This document provides information on malnutrition definitions, prevalence, causes, admission and discharge criteria, and general management for malnutrition in India from the National Institute of Nutrition (ICMR). It defines severe acute malnutrition and provides WHO criteria for identifying, admitting, and discharging patients. It also outlines the general 10 step management approach including stabilizing hypoglycemia, hypothermia, and infections before beginning rehabilitation with formula diets like F-75 and F-100 to support catch-up growth.
simlpe approach to anemia in children , how to diagnose anemia in kids ,types of anemias ,causes of anemia , iron deficeincy anemia, hemolytic anemias , laboratory tests in anemia ,
It is important topic which needs to be understand by students and i am using for teaching to VI semester mbbs students. i think it will give a brief idea about protein energy malnutrition.
simlpe approach to anemia in children , how to diagnose anemia in kids ,types of anemias ,causes of anemia , iron deficeincy anemia, hemolytic anemias , laboratory tests in anemia ,
It is important topic which needs to be understand by students and i am using for teaching to VI semester mbbs students. i think it will give a brief idea about protein energy malnutrition.
This slide contains information regarding Protein Energy Malnutrition. This can be helpful for proficiency level and bachelor level nursing students. Your feedback is highly appreciated. Thank you!
Management of SEVERE ACUTE MALNUTRITIONRAVI PRAKASH
MANAGEMENT OF SEVERE ACUTE MALNUTRITION :-
DEALT WITH INVESTIGATION AND TREATMENT OF CHILD SUFFERING FROM SEVERE ACUTE MALNUTRITION, ESSENTIAL AND LATEST GUIDELINES FOR MANAGEMENT
Weighing of the child at regular intervals, the plotting of that weight on a graph (called a growth chart) enabling one to see changes in weight, and giving advice to the mother based on this weight change is called ‘GROWTH MONITORING’
This presentation is about Malnutrition in Pediatrics; Epidemiology, Risk factors, etiology, Clinical Evaluation, plotting on Growth charts and Management are Covered.
This slide contains information regarding Protein Energy Malnutrition. This can be helpful for proficiency level and bachelor level nursing students. Your feedback is highly appreciated. Thank you!
Management of SEVERE ACUTE MALNUTRITIONRAVI PRAKASH
MANAGEMENT OF SEVERE ACUTE MALNUTRITION :-
DEALT WITH INVESTIGATION AND TREATMENT OF CHILD SUFFERING FROM SEVERE ACUTE MALNUTRITION, ESSENTIAL AND LATEST GUIDELINES FOR MANAGEMENT
Weighing of the child at regular intervals, the plotting of that weight on a graph (called a growth chart) enabling one to see changes in weight, and giving advice to the mother based on this weight change is called ‘GROWTH MONITORING’
This presentation is about Malnutrition in Pediatrics; Epidemiology, Risk factors, etiology, Clinical Evaluation, plotting on Growth charts and Management are Covered.
Management of Severe Acute Malnutrition.pptxEfosa Aimien
Severe acute malnutrition is a standard term referred to a condition where a child has severe wasting and/or bilateral pedal edema.
The health, social and economic burden of this condition cannot be overemphasised. It is needful and timely yet again to reiterate and summarily but comprehensively outline the management of this condition. Thus, this presentation is a comprehensive summary of the management of severe acute malnutrition as outlined in standard paediatric textbooks.
A detailed explanation should however be sourced from standard texts and updated journals.
This presentation is cannot be cited or referenced in publications, presentations nor public fora.
The presenters:
Dr Efosa Emmanuel Aimien is a Paediatric Resident on outside posting at the National Hospital Abuja. He had his medical training at the prestigious College of Health Sciences, Ahmadu Bello Univeristy, Zaria. Nigeria.
Dr Zarah Fatima Abdu is a Paediatric Senior Resident at the Department of Paediatrics, National Hospital Abuja. Her vastness and clinical acumen in child health especially malnutrition is without question.
