Title: Managing the malnourished child - a team approach -
1Managing the malnourished child - a team approach
-
- Dr E Malek
- Principal Specialist Senior Lecturer
- Witbank Hospital, University of Pretoria
2Outline
- 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
3Framework 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.
5Overview 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
7Recognising 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
8Assessing 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)
10Improving 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.)
11Potential team members
- Doctor
- Nurse
- Dietician
- Mother / care-giver
- Social worker
- Physio / O.T.
- Volunteers
- NGOs
12Case 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?
13Case 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?
14Case 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?
15Case 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?
16WHO 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
17WHO 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)
18WHO 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
19WHO 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
20WHO 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
21WHO 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 )
22WHO 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
23Time 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
25Dealing 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.
26Dealing 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
27Evaluating 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
28Methods
- 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 ()
30Duration of Attendance (months)
31Catch-up Growth at Outcome()
32Degree of Change (WAZ-score)
33The PEM Scheme for children problems
- limited human resource capacity
- lack of nutrition education
- no links to community-based programmes
- poor monitoring and evaluation
34Outcome 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
35Managing 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
36Severe MalnutritionBefore and After
37Conclusion
- 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 -
38Useful 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)