Malnutrition by Nadia Baasher

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Malnutrition by Nadia Baasher

  1. 1. Port Sudan Teaching Hospital Department of Pediatrics unit of Dr. Zeinab Gaily Recognizing and Managing severe malnutrition Prepared by Dr. Nadia Khalid Baasher
  2. 2. <ul><li>Malnutrition is the Impairment of physical and/or mental health resulting from a failure to fulfill nutrient requirements </li></ul><ul><li>Malnutrition may result from : </li></ul><ul><li>1- Consuming too little food. </li></ul><ul><li>2- A shortage of key nutrients </li></ul><ul><li>3- Impaired absorption or metabolism </li></ul><ul><li>due to disease. </li></ul>
  3. 3. <ul><li>Severe Malnutrition is one of the most common causes of morbidity and mortality among children under the age of 5 years worldwide. </li></ul><ul><li>Many children die at home without care , but even when hospital care is provided case fatality rates may be high. </li></ul>
  4. 4. <ul><li>Severely malnurourished children often die because doctors unknowingly use practices that are suitable for most children but highly dangerous for severely malnourished children. </li></ul><ul><li>With proper management in hospitals and follow up care the lives of many children can be saved . </li></ul>
  5. 5. Recognizing the signs of Severe Malnutrition <ul><li>Severe Wasting </li></ul><ul><li>Oedema </li></ul><ul><li>Dermatosis </li></ul><ul><li>Eye signs </li></ul><ul><li>Stunting </li></ul>
  6. 6. 1-Severe Wasting: <ul><li>A child with severe wasting has lost fat and muscle and appears like “ skin and bones “ (marasmus) </li></ul><ul><li>To look for severe wasting : </li></ul><ul><li>Remove the child’s clothes </li></ul><ul><li>Look at the front view of the child : </li></ul><ul><li>1 - is the outline of the child’s ribs easily seen. </li></ul><ul><li>2- Does the skin of the upper arms look loose. </li></ul><ul><li>3- Does the skin of the thighs look loose. </li></ul>
  7. 7. <ul><li>Look at the back view of the child : </li></ul><ul><li>1- Are the ribs and shoulder bone easily seen. </li></ul><ul><li>2- Is flesh missing from the buttocks. </li></ul><ul><li>When wasting is extreme there are folds of skin on the buttocks and thighs it looks like the child is wearing “baggy pants “ </li></ul><ul><li>When any of these signs are found in a child he is to be assessed for admition to the malnutrition ward. </li></ul>
  8. 9. Baggy pants sign:
  9. 11. 2-Oedema: <ul><li>To be considered a sign of severe malnutrition oedema must appear in both feet. </li></ul><ul><li>The extent of odema is rated as follows : </li></ul><ul><li>+ mild : both feet </li></ul><ul><li>++ moderate : both feet , plus lower legs , hands or lower arms </li></ul><ul><li>+++ Severe : Generalized Odema including both feet,hands,arms </li></ul><ul><li>and face. </li></ul><ul><li>When Oedema is found in a child he is to be assessed for admition to the malnutrition ward after exclusion of other causes of odema. </li></ul>
  10. 15. 3- Dermatosis: <ul><li>The extent of Dermatosis is described as follows: </li></ul><ul><li>+ mild : discoloration or a few rough patches of skin. </li></ul><ul><li>++ moderate : multiple patches on arms and/or legs. </li></ul><ul><li>+++ severe : flaking skin , raw skin , fissures. </li></ul>
  11. 16. flaking skin , raw skin , fissures
  12. 17. 4- Eye signs: <ul><li>Children with severe malnutrition may have signs of eye infection and/or vitamin A deficiency. </li></ul><ul><li>Eye signs are in the form of: </li></ul><ul><li>1- Pus and Inflammation : eye infection </li></ul><ul><li>2- Bitot’s spots : superficial foamy white spots on the conjunctiva (associated with vit A deficiency) </li></ul><ul><li>3- Corneal clouding : opaque appearance of the cornea </li></ul><ul><li>( sign of vit A deficiency) </li></ul><ul><li>4- Corneal ulceration : break in the surface of the cornea </li></ul><ul><li>this is caused by severe vit A deficiency it requires urgent treatment as it may lead to blindness </li></ul>