We hope this presentation contributes to the ease of gaining medical knowledge especially in Paediatrics.
Thank you.
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
CRISPR-Cas9, a revolutionary gene-editing tool, holds immense potential to reshape medicine, agriculture, and our understanding of life. But like any powerful tool, it comes with ethical considerations.
Unveiling CRISPR: This naturally occurring bacterial defense system (crRNA & Cas9 protein) fights viruses. Scientists repurposed it for precise gene editing (correction, deletion, insertion) by targeting specific DNA sequences.
The Promise: CRISPR offers exciting possibilities:
Gene Therapy: Correcting genetic diseases like cystic fibrosis.
Agriculture: Engineering crops resistant to pests and harsh environments.
Research: Studying gene function to unlock new knowledge.
The Peril: Ethical concerns demand attention:
Off-target Effects: Unintended DNA edits can have unforeseen consequences.
Eugenics: Misusing CRISPR for designer babies raises social and ethical questions.
Equity: High costs could limit access to this potentially life-saving technology.
The Path Forward: Responsible development is crucial:
International Collaboration: Clear guidelines are needed for research and human trials.
Public Education: Open discussions ensure informed decisions about CRISPR.
Prioritize Safety and Ethics: Safety and ethical principles must be paramount.
CRISPR offers a powerful tool for a better future, but responsible development and addressing ethical concerns are essential. By prioritizing safety, fostering open dialogue, and ensuring equitable access, we can harness CRISPR's power for the benefit of all. (2998 characters)
Global launch of the Healthy Ageing and Prevention Index 2nd wave – alongside...ILC- UK
The Healthy Ageing and Prevention Index is an online tool created by ILC that ranks countries on six metrics including, life span, health span, work span, income, environmental performance, and happiness. The Index helps us understand how well countries have adapted to longevity and inform decision makers on what must be done to maximise the economic benefits that comes with living well for longer.
Alongside the 77th World Health Assembly in Geneva on 28 May 2024, we launched the second version of our Index, allowing us to track progress and give new insights into what needs to be done to keep populations healthier for longer.
The speakers included:
Professor Orazio Schillaci, Minister of Health, Italy
Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
Professor Ilona Kickbusch, Founder and Chair, Global Health Centre, Geneva Graduate Institute and co-chair, World Health Summit Council
Dr Natasha Azzopardi Muscat, Director, Country Health Policies and Systems Division, World Health Organisation EURO
Dr Marta Lomazzi, Executive Manager, World Federation of Public Health Associations
Dr Shyam Bishen, Head, Centre for Health and Healthcare and Member of the Executive Committee, World Economic Forum
Dr Karin Tegmark Wisell, Director General, Public Health Agency of Sweden
CHAPTER 1 SEMESTER V PREVENTIVE-PEDIATRICS.pdfSachin Sharma
This content provides an overview of preventive pediatrics. It defines preventive pediatrics as preventing disease and promoting children's physical, mental, and social well-being to achieve positive health. It discusses antenatal, postnatal, and social preventive pediatrics. It also covers various child health programs like immunization, breastfeeding, ICDS, and the roles of organizations like WHO, UNICEF, and nurses in preventive pediatrics.
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
QA Paediatric dentistry department, Hospital Melaka 2020Azreen Aj
QA study - To improve the 6th monthly recall rate post-comprehensive dental treatment under general anaesthesia in paediatric dentistry department, Hospital Melaka
Navigating the Health Insurance Market_ Understanding Trends and Options.pdfEnterprise Wired
From navigating policy options to staying informed about industry trends, this comprehensive guide explores everything you need to know about the health insurance market.
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
Medical Technology Tackles New Health Care Demand - Research Report - March 2...pchutichetpong
M Capital Group (“MCG”) predicts that with, against, despite, and even without the global pandemic, the medical technology (MedTech) industry shows signs of continuous healthy growth, driven by smaller, faster, and cheaper devices, growing demand for home-based applications, technological innovation, strategic acquisitions, investments, and SPAC listings. MCG predicts that this should reflects itself in annual growth of over 6%, well beyond 2028.
