MALNUTRITION

WHAT IS MALNUTRITION
Consequence of deficiency in nutrient intake and/or absorption in the body Types of malnutrition 1.)Chronic Malnutrition Growth failure -Underweight (Weight for age index) -Stunted (Height for age index)

2.) Acute Malnutrition -Wasting (MUAC / Weight for height) -Edema or Manas *** PEM (Protein Energy Malnutrition) - Obsolete term!

CAUSES OF MALNUTRITION
IMMEDIATE CAUSES(Affecting the individual) -Inadequate food intake -Disease UNDERLYING CAUSES(Household Level) -Household food security -Inadequate maternal care -public Health

BASIS CAUSES(Society Level) PEST -Local priorities -Formal and informal infrastructures -Political ideology -Resources -Human, Structural, Financial

WHAT IS ACUTE MALNUTRITION

Cause by decreas in food consumption and/or illness leadin to bilatearl pitting edema (mana) or wasting (matinding pangangayayat). Types of Acute malnutrition
Sever

Acute Malnutrition (SAM) Moderate Acute Malnutrition (MAM) Global Acute Malnutrition (GAM) = SAM = MAM

WHY FOCUS ON ACUTE MALNUTRITION?

20 Million children suffer from SAM worldwide More than 1 Million deaths of under-5 children every year is associated with SAM Higher mortality Related to illness Can be treated to identified, and prevented in the community before complications arise!

WHAT IS CMAM?

CMAM = Community-Based management of Acute Malnutrition

Most

children with SAM without medical complications can be treated as outpatients at accessible, decentralized sites Children with SAM and medical complications are treated as inpatients Community outreach for community involvement and early detection and referral cases

First pilot Progamme: 2000 (Africa)

Philippines: 2009 (Mindanao)

PRINCIPLES OF CMAM
1. Maximum Access and Coverage -Bring treatment close to where people live 2. Timeliness -Treat before onset of complication 3. Appropriate Medical Care and Nutrition Rehabilitation -Provide the right treatment to children in need 4. Care as long as it is needed -Reduce barriers to access and prevent relapses

COMPONENTS OF CMAM
1. 2. 3. 4.

Community mobilization Outpatient Therapeutic Programme (OTP) Stabilization Centre (SC) Supplementary Feeding Programme (SFP)

COMMUNITY MOBILIZATION
Community assessment and mobilization Active case-finding Education and sensitization (awareness and acceptance) Case follow-up

SUPPLEMENTARY FEEDING PROGRAMME

For moderate Acute Malnutrition(MAM)

Corn

Soya Blend (CSB) Plumpy Doz Should be coordinated with existing CMAM programs -Referral -Discharges -Admissions -Monitoring and Evaluation

CMAM PRIORITIES
Rapid decentralization of care Community Mobilization / Timely Active Case Finding Prevention of deterioration in nutritional status of the population (SFP) Prevention of mortality (OTP) Establish high coverage (geographic & case coverage) Establish SC

MEASURING AND CLASSIFYING ACUTE MALNUTRITION

1. 2. 3. 4.

Four Forms of Malnutrition Acute Malnutrition Chronic Malnutrition or Stunting Underweight Micronutrient deficiency

Chronic Malnutrition Also known as stunting Indicators

Weight for age Height for age

ACUTE MALNUTRITION

Defined by the presence of: 1.) Wasting

a.) MUAC b.) Weight-for-Height or Weight-for-Length Or 2.) Bilateral Pitting Edema

MEASURING WEIGHT WITH SALTER SCALES

Make sure the child is secure! Read the measurement at eye-level Make sure the meter is at ZERO before measuring the child -If not, adjust until at ZERO before placing the child Do not use the scale to weigh other objects (rice, supplies, equipment, etc) Do not weight beyond maximum capacity (25kg) to prevent damage to the scale

GRADING OF EDEMA
+1 Edema = Bilateral pitting edema only on the feet +2 Edema = Bilateral pitting edema on the feet, lower legs (may include hands and lower arms) +3 Edema = Generalized edema Bilateral pitting edema of legs and upper arms and includes dacial edema with swelling around the eyes.

ACUTE MALNUTRITION
MUAC WIGHT-FORHEIGHT/LENGTH Z-SCORE Less than -3 SD

SAM

Less than 11.5 cm (RED) 11.5 cm to 12.5 cm (YELLOW)

MAM

From -3 SD to les than -2 SD

ACUTE MALNUTRITION

Clinical Manifestations of Severe Acute Malnutrition:

Marasmus Kwashiorkor Marasmic Kwashiorkor

MARASMUS
CLINICAL SIGNS OF MARASMUS A child with marasmus mught have these characteristics: Thin appearance, old man face Apathy: the child is very quiet and does not cry The ribs and bones are easily seen The skin under the upper arms appears loose On the back, the ribs and shoulder bones are easily seen In extreme cases of wasting, the skin on the buttocks has a baggy pants look No bilateral pitting edema

MARASMUS

INDICATOR SEVERE WASTING MUAC < 11.5cm X-Score <-3 SD

These children have lost fat and muscle and will weight less than other children of similar height

