The Management Of Severe Malnutrition

Front 1

What are the 10 management activities (aims) in severe malnutrition?

Back 1

• Treat: Hypoglycaemia, Hypothermia, deHydration.

• Electrolytes correction

• Infection treatment

• Micronutrients and Iron

• Macronutrients

• Discharge prep

• Emotional + sensorineural development

• Catch-up growth

Hint 1

Ha Ha Ha Eat In Iron Macdonalds & Dis Emo Cat

Front 2

What is the timeframe for treatment of hypoglycemia?

Back 2

Days 1-2

Front 3

What is the timeframe for treatment of hypothermia?

Back 3

Days 1-2

Front 4

What is the timeframe for treatment of dehydration?

Back 4

Days 1-2

Front 5

What is the timeframe for treatment of correction of electrolytes?

Back 5

Up to week 6

Front 6

What is the timeframe for treatment of infection?

Back 6

Week 1

Front 7

What is the timeframe for feeding (short term, emergency)?

Back 7

Week 1

Front 8

What is the timeframe for giving Iron?

Back 8

Weeks 2-6

Front 9

What is the timeframe for giving micronutrients?

Back 9

Up to week 6

Front 10

What is the timeframe for catch-up growth feeding?

Back 10

Week 2 onwards until week 26

Front 11

What is the timeframe for stimulating emotional and sensorineural development?

Back 11

Day 1 - week 26

Front 12

What is the timeframe for preparing for discharge?

Back 12

Weeks 2 - 6

Front 13

What are the specific time frames involved in management?

Back 13

• Treatment: Week 1 (immediate = day 1-2)

• Recovery: Week 2-6

• Follow-up: Week 7-26

Hint 13

Please give their names and durations.

Front 14

A patient with severe malnutrition has just been admitted today. Name which management activities should be started today.

Back 14

• Treat hypoglycaemia, hypothermia, dehydration (2days)

• Correct electrolytes (6wks)

• Treat infection (1wk)

• Micronutrients (6wks) (NO IRON YET)

• Begin feeding (emergency) (1wk)

• Stimulate emotional and sensorineural development (26wks)

Front 15

A patient with severe malnutrition was admitted 1 week ago. This is day 8 of their admission. What phase has the patient now entered? Name which management activities should be started/stopped/continued today.

Back 15

The Recovery phase: week 2 - week 6.

• Treatment of hypoglycaemia, hypothermia and dehydration should have been stopped after day 2 already.

• Electrolyte correction must continue until end of the recovery phase (wk6).

• Micronutrients must continue until the end of the recovery phase (wk6).

• However, now IRON may BE COMMENCED. (UNTIL WK6).

• Feeding with the aim of catch-up growth should be commenced now (until week 26), shifting aim from immediate/emergency feeding.

• Planning for discharge should commence now (until week 6).

• Emotional and sensorineural development should continue (until week 26).

Front 16

It is the beginning of week 7 for your patient.

1) What is this phase called?

2) What must happen now to the patient?

3) What activities must be stopped?

4) What activities are important to continue in this phase?

Back 16

1) Follow-up phase (wk7-26)

2) Discharge

3) Stop: micronutrient replacement, Iron replacement, electrolyte correction, discharge preparation

4) Continue: feeding for catch-up growth, emotional and sensorineural development

Front 17

Where should the child be admitted?

Back 17

The nutritional support unit of a hospital.

Front 18

Where should the child be transferred to for the recovery phase? What happens there?

Back 18

A day hospital with a nutritional rehabilitation centre. Child gets supportive treatment during the day then goes home to sleep at night.

Front 19

What are the differences between hospital care and day centre facilities?

Back 19

Treatment: Immediate emergency care available in hospital.

Timing: hospital is 24hr care, so child can be fed throughout night.

Infection rates: higher in hospitals.

Family contact: better in day centre and child gets to go home at night (may be good and bad e.g. inappropriate remedied given by family at home, reinfection at home etc.)

Front 20

What is the definition of "severe malnutrition"?