According to Chris Mouchabhani, Managing Partner at M Capital Group, “Despite all economic scenarios that one may consider, beyond overall economic shocks, medical technology should remain one of the most promising and robust sectors over the short to medium term and well beyond 2028.”
There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
In addition, there has also been a lasting impact on consumer and medical demand for home care, supported by the pandemic. Lockdowns, closure of care facilities, and healthcare systems subjected to capacity pressure, accelerated demand away from traditional inpatient care. Now, outpatient care solutions are driving industry production, with nearly 70% of recent diagnostics start-up companies producing products in areas such as ambulatory clinics, at-home care, and self-administered diagnostics.
4.
MALNUTRITION
WHO defines Malnutrition as :
"the cellular imbalance between the supply of nutrients and energy
and the body's demand for them to ensure growth, maintenance,
and specific functions.“
Malnutrition is the condition that develops when the body
does not get the right amount of the vitamins, minerals, and
other nutrients it needs to maintain healthy tissues and organ
function.
N.I.N (ICMR)
Definitions
5. SEVERE ACUTE MALNUTRITION (WHO-UNICEF*)
macro & micronutrient deficiency
WFH or weight for height below –3 standard deviation (SD or Z
scores) of the median WHO growth reference (2006),
visible severe wasting,
presence of bipedal oedema
Mid Upper Arm Circumference (MUAC) below 115mm or 11 cm”.
Based on the Welcome classification, if the child has Kwashiorkor,
Marasmus, or Marasmic-Kwashiorkar
MARASMUS
Represents simple starvation . The body adapts to a chronic state of
insufficient caloric intake
KWASHIORKOR
It is the body’s response to insufficient protein intake but usually sufficient
calories for energy
NIN (ICMR)
7. NIN (ICMR)
Severely malnourished under-five children in India are estimated to
constitute 6.4 per cent in addition to 19.8 per cent who are moderately
malnourished. This translates to 8.1 million children with severe acute
malnutrition (SAM) in India.
10. The causes of malnutrition in India are due to a variety of
factors;
Including low birth weight of babies,
Early marriage and pregnancy,
Low status of women and
Lack of access to quality health care at the primary level.
Highest rate of open defecation in the world (58% of the
global total),
Poor access to potable drinking water and cultural
practices that inhibit early initiation of breastfeeding.
Infections (worms, measles, T.B)
Diarrhoea & malabsorption
NIN (ICMR)
11. NIN (ICMR)
ADMISSION AND DISCHARGE CRITERIA
FOR CHILDREN WHO ARE 6–59 MONTHS
OF AGE WITH SEVERE ACUTE
MALNUTRITION
12.
Criteria for identifying children with severe acute
malnutrition for treatment (WHO )
1. IDENTIFICATION IN COMMUNITY:
Trained community health workers and community members should measure:
the MUAC of infants and children who are 6–59 months of age
examine them for bilateral pitting oedema.
Infants and children who are 6–59 months of age and have a mid-upper
arm circumference <115 mm, or who have any degree of bilateral oedema
should be immediately referred for full assessment at a treatment centre for
the management of severe acute malnutrition.
13. NIN (ICMR)
2. IDENTIFICATION IN PRIMARY HEALTH-CARE FACILITIES
AND HOSPITALS
Health-care workers should assess :
The mid-upper arm circumference (MUAC) or the weight-for-
height/weight-for-length status of infants and children who are 6–59
months of age
examine them for bilateral oedema.
Infants and children who are 6–59 months of age and have a mid-
upper arm circumference <115 mm or a weight-for-height/length <–3
Z-scores of the WHO growth standards (2), or have bilateral oedema,
should be immediately admitted to a programme for the management
of severe acute malnutrition.
14.
Criteria for inpatient or outpatient care*
(WHO )
Children who are identified as having severe acute malnutrition should
first be assessed with
• a full clinical examination
• Children who have appetite (pass the appetite test) and are clinically
well and alert should be treated as outpatients.
