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Global Health Block Ed September 25, 2015Mike Pitt | Stacene Maroushek | Cindy Howard | Tina Slusher | Nate Meuser-Herr
MalnutritionDivision of Global Pediatrics Block Education
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Team Based LearningTake Test Solo (5
Minutes)
Form Groups of 4-6 and Agree on Team Answers
(10-15 Minutes)
Large Group will Discuss in More Depth the Questions that Fewer than
80% of Room Answered Correctly
TEAM BASED LEARNING
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University of Minnesota Division of Global Pediatrics
WHO: Guidelines for the Inpatient Treatment of Severely Malnourished Children: Ten Steps
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University of Minnesota Division of Global Pediatrics
Malnutrition 35-50%
Liu et al. Global causes of childhoood deaths. Lancet May 2012.
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University of Minnesota Division of Global Pediatrics
10 StepsStabilize/Rehabilitate
*Anemia- evaluate and treat: Hgb < 4 gm/dl or 4-6 gm/dl and symptomatic
PHASE
STABILISATION
REHABILITATION
Day 1-2 Day 2-7+
Week 2-6
1. Hypoglycaemia
2. Hypothermia
3. Dehydration
4. Electrolytes
5. Infection
6. Micronutrients
7. Cautious feeding
8. Rebuild tissues
9. Sensory stimulation
10. Prepare for follow-up
no iron
with iron
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University of Minnesota Division of Global Pediatrics
Step 1: Prevent/treat hypoglycemiaGlucose:
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University of Minnesota Division of Global Pediatrics
Step 2: Prevent/treat hypothermia
Keep warm: >36.5C or 97.5F
Skin to skin contactKangeroo Care
Warm blanket Heat lamp cautiously Cover head Keep dry Avoid drafts Warm room Separate from infectious patients Look for and treat infection
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University of Minnesota Division of Global Pediatrics
1. Give newer (2006) standard oral rehydration solution or ReSoMal. (less sodium and more potassium)
2. Feed through diarrhea, continue breast feeding and/or F-75
Step 3: Treat/Prevent Dehydration
NOTE: NO IV UNLESS SHOCK and then CAUTIOUS(theoretical risk of fluid overload and cardiac failure)
Note: assessment of hydration status is difficult
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University of Minnesota Division of Global Pediatrics
ASSUME: Excessive Na Deficient potassium (added to F-75) Deficient magnesium (added to F-75)
REMEMBER: Two weeks minimum to correctPrepare meals w/o saltDo NOT use a diuretic to treat edema
Step 4: Correct Electrolyte Imbalances
In community management probably means supplementing appropriately w/out actual levels. In fact, labs can be misleading
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University of Minnesota Division of Global Pediatrics
Broad-spectrum antibioticAmoxicillin x 7 to 10 days or Ampicillin and Gentamicin
Measles vaccine > 6 mo old Mebendazole: 100 mg
BID x 3 days orAlbendazole: 400 mg once
(Metronidazole: 15 mg/kg/d div tid) Screen or treat for malaria Tuberculosis: contact or cough x 2wks Screen for HIV
Step 5: Treat Infection
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University of Minnesota Division of Global Pediatrics
Must supplement as follows:
Day 1: Zinc, copper, folic acid and MV daily, Vitamin A
Do NOT give iron until the child has a good appetite and starts gaining weight (usually during the second week of treatment).
Step 6: Correct Micronutrient Deficiencies
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University of Minnesota Division of Global Pediatrics
Breast Milk or Starter Formula F-7575 kcal and 0.9 grams of protein/100mlIncludes electrolyte/micronutrient solution Days 1 7 Low in protein and iron(May be cereal-based to treat diarrhea)
Small, frequent feeds: 130ml/kg (100/ml/kg/d if severe edema) divided into 12 feeds per day (every 2 hrs)
Step 7: Initial Feeding
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University of Minnesota Division of Global Pediatrics
Days Frequency Vol/kg/feed Vol/kg/day1-2 Q2 hrs* 11 ml 130 ml3-5 Q3 hrs 16 ml 130 ml>6 Q4 hrs 22 ml 130 ml
End point for this step: Return of appetite & resolution of edema
Cautious FeedingDecreased intestinal motility, decreased insulin, decreased absorption with large feeds
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University of Minnesota Division of Global Pediatrics
Important! Frequent reassessment
Monitor
HR RR Daily Weight Intake Output Emesis and Diarrhea
Replace with ReSoMal orcomparable ORS
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University of Minnesota Division of Global Pediatrics
Advance to F-100: 100 kcal and 2.9 grams of protein/100ml
200 ml/kg/day div q 3 to 4 hours Advance to local foods:
beans, margarine energy-dense local foods
If tolerating, Day 3 -Increase feeds slowly by10 ml/feed F-100
Goal:10 gm/kg day wt gain
Step 8: Rebuild Tissues and Catch Up Growth
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University of Minnesota Division of Global Pediatrics
Ready-to-Use Food (RUTF)
RUTF is an energy dense, mineral- and vitamin-enriched food, with a similar nutrient profile but greater energy and nutrient density than F100
Low moistureLong half life Often peanut basedLocally produced
RUTF has made outpatient treatment possible
Treating severe acute malnutrition seriously.Steve Collins, Arch Dis Child. May 2007
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University of Minnesota Division of Global Pediatrics
Plumpy Nut High protein High energy Peanut-based paste Ingredients: Peanut paste,
vegetable oil, powdered milk, powdered sugar, vitamins and mineral including iron, iodine and zinc
500 kcal no water preparation no refrigeration two year shelf life
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University of Minnesota Division of Global Pediatrics
Structured play and physical activity A cheerful, stimulating environment
Encourage mothers involvement
Step 9: Stimulation, Play and Loving Care
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University of Minnesota Division of Global Pediatrics
MUAC >125 mm or WHZ > minus 2 or no edema depending on the enrollment criteria
Good appetite and eating RUTF
Immunization update Follow-up planned
Nutritional education
Individualize plan for children with chronic problems such as CP or CHD.