KWASHIORKOR / BILATERAL PITTING EDEMA

CLINICAL SIGNS OF KWASHIORKOR (BILATERAL PITTING EDEMA) A child with kwashiorkor (bilateral pitting edema) might have these characteristics: Moon face Dermatosis: flaky skin or patches of abnormally light or dark skin (in sever cases) Apathy, little energy Loss of appetite Hair Changers Irritable, cries easily

KWASHIORKOR

INDICATOR BILATERAL PITTING EDEMA

MARASMIC-KWASHIORKOR
CLINICAL SIGNS OF MARASMIC-KWASHIORKOR A child with marasmic kwashiorkor has these characteristics: Bilateral pitting edema Severe wasting

INDICATOR Bilateral pitting edema and Severe Wasting MUAC <11.5cm Z-Score <-3 SD

ACUTE MALNUTRITION

Complicated acute malnutrition

+++edema Marasmic kwashiorkor OR MUAC <11.5cm W/H <-3 Z Scores And one of the following:

No appetite LRTI/Pneumonia Severe Dehydration Severe Anemia Not alert

Inpatient care

ACUTE MALNUTRITION

Severe acute malnutrition

MUAC <11.5CM OR W/H <-3-Z scores OR Bilateral pitting edema, AND

Appetite Clinically well Alert Outpatient therapeutic Care

ACUTE MALNUTRITION

Moderate acute malnutrition

MUAC 11.5cm to <12.5cm OR w/h -3 to -2Z scores AND No edema AND Appetite Clinically well Alert Supplementary feeding

REDUCTIVE ADAPTATION IN SAM

Treatments and drugs that are used appropriately in normally nourished patients can be harmful to SAM patients
Temporary

electrolyte disequilibrium -> leads to death from fluid overload and heart failure if dehydration is managed with IV fluids
ORS

vs ReSoMal

Liver

and Kidney function are abnormal -> drugs are not eliminated normally (e.g. Paracetamol)

REDUCTIVE ADAPTATION

Presume and treat infection

Assume

that infection is present and treat all severe malnutrition admissions with antibiotics specified in the protocol Common infections in the severely malnourished child: pneumonia, ear infection, UTI

PROVIDING IN-PATIENT CARE

Hospitals or Major health centers

24-hour

care available.

Treatment

at night is required for very ill children, those that get refeeding diarrhea and those that have not taken food during the day. 8 meals per 24 hours with full medical surveillance and treatment of complications (there needs to be adequate staff at night).

USE OF DRUGS IN ACUTE MALNUTRITION

Drugs that cause appetite loss should not be used such as anti-emetics Drugs affecting liver, pancreatic, renal, cardiac or intestinal functions should not be used Malnutrition is treated first before standard doses of drugs are given If really needed, initially give reduced doses of drugs -Standard doses are given in the later stages of OTP treatment or have lesser degrees of malnutrition Common drugs such as paracetamol do not work in AM and can cause liver damage

INPATIENT ANTIBIOTIC DOSAGES

DRUGS AMOXYCILLIN Co-AMOXYCLAV PREPARATION 125mg/5ml 156 mg/5mg(Amox125mg; Clav31) DOSAGES 20-100mg/kg/day BID 50-100mg/kg/day BID

CEFTRIAXONE GENTAMYCIN CHLORAMPHENICOL CIPROFLOXACIN NYSTATIN 100,000iu/ml

50mg/kg IM OD for 2 dyas 5mg/kg IM OD 25mg/kg/d BID 10-30mg/kg/d BID 100,000iu PO QID

APPETITE TEST
BODY WEIGHT Less than 4kgs 4 - 6.9 7 - 9.9 10 - 14.9 15 29 Over 30kgs PASTE IN SACHETS(PORTION OF WHOLE SACHET 96g) Poor <1/8 <1/4 <1/3 <1/2 <3/4 <1 Moderate 1/8 - 1/4 1/4 - 1/3 1/3 - 1/2 1/2 - 3/4 3/4 - 1 >1 Good >1/4 >1/3 >1/2 >3/4 >1

RUTF OTP RATION

Weight of child (kg) 3.5 3.9 4.0 5.4 5.5 6.9 7.0 8.4 8.5 9.4 9.5 10.4 10.5 11.9 >12 Sachets per week 11 14 18 21 25 28 32 35 Sachets per day 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0

FOR <6 MONTH OLD INFANTS

SUPPLEMENTAL SUCKLING: Amounts of diluted F100 to give for 24 hours (456 gm of F100 in 2.7L water OR 1 scoop in 20ml water) WEIGHT >=1.2kg 1.3 to 1.5 kg 1.6 1.7 1.8 2.1 2.2 2.4 2.5 2.7 2.8 2.9 3.0 3.9 3.5 3.9 4.0 4.4 ml per feed (8 feeds/day) F100 dilute 25ml per feed 30 35 40 45 50 55 60 65 70

ACUTE PHASE (< 6 MONTHS OLD INFANTS)

Amounts of infant formula, F100 dilute or F&% to give for non-breastfed infants for 24 hours
WEIGHT (KG) ml of diluted F100 or F75 or infant formula per feed in Acute Phase (8 feeds/day) 30ml per feed 35 40 45 50 55 60 65 70

<=1.5kg 1.6 1.8 1.9 2.1 2.2 2.4 2.5 2.7 2.8 2.9 3.0 3.4 3.5 3.9 4.0 4.4