EPIDEMIOLOGY AND RECENT ADVANCES IN DIAGNOSIS & MANAGEMENT OF SEVERE ACUTE MALNUTRITION

DR. samarjeet kaur (jr-ii) Community medicine deptt. Brd med. College(gkp)

What is undernutrition
A consequence of a deficiency in nutrients in the body

Types of undernutrition:
Acute malnutrition (wasting and bilateral pitting oedema)

Stunting
underweight (combined measurements of stunting and wasting)

Micronutrient deficiencies

What is severe acute malnutrition

According to new definition Severe acute malnutrition is defined by a very low weight for height (below -3z scores of median WHO growth standards), by visible severe wasting, or by the presence of nutritional oedema. Old definition Severe acute malnutrition (SAM), is defined as a weight-for-height measurement of 70% or more below the median, or three SD or more below the mean NCHS reference values, which is called wasted; the presence of bilateral pitting oedema of nutritional origin, which is called oedematous malnutrition; or a mid-upper-arm circumference of less than 110 mm in children age 15 years.

Worldwide public health significance of malnutrition

Malnutrition is a major public health problem

throughout the developing world and is an underlying factor in over 50% of the 10-11 million children under 5 years of age who die each year of preventable causes. Worldwide there are about 60 million children with moderate acute and 26 million with severe acute malnutrition. The risk of mortality in acute malnutrition is directly related to severity : moderate wasting is associated with a mortality rate of 30-148 per 1000 children per year and severe wasting is associated with a mortality rate of 73-148 per 1000 children per year.

Global situation : stunting

6th report on world nutritional status (progress towards mdg-1- region wise)

Magnitude of wasting around the world-not only in emergencies

Where does india stand: (nfhs-3)

Under nutrition in children less than 3 years

60 50 40 30 20 10 0

51 45 43 40

20

23

Stunted

Underweight NFHS-2 NFHS-3

Wasted

Children's nutritional status varies by state

70

Children under age 5 years who are underweight (%)

60 60 49 56 57

50 42 43 40 40 40 41 38 38 39 36 37 37 33 33 30 30 20 20 20 22 23 25 25 25 26 26 45

47

40

10

AP

GA

NA

AR

AS

MZ

KA

WB

PJ

GJ

DL

RJ

MN

MH

MG

MP

KE

HP

UP

SK

OR

JK

IN

HR

CH

BH

UT

TN

TR

JH

 Globally more than 20 million children suffer from

SAM.

Mortality rates for children with SAM are 5-20 times

higher compared to well nourished children. year.

SAM accounts for about 1 million child death each In India, estimates from the most recent Nationally

representative survey indicate that 6.4% of children below 60 months of age have weight for height below 3 SD i.e. roughly 8 million (i.e. 31.2% of world severely wasted children) can be assumed to be suffering from SAM.

Diagnostic criteria for severe acute malnutrition

The World Health Organization (WHO) and

i.

ii. iii. iv.

United Nations Childrens Fund proposed diagnostic criteria for severe acute malnutrition in children aged 6 to 60 months include any of the following : Weight for height below -3 standard deviation (SD or Z scores) of the median WHO growth reference (2006); Visible severe wasting; Presence of bipedal edema; and Mid upper arm circumference below 115 mm.

 Reasons for the choice of this cut-off: 1. Children below this cut-off have a highly elevated

risk of death compared to those who are above; 2. These children have a higher weight gain when receiving a therapeutic diet compared to other diets, which results in faster recovery; 3. In a well nourished population there are virtually no children below -3 SD(<1%).

to define SAM with MUAC ? 1. There are very few children aged 6-60 months with MUAC less than 115 mm. 2. Children with MUAC less than 115 mm have a highly elevated risk of death compare to those who are above.

Why to increase the cut-off point from 110 to 115

Recent history in management of sam

Traditionally , children with SAM are treated in centre based care like-

pediatric ward, therapeutic feeding centre(TFC), nutritional rehabilitation unit(NRU), other inpatient care sites. These centre based care model follows the WHO guidelines for management of severe malnutrition.

Centre based care for children with sam: challenges

Low coverage leading to late

presentation Overcrowding Heavy staff work loads Cross infection High default rates due to need for long stay

What is community based management of acute malnutrition

A community based approach to treat SAM-

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 of cases.

Components of cmam
1. Community outreach Community assessment Community mobilization and involvement Community outreach workers
- early identification and referral of children with SAM before the onset of serious complications - follow up home visits for problem cases.

Community outreach to increase access

and coverage.

2. Outpatient care for children with SAM without medical complications at decentralized health facilities and at home. Initial medical and anthropometry assessment with the start of medical treatment and nutrition rehabilitation with take home ready-to-use-therapeutic-food

(RUTF) Weekly or bi-weekly medical and anthropometry assessments monitoring treatment progress Continued nutrition and rehabilitation with RUTF at home

3.

Inpatient care for children with SAM with medical complications or no appetite Child treated in a hospital for stabilization of the medical complications Child resumes outpatient care when complications are resolved.

4.

Services or programmes for the management of moderate acute malnutrition

Source: FANTA-2 Project, 2008

Community based identification of severe acute malnutrition

Community health workers or volunteers can

easily identify the children affected by severe acute malnutrition using simple colored plastic strips that are designed to measure mid upper arm circumference (MUAC)

Community health workers can also be trained

to recognize nutritional oedema of the feet.

 Once children are identified as suffering from severe acute malnutrition , they need to be seen by a health worker who has the skills to fully assess them following the Integrated Management of Childhood Illness(IMNCI)

approach.

The health worker should then determine

whether they can be treated in the community with regular visits to the health centre , or whether referral to in-patient care is required.

Ready to- use- therapeutic foods

 Children with

SAM need safe, palatable foods with high energy content and adequate amounts of vitamins and minerals.

 RUTF are soft or crushable foods that can be

consumed easily by children from the age of six months without adding water. RUTF have a similar nutrient composition to F100, which is therapeutic diet used in hospital settings. But unlike F100, RUTF are not water-based, thus bacteria cannot grow in them. Therefore these foods can be used safely at home without refrigeration and even in areas where hygiene conditions are not optimal.

 Where there are no medical complications, a

malnourished child with appetite, if aged six months or more, can be given a standard dose of RUTF adjusted to their weight. Guided by appetite, children may consume the food at home, with minimal supervision, directly from a container, at any time of the day or night. Because RUTF do not contain water, children should also be offered safe drinking water to drink at will.

 The technology to produce RUTF is simple and can

be transferred to any country with minimal industrial infrastructure. RUTF costs about US$ 3 per kilogram when locally produced. A child being treated for severe acute malformation will need 10-15 kg of RUTF, given over a period of six to eight weeks.

Community based management of sam in the context of high hiv prevalence

The majority of HIV-positive children

suffering from severe acute malnutrition will benefit from community based treatment with RUTF. However, the rates of weight gain and recovery are lower among these children than among those who are HIV negative, and their case-fatality rate is higher. The lower weight gain is probably related to a higher incidence of infections in children who are HIV-positive.

RUTF are high-

energy, fortified, ready to eat foods suitable for treatment of children with SAM. It should be soft or crushable and should be easy for young children to eat without any preparation. At least half of the proteins contained in the foods should come from milk products.

safety
The food should be free

from objectionable matter. It must not contain any substance originating from microorganisms or any other poisonous or deleterious substances, including anti-nutritional factors, heavy metals or pesticides in amounts that may represent a hazard to death.

Lancet series-global perspective

(lancet series on mother and child undernutrition)

thank you