Step 10: Preparation for Discharge
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University of Minnesota Division of Global Pediatrics
Outpatient versus Inpatient?Assess for complications
ANOREXIA: Test feed 30 g RUTF Severe dehydration Respiratory distress High fever Hypoglycemia with lethargy Anemia requiring transfusion
HIV screening for all childrenTreat as outpatients if eating (prompt initiation of ART improves outcome)
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University of Minnesota Division of Global Pediatrics
Outpatient Management
2001-2005Malawi, Sudan, Ethiopia23,511 severely malnourished children74% treated solely as outpatientsCFR=4.1%
Niger, MSF60,000 children with SAM70% outpatientCFR=5%
Lancet, 2006
http://www.doctorswithoutborders.org/
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University of Minnesota Division of Global Pediatrics
Bibliography Stunting, Wasting, and Micronutrient Deficiency Disorders, Laura E. Caulfield,
Stephanie A. Richard, Juan A. Rivera, Philip Musgrove, Robert E. Black, Disease Control Priorities in Developing Countries, 2nd edition, 2006, pages:551-567
Management of Severe Acute Malnutrition in Children, Steve Collins, Nicky Dent, Paul Binns, Paluku Bahwere, Kate Sadler, Alistair Hallam, Lancet, Vol. 368, December 2, 2006, pages: 1992-2000.
What works? Interventions for maternal and child undernutrition and survival. Bhutta ZA, Ahmed T, Black RE, Cousens S, Dewey K, Giugliani E, Haider BA, Kirkwood B, Morris SS, Sachdev HP, Shekar M; Maternal and Child Undernutrition Study Group, Lancet, February 2, 2008.
Guidelines for the Inpatient Treatment of Severely Malnourished Children Nonserial PublicationAshworth, A., Khanum, S., Jackson, A., Schofield, C. World Health Organization ISBN-13 9789241546096 ISBN-10 9241546093
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Bhutta%20ZA%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Ahmed%20T%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Black%20RE%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Cousens%20S%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Dewey%20K%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Giugliani%20E%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Haider%20BA%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Kirkwood%20B%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Morris%20SS%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Sachdev%20HP%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Shekar%20M%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Maternal%20and%20Child%20Undernutrition%20Study%20Group%22%5BCorporate%20Author%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus
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University of Minnesota Division of Global Pediatrics
Bibliography Countdown to 2015 decade report (2000-10): taking stock of maternal,
newborn, and child survival. Prof Zulfiqar, A Bhutta PhD, et al The Lancet, Volume 375, Issue 9730, Pages 2032 - 2044, 5 June 2010
Global, regional, and national causes of child mortality in 2008: a systematic analysis. Prof Robert E Black MD et al. The Lancet, Volume 375, Issue 9730, Pages 1969 - 1987, 5 June 2010
Protein Energy Malnutrition. Grover, Z Pediatric Clinics of North America, Volume 56, Issue 5, pages 1055, October, 2009.
Management of severe acute malnutrition in low-income and middle-income countries. Trehan, I. and Manary M. Arch Dis Child 2015:100:283-287.
Malnutrition treatment to become a core competency. Schofield C. et al. Arch Dis Child. 2012 May;97(5):468-9.
http://www.thelancet.com/search/results?fieldName=Authors&searchTerm=Zulfiqar%20A+Bhuttahttp://www.thelancet.com/journals/lancet/issue/vol375no9730/PIIS0140-6736(10)X6131-1http://www.thelancet.com/search/results?fieldName=Authors&searchTerm=Robert%20E+Blackhttp://www.thelancet.com/journals/lancet/issue/vol375no9730/PIIS0140-6736(10)X6131-1
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University of Minnesota Division of Global Pediatrics
Bibliography Neonatal, postnatal, childhood and under five mortality for 187 countries, 1970
2010: a systematic analysis of progress towards Millennium Development Goal 4 Julie Knoll Rajaratnam, Jake R Marcus, Abraham D Flaxman, Haidong Wang, Alison Levin-Rector, Laura Dwyer, Megan Costa, Alan D Lopez, Christopher J L Murray The Lancet, June 5, 2010
Maternal mortality for 181 countries, 19802008: A systematic analysis of progress towards Millennium Development Goal 5 Margaret C Hogan, Kyle J Foreman, Mohsen Naghavi, Stephanie Y Ahn, Mengru Wang, Susanna M Makela, Alan D Lopez, Rafael Lozano, Christopher J L Murray The Lancet, May , 2010
Refeeding Syndrome. J Funtebella et al. Pediatric Clinics of North America, October, 2009.
Gut microbiomes of Malawian twin pairs discordant for kwashiorkor. Smith et al. Science. February, 2013.
Slide Number 1Slide Number 2Team Based LearningSlide Number 4Slide Number 5Slide Number 610 StepsStabilize/RehabilitateStep 1: Prevent/treat hypoglycemiaGlucose: