reaching 50% in edematous malnutrition(2). There - PDF document

reaching 50% in edematous malnutrition(2). There 44 17, 2007 17, 20071.Treat/prevent hypoglycemia2.Treat/prevent hypothermia3.Treat/prevent dehydration4.Correct electrolyte imbalance5.Treat/prevent infection6.Correct micronutrient deficiencies7.Start cautious feeding8.Achieve catch-up growth9.Provide sensory stimulation and emotional10.Prepare for follow-up after recovery depicts the time-frame for initiating/and risk of mortality in severelymalnourished children (•Blood glucose level be measured, assume hypoglycemia•Hypoglycemia may be asymptomatic or•Hypothermia, infection and hypoglycemia•Give 50 mL of 10% glucose or sucrose 44 17, 2007•Start feeding 2 hourly day and night (Initially•Start appropriate antibiotics.•Give 10% dextrose i.v. 5 mL/kg (if unavailable•Follow with 50 mL of 10% dextrose or sucrose•Start feeding with the starter F75 diet as quickly•Start appropriate antibiotics.•In case the body temperature falls (axillary•Feed 2 hourly starting immediately (if•Ensure the child is fed regularly throughout•Hypothermia is diagnosed if the rectal•Hypothermia can occur in summers as well.•Always measure blood glucose and screen forNo. of% weight deficitBlood sugarMortalitycasesfor length(mg/100 mL)rate (%)MaxMeanMimKwashiorkor102610077450�glucose 50 mg%182981685116.6glucose 152950341426.6symptomatic hypoglycemia21292511052.1 17, 2007•Feed the child immediately (if necessary•Clothe the child with warm clothes and use a•Provide heat with an overhead warmer, an•Or the child could be put in contact with•Give appropriate antibiotics.•Give warm humidified oxygen.•Give 5 mL/kg of 10% dextrose IV immediately•Start IV antibiotics (see section below). Provide heat using radiation (overhead•Give warm feeds immediately, if clinical•Rehydrate using warm fluids immediately, when•Measure the child’s temperature 2 hourly till it•Monitor temperature especially at night whenthe ambient temperature falls and ensure the•Check for hypoglycemia whenever•Feed the child 2 hourly starting immediately•Ensure feeds are administered through the night.•Always keep the child well covered. Ensurethat head is also covered well with a scarf or a•Place the child’s bed in a draught-free area away•Minimize exposure after bathing or clinical•Minimize contact with wet clothes and nappies•Let the child sleep in close contact with the•The child could also be put in contact with theStep 3: Treat/Prevent Dehydrationmalnourished children with watery diarrhea mayhave some dehydration. It is important to recognize 44 17, 2007•Feeding must be initiated within two to three hours 2, 4, 6)with reduced osmolarity ORS (hours 3,5,7) (see and VII•Pulse rate•Respiratory rate•Oral mucosa•Urine frequency/volume•Frequency of stools and vomitingrespiratory rate by 5 per min and pulse rate by 15 perStop ORS for rehydration if any four hydration•If the child is breastfed, continue breastfeeding.•Initiate re feeding with starter F-75 formula.•Give reduced osmolarity ORS between feeds toSevere Dehydration with Shockand rapid improvement on intravenous fluidsWHO suggests that when using the new ORS solution, Add 20 mmol/L of additional potassium as syrupSodium75Chloride65Potassium20Citrate10Glucose75Osmolarity245 17, 2007 A severely malnourished child with signshistory of watery diarrhea should be treated forrehydrating fluid. If not available, use half normal•Give oxygen•Give rehydrating fluid at slower infusion rates of•Administer IV antibiotics.•Monitor pulse and respiratory rates every 10-15switch to reduced osmolarity ORS at 5-10 mL/•If there is no improvement or worsening after theof 1.5 mL per 100 mL after the patient passes for management of septicStep 4: Correct Electrolyte Imbalance•All severely malnourished children need to becommon preparation available has 20 mmol/and there is severe hypokalemia i.e., serum mmol/L with ECG•On day 1, give 50% magnesium sulphategiven orally as a magnesium supplement mixed•Prepare food without adding salt.the WHO electrolyte and mineral mix and adding 44 17, 2007consider septic shockcapillary refill/increase in blood pressure)If accept orally start ORSClinically better but not accepting orally: Give ORS (5-10 mL/kg/h) through a nasogastric tube. If the child does not tolerate oral/NG fluid, AuthorsAgeChildrenPrevalence ofBacterial isolatesYear publishedstudiedinfection(1992)16492%E. coli( 1994)4-60 mo90�80%Gram –ve enteric organism2005)2-60 mo9128.9%Mostly Gram –ve Similarly, there are studies that have docu-mented high rates of urinary tract infections inchildren with SMN (Table V).All these studies showed high rates ofinfection and majority of the blood streaminfections were due to gram negative bacteria.This provides the basis for the recommendationthat all severely malnourished children should beassumed to have a serious infection on their Fig. 1. Fluid management for severe dehydration in severely malnourished children. 17, 2007•Hb, TLC, DLC, peripheral smear•Urine analysis and urine culture•Blood culture•Mantoux test•Gastric aspirate for AFB•Peripheral smear for malaria (in endemic•CSF examination (if meningitis suspected)•Ampicillin 50 mg/kg/dose 6 hourly I.M. or I.V.•Gentamicin 7.5 mg/kg Amikacin 15-20 mg/kg I.M or I.V once daily6 hourly) and IV Amikacin (15 mg/kg/day 8 hourly)Authors /CountryChildren studiedPrevalence of UTICommon bacterial isolates(1983), Atlanta(9)6831%( 2000) (11)10330% (2002), Nigeria(12)19411.3%Gram negative bacteria; E. coli et al. (2003), India (13)112Bacteriuria in 17 (15.2%) SMN 44 17, 2007improvement or deterioration of the symptoms/recommended daily allowance of variousanemia is common, do not give ironinitially. Wait until the child has a good•�Vitamin A orally on day 1 (if age 1 year giveage 0-5 m give 50,000 IU) unless there ).•Folic acid 1 mg/d (give 5 mg on day 1).•Zinc 2 mg/kg/d (can be provided using zinc•Copper 0.2-0.3 mg/kg/d (will have to use a•Iron 3 mg/kg/d, only once child starts gaining•Osmolarity less than •Lactose not more than 2-3 g/kg/day.•Appropriate renal solute load (urinary•Initial percentage of calories from protein•Adequate bioavailability of micronutrients.•Low viscosity, easy to prepare and socially•Adequate storage, cooking and refrigeration.Start cautious feeding•Start feeding as soon as possible as frequent•Recommended daily energy and protein intakefrom initial feeds is 100 kcal/kg and 1-1.5 g/kg•Total fluid recommended is 130 mL/kg/day;•Continue breast feeding Starter diets (adapted from WHO guidelines) 17, 2007). However, there 3.). The calories should bein 2-3 days higher intakes should be encouraged.at each feed should be increased. It isDiets contents (per 100 mL)F-75 StarterF-75 StarterF-75 Starter(Cereal based)(Cereal based)Ex: 1Ex: 2Cows milk or equivalent (mL)303025(1/3)(1/3)(1/4)Sugar (g)963(approximate measure of one level teaspoon)(1 + 1/2)(1 )Cereal: Powdered puffed rice* (g)–2.56(3/4)(2)Vegetable oil (g)22.53(1/2)(1/2+)Water: make up to (mL)100100100Energy (kcal)757575Protein (g)0.91.11.2Lactose (g)1.21.21.0 DaysFrequencyVol/kg/feedVol/kg/day1-22 hourly11 mL130 mL3-53 hourly16 mL130 mL6 -4 hourly22 mL130 mL WHO guidelines(3). for the detailed charts on feeding 44 17, 2007kcal/kg/day, and the proteins to 4-6g/kg/day.in the WHO manual ()(2).between osmolarity and digestibility(15) for an example 6, Treatment of associatedStep 9:Provide sensory stimulation and•A cheerful, stimulating environment.•Age appropriate structured play therapy for at DietsF-100F-100 Catch-upContentsCatch-up(cereal based)(per 100 mL)Example 1Cows milk/toned9575(3/4+)(1/2)Sugar (g)52.5(approximate measure(1)(1/2–)of one level teaspoon)Cereal: Puffed rice (g)–7(approximate measure(2)of one level teaspoon)Vegetable oil (g)22(1/2)(1/2)of one level teaspoon)Water to make (mL)100100Energy (kcal)101100Protein (g)2.92.9Lactose (g)3.83 •Age appropriate physical activity as soon as•Tender loving care.•Failure to regain appetite by day 4.•Failure to start losing edema by day 4.•Presence of edema on day 10.•Failure to gain at least 5.g/kg/day by day 10.•G�ood weight gain is 10 g/kg/day and•Moderate weight gain is 5-10 g/kg/day;•Poor weight gain is 17, 2007 Inadequate feeding•That night feeds have been given•That target energy and protein intakes are•Feeding technique: Is the child fed frequently•All aspects of feed preparation: Scales,•If giving family foods with catch-up F-100, Specific nutrient deficiencies1.Adequacy and the shelf life of the2.Preparation of electrolyte/mineral solution Untreated infection•Re-examine carefully.•Repeat urinalysis for white blood cells.•Examine stool.•If possible, take chest HIV/AIDSchronic diarrhea. Treatment should be the same Psychological problems Catch-up low lactose dietsExample 1Example 2Milk (cow’s milk or toned dairy milk)25 mL25 mLEgg white *(g)12 –(approximate measure of one level teaspoon)(2+)Roasted powdered groundnut–5 gVegetable oil (g)4(approximate measure of one level teaspoon)(1)Cereal flour: Powdered puffed rice** (g)1212(approximate measure of one katori)(4)(4)Energy (kcal)100 –Protein (g)2.92.9Lactose (g)11 Jaggery could be used instead of glucose/sugar. 44 17, 2007•Absence of infection.•The child is eating at least 120-130 cal/kg/day•There is consistent weight gain (of at least•WFH is 90% of NCHS median; The child is•Absence of edema.•Completed immunization appropriate for age.•Caretakers are sensitized to home care.•Bring child back for regular follow-up checks.•Ensure booster immunizations are given.•Ensure vitamin A is given every six months.•Feed frequently with energy-and nutrient-•Give structured play therapy.complete is shown in The data were presented at a workshop1.Pelletier DL, Frongillo EA Jr, Schroeder DG,2.Ashworth A, Khanum S, Jackson A, Schofield C.3.Severe malnutrition. Pocket Book of Hospital care4.Myatt M, Khara T, Collins S. A review of methods to5.Kerpel-Fronius E, Kaiser E. Hypoglycaemia in6.Isaack H, Mbise RL, Hirji KF. Nosocomial bacterial7.Shimeles D, Lulseged S. Clinical profile and pattern8.Noorani N, Macharia WM, Oyatsi D, Revathi G.9.Aref GH, Osman MZ, Zaki A, Amer MA, Hanna SS.Clinical and radiological study of the frequency and10.Berkowitz FE. Infections in children with severe11.Caksen H, Cesur Y, Uner A, Arslan S, Sar S, Celebi. Urinary tract infection and antibiotic12.Rabasa Ai, Shattima D. Urinary tract infection in13.Bagga A, Tripathi P, Jatana V, Hari P, Kapil A,14.Bhan MK, Bhandari N, Bahl R. Management of the 17, 200715.Bhatnagar S, Bhan MK, Singh KD, Saxena SK,16.WHO, Child and Adolescent Health andBooklet 2002; 22. Appendix 1Treatment of septic shock (see flow chart below)(Adapted from: Carcillo JA, Fields AI. American College of Critical Care Medicine Task Force Committee Members. Clinicalpractice parameters for hemodynamic support of pediatric and neonatal patients in septic shock. Crit Care Med 2002; 30: 1365-1378). suspected i.e., hypoglycemia, hyponatremia, hyperkalemia 44 17, 2007gmolor contentPotassium chloride: KCl22424 mmoLO812 mmoL.763 mmoLO763 mmoLZinc acetate:Zn acetate, 2HO8.2300 O1.445 Water: Make up to2500 mL 10H•Dissolve the ingredients in cooled boiled water.•Store the solution in sterilized bottles in the•Add 20 mL of the concentrated electrolyte/it is not possible to prepare this electrolyte/•Continue administration of oxygen.•Give 10 mL/kg Normal Saline or Ringers’•Consider colloids •Monitor vitals, urine output, sensorium, features•Stop bolus and restrict fluids/colloids at first sign•Consider Central Venous Pressure (CVP)•Consider mechanical ventilation in fluid refrac-•Start vasoactive agents, dopamine (10-20 •Consider 10 mL/kg packed red blood cells•Use appropriate and adequate antibiotics: Third•Steroids: Consider using hydrocortisone @ 100 hypoglycemia, hyponatremia, hyperkalemiaStarter lactose free dietsEx: 1Egg white *(g)5(approximate measure of one level teaspoon)(2)Glucose (g)3.5(approximate measure of one level teaspoon)(3/4+)Cereal flour: Powdered puffed rice** (g)7(approximate measure of one level teaspoon)(2+)Vegetable oil (g)4(approximate measure of one level teaspoon)(1)Water to make (mL)100Energy (kcal)75Protein (g)1Lactose- 17, 20072-hourly3-hourly4-hourly(kg)(mL/feed)(mL/feed)(mL/feed)2.02030452.22535502.42540552.63045552.83045603.03550653.23555703.43555753.64060803.84060854.04565904.24570904.45070954.650751004.855801055.055801105.255851155.460901205.660901255.86595130 Catch-up lactose free dietsEx: 1Egg white *(g)20(approximate measure of one level teaspoon)(2+)Glucose or sugar (g)4(approximate measure of one level teaspoon)(1)Cereal Flour: Puffed rice** (g)12(approximate measure of one level teaspoon)(3 + 1/2)Vegetable oil (g)4(approximate measure of one level teaspoon)(1)Water to make (mL)100(approximate measure of one katori)(3/4)Energy (kcal)100Protein (g)3Lactose (g) *Egg white may be replaced by 3g of chicken. Chicken**Powdered puffed rice may be replaced by commercial Whip the egg white well. Add Cook the chicken and puree it6.0651001306.2701001356.4701051406.6751101456.8751101507.0751151557.2801201607.4801201607.6851251657.8851301708.0901301758.2901351808.4901401858.6951401908.8951451959.01001452009.2100150200hild’s weight2-hourly3-hourly4-hourly(kg)(mL/feed)(mL/feed)(mL/feed) * Powdered puffed rice may be replaced by commercial 44 17, 20071.Hb is less than 4g/dL or2.If there is respiratory distress and Hb between 4for two months to replete iron stores BUT this1.Whole blood 10 mL/kg bodyweight slowly over2.Furosemide 1 mg/kg IV at the start of the1.Fever2.Itchy rash3.Dark red urine4.Confusion5.Shock1.�Vitamin A on days 1, 2 and 14 (if aged 1 year1.Instil chloramphenicol or tetracycline eye drops,2.Instil atropine eye drops, 1 drop three times daily3.Cover with saline-soaked eye pads and bandage.1.Hypo- or hyper-pigmentation.2.Desquamation.3.Ulceration (spreading over limbs, thighs,4.Exudative lesions (resembling severe burns)1.Dab affected areas with 0.01% potassiumpermanganate solution. 17, 20071.�Is aged 12 months.2.Has completed antibiotic treatment.3.Has good appetite and good weight gain.4.Has taken 2-weeks of potassium/magnesium/2.Apply barrier cream (zinc and castor oil3.Omit nappies/diapers so that the perineum can Catch-1.Perform Mantoux test (NB false negatives are2.Chest 1.Is not employed outside the home.2.Is specifically trained to give appropriate feeding3.Has the financial resources to feed the child.4.Lives within easy reach of the hospital for urgent5.Can be visited weekly.6.Is trained to give structured play therapy.7.Is motivated to follo]w advice given.1.Are trained to support home care.2.Are specifically trained to examine child3.Are motivated.essential to give frequent meals with a high energy1.Give appropriate meals at least 5 times daily.2.Give high energy snacks between meals (3.Assist and encourage the child to complete each4.Give electrolyte and micronutrient supplements.5.Breastfeed as often as child wants. 44 17, 2007Advisors:M.K. BhanChairperson:Nitin ShahConveners:Shinjini BhatnagarCo-Convener:Rakesh LodhaMembers:Naveen Thacker, Raju UNICEF:K. Suresh, Anjana Gulani, Yogesh Jain, Gaurav Arya, Raman Atkuri, Sherin VarkeyWHO:Harish Kumar