  13. 18. : Inflammation of the eye
  14. 19. Bitot’s spots Bitot’s spots
  15. 20. Corneal clouding
  16. 21. Corneal ulceration
  17. 23. 5-Stunting: <ul><li>Stunting is unusually low height or length for age , often due to chronic malnutrition. </li></ul><ul><li>Stunted children should be managed in the community rather than in the hospital </li></ul>
  18. 24. This 5 year old child was severly malnourished althought recoverd but has stunted growth
  19. 26. Weigh and measure the child: <ul><li>In addition to looking for the visible signs of severe malnutrition it is important to weigh and measure the child </li></ul><ul><li>The child’s weight-for-height is then compared to averages. </li></ul><ul><li>Measure length using measuring board </li></ul><ul><li>Measure height using stadiometer </li></ul><ul><li>Two people should work together to measure the child properly </li></ul><ul><li>Weigh the child on scales after removing clothing </li></ul><ul><li>Scales and Stadiometers must be standardized daily to ensure accuracy . </li></ul>
  20. 33. Determine standard deviation score(SD-score) based on child’s weight and height/length : <ul><li>SD-score is a way of comparing a measurement, in this case it compares a child’s weight-for-length to an ‘average” </li></ul><ul><li>Average is provided by the WHO normalized reference values for weight-for height and weight for length. </li></ul><ul><li>SD-score are interpreted as follows : </li></ul><ul><li>-1 SD approximately corresponds to 90% of the median weight-for-height . </li></ul><ul><li>-2SD approximately corresponds to 80% of the median weight-for height. </li></ul><ul><li>-3SD approximately corresponds to 90% of the median weight-for height. </li></ul>
  21. 34. Recommended criteria for admission to a severe malnutrition ward: <ul><li>Weight – for – Height less than -3SD </li></ul><ul><li>(less than 70%) </li></ul><ul><li>and/ or </li></ul><ul><li>Odema of both feet </li></ul>
  22. 35. How does the physiology of malnutrition affect the care of the child: <ul><li>The child with severe malnutrition must be treated differently because his physiology is seriously abnormal due to reductive adaptation . </li></ul><ul><li>What is reductive adaptation ? </li></ul><ul><li>With severe malnutrition the body systems begin to “ shut down” and do less in order to allow survival on limited calories. This slowing down is known as reductive adaptation. </li></ul><ul><li>As the child is treated the body systems must gradually “ learn “ to function fully again </li></ul><ul><li>Rapid changes (such as rapid feeding of fluids) will overwhelm the systems . So feeding must be slowly and cautiously increased. </li></ul>
  23. 36. Important implications of management based on reductive adaptation <ul><li>1- Presume and treat infection: </li></ul><ul><li>Nearly all children with severe malnutrition have bacterial infections. </li></ul><ul><li>However due to reductive adaptation the usual signs of infection may be no apparent , because the body does not use the limited energy to respond in the usual ways such as inflammation or fever. </li></ul><ul><li>Examples of common infections in severely malnourished children: </li></ul><ul><li>Pneumonia </li></ul><ul><li>UTI </li></ul><ul><li>Otitis media </li></ul><ul><li>Assume that infection is present and treat all severe malnutrition admissions with broad spectrum antibiotics. </li></ul>