• Children who have medical complications, severe oedema (+++)***,
or poor appetite (fail the appetite test****) or present with one or more
IMCI danger signs† should be treated as inpatients.
NIN (ICMR)
15.
Criteria for transferring children from inpatient to
outpatient care* (WHO )
• Children with SAM who are admitted to hospital can be transferred to
outpatient care when their medical complications, including oedema,
are resolving and they have good appetite, and are clinically well and
alert.
• The decision to transfer children from inpatient to outpatient care
should be determined by their clinical condition and not on the basis
of specific anthropometric outcomes such as a specific mid-upper arm
circumference or weight-for-height/length.
NIN (ICMR)
16.
Criteria for discharging children from treatment
(WHO )
a) Children with severe acute malnutrition should only be discharged
from treatment when their:
weight-for-height/length is ≥–2 Z-score and they have had no
oedema for at least 2 weeks, or
mid-upper-arm circumference is ≥125 mm and they have had no
oedema for at least 2 weeks.
b) The anthropometric indicator should be used to assess whether a
child has reached nutritional recovery.
c) Children admitted with only bilateral pitting oedema should be
discharged from treatment
d) Percentage weight gain should not be used as a discharge criterion.
NIN (ICMR)
19.
Management of Severe Acute
Malnutrition
World Health Organization (WHO) 1999:
Facility-based care for the management of severe
acute malnutrition (SAM)
Children under 5 with SAM are treated until full
recovery in paediatric ward, nutrition
rehabilitation unit, therapeutic feeding centre
20.
General Management
Follow WHO Guidelines
1. Treat/prevent hypo-glycaemia
2. Treat/prevent hypothermia
3. Treat/prevent dehydration
4. Correct electrolyte imbalance
5. Treat/prevent infection
6. Correct micronutrient deficiencies
7. Initiate re feeding
8. Facilitate catch-up growth
9. Provide sensory stimulation and emotional support
10. Prepare for follow-up after recovery
21.
10 step approach
STABILIZATION REHABILITATION
DAY 1-2 DAY 3-7 WEEKS 2-6
Hypoglycemia -------------
Hypothermia -------------
Dehydration -------------
Electrolyte imbalance ---------------------------------------------------------------------
Infections ----------------------------------
Micronutrient ------NO IRON-----------------------WITH IRON------------
Initiate feeding -----------------------------------
Catch up growth ---------------------------
Sensory stimulation --------------------------------------------------------------------
Prepare for follow-up ---------------------------
Time frame for the management of a child with complicated severe acute
malnutrition
22.
Hypoglycemia
<54mg/dl
Imp cause of death in first 2 days of treatment
To prevent, child should be feed every 2 or 3
hours day and night.
Signs: hypothermia , lethargy , limpness, LOC.
Treatment:
If conscious: give 50 ml of 10% D/W or F-75 diet by
mouth (whichever is available)
If not conscious: 5ml/kg of 10% D/W I/V then 50 ml 10
% D/W by NG tube.
When gains consciousness then immediately start F-75
diet or glucose in water (60g/l)
Continue frequent diets to prevent recurrence
Should also be treated with broad spectrum antibiotics.
23.
Hypothermia
Rectal temp. <35.5 C (95.5 F) or axillary temp 35 C
(95 F)
Temp should be measured ½ hrly during
rewarming
All hypothermic should also be treated for
hypoglycemia.
Dehydration and septic shock
Difficult to differentiate in severely malnourished
Dehydration tends to be over diagnosed and its
severity over estimated
Some :5% wt loss
Severe : 10 % wt loss
24.
Reliable points
History of diarrhoea
Thirst
Hypothermia
Recent sunken eyes
Weak or absent radial
pulse
Cold hands and feet
Urine flow
Not reliable points
Mental status
Mouth tongue tears
Skin elasticity
Incipient septic shock
Limp, apathic,
anorexic
Developed septic shock
Engorged superficial
veins
Engorged lung vein
leading to resp.
distress cough,
grunting, groaning
Liver, kidney, cardiac
failure
Hemet emesis, blood
in stool, abd
distension.
