Severe malnutrition - centre based rehabilitation

Transcription

1 CHRISTA KITZ SMO f pediatrics tropical medicine Medical Mission Institute Tropical medicine & epidemic control Hermann Schell Str Wuerzburg Tel.: christa.kitz@medmissio.de Severe - centre based rehabilitation Energy 2100 kcal Energy 2100 kcal Protein 10-12% total energy (52g-63g), but<15% Protein 10-12% total energy (52g-63g), but<15% Fat Vitamin A Thiamine (B1) Riboflavin (B2) Folic acid Niacin (B3) Vitamin B12 Vitamin C 17% of total energy (40g) IU ( 0.5 mg retinol equivalent) 0.9 mg ( 0.4 mg per 1000 kcal intake) 1.4 mg ( 0.6 mg per 1000 kcal intake) 160 ug 12 mg ( 6.6 mg per 1000 kcal intake) 0.9 ug 28 mg Mean population requirements per day Fat Vitamin A Thiamine (B1) Riboflavin (B2) Folic acid Niacin (B3) Vitamin B12 Vitamin C 17% of total energy (40g) IU ( 0.5 mg retinol equivalent) 0.9 mg ( 0.4 mg per 1000 kcal intake) 1.4 mg ( 0.6 mg per 1000 kcal intake) 160 ug 12 mg ( 6.6 mg per 1000 kcal intake) 0.9 ug 28 mg Mean population requirements per day Vitamin 3.2-3,8 ug calciferol Vitamin 3.2-3,8 ug calciferol Iron 22 mg (low bioavailability ie 5-9%) Iron 22 mg (low bioavailability ie 5-9%) Iodine 150 ug Iodine 150 ug Magnesium 201 mg Magnesium 201 mg Zinc 12.3 mg Zinc 12.3 mg Selenium 27.6 ug Selenium 27.6 ug Vitamin E 8.0 mg alpha TE Vitamin E 8.0 mg alpha TE Vitamin K Biotin Pantothenate 48.2 ug 25.3 ug 4.6 ug FAO / WHO 2002 Vitamin K Biotin Pantothenate 48.2 ug 25.3 ug 4.6 ug FAO / WHO 2002 Micronutrient deficiency Micronutrient deficiency iodine goitre cretinism vitamine B2 (Riboflavin) ariboflavinosis vitamin A (retinol) erophthalmia keratomalacia vitamin B3 (Niacin) pellagra vitamin B1 (thiamine) beriberi vitamin C (ascbic acid) scurvy

2 Micronutrient deficiency vitamine rickets Therapeutic Feeding iagnosis treatment of severe in children adults Saving capacity of the adult f essential micronutrients Calcium Vitamin B12 Vitamin A Iron Folic acid Vitamin C Niacin Protein Vitamin B years 3 5 years 1 2 years 1 2 years 3 4 months 3 4 months 3 4 months 6 8 weeks 4 10 days Source: Leitzmann 1984, p.33 TFC-Required utilities fever thermometer nasogastric tube covers, clothing Scales + skilled staff drugs food ingredients electrolytes mineral nutrients (K, Mg, Zn a.o.) ORS/ReSoMal Types of TFCs TFC 24h/24h : 24 hr care is most appropriate f the admission of complicated severely malnourished cases ay-care TFC : if it is difficult to admit the cases, particularly at night Nutritional Unit in the hospital. TFC should only eist during emergencies f a limited period. Eventually, nutrition units in local hospital should be able to treat severe, with protocols based on the same principles CTC Home based treatment, a new strategy: The future? Foto: Christa Kitz Therapeutic feeding Therapeutic feeding The individual case: Who needs treatment? (criteria of severe ) Which treatment is recommended? (treatment protocols) Moniting the course The community: Is a problem? survey What should be the management? SFP, TFC, CTC, etc Evaluation of TFC What is TF? It is a curative strategy, that aims: - To crect the nutritional status of children / adults affected by severe acute. - To reduce mtality mbidity. - To crect the vitamin mineral deficits. - To immunize the children f the 6 illnesses of EPI, but particularly against measles. Target population: severe acute

3 Severe can present as: Clinically evident fms: - Marasmus severe wasting - Kwashik oedematous Non- clinical fms - wasting - stunting - underweight (detected only by anthropomethry). Marasmus Kwashik Marasmus Kwashik Kwashik Always look f oedema Eamine the child well The liver is always affected, it becomes fatty (steatosis). There is reduction of the activity of the liver enzymes. reduction of the liver function / metabolism Immunological changes with acute T- B-cell population natural killer cells immunoglobulines / antibodies phagocytic capacity complement facts Who needs to be treated? Look f associated signs: ermatosis: me frequent in Kwashik Similar to burns increased risk of infection Eye signs related to Vitamin A deficiency to eye infection