  24. 37. 2- Don’t give Iron early in treatment: <ul><li>Due to reductive adaptation , the severely malnourished child makes less hemoglobin . </li></ul><ul><li>Iron that is not used for making hemoglobin is put into storage. </li></ul><ul><li>Thus there is an ‘extra’ iron storage in the body even though the child may appear anemic </li></ul><ul><li>Giving iron early in treatment will lead to “ Free Iron “ in the body . </li></ul>
  25. 38. <ul><li>Free iron can cause : </li></ul><ul><li>Free iron gives free radicals which cause damaging chemical reactions. </li></ul><ul><li>Free iron promotes bacterial growth making infections worse. </li></ul><ul><li>Body tries to protect itself from free iron by converting it to ferritin the energy used in this conversion is diverted from other critical activities. </li></ul><ul><li>Later as the child recovers and begins to build new tissue and form more RBCs , the iron in storage will be used and supplements will be needed </li></ul>
  26. 39. 3-Provide K+ and restrict Na+: <ul><li>Due to reductive adaptation Na+ - K+ pump becomes slower as a result the level of Na+ in cells increases and K+ leaks out of the cells and is lost . </li></ul><ul><li>Fluid may accumulate outside of the cells (odema) </li></ul><ul><li>All severely malnourished children should be given K+ to make up for what is lost </li></ul><ul><li>They should also be given Magnesium which is essential for potassium to enter the cells and be retained </li></ul><ul><li>Sodium should be restricted. </li></ul><ul><li>If there diarrhea a special rehydration fluid called ReSoMal should be used instead of ORS it has less sodium and more potassium than ORS. </li></ul>
  27. 40. Initial care of the severely malnourished child: <ul><li>This includes : </li></ul><ul><li>Management of hypoglycemia. </li></ul><ul><li>Management of hypothermia. </li></ul><ul><li>Management of shock in the severely malnourished child. </li></ul><ul><li>Management very severe anaemia. </li></ul><ul><li>Management of watery diarrhea and vomiting with ReSoMal </li></ul><ul><li>Management of corneal ulceration </li></ul><ul><li>Selecting antibiotics . </li></ul><ul><li>The focus of initial management is to prevent death while stabilizing the child. </li></ul>
  28. 41. 1-Manegment of hypoglycemia: <ul><li>Hypoglycemia is low level of blood glucose. </li></ul><ul><li>In severely malnourished children the level considered low is <3mmol/L (<54mg/dl) </li></ul><ul><li>Signs of hypoglycemia include : </li></ul><ul><li>Lethargy </li></ul><ul><li>Limpness </li></ul><ul><li>Loss of consciousness </li></ul><ul><li>Sweating and pallor may not occur </li></ul><ul><li>Often the only sign before death is drowsiness </li></ul><ul><li>The hypoglycemic child is usually hypothermic. </li></ul>
  29. 43. Test blood glucose If not low > Or = 54mg/dl If low < 54md/dl Start F75 immediately To prevent hypoglycemia Give glucose to treat hypoglycemia
  30. 44. Treatment of hypoglycemia: <ul><li>If blood glucose is low or hypoglycemia is suspected immediately give a 50 ml bolus of Glucose 10% </li></ul><ul><li>If the child can drink give the 50 ml bolus orally if the child is alert but is not drinking give the 50 ml bolus by NG tube. </li></ul><ul><li>If the child is lethargic, unconscious or convulsing give 5ml/kg body weight of glucose 10% I.V followed by 50 ml by NG tube. </li></ul><ul><li>if the child is going to be given I.V fluids for shock there is no need for the NG bolus. </li></ul><ul><li>Start feeding with F75 half an hour after giving Glucose and give it every half an hour for the first 2 hours </li></ul><ul><li>The amount of F75 for a hypoglycemic child is ¼ of the 2 hourly amount shown on the table. </li></ul>