Back 20

• Oedamoutous malnutrition (~oedema, although maybe missing some other clinical features of oedema)

• Severe wasting (marasmus)

• Severe stunting

Front 21

How do you know if a child has oedematous malnutrition?

Back 21

If they have SYMMETRICAL oedema

Front 22

How do you know if a child has severe wasting?

Back 22

Their weight-for-height ratio is <-3SD (<79%) from the median WHO value for that height.

Front 23

How do you know if a child has moderate wasting?

Back 23

-3SD ≤ weight-for-height <-2SD

(70-79%)

Front 24

When is measuring height not appropriate?

What measurement would you use instead?

Back 24

When:

• Child younger than 2 yrs old

• Child less than 85cm tall

• Too ill to stand.

Instead: measure child's length lying down.

Front 25

How do you know if a child is severely stunted?

Back 25

Height-for-age <-3SD from median.

Front 26

Moderately stunted definition

Back 26

-3SD ≤ Height-for-age <-2SD

Front 27

1) If a child has non-symmetrical oedema, does the child have "oedematous" malnutrition?

2) Can the child still be malnourished in this case?

Back 27

1) No.

2) Yes. As they may have severe wasting and/or severe stunting, either of which would constitute "severe malnutrition".

Front 28

1) Is the child with severe stunting severely malnourished?

2) How does the management differ?

Back 28

1) Yes.

2) Severely stunted: Treatment phase is skipped and masnagement begins at recovery phase (week 2).

Front 29

What units are used to measure height and weight?

Back 29

cm and kg respectively

Front 30

Name 14 things you would want to know from the history.

Back 30

MALNUTRITION:

• Age [needed for assessment of malnutrition]

• Usual diet before current episode of illness [malnutrition, infection]

• Food taken past few days [malnutrition, dehydration]

KID:

• Birth weight

• Breastfeeding history

• Milestones (sitting, standing etc.)

• Sibling(s) death(s)

INFECTION:

• D&V: duration and frequency [infection]

• Contacts with measles [infection]

• Contacts with TB [infection]

• Immunisations [infection]

DEHYDRATION:

• Time when URINE WAS LAST PASSED [dehydration]

• Fluid taken past few days [malnutrition, dehydration]

• Recent sinking of eyes [dehydration]

Hint 30

Think "Malnourished KID"

Front 31

Define SIRS

Back 31

At least 2 of:

Temp >38°C or <36

rr >20 bpm or PaCO2 <32mmHg

WCC >12 or <4 (×10^9 cells/L) or >10% immature [band] cells

HR >90 bpm

Front 32

What 5 questions do you want answered from the examination?

What examination signs will answer these questions?

Back 32

1) Is the child MANOURISHED? (A) height/length, weight, oedema. Eyes: vit A def = corneal lesions.

2) Hypoglycaemia? (A) Limp, LOC, Lethargic, low temp

3) Hypothermic? (A) Check temp

4) Dehydrated? (A) Thirst, eyes sunken (not reliable), skin turgor not useful

---> HV Shock: (A) Cold hands and feet, weak radial pulse, low consciousness, heart failure signs, HR, BP.

5) Infection: (A) skin: rashes/purpura. Resp: rr, pneumonia, ENT. GI: upper = liver enlarged/tender, jaundice. Lower = Abdo, faeces. Fever (check temp).

---> Septic shock (≥2 SIRS signs)

Front 33

What investigations may be useful? What would you see if positive?

Back 33

• BLOOD GLUCOSE (<3 mmol/L = hypoglycaemia) (<54mg/dL)

• Blood film: malaria parasites

• Urine exam/dipstick/microscopy/culture: UTI if bacteria on microscopy or >10 WBCs per high-power field

Front 34

What are 2 causes of hypoglycaemia in a malnourished child?

Back 34

- Not been fed in last 4-6 hours

- serious systemic infection

Front 35

How often must a child be fed to PREVENT hypoglycaemia?