25. 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
26.
How to prepare ?
Commercially available
One pack of standard ORS in 2 litre of water +50
gm. sucrose + 40 ml mineral mix solution.
Amount
70-100 ml/kg in 12 hour
5 ml/kg every 30min in first 2 hours orally or NG
then 5-10ml/kg per hour
Add acc. to loss in stool, vomiting. Add 50-100ml
after every stool for under 2 years of age and 100-
200ml for older children
Immediately stop if signs of overhydration
appears( Resp rate & pulse rate increase,
engorged jugular veins, puffy eyelids)
Rehydration completed : if no thist, urine passed,
signs of dehydration disappeared.
27.
How to give
Sip by sip or spoon every few minutes.
If exhausted then NG
NG should be used in all children who are exhausted, weak
enough, who vomit, have fast breathing, stomatitis.
IV rehydration
Only indication in circulatory collapse
Use in preference
1- Half strength Darrow’s solution with 5%glucose
2- R/Lactate with 5% glucose
3- 0.45% ( Half normal) saline with 5%glucose
Give 15ml/kg over 1 hr. monitor for over hydration
Meanwhile continue NG RESOMAL (10ml/kg per hr.)
If still severely dehydrated after 1st bolus then repeat IV
15ml/kg over 1 hr. and switch to RESOMAL.
If still no improvement then consider septic shock and treat
accordingly.
Feeding
Continue feeding during rehydration. Start F-75 diet orally or
NG as possible within 2-3 hrs after starting rehydration.
Diet and RESOMAL are given in alternate hrs.
28.
Dietary Treatment
Formula diets
Two formula diets, F-75 and F-100.
F-75 (75kcal/100ml) is used during initial phase of
treatment.
F-100 (100kcal/100ml) is used during rehabilitation
phase, after the appetite has returned
How to prepare ?
Ingredient Amount
F-75 F-100
Dried skimmed milk 25gm 80gm
Sugar 70gm 50gm
Cereal flour 35gm ----
Vegetable oil 27gm 60gm
Mineral mix 20ml 20ml
Vitamin mix 140mg 140mg
Water to make 1000ml 1000ml
29.
Mineral mix solution Vitamin mix
Substance Amount
Potassium chloride 89.5gm
Tripotassium citrate 32.4gm
Magnisium chloride 30.5gm
Zinc acetate 3.3gm
Copper sulfate 0.56gm
Sodium selenate 10mg
Potassium iodide 5mg
Water to make 1000ml
Substance Amount per lt
of liquid diet
Water soluble
Thiamine (B1) 0.7mg
Riboflavin (B2) 2.0mg
Nicotinic acid 10mg
Pyridoxine (B6) 0.7mg
Cyanocobalamine (B12) 1 µg
Folic acid 0.35mg
Ascorbic acid( Vit C) 100mg
Pantothenic acid (B5) 3mg
Biotin 0.1 mg
Fat soluble
Retinol( vit A) 1.5mg
Calciferol (vit D) 30 µg
Tocopherol (vit E) 22mg
Vit K 40 µg
30.
Composition
Constituents Amount per 100 ml
F-75 F-100
Energy 75kcal 100kcal
Protein 0.9gm 2.9gm
Lactose 1.3gm 4.2gm
Potassium 3.6mmol 5.9mmol
Sodium 0.6mmol 1.9mmol
Magnesium 043mmol 0.73mmol
Zinc 2.0mg 2.3mg
Copper 025mg 0.25mg
Percentage of energy from
Protein 5% 12%
Fat 32% 53%
osmolarity 333mOsmmol/l 419mOsmol/l
31.
How to give feed
To avoid overloading intestine, liver, kidneys;
frequent and small feeds should be given. Every
2,3 or 4 hourly, day and night.
If can’t take orally, then use NG.
