federal ministry of health, nigeria family health ...€¦ · 3 3 3.1.1.4 absent bowel sounds,...
TRANSCRIPT
1
1
NATIONAL GUIDELINES FOR INPATIENT MANAGEMENT OF SEVERE ACUTE MALNUTRITION IN INFANTS AND YOUNG CHILDREN IN NIGERIA
FEDERAL MINISTRY OF HEALTH, NIGERIA FAMILY HEALTH DEPARTMENT
NUTRITION DIVISION FEBRUARY, 2016
2
2
NATIONAL GUIDELINES FOR INPATIENT MANAGEMENT OF SEVERE ACUTE MALNUTRITION IN INFANTS AND YOUNG CHILDREN IN NIGERIA
Table of Contents Page No Acknowledgements - - - - - - - - - 4 Foreword- - - - - - - - - - - 6 List of Contributors - - - - - - - 7 Acronyms and Abbreviations - - - - - - - 9 List of Figures, Boxes and Tables
CHAPTER 1: Background
1.1. Severe Acute Malnutrition (SAM) in Nigeria 1.2. Integrated Management of Acute Malnutrition (IMAM) approach
CHAPTER 2: Assessment of severe acute malnutrition
2.1. Definition of severe acute malnutrition 2.2. Inpatient admission criteria
2.3. Anthropometric Measurement Techniques
2.3.1. Measuring MUAC 2.3.2. Checking bilateral oedema and Grading 2.3.3. Measuring Weight 2.3.4. Measuring Length/Height 2.3.5. Determining Weight- for-Height/length Z-Score
2.4. Initial clinical assessment 2.5. Medical complications in patients with SAM 2.6. Appetite test
2.6.1. How to do Appetite Test 2.6.2. Interpretation of Appetite Test
CHAPTER 3: Principles of Inpatient care
3.1. Phases of Inpatient Care for Children 6-59m 3.1.1. Stabilization Phase
3.1.1.1 Dehydration in marasmic patients 3.1.1.2 Shock 3.1.1.3 Septic (Toxic) shock
3
3
3.1.1.4 Absent bowel sounds, gastric dilatation and intestinal splash with abdominal distension
3.1.1.5 Heart Failure 3.1.1.6 Hypernatremic Dehydration 3.1.1.5 Correct Severe anaemia 3.1.1.6 Hypoglycemia 3.1.1.7 Hypothermia 3.1.1.8 Infection
3.1.1.9 Micronutrient deficiencies 3.1.1.10 Feeding including Breastfeeding 3.1.1.11 Addressing Associated Conditions
3.1.1.1. Vitamin A Deficiency 3.1.1.2. Dermatoses 3.1.1.3. Scabies 3.1.1.4. Helminthiasis 3.1.1.5. Persistent diarrhea and dysentery 3.1.1.6. Tuberculosis 3.1.1.7. HIV 3.1.1.8. Other Infections and Conditions 3.1.1.9. Malaria 3.1.1.10. Fever 3.1.1.11. Refeeding syndrome 3.1.1.12. Associated conditions
3.1.2. Transition Phase
3.1.2.1. Catch-up Growth Feeding 3.1.3 Rehabilitation Phase
3.1.3.1 Referral from Inpatient to OTP 3.1.3.2 Providing Sensory Stimulation
3.1.3.3. Nutritional Counselling and Appropriate Infant and Young Child Feeding (IYCF) practices
3.2 Infants <6months with SAM
4
4
CHAPTER 4: Organization of Inpatient Facility (IPF)
4.1. Admission ward
4.2. Roles of Service providers
4.2.1. Doctors 4.2.2. Nurses 4.2.3. Dietitians and Nutritionists 4.2.4. Pharmacist 4.2.5. Records Officer 4.2.6 Community Health Extension workers/Community Health Officers 4.2.7 Medical Social Workers
4.3. Records
4.3.1. Malnutrition record books 4.3.2. Admission and monitoring charts
4.4. Medicines
4.4.1. Routine first line 4.4.2. Alternative and supplementary medicines
4.5. Equipment and supplies
4.5.1. Anthropometric tools 4.5.2. Kitchen equipment and supplies 4.5.3. Therapeutic foods 4.5.4. Other materials
CHAPTER 5: Failure to respond to treatment
5.1. High Mortality 5.2. Low weight gain during rehabilitation phase 5.3. Re-feeding syndrome
CHAPTER 6: Transfer to Outpatient Therapeutic Program (OTP)
6.1. Transfer criteria for rehabilitation in OTP
5
5
6.2. Two way referral system 6.3. Follow-up at OTP 6.4. Discharge criteria
CHAPTER 7: Monitoring quality of care
7.1. Definition of terms 7.2. Performance indicators 7.3. Mortality audit 7.4. IPF Monthly reporting 7.5. Categories for report writing 7.6. IPF Supervision by relevant agents
List of Tables Table 1 - Admission Criteria for inpatient care Table 2 - MUAC reading interpretation Table 3- Grading of oedema Table 4- Interpretation of weight for height Z-scores Table 5- Medical Complications for admission into inpatient care Table 6- Interpretation of Appetite test Table 7- Vitamin A doses by age Table 8- Amounts of F75 to give during Stabilization Phase Table 9- Look up table for RUTF in Transition Phase per 24h Table 10- Look up table for F-100 in Transition Phase per 24h Table 11- Admission criteria for infants < 6 months Table 12- Criteria for Failure-to-respond for In-Patients Table 13- Case fatality rates Table 14- Categorization of weight changes Table 15- Admission and exit criteria Table 16- SPHERE Indicators
List of Figures Figure 1- Care model for severe acute malnutrition Figure 2- Bilateral pitting pedal oedema Figure 3- Measuring the length of the child less than 87cm Figure 4- Measuring the height of the child greater than 87cm Figure 5- Determination of Weight for height Z –Scores using unisex table Figure 6- Treatment of dehydration in marasmic children Figure 7- Monitoring rehydration in Marasmic children Figure 8- Algorithm of respiratory distress Figure 9- Managing Anaemia Figure 10- Feeding F-75 by mouth Figure 11- Breastfeeding Infant Figure 12- Supplementary suckling technique
Annexes
Annex 1- Anthropometric measurement techniques Annex 2- Weight for length/Height Unisex Table
6
6
Annex 3- Recipes for F-75,F-100 and ReSoMal Annex 4- Critical Care Pathway Chart Annex 5- Weight loss and weight gain by 5% chart Annex 6- Drug reference tables Annex 7- RUTF specification Annex 8- Daily Ward Feed chart Annex 9- F-75 feed volumes for children Annex 10- Multi- chart for monitoring progress Annex 11- Inserting a Nasogastric tube RUTF ration chart Annex 12- Simple toys for emotional and psychological stimulation Annex 13- RUTF/F-100 ration chart Annex 14- Supplementary Sucking technique milk volumes Annex 15- IPF Record book Annex 16- F-100 Dilute look- up table Annex 17- Transfer form Annex 18- IPF Monthly reporting form Annex 19- IPF Supervisory checklist
7
7
ACKNOWLEDGEMENTS
The Federal Ministry of Health is indebted to several Stakeholders for their concerted efforts
in the development of this guideline. The process included series of consultative meetings
and workshops in collaboration with relevant stakeholders in Nutrition on the review of
various materials and experiences in the management of acute malnutrition in Nigeria and
global research findings.
The technical and financial contributions of UN Agencies, Development partners, Multi-lateral and Bi-lateral agencies, representatives from the Core Technical Committee on Maternal, Newborn and Child Health (MNCH), National Primary Health Care Development Agency (NPHCDA), State Ministries of Health and State Primary Health Care Development Boards is highly commendable.
The Academia and Professional bodies including Dietitians Association of Nigeria, Nutrition
Society of Nigeria, Paediatric Association of Nigeria, Paediatric Nurses Association of
Nigeria and Consultants whose contributions in reviewing this document are also
appreciated.
Finally, the facilitation of the Federal Ministry of Health; Department of Family Health,
Nutrition Division under the leadership of Dr. Chris Osa Isokpunwu is acknowledged
gratefully.
Dr. Wapada I. Balami, mni Head, Family Health Department February, 2016
8
8
FOREWORD
Management of acute malnutrition has been primordial due to the nutritional effects on the
socio-economic development of any nation. The 21st century eight-millennium development
goals and the current seventeen Sustainable Development Goals (SDGs) emphasized at
various International and National Summits have direct or indirect link to nutrition.
Though poor knowledge of basic nutrition education and poverty are major challenges to
optimal nutritional practices, yet, inherent behavioural factors are consistently the basic
cause of poor health seeking and promotion practices in Nigeria.
Nigeria has developed National Guidelines and Training Manuals for Community
Management of Acute Malnutrition with emphasis on management at Primary Health
facilities called Outpatient Therapeutic Programme (OTP) sites. According to WHO (2013),
the use of Inpatient guidelines on Management of Severe Acute Malnutrition has
contributed immensely to the reduction of case fatality load in secondary and tertiary
facilities. The use of both National Guidelines for Inpatient and Community Management of
Acute Malnutrition would “strengthen the effective and safe nutrition actions to
counteract the public health effects of malnutrition”.
The National Guidelines for Inpatient Management of Severe Acute Malnutrition at
Inpatient facilities seek to provide practical guide to health and nutrition workers who
design, implement, monitor and evaluate acute management programmes in Secondary and
Tertiary health facilities. The adaptation of this guideline is from the 2013 WHO Updates on
the management of Acute malnutrition in infants and children and the 2012 Generic
Protocol for Integrated Management of Acute Malnutrition (WHO, 2013; Golden et al.,
2012). It would be useful to all health practitioners and planners/managers in Public and
Private Institutions as it takes cognizance of the local realities and circumstances of Nigeria.
I recommend that this relevant information for management of complicated acute
malnutrition will be useful to all health workers in various Referral Health institutions
across the Federation.
Professor Isaac F. Adewole FAS, FSPSP, DSc (Hons) Honourable Minister of Health February, 2016
9
9
LIST OF CONTRIBUTORS
Federal Ministry of Health
Dr. Wapada I. Balami, mni
Dr. Chris Osa Isokpunwu
Mrs. R. E. Gabriel
Mr. J. E. Uruakpa
Thompson K.C.
Mr. E. A. Peter
Ms. F. R. Kia
Mrs. B.N. Ali
Mrs. F.U.Oyibo
Pharm Gbenga. S. Joseph
Mrs. O.E. Oladapo
National Primary Health Care Development
Agency
Mrs. Chinwe Ezeife
Dr. Ogechi Akalonu
Lagos State Ministry of Health
Dr. Abimbola Ajayi
Mrs. Oluwatoyin Adams
Aishatu Yahya Muhammad Kano State Primary Health Care
Management Board
Mrs. Endaline Ezeri Women and Children Welfare Clinic,
Sokoto
Prof. E. O. Ojefeitimi Academia
Professional Bodies
Sani S. Hassan Nutrition Society of Nigeria
Tamra Runsewe-Abiodun Paediatric Association of Nigeria
10
10
Lawal R. Olubunmi Paediatric Nurses Association of Nigeria
PARTNERS
Dr. Andrew L. Mbewe WHO
Dr. B.D. Omotola UNICEF
Christine Kaligirwa
Oluniyi Oyedokun
Dr. Tamanna Ferdous ACF
Dr. Adaeze Oramalu SCI
Dr. Friday Ilop Joseph
CONSULTANTS
Dr. Chika Ndiokwelu
Dr. Halima Abdu
Administrative staff
Mrs. Theresa Danjuma
Mr. Umar Abdul
Mrs. Glory Owunna
Mrs. Theresa Oyi
11
11
ACRONYMS AND ABBREVIATIONS
ACF Action La Contre Faim (Action against Hunger)
ACT Artemisinin Combination Therapy
AIDS Acquired immunodeficiency syndrome
ART Antiretroviral therapy
BCG Bacille Calmette-Guérin
CSF Cerebrospinal fluid
DHS Demographic and Health Survey
F-75 Therapeutic milk used in acute phase of SAM Inpatient treatment
F-100 Therapeutic milk used in Transition/Recovery phases of SAM treatment
GAM Global Acute Malnutrition
GMP Growth Monitoring and Promotion
Hb Haemoglobin
HIV Human immunodeficiency virus
IFE Infant Feeding in Emergency (documents on feeding infants less than 6 months
IM Intramuscular (injection), intramuscularly
IMAM Integrated Management of Acute Malnutrition
IMCI Integrated Management of Childhood Illness
IPF In-Patient Facility
IU International Units
IV Intravenous (injection), intravenously
IYCF Infant and Young Child Feeding
Kg Kilogramme
LoS Length of Stay
MAM Moderate Acute Malnutrition
MUAC Mid Upper Arm Circumference
ORS Oral rehydration salt(s)
OTP Outpatient Therapeutic Programme
PENTA Pentavalent vaccine that has replaced Diphtheria, pertussis, tetanus (DPT)
ReSoMal Rehydration solution for malnutrition
RUTF Ready-to-Use Therapeutic Food (has same nutritional composition as F100 with
added iron and clinically tested in efficacy trials to ensure their therapeutic equivalence to F100
SAM Severe Acute Malnutrition
SC Stabilization Centre
SD Standard Deviation
SFP Supplementary Feeding Programme
SNO State Nutrition Officer
TB Tuberculosis
12
12
UNICEF United Nations Children Fund
WFH Weight-for-Height (Z scores)
WFP World Food Programme
WHO World Health Organization
W/H &W/L Weight-for-Height & Weight-for-Length
Z score Standard Deviations score
CHAPTER 1: BACKGROUND
1.1. Severe Acute Malnutrition(SAM) in Nigeria
Childhood undernutrition is a major global health problem, contributing to childhood
morbidity, mortality, impaired intellectual development, poor school achievement,
suboptimal adult work capacity, and increased risk of non-communicable diseases in
adulthood. From the end of the neonatal period and through the first five years of life, the
main causes of death are pneumonia, diarrhoea and malaria with malnutrition as the
underlying contributing factor in about 45% of all child deaths and making children more
vulnerable to severe diseases (WHO, 2015). Severe acute malnutrition (SAM) remains a
major cause of child mortality worldwide. Of the 7.6 million deaths annually among
children who are under 5 years of age in developing nations, approximately 50% are due to
nutrition-related factors and 4.4% of these deaths have been shown to be specifically
attributable to severe wasting (Black et al., 2013).
The 2013 Nigeria Demographic and Health Survey (NDHS, 2013) in comparison with 2008
results revealed an increase in wasting from 14% to 18%, underweight from 23% to 29% and
a marginal drop in stunting from 41% to 37% (NDHS, 2013) These are the visible signs of
malnutrition but there are other forms of malnutrition that are less obvious, they are called
'hidden hunger' and occur as a result of inadequate, unbalanced or excessive consumption
of micronutrients.
As data have confirmed, malnutrition starts in utero and increase markedly from 3 to 23
months of age. Ensuring adequate nutrition during this “1000 days window of opportunity”,
therefore, is critical in preventing long-term and irreversible damage to children’s health,
cognitive and physical development (Save the Children, 2012)
Infants and young children are particularly susceptible to malnutrition if complementary
foods are of low energy, low nutrient density and have low bioavailability of micronutrients.
In addition, children’s nutritional status will be further compromised if complementary
foods are introduced too early or too late, or are contaminated. The nutritional status of
children can also be affected by chronic infections such as HIV and tuberculosis. It is
estimated that over 2 million children worldwide are living with HIV, 90% of them in sub-
13
13
Saharan Africa and nearly 60,000 Nigerian children infected with the virus in
2012.(2013:Global HIV report)
Based on the above findings, the improved management of severe acute malnutrition as an
integral part of the World Health Resolution on Infant and Young Child Nutrition (WHA
63.23), to improve child survival and to reduce the global burden of disease is strategic.
1.2. Integrated Management of Acute Malnutrition (IMAM) approach
Previously, children suffering severe forms of malnutrition were treated exclusively at the
hospital level. Several elements have facilitated the shift to an integrated approach that aims
for improved coverage for the treatment of severe acute malnutrition.
This approach involves:
active case-finding
treatment of malnourished individuals in the community wherever possible (Severe Acute malnutrition (SAM) to nearest Outpatient Therapeutic Program (OTP) and moderate acute malnutrition (MAM) to nearest Supplementary Feeding Centre (SFC))
improved treatment of severely malnourished infants and young children with medical complications in hospitals for stabilization
creation of opportunities for increased capacity building, supervision, and investment in community nutrition and development
Emotional and physical stimulation for malnourished children and psychosocial support for their caregivers to minimize the effects of malnutrition on brain and cognitive development
In order to achieve early identification of children with SAM (and with MAM if a program
exists) in the community, trained community health workers and community members
should measure the mid-upper arm circumference and examine them for bilateral pitting
oedema. Infants and children who are 6–59 months of age and have a mid-upper arm
circumference <11.5cm, or have any degree of bilateral oedema, should be immediately
referred for full assessment at an outpatient treatment program(OTP), a component of the
Integrated Management of Acute Malnutrition (IMAM) for the management of severe acute
malnutrition without medical complications. Outpatient treatment of uncomplicated severe
acute malnutrition is increasingly provided, using Ready-to-Use Therapeutic Foods
(RUTF).This is a high -energy, fortified, ready-to-eat foods used to treat children with severe
acute malnutrition.
14
14
A small but significant percentage of these children with SAM may present with various
complications (such as anorexia (lack of appetite, lethargic, hypothermia, severe oedema
(+++), hypernatremic dehydration, hypoglycaemia, absent bowel sounds, heart failure,
fever, severe anemia, refeeding syndrome, HIV/AIDS, tuberculosis, skin infections,
respiratory and urinary tract infections, septic shock, persistent or chronic diarrhea, re-
feeding diarrhoea after admission as a result of profoundly disturbed physiology and
metabolism and require special attention. These patients cannot be managed as outpatients
and would need specialized care in inpatient facilities (IPF) to bring them out of danger. In
exceptional circumstances, patients can remain in the IPF for rehabilitation phase. This
applies to children that are abandoned by their families, where the home circumstances are
challenging, where there is no caregiver or the caregiver is incapable of managing the
patient and there is no alternative caregiver.
In view of the above, it was imperative that the National guideline for inpatient
management of infants and young children with Stabilization Care of SAM children in
Nigeria be developed. This guideline is adapted in part through subsequent WHO and
UNICEF publications on the outpatient management and inpatient treatment of children
with severe acute malnutrition.