  31. 45. 2- Management of hypothermia: <ul><li>Hypothermia is low body temperature </li></ul><ul><li>The severely malnourished child is hypothermic if rectal temperature is <35.5 C or if the axillary temperature is < 35C </li></ul><ul><li>Hypothermia is very dangerous and rewarming is essential. </li></ul><ul><li>The following measures are essential for all malnourished children to prevent hypothermia : </li></ul><ul><li>cover the child including the head. </li></ul><ul><li>Move the child away from the window </li></ul><ul><li>Maintain a room temperature of 25-30 C </li></ul><ul><li>Warm hands before touching the child </li></ul><ul><li>Promptly change wet clothes of bedding </li></ul><ul><li>Dry the child well after bathing </li></ul>
  32. 46. Active re-warming of the hypothermic child: <ul><li>Re-warming techniques include: </li></ul><ul><li>Kangaroo technique : in which the mother holds the child with his skin next to her skin and cover the child, keep the child’s head cover. </li></ul><ul><li>Use a heater or incandescent lamp caution . </li></ul><ul><li>Monitor rectal temperature every 30 mins to make sure the child does not get too hot. </li></ul><ul><li>Do NOT use hot water bottles due to danger of burning fragile skin. </li></ul>
  33. 47. Kangaroo technique:
  34. 50. Managing the severely malnourished child with shock : <ul><li>The severely malnourished child is considered in shock if he/she is : </li></ul>Is lethargic or unconscious Has cold extremities Has slow capillary refill (longer than 3 seconds) Weak rapid pulse Hypovolemic shock and septic shock usually coexist in severely Malnourished children They may be difficult to differentiate Hypovolemic shock will respond to fluid replacement septic shock will not
  35. 51. 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
  36. 52. Fluid replacement in the shocked severely malnourished child: <ul><li>To give I.V fluids : </li></ul><ul><li>Check the starting RR and Pulse . </li></ul><ul><li>Infuse 15ml/kg over one hour of Ringer’s Lactate </li></ul><ul><li>Monitor RR and Pulse every 10 minutes </li></ul><ul><li>If RR and Pulse rate increase stop the i.v fluids </li></ul><ul><li>If RR and Pulse are slower after one hour are slower and the child is improving repeat the same amount of i.v fluids for another hour with Monitoring of RR and Pulse every 10 minutes. </li></ul><ul><li>After 2 hours of i.v fluids switch to oral or NG rehydration with ReSoMal give 5-10 ml /kg in alternate hours with F75 up to 10 hours. </li></ul>
  37. 53. If no improvement with i.v fluids give blood transfusion: <ul><li>Blood transfusion in severely malnourished children is can only be given on day 1 of admission and then not until day 14 </li></ul><ul><li>If the child fails to improve after i.v fluids for one hour then assume septic shock </li></ul>
  38. 54. Give maintenance i.v fluids 4ml/kg/hour while waiting for the blood If there are NO signs of heart failure If there are signs of heart failure give whole blood 10 ml/kg slowly over 3 hours give packed cells 10 ml/kg slowly over 3 hours diuretics should be given to make room for the blood 1 mg/kg i.v before and after transfusion no diuretic is given. how Blood transfusion is done? If there are NO signs of heart failure give whole blood 10 ml/kg slowly over 3 hours If there are NO signs of heart failure diuretics should be given to make room for the blood 1 mg/kg i.v before and after transfusion give whole blood 10 ml/kg slowly over 3 hours If there are NO signs of heart failure
