Severemalnutrition1 recognition andearlytreatment.

Mortalityinhospitalisoften30%

Objectives
Learntorecogniseseveremalnutrition LearntomanageALL theproblemspresentin thesechildren Understandnewapproachestofeedingand recognise i i itasthe h primary i treatment.

DefinitionsofSeverePEM(1)
WHOClassification:
+ Oedema <70% weight for height (WHZ <-3) Severe wasting g + oedema* No oedema

Severe wasting

* If there is severe oedema the weight may appear reasonable initially.

DefinitionsofSeverePEM(2)
WHOClassification:
+ Oedema <70% weight for height (WHZ <-3) Severe wasting + oedema oedema* No oedema

Severe wasting

Two simple signs are useful for classification

WeightforAge WAZ

WeightforAge WAZ(2)
Earlyoutpatient treatmentmay yhave preventedthisweight pattern Thisboynowhasa WAZmuch<3 Iftheboyisillandhas clinicalsignsofsevere malnutritionhemay needinpatient treatment

ClinicalDiagnosis Youmustlook!

Checklargemusclegroups Buttocksandthighs Shouldersandupperarms

Checktheseverityofoedema Feet knee, knee sacrum, sacrum face Feet, Oedema canmakeWAZlookOK

Kwashiorkor wherelogic g fails

Protein P t i deficiency Treatment with a high protein diet

Kwashiorkor wherelogic g fails

Protein P t i deficiency

Treatment g with a high protein diet

Severemalnutrition

Protein Energy Malnutrition

Severemalnutrition

Protein Energy Malnutrition

Electrolyte and mineral deficiencies

Micronutrient and Vitamin deficiencies

Electrolyte/MineralDeficiencies
Potassium:
Potassiumsupplementshelp reduce oedema

Magnesium Zinc Copper Selenium

PrepackagedF75andF100and R d to Ready t Use U Foods F d (RTUF)have h allthegoodones theydo notneedtobeadded

Thereistoomuch sodiumsosalty foodscanbe dangerous

Whatotherproblemsdothesechildren commonlyhave?

10StepApproach
Hypoglycaemia Hypothermia Monitoring g Dehydration Electrolytes Infection Micronutrients Initiate feeding g Catch-up growth Sensory stimulation Discharge preparation

HypoglycaemiaandHypothermia
Allnewadmissionswithmalnutrition p warmuntiltherearesigns g of shouldbekept recovery. ivorngtglucoseforthosewhoare unconsciousorveryseverelyillwithno glucosemeasurement. measurement Immediatengtfeedingforconscious childrenwithbloodglucose<3mmol/l

Dehydration
Sh Shock kis i treated dwith i hspecial i lfl fluid idplans l and d HalfStrengthDarrowswith5%dextrose. OralrehydrationiswithRESOMAL. Feeding gmustbeintroducedduring gthefirst 12hoursoftreatingdehydration.

OralrehydrationinSevereMalnutrition
Resomal5ml/kgevery30minsfor2hours
Simplifiedto10mls/kgeveryhour.

Useanngtearly. Then5 10mls/kgeachhourforamaximumof 10hours

Give10ifthechildthirsty/severedehydration, dehydration 5if not.

Introducestartermilk(F75)at4hoursandslowly replaceResomalwithstartermilkover12hours. hours Continuebreastfeedingthroughout.

Electrolytes&Minerals
Ifprepackaged k dF75/F100/RTUFareNOT available
Allshouldreceiveanextra4mmol/kg/dayoforal potassium (afterstoppingORS). AllshouldreceiveZincideallyaspartofmineral mixcontainingCu,Se,Mgetc

Infection
Upto1/3rd childrenwithmalnutritionwhodie havesepticaemia/bacteraemia Feverandothersignsofinfectionarenothelpful inidentifyinginfectioninthesechildren ALL sickchildrenwithseveremalnutritionin hospitalshouldbestartedonPenicillin(or Ampicillin)andGentamicin foratleast5days. days Inadditiontheyreceive:
Oralmetronidazole Treatmentforthrushifpresent TEOifthereareredeyes. y

VitaminAdeficiency

Vitamins
VitaminA:
WithEyesigns:200,000iuonadmission,onDay2 andonDay14(100 (100,000 000iuifaged<12months). months) WithoutEyesigns: statdoseappropriateforage

Multivitamins 1tablettwicedailyfor14days (ifnoprepackagedF75/F100/RTUF).

Questions?

Summary.
Theriskofdeathinchildrenwithsevere malnutritionisveryhigh. Thechildrenhavemanyproblemsandeach needstreating. The Th 10stepsapproach hallows ll each hproblem bl to betreated Feedingshouldnotbeahighproteindiet.