malnutrition global health block ed – september 25, … · malnutrition. division of global...

Global Health Block Ed September 25, 2015Mike Pitt | Stacene Maroushek | Cindy Howard | Tina Slusher | Nate Meuser-Herr

MalnutritionDivision of Global Pediatrics Block Education

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

University of Minnesota Division of Global Pediatrics

WHO: Guidelines for the Inpatient Treatment of Severely Malnourished Children: Ten Steps


Malnutrition 35-50%

Liu et al. Global causes of childhoood deaths. Lancet May 2012.


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


Step 1: Prevent/treat hypoglycemiaGlucose:


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


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


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


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


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


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


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


Important! Frequent reassessment

Monitor

HR RR Daily Weight Intake Output Emesis and Diarrhea

Replace with ReSoMal orcomparable ORS


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


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


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


Structured play and physical activity A cheerful, stimulating environment

Encourage mothers involvement

Step 9: Stimulation, Play and Loving Care


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


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)


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/


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


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


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:

malnutrition global health block ed – september 25, … · malnutrition. division of global...

Documents