  39. 56. Emergency eye care: <ul><li>1- Examine the eyes : </li></ul><ul><li>Wash your hands , touch the eyes extremely gently and as little as possible , wash your hands again after examining eyes. </li></ul><ul><li>2- Give vitamin A and atropine drops immediately for corneal ulceration: </li></ul><ul><li>Vit A </li></ul>100 000 IU 6 – 12 months 200 000 IU > 12 months 50.000 IU < 6 months Vit A Oral dose Child’s age
  40. 57. <ul><li>If the child is severely ill and anorexic and cannot take orally give vit A I.M the dosage is 100.000 IU except for children under 6 months give 50.000 IU. </li></ul><ul><li>Instill one drop of 1% of atropine drops to relax the eyes. </li></ul><ul><li>Tetracycline eye drops and bandaging are also needed. </li></ul><ul><li>To bandage eyes : </li></ul><ul><li>1- Wash hands. </li></ul><ul><li>2- Soak eye pads with saline. </li></ul><ul><li>3- Place a pad over each affected eye. </li></ul><ul><li>4- Wrap gauze bandage over the pads. </li></ul>
  41. 59. Managing watery diarrhea and or vomiting with ReSoMal: <ul><li>ReSoMal ( Rehydration Solution for Malnutrition) </li></ul><ul><li>ReSoMal is a modification of ORS </li></ul><ul><li>ReSoMal contains less sodium , more sugar and more potassium. </li></ul><ul><li>It should be given by mouth of NG tube. </li></ul><ul><li>Do NOT ORS to a severely malnourished child. </li></ul>Contents of ReSoMal as prepared from standard ORS Water 2 liters WHO- ORS one packet Sugar 50 g Mineral mix solution 40 ml
  42. 61. 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
  43. 62. Calculating the amount of ReSoMal: 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 stool For children 2 years and older give 100 – 200 ml after each loose stool 5 – 10 ml/kg Alternate hours for up to 10 hours 5 ml/kg Every 30 mins for the first 2 hours Amount to give How often to give ReSoMal
  44. 63. Monitoring the child who is taking ReSoMal: <ul><li>ReSoMal should be given slowly orally or by NG tube. </li></ul><ul><li>Signs to check when monitoring the child : </li></ul>Respiratory rate Pulse rate Urine output Stool and vomit frequency Signs of hydration
  45. 64. Signs of overhydration: Rapid and marked increase in Pulse rate and RR Jugular vein engorgement Increasing edema
  46. 65. Important thing NOT to do in the initial management of a severely malnourished child: <ul><li>Do not give diuretics to treat odema </li></ul><ul><li>Do not give iron during the initial phase </li></ul><ul><li>Do not give high protein formula </li></ul><ul><li>Do not give I.V fluids routinely </li></ul>
  47. 66. Selecting antibiotics: Chloramphenicol i.v or i.m 25mg/kg every 8 hours for 5 days. If the child fails to improve within 48 hrs add Gentamicin i.v or i.m (7.5mg/kg) once daily for 7 days + Ampicillin i.v or i.m(25mg/kg) every 6 hours for 2 days followed by Amoxicillin orally 15mg/kg every 8 hours for 5 days Complications ( shock . Hypoglycemia , dermatosis +++ , respiratory or urinary tract infection ) Cotrimoxazole orally(25 mg sulfamethoxazole + 5mg trimethoprim/ kg) Every 12 hours for 5 days orally No Complications GIVE: IF:
  48. 67. Feeding formulas and feeding phases: <ul><li>Types of Feeding formulas : </li></ul><ul><li>These are F-75 and F-100 </li></ul>Given because severely malnourished children can not tolerate high amounts of protein and fat at this stage. It contains 100 kacl and 2.9 g protein per 100 ml It contains 75 kcal and 0.9 g protein per 100 ml Catch-up formula used to rebuild wasted tissues. Given starting from transitional phase Starter formula used during the stabilizing phase 2-7 days F-100 F-75