If vomiting occurs, then amount and interval
should be reduced.
F-75 diet should be given during initial phase.
Child should be given at least 80kcal/kg but not
more than 100kcal/kg.
If <80kcal/kg per day are given, tissue will
continue to break and child will deteriorate.
And if >100kcal/kg per day are given, then child
may develop serious metabolic imbalance.
32.
Amount of diet to give at each feed to achieve a
daily intake of 100kcal/kg.
Weight of child
(Kg)
Volume of F-75 per feed (ml)
Every 2 hr
(12 feeds)
Every 3 hrs
(8 feeds)
Every 4 hrs
(6 feeds)
2 20 30 45
3 35 50 65
4 45 70 90
5 55 80 110
6 65 100 130
7 75 115 155
8 90 130 175
9 100 145 200
10 110 160 220
33.
Child should be fed with cup and spoon, not by feeder
as it is an important source of infection.
Very weak may be fed using a dropper and syringe.
Nasogastric (NG) feeding
Many children will not take sufficient diet by mouth during first
few days of treatment due to poor appetite, weakness,
stomatitis. Such patients should be given through NG tube.
At each feed, the child should first be offered the diet orally.
After the child has taken as much he or she can, the remainder
should be given thru NG.
NG should be removed when child is taking ¾ of day’s diet
orally, or takes 2 consecutive feeds fully by mouth.
If next 24 hrs. child fails to take 80kcal/kg then reinsert tube.
And if child develops distension during NG feed, give 2 ml of
Mg sulfate IM.
NG should be always aspirated before feeds Are administered.
Should be passed by trained staff to avoid aspiration
34.
THE INITIAL PHASE OF TREATMENT ENDS
WHEN THE CHILD BECOMES HUNGRY.
This indicates that
Infections are under control
Liver is able to metabolize diet
Other metabolic abnormalities are improving.
Child is now ready to begin rehabilitation phase.
This usually occurs after 2-7 days of treatment.
While children with complication takes longer time
while some are hungry from the start and can be
shifted to F-100.
Replace the equal amount of F-75 diet with F-100 for
2 days before increasing the volume.
Type of feed given, amount offered and taken date
time must be recorded accurately after each feed. If
child vomits, the amount lost should be noted in
terms of whole feed, half of feed etc.
35.
Treatment of infection
Nearly all severely malnourished children have bacterial infections
when first admitted. 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.
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 diagnosed.
Measles and other viral infections
All should be given measles vaccine on admission and on discharge
36.
Vitamin deficiencies
Vitamin A deficiency
Signs of VAD
Night blindness
Conjuctival xerosis
Bitot’s spots
Corneal xerosis
Corneal ulceration
Keratomalacia
Other vitamin deficiency
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
37.
Catch up growth
Signs that a child has reached this
phase:
return of appetite,
edema gone and
no episodes of hypoglycemia
38.
Treatment:
Gradual transition from starter to catch up
Replace F75 with an equal amount of
F100(100kcal/100ml and 2.9g protein/100ml)
or RUTF for 2-3 days
On day 3 increase each successive feed by
10ml till some remains uneaten at abt
200ml/kg/d
Aft gradual transition give frequent feeds
unlimited amts, 150-220kcal/kg/d, 4-6g of
protein/d
39. Ready-to-Use Therapeutic Food
(RUTF)
Energy- and nutrient-
dense lipid-based paste:
500 kcal/92 g
Same formula as F-100
(except it contains iron)
No microbial growth,
even when opened
Safe and easy for home
use
Is not given to infants
under 6 months
40.
Sensory stimulation
Tender, loving care
Structured play therapy for 15- 30 mins/d
Physical activity as soon as the child is well
enough.
A cheerful, stimulating environment.
Encourage mother’s involvement e.g.
comforting, feeding, bathing, play
Provide suitable toys for the children.
41.
