The presentation was anchored as a resource person to train staff in identifying complications from malnutrition and how to manage it. especially cases arising from insurgency prone region of the world.

1. Undernutrition, Protein Energy Malnutrition, its
complication and management
By Dr George
Duke Mukoro
Tropical Medicine
Physician
And DR
precious
M.
•For
ICRC

2. B Y D R P R E C I O U S
Management of Complications from Undernutrition
at in-patient Therapeutic center for children

3. List of complications
Anemia
Shock and Dehydration
Hypothermia
Electrolytes imbalance
Severe hypovitaminosis
Opthalmopathies
Respiratory infections :
Hypoglycemia
Infection
Wounds and ulcers

4. Management of anaemia in
Undernourished(PEM) children
To start treatment:
• give oxygen
• measure and record pulse and respiration rates every 15 minutes
A blood transfusion is required if:
• Hb is less than 4 g/dl or if there is respiratory distress and Hb is between 4 and 6 g/dl
Give:
• whole blood 10 ml/kg body weight slowly over 3 hours
• furosemide 1 mg/kg IV at the start of the transfusion
It is particularly important that the volume of 10 ml/kg is not exceeded in
severely malnourished children. If the severely anaemic child has signs of
cardiac failure, transfuse packed cells (5-7 ml/kg) rather than whole blood.
Monitor for signs of transfusion reactions. If any of the following signs develop
during the transfusion, stop the transfusion:
• fever
• itchy rash
• dark red urine
• confusion
• shock
Note: Deficit x wt x 4.5 OR Deficit x wt x 6

5. Anemia Contd
 Also monitor the respiratory rate and pulse rate
every 15 minutes. If either of
 them rises, transfuse more slowly. Following the
transfusion, if the Hb remains
 less than 4 g/dl or between 4 and 6 g/dl in a child
with continuing respiratory distress, DO NOT
repeat the transfusion within 4 days.
 In mild or moderate
 anemia, oral iron should be given for two months
to replenish iron stores
 BUT this should not be started until the child has
begun to gain weight.

6. Check the conjunctiva and palms & heart rate

7. Management of shock
 Shock and severe dehydration some
complication.
 Shock from dehydration and sepsis are likely to
coexist in severely malnourished children. They are
difficult to differentiate on clinical signs alone.
 Children with dehydration will respond to IV fluids.
Those with septic shock and no dehydration will not
respond. The amount of fluid given is determined by
the child’s response. Overhydration must be avoided.

8.  Reliable points
 History of diarrhoea
 Thirst
 Hypothermia
 Recent sunken eyes
 Weak or absent radial
pulse
 Cold hands and feet
 Urine flow
 Anterior fontanelle
 Not reliable points
 Mental status
 Skin elasticity
 Incipient septic shock
 Limpiness, apathic,
anorexic,febrile
 Developed septic shock
 Engorged superficial
veins/bulging anterior
fontanelle
 Engorged jugular vein
leading to resp. distress
cough, grunting,
groaning
 Liver, kidney, cardiac
failures
 Hemetemesis, blood in
stool, abdominal
distension.

9. Identifying dehydration signs
 The posterior fontanelle
generally closes 8–12
weeks after birth;
Anterior fontanelle
closes 6 to 18 months
after birth;

10. Treatment of dehydration
 Whenever possible
should be rehydrated
orally. IV infusion easily
causes overhydration
and heart failure should
only be used when
definite signs of shock
 RESOMAL
(Recommended ORS
solution for severely
malnourished
children)
Component RESOMAL
(mmol/l)
Reduced
osmolarity
ORS
Glucose 125 75
Sodium 45 75
Potassium 40 20
Chloride 70 65
Citrate 7 10
Magnesium 3 ----
Zinc 0.3 ----
Copper 0.045 ----
Osmolarity 300 245

11.  • give oxygen
 • give sterile 10% glucose (5 ml/kg) by IV
 • give IV fluid at 15 ml/kg over 1 hour. Use Ringer’s lactate with
5%
 dextrose; or half-normal saline with 5% dextrose; or half-strength
 Darrow’s solution with 5% dextrose; or if these are unavailable,
 Ringer’s lactate
 • measure and record pulse and respiration rates every 10
minutes
 • give antibiotics
 If there are signs of improvement (pulse and respiration
rates fall):
 • repeat IV 15 ml/kg over 1 hour; then switch to oral or
nasogastric rehydration with ReSoMal, 10 ml/kg/h for up to 10
hours. (Leave IV in place in case required again);
 Give ReSoMal in alternate hours with starter F-75, then
• continue feeding with starter F-75

12.  Developed septic shock
 Begin IV rehydration immediately 15ml/kg in 1 hr.
continously observe for overhydration. As soon as radial
pulse become palpable start orally or NG.
 If signs of congestive heart failure develop or does not
improve after 1st hr, give blood transfusion(10ml/kg)
over at least 3 hrs.
 If there are signs of liver failure ( purpura, jaundice,
tender hepatomegaly), give a single ose of 1 mgVit K IM.
- If sign of congestive heart failure( distension of jugular
veins, increasing resp rate or resp distress), give a
diuretic and slow rate of transfusion.No concomitant
fluid administration
 If child develops abdominal distension or vomits
repeatedly give the diet slowly if problem does not
resolvr, stop feeding the child give fluid at rate of 2-
4ml/kg per hour.
 Also give 2ml of 50% Mg sulphate IM.
If the child fails to improve after the first hour of
treatment

13. Respiratory infections
 Severe respiratory
distress (IMCI criteria)
 >50 resp/min from 2 to
12 months
 >40 resp/min from 1 to 5
years
 >30 resp/min for over 5
years-olds
 Any chest indrawing
 Signs AND symptoms
 Cough
 Respiratory distress
 Chest In-drawing
 Intercostal and sub
coastal recession
 DULL percussion Note
 Bronchial /harsh breath
sounds