  49. 68. <ul><li>If you have cereal flour and cooking facilities, use one of </li></ul><ul><li>the top three recipes for F-75: </li></ul><ul><li>Alternatives Ingredient Amount for F-75 </li></ul><ul><li>Dried skimmed milk 25 g </li></ul><ul><li>If you have Sugar 70 g </li></ul><ul><li>dried skimmed Cereal flour 35 g </li></ul><ul><li>Milk Vegetable oil 30 g </li></ul><ul><li>Mineral mix* 20ml </li></ul><ul><li>Water to make 1000 ml 1000 ml** </li></ul><ul><li>Dried whole milk 35 g </li></ul><ul><li>If you have Sugar 70 g </li></ul><ul><li>dried whole Cereal flour 35 g </li></ul><ul><li>milk Vegetable oil 20 g </li></ul><ul><li>Mineral mix* 20 ml </li></ul><ul><li>Water to make 1000 ml 1000 m/** </li></ul><ul><li>Fresh cow's milk, or full- 300ml </li></ul><ul><li>If you have Cream (whole) long life milk </li></ul><ul><li>fresh cow's Sugar 70 g </li></ul><ul><li>milk, or full- Cereal flour 35 g </li></ul><ul><li>cream (whole) Vegetable oil 20 g </li></ul><ul><li>long life milk Mineral mix* 20 ml </li></ul><ul><li>Water to make 1000 ml 1000 ml** </li></ul><ul><li>If you do not have cereal flour, or there are no cooking No cooking is </li></ul><ul><li>facilities, use one of the following recipes for F-75: required for F-100: </li></ul><ul><li>Alternatives Ingredient Amount for F-75 Amount for F-100 </li></ul><ul><li>Dried skimmed milk 25 g 80 g </li></ul><ul><li>If you have Sugar 100 g 50 g </li></ul><ul><li>dried skimmed Vegetable oil 30 g 60 g </li></ul><ul><li>milk Mineral mix* 20 ml 20 ml </li></ul><ul><li>Water to make 1000 ml 1000 ml** 1000 ml** </li></ul><ul><li>Dried whole milk 35 g 110 g </li></ul><ul><li>If you have Sugar 100 g 50 g </li></ul><ul><li>dried whole Vegetable oil 20 g 30 g </li></ul><ul><li>milk Mineral mix* 20 ml 20 ml </li></ul><ul><li>Water to make 1000 ml 1000 ml** 1000 ml** </li></ul><ul><li>Fresh cow's milk, or full- 300 ml 880 ml </li></ul><ul><li>If you have Cream (whole) long life milk </li></ul><ul><li>fresh cow's Sugar 100 g 75 g </li></ul><ul><li>milk, or full- Vegetable oil 20 g 20 g </li></ul><ul><li>cream (whole) Mineral mix* 20ml 20ml </li></ul><ul><li>long life milk Water to make 1000 ml 1000 ml** 1000 ml** </li></ul>
  50. 69. Feeding phases: <ul><li>Stabilizing phase </li></ul><ul><li>this phase is from admission until the child is stable usually takes from 2-7 days . </li></ul><ul><li>If the child has oedema in this stage the child should first drop in weight and then gradually rise after the odema has begun to subside. </li></ul><ul><li>F-75 is given in this stage </li></ul><ul><li>Feeding is orally or by NG tube if the child cannot drink </li></ul><ul><li>Intake and output are recorded on a 24-hour food intake chart. </li></ul><ul><li>Amount to give of F-75 is taken from WHO reference card. </li></ul>
  51. 71. <ul><li>Transitional phase : </li></ul><ul><li>This phase begins after the child is stabilized on F-75 </li></ul><ul><li>In this phase F-100 is started </li></ul><ul><li>Child is ready for transition when : </li></ul><ul><li>1- appetite returns ( easily finishes his feeds) </li></ul><ul><li>2- Reduced or minimal oedema </li></ul><ul><li>In order to be moved to transitional stage the child must be stable taking orally without an NG tube and no I.V line. </li></ul><ul><li>Transitional phase takes 3 days and weight is usually static </li></ul><ul><li>F-100 must be given slowly and gradually as follows : </li></ul><ul><li>For the first 48 hours give F-100 4 hourly in the same amount as you last </li></ul>
  52. 73. <ul><li>F-100 must be given slowly and gradually as follows : </li></ul><ul><li>For the first 48 hours give F-100 4 hourly in the same amount as you last gave F-75 </li></ul><ul><li>Do not increase the amount for 2 days </li></ul><ul><li>Then on the 3 rd day increase each feed by 10 ml as long as the child finishes his feeds continue to increase until some milk is left after most feeds. </li></ul><ul><li>If the child is breastfeeding encourage breastfeeding between feeds </li></ul><ul><li>Monitor child carefully during transition </li></ul><ul><li>Record intake and output and plan feeding for next 24 hours. </li></ul>
  53. 74. <ul><li>Rehabilitation phase : ( feed freely with F-100) </li></ul><ul><li>In this phase child can feed freely with F-100 with an upper limit of 220 kcal/kg/day. </li></ul><ul><li>amount , minimums and maximums are taken from the WHO- reference card for F-100. </li></ul><ul><li>Use input/output 24 hour chart. </li></ul>
  54. 76. Daily care of the malnourished child on the malnutrition ward: <ul><li>This includes : </li></ul><ul><li>1- Preparing and maintaing a weight chart </li></ul><ul><li>2- Caring for the skin and bathing . </li></ul><ul><li>3- Giving prescribed antibiotics and other medications and supplements </li></ul><ul><li>4- Caring for eyes </li></ul><ul><li>5- Monitoring pulse,RR,Temp and watching for danger signs </li></ul>
  55. 77. Care for skin and bathing : <ul><li>Bath children daily unless the are very ill. </li></ul><ul><li>If the child has severe (+++) dermatosis bath for 10 -15 min/day in 1% potassium permanganate solution. </li></ul><ul><li>If the child has severe (+++) dermatosis but is to sick to be bathed dab 1% potassium permanganate solution on the bad spots and dress oozing areas with gauze to keep clean. </li></ul><ul><li>If potassium permanganate is not available gentian violet can be used. </li></ul><ul><li>Napkin dermatitis is treated with nyastatin oinment and diapers left off and area kept dry. </li></ul><ul><li>Always dry child after bath and keep warm. </li></ul>
  56. 79. Supplements: <ul><li>Folic acid: </li></ul><ul><li>it is given as one single dose on the day of admission 5 mg and then on discharge. </li></ul><ul><li>Vitamin A: </li></ul>SAME SAME Day 2 and DAY 15 Only children with eyes signs or recent measles 50.000 IU 100.000 IU 200.000 IU <6 months 6-12 months > 12 months Day 1 All children Dosage age timing
  57. 80. <ul><li>First dose of vitamin A is given by I.M and the rest orally. </li></ul><ul><li>Multivitamins: </li></ul><ul><li>if CMV is used in preparing feeds then there will be no need for multivitamins if not give multivitamin drops daily (not including iron) </li></ul><ul><li>If the child has worms give the appropriate drugs </li></ul><ul><li>After two days of F-100 give iron daily. </li></ul>1 ml 10 -15 kg 0.75 ml 6-10 kg 0.5 ml 3 – 6 kg Dose of ferrous sulphate Weight of child
  58. 81. <ul><li>Care for the eyes: </li></ul>Doses: Chloramphenicol or tetracycline: 1 drop 4 times daily Atropine : I drop 3 times daily. Give both Chloramphenicol or tetracycline a and Atropine eye drops Corneal clouding or Corneal ulceration Give chloramphenicol or tetracycline eye drops Pus or inflammation No eye drops needed Bitot’s spots only then If the child has
  59. 82. On the ward monitor pulse, RR, temperature and WATCH for danger signs: suggests Danger sign Infection or Hypothermia Any sudden increase or decrease Rectal temp 35.5 C Temperature Pneumonia Fast breathing : 50 /min or more in a 2 month child up to 12 months 40 /min or more in a child 12 months up 5 years RR only Infection or Heart failure( possibly from overhydration due to feeding or rehydrating too fast) Confirmed increase in pulse rate of 25 or more per minute + increase in RR of 5 breaths per minute. Pulse and RR
  60. 83. Other Danger signs: <ul><li>Loss of appetite </li></ul><ul><li>Change in mental state </li></ul><ul><li>Jaundice </li></ul><ul><li>Cyanosis </li></ul><ul><li>Difficult breathing </li></ul><ul><li>Abdominal distention </li></ul><ul><li>New oedema </li></ul><ul><li>Increased vomiting </li></ul><ul><li>petechiae </li></ul>