Associated conditions
Eye problems
vitamin A, days 1,2,14
Signs of corneal clouding/ulceration
Caf/tetracycline eye drops qid for 7-10
days
Atropine eye drops 1 drops tid 3-5 days
Cover with saline soaked pads
Bandage eyes
42.
Severe Anaemia
Transfuse: Hb < 4gldl,4-6g/dl in resp. distress
Whole blood – 10 ml/kg slowly for 3hrs + frusemide
1mg/kg iv at the start of transfusion
Packed cells – 10 ml/kg if in CCF
Continuing diarrhoea
Replacement fluids CT
Stool m/c/s and treat accordingly. giardia; flagyl
7.5mg/kg TID x 7d
Osmotic diarrhoea: Diarrhea worsens with
hyperosmolar F75 and ceases when sugar content and
osmolarity are reduced.Rx-lower osmolar feeds
43.
Rehabilitation
Appetite has returned
Principles: encourage child to eat as much as
possible, breastfeeding, emotional care, prepare
mum for continued care
Criteria 4 Discharge : eating well, improved mental
status, normal temp, no vomiting/diarrhea/edema,
gaining weight >5g/kg/d for 3consecutive days.
Continue monitoring progress.
45.
Discharge and follow-up
Discharge Criteria
All infections, other conditions have been treated
Good appetite and gaining weight (90% expected
WH )
Lost any oedema
Appropriate support in the community or home
Mother/carer: available, understands child’s
needs, able to supply needs
46.
Follow up
Planned and regular, nutrition clinic
Risk of relapse greatest aft discharge then
should be seen aft 1wk,2wks,1mth,3mths
If a problem is identified more frequent
visits
Aft 6mths,do yearly visits till 3yrs of age.
49.
Thanks to an appropriate management
scheme, from being severely
malnourished (weight 4.75 kg), this 2-
year old girl not only gained 32% more
weight in 3 weeks (weight 6.28), but
she also gained an appetite for living.
SOURCE** - WHO
An example of a young child with severe
acute malnutrition who, with the
interventions of a community health
system and Plumpy'Nut, recovered her
health in about 7 weeks.
SOURCE** - EDESIA
NUTRITION
51.
PREVENTION
Appropriate nutrition policies programmes
Improving food security
Protection and promotion of good health
Appropriate care practices for good nutrition
SUMMARY- GOBIFFF the UNICEF adaptation
Growth monitoring
Oral rehydration
Breast feeding
Immunization
Feeds (supplements)
Female education
Family spacing
52. NIN (ICMR)
1. WHO. Guideline: Updates on the management of severe acute malnutrition in infants and children. Geneva, World Health
Organization; 2013 (http://www.who.int/nutrition/publications/guidelines/updates_management_SAM_
Infant and children/en/).
2. WHO Multicentre Growth Reference Study Group. WHO child growth standards: methods and development. Growth velocity
based on weight, length and head circumference. Geneva, World Health Organization; 2009
(www.who.int/childgrowth/standards/velocity/technical_report/en/index.html).
3. WHO. Management of severe malnutrition: a manual for physicians and other senior health workers. Geneva, World Health
Organization; 1999 (http://www.who.int/nutrition/publications/severemalnutrition/9241545119/en/).
4. WHO, WFP, UNSCN, UNICEF. Community-based management of severe acute malnutrition. A joint statement by the World
Health Organization, World Food Programme, United Nations Standing Committee on Nutrition, United Nations Children’s
Fund. Geneva, World Health Organization; 2007
(http://www.who.int/nutrition/publications/severemalnutrition/9789280641479/en/).
5. WHO child growth standards and the identification of severe acute malnutrition in infants and children. A joint statement by the
World Health Organization and the United Nations Children’s Fund. Geneva:, World Health Organization; 2009
(http://www.who.int/maternal_child_adolescent/documents/9789241598163/en/).
6. Integrated management of childhood illness: caring for newborns and children in the community. Geneva, World Health
Organization; 2011 (http://www.who.int/maternal_child_adolescent/documents/imci_community_care/en/).
BIBLIOGRAPHY