15
15
Fig 1: Care model for severe acute malnutrition
CHAPTER 2: ASSESSMENT OF SEVERE ACUTE MALNUTRITION
2.1. Definition of Severe Acute Malnutrition (SAM)
16
16
Severe acute malnutrition is defined as the presence of bilateral oedema and or severe
wasting (weight-for-height/length <-3 Z score or mid-upper arm circumference < 115
mm).These criteria may be used for children up to the age of ten years. However this
guideline focuses on infants and children five years and below.
No distinction is made between the clinical conditions of kwashiorkor or severe wasting
because their treatment is similar, however children with Kwashiorkor are generally more
fragile with a higher risk for mortality than wasted children and need closer monitoring.
Children who are <-3 Z weight-for-age may be stunted (short stature) but not be severely
wasted. Stunted children who are not severely wasted do not require hospital admission
unless they have a serious illness where they should be treated according to the protocol for
integrated management of Childhood illnesses (IMCI) in a pediatric ward (WHO, 2013).
Inpatient admission criteria
Table 1: Admission Criteria for inpatient care:
Children 6 to 59 months
Infants < 6 months OR < 3 kg
Mid –upper arm circumference (MUAC) < 115mm
OR
The infant is too weak or feeble to suckle effectively (irrespective of his/her weight –for-length(WL), Weight-for- Age (WA) or any other anthropometry
weight-for-height/ length (WHZ) < -3 Z score (WHO2006 standards unisex table) OR
Weight for length (WLZ)<-3 Z ( OR
Bilateral oedema (+++)
OR
Bilateral Oedema (any grade) OR
Body weight less than 3.5kg Infant not gaining weight at home(by serial measurement of weight during Growth Monitoring Promotion (GMP)
Presence of medical complications including lack of appetite
Where only inpatient facility care is available, all children who are 0 to 59 months and have
the above diagnostic features of Severe Acute Malnutrition should be admitted for
stabilization care and as soon as they regain their appetites should continue as outpatients,
whenever the caregiver agrees and an outpatient program is in place. In exceptional cases
the patients can remain in the inpatient facility for the recovery phase.
In areas where IMAM exists and inpatient facility is also available
17
17
Patients more than 6 months with SAM without medical complications and a good
appetite should be treated in the Community based outpatient therapeutic program
Patients more than 6 months with SAM, medical complications and or a failed
appetite test should be admitted for stabilization care in the inpatient facility.
Infants less than 6 months with the above features should also be admitted into the
IPF because they have special dietary needs and are metabolically more vulnerable.
2.2. Nutritional Assessment
Nutritional assessment parameters include anthropometric, biochemical, clinical, and
dietary tests. However, for admission to the program the anthropometric and bilateral
pitting pedal oedema parameters are used exclusively. The skilled trained health care
provider should thoroughly assess the children as follows:
Measure Mid upper arm Circumference (MUAC)
Measure Weight
Measure Height
Determine the weight for height/Length z score using the weight for height/length
reference card
Check for bilateral oedema of the feet and grade the oedema
Measuring the MUAC
MUAC is a measure of ‘’thinness’’. It is used for children over 6 months.
The measurement procedure for MUAC is
Bend left arm at right angles
Locate tip of shoulder (acromion) and elbow (olecranon)
Measure the distance between the two points and locate the midpoint
With arm relaxed – and straight, wrap tape around the midpoint and measure
Note: Tape should snug against the skin without pinching or leaving gaps
A pictorial guide to measuring MUAC is provided in Annex 1
The MUAC is interpreted as follows Table 2: MUAC reading interpretation
Color coding Measurement Indicator
RED <11.5cm Severe acute Malnutrition
YELLOW 11.5 - < 12.5 cm Moderate acute Malnutrition
18
18
GREEN ≥ 12.5 cm No acute Malnutrition
Check for bilateral pitting pedal oedema and grading.
Bilateral oedema is a sign of Kwashiorkor. These children are associated with a high risk of mortality. In order to determine the presence of oedema, apply pressure on the top of both feet for three seconds and observe for a pit (indentation) on the foot when the thumb is lifted (See annex 1 for pictorial guide)
Fig 2: Bilateral pitting pedal oedema Oedema in all children is graded using the classification below: Table 3: Grading of oedema
Grade of Oedema Definition
Grade + Mild: both feet/ankles
Grade ++ Moderate: more than feet/ankles but not generalized to the whole body
Grade +++ Severe: generalized oedema including feet, legs, hands, arms and face.
Measuring weight
Children may be weighed by using electronic balance (e.g. SECA scale) or 25kg hanging salter scale graduated to 100gm and for children less than 8kg a precision scale with 10-20g precision. The electronic scale SECA was conceived to allow the weighing of children and
19
19
women. The scale allows for fast, easy and precise weighing. However if not available, the salter scale with basin may be used as an alternative. (See annex 1 for pictorial guide on measuring weight)
Measuring length/height
For children less than 87 cm, the measuring board is placed on the ground. The child is
placed, lying along the middle of the board. The assistant holds the sides of the child’s head
and positions the head until it firmly touches the fixed headboard with the hair compressed.
The measurer places her hands on the child’s legs, gently stretches the child and then keeps
one hand on the thighs to prevent flexion. While positioning the child’s legs, the sliding foot-
plate is pushed firmly against the bottom of the child’s feet. To read the measure, the foot-
plate must be perpendicular to the axis of the board and vertical. The height is read to the
nearest 0.1 centimetre.(See pictorial annex 1)
The longer lines indicate centimetre marking; the shorter lines indicate millimetre.
©WHO Growth standard training
20
20
Fig 3: Measuring the length of the child less than 87cm For children more than 87 cm, the measuring board is fixed upright where the ground is level. The child stands, upright in the middle, against the measuring board. The child’s head, shoulders, buttocks, knees, heels are held against the board by the assistant, while the measurer positions the head and the cursor. The height is read to the nearest 0.1 centimetre
(See pictorial annex 1)
Detail of the measurement
©WHO Growth standard training
©Shorr Productions
Fig 4: Measuring the height of the child greater than 87cm NOTE: Whatever measure (MUAC or weight for Height) is used for admission should be the measure used for discharge from nutritional care.
21
21
Determination of Weight for height Z –Scores using unisex table
The examples below will describe how to use the weight/height z-score tables (See Unisex table in Annex 2)
Example: a child is 63 cm length and weighs 6.5 kg.
Take the table, look in the 1st column and look for the figure 63cm (=height).
Take a ruler or a piece of card, place it under the figure 63 and the other figures on the same line.
On this line find the figure corresponding to the weight of the child, in this case 6.8.
Look to see what column this figure is in. In this case it is in the MEDIAN WEIGHT column.
In this example the child’s weight is normal in relation to his LENGHT. He therefore has an appropriate weight for his length.
Example: a child is 78 cm tall and weighs 8.3 kg
This child is between the column -2 & -3 Z-score or between MAM and SAM. He is too thin in relation to his length or less than -2 and more than -3; he is <-2 (less) and >-3 (more): he is MODERATELY MALNOURISHED but NOT Severely Malnourished.
NOTE: It may be that the weight or the height is not a whole number.
Example: length: 80.4 cm and weight 7.9 kg. These 2 figures are not in the table.
For the height/length: The height/length measurement has to be rounded to the nearest 0.5cm, as it is in the following example.
LENGTH in cm
80.0
80.1
80.2
80.3
80.4
80.5
80.6
80.7
80.8
80.9
81.0
81.1
81.2
Fig 5.Determination of Weight for height Z –Scores using unisex table
80.0cm is used for:
80.1 and 80.2cm
80.5cm is used for:
80.3 and 80.4cm
80.5cm is used for:
80.6 and 80.7cm
81.0cm is used for:
80.8, 80.9 cm as well as 81.1
and 81.2 cm
22
22
For the weight: Looking at the table, for a length of 80.5 cm the weight is 7.9 kg. This is between 7.7 and 8.3 kg. Conclusion, to express the fact that the child is between these 2 weights, write down that this child’s Z-score is between -4 and -3 Z-score or <-3 AND >-4 Z-score. The child has SAM (See pictorial annex 1). Table 4: Interpretation of weight for height Z-scores
Z –scores Indicators
< -3 z Severe acute malnutrition
<--2 z to and ≥–3z Moderate acute malnutrition
≥- 2 z Normal nutrition
2.3. Clinical Assessment (IMCI) Assess for general danger signs or emergency signs and take a history concerning:
recent intake of food and fluids
usual diet before the current illness
breastfeeding
duration and frequency of diarrhoea and vomiting
type of diarrhoea (watery/bloody)
loss of appetite
family circumstances
Birth weight
cough > 2 weeks
contact with TB
recent contact with measles
known or suspected HIV
Infection /exposure
Immunization status Medical complications in patients with SAM
Children with one or more IMCI signs should be admitted into the inpatient facility (IMCI, 2011)
Table 5: Medical Complications for admission into inpatient care
Category Criteria Children >6months
Any of the following Bilateral pitting oedema+++
23
23
OR Kwash-marasmus (W/H<-3SD AND bilateral oedema)
OR
MUAC <11.5cm or W/H <- 3 SD AND bilateral pedal oedema +/++
WITH any of the following complications
anorexia or poor appetite test Severe vomiting Hypothermia ≤ 350 C (axillary) Fever ≥ 390 C (axillary) Severe respiratory distress
>60 breaths/min for under 2 months >50 breaths/min from 2 to 12 months >40 breaths/min from 1 to 5 years >30 breaths /min for > 5years
Chest in-drawing Very pale (Severe anaemia)
Severe dehydration- Diarrhoea and dehydration
based on history & change in appearance (clinical
signs are unreliable in the malnourished and should
NOT be used to diagnose dehydration)
Not alert (very weak, lethargic, unconscious, fits or convulsions)
Shock (lethargic, unconscious; with cold hands, slow capillary refill (> 3s) or weak (low volume), rapid pulse and low blood pressure
Eye signs of Vitamin A deficiency: - Dry conjunctiva or cornea, bitot spots - Corneal ulceration - Keratomalcia
Extensive skin lesions Conditions requiring IV infusion or NG tube feeding
Choice of the caretaker Children < 6months Infant too weak or feeble to suck
effectively(INDEPENDENTLY of his/her weight –for-length) OR
Weight-for-length (W/L)<-3SD OR
Visible severe wasting OR
Presence of bilateral oedema
2.5. APPETITE TEST
24
24
The appetite test is a reliable way to differentiate complicated from uncomplicated cases of SAM. A poor appetite test is an indication of significant infection or a major metabolic abnormality and an immediate risk of death. It is an indication for care in an Inpatient Facility (IPF). The appetite test will also be used in inpatient setting to assess if the child in the stabilization phase can transit from the IPF to the outpatient program (OTP). How to do the appetite test
Explain to the caregiver the purpose of appetite test and how it is carried out
Let the mother wash her hands properly with soap and water
Let the mother wash the hands and face of her child with soap and water
Open the ready to use therapeutic food and give the child to eat directly or put a small amount on the mother’s finger and give it to the child.
Pre-Prepare graduated 20 to 25 ml medicine cups before the start of the appetite test. The packet of RUTF normally holds almost 100g of the paste. It is much easier to judge the amount taken from a graduated medicine cup than from the packet itself
The mother or caregiver must NOT consume any of the RUTF.
If child refuses, continue to quietly encourage the child. Do not force the child to take the RUTF. It often helps if the mother pretends to take some and like it; seeing the mother eat the RUTF herself is the best way to encourage the child.
Sometimes the child will not eat the RUTF because he or she is frightened, distressed or fearful of the environment (e.g. if nosily) or the staff. The child may be taken to a quiet place to do the test and the child may be initially allowed to play with the RUTF packet and become familiar with the environment.
The RUTF must be given with plenty of water to drink
The caregiver must not force feed the child Interpretation of the Appetite test Table 6: Interpretation of Appetite test
APPETITE TEST
“Moderate” is the minimum amount that malnourished patients should take to pass the
appetite test
BODY
WEIGHT
PASTE IN SACHETS
(PROPORTION OF WHOLE SACHET
92G)
PASTE IN CONTAINERS
(ML or GRAMS )
poor moderate Good poor moderate good
Less than 4
kg <1/8
1/8 –1/4
>1/4 <15
15 – 25
>25
4 – 6.9 <1/4 1/4 – 1/3 >1/3 <25 25 – 30 >35
25
25
7 – 9.9 <1/3 1/3 – 1/2 >1/2 <35 35 – 50 >50
10 – 14.9 <1/2 1/2 –3/4 >3/4 <50 50 – 75 >75
15 – 29 <3/4 3/4 – 1 >1 <100 100 – 150 >150
Over 30 kg <1 >1 <150 >150
Note: if different size small medicine cups are used then a new table should be constructed,
depending on the size of the cup. The table should be in the number of medicine-cups the child
should take for his/her category of weight. The majority of children will be from 4 to 6.9kg so
the minimum test to differentiate a poor appetite would then be one level medicine-cup of
25ml.
Pass appetite test
A child that takes at least the moderate amount of RUTF shown in the appetite test table passes the appetite test.
Fail appetite
A child that does not take at least the “moderate” amount of RUTF fails the test. Even if the child is not taking the RUTF because s/he does not like the taste or is frightened, the child did not pass the appetite test.
CHAPTER 3: THE PRINCIPLES OF INPATIENT CARE
Patients that require in-patient care generally have poor appetites and usually have complications such as diarrhoea, dehydration, sepsis, pneumonia, severe anaemia, etc. The management of acute or life threatening complications take precedence over routine care and may change the way in which the routine care is given.
On arrival in the Inpatient facility, all SAM patients must be treated as an emergency in the paediatric ward and not in the Emergency ward or Casualty department, unless the Staff of these units have had specific training on the management of complications in malnourished children. Experience has shown that rapid staff turnover and workload in the Emergency and Casualty departments are such that these are the main places where misdiagnosis, mistreatment and iatrogenic death take place.
In the Inpatient Facility (IPF)
26
26
Anthropometric and clinical assessments should be taken to classify the status as discussed in the earlier chapter and monitor progress.
Explain the situation to the caregiver
The Record officer should open an inpatient card and assign a number (The SAM number on the transfer slip if from an OTP should be clearly noted on the card, see section on Monitoring)
The child should then be admitted into the specially designated admission ward or area for malnourished children.
3.1. Phases of inpatient Care for children 6- 59 months
The phases of inpatient care are divided into three;
Stabilization phase:
This is the most critical period in inpatient care where life threatening problems are identified, specific deficiencies are corrected, metabolic abnormalities are reversed and feeding is begun and occurs in the hospital setting. This phase may take 3 to 5 days, however this duration also depends on the severity of the complication. The following medical complications should be addressed in the stabilization phase of care
Dehydration Shock Septic (Toxic) shock Absent bowel sounds, gastric dilatation and intestinal splash with abdominal
distension Heart Failure Correct Severe anaemia Hypoglycemia Hypothermia Infection Micronutrient deficiencies Therapeutic feeding Including Breastfeeding Addressing Associated Conditions
o Vitamin A Deficiency o Dermatoses o Scabies o Helminthiasis o Persistent diarrhea and dysentery o Tuberculosis o HIV
3.1.1.1: Treat and Prevent dehydration in Marasmic patients
Diagnosis
27
27
Dehydration is a common occurrence in children. However, dehydration tends to be over diagnosed and its severity overestimated in children with severe acute malnutrition. It is difficult to determine dehydration accurately from clinical signs alone because the clinical signs of dehydration may already be present in these children (e.g. slow skin pinch, sunken eyes, dry mouth). Rehydration fluids are never given “routinely” to malnourished patients.
With severe malnutrition the “therapeutic window” is narrow, so that even dehydrated children can quickly go from having a depleted circulation to over-hydration with fluid overload and cardiac failure. IV infusions are rarely used. In malnutrition (both marasmus and, to a greater extent, kwashiorkor) there is a particular renal problem that makes the children sensitive to salt (sodium) overload.
Do NOT use the standard protocol for the well-nourished dehydrated child
Do NOT make a bucket of ORS or ReSoMal freely available for the caretakers to give to their SAM children whenever they have a loose stool. This leads directly to heart failure, as well as failure to lose œdema, re-feeding œdema, and failure to report and record significant problems.
Do NOT treat if there is no dehydration, diarrhoea is not treated with rehydration fluids to “prevent” the onset of dehydration in SAM children. This again leads to over-hydration and heart failure.
It is important to note that poor circulatory volume or perfusion can co-exist with oedema.
Do NOT use the classical signs of dehydration, they are unreliable.
Thus, marasmic skin normally lies in folds and is inelastic so that the “skin pinch” test is usually positive whether or not the child is dehydrated.
Do NOT use the skin pinch test to diagnose dehydration in severely malnourished children.
Marasmic eyes are normally sunken without them being dehydrated.
Do NOT diagnose dehydration in malnourished patients because they have sunken eyes.
The consequences of over-hydration are very much more serious than slight dehydration. On the other hand truly dehydrated children must be appropriately rehydrated if they are to survive.
The malnourished child is managed entirely by
Weight changes and
Clinical signs of improvement and
Clinical signs of over-hydration
Treatment
28
28
Do not use the IV route for rehydration, except in cases of shock. Rehydrate slowly, either orally or by nasogastric tube, using commercially prepared oral rehydration solution for malnourished children (ReSoMal). The standard low-osmolarity WHO ORS solution for general use has a high sodium and low potassium content, which is not suitable for severely malnourished children.
Weigh the child – TO THE NEAREST 10g!!! Note the liver edge Record respiratory rate and pulse rate Give the ReSoMal rehydration fluid orally or by nasogastric tube, more slowly than
you would when rehydrating a well-nourished child: o Give 5 ml/kg every 30 min for the first 2 hours.
If ReSoMal is not available, then give half strength low osmolarity WHO oral rehydration solution with added potassium and glucose as per the ReSoMal recipe in annex 3, unless the child has cholera or profuse watery diarrhoea.
Give 30 mls of ReSoMal for each watery loose stool that is lost During re-hydration breastfeeding should not be interrupted. Begin to give F75 as
soon as possible, orally or by naso-gastric tube. ReSoMal and F75 can be given in alternate hours if there is still some dehydration and continuing diarrhoea. Introduction of F75 is usually achieved within 2-3 hours of starting re-hydration.
If in shock or severe dehydration but cannot be rehydrated orally or by nasogastric tube, give IV fluids, either Ringer’s lactate solution with 5% dextrose or half-strength Darrow’s solution with 5% dextrose. If neither is available, 0.45% saline with 5% dextrose should be used.
Do not interrupt breastfeeding during rehydration. Monitoring
During rehydration, respiration and pulse rate should fall and urine start to be passed. The return of tears, a moist mouth, less sunken eyes and fontanelle, and improved skin turgor are also signs that rehydration is proceeding, but many severely malnourished children will not show these changes even when fully rehydrated. Monitor weight gain.