4 Non-clinical fms of Wasting Stunting Underweight Weight f height Height f age weight f age (arthropometric measures) Who needs to be treated? Why do we need anthropometric measurements? 1. Sometimes, the severity of cannot be immediately determined by clinical eamination 2. To calculate doses of feeds drugs 3. monit progress. What measures are indicated? Weight / Height (W/A): method of choice in all ages (ecept pregnant women) f acute severe wasting Medium Upper Arm Circumference (MUAC): alternative method, good predict of sht term mtality. BMI : In adults. Only recommended to classify chronic undernutrition in some nutritional surveys Child growth stards? A new classification system f acute Severe complicated Severe uncomplicated moderate uncomplicated <70% W/H (<-3 S Sce) bilateral pitting oedema one of the following: - Aneia - Lower respiraty tract infection - high fever - severe dehydration - sever anemia - not alert <70& W/H (<-3 S Sce) Bilateral pitting oedema - clinically well 70-80% W/H (<-3 to <-2 S Sce) no oedema MUAC mm - Clinically well Inpatient stabilisation care therapeutic care supplementary feeding A new classification system f acute Severe complicated <70% W/H (<-3 S Sce) bilateral pitting oedema one of the following: - Aneia - Lower respiraty tract infection - high fever - severe dehydration - sever anemia - not alert complicated Inpatient stabilisation care Severe uncomplicated <70& W/H (<-3 S Sce) Bilateral pitting oedema - clinically well moderate uncomplicated 70-80% W/H (<-3 to <-2 S Sce) no oedema MUAC mm - Clinically well Non - complicated therapeutic care supplementary feeding Treatment recommendations Treatment occurs in 3 phases: initial phase = stabilisation rehabilitation phase aftercare marasmus, kwashik, marasmic kwashik Severe is a life-threatening state required fast action. The initial phase should take place under hospital conditions in a feeding centre with 24-hour care.

5 Principles of treatment Reductive adaptation The systems of the body slow down to survive with reduced calies. Consequences: The blood glucose cannot be maintained: risk of hypoglycaemia Immunity is depressed with high risk of infections; BUT there are not signs of infection No ability to control temperature: risk of hypothermia The function has to recover slowly: progressive feeding Iron is dangerous if given early Na/K pomp goes slow: electrolyte imbalances Management of severe Stabilisation Rehabilitation ay 1 2 ay 3-7 Weeks Hypoglycemia 2. Hypothermia 3. ehydration 4. Electrolytes 5. Infection 6. Micro-nutrients no iron with iron 7. Initial fmula 8. Follow on fmula 9. Stimulation 10. Preparation of aftercare (source: Management of the child with a serious infection / severe, WHO 2000) Phase I: Complications Hypoglycaemia Hypothermia Septic shock Heart failure (Hypocaliemia) Heart failure (too much volume) Associated!! Frequent Life threatening Phase I: Complications Hypoglycaemia (<3mmol/l) Suspect if the child is: lethargic, floppy, unconscious, has convulsions. IF SUSPECTE: TREAT With al glucose 10% 50ml» IV If unconscious convulsions: IV first 5ml/kg 10% Give antibiotics: Penicillin Gentamycin PREVENT: frequent feeding Hypothermia (aillary<35º) TREAT : warming carefully Kangaroo f small children Give Antibiotics glucose PREVENT: cover, avoid bath Phase I: Complications Infection / Septic shock ue to immunosuppression They are life-threatening, but the signs are absent: look actively f it! TREAT: always give antibiotics ROUTINE al antibiotics Amoicillin, Cotrimoazol IM/IV if oedema complications Prevent: Measles vaccine on admission befe discharge. Hygiene Vitamin A supplementation can reduce child mtality in acute measles by 50%

6 SYSTEMATIC TREATMENT f severe Vaccination is the most effective tool to increase the gross national product of a country Wld bank 2006 RUGS Vitamine A Folic Acid Measles vaccination Amoicilline Paracheck (if available) Antimalarials (Artesunate+Fansidar) Mebendazole Iron, folic acid ischarge Phase I: Other complications ReSoMal (rehydration solution f the malnurished) ehydration (al) on t use IV FLUIS!!! : Oral rehydration with ReSoMal: (rehydration solution f the malnurished) 5 ml/kg every 30 min/2 hrs ml/kg/hr/f 4 10 hrs. Water + ORS + Sugar (50g) + Vitamins 2 litres 1 packet 3 spoons 1 measures ehydration on t use IV FLUIS!!! : Use ReSoMal. Phase I: Other complications Shock (unconsciousnes) Is the only indication f IV fluids Suspect if: dehydration without diarrhoea ehydration with oedema Criteria:» Lethargy + cold feet hs + weak poulse slow capillary refill, unconscious Treated with: IV fluids: 15 ml/kg/hr Ringer with 5% glucose ½ 0.9% sodium chlide + ½ 5% glucose If no improvement: IV Fluids 4ml/kg/hr blood (if no improvement): 10 ml/kg over 3 hrs Oygen Moniting respiraty heart rate (every 5 10 min) Interruption of infusion if state wsens Breast is best