Adapted IMNCI malnutrition 2020
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Diagnosis and Management of children with Malnutrition with reference to IMNCI (Integrated Management of Neonatal and Childhood Illness)
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Adapted IMNCI malnutrition 2020
- 1. Adapted A practical approach to the child with Malnutrition Background, Assessment and Management Prof. Imran Iqbal Prof of Paediatrics (2003-2018) Prof of Pediatrics Emeritus, CHICH Prof of Pediatrics, CIMS Multan, Pakistan
- 3. IMNCI A Strategy for Outpatient Case Management of Children under five years of age
- 4. Step 1 General Danger Signs Check for General Danger Signs in all Children General Danger Signs indicate severe disease Presence of any one of the General Danger Signs means that the child needs to be referred / admitted to the emergency
- 5. Check for General Danger Signs • Unable to drink or breastfeed • Vomiting everything • Lethargic or unconscious • Convulsions • General Danger Signs indicate severity of illness • Not diagnostic but suggests acuity of situation
- 6. Step 2 Assess for Cough or Difficult Breathing Ask the mother: Does the Child have Cough
- 7. Step 3 Assess for Diarrhoea Ask the mother: Does the Child have Diarrhea
- 8. Step 4 Assess for Sore Throat Ask the mother: Does the Child have Sore Throat
- 9. Step 5 Assess for Ear Problem Ask the mother: Does the Child have Ear Problem
- 10. Step 6 Assess for Fever Ask the mother: Does the Child have Fever
- 11. Step 7 Assess for Malnutrition Assess all children for Malnutrition
- 12. What is Malnutrition ?
- 13. Nutritional status Nutritional status is determined by balance of Nutritional Intake and Nutritional Expenditure NUTRITIONAL INTAKE NUTRITIONAL EXPENDITURE NUTRITIONAL STATUS
- 14. What is Malnutrition ? • Malnutrition is a Pathological State resulting from Deficiency of One or More Essential Nutrients • Protein – Calorie Malnutrition (PCM / PEM) • Severe Acute Malnutrition (SAM) • Specific Micronutrient deficiency - Vit A deficiency immunodeficiency - Vit D deficiency Rickets - Iron deficiency anemia - Iodine deficiency goitre
- 15. Clinical Types of Malnutrition Previous terminology (clinical picture) • Marasmus • Kwashiorkor • Marasmic Kwashiorkor New terminology (Weight, Height, MUAC measurements) • Low weight • Stunting • Wasting • MAM (moderate acute malnutrition) • SAM (severe acute malnutrition)
- 16. Growth Charts (Weight for Age)
- 17. Growth Charts (Weight for Length / Height)
- 18. Weight for Height Reference Tables
- 19. Normal Anthropometric Measurements • Weight – more than – 2 z-score (> 80 % of mean or expected for age) • Length / Height – more than – 2 z-score (> 80 % of mean or expected for age) • Mid arm circumference (MUAC) – 125 mm to 160 mm (at 6 months to 5 years of age)
- 20. Clinical types of Malnutrition • Underweight child – Weight for Age less than – 2 z-score (< 80 % of mean or expected for age) • Wasting – Low Weight for Height (indicates acute malnutrition) • Stunting – Low Height for Age (indicates chronic malnutrition)
- 22. Moderate Acute Malnutrition (MAM) (Presence of any of the following) • Weight for Height < -2 z-score (< 80 %) • MUAC < 125 mm
- 23. Severe Acute Malnutrition (SAM) (Presence of any of the following) • Weight for Height < -3 z-score (< 70 %) • MUAC < 115 mm • Edema
- 24. Severe Acute Malnutrition • Age = 11 months • Length = 70 cm • Weight = 5.5 kg ( - 4 SD)
- 25. Epidemiology
- 26. Prevalence of Malnutrition under 5 years of age National Nutrition Survey – 2018
- 27. Contribution of Malnutrition in Child Deaths
- 28. Causes of Malnutrition in Pakistan
- 29. Nutrition Causal Framework Adapted from Unicef Outcome Under-Nutrition Immediate Causes Inadequate Dietary Intake Disease Underlying Health / Nutrition Causes Inadequate Care for Mothers and Children Insufficient Access to Food Lack of health services & unhealthy environment
- 30. Causes of Malnutrition in Pakistan LOW INTAKE (underfeeding) + RECURRENT INFECTIONS
- 32. Reductive adaptation •Smaller size •Thinness •Smaller organs •Reduced immunity
- 33. Physiological Effects of Malnutrition • Cardiovascular - ↓ cardiac output and stroke volume • GI - ↓ absorption of nutrients • Renal - ↓ glomerular filtration • Immune - ↓ immunoglobulins, ↓ cell-mediated immunity • Liver - ↓ glycogen, Hypoglycemia • Endocrine - ↓ insulin levels • Cellular function - ↑ permeability of cell membranes • Temperature regulation - ↓ BMR, Hypothermia • Skin, muscles, glands – atrophy, muscle fatigue
- 34. Acute Complications • Acute infections – Diarrhea, pneumonia, • Hypoglycemia • Hypothermia • Dehydration • Electrolyte deficiency – K+
- 35. Chronic Complications • Chronic infection e.g T.B • Malabsorption / Chronic diarrhea • Anemia • Vitamin Deficiencies • Growth retardation • Learning disorders ( low IQ)
- 37. WHO IMNCI Assessment and Management
- 38. Assess and Classify Malnutrition • Edema feet • Weight for Height / Length (determine z-score as per chart or table) • MUAC (age > 6 months) • Medical complications (extensive infections, severe dehydration, severe anemia, hypothermia / high fever, hypoglycemia, lethargy, convulsions, severe vomiting • Anorexia
- 39. No Acute Malnutrition • Wt for Ht > - 2 z-score (> 80 % ) • MUAC > 125 mm • Compliment the mother • Give Feeding advice • Micronutrients if needed
- 40. MAM - Moderate Acute Malnutrition • Wt for Ht between – 3 and – 2 z-score (70 - 80 % ) • MUAC = 115 - 125 mm • Assess the Child Feeding • Give Feeding advice • Micronutrients
- 41. SAM - Severe Acute Malnutrition • Wt for Ht less than – 3 z-score (less than 70 % ) • MUAC = less than 115 mm • Edema (nutritional cause) • No Medical Complications • No Anorexia - Able to feed adequately • Assess the Child Feeding • Give Feeding advice • Micronutrients • Give Therapeutic Feeds (RUTF)
- 42. Severe Acute Malnutrition with complications • SAM + Medical complications (acute illness / poor appetite / severe edema) • Admit / Refer for Inpatient care • Admit in Stabilization Centre (SC) • Manage according to Guidelines • Phase I (Stabilization) • Phase II (Rehabilitation)
- 43. Principles in Management of Malnutrition • Treat Acute complications - hypothermia, hypoglycemia, dehydration, diarrhea, infection • Adequate diet which the child can digest (150 – 200 calories / kg / day) • Micronutrients ( Vitamin A ) • Growth monitoring (assess weight daily or weekly) • Follow-up (monthly to prevent relapse)
- 44. Time frame for the management of a child with severe malnutrition Stabilization Rehabilitation 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
- 45. ReSoMal (Rehydration Solution for Malnutrition) • Sodium Chloride 1.75 gm • Sodium Citrate 1.45 gm • Potassium Chloride 2.54 gm • Potassium Citrate 0.65 gm • Magnesium Chloride 0.61 gm • Zinc Acetate 0.0656 gm • Copper Sulphate 0.0112 gm • Glucose 10 gm • Sucrose 25 gm
- 46. Therapeutic diets given in SAM • Mother milk • F – 75 diet (milk, sugar, vegetable oil, water) - 75 calories / 100ml • F – 100 diet (milk, sugar, vegetable oil, water) - 100 calories / 100ml • RUTF (Ready to use therapeutic food) • Semisolid and solid home foods which the child can take easily (e.g. blended egg, rice, banana, potato)
- 47. Recipe for F-75 and F-100 Alternatives Ingredient Amount for F-75 Amount for F-100 Dried whole Milk Dried whole milk sugar vegetable oil Mineral mix* water to make 1000ml 35 g 100 g 20 g 20 ml 1000 ml** 110 g 50 g 30 g 20 ml 1000 ml** Fresh cow’s Milk Fresh Cow’s milk, or full cream (whole) long life milk sugar vegetable oil Mineral mix* water to make 1000 ml 300 ml 100 g 20 g 20 ml 1000 ml** 880 ml 75 g 20 g 20 ml 1000 ml**
- 48. 48 Composition of RUTF (supplied by Unicef) • Peanuts (ground into a paste) • Vegetable oil • Powdered sugar • Powdered milk • Vitamin and mineral mix (special formula)
- 49. Recovery from SAM • WEIGHT GAIN should be 5 – 10 gm / kg / day • Child is considered to be recovered when – 1 SD weight for length / height (90 % of expected weight for length / height) has been achieved
- 50. Hifsa’s journey from malnutrition to health
- 52. PREVENTION OF MALNUTRITION • Nutrition education • Adequate feeding and diet • Growth monitoring • Protection against infections
- 53. Adequate feeding and diet • Breast feeding for 2 Yrs • Weaning at 4 – 6 months • Adequate diet for children • Feeding during illness
- 54. Growth Monitoring • Weigh the baby/ child every month upto five years of age • Plot the weight on the Growth chart • Ensure that the weight is increasing normally
- 55. Protection against Infections • Vaccination • Handwashing • Use Masks • Social distancing • Breastfeeding • Adequate Nutrition • Micronutrients • Safe water • Clean food