Management of Malnutrition in Children 2019

1. Management of
Malnutrition
in children
Prof. Imran Iqbal
Prof of Paediatrics (2003-2018)
Prof of Pediatrics Emeritus, CHICH
Multan, Pakistan

2. In the name of Allah,
the most gracious, the most merciful.

4. MALNUTRITION
IS A PATHALOGICAL STATE
RESULTING FROM
DEFICIENCY OF
ONE OR MORE
ESSENTIAL NUTRIENTS

5. ACUTE COMPLICATIONS
1. Acute infections –
Diarrhea, pneumonia,
2. Hypoglycemia
3. Hypothermia
4. Dehydration
5. Electrolyte deficiency – K+

6. CHRONIC COMPLICATIONS
1. Chronic infection e.g T.B
2. Chronic diarrhea
3. Malabsorption
4. Anemia
5. Vitamin Deficiencies
6. Growth retardation
7. Learning disorders ( low IQ)

7. Management of Malnutrition

8. Management of Malnutrition
• Adequate calories
• Micronutrients
• Growth monitoring
• Follow-up

9. PRINCIPLES of Management
Assessment
- Severity and type of malnutrition
- Any complications
- Associated deficiencies
- Epidemiological factors
Hospital treatment
- Severe and complicated malnutrition
Home treatment
- Severe malnutrition--uncomplicated cases
- Moderate malnutrition

10. CMAM
Community-based
Management
of
Acute Malnutrition

11. Community Mobilization
Supplementary Feeding
Programme (SFP)
Outpatient Therapeutic
Programme (OTP)
Stabilization centers (SC)

12. Programme Approach
Community-based Management of Acute Malnutrition (CMAM)
CMAM has four components:
• Community mobilization (for early detection & referral of the
malnourished, follow up at home, and prevention activities)
• Supplementary Feeding Program (SFP) to treat moderate
acute malnutrition (MAM) -
• Outpatient Therapeutic Program (OTP) to treat severe acute
malnutrition without medical complications
• Inpatient care or Stabilization Centre (SC) to treat severe acute
malnutrition with medical complications

13. Community-based Management of Acute Malnutrition
(CMAM)
Community mobilization
(Lady Health Workers)
• Early detection
• Referral of the malnourished child
• Follow up at home
• Prevention activities

14. Community-based Management of Acute Malnutrition
(CMAM)
Supplementary Feeding Program (SFP)
(MAM) moderate acute malnutrition
•Feeding advice
•Micronutrients

15. Community-based Management of Acute Malnutrition
(CMAM)
Outpatient Therapeutic Program
(OTP)
Severe Acute Malnutrition without
medical complications
• Feeding advice
• RUTF (ready to use therapeutic
food)

16. Community-based Management of Acute Malnutrition
(CMAM)
Stabilization Centre
(SC)
Inpatient care to treat severe acute
malnutrition with
• Medical complications
• Anorexia
• Severe edema
• Severe wasting and edema

17. Medical Complications
• extensive infections,
• severe dehydration,
• severe anaemia,
• hypothermia / high fever
• hypoglycaemia
• lethargy
• convulsions
• severe vomiting

18. Uncomplicated
OPD assessment
• Wt and Ht
• MUAC
• Medical
Assessment
• Appetite
Assessment

19. Triage for SAM
• Once the diagnosis of SAM has been
made:
Assess medical complications:
– accurate medical history
– thorough medical examination
Appetite test:
- able to finish one-third of RUTF sachet
16-Jun-19 19

20. Triage for SAM
• Decide outpatient or inpatient care:
• Inpatient treatment (any of the following):
– Bilateral pitting oedema (+++)
– A combination of oedema and wasting
– SAM with poor appetite (failed appetite
test)
– SAM with medical complications
16-Jun-19 20

21. MAM
Moderate Acute Malnutrition
Wt for Ht 70 – 80 %
• Supplementary Feeding program
(SFP)
• Feeding advice
• Micronutrients (Sprinkles sachet)

22. SAM
Severe Acute Malnutrition
Wt for Ht < 70 %
OR MUAC < 11.5
OR Edema (nutritional cause)
• Outpatient Therapeutic Feeding
Program (OTP)
• RUTF (Ready to use Therapeutic Food)