14. Treatment
 Oxygen 2-3 LITER per
hour
 Treat infection
 Treat hypoglycaemia
 Arrest convulsion
Diazepam,phenobarbitone,
 Emergency ABCDE
 Airway patent :
chin list ,jaw thrust, Suction
as necessary
 Breathing ,
no respiratory effort ,AMBU
Bag 2 breath ,30 compression
 Circulation:
bradycardic or no heart
sound,Chest compression ,IV
line with fluid of fresh screen
blood.Stop Bleeding.
 Drugs:
Adrenaline,Atropine,Hydroco
rtisone, Promethiazine,

15. Management of hypothermia
 Hypothermia is a reduction in the mean body
temperature. In severe malnutrition, this
complication is defined by WHO as a rectal
temperature below 35.5 °C (95.9 °F) or an
underarm temperature below 35.0° C (95.0
°F).WHO
 Worst with marasmus that kwashiorkor
 Several factors cause hypothermia etc

16. Methods to Treat Hypothermia
 One of the first steps in initiation/resuscitative
 kangaroo technique". infants or early under 5
 Alternatively, the child can be well clothed,
including the head, covered with a warmed blanket
and placed under an incandescent lamp, making
sure that the lamp does not touch the child's body.
 The use of hot-water bottles is not recommended.

17. KANGAROO MOTHER CARE

18. Management of hypoglycemia in
undernurished children
 Hypoglycaemia, is defined as a blood
glucose concentration of less than three
(mmol/l) or less than 54 (mg/dl) in
children with severe malnutrition.
 Children cut of in africa is less than
2.6mmol/liter(Tropical Paediatrics)
Hypoglycaemia is a common
brain damage – since glucose is the
main fuel for the brain – Severe
lack- ultimately death.

19. Continue
 The underlying causes
A. Reduced muscle wasting.
B. Impaired glucose equilibrium by converting
protein and fat reserves into glucose are impaired.
C. The immune response to infections.
D. Glucose absorption is impaired.
E. Poor feeding technique and lack or limited availability
.
The signs of hypoglycaemia
include a body temperature of less than 36.5 °C, lethargy,
limpness and loss of consciousness .
Confirmed low value on handy glucometer.

21.  If the hypoglycemic child is conscious and is
able to drink, then he/she should be given 50 ml of
10% glucose or 10% sucrose (one rounded teaspoon
of sugar in 3.5 tablespoons water). Then he/she
should be provided, orally, with an F-75 diet every 30
minutes for two hours.
 if the child is unconscious, cannot be aroused or
is convulsing, then he/she must receive
intravenously 5 ml/kg of body weight of sterile 10%
glucose, followed by 50 ml of 10% glucose or sucrose
by nasogastric tube. If intravenous glucose cannot be
given immediately, then the nasogastric dose should
be given first.

22.  When the child regains consciousness,
 F-75 diet should be started , every two to three hours day
and night of The F-75(75kcal or 315kJ/100mls), It
consists of dried skimmed milk, sugar, cereal flour, oil,
mineral mix and vitamin mix, and thus is low in protein,
fat and sodium, and high in carbohydrates.
 Treat infections which is an underlying cause of
hypoglycemia.
 However, shortfalls, such as insufficient monitoring of
the feedings by health professionals, neglect of night
feedings5, inadequacy of the meals provided,
unfamiliarity with best practices and guidelines for the
treatment of severe malnutrition, continue to
compromise care. Further training of health-care
providers should be considered.

23. Ophthalmic complications & Vitamin deficiencies
 Vitamin A deficiency:Give Vit A Prophylactically
 Signs of vit A def
 Night blindness
 Conjuctival xerosis
 Bitot’s spots
 Corneal xerosis
 Corneal ulceration
 Keratomalacia
 Other vitamin def
 Folic acid should be given to all ( 5mg on day 1and then
1mg daily.
 While other vit are added in vitamin mix solution.

Timing Dosage
Day 1
<6 months 50,000IU
6-12 months 100,000IU
>12 months 200,000IU
Day 2 Repeat same dose
2 weeks later Repeat same dose
in follow-up

24. Treatment of infection
 Nearly all severely malnourished children have bacterial infections when first
admitted. LRTI is especially common. Unlike well nourished children, who
respond like fever and inflammation, malnourished children with serious
infection may only be drowsy and apathetic.
 Early anti microbial treatment improves nutritional response, prevent septic
shock, reduce mortality.
 These are divided into
 First line treatment.
 Which is given empirically to all.
 Co-trimoxazole BD 5 Days
 Ampicillin 2 days then amoxicillin for 5 days
 Gentamycin 7 days
 Second line treatment
 If no response, add chloramphenicol for 5 days.
 If specific infection is detected like dysentery, candidiasis, malaria, intestinal
helminthiasis, then treat accordingly
 Tuberculosis is also very common, ATT should be given only when TB is
daignosed.
 Measles and other viral infections
 All should be given measles vaccine on admission and on discharge
 All must Immunised for age before discharge .Clerk for missed opportunity.

25. ULCER AND
WOUND CARE
Sterile Wound dressing
Antiseptic cream with Triple
Action of funbact A
For deep ulcers :
Investigate and dress
use sufratulle to stimulate
granulation tissue before wound
coverings.
Subcutaneous ATS and IM TT
offer for dirty would ATS Before
TT.

26. ANY
QUESTIONS ?
Thank you
By
Dr George M.D
Tropical Medicine
Physician, DTM&H
Liverpool
&
Dr Precious M.
Medical officer
In-charge Paediatric
Unit,Biu General
Hospital
Resource Persons ICRC
HOPE FOR THE FUTURE