Back 35

Every 2-3 hours day AND night

Front 36

Why do malnourished children need small frequent feeds?

Back 36

Frequent: reduced insulin levels, reduced gluconeogenesis.

Small: Glucose intolerance (due to reduced insulin levels), decreased gastric avid secretion, intestinal motility reduced, pancreas and small intestine mucosa atrophied so digestive enzyme production and secretion reduced.

Front 37

Give 4 signs of hypoglycaemia

Back 37

Limp

Lethargy

Loss of consciousness

Low temp (<36.5°C)

(Often the only sign before death is drowsiness!)

Hint 37

Remember the 4 Ls

Front 38

A lethargic malnourished child is admitted so you suspect they might hypoglycaemia. What do you do?

Back 38

Treat IMMEDIATELY for hypoglycaemia, even if you might be wrong:

- Give 50ml 10% glucose (or sucrose) solution to drink PO OR F-75 PO.

Front 39

Only 50% Glucose solution is available. What do you do?

Back 39

Dilute one part of it with 4 parts water and give 50ml of that.

Front 40

When would PO treatment for hypoglycaemia not be an option?

Back 40

- Cannot be roused to drink

- Losing consciousness

- Having convulsions

Front 41

The child is losing consciousness and begins having convulsions. What do you do?

Back 41

Give IMMEDIATELY

• IV 5mg/kg 10% sterile glucose solution

AND THEN FOLLOWED BY

• 50ml 10% glucose solution via NG TUBE.

Front 42

The IV infusion is taking a long time and cannot be prepared quickly enough. What do you do?

Back 42

Give the NG dose first, don't wait for the IV!

Front 43

What do you do after you've given the dose?

Back 43

- STAY with the child until they are FULLY ALERT

- immediately commence F-75 diet OR glucose in water 60g/L

- Commence BROAD SPECTRUM ABx for suspected serious systemic infection

Front 44

What are you going to do to PREVENT the child getting a hypoglycaemic episode again?

Back 44

FEED THEM every 2-3 hrs day and night via PO or via NG.

Front 45

Name 5 risk groups in malnourished children that are more susceptible to hypothermia.

Back 45

1) infants <1 year old

2) marasmus

3) large areas of damaged skin

4) have a serious infection

5) hypoglycaemic

Front 46

How do you know if the child should be warmed?

Back 46

Temperature:

- RECTAL < 35.5°C

OR ARMPIT < 35°C.

Front 47

What measures must you take with all non-hypothermic malnourished children that are admitted in order to PREVENT them becoming hypothermic?

Back 47

• Environment: Room temp 25–30°C NECESSARY. KEEP AWAY from window/draught. Close windows at night.

• Clothes: Lots of clothes incl hat, blankets.

• Activities: Only wash if necessary and do during day. Dry IMMEDIATELY and thoroughly.

Front 48

How do you TREAT a hypothermic child?

Back 48

Either:

1) Kangaroo technique: Skin to skin contact with mother's chest or abdomen and cover both of them

OR

2) Lamp-warming: CLOTHE child well including a HAT, cover with WARMED BLANKET, incandescent lamp over but NOT TOUCHING child's body.

Front 49

You only have a fluorescent lamp. Is that good enough?

Back 49

No. They do not work.

Front 50

What about a hot water bottle?

Back 50

Too dangerous, cause burns.

Front 51

What is he risk when rewarming using the lamp technique? How would you prevent this?

Back 51

Child becomes hyperthermic quickly.

Monitor RECTAL temperature every 30 MINS.

Front 52

That seems a aggressive, can I just use armpit temperature?

Back 52

No. Because it is NOT a reliable easement of core body temp during rewarming.

Front 53

Considering the reasons why a malnourished child would be more likely to become hypothermic (think RFs), what else must you treat the hypothermic malnourished child for in addition to their hypothermia?

Back 53

Hypothermia can be caused by serious systemic infection and/or hypoglycaemia. Therefore, all hypothermic malnourished children must be treated for HYPOGLYCAEMIA and SYSTEMIC INFECTION.