23. Severe Acute Malnutrition
with complications
SAM + complications
acute illness / poor appetite / severe edema
• Stabilization Centre (SC) Inpatient
care
• Phase I (Stabilization)
• Phase II (Rehabilitation)

24. Severe Acute Malnutrition

25. 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

26. 1-2.Treat/prevent hypothermia and hypoglycemia (which are often related) by feeding, keeping warm, and
treating infection
3. Treat/prevent dehydration using Rehydration Solution for Malnutrition (Resomal).
4. Correct electrolyte imbalance (by giving feeds and ReSoMal prepared with mineral mix or CMV).
5. Presume and treat infections with antibiotics.
6. Correct micronutrient deficiencies (by giving feeds prepared with mineral mix or CMV and by giving extra
vitamins and folic acid as needed).
7. Start calculating feeding with F-75 to stabilize the child (usually 2-7 days).
8. Rebuild wasted tissues through higher protein/caloric feeds (F-100).
9. Provide stimulation, play and loving care.
10. Prepare parents to continue proper feeding and stimulation after discharge.

27. Initial Management
• Hypoglycemia
• Hypothermia
• Shock
• Very severe anaemia
• Corneal ulceration
• Watery diarrhea and /or vomiting
• Prepare Re So Mal
• Appropriate antibiotics
• Record initial findings and treatments

28. HYPOGLYCEMIA
• RBS less than 54mg/dl (< 3 mmol / L) is
hypoglycemia
• Signs of hypoglycemia
– Lethargy
– Hypothermia
– Loss of consciousness

29. Hypoglycemia is a sign of infection
• Hypoglycemia is due to:
• Infrequent feeding
• Vomiting
• Reluctance to feed due to infection
• If no glucometer available presume
hypoglycemia and treat

30. MANAGEMENT of HYPOGLYCEMIA
• Check blood sugar
• If blood sugar is < 54mg.dl (< 3 mmol / L) give 50 ml
of 10% glucose orally
• Give by N-G if cannot take orally
• If child drowsy give 5 ml/kg of 10% glucose by IV
followed by 50 ml of 10% glucose by N-G.
• START FEEDING f-75 every half hour for 2 hours
• Give ¼ of the 2 hourly feed every half hour.
• Check blood sugar after 2 hours
• If >54 mg/dl (> 3 mmol / L) give F-75 every 2 hours
• If < 54 mg/dl (< 3 mmol / L) keep giving F-75 every
half hour for 2 hours

31. HYPOTHERMIA
• Rectal temperature <35.5 °C or 95.9 °F or
• Axillary temperature <35 °C or 95.0 °F
• Hypothermia is a sign of serious infection
• Hypothermic children should be treated for
infection and hypoglycemia

32. MANAGEMENT OF HYPOTHERMIA
• Cover the child including his head
• Keep windows closed
• Maintain room temperature of 25-30 °C
• Change wet clothes immediately
• Avoid leaving child uncovered during
examination and weighing
• Warm your hands before examining the child
• Monitor temperature ½ hourly till normal

33. Rewarming the hypothermic child
• Heater or warmer can be used
• Skin to skin contact with mother
• Blankets to cover the child
• Head covered with a cap
• Do not use hot water bottles

34. SHOCK
• Lethargic or unconscious
• Cold hands
• Slow capillary refill (>3 seconds)
• Weak or fast pulse
• Shock can be due to dehydration or sepsis
• Difficult to differentiate
• Children with dehydration respond to IV
fluids
• Those with sepsis and no dehydration do not
respond to IV fluids

35. Treatment of shock
• Give oxygen
• Give 5 ml/kg of 10% glucose IV
• Keep child warm
• Give IV fluids

36. IV FLUIDS for SHOCK
• Check respiratory and heart rate and record
• Give D-Ringer’s lactate or 5% ½ strength normal saline 15
ml/kg over 1 hour
• Monitor heart rate & respiratory rate every 10 minutes
• Stop IV if RR & HR increase
• At the end of 1 hour if RR & HR decreased, repeat 15 ml/kg
over next 1 hour with monitoring of HR & RR
• At the end of 2 hrs start Resomal
• If child fails to improve after 1 hour give 10 ml/kg of fresh
blood over 2 hours
• Give lasix with blood
• Give IV fluids 4 ml/kg/hr while blood is being arranged
• At the end of blood transfusion start oral fluids i.e. Resomal
as above

