1.
Hypoglycaemia 2. Hypothermia 3.
Dehydration 4. Electrolytes 5. Infection 6.
Micronutrients no iron
with iron 7.
Initiate feeding 8. Catch up growth 9.
Sensory stimulation 10. Prepare for
follow-up Source WHO
24
Extent of malnutrition
Tip of the ice-berg severe malnutrition Below
the surface mild to moderate malnutrition

25
Dealing with the ice-berg
  • Underlying issues poverty, female literacy
  • Public health education feeding rec.s
  • Disease prevention/early intervention (HIV)
  • Timely treatment of illness (IMCI), regular
    growth assessment (RTHC), nutrit. counselling
  • Health worker access, skill and attitude
  • Support household food security/grants/etc
  • Advocacy eg. BFHI, Code of Conduct, etc.

26
Dealing with the ice-berg (cont.)
  • Short term programs
  • Relief feeding PEM Scheme? food parcels?
  • Identifying those most in need - WFH vs WFA
  • Long term initiatives
  • Multi-secoral approach ?NPA PPA (National and
    Prov-incial Programs of Action for Children)
  • Community upliftment

27
Evaluating the PEM Scheme
  • To review the PEM Scheme in relation to the
    Integrated Nutrition Programme, with special
    emphasis on
  • a) its potential for impacting on
    anthropometric measurements
  • b) current implementation in the Mitchells
    Plain district
  • c) implications for nutrition policy

28
Methods
  • Clinic record review (3/95-3/96)
  • Analysis of anthropometric data
  • Staff interviews and observation
  • Policy review

29
Results (n 831) Weight for Age
at Entry ()
30
Duration of Attendance (months)
31
Catch-up Growth at Outcome()
32
Degree of Change (WAZ-score)
33
The PEM Scheme for children problems
  • limited human resource capacity
  • lack of nutrition education
  • no links to community-based programmes
  • poor monitoring and evaluation

34
Outcome of PEM Scheme
  • Can effect catch-up growth
  • Restructuring of the PEM Scheme is essential
  • Recommendations for policy review
  • Practical strategies have been recommended to
    implement revised policy

35
Managing the malnourished child a team
approach...

Growth development
Manifestations
Adequate Psychosocial dietary well
being Health intake
Immediate determinants
Household Food Security
Health Services
Adequate care of children and women
Health
Underlying determinants
EDUCATION
Potential resources
Source UNICEF
36
Severe MalnutritionBefore and After

37
Conclusion
  • Many things we need can wait. The Child cannot.
    Right now is the time his bones are
    being formed, his blood is being made and his
    senses are being developed. To him we cannot
    answer Tomorrow. His name
    is Today.
  • - Gabriela Mistral -

38
Useful Resources
  • WHO IMCI Manual Management of the child with a
    serious infection or severe malnutrition
  • WHO Website (IMCI) http/www.who.int/child-adoles
    cent-health
  • IMCI charts also available on UP Intranet
    (www.ais.up.ac.za) at UpeXplore (Academic Info
    Services Course IMCI)
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