Monitor the progress of rehydration every 30 mins for 2 hours, then every hour for the next 4 –10 hours and document in the CCP chart (Annex 4). Be alert for signs of over hydration, which is very dangerous and may lead to heart failure. Check for:
weight gain to ensure that it is not quick and excessive. increase in respiratory rate (increase of ≥ 5 breaths /min) increase in pulse rate ( increase of ≥25beats/min ) puffy eyelids enlarging liver size on palpation
If you find signs of over hydration (early signs are respiratory rate increasing by 5 breaths/min and pulse rate by 25beats/min), stop ReSoMal immediately and reassess after 1 hour. Target weight for rehydration with watery diarrhoea
29
29
1. If the child has been in under treatment for SAM and there is a pre-diarrhoeal weight that has been recorded before the diarrhoea starts:
If there has been no weight loss with the diarrhoea then the child is NOT dehydrated and no rehydration treatment should be given.
If there has been weight loss, the actual fluid loss is equal to the weight loss and the target rehydration-weight is the pre-diarrhoeal weight. Treatment should not be given to increase the weight beyond the pre-diarrhoeal weight.
After admission diarrhoea is often “refeeding diarrhoea” (see end of chapter).
2. If the patient is newly admitted, it is extremely difficult to judge the amount of fluid that has been lost in the child with marasmus as all the clinical signs are unreliable. Because of the narrow therapeutic window and the danger of going from under-hydration to over-hydration, the estimated weight deficit should be conservative. It is better and much less dangerous to slightly under-estimate the amount of weight deficit than to over-estimate the weight deficit in malnourished children.
In practice, the weight loss is generally 1% to 3% of body weight in most children and in a few up to 5%.
Do not attempt to increase body weight by more than 5% in conscious children.
If there is weight gain of up to 5% of body weight with rehydration, the truly dehydrated child will show dramatic clinical improvement and should be out of immediate danger from death due to dehydration; treatment can then be continued with F75 (see annex 5: table of 5% weight gain/5% weight loss).
Prevention Measures to prevent dehydration due to continuing watery diarrhoea are similar to those for well-nourished children except that ReSoMal fluid is used instead of standard low osmolarity (ORS).
If the child is breastfed, continue breast feeding. Keep feeding with starter F-75. Give ReSoMal between feeds to replace stool losses. After rehydration usually no
further treatment is given; however, for malnourished children from 6 to 24 months, 30ml of ReSoMal can be given for each watery stool that is lost. The objective is only to replace what is being lost and not to change the overall fluid balance of the patient.
30
30
Fig 6: Treatment of dehydration in marasmic children
Fig 7: Monitoring rehydration in Marasmic children 3.1.1.2. Diagnosis of Dehydration in Children with Oedema
31
31
All children with oedema have an increased total body of water and sodium; they are over hydrated. Oedematous children cannot be dehydrated though they are frequently hypovolemic. The hypovolemia is due to dilatation of blood vessels and low cardiac output. If a child with hypovolemia has definite acute watery diarrhoea and is deteriorating clinically (excessive weight loss, more than 2% of the body weight daily), then the fluid can be replaced on the basis of 30mls of RESOMAL. The treatment of hypoglycemia with oedema is the same as children with septic shock. 3.1.1.3. Hypernatremic Dehydration
Hypernatremic dehydration is common in areas with a very dry atmosphere (deserts) particularly if there is also a high temperature.
It is most likely to occur in children that have been carried for long distances to the IPF/OTP in the sun, without the mother stopping to rest or give the child something to drink. It is important that those arriving at clinics, OTP etc. are given water/sugar-water to drink on arrival and not kept waiting to be seen without shade. It also occurs when the feeds are over-concentrated.
Although hypernatremia is difficult to treat safely, it is easy to prevent safely. Malnourished children, particularly those in dry and hot environments should be given continuous access to sufficient plain water.
NOTE: in desert areas where the humidity is very low and the day-time temperature is very high ALL the children must be offered water to drink at frequent intervals
Diagnosis
The first sign to appear is a change in the texture and feel of the skin.
o The skin develops plasticity similar to the feel of dough (flour and water mixed for bread making).
o The eyes can sink somewhat.
o The abdomen frequently then becomes flat and may progress to become progressively sunken and wrinkled (so called “scaphoid abdomen” or “prune belly”).
o The child may develop fever.
o The child becomes progressively drowsy and then unconscious.
o Convulsions follow and if treatment for hypernatremia is not instituted this leads to death. The convulsions are not responsive to the normal anti-convulsants (phenoparbitone, diazepam etc.).
o Failure to control convulsions with anti-convulsants may be the first indication of the underlying diagnosis.
The diagnosis can be confirmed by finding an elevated serum sodium. Normally hypernatræmia is diagnosed when the serum sodium is more than 150mmol/l.
Treatment
For insipient hypernatræmic dehydration – that is a conscious, alert child who is only showing changes in the texture and feel of the skin,
32
32
Breastfeed the child or give breast milk. This can be supplemented with up to about 10ml/kg/h of 10% sugar-water in sips (little by little) over several hours until the thirst of the child is satisfied. At this early stage treatment is relatively safe.
Give water but the child should not drink large amounts rapidly – take several hours to correct the mild hypernatræmic dehydration.
For developed hypernatræmic dehydration, treatment must be slow.
If it is possible, measure serum sodium
then aim to reduce the serum sodium concentration by about 12 mmol/24h. To correct the hypernatræmia more quickly than this risks death from cerebral œdema.
If it is not possible to measure the serum sodium
then aim to take at least 48h to correct hypernatræmic dehydration. The treatment should start slowly and as the serum sodium approaches normality, the rate of repletion can be increased.
The text-book treatment of hypernatræmia is to give normal saline, slowly, either orally or intravenously. Sodium intake in the severely malnourished child should be restricted so that this treatment is NOT used in SAM.
Progress is assessed by serial weighting of the child.
First, put the child in a relatively humid, thermoneutral (28˚ to 32˚ C) environment (mist or spray water into the air in desert areas) – this is the most important step and must not be omitted.
Weigh the child on an accurate balance and record the weight.
The objective of treatment is to put the child into positive water balance of about 60ml/kg/d over the course of treatment (assessed by weight gain) which is equivalent to 2.5ml/kg/h of plain water. This amount should not be exceeded until the child is awake and alert.
If the child is conscious or semi-conscious and there is no diarrhoea,
Then, put down an NGT and start 2.5ml/kg/h of 10% sugar water or breast milk. Do not give F75 at this stage. Never give F100 or infant formula. Expressed breast milk is the best “rehydrating” fluid available.
Reweigh the child every 2 hours.
o If the weight is static or there is continuing weight loss, recheck the immediate environment to try to prevent on-going water losses. Then, increase the amount of sugar-water intake to compensate for the on-going weight loss (calculated as g/h and increase the intake by this amount).
o If the weight is increasing continue treatment until the child is awake and alert.
If there is accompanying diarrhoea,
then give one fifth normal saline in 5% dextrose orally or by NG-tube.
If the child is unconscious,
33
33
then the same volumes of fluid (5% dextrose if there is no diarrhoea and one fifth normal saline in 5% dextrose if there is diarrhoea) can be given by intravenous infusion. There should be a peristaltic pump or accurate paediatric burette in order to ensure that that the rate of administration of fluid is not exceeded during treatment.
When the child is awake and alert and the skin quality returns to normal (or the serum sodium is normal if there are facilities to measure sodium),
then recommence feeding with F75.
3.1.1.4. Treatment of shock
Diagnosis of shock is made when there is a definite dehydration from both history and examination and
Semi-consciousness a weak and fast pulse(≥160 beats/min for children 2 to 12 months and ≥
140beats/min for children 1- 5 years) or absent radial or femoral pulse cold clammy hands and feet poor capillary refill in the nail beds (> 3 seconds)
There may be also decrease in level of consciousness so that the patient is semi-conscious or cannot be aroused. In this case there is severe shock.
Types of Shock in SAM patients
Like non- malnourished children, the different types of shock may exist but the commonest causes are:
Hypovolemic shock- which may be caused by diarrhoea, vomiting and inadequate intake. But also occurs frequently in oedematous children who are NEVER dehydrated (they are overhydrated with the excess fluid in their tissues).
Septic (Toxic) shock-may occur without history of watery diarrhoea Cardiogenic shock
Treatment
Give oxygen Give sterile 10% dextrose (5ml/kg) by IV ONLY, if the patient meets the criteria for shock above should the child be treated
with intravenous fluid. The amount given should be half the amount in normally nourished children. The following are the recommended fluids
Half strength Ringer-lactate with 5% dextrose
Half strength Saline with 5% dextrose
Give 15mls/kg IV over the first hour and reassess the child
34
34
DO NOT GIVE BOLUS FLUID to this group of children. Bolus fluids have been associated with high levels of mortality among children with severe infection and should not be used.
If there are signs of improvement (pulse and respiratory rates fall)
o Repeat the 15ml/kg IV over another one hour. o Then stop the drip and switch to oral or NGT rehydration with ReSoMal
10ml/kg/hr o Continue with the protocol (above) for re-hydration of the child orally;
continue to use weight change as the main indicator of progress. If the child fails to improve (pulse and respiratory rates remain high)
and the child has gained weight, then assume that the child has toxic, septic or cardiogenic shock or liver failure. Stop rehydration treatment. Search for other causes of loss of consciousness
For septic shock, see protocol below. Monitoring management of shock
STOP all rehydration (oral or intravenous) therapy immediately if any of the following are observed:
The target weight for rehydration has been achieved (go to F75)
The visible veins become full (go to F75)
The development of œdema (over-hydration – go to F75)
The development of prominent neck veins*
The neck veins engorge when the abdomen (liver) is pressed*.
An increase in the liver size by more than one centimetre.*
The development of tenderness over the liver.*
An increase in the respiration rate by 5 breaths per minute or more*
The development of a “grunting” respiration (this is a noise on expiration NOT inspiration).*
The development of râles or crepitations in the lungs*
The development of a triple rhythm*
*If these signs develop then the child has fluid overload, an over-expanded circulation and is going into heart failure.
Septic (OR Toxic) Shock
Septic shock presents with some of the signs of true dehydration but also of cardiogenic shock and frequently of liver dysfunction; the differential diagnosis is often very difficult.
Children that appear “very ill”, may have septic shock, ordinary dehydration, hypernatræmic dehydration, cardiogenic shock, liver failure, or toxic shock from poisoning with traditional medicines or overdose of therapeutic drugs, aspirin poisoning, malaria, acute viral infection or other severe conditions. All “very ill” children should not be
35
35
automatically diagnosed as having septic shock; the true reason for the condition should be sought.
Shock developing after admission
Children with septic shock normally present with very severe illness, if the condition develops after admission then it is more likely to be cardiogenic shock, or an adverse reaction to the treatment that is being given.
If the child deteriorates after admission to the in-patient facility, then:
Review the treatment given to the child to determine if the treatment is the cause of the clinical deterioration.
Review the fluid (sodium) intake, particularly any treatment given in the emergency ward during admission (if this is excessive treat for cardiogenic shock/heart failure). 1
Examine the daily weight changes as this may indicate cardiogenic shock; do not diagnose septic shock in a very ill child if child has gained weight during the preceding 24h: treat for heart failure.
Stop any drugs being given that are not included in the protocol
Check the dose of drugs given to ensure that they have been adjusted for the malnourished state.
Diagnosis of septic shock
To make a diagnosis of developed septic shock requires the signs of hypovolæmic shock to be present
A fast weak pulse with
Cold peripheries
Slow capillary refill in the nail beds (more than 3 seconds)
Disturbed consciousness
Absence of signs of heart failure
Treatment of septic shock
To all patients with septic shock,
1. Give broad-spectrum antibiotics (for doses see annex 10 )
Cefotaxime by SLOW IV injection once per day (100mg/kg/d on the first day, followed by 50mg/kg/d on subsequent days)
AND ADD
Ciprofloxacin orally 30mg/kg/d in 3 doses (or Gentamicin 5 mg/kg/day once daily injection IM
1 In some areas the drinking water contains appreciable concentrations of sodium. Ensure that the patient has not been taking the mother’s food.
36
36
AND
Metronidazole 10 mg/kg/d orally or rectally
If there are extensive open skin lesions or signs suggestive of pulmonary abscesses, add Cloxacillin IV: Children: 100-200 mg/kg/d divided into 3 injections, one every 8 hours
If there is no improvement in 24h, then
Add Fluconazole: orally 3mg/kg/d once daily
In areas of high HIV prevalence, where there is oral candidiasis or where the prevalence of candidiasis is >20%, add fluconazole at the start of treatment for all very ill children.
Keep warm to prevent or treat hypothermia.
Give sugar-water by mouth or NGT as soon as the diagnosis is made to prevent hypoglycæmia.
Physically disturb the patient as little as possible (no washing, excess examination, investigations in other departments, etc.).
Do not transport to another facility unless there are proper facilities to safely transport the patient.
For Incipient septic shock: Give the standard F75 diet by NGT, if gastric residues are aspirated from the NG-tube, start with half the recommended quantity of F75 until there are no gastric aspirates.
For Developed septic shock: If the patient is semi-conscious or unconscious because of poor brain perfusion,
then a slow IV infusion of one of the following can be given (do not give if there is a possibility of cardiogenic shock):
o Whole blood of 10ml/kg over at least 3 hours – nothing should be given orally during the blood transfusion or for 3 hours after the transfusion.
o Or 10ml/kg/h for 2 hours of one of the following:
o Or Ringer’s lactate solution with 5% glucose or Half-normal (0.45%) saline with 5% glucose
Monitor every 10 minutes for signs of deterioration, especially over-hydration and heart failure.
o Increasing respiratory rate,
o Development of grunting respiration,
o Increasing liver size,
o Vein engorgement.
As soon as the patient improves (stronger radial pulse, regain of consciousness)
Stop all IV intake – continue with F75 diet by NG-tube.
37
37
Absent Bowel Sounds, Gastric Dilatation and Intestinal Splash With Abdominal Distension
There is a functional ileus with bacterial overgrowth similar to that with intestinal obstruction. In this situation there has normally been gram-negative bacterial translocation across the intestine with septicaemia.
The following measures should be taken:
Give antibiotics intravenously as outlined for developed septic shock
STOP all other drugs that may be causing toxicity (including anti-retrovirals)
Give an IM injection of magnesium sulphate (2ml of 50% solution) and repeat twice daily until stool is passed and gastric aspirations drop.
Pass a NGT and aspirate the contents of the stomach, then “irrigate” the stomach with isotonic clear fluid (5% dextrose or 10% sucrose –the solution does not need to be sterile). Do this by introducing 50ml of solution into the stomach and then gently aspirating all the fluid back again. This should be repeated until the fluid that returns from the stomach is clear.
Put 5 ml/kg of sugar-water (10% sucrose solution) into the stomach and leave it there for one hour. Then aspirate the stomach and measure the volume that is retrieved. If the volume is less than the amount that was introduced then return the aspirate to the stomach 2 and make up the volume to 5ml/kg with more sugar-water.
There is frequently gastric and oesophageal candidiasis, put oral nystatin suspension, or fluconazole down the NGT
Keep the child warm
Give intravenous glucose, these children are usually unconsciousness, semiconscious or delirious (see section on hypoglycæmia)
Do not put up a drip at this stage but monitor the child carefully for 6 hours, without giving any other treatment
Use the critical care form
Monitor continuously to see if there is any Improvement
o First, by a change in intestinal function – decrease in the distension of the abdomen, visible peristalsis seen through the abdominal wall, return of bowel sounds, decreasing size of gastric aspirates
o Second, by improvement in the general condition of the child
If there is intestinal improvement,
2 Discarding the aspirate can lead to alkalosis and electrolyte disequilibrium. However, if there is any gastric
bleeding (coffee grounds) the aspirate should always be discarded.
38
38
then start to give small amounts of F75 by NG tube (half the quantities given in the F75 – table). Aspirate the stomach before each feed.
If the volume of residual feed remaining is large, then decrease the amount of F75.
If the amount of aspirate is small then the amount can be gradually increased.
If there is no improvement after 6 hours then:
Consider putting up an IV drip. It is very important that the fluid given contains adequate amounts of potassium. Sterile Potassium Chloride (20mmol/l) should be added to all solutions that do not contain potassium. If it is available use one-fifth normal saline in 5% dextrose, otherwise use Ringer-Lactate in 5% dextrose or half-strength saline in 5% dextrose. The drip should be run VERY SLOWLY – the amount
of fluid that is given should be NO MORE THAN 2 to 4 ml/kg/h (a paediatric burette or peristaltic pump should be used).
When the gastric aspirates decrease so that one half of the fluid given to the stomach is absorbed, discontinue the IV treatment and continue with oral treatment only.
Heart Failure
Signs and symptoms
Heart failure should be diagnosed when there is:
Physical deterioration with a gain in weight
o this is the most common way of making the diagnosis and does not require any equipment or particular clinical skill
An increase in respiration rate with weight gain
o an acute increase in respiration rate of more than 5 breaths per minute (particularly during rehydration treatment)
o > 50 breaths/minute in infants and
o >40 in children 1-5 years,
A sudden increase in liver size (this is why the liver is marked before starting any infusion)
Tenderness developing over the liver
Respiration that has or develops a “grunting” sound during each expiration
Crepitations or râles in the lungs
Prominent superficial and neck veins
Engorgement of the neck veins when the abdomen (liver) is pressed
Enlargement of the heart (very difficult to assess in practice)
Appearance of triple rhythm (difficult to assess in practice)
An acute fall in haemoglobin concentration or hæmatocrit (needs laboratory, but measures quite accurately the degree of expansion of the intravascular volume)
39
39
As the heart failure progresses there is either 1) marked respiratory distress progressing to a rapid pulse, cold hands and feet, œdema and cyanosis or 2) sudden, unexpected death. This is cardiogenic shock, it usually occurs in the severely malnourished patient after treatment has started.
The cause is an excessive intake of sodium, either from the diet, from rehydration fluids or from drugs; even with sodium restriction there may still be heart failure due to the residual sodium in the diet and the amount of sodium that comes out of the cells as the cells recover. Excess sodium given in an emergency department or during the initial treatment of dehydration at admission can give rise to heart failure several days later as the sodium inside the cells enters the vascular space.
There is usually also weight gain. As heart failure usually starts after (and is due to) treatment, there is nearly always a record of the weight of the patient that was taken before the onset of heart failure.
Differential diagnosis
Heart failure and pneumonia are clinically similar and very difficult to tell apart.
o If there is an increased respiratory rate AND any gain in weight, then heart failure should be the first diagnosis.
o If there is an increased respiratory rate with a loss of weight, then pneumonia can be diagnosed.
o If there is no change in weight (fluid balance) then the differentiation has to be made using the other signs of heart failure.
o Pneumonia should NOT be diagnosed if there has been a gain of weight just before the onset of respiratory distress.
Children with oedema can go into heart failure without a gain in weight, if the expanded circulation is due to oedema fluid being mobilised from the tissues to the vascular space.
Treatment
As oedema fluid is mobilised (kwashiorkor) and the sodium is coming out of the cells (both kwashiorkor and marasmus), the plasma volume expands but the volume of red cells remains constant so that there is a FALL IN HÆMOGLOBIN concentration. This DILUTIONAL anaemia happens to some extent in nearly all children as they recover. A substantial fall in haemoglobin, as a sign of an expanding circulation, is also a sign of impending or actual volume overload with heart failure. These children should never be transfused. The heart failure is not caused by the anaemia – the increasing anaemia is a sign of the expanding blood volume causing the heart failure. This is a common error. Children with respiratory distress and anaemia should not be transfused.
40
40
Fig 8: Algorithm of respiratory distress When heart failure is diagnosed,
Stop all intakes of oral or IV fluids. No fluid or food should be given until the heart failure has improved even if this takes 24-48 hours. Small amounts of sugar-water can be given orally to prevent hypoglycaemia.
Review drug regimen and reduce dose or stop those which are given as the sodium salt
Give frusemide (1mg/kg) (generally it is not very effective and diuretic treatment should not be relied upon in the malnourished patient to manage heart failure)
Optional: Digoxin can be given in single dose (5 micrograms/kg – note that this is lower than the normal dose of digoxin. A loading dose is not given. Use the paediatric preparation, not small quantities of the adult preparation).
If heart failure is associated with severe anaemia, the treatment of heart failure takes precedence over the treatment of anaemia. A patient with heart failure should never be transfused (except there are facilities for exchange transfusion.)
3.1.1.3. Correct electrolyte All severely malnourished children have deficiencies of potassium and magnesium, which may take about 2 weeks to correct. However these electrolytes are available in sufficient quantity in commercially prepared F75 and ReSoMal the child does not require additional intake. Oedema is partly a result of potassium deficiency and sodium retention. Excess body sodium exists even though the plasma sodium may be low. Giving high sodium loads could kill the child.
41
41
Treatment
When rehydrating, give the commericially prepared low sodium rehydration fluid (ReSoMal) which contains adequate amounts of K and Mg.
Prepare food without added salt. DO NOT treat oedema with diuretics
The extra potassium and magnesium should only be added to the feed during its preparation as a last resort if not using commercial F75 or F100 OR pre-mixed sachet called Combined Mineral and Vitamin Mix.
3.1.1.4. Correct Severe Anaemia
Diagnosis
A frequently encountered complication among children hospitalized for severe acute malnutrition is severe anaemia, often associated with bacteremia, frequent bouts of malaria, hookworm infection, HIV infection and micronutrient deficiency. The hemoglobin on admission for all SAM patients who come to the facility should be measured.
Treatment
Blood transfusion should be given ONLY WITHIN the first 24 hours only if the child
presents with a:
Hb is < 4 g/dl (PCV <12%) Hb is 4– 6 g/dl (PCV 12 – 18%) and the child has respiratory distress.
In severe acute malnutrition, the transfusion must be slower and of smaller volume than for a well-nourished child.
Give:
whole blood, A MAXIMUM OF 10 ml/kg, slowly over 3 hours frusemide 1 mg/kg IV at the start of the transfusion. Do not transfuse a child within 48 hours of starting F-75 Do not start iron in the stabilization phase
If the child has signs of heart failure, give 5-7 ml/kg of packed cells with IV furosemide at 1mg/kg, because whole blood is likely to worsen this condition. Children with severe acute malnutrition with oedema may have redistribution of fluid leading to apparent low Hb and a fall in Hb can be expected during treatment due to haemodilution, so do not transfuse if the Hb becomes <4 g/dl after Day 1.
Monitoring
Monitor the pulse and breathing rates, listen to the lung fields, examine the abdomen for liver size and check the jugular venous pressure every 30 during the transfusion.
42
42
If the following occurs during transfusion, stop the blood transfusion
If either breathing or heart rate increases (breathing by 5 breaths/min or pulse by 25 beats/min),
If there are basal lung crepitations or an enlarging liver, stop the transfusion and give frusemide at 1 mg/kg IV.
Itchy rash Dark or coke-colored urine Confusion Shock
Note: Do not repeat transfusion even if the Hb is still low or within 4 days of the last transfusion and there are no signs of decompensation. Note that feeding with F75 causes movement of Na and K into the cells and during days 2-14 days there is electrolyte disequilibrium which makes the Hb fall and the heart to come under stress.
In all cases of anaemia (mild, moderate and severe), oral (elemental iron 3mg/kg/day) should be given for three months to replenish iron stores. BUT THIS SHOULD NOT BE
STARTED in the stabilization phase and until the child has begun to gain weight and infections are cleared.
Fig 9: Managing Anaemia
3.1.1.1. Treat and prevent hypoglycaemia
All severely malnourished children are at risk of hypoglycaemia and, immediately on admission, should be given a feed or 10% glucose (see below). Frequent 3-4 hourly feeding is important.
Diagnosis
43
43
Hypoglycaemia is present when the blood glucose is < 3 mmol/litre (< 54 mg/ dl). If there is any suspicion of hypoglycaemia and when blood glucose can be measured quickly (e.g. with Dextrostix®), this should be done immediately. Care must be ensured the dextrostix are not expired and are stored at the right temperature to prevent a false positive result. If blood glucose cannot be measured, it should be assumed that all children presenting with severe acute malnutrition are hypoglycaemic and given treatment.
There are often no signs at all of hypoglycaemia. Most hypoglycæmic malnourished children do not sweat, have raised hair on their arms or go pale. They simply become less responsive and slip into coma and often present with hypothermia. One sign of the overactive sympathetic nervous system, which starts before actual hypoglycemia develops, and is seen in the malnourished child, is eye-lid retraction. If a patient sleeps with his/her eyes slightly open, then s/he should be woken up and given sugar-water or F75 to drink; the mothers and staff should be taught to look for this sign during the night.
Treatment
For Patients who are conscious and able to drink, give about 50 ml (approximately 5 to 10ml/kg) of sugar-water (about 10% ordinary sugar in water), or F75 by mouth. The actual amount given is not critical.
For Patients losing consciousness, give 50 ml of sugar-water by NGT immediately. When consciousness is regained give F75 feeds frequently.
For semi-conscious and unconscious patients, give sugar-water by NGT immediately. They should then be given glucose as a single intravenous injection (approximately 5ml/kg of a sterile 10% glucose solution).
Treat all malnourished patients with hypoglycemia with second-line antibiotics (see annex).
The response to treatment is dramatic and rapid. If a very lethargic or unconscious patient does not respond in this way,
then it is urgent that another cause for the clinical condition is considered, found and treated (e.g. cerebral malaria, meningitis, hypoxia, hypernatremia, shock, etc.)
Monitoring
If the initial blood glucose was low, repeat the measurement (using finger or heel prick blood and measure with the Dextrostix®, when available) after 30 min.
If blood glucose falls to < 3 mmol/litre (< 54 mg/dl), repeat the 10% glucose or oral sugar solution.
If the rectal temperature falls to < 35.5 °C, or if the level of consciousness deteriorates, repeat the Dextrostix® measurement and treat accordingly.
Prevention
Give sugar-water to all children that have travelled for long distances as soon as they arrive at the centre.
44
44
Give extra sugar to all children who get hypothermia or have septic shock, whether or not they have low blood glucose.
The children who develop hypoglycaemia are those that have not taken food (carbohydrate) for at least 12 hours. Any child that has not taken food during the day needs at least one feed during the night. A child who has taken all the diet during the day will not develop hypoglycaemia overnight and does not need to be woken for night-time feeding because of the danger of hypoglycaemia.
Feed every 3hours, starting immediately (see initial feeding) or, when dehydrated, rehydrate first. Continue feeding during the night.
Encourage mothers to watch for any deterioration, help feed and keep the child warm.
Check on abdominal distension.
3.1.1.2. Treat and prevent hypothermia
Severely malnourished children are highly susceptible to hypothermia and often indicates coexisting hypoglycaemia or serious infection. The thermoneutral range for malnourished children is 28 °C to 32 °C. This is uncomfortable range for the staff who may adjust the temperature to suit themselves. Children should always sleep with their mothers and not in traditional child cots/cages. There should be adequate blanket and a thick sleeping mat or adult bed.
Diagnosis
If the axillary temperature is < 35 °C (< 95°F) or does not register on a normal thermometer, assume hypothermia. When a low-reading thermometer is available, take the rectal temperature (< 35.5 °C or < 95.9 °F) to confirm hypothermia.
Treatment
All children with hypothermia should be treated routinely for hypoglycaemia and infection.
Keep the child warm by using the “kangaroo technique” where the child is put skin-to-skin contact on the mother’s bare chest or abdomen and both of them are covered with a warmed blanket and/or warm clothing and child head covered with a hat.
Give hot drinks to the mother so her skin gets warmer (plain water, tea or any other
hot drink).
Keep the room warm Keep the child away from draughts and windows and doors closed at night.
Feed the child immediately and then every 3-4 hours unless they have abdominal
distension; if dehydrated, rehydrate also
Monitor body temperature during re-warming (every 30 minutes).
For children with hypothermia commence appropriate second line IV or IM
antibiotics (see annex 6).
Monitoring
45
45
Monitor body temperature during re-warming (every 30 minutes). Ensure that the child is covered at all times, especially at night. Keep the head
covered, preferably with a warm cap, to reduce heat loss. Check for hypoglycaemia whenever hypothermia is found.
Prevention
Place the bed in a warm, draught-free part of the ward, and keep the child cover (the thermo-neutral temperature for malnourished is from 28oC and 32 oC)
Avoid exposing the child to cold (e.g. after bathing or during medical examinations).
Change wet nappies, clothes and beddings to keep child and bed dry. Dry carefully after bathing, but do not bathe if very ill
Keep windows and doors closed at night. Monitor the temperature with a maximum-minimum thermometer on the wall. Use adult beds so the children sleep with their mothers. There should be adequate
blankets Feed immediately on admission and every 3-4 hours
3.1.1.7. Treatment and prevention of infection
Diagnosis
In severe malnutrition the usual signs of infection, such as fever, are often absent, and infections are often hidden. Studies have also noted that small bowel bacterial overgrowth is common in children with severe acute malnutrition and affects intestinal function. Despite the absence of clinical signs, these children are all infected; these infections are treated blindly. This is NOT prophylaxis.
Therefore give routinely on admission:
broad-spectrum antibiotic(s) AND
measles vaccine if child is > 6m and not immunized (delay if the child is in shock)
For the choice of broad-spectrum antibiotics, see annex 9 for antibiotic dosage.
For children attending the OTP and have no complications they are routinely given oral amoxicillin at 15mg/kg 12 hourly for 5 days
If the child is severely ill (apathetic, lethargic) or has complications (hypoglycaemia;
hypothermia; broken skin; respiratory tract or urinary tract infection) antibiotics should be given parentrally.
The choice of antibiotics will be based on antibiotic susceptibility in the different areas of the Country. However, based on currently available studies, the following antibiotics are recommended (see also annex 6)
o For first line treatment
46
46
o I.V Amoxycillin (50mg/kg/day) every 12 hours for 72hours then change to oral amoxcillin at 50mg/kg/day every 12 hours to complete one week OR I.V Cefotaxime 50 mg/kg every 12h for 5d. In some countries, IV Ampicillin may be used which is cheaper however this is not recommended in Nigeria due to the high level of bacterial resistance to the drug
o Add gentamcin I.M ( 3-5mg/kg/day) once daily for 7 days if the patient is making urine
o and/or suppress small bowel overgrowth with I.V metronidazole
10mg/kg/da y given 12 hourly for 72hours then change to oral 10mg/kg/day every 12 hours to complete one week
o For Second line treatment o If the child fails to improve clinically by 48 hours or deteriorates after 24hours
change to I.V Ciprofloxacin at the dose of 10mg/kg/dose every 12hours for 72hours and continue for one week
o Or I.V Ceftriaxone at the dose of 50-100mg/kg/day once a day for 5 days if meningitis is suspected then give every 12 hours
3.1.1.8. Correct micronutrient deficiencies
All severely malnourished children have vitamin and mineral deficiencies. The vitamin A intake of children who are fed therapeutic food (F-75, F-100 or ready-to use therapeutic foods) that complies with WHO specifications exceeds the recommended nutrient intake for well-nourished children and seems adequate for malnourished children; there is no clear rationale for giving a single high-dose vitamin A supplement, unless children have eye signs of vitamin A deficiency or have had measles or diarrhoea recently. Although anaemia is common, do NOT give iron initially but wait until the child has a good appetite and starts gaining weight (usually by the second week), as giving iron can make infections worse.
ALL essential nutrients, in the appropriate amounts and ratios including vitamin A and folic acid, zinc and copper are already present in F-75, F-100 and ready-to-use therapeutic food packets (see annex 7). When premixed packets are used, additional doses MUST NOT BE GIVEN; this will lead to giving potentially toxic doses –there is evidence that additional vitamin A and zinc leads to an increase in mortality. In addition, if there are no eye signs or history of measles, then do not give a high dose of vitamin A because the amounts already present in therapeutic foods are enough.
Treatment
low-dose (5000 IU) vitamin A supplementation (Which is present in RUTF) given daily to children with severe acute malnutrition, from the time of admission until discharge from treatment, is more effective in reducing the mortality of children with oedema, the incidence of severe diarrhoea, and the incidence and duration of respiratory infection than single high-dose vitamin A supplementation on day 1 of admission
ONLY IF child recently had Measles or is ongoing and or the child has eye signs of Vitamin A deficiency. Then, give Vitamin A on Day 1:
47
47
Table 7: Vitamin A doses by age
Age Dosage
< 6 months 50,000 I.U (15,000 µg) ONCE
6-12 months 100,000 I.U (30,000µg )ONCE
>12 -59 months 200,000 I.U (60,000µg) ONCE
Children who are 6–59 months of age with severe acute malnutrition do not require multivitamins if they are receiving F-75, F-100 or ready-to-use therapeutic food that complies with WHO specifications (and therefore already contains sufficient vitamins and minerals). If child is not on any of the pre-mixed therapeutic foods, give the following micronutrients daily for at least 2 weeks (to continue even on transfer out of IPF to OTP): _ folic acid at 5 mg on day 1; then 1 mg daily _ multivitamin syrup at 5 ml _ zinc at 2 mg/kg per day _ copper at 0.3 mg/kg per day Commercial preparation is ideal because of quality control challenges in the local preparation of combined electrolyte/mineral solution in hospital pharmacies. 3.1.1.9. Therapeutic feeding including breast feeding The milk based diet used in the stabilization phase of treatment is F75. F75 is NOT a dilute form of F100; it provides 75 kilocalories/100ml and has a completely different nutrient composition and balance. It is designed for patients with severe complicated malnutrition who have impaired liver and kidney function with infection. The diet allows their biochemical, physiological and immunological function to start to recover before they have the additional stress of making new tissues. The process of initial re-feeding should be started as soon as possible after admission.
Feeding process
For children less than 23 months who are still breastfeeding, half an hour before the scheduled time for giving the feed, ask the mothers to breast-feed their children;
Calculate the total quantity of F75 to prepare in the ward according to the number of patients , their weights and the number of feeds (refer to annex 8);
Prepare the quantity of water and F75 for the feeds (see paragraph “preparation”);
Ask the mother to wash their own and their children’s hands; Frequent (every 3-4 hours) oral small feeds for 1-2 days Then graduate to giving five or six feeds per day for most children (make out
a time schedule and post it on the wall) Give 5-6 (or more) feeds per day over 24hours (night as well as daytime since
most facilities do not have sufficient staff to prepare and distribute the feeds at night) but for the few children who cannot tolerate the increased volumes
48
48
when 5 or 6 feeds quite closely spaced during the day are given, these may be given 8 feeds and this includes:
those that are very severely ill,
develop re-feeding diarrhoea on the routine schedule,
have had very little food during the day (e.g. new arrivals),
have vomited some or all of their feeds during the day,
have had an episode of hypoglycaemia,
have had hypothermia, where there are sufficient staff to prepare and distribute the feeds at
night (unusual).
Preparation of F-75
Add either one large packet of F75 (410g) to 2 litres of water or one small packet of F75 (102.5g) to 500 ml of water. Where small numbers of children are being treated as in-patients, do not order the large packets of F75. These are for use in emergency settings with large numbers of SAM patients. ONLY IF F75 is not available use one of the recipes given in the annex 3. As cereal-based F-75 partially replaces sugar with cereal flour, it has the advantage of lower osmolarity, which may benefit some children with persistent diarrhoea, but it has to be cooked.
Note: Preparation instruction of manufacturer should be strictly adhered to.
Amounts to give
Feed from a cup and saucer. Even premature infants can ‘lap’ from a cup before they can properly suckle. Spoons should not be used because both baby and mother can tire out easily and it can cause damage to the child’s mouth if attempts are made to force feed the child. Give the amounts as stated in annex 9 to each child. This provides calories at 100ml/kg per day and protein at 1-1.5g/kg per day.
Amounts of F-75 to give
Give the amounts in the table below to each patient.
Table 8: Amounts of F75 to give during Acute-phase (or Stabilization Phase)
CLASS OF WEIGHT (KG) 8 FEEDS PER DAY ML FOR EACH FEED
6 FEEDS PER DAY ML FOR EACH FEED
5 FEEDS PER DAY ML FOR EACH FEED
2.0 to 2.1 kg 40 ml per feed 50 ml per feed 65 ml per feed
2.2 – 2.4 45 60 70
2.5 – 2.7 50 65 75
2.8 – 2.9 55 70 80
3.0 – 3.4 60 75 85
3.5 – 3.9 65 80 95
4.0 – 4.4 70 85 110
4.5 – 4.9 80 95 120
5.0 – 5.4 90 110 130
5.5 – 5.9 100 120 150
49
49
6.0 – 6.9 110 140 175
7.0 – 7.9 125 160 200
8.0 – 8.9 140 180 225
9.0 – 9.9 155 190 250
10 – 10.9 170 200 275
11 – 11.9 190 230 275
12 – 12.9 205 250 300
13 – 13.9 230 275 350
14 – 14.9 250 290 375
15 – 19.9 260 300 400
20 – 24.9 290 320 450
25 – 29.9 300 350 450
30 – 39.9 320 370 500
40 – 60 350 400 500
NOTE: Patients on F75 are NOT expected to gain weight.
Monitoring
Monitor and record in the daily multi-chart (Annex 10):
amount of feed offered and left over vomiting stool frequency and consistency daily body weight-oedematous children should lose weight within the first 24 to 72
hours, while the weight of children with marasmus are expected to remain stable. NOTE: Patients on F75 are NOT expected to gain weight.
Naso-gastric feeding
Naso-gastric tube (NGT) feeding is used when a patient is not taking sufficient diet by mouth. This is defined as an intake of less than 75% of the prescribed diet (for children about 75 Kcal/ kg/ day).
The reasons for use of an NG tube are:
Taking less than 75% of prescribed diet per 24 hours
Pneumonia with a rapid respiration rate
Painful lesions of the mouth
Cleft palate or other physical deformity
Disturbances of consciousness
Every day, try patiently to give the F75 by mouth before using the NGT. The use of the NGT should not normally exceed 3 days and should only be used in the stabilization phase.
See Annex 11 for NGT insertion technique.
50
50
Fig 10: Feeding F-75 by mouth
Feeding technique
The muscle weakness, slow swallowing and poor peristalsis of these children makes aspiration pneumonia very common.
Tell the mother to put the child on the mother’s lap against her chest, with one arm behind her back. The mother’s arm encircles the child and holds a saucer under the child’s chin. The child should be sitting straight (vertical).
Give the F75 in a cup, any dribbles that fall into the saucer are returned to the cup. Tell the mother not to force feed the child and never to pinch his/her nose, squeeze
the cheeks to force the mouth open or lie back and have the milk poured into the mouth.
If a child “splutters” or coughs during feeding, tell the mother that it is probably due to incorrect feeding-technique.
Re-train the mother. It is better for the child not to finish the feed and have an NGT inserted than to develop aspiration pneumonia.
Meal times should be sociable.
Make the mothers sit together in a semi-circle around an assistant.
Encourage the mothers, talk to them, correct any faulty feeding technique and observe how the child takes the milk.
Remark: In many hospital wards, the mothers feed the children on their beds individually. Often the F75 is “kept” by the mother for later feeding if the child does not finish the feed. This can lead to bacterial growth in the F75 and underestimation of the amount taken by the child. It is better to have a “feeding” area where all the children and mothers are brought together. The children can encourage each other.
The meals of the caregivers should never be taken beside the patient. It is almost impossible to stop the child demanding some of the mother’s meal. Sharing the mother’s meal with the child can be dangerous as the mother’s meal usually has salt or condiment added in sufficient amounts and can provoke fluid retention and heart failure in the malnourished child. Furthermore, the mother’s diet does not contain the correct balance of nutrients to treat metabolic malnutrition and will disturb the child’s appetite for the F75. The only food apart from F75 that the child should receive is breast milk.
Monitoring recorded on the IPF multi-chart (Annex 10)
Weight (annex 1) is measured, entered and plotted on the multi-chart each day; The degree of oedema (0 to +++) is assessed each day; Body temperature is measured twice per day;
51
51
The standard clinical signs (stool, vomiting, dehydration, cough, respiration and liver size) are assessed and noted in multi-chart each day;
MUAC is taken each week; A record is taken (on the intake part of the multi-chart) if the patient is absent,
vomits or refuses a feed, and whether the patient is fed by Naso-Gastric Tube (NGT) or is given an IV infusion or transfusion. There are appropriate places for these to be recorded each day.
Addressing Associated Conditions
3.3.1. Vitamin A deficiency
In addition to impairing immune responses, vitamin A deficiency causes the epithelial lining to produce less mucus, which enables bacterial adherence and thereby the invasion of pathogenic microbes. Untreated vitamin A deficiency in all children, including severely malnourished children, leads to blindness and increased susceptibility to infection and mortality.
Commercially available therapeutic formulae (F-75 and F-100) and ready-to-use therapeutic food that complies with the WHO specifications are fortified with vitamin A.
Children with SAM should receive the daily recommended nutrient intake of vitamin A throughout the treatment period. They should be provided with about 5000 IU vitamin A daily, either as an integral part of therapeutic foods or as part of a multi-micronutrient formulation.
Children with SAM DO NOT require a high dose of vitamin A as a supplement if they are receiving F-75, F-100 or RUTF that comply with WHO specifications (and therefore already contain sufficient vitamin A), or vitamin A is part of other daily supplements.
Children with SAM should be given a high dose of vitamin A (50 000 IU,100 000
IU or 200 000 IU, depending on age) on admission, ONLY IF they are given therapeutic foods that are NOT fortified as recommended in WHO specifications and vitamin A is not part of other daily supplements.
A high dose (50 000 IU, 100 000 IU or 200 000 IU, depending on age) of vitamin A
should be given to all children with SAM and eye signs of vitamin A deficiency on day 1, with a second and a third dose on day 2 and day 15 (or at discharge from the programme), irrespective of the type of therapeutic food they are receiving.
A high dose (50 000 IU, 100 000 IU or 200 000 IU, depending on age) of vitamin A
should be given to all children with SAM with recent measles on day 1 irrespective of the type of therapeutic food they are receiving.
3.3.2. Dermatosis
Skin changes are common among children with SAM and include:
hypo-or hyperpigmentation
52
52
desquamation ulceration (spreading over limbs, thighs, genitalia, groin, and behind the ears) exudative lesions (resembling severe burns) often with secondary infection,
including Candida
Zinc deficiency is usual in affected children and the skin quickly improves with zinc supplementation with improvement in general condition of the child. In addition:
apply barrier cream (Silver sulfadiazine impregnated tulle or cream (1%) once per day, if unavailable dress with Zinc Oxide (10%) and castor oil ointment, or petroleum jelly or paraffin gauze) to raw areas
Expose the lesions directly to the atmosphere during the heat of the day so that they dry (form a crust), do not cover with occlusive dressings. Do not use nappies so that the perineum can dry
Gently massage oil (e.g. mustard or soya oil) into the areas of unaffected skin to prevent further breakdown of the skin.
If the patient has candidiasis apply miconazole cream to the skin lesions until they are dry.
SCABIES Scabies is particularly common in warm wet areas where people sleep together. The mites are mostly found between the fingers and toes, the wrist, axilla and groins, In SAM and immuno-compromised patients they can spread to most of the body surface and become encrusted (so called “Norwegian scabies”).
Treatment
Apply permethrin3 cream (5%) or lotion (1%) over the whole body and wash with soap after at least 12 hours (Annex 6). Ensure that the web spaces of the fingers and toes, wrists, axillae, groins, perineum and buttocks are covered.
Do not apply to mucus membranes or ulcerated skin.
If the patient washes within 8 hours then repeat the application and leave on for 12 hours.
3 This is the same product that is used to impregnate bed nets and has less toxicity than most other products.
Although Benzyl benzoate is cheaper it is less effective and leads to excoriation of the skin of malnourished patients and should be avoided unless there is no alternative.
53
53
Treat anyone who sleeps with or has “close sweaty contact” with the patient at the same time.
For head or body lice apply permethrin lotion to the infested hair – in children this is usually confined to the head, in adults the pubic area and axillae can also be infected.
Change and boil all clothes and bedclothes.
3.3.3. Helminthiasis
Children with SAM are prone to helminthic infection. Deworm drugs should be given at the OTP but If the child must remain in IPF, then during the rehabilitation phase they should receive a single dose of any of the following
200mg albendazole for children aged 12- 23 months, 400mg albendazole for children aged ≥ 24 months, which is more efficacious in treating ascaris and hookworm
or give mebendazole 100 mg orally, twice daily for 3 days for children ≥ 6 months ( not
recommended below 6 months) 3.3.4. Persistent diarrhoea and dysentery
Children with persistent diarrhoea (without an acute watery exacerbation) do not need acute rehydration therapy. They have adapted over the weeks to their altered hydration state and should not be rehydrated over a few hours. The appropriate treatment of persistent diarrhoea is nutritional; it is most often due to nutrient deficiency and will resolve with F75 and suppression of small bowel bacterial overgrowth. Small bowel overgrowth is suppressed with most routine antibiotics used for severely malnourished children; if the diarrhoea persists a course of metronidazole (10mg/kg/d) can be given (see annex 6).
Mucosal damage and giardiasis cause persistent diarrhoea.
Treat giardiasis with metronidazole (7.5 mg/kg/day for 7 days) if not already given or treat if stool examination cannot be under taken or there is clinical suspicion
Shigella: If stool contains visible blood, treat the child with an oral antimicrobial effective against the most local strains of Shigella.
Give Ciprofloxacin 10mg/kg/12 for 3 days lactose intolerance: Only rarely is diarrhoea due to lactose intolerance. Treat only if
continuing diarrhoea is preventing general improvement. Starter F-75 is a low-lactose feed. In exceptional cases:
substitute milk feeds with yoghurt or a lactose-free infant formula reintroduce milk feeds gradually in the transition and rehabilitation phase
Osmotic diarrhoea may be suspected if diarrhoea worsens substantially with hyperosmolar starter F-75 and ceases when the sugar content is reduced and osmolarity is <300 mOsmol/l.
54
54
In these cases:
commercially available isotonic F75 or low osmolar cereal-based F-75 (Annex 3 for recipe)
Then introduce RUTF (where RUTF is not available then F-100)
3.3.5. Tuberculosis (TB)
If TB is strongly suspected (contacts with adult TB patient, poor growth despite good intake, chronic cough, chest infection not responding to antibiotics):
perform Mantoux test (false negatives are frequent) chest X-ray if possible
If test is positive or there is a strong suspicion of TB, treat according to protocol for children with malnutrition in the National TB guidelines for Nigeria, however, the treatment of the SAM takes precedence in view of the respective mortality rates. Treatment for TB can also be delayed for at least two weeks, except in the cases of military TB, TB meningitis and Pott’s disease when treatment should start immediately despite the danger of drug toxicity. Do not immediately transfer to a TB centre if they have little experience/ are untrained in treating SAM;
Avoid co-artem and rifampicin if the patients have SAM and are on ARVs. If rifampicin must be used then reduce the dose
Isoniazide is also hepatotoxic but much less than rifamipcin
3.3.6. HIV
Where there is an effective Hospital Counselling and Testing (HCT) program and, at least, prophylaxis and treatment for opportunistic infections is available, Voluntary Counselling and Testing (VCT) should be offered to all patients with severe malnutrition and their caregivers.
Where anti-retroviral treatment is available, there should always be HCT associated with the identification and management of SAM.
Where the parent has HIV/AIDS, additional support needs to be available as the parent will have recurrent illness. During these illnesses she may not be able to care for her children. Indeed, OTP may not be feasible. The care and treatment centres that have been established
55
55
for HIV should also be able to provide treatment for severe malnutrition and TB, on an out-patient basis.
Nigeria’s policy on infant feeding in the context of HIV instructs health workers to counsel HIV-positive mothers to breastfeed their infants (exclusively for 6 months and continued breastfeeding up to 1 year of life) and take anti-retroviral drugs during pregnancy and breastfeeding period or longer.
If treatment with anti-TB drugs or ARVs is started in the severely malnourished patient whilst they have physiological malnutrition, they are likely to develop very severe side effects from the drugs. Such side effects can lead to death or withdrawal of many of the patients from the ARV treatment programs. All ARV drugs have significant side effects, and their toxicity and pharmacokinetics have not been adequately assessed in the severely malnourished child. The treatment of the malnutrition is the same whether the patient is HIV positive or negative (both in and out-patients).
Start SAM treatment, at a minimum two weeks, before the introduction of ARV drugs to diminish the risk of serious side effects from the ARV drugs. In responding children, delay ARV treatment until the recovery phase is well established in OTP. For failure-to-respond children start ARV after two weeks of SAM treatment with F75.
Give co-trimoxazole prophylaxis against pneumocystis pneumonia for children with HIV. This is inadequate antibiotic cover for the severely malnourished patient so give the routine antibiotics as well
o Avoid amphotericin B in SAM patients with HIV.
Once the SAM is being treated satisfactorily and s/he has had adequate amounts of the essential nutrients to resist the toxic effects of the drug treatment of HIV and TB,
o then start the treatment for HIV and follow the national guidelines.
3.3.7. Other infections and conditions
3.3.7.1 Malaria
Every child who presents with SAM should have a rapid diagnostic test or a blood film to test for the presence of malaria parasites. If positive, all SAM children should be treated according to the National protocol.
56
56
NOTE: Some of the drugs used in treating malaria are potentially more toxic in the malnourished than in well-nourished patients and should be avoided if possible. Combinations containing amodiaquine should be avoided in the SAM children until their safety is confirmed in this group of children.
Do NOT give oral or intravenous infusions of quinine to SAM patients for at least the first two weeks of treatment. In severely malnourished patients quinine often induces prolonged and dangerous hypotension, hypoglycaemia, arrhythmia and cardiac arrest. There is only a small difference between the therapeutic dose and the toxic dose.
Long lasting Insecticidal Nets should be on all the beds in the IPF and encouraged to be used at home.
3.3.7.2. Fever
Severely malnourished children do not respond to anti-pyretics. Because they fail to work, caregivers and staff often repeat the dosage inappropriately, frequently leading to toxicity. Antipyretics are much more likely to be toxic in the malnourished than a normal child.
Do not give aspirin or paracetamol to SAM children in the IPF.
For moderate fevers, up to 38.5°C rectal,
Do not treat moderate fevers, up to 38.5°C rectal or 38.0°C underarm
Maintain routine treatment
Remove blankets, hat and most clothes and kept in the shade in a well-ventilated area
Give water to drink
Check for malarial parasites and examine for infection
Fevers of over 39°C rectal or 38.5°C underarm, where there is the possibility of hyperpyrexia developing,
In addition to the above, also:
Place a damp/wet room-temperature cloth over the child’s scalp, re-dampen the cloth whenever it is dry
Monitor the rate of fall of body temperature
Give the child abundant water to drink
If the temperature does not decline, the damp/wet cloth can be extended to cover a larger area of the body
When the temperature falls below 38°C rectal, stop active cooling. There is a danger of inducing hypothermia with aggressive cooling.
57
57
Refeeding syndrome
“Refeeding syndrome” refers to malnourished patients (and those who have been fasting for more than one week4) who develop any of the following shortly after they have a rapid, large increase in their food intake: acute weakness, “floppiness”, lethargy, delirium, neurological symptoms, acidosis, muscle necrosis, liver and pancreatic failure, cardiac failure or sudden unexpected death. The syndrome is due to rapid consumption of key nutrients for metabolism particularly if the diet is unbalanced. There is frequently a large reduction in plasma phosphorus, potassium and magnesium.
Other separate problems during early refeeding include refeeding-œdema and refeeding-diarrhoea.
Prevention
It is necessary at the start of treatment not to have a sudden jump in the adapted malnourished state to a very high intake. On admission, malnourished patients should never be force-fed amounts of diet in excess of those prescribed in the protocol; particular care needs to be taken with those who are being fed by NG Tube. Prevention of refeeding syndrome is the purpose of the transition phase of treatment. In the OTP protocol very large amounts of RUTF are sometimes given at the start of treatment. If any mother forces her child to take all the diet then refeeding syndrome is a real possibility.
Treatment
For patients in the recovery phase
If there is deterioration during the recovery or transition phase of treatment,
o Then the child should be returned to the acute phase.
For patients that are in the acute phase,
o Reduce the diet to 50% of the recommended intake until all signs and symptoms disappear and then gradually increase the amount given
o Check to make sure that there is sufficient potassium and magnesium in the diet. If the diet is not based on cow’s milk (or the mother is also giving cereals/pulses etc.) additional phosphorus should be given to prevent refeeding syndrome.
3.1.2. Transition phase: During this period, the child is out of the emergency period and is being prepared to move from stabilization care in the IPF to rehabilitation phase in the OTP. The ONLY change that is made to the treatment on moving from Acute-phase to Transition-Phase is a change in the diet from F75 to RUTF, or if the RUTF is not accepted to F100.
3.1.2.1. Catch up growth feeding
4 The syndrome also occurs in obese patients who have been fasting as part of their treatment; they are not wasted but, like the malnourished patient, have metabolically adapted to a low intake of food.
58
58
This takes place during the transition phase in the IPF after resuscitation and correction of medical complications. This short phase begins to prepare the child for exiting to the outpatient therapeutic program.
The expected period within the stabilization phase is 3 – 5 days but may be longer, particularly when there is another pathology (e.g. TB or HIV); .The patient should not be transferred out of stabilization phase if not improving. A prolonged stabilisation phase is a criterion for failure-to-respond. The transition phase usually lasts between 1 and 3 days.
Feeding process
Transit patient from starter F-75 to ready-to-use therapeutic food once the child begins to show signs of improvement and appetite returns. Every child still breastfeeding should be offered breast milk first before every RUTF feed and on demand
It is preferable to use RUTF in the Transition Phase. Those children who have been very ill and are going to continue treatment as out-patients with take-home treatment should become habituated to RUTF before they go home.
o Give the total amount of RUTF that should be taken during the day according to the table(see annex 13)
o Advise the mother to breastfed the child 30 min before giving the RUTF;
o Tell the mother to wash hands before giving the sachet of RUTF to the child;
o Tell the mother to offer plenty of water to the child;
o Advise the mother to put the sachet in a box (insect and rodent proof) when the child has finished each session of eating;
o CHECK five times during the day the amount given by the mother. It is important for the assistant to check regularly and counsel the mother and not assume that the mother will give all the RUTF to the child. It is useful to have regular “meal times” for the children where the mothers all gather together in one place to feed their children.
For children that are not taking sufficient RUTF (not gaining any weight),
o Either give F100 (Annex 16) for a few days and then re-introduce RUTF;
o Or return the child to the acute-phase for a day or so and give F75;
o Do NOT give any other food to the patient during this period;
o Do NOT let the caretaker eat in the same room as the malnourished children;
o Check that the caretaker or other children do not consume the patients’ RUTF;
o Make drinking water available both in the ward and also to individual children. The mother must offer as much water to drink as they will take during and after they have taken some of the RUTF;
o Write on the chart, the amount given and taken.
One advantage of the RUTF is that there is no need for surveillance during the night so that minimum or no night staff are needed.
59
59
Some patients initially refuse the RUTF completely. If this is the case they should be given the F100 diet for one or two days and then the RUTF re-introduced. Other children prefer the RUTF. It is good practice to give the diet that the children prefer – the two diets are nutritionally equivalent.
If RUTF is not available, or the child does not readily take the RUTF (younger children and about 10% of the older children prefer a liquid diet) then use F100 (130ml = 130kcal).
When F100 is used the number of feeds, their timing and the volume of the diet given remains exactly the same in Transition Phase as it was in Acute-phase.
o Ask the mother to breastfed their children, half an hour before giving the feed;
o Prepare the diet: It is made up from one small package of F-100 (114g) diluted into 500 ml of water or one large package of F100 (456g) diluted into 2 litres of water;
o Give five or six feeds per day;
o Write on the daily care multi-chart the amount to take and taken.
Even if the child is going to remain in a facility for recovery-phase, RUTF can be given for transition phase and subsequently; this relieves the burden on the staff of making up feeds frequently.
Warning: F100 should never be given to be used at home. F100 is always prepared and distributed in an in-patient unit by staff trained in its use. F100 should not be kept in liquid form at room temperature for more than 3 hours before it is consumed, if there is a functioning refrigerator, constant electricity and a very clean kitchen/ utensils, then it can be kept (cold) for up to 8 hours (i.e. overnight).
Amounts of RUTF to give per 24h in Transition phase
The amounts given in the table are for the full 24h period.
Table 9: Look up table for RUTF in Transition Phase per 24h
CLASS OF
WEIGHT (KG) PASTE PASTE BARS
TOTAL IN GRAMS SACHETS BARS KCAL
3.0 – 3.4 90 1.00 1.5 500
3.5 – 3.9 100 1.00 1.5 550
4.0 – 4.9 110 1.25 2.0 600
5.0 – 5.9 130 1.50 2.5 700
6.0 – 6.9 150 1.75 3.0 800
7.0 – 7.9 180 2.00 3.5 1000
8.0 – 8.9 200 2.00 3.5 1100
9.0 – 9.9 220 2.50 4.0 1200
10 – 11.9 250 3.00 4.5 1350
12 – 14.9 300 3.50 6.0 1600
15 – 24.9 370 4.00 7.0 2000
25 – 39 450 5.00 8.0 2500
40 – 60 500 6.00 10.0 2700
60
60
NOTE: If both F100 and RUTF are being given, they can be substituted on the basis of 100ml of F100 = 20g of RUTF5.
Table 10: Look up table on the amounts of F100 to give for 6 – 5 feeds per day
CLASS OF WEIGHT (KG) 6 FEEDS PER DAY 5 FEEDS PER DAY
Less than 3.0 F100 full strength should not be used
3.0 – 3.4 75 ml per feed 85 ml per feed
3.5 – 3.9 80 95
4.0 – 4.4 85 110
4.5 – 4.9 95 120
5.0 – 5.4 110 130
5.5 – 5.9 120 150
6.0 – 6.9 140 175
7.0 – 7.9 160 200
8.0 – 8.9 180 225
9.0 – 9.9 190 250
10.0 – 10.9 200 275
11.0 – 11.9 230 275
12.0 – 12.9 250 300
13.0 – 13.9 275 350
14.0 – 14.9 290 375
15.0 – 19.9 300 400
20.0 – 24.9 320 450
25.0 – 29.9 350 450
30.0 – 39.9 370 500
40.0 – 60.0 400 500
NOTE: if small quantities of F100 are being reconstituted from the commercial powder, the red scoop should be used and 14ml of water added to each scoop (not compressed) of F100.
The table gives the amount of F100 (full strength) that should be offered to the patients in transition phase who are not taking RUTF. They should normally be taking 5 feeds during the day and none at night.
Key Messages for Children on RUTF
Sensitize the mother of the importance of breast-feeding and that the child should
always get breast-milk before they are given RUTF and also on demand.
Explain to the caregiver how to give the RUTF
5 If tables are to be constructed then 100 ml of F100 = 18.5g of RUTF: 10g of RUTF = 54ml of F100 should be used and the resulting values rounded to the nearest 5 or 10 ml
61
61
For breast-fed children, always give breast milk before the RUTF.
RUTF is a food and a medicine for malnourished patients only. It should not be shared with the other family members even if the patient does not consume all the diet offered. Opened packets of RUTF can be kept safely and eaten at a later time6 – the mother or other family members should not eat any that is left over at a particular meal.
Wash the patient’s hands and face with soap before feeding.
These patients often only have moderate appetites during the first few weeks and eat slowly. They must be fed separately from any other children in the household. The patient can keep the RUTF with him/her to eat it steadily throughout the day – it is not necessary to have set meal times if the food is with the patient all the time. However, with children, the caretaker should attend to the child every 3-4 hours at least and encourage the child, or give small regular meals of RUTF at these times. Tell the mother how much her child should eat each day (this is given in the look-up table).
Explain that for the first week or two the patient will probably not finish all the RUTF given. The mother should not be upset by this as excess has been given, but as the child recovers his/her appetite will improve so that all the diet will be taken later on in recovery. Uneaten RUTF should not be taken by other members of the family but returned to the OTP – as the child improves s/he will start to consume nearly all the food.
Explain that RUTF is the only food the patient needs to recover during her/his time in the programme. It contains all the ingredients that the patient needs to recover and is really like a special medicine. It is not necessary to give other foods.
Tell the caregiver that there are special medical nutrients and milk powder inside the RUTF, and that it is not just peanut butter. Tell her that all the nutrients are needed by the child to recover and that if the child does not take sufficient RUTF then they will not get enough of these medical nutrients. Normal food does not contain the right amounts and balance of these nutrients.
Explain that the illness has damaged the child’s intestine so that the normal family food is not sufficient for the child and may even cause some diarrhoea. Tell the mother that some common foods will delay the recovery of her child. If the child asks for other foods small amounts can be given but she should always give the RUTF before other foods and at a different time from regular family meals.
Never mix the RUTF with other foods. Most cereals and beans contain anti-nutrients and inhibitors of absorption that make the special nutrients in the RUTF that the child needs to recover unavailable for the child. If other foods are given they should be given at a separate time from the RUTF.
Explain that the child must NEVER be force fed and should always offer plenty of clean water to drink while eating RUTF.
6 The actual length of time depends upon storage conditions. If the package is kept in a closed container and protected from insects and rodents it can usually be kept for several weeks (at least until the next OTP visit); there is certainly no necessity to consume a whole sachet at one meal.
62
62
Explain that the caregiver should have an attentive, caring attitude while feeding the baby; talk, sing and play with the child to stimulate appetite and development.
Routine Medicine
Routine antibiotic should be continued for 4 more days after acute-phase or until transferred to recovery-phase as an outpatient
Monitoring
The monitoring of stabilization phase is maintained in transition Phase.
Criteria to move back from transition phase to the stabilization phase
Move the child back to acute-phase:
o If there is a rapid increase in the size of the liver
o If any other signs of fluid overload develop (increased respiratory rate)
o If the patient gains weight more rapidly than 10g/kg/d (this indicated excess fluid retention)
o If tense abdominal distension develops (indicates abnormal peristalsis, small bowel overgrowth and perhaps excess carbohydrate intake)
o If the patient gets significant re-feeding diarrhoea so that there is weight loss (see separate section)
o If a complication arises that necessitates an intravenous infusion (e.g. malaria, dehydration, etc.)
o If there is any deterioration in the child’s condition (see section on refeeding syndrome)
o If there is increasing oedema (look for unexpected sodium intake, particularly from mother’s diet or drugs – if an extraneous source of sodium is found then it should be eliminated and children with good appetites can remain in transition-phase)
o If a child who does not have oedema develops oedema (look for extraneous intake of sodium)
It is common for the children to get some change in stool frequency when they change diet. This does not need to be treated unless the children lose weight. Several loose stools without weight loss is not a criterion to move back to acute-phase.
Criteria to progress from transition phase to OTP
Transfer the patient to the OTP
o If s/he has a good appetite - This means taking at least 90% of the RUTF (or F100) prescribed for transition phase
o For oedematous patients (kwashiorkor), if there is a definite and steady reduction in oedema
o If there is a capable caregiver
63
63
o If the caregiver agrees to out-patient treatment
o If there are reasonable home circumstances
o If there is a sustained supply of RUTF
o If an OTP program is in operation in the area close to the patient’s home
A patient transferring from one to another phase of treatment, one as an in-patient and the other as an outpatient, is still under the care of the IMAM program for this episode of severe malnutrition; this is not a “discharge” from the in-patient facility but an internal transfer to another part of the same program – nevertheless the IPF records this as “successful treatment”.
DISCHARGE PROCEDURES
o Register the patient in the registration book as successfully treated, dead, defaulter or a medical referral;
o Complete the daily chart form and fill in a transfer form with the SAM N° and give all the required information about the treatment;
o Call the OTP to give them notice about the patient returning home;
o Give the mother a copy of the transfer form, the name and address of the OTP and the day of the consultation and a provision of RUTF until the next appointment in the OTP;
o Write in the child’s health card the treatment given and the weight.
3.1.3. Rehabilitation phase: This should only take place in the OTP. In Nigeria, this is usually in the Primary health care centres closest to the child’s home and if not available then in outpatient section of the hospital.
Referral from Transition phase to Outpatient therapeutic Program (OTP) for rehabilitation
Although it is highly desirable that the rehabilitation phase be managed on an out-patient basis at an OTP in the community, this is not always possible. If there is no capable caregiver, impossible home circumstances, no other family willing to care for the child, an abandoned child without an available orphanage, no operational OTP service or no supply of RUTF, then patients may have to be kept in the IPF until fully recovered. In these circumstances the program is insufficient and needs to be upgraded. Orphanages must be able to care for children in the rehabilitation phase of treatment and their staff should receive special training and able to care for abandoned children and where there is no-one willing within the household; the children can be returned from the orphanage to the family by agreement when the child has recovered.
64
64
Providing sensory stimulation and emotional support
As children become malnourished, they gradually reduce their activity. When fully malnourished they do not play, cry, smile, complain or show normal emotions – they become lethargic and feeble .Because they do not play, they do not learn. With time this leads to delayed mental and behavioural development. If this is not treated it is the most serious long-term outcome of malnutrition. Emotional and physical stimulation through play programmes that start during rehabilitation and continue after discharge can substantially reduce the risk of permanent mental and emotional damage.
Provide:
tender loving care a cheerful, stimulating environment structured play therapy for 15 –30 min/day. Teach the mothers how to make simple
toys and emphasize the importance of regular play sessions at home (see annex 12) physical activity as soon as the child is well enough support for as much caregiver involvement as possible (e.g. comforting, feeding,
bathing, playing).
65
65
Nutritional counselling and appropriate Infant and Young Child Feeding (IYCF) practices
Inadequate knowledge about appropriate foods and feeding practices is often a greater determinant of malnutrition than the lack of foods. Virtually all women can breastfeed provided they have accurate information and support within their families, communities and from health system.
Mother should continually receive nutritional counselling integrated with other health topics to improve infant care, while on admission in the IPF. Providing sound and culture specific nutrition counselling to mothers of young children and recommending the widest possible indigenous foodstuffs will help ensure that local foods are prepared at a low-cost and fed safely at home. The infant and young Child feeding practices to be addressed include:
Figure 11: Breastfeeding Infant
Breastfeeding as an unequalled way of providing ideal food exclusively for 6 months Complementary feeding to commence at 6 months with breastfeeding continuing till
23 months to meet their evolving nutritional requirements Complementary foods need to be
o Timely –introduced at 6 months when the need for energy and nutrients exceeds what can be provided through exclusive and frequent breastfeeding
o Adequate- provide sufficient energy, proteins and micronutrients to meet growing child’s needs
o Safe- hygienically prepared and stored and fed with clean hands using utensils and not bottles and teats
o Properly fed-given consistent with a child’s signals of appetite and satiety, and that meal frequency and feeding method- actively encouraging the child, even during illness, to consume sufficient food using fingers, spoon or self -feeding as suitable for age.
Other key nutrition information include
o Maternal nutrition o Control of anaemia o Control of iodine deficiency and o Vitamin A supplementation
66
66
Other packages cover subjects such as counselling on growth and feeding (WHO), growth monitoring and promotion, immunization, hygiene and sanitation, malaria control and de-worming. Food demonstration sessions are mandatory in the IPF.
Referral to mother-to-mother support groups will also provide counselling and support to the mother as well as other community IYCF program
3.2. Infants <6months with Severe Acute Malnutrition
Severe acute malnutrition is very common in infants < 6 months than in older children. AS WITH ALL MALNOURISHED CHILDREN, an organic cause for the malnutrition or failure to thrive should be considered, and if present then appropriately treated. However, the development of severe acute malnutrition in this age group commonly reflects suboptimal feeding practices, especially breastfeeding practices and may be associated with a psychological cause.
Criteria for admission
Infants less than 6 months of age or less than 3.5 Kg - with breastfeeding failure with any of the following complicating factors should be admitted for inpatient care:
67
67
Table 11: Admission criteria for infants < 6 months
AGE ADMISSION CRITERIA
INFANT LESS THAN 6
MONTHS OR LESS
THAN 3.5KG
The infant is too weak or feeble to suckle effectively (irrespective of his/her Weight-for-Length(WL), Weight-for-Age (WA) or other anthropometry) The following criteria are also important complicating factors and warrant admission The infant is not gaining weight at home (by serial
measurement of weight during growth monitoring, i.e. change in weight-for-age)
or W/L (Weight-for-Length) less than <-3 SD
or Presence of bilateral oedema
or general danger signs (IMCI ) or serious clinical condition
as outlined for infants 6 months or older
or any social issue requiring detailed assessment or intensive
support (e.g. disability or depression of caregiver or other adverse social circumstances).
Infants who are malnourished are weak and do not suckle strongly enough to stimulate an adequate production of breast milk. The mother often thinks that she herself has insufficient milk and is apprehensive about her ability to adequately feed her child. Attempts to put such infants to the breast repeatedly fail, the infant continues to lose weight and the mother is confirmed (correctly) in her view that attempts at exclusive breast feeding will not work after her infant has become so malnourished. This does not work.
MANAGEMENT
Treat infections
Give parenteral antibiotics to treat possible sepsis, and appropriate treatment for other medical complications, based on antibiotic sensitivity patterns
Diet The objective of treatment of these patients is to RETURN THEM TO FULL
EXCLUSIVE BREAST-FEEDING. These infants should be breastfed where possible and the mothers or female caregivers should be supported to breastfeed the infants.
68
68
Good positioning and good attachment should be identified for effective suckling to occur
If an infant is not breastfed, support should be given to the mother or female caregiver to re-lactate.
If this is not possible, wet nursing should be encouraged; and
The infants should also be provided a supplementary feed: This is achieved by stimulating breast-feeding at the same time as supplementing the child during breast feeding until the infant becomes stronger and breast milk production is sufficient to allow the child to grow properly. Treating the infant with artificial diets rapidly leads to weaning and the mother sees that the “formula” is the only way to allow her child to recover. Weaning an infant in most circumstances where malnourished infants are found carries a high risk of mortality. This is not recommended.
Breast milk output is stimulated by the Supplemental Suckling (SS) technique; it is important to put the child to the breast as often as possible. The SS technique is time consuming and requires skill, but is the only technique that works in practice. The SS-milk can be either generic infant formula or made by diluting F100 to make F100dilute.
Note: Full strength F100 should NEVER be used for small infants. The renal solute load is too high for this category of infant and could provoke hypernatraemic dehydration.
Type of milk
For oedematous infant: Give F75 For Non oedematous infant: Give Generic Infant formula or F100dilute If there is a choice, use a formula designed for premature infants.
NOTE: Unmodified powdered whole animal milk should NOT be used.
Preparation
For Infant formula,
o Dilute according to the supplier’s instructions. For F100dilute,
o Put one small packet (102.5g) of F100 into 670ml of water instead of 500ml (or, if you do not have a small packet, one large packet of 457g F100 into 2.7 l of water instead of 2l to make F100 dilute).
o Use 100ml of F100 already prepared and add 35ml of water, then you will get 135ml of F100diluted. Discard any excess waste.
o Don’t make smaller quantities.
Amounts to give by SS technique
o Give the amount of SS-milk at each feed according to the look up table in annex 14. o Do NOT increase the amount given as the infant starts to regain strength, suckle
more strongly and gain weight.
69
69
o Encourage the mother when the infant is gaining weight and tell her, that “the recovery is due to her own breast milk”.
o Ask the mother to breast-feed every 3 hours for at least 20 minutes, more often if the infant cries or seems to want more.
o Shortly after (30 to 60 minutes) giving a normal breast-feed, return the infant to the breast and help the mother to give the generic infant formula/F100dilute using the SS technique.
o Write the information on the infant chart.
Supplementary Suckling Technique
At the beginning of the SS technique
o Use a tube the same size as n°8 NGT (an n°5 tube can be used and is better for the infant, but the milk should be strained through sterile gauze to remove any small particles that block the tube).
o Put the appropriate amount of SS-milk in a cup and hold it.
o Put the end of the NG tube in the cup.
o Put the tip of the tube on the breast at the nipple.
o Tell the mother to offer the breast in the normal way so that the infant attaches properly.
Note: At the beginning the mothers find it better to attach the tube to the breast with some tape, later as she gets experience this is not normally necessary.
o When the infant suckles on the breast, with the tube in his mouth, the milk from the cup is sucked up through the tube and taken by the infant. It is like taking a drink through a straw.
o Help the mother at first by holding the cup and the tube in place.
o Encourage the mother confidently.
o Place the cup at first about 5 cm to 10 cm below the level of the nipple so the SS-milk can be taken with little effort by a weak infant.
o NEVER place the cup above the level of the nipple, or it will flow quickly into the infant’s mouth by siphonage with a major risk of inhalation.
o Tell the mother to relax. Excessive or officious instructions about the correct positioning or attachment positions often inhibit the mothers and make her think the technique is much more difficult than it is. Any way in which the mother is comfortable and finds that the technique works is satisfactory.
70
70
It may take one or two days for the infant to get used to the tube and the taste of the mixture of milks, but it is important to persevere.
Later, as the infant becomes stronger
o Lower the cup progressively to about 30cm below the breast.
o Later when the mother is more confident, ask if she wants to manage to hold the cup and tube without assistance. The mother, instead of the assistant, can hold the tube at the breast with one hand and the other holds the infant and the cup. In this way, she can perform SS-feeding without assistance.
o Use another mother who is using the technique successfully to help.
o Try to have the mothers sit together at the same time using the SS technique. Once one mother is using the SS-technique successfully, the other mothers are greatly encouraged and find it relatively easy to emulate her.
o If the SS-milk formula is changed suddenly then the infant normally takes a few days to become used to the new taste. It is preferable to continue with the same supplementary diet throughout the treatment.
Fig 12: Supplementary suckling technique
Cleaning the tube
o After feeding, flush the tube through with clean water using a syringe.
o Then spin the tube rapidly to remove the water in the lumen by centrifugal force, and inspect to ensure that no water remains in the tube. If convenient, the tube is then left exposed to direct sunlight. The UV rays in sunlight penetrate the plastic and can effectively sterilise the tube if it is already clean and all opaque matter are removed.
This infant is suckling the breast and also getting the SS-milk (135ml/kg/d) by the supplemental suckling technique.
Raising or lowering the cup determines the ease with which the infant gets the supplement: for very weak infants it can be just below the level of the infant’s mouth. If it is above this level, the feed can go into the child by siphonage where there is a danger of aspiration.
71
71
Progress and follow up
o Monitor the progress of the infant by the daily weight with a scale graduated within 10g (or 20g) and write on the infant monitoring chart.
If the infant loses weight over 3 consecutive days yet seems hungry and is taking all his F100 dilute/infant formula,
o Add 5ml to each feed.
The principle of SS feeding is giving maintenance amounts. If it is being taken and there is weight loss, either the maintenance requirement is higher than calculated or there is significant malabsorption.
If the infant grows regularly with the same quantity of milk,
o Tell the mother that the quantity of breast milk is increasing and she is “responsible” for recovery.
If after some days, the infant does not finish all the supplemental food, but continues to gain weight,
o Tell the mother that the breast milk is increasing and that the infant is getting enough to fully recover.
o Reduce the amount of SS-milk given at each feed by the amount not taken.
When a baby is gaining weight at 20g per day (whatever her/his weight),
o Decrease the quantity of SS-milk given at each feed to half of the maintenance intake.
If, on half the SS-intake, the weight gain is maintained at 10g per day (whatever her/his weight),
o Then stop supplement suckling completely. Tell the mother that she is doing this all by herself.
If the weight gain is not maintained when the SS-milk intake is cut in half,
o Then change the amount given to 75% of the maintenance amount for 2 days and then reduce it again if weight gain is maintained.
If the mother wishes to go home as soon as the infant is taking the breast milk greedily and gaining weight, they should be discharged.
If the mother is agreeable, keep in the centre for a further 2 days on breast milk alone to confirm that her infant continues to gain weight on breast milk alone.
Then discharge the infant, no matter his current weight for age or weight for length.
72
72
Routine Medicine
o Give Antibiotics: Amoxicillin (from 2kg): 30mg/kg 2 times a day (60mg/day) in association with Gentamicin once daily for five days.
Monitoring
Monitor the infant and write it on the infant monitoring chart:
o Weight is measured daily
o Body temperature is measured twice per day.
o The standard clinical signs are assessed and noted in the progress monitoring charts each day
o Respiratory rate
o Stool
o A record is taken (on the intake part of the multi-chart) the patient is absent, vomits or refuses a feed
Care for the mothers
As the aim is to increase breast milk, the mother’s health and nutritional status are critical for the nutritional repletion of the infant.
o Explain to the mother what the aim of treatment is and what is expected of her
o Do not make the mother feel guilty for the state of her child or blame her for giving other foods
o Introduce her to the other mothers in the centre and introduce her to the staff personally. Make her feel “at home” in a friendly and relaxing atmosphere
o Empathize with her that she may not have enough milk at present – but strongly reassure the mother that the technique works and that enough milk will “come into” her breasts as her baby recovers. She will then be able, with her own milk, to make her baby better
o Tell her and encourage her to drink at least 3 litres of fluid per day
o Make the necessary arrangement for the mother so she can eat about 2500kcal/day of a high quality diet (an extra meal a day or 2 snacks)
o Give to the mother Vitamin A:
o If the infant is below 2 months or the mother is having her menses: 200,000IU (there should be no risk of pregnancy),
o If the infant is above 2 months: 25,000IU once a week
73
73
o Give Micronutrient supplements
o Decrease as much as possible the length of stay in the facility
o If needed, give drugs which help with lactation (e.g. metoclopramide 10mg 8 hourly)
Other drugs that increase milk flow (e.g. chlorpromazine, are less effective, cross into breast milk and will potentially affect the mother and child adversely. In some cultures there are local spices that stimulate breast milk output but their safety has not been established.
There are no anthropometric criteria for discharge of the fully breast-fed infant who is gaining weight. They can be transferred to the outpatient department of the IPF based on improvement on breastfeeding, weight gain and good caregiver support for optimal IYCF practices.
ANNEX 19 – INFANTS WITHOUT ANY PROSPECT OF BEING BREAST-FED These young infants are particularly vulnerable because they have neither a mother nor the protection of breast milk.
Anthropometry in these small infants is difficult and imprecise. MUAC is not yet used in this age group. Where there is a growth monitoring program change infants that are losing weight or have crossed weight-for-age centile lines because their weight is static can be admitted.
Admission Criteria7
AGE ADMISSION CRITERIA
Infant less than 6 months or less than 3 kg with no prospect of being breast-fed
The infant is not gaining weight at home (by serial measurement of weight during growth monitoring, i.e. change in weight-for-age)
or W/L (Weight-for-Length) less than <-3 Z
or Presence of bilateral œdema.
When there is no prospect of being given breast milk then severely malnourished, less than 6 months old infants should be treated according to the standard protocol with the following modifications.
Acute phase
The diet should normally be based upon Generic Infant formula except for those with oedema when F75 is used in the acute phase. Generic infant formula is preferred, however, F100diluted can be used, but full strength F100 must never be used8. (See table below for amounts in the different
7 There are no standards for infants below 45cm and the increments to judge nutritional status require precise scales that are not generally available. The in-patient therapeutic unit is not appropriate for managing premature and low-birth-weight non-breast-fed infants below 45cm in length. These infants should be referred to the neonatology service/nursery and given infant formula. 8 NEVER use full strength F100 – it can cause hypernatraemic dehydration in these infants. There has been very little experience in treating these infants in the developing world. In the developed world special formula for premature infants
74
74
phases). The criteria for using an NG-Tube and passage to transition phase are the same as for older children.
The infants must have antibiotics routinely and the management of complications is the same as for older infants and children.
Transition Phase
If the infant has been taking F75 during the acute phase then this is changed to Generic Infant Formula (or F100diluted) during the transition Phase. Otherwise there is no change in the diet given, but the volume offered is increased by about one third.
Recovery phase
During Recovery-phase, twice the volume of Generic Infant Formula (or F100diluted) is OFFERED to the infants. This is a large amount to encourage rapid catch up growth; they must NEVER be force fed. The frequency of feeding can be reduced to 6 times per day.
is used – if available it is suggested that these formula are used. The diets given can be the same as those given to infants being fed with the SS-technique. Nearly all these infants have been born prematurely or have had intra-uterine growth retardation, with low birth weight. Thus, the aetiology of the “malnutrition” in the small infant is normally different from the older child.
75
75
Look up table of the amounts of Generic Infant formula, F100dilute or F75 to give for
infants not breast-fed in the Acute, Transition and Recovery phases.
Acute Phase Transition Phase Recovery Phase
Class of weight (kg) Amount (ml) of Generic Infant Formula F100dilute or F75 to give per feed
8 feeds/day 8 feeds/day 6 feeds/day
≤ 1.5 kg 30 40 60
1.6 – 1.8 35 45 70
1.9 – 2.1 40 55 80
2.2 – 2.4 45 60 90
2.5 – 2.7 50 65 100
2.8 – 2.9 55 75 110
3.0 – 3.4 60 80 120
3.5 – 3.9 65 85 130
4.0 – 4.4 70 95 140
CRITERIA for DISCHARGE
When the infant reaches -1.5Z score weight-for-height and is gaining weight at 20g/d s/he can be discharged.
The infants will be discharged on generic infant formula.
It is essential that the caretaker has access to adequate amounts of generic infant formula. This has to be supplied by the clinic or orphanage/foster parents. Commercially produced formulae are nearly always unaffordable by families with malnourished young infants when no mother or wet-nurse is available. Most caretakers9 (fathers, siblings) in this situation over-dilute the formula to make it “stretch” and last longer, others use the cheapest milk, which will be dried whole milk, evaporated or condensed milk; these are all unsuitable for the growth and development of the previously malnourished infant.
The caretaker (father/siblings) must have the knowledge and facilities to prepare the formula milk safely.
Follow-up for these infants and their caretakers is very important and should be organised by the outreach worker in conjunction with the community volunteers.
9 In many areas with a high prevalence of HIV there are substantial numbers of “child-headed households”, where the adults have all died. These children looking after children present a particular difficulty in terms of livelihood, knowledge, exploitation etc. The whole household needs direct assistance.
76
76
CHAPTER 4: ORGANIZATION OF INPATIENT FACILITY
4.1. Stabilization Centre (SC)
Children who have severe oedema +++ or a poor appetite (fail the appetite test) or present
with one or more general danger signs or medical conditions requiring admission should be
treated as inpatients. This stabilization care should be provided in tertiary and secondary
hospitals, as well as comprehensive Primary Health Care Centres (CPHCs) with the full
complement of a medical team headed by the Doctor. This specially designated ward or
alternatively an area in the children’s ward is usually called Stabilization Centre.
The SC in the IPF only needs:
A space to take the anthropometric measurements, examine and carry out routine
admission procedures for the patients, a ward kitchenette for preparation of the
therapeutic milk (F75/F100) (if there is no Department of Nutrition and Dietetics
which will provide 24hservice), toilet and washing facilities and provision for the
caregivers to cook (and where possible food given to the caregivers), storage facility
for medicine and therapeutic foods [F75/F100/RUTF].
There should be long lasting insecticidal nets (LLINs) for each bed. Adult beds or
even mattresses on the floor are preferred to cots: mothers should sleep with their
children to avoid hypothermia, emotional stress and interruption of breast feeding.
This is to ensure that the caregivers do not get exhausted, are able to make rational
decisions and are less likely to default.
An area in the ward designated for play equipped with toys.
4.2. Roles of Service Providers
All the Human resources (doctors, nurses, dietitians/nutritionists, pharmacists and medical
social workers/community health officers) should be trained before managing SAM
patients. All personnel involved in the in-patient management of children with SAM should
have regular update courses or re-trainings. The SAM managing team should attend the
weekly clinical meetings in the health facility.
4.2.1. The Doctor
The doctor’s main duty is to admit and assess the patients, manage complications,
concentrate upon patients that fail to respond to treatment or present diagnostic difficulties.
It is also their responsibility to transfer those with good appetite and without medical
complications directly to the OTP and provide technical support and guidance to other team
members.
77
77
4.2.2. The Nurse
Applies the procedure of triage and admits the SAM patients with complications to the
malnutrition ward and ensures that all daily prescriptions, nursing care and feeding plans
are strictly adhered to. They are also to ensure that the Ward malnutrition record book is
filled.
4.2.3. Dietitian/Nutritionist
The Dietitian/Nutritionist should provide nutrition care plan, formulate and make available
the feeds for SAM patients. They should make appropriate recommendations in line with
management plan as agreed by the team and ensure documentation. In the event in which
there is no Dietitian/Nutritionist this role can be carried out by the nurse.
4.2.4. Pharmacist
Should ensure the flow of routine medicines from State Medical Store to the inpatient
facility.
At the tertiary level of health care, assesses the needs of the programme with respect
to medicines, makes provision for their procurement, ensures an adequate stock and
allows for a 3 month buffer-stock.
Submits monthly report including any adverse drug reaction to the State or National
level in a timely manner.
4.2.5. Record Staff
Shall be responsible for opening an inpatient file with the unique SAM-number and shall
ensure that record forms like the Critical Care pathway (CCP), multi-charts and transfer
forms are also well identified.
4.2.6. Medical Social Worker/ Community Heath Officer/ Community Health
Extension Worker
The staff of the IPF identifies the children needing follow-up at home. Either the follow up
visits of SAM patients should be carried out actively by the Medical Social workers or
Community health Officers as it applies to the health facility.Follow-up at home is necessary
for:
Children who have defaulted for more than 48 hrs from IPF
Children whose caregivers have refused admission to the IPF
In cases where rehabilitation phase is carried out in the outpatient department of the
inpatient facility, children who do not return for appointments (to determine if they
have moved away, defaulted or died)
78
78
Children in whom social problems have been identified e.g. single parent,
unemployment of mother, deaths of older siblings from malnutrition etc.
4.3. Record tools
4.3.1. Inpatient facility record book
A separate record book should be kept for malnourished children within the ward.
It should contain all the information necessary to complete the monthly report and
other reports. See annex 15.
4.3.2. Monitoring Charts
The Critical Care Pathway (CCP) Chart is used during the stabilization phase for
all patients to ensure intensive monitoring during the acute treatment of
complications as shown in annex 4
Monitoring records. The multi –chart is used to monitor the vital signs, feeding
progress and weight changes (see annex 10). Each child should have his/her
unique SAM number (see Chapter 7) written on all documents.
4.4. Medicines
4.4.1 Routine First line
These include: (amoxycillin, gentamicin, anti-malarials, measles vaccine) and
specific medicines for complications (vitamin A, ReSoMal, , anti-fungal.
o I.V Amoxycillin (30-50mg/kg/day)every 8 hours for 72hours then change to
oral amoxycillin at 30-50mg/kg/day every 6hours to complete one week OR
I.V Cefotaxime 50 mg/kg every 12 hours for 5days
o Add gentamicin I.M ( 3-5mg/kg/day) once a day for 7 days if the patient is
making urine
o and/or suppress small bowel overgrowth with IV
metronidazole(10mg/kg/day) once a day for 72h then change to oral
Metronidazole 10mg/kg/day to complete one week. See annex 6 for
antibiotic reference list.
NOTE: Ampicillin may be used if amoxicillin not available, however in Nigeria there is high
bacterial resistance profile and is not recommended.
4.4.2 Alternative and Supplementary medicines
These are, second and third line antibiotics, furosemide, glucose, magnesium
sulphate injection, etc (see annex 10 for Drug list).
4.5. Equipment and Supplies
79
79
4.5.1. Anthropometric tools
MUAC tapes
Length/height board
Scale within at least 100g precision
A scale with 10g precision for children and infants less than 8kg
4.5.2. Therapeutic foods
Pre-packaged F75, F100 and RUTF, If the pre-packaged F75 and F100 are not
available alternative recipes and equipment for making these diets are given in
Annex 3
4.5.3. Kitchen equipment and other supplies
Cups and measuring jugs
blender or manual whisks and wooden ladle,
drinking water,
sugar
Different sizes of naso-gastric tube for children
Laminated look-up charts on weight-for-height and feed volumes
Diagnostic sets
Body thermometers (axillary)
maximum-minimum wall thermometers (to determine the
environmental temperatures during the day and night)
calculator
Multi-charts, Critical care pathway charts, transfer forms,
IPF SAM record book,
Clean water and soap
Toys for the children
Copies of the National Guideline and training manual
Wall charts, tables and algorithms pasted on the walls for easy reference
Infant and young child feeding (IYCF) counselling cards and food
models for nutritional counselling
80
80
CHAPTER 5: FAILURE TO RESPOND TO TREATMENT
For a child with SAM admitted for care, improvement in clinical status is the immediate goal of the managing team; conditions may arise where the child fails to respond to the treatment. The criteria for failure to respond to inpatient care are shown in the table below:
Table 12: Criteria for Failure-to-respond for In-Patients
Criteria for failure to respond Time after admission
Failure to improve/regain appetite Day 4
Failure to start to lose oedema Day 4
oedema still present Day 10
Failure to fulfil the criteria for recovery-phase (OTP) Day 10
Clinical Deterioration AFTER admission At any time
Note that the day of admission is counted as day 0, so that day 1 is the day after admission.
Failure to respond results in:
High mortality Low weight gain during rehabilitation phase
5.1. High mortality
Case fatality rates vary widely and are categorized as in the table below:
Table 13: Case fatality rates
Fatality category Rates
Unacceptable >20%
Poor 11-20%
Moderate 5-10%
Good <5%
81
81
If mortality is >5%, determine whether the majority of deaths occur:
Within 24 hours: consider untreated or delayed treatment of hypoglycaemia, hypothermia, septicaemia, severe anaemia or incorrect rehydration fluid or volume and skills of health staff
Within 72 hours: check whether the volume of feed is too much or the wrong formulation is used; check whether potassium is given if patient not on F-75 and correct antibiotics were given
At night: consider hypothermia from insufficient covers, or night feeds for children who have not taken their feeds during the day.
When changing to RUTF/catch-up F-100: consider too rapid a transition After 7 days: consider immune reconstitution syndrome or hospital- acquired sepsis
5.2. Low weight gain during the rehabilitation phase
Ideally this is addressed at the OTP during rehabilitation phase.
Low weight gain is categorized as follows
Table 14: Categorization of weight changes
Category Weight gain
Poor <5g/kg/day
Moderate 5-10g/kg/day
Good >10/kg/day
If weight gain is <5 g/kg/day determine:
whether this is for all cases (need major management overhaul) whether this is for specific cases (reassess child as for a new admission) Possible causes of poor weight gain are:
a) Inadequate feeding
Check:
if night feeds are given if target energy and protein intakes are achieved: is actual intake (offered minus
leftovers) correctly recorded? Is the quantity of feed recalculated as the child gains weight? Is the child vomiting or ruminating?
Feeding technique: is the child fed frequently and according to protocol Quality of care: Is staff motivated/gentle/loving/patient and trained in managing
complications of children with SAM? All aspects of feed preparation: scales, measurement of ingredients, mixing, taste,
hygienic storage, adequate stirring if the ingredients separate out; In exceptional circumstances when rehabilitation is carried in the IPF and family foods is being given, ensure that they are suitably modified to provide >100 kcal/100g.
82
82
b) Specific nutrient deficiencies
Check:
adequacy of multivitamin composition and shelf-life preparation of electrolyte/mineral solution and whether this is correctly prescribed
and administered. If in goitrous region, ensure potassium iodide (KI) is added to the electrolyte/mineral solution (12 mg/2500 ml) or give all children Lugol’s iodine (5-10 drops/day)
If feeding is adequate and there is no malabsorption, some hidden infection can be suspected. Urinary tract infections, otitis media, TB and giardiasis are easily overlooked, hence
o re-examine carefully o repeat urinalysis for white blood cells o examine stools o if possible, take chest X-ray
Alter the antibiotic schedule to 2nd or 3rd line antibiotics, if there is failure to respond.
c) HIV/AIDS
In children with HIV/AIDS, good recovery from malnutrition is possible though it may take longer and treatment failures may be common. Lactose intolerance occurs in severe HIV-related chronic diarrhoea. Treatment should be the same as for HIV negative children.
d) Psychological problems
Check for:
Abnormal behavior such as stereotyped movements (rocking), rumination (self-stimulation through regurgitation) and attention-seeking. Treat by giving the child extra care, love and attention. Also rule out extrapyrimidal effects of drug toxicity for anti-emetic. For the ruminator, firmness, but with affection and without intimidation, can assist.
When a child deteriorates after having progressed satisfactorily initially, it is usually due to:
o Electrolyte imbalance with movement of sodium from the cells and an expansion of the circulation to give fluid overload or to the re-feeding syndrome.
o Inappropriate dosage of medicines, or use of medicines not recommended for the severely malnourished child.
o Inhalation of diet into the lungs.
o An acute infection that has been contracted in the IPF from another patient (called a “nosocomial” infection) or from a visitor/ sibling/ household member.
o Sometimes as the immune and inflammatory system recovers, there appears to be “reactivation” of an existing infection during recovery
83
83
o A limiting nutrient in the body that has been “consumed” by the rapid growth and is not being supplied in adequate amounts by the diet. This is uncommon with modern diets commercially produced (F100 and RUTF) but may well occur when they are made in the facility or where untried recipes are introduced or sharing of the mother’s food (see re-feeding syndrome).However remember that with F-75 no weight gain is expected.
5.3. Re-feeding syndrome
“Re-feeding syndrome” refers to malnourished patients (and those who have been fasting for more than one week) who develop any of the following shortly after they have had a rapid, large increase in their food intake: acute weakness, “floppiness”, lethargy, delirium, neurological symptoms, acidosis, muscle necrosis, liver and pancreatic failure, cardiac failure or sudden unexpected death. The syndrome is due to rapid consumption of key nutrients for metabolism particularly if the diet is inadequate in these micronutrients. There is frequently a large reduction in plasma phosphorus, potassium and magnesium.
Prevention
It is necessary at the start of treatment not to have a sudden jump in the adapted malnourished state to a very high intake. On admission, malnourished patients should never be force-fed amounts of diet in excess of those prescribed in the protocol. Particular care needs to be taken with those who are being fed by NG Tube.
Treatment of re-feeding syndrome
For patients in the recovery phase
If there is deterioration during the rehabilitation or transition phase of treatment,
Then the child should be returned to the stabilization phase.
For patients that are in the stabilization phase,
Reduce the diet to 50% of the recommended intake until all signs and symptoms disappear and then gradually increase the amount given
Check to make sure that there is sufficient potassium and magnesium in the diet. If the diet is not based on cow’s milk (or the mother is also giving cereals/pulses etc.) additional phosphorus should be given to prevent re-feeding syndrome
84
84
Management of patients failing to respond to inpatient care
1. Record on the chart the diagnosis and refer the child to more senior and experienced staff
2. Take a detailed history and fill the clinical history and examination form
3. Examine the child carefully. Measure the temperature, pulse rate and respiratory rate accurately
4. Where appropriate, examine urine for pus cells and culture blood, culture sputum or tracheal aspirate for TB; examine the retina in a low light for retinal tuberculosis
5. Do a chest x-ray
6. Examine stool for blood, look for trophozoites or cysts of giardia; culture stool for bacterial pathogens. Test for HIV, hepatitis and malaria
7. Examine and culture Cerebral Spinal Fluid (CSF)
8. Sometime parents bring traditional medicines and other treatments into the facility and give them to the child (a sort of “insurance” in their mind to have both modern and traditional treatments). This should be strongly discouraged using adequate counselling.
9. Systematically consider the common causes listed above
10. Review of the supervision of staff with refresher training if necessary
11. Re-calibration of scales (and length-boards)
12. Refer children with chronic diseases (Congenital heart disease, neural tube defects, cerebral palsy, broncho-pulmonary dysplasia, chronic renal failure, etc.) to the appropriate paediatric ward under the care of the paediatrician – these patients are referred out of the program and all further management decisions and treatment will be under the direction of another service.
85
85
CHAPTER 6: Transfer to Outpatient Therapeutic Program (OTP)
6.1. Transfer criteria for rehabilitation at OTP
All the following criteria must be present for a patient to be transferred from IPF to OTP:
Return of appetite and
Beginning of loss of oedema (Normally judged by an appropriate and proportionate weight loss as the oedema starts to subside) and
Patient appears to be clinically recovering
However, there is no “fixed” time that a child should remain in IPF. It is expected that the most severely ill children may remain in the IPF for longer than average and the less severely complicated cases and those that respond readily to treatment a shorter time.
Children admitted to inpatient facilities with complicated severe acute malnutrition
should be transferred to outpatient care during the rehabilitation phase as soon as
possible in the OTP. Carefully assess the child and the available community support.
However, the outpatient section in the secondary or tertiary health facility can serve as
an OTP site when there are no designated OTP in the patient’s community. The decision
to transfer children to outpatient care should not be based on achievement of specific
anthropometric or weight-for-height/length outcomes.
It is important to prepare the parents for outpatient treatment and a community support nutrition programme where such services are available. The caregiver should: • be available for child care • have received specific counselling on appropriate IYCF practices • have the resources to feed the child. If this is not the case, give advice on available
support.
Outgoing transfers are children leaving the site of treatment. They are NOT counted as
discharged as they are still under treatment since they have not yet reached the discharge
criteria. They temporarily exit the IPF to be transferred to the OTP or another health facility
for continued treatment. Upon return, they re-enter the site as a transfer in.
6.2. List of Outpatient Therapeutic Program (OTP) sites
The list of all OTP sites in the Local Government where the IPF is sited should be clearly written and pasted up in the IPF .All staff working in the IPF should be aware of this list to enable them transfer patient’s to the OTP nearest to the patient’s home for continued nutritional care.
86
86
6.3. Two way referral system
A good two-way referral system minimizes the risk of doubly medicating a child and provides a strong continuum of care between centres.
Provision of a tracking slip during such transfers also facilitates the transmission of information between services when the child needs transfer.
This same form can be used for transfer from outpatient to inpatient (and vice versa), movements between two outpatient units or when discharged to supplementary feeding services where they exist (Annex 17).
It is important that when a child is transferred to outpatient, a plan is made for follow-up of the child until full recovery,
Through a two-way referral system, contact is maintained with the community based component of CMAM (the OTP and the Inpatient Facility). This can strengthen the activities of Social Workers who also receive a copy of the referral slip to enable them track the patient back to the OTP and community
In general, the child should be weighed weekly after referral to OTP. If he or she fails to gain weight over a 2-week period or loses weight between two measurements or develops loss of appetite or oedema, the child should be transferred back to IPF for further assessment.
Once discharged from the nutritional treatment, he or she should be periodically monitored to avoid relapse.
6.4. Follow-up at Out Patient Therapeutic Programme
Transferred patients to OTP will continue to receive nutritional care with RUTF and medical care on weekly basis. During these visits, health and nutrition education sessions will be given to caregivers until the child is discharged as recovered from the OTP.
6.5. DISCHARGE
A patient transferring from one to another phase of treatment, one as an in-patient and the other as an outpatient, is still under the care of the IMAM program for this episode of severe malnutrition; this is not a “discharge” from the in-patient facility but an internal transfer to another part of the same program – nevertheless the IPF records this as “successful treatment”.
DISCHARGE PROCEDURES
1. Register the patient in the record book(annex 15) as successfully treated, dead, defaulter or a medical referral;
2. Complete the multi-chart and fill in a transfer form with the SAM N° and give all the required information about the treatment;
3. Call the OTP to give them notice about the patient returning home; 4. Give the mother a copy of the transfer form, the name and address of the OTP and
the day of the consultation and a provision of RUTF until the next appointment in the OTP
5. Write in the child’s health card the treatment given and the weight.
87
87
CHAPTER 7: MONITORING THE QUALITY OF CARE
Acute malnutrition is associated with an increased morbidity and mortality. To assess the response to managing children with severe acute malnutrition, every component of the integrated management of acute malnutrition must be held accountable for the quality of care it offers even at the inpatient facility.
Standard terms of outcome must be universally defined and applied in all areas of managing acute malnutrition to enable the quality of care to be assessed over a period of time (monthly, quarterly, yearly). A malnutrition record book should be kept in the IPF. This should contain information about the children (such as weight, age, sex, anthropometric measures), day of admission, date of transfer to OTP, date of discharge, date and time of death and outcomes as defined below(see annex 15).
7.1. Definitions of terms
7.1.1. “SAM-Number”
The SAM-Number is defined as a unique ID-number assigned to each patient at first diagnosis with SAM and entering the IMAM program. It is in addition to any other numbers that may be given by an inpatient facility.
The SAM-Number must be used on all internal transfer forms and documents related to that patient (SC progress monitoring charts, OTP chart, register and record books).
The unique SAM-Number in Nigeria should take the following format:
If patient FIRST seen at the OTP: State code/LGA code/HF code/OTP/year/Child Number
If patient FIRST seen at the SC: State code/LGA code/HF code/SC/year/Child Number.
For example, Federal Medical Centre Azare in Katagum LGA, the child will have the SAM SC number of 05/12/0034/SC/2014/0001.This number helps to tract the child within the program and prevents the child’s data from being replicated as he/she moves through different components of the program. The Federal Ministry of Health has assigned codes for each State, LGA and health facility in the country and should be used to ensure conformity.
7.1.2. “New admission”
A new admission is defined as a patient with SAM who has not been treated elsewhere for this episode of SAM and has not been assigned a SAM-Number at SC/OTP. The new admissions to each site should have consecutive SAM-Numbers so that the total number of new admissions can be verified from the numbers.
7.1.3. “Relapse”
Relapse is defined as a patient who has been previously treated for SAM, discharged as cured and is being readmitted for SAM. A relapse should be counted as a “new admission”.
SAM-Number and relapse: A postfix shall be affixed to the child’s SAM-Number thus: XXXX-b to denote that this is the second episode of SAM for this patient. If the original
88
88
SAM-Number cannot be found, a new SAM-Number should be given, but it should always have XXXX-b to denote a second admission to the program.
Children that have relapsed are particularly vulnerable and the fact that they are relapses should be noted in the “Major problem” section of their charts.
7.1.4. “Readmission”
Readmission is defined as a defaulter who returns to either the IPF/OTP to resume treatment after an absence of 2 months or less. The child is not a new admission and is reassigned his/her original SAM-number.
7.1.5. “Internal-Transfer”
Internal transfer is defined as a child who arrives because she/he has been transferred from another facility (from OTP to IPF, OTP to another OTP, or IPF to OTP) after receiving the SAM-Number.
Such transfers are recorded in both the entry and exit sections of the hospital register and SC record books. If it is necessary to differentiate these two, then the terms transfer-in and transfer-out can be applied as follows.
1- “Transfer-in” is a child arriving from another facility (IPF/ OTP )
2- “Transfer-out” is a child sent to another facility to continue treatment (IPF/ OTP)
7.1.6. “Cure”
Cure is defined as a child reaching the criteria for discharge. This also applies to infants less than 6 months who are discharged gaining weight on exclusive breast feeding.
7.1.7. “Successfully treated”
This term is used for a child in the IPF who successfully completed stabilization phase (acute-phase) of treatment and is transferred to OTP to continue his/her treatment. When the child exits the SC to continue treatment in the OTP he/she still in the program and has not reached the criteria for discharge that is he/she is not yet “cured”.
7.1.8. “Length of stay”
The length of stay is defined as the time from admission to the time of reaching “cured” status in the OTP or “successful treated” status in IPF and not the time of physical exit from the program or facility.
7.1.9. “Died” or “Dead”
Died or Dead is defined as a child who died during his/her stay in the SAM program after he/she has been assigned a SAM-Number. This includes children who died in transit from one facility to another. Where a child with SAM dies during transit from an OTP to an IPF, the death should be recorded as death within the program and assigned to the OTP report.
89
89
If the child was previously reported as “defaulter unconfirmed” and is subsequently found to have died, this should be notified in a subsequent monthly report in the “change of category section”; a note is made in the registration book and the IPF/OTP chart.
7.1.10. “Defaulter-Confirmed”
A defaulter-confirmed is defined as a child who is absent, without making any arrangements with the staff, for 3 consecutive weeks (21 days in OTP and 2 days in an SC) and without being officially discharged, who is known to be still alive (from home visit, neighbour, volunteer or outreach worker’s feedback).
7.1.11. “Defaulter-Unconfirmed”
A defaulter-Unconfirmed is defined as a child that fulfils the definition for defaulter, but it is uncertain whether they are in fact alive or dead.
7.1.12. “Non-Response” (to standard treatment)
Non-Response to treatment is defined as a child in IPFwho fulfils the criteria set out in the guidelines as failure-to-respond to treatment (see Chapter 5)
7.1.13. “Medical-referral”
Medical-referral is defined as a child who has a serious underlying illness that requires treatment beyond the scope of the IPF for SAM (or is suspected of having such a condition that requires diagnostic tests beyond the capacity of the IPF) and is referred to another service which takes over the complete management of the child.
7.1.14. “Refusal-of-transfer”
Refusal of transfer is defined as a child who fulfils the criteria for admission to an IPF (according to the transfer criteria) but declines the transfer from the OTP or a child who fulfils the criteria for transfer from the IPF to OTP but refuses and requests to complete treatment in IPF.
This is not a reason for discharge from the OTP, where the child remains for continued treatment. A note is made in the register and the chart to say that the patient declined transfer. This is not recorded in the monthly report. But as it can be an explanation for mortality in the OTP should be periodically examined for the annual report and evaluations; if frequent, this should signal the need for investigation of the reasons (distance to the IPF, reputation of the IPF, etc.) and remedial action to be taken.
7.1.15“Exit”
An exit is defined as children leaving a facility – it is the sum of children cured/stabilized, died, defaulted, medical referral, and internal transfers. For the OTP this represents the sum of discharges and internal transfers. For the IPF, this is the sum of successfully treated children, discharges and medical referrals.
90
90
7.1.16. “Discharge”
A discharge is defined as a child who leaves the IMAM program because he/she is cured died, defaulted, or medically referred.
There definitions can be broadly divided into two based on the admission and exit criteria.
Table 15: Admission and exit criteria
CRITERIAS
Admissions Exits New admissions =( Never been treated before or relapsed)
Successfully treated Cured
‘Old Admissions’=(Return defaulters or transfers within IMAM)
Death
Defaulter confirmed Defaulter unconfirmed Medical referrals
7.2. Performance indicators
A set of minimum standards used internationally to assess quality of care and enable accountability of the care given to children with acute malnutrition is needed to determine performance in IPF. These may be used in both emergency and non-emergency context. The SPHERE indicator has been adapted to suit the IPFs in Nigeria.
Table 16: SPHERE Indicators
Indicators Standards
Successfully treated Discharged Cured <6months
>75% >75%
Default <15%
Died <10%
Non-recovered No standard (Zero)
These performance indicators are calculated as follows:
Cure Rate =Number of infants <6months cured X 100 Total number of infant <6months who exit the IPF for a period Successfully treated =Number of children successfully treated in IPF X 100
Total number of Exit from IPF for a period
Death rate = Number of children that died X 100 Total number of exit from IPF for a period Defaulter rate = Number of children defaulted X 100
Total number of exit from IPF for a period
91
91
Non-recovery rate = Number of children non-recovered X 100
Total number of exit from IPF for a period
7.3. Mortality audit
A mortality audit should be carried out to identify factors that can be changed to improve care, determine when and why most of the deaths occurred.
If deaths occur:
within 24hrs: consider untreated or delayed treatment of hypoglycaemia, hy pothermia, septicaemia or severe anaemia, incorrect rehydration fluid or volume of fluid or overuse of IV fluids.
within 72hrs: check whether the volume of feed given during re-feeding was too high or the formulation was wrong. Were potassium and antibiotics given?
over 72 hrs: consider nosocomial infection, re-feeding syndrome, heart failure and HIV infection.
7.4. Inpatient Facility reports
7.4.1. Monthly reports
The monthly report is the standard report. A report from each facility (IPF/ OTP) should be completed and submitted to the Local Government Nutrition Officer each month. These are entered into the Local government database, which is transmitted, to the State team through the State Nutrition Officer and then to the Nutrition Division, Family Health Department, Federal Ministry of Health for an assessment of the quality of services provided at facility level. The monthly reports from each LGA are also collated together to give an overall picture of the quality of service and magnitude of the problem of SAM at each level. The results of the analysis are reported back to the IPF/ OTP Supervisors at the next monthly meeting.
The monthly report should include the total at the start of the month; the total entry (in categories); total exits (in categories); total at the end of the month and stock control data (see Annex 18)
7.4.2. Annual reports
In addition to the standard monthly report, there should be:
1) an annual report where additional data is collected from the OTPs and IPFs and
2) a three yearly external evaluation of the IMAM program in each LGA.
The Annual report, in addition to the totals for the whole year, should include the average rate of weight gain; the average length of stay and disaggregation of the data by gender.
92
92
The three yearly evaluation report should include:
review of each component of the program (community aspects, screening, OTPs, IPFs, organization, etc.) with an overview of the monthly and annual reports,
a review of the tools, modules and methods of training,
the quality of supervision,
the staffing and organization,
the logistics,
the financing of the program, and
Recommendations for adjustment.
Categories for report writing
The monthly report should contain the following:
Type of malnutrition: oedematous and Non- oedematous Age groups : <6 months, 6-23months, 24-59months Numbers of patients by type of entry and exit to the OTP The types of entry to the IPF should be: new admissions (including relapses)
readmissions (after defaulting) and internal transfers (transfer-in) where new SAM numbers are not given.
The types of exit from the IPF should be: Successfully treated (i.e. transfer-out to OTP) and discharged cured (< 6 month successfully breast feeding and gaining weight and those completing phase two in IPF), died, defaulter, medical-referral (including non-responders).
Other information: There is a separate section of the report enabling correction of previously submitted reports. In particular, reclassification of children previously classified as “defaulters-unconfirmed” into those that have been confirmed as defaulters and those that have died. The report also contains stock details of the major consumables of the centre and those liable to pipeline rupture. In particular RUTF, but other essentials such as routine medicines can be included (e.g. antibiotics, anti-malarials, etc.). The data should include stock at the beginning of the month, stock received and stock at the end of the month.
7.5. IPF Supervision by relevant agents Government staff and Non-governmental agents at all levels of care should carry out supervision. A generic checklist should be used to assess the quality of care (Annex 19).Findings should be used to improve program implementation.
93
93
ANNEXES