37. ANAEMIA
• Haemoglobin < 4 mg/dl is very severe
anaemia
• Very severe anaemia leads to heart failure
• It requires a transfusion
• Mild to moderate anaemia should be treated
after the 1st week with Iron

38. Treatment of Very Severe Anaemia
• Stop oral intake and IV fluids
• Look for signs of heart failure
• If there are signs of heart failure give 5-7
ml/kg of packed cells in 3 hours
• If no heart failure give 10 ml/kg of fresh
blood in 3 hours
• Give diuretic lasix 1 mg/kg by IV

39. CORNEAL ULCERATION
• It is a break in the surface of the cornea
• Can lead to extrusion of lens and blindness
• Child has photophobia

40. CORNEAL ULCERATION
• Give first dose of vitamin A immediately
• Oral dose is
50,000 IU for <6 months
100,000 IU for children 6-12 month
200,000 IU for <12 months
• Instill one drop of 1% atropine to relax the eye
• It prevents extrusion of lens
• Put tetracycline eye drops and bandage the eye

41. DIARRHOEA AND DEHYDRATION
• Difficult to assess dehydration in a
malnourished child
• History of vomiting diarrhea if present,
assume dehydration
• Assess for dehydration even through signs
are misleading
• Disappearance of these signs on dehydration
indicate improvement

42. Signs of dehydration
• Lethargy
• Restlessness, irritability
• Sunken eyes
• Absent tears
• Dry mouth & tongue
• Thirst
• Skin pinch goes back slowly

43. RE SO MAL
• Modified oral rehydration solution for
severely malnourished children
• Has less sodium, more sugar and more
potassium
• Standard ORS should not be used in severely
malnourished
• If Re So Mal not available prepare from
standard ORS

44. 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

45. ORS, low osmolar ORS and ReSoMal
Amount in 1 litre ORS Low Osmolality
ORS
ReSoMal
Sodium Chloride 3.5 gm 2.6 gm 1.75 gm
Sodium Citrate 2.9 gm 2.9 gm 1.45 gm
Potassium Chloride 1.5 gm 1.5 gm 2.54 gm
Potassium Citrate 0.65 gm
Magnesium Chloride 0.61 gm
Zinc Acetate 0.656 gm
Copper Sulphate 0.0112gm
Glucose 20 gm 13.5 gm 10 gm
Sucrose 25 gm
Osmolality 311 245 300

46. ORS, low osmolar ORS and ReSoMal
mmol / litre ORS Low Osmolality
ORS
ReSoMal
Sodium 90 75 45
Potassium 20 20 40
Chloride 80 65 70
Citrate 10 10 7
Magnesium 3
Zinc 0.3
Copper 0.045
Glucose 111 75 125
Osmolality 311 245 300

47. Preparation of Re So Mal
• take 1 packet of standard ORS packet
• pour into a container that holds more than 2 liters
• Add 40 meq of kcl
• measure and add 50 gms of sugar
• measure and add 2 liters cooled boiled water
• stir
• use within 24 hours

48. How often and how much to give?
• 5 ml/kg of Re So Mal every 30 minutes for 2
hours, 5-10 ml/kg every alternate hour for 10
hours (if child not in shock)
• Omit first 2 hours treatment if patient has
received treatment for shock
• If child too sick feed through N-G feed

49. Monitoring when taking Re So Mal
• Check respiratory rate
• Check pulse rate
• Ask about urine frequency
• Number of vomiting
• Ask about stool frequency
• Assess signs of dehydration

50. Phases of Treatment
• Stabilization Phase Day 1 – 2
• Transition Phase Day 3 – 7
• Rehabilitation Phase Week 2 – 6
• It may take up to 7 or more days for the child
to stabilize.
• Weight gain is not expected during
stabilization

51. Stabilization Phase Day 1-2
• Treat Acute Complications
• Give micronutrients
• Initiate feeding
• Provide love and nursing care

52. TREAT ACUTE COMPLICATIONS
• Respiratory distress – Oxygen
• Hypothermia – warm environment
• Hypoglycemia – IV / NG / oral dextrose
• Hypokalemia – ReSoMal
• Dehydration – ReSoMal
• Severe anaemia – blood transfusion
-