  61. 84. Providing continuing care at night: <ul><li>Night staff must : </li></ul><ul><li>keep each child covered to prevent hypothermia. </li></ul><ul><li>Feed each child according to schedule the night. </li></ul><ul><li>this will involve gently waking the child to feed. </li></ul><ul><li>Take 4-hourly measurements of pulse , respirations </li></ul><ul><li>and temperature. </li></ul><ul><li>Watch carefully for danger signs and call a physician. </li></ul>
  62. 85. Weigh the child daily and maintain weight chart: <ul><li>Label the vertical axis of the graph with range of weights that includes the child’s starting weight and desired discharge weight. </li></ul><ul><li>Each horizontal line on the graph should represent a difference of 0.1 kg </li></ul><ul><li>If the child has oedema label the axis so that the starting weight will be near the bottum but allow a little space for possible weight loss. </li></ul><ul><li>If the child has oedema allow more space for wegiht loss. </li></ul><ul><li>Allow for up to : </li></ul><ul><li>1 kg weight loss of mild(+) or moderate oedema (++) </li></ul><ul><li>2 kg weight loss if severe (+++) oedema (child <7kg) </li></ul><ul><li>3 kg weight loss if severe (+++) oedema (child >7kg) </li></ul>
  63. 86. <ul><li>Mark the desired discharge weight with a horizontal line across the chart. </li></ul><ul><li>Each day , plot the child’s weight on the chart plot the starting weight on day 1 then day 2 day 3 e.t.c </li></ul><ul><li>Connect the points for the daily weights to see the child’s progress </li></ul><ul><li>Highlight the day of beginning F100 ( first day of transition) </li></ul>
  64. 87. Mental stimulation: <ul><li>Malnourished children have a depressed mood and many of them may suffer from maternal deprivation due to death or birth of a younger sibling. </li></ul><ul><li>Emotional stimulation is very important after the child is stabalized </li></ul><ul><li>Playing sessions should be arranged to stimulate mental and emotional development </li></ul><ul><li>Mothers should join in this effort </li></ul><ul><li>Involving the father is also very important as he plays a big role in the encoragement of the child and mother . </li></ul>
  65. 90. Educating mothers: <ul><li>During the stay on the ward it is a chance to educate mothers on : </li></ul><ul><li>how to continue good care at home </li></ul><ul><li>and how top prepare nourishing food from simple , affordable and available ingredients </li></ul><ul><li>importance of stimulating the child and improving their mental development by talking to and playing with the child </li></ul><ul><li>Teaching the mother how to bath and feed the child </li></ul><ul><li>The importance of the routine vaccinations. </li></ul><ul><li>It is also recommended that nurses allow mother to help and participate in caring for the children on the ward </li></ul>
  66. 94. Discharge criteria: <ul><li>Child has reached his ideal weight </li></ul><ul><li>Antibiotic treatment is finished </li></ul><ul><li>The child is eating well </li></ul><ul><li>No signs of malnutrition </li></ul><ul><li>Mother has been trained on how to feed the child at home and give supplements </li></ul><ul><li>Danger signs have been explained to mother and she knows to return immediately if any appear. </li></ul><ul><li>Arrangemnts have been made for support and follow-up. </li></ul><ul><li>A discharge card is given in which all information is recorded and child return for frequent visits to be checked . </li></ul>
  67. 95. Before and after
  68. 96. الحمدالله الحمدالله الحمدالله الحمدالله الذى عافانا مما ابتلاك به وفضلنى عليك تفضيلا <ul><li>THANKYOU </li></ul>

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