53. Treat acute infections
• Pneumonia
• Diarrhoea
• Skin infections
• ENT infections
• Note: signs of acute infection may be
masked due to severe malnutrition

54. Micronutrients
• Vitamin A 1-2 lac units once
• Zinc 1-2 mg per kg daily
• Folic Acid 5 mg per day
• Vitamin D 400 IU daily
• Iron 1-2 mg per kg daily (start when
gaining weight)

55. Start Feeding
• Start gradual feeds
• Give NG / oral feeds
• Target calories 100 calories/kg/day
• Proteins 1-1.5 gm /kg/day
• Prepare feeds with a base of milk

56. Therapeutic diets
• F – 75 Start from Day 1
• F – 100 Start during transition
• RUTF / RUSF when gaining weight

57. 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
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

58. Cereal based F-75
• F – 75 contains 100 gm sugar /1000 ml
• 30 gm sugar can be replaced by cooked
Rice flour 35 gm
• It reduces diarhoea quickly

59. Modified Rice based F-75
• Milk 300ml
• Rice flour 75 gm is cooked and added
• Sugar 35 gm is added
• Cooking oil 20 ml
• Potassium Chloride 20 ml
• Water to make 1000 ml
• Blended and given

60. Smoothie diet
• Rice flour half cup is cooked
• Potato boiled one small
• Banana one small
• Egg white boiled one
• Blended and given with spoon

61. 61
RUTF - 500 kcal / 92 gm
–Peanuts (ground into a paste)
–Vegetable oil
–Powdered sugar
–Powdered milk
–Vitamin and mineral mix (special
formula)

62. Feeding in STABLIZATION PHASE
• Start feed with F-75,
• initially give 2 hourly feed,
• than shift to 3 hourly feed
• transfer to 4 hourly feed
• Volume of feed 130 ml /kg/day
• Change guided by condition of the patient

63. Start Nasogastric Feeding
• Very weak child
• Mouth ulcers
• Unable to take at least 80% of the
amount offered
• Do not force the feed down the NG
tube

64. Stop Nasogastric Feeding
• Remove N.G tube when ………..
• 80% of the daily amount is taken
orally.
• Two consecutive feeds taken fully
by mouth
• Remove the tube in the day time

65. Signs of Improvement
Transition Phase
• Smile of child
• Loss of edema
• Improved appetite
• This phase should continue for 4-5 days

66. FEEDING DURING TRANSITION
(2 – 7 days)
• F – 75 decrease gradually and stop
• F – 100 Start 130 ml / kg / day and
increase gradually after 2 days
• RUTF 500 kcal / sachet
• RUSF as liked by child

67. Feeding in Rehabilitation Phase
• Increse feeding by 10 ml per feed slowly
• The child can be fed freely on F-100 to an
upper limit of 220 ml/kg/day.
• In rehabilitation phase encourage the child to
eat as much as he wants

68. Daily Follow-up
• History (appetite, vomits, diarrhoea)
• Physical examination (smile, edema,
diarrhoea, skin )
• Vitals
• Medications
• Amounts of Feeds taken
• Weight
• Growth chart

69. RECOVERY
• WEIGHT GAIN should be 10 gm / kg / day
• Child is considered to be recovered
when Weight for length / height is more
than -1 SD or 90 % of expected

70. Catch-up growth
• Catch-up growth occurs during the period
of recovery from malnutrition
• During this period child grows at above
the normal growth rate
• Gain in height and weight is more than
expected for that age period
• This above normal growth allows the child
to catch-up with other children of his age

71. When catch-up growth will occour?
• After acute complications have been
managed
• When the child is free of infection
• When calories intake is 100 – 200 Cal /
kg of actual weight

72. RECOVERY
• WEIGHT GAIN should be 10 gm / kg /
day
• Child is considered to be recovered
when 90 % of expected weight for
length has been achieved

74. Hifsa’s journey from malnutrition to health

75. 0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29
Weight gain chart for Hifsa
Weight

76. ?

77. Professional Ethics in Medicine
Knowledge
(Ilm)
Honesty
(Amanat)
Sincerity
(Ikhlas)
Excellence
(Ehsan)

78. Core Values in Institution
Team Work Respect
Professionalism Justice

79. Basic Principles in Work
Punctual
Time
Dedicated
Effort
Sincere
Obedience
Kind
Supervision

80. Thankyou