MANAGEMENT

OF
SEVERE MALNUTRITION
MARNIAR
C20911804
MANAGEMENT OF SEVERE MALNUTRITION:
A MANUAL FOR PHYSICIANS AND OTHER
SENIOR HEALTH WORKERS
World Health Organization
1
Geneva, 1999
INITIAL PHASE

2
 PRINCIPLES OF
MANAGEMENT
Children with severe malnutrition are often seriously ill
when they first present for treatment

constantly monitored
should be kept in
a special area
25–30 °C

3
Initial treatment begins with admission to hospital
and lasts until the child’s condition is stable and
his or her appetite has returned

2–7 days

4
 The principal tasks during initial
treatment are :
to treat or prevent hypoglycaemia and hypothermia

to treat or prevent dehydration and restore

electrolyte balance
to treat incipient or developed septic shock,
if present
to start to feed to identify and treat any
the child other problems, including
vitamin deficiency, severe
to treat infection anaemia and heart failure5
 HYPOGLYCAEMIA
All severely malnourished children are at risk
of developing HYPOGLYCAEMIA

serious systemic infection

THE CHILD
SHOULD
has not beenBE
fed FED
for 4–6 hours
AT LEAST
EVERY 2 OR 3 HOURS
DAY AND NIGHT
6
 t e d
Signs of hypoglycaemia p e c
s u s e d
t h rea for t
w i t
e n b e al s
low body Iftemperature
hypoglycaemia r
(<36.5
d als is°Csuspected,
)o
b i
lethargy
i l r
c no
treatmentchshould ld be m i
given
e d o u t i t io
immediately
loss i sh a swithout
of rconsciousness h a nlaboratory
f e c limpness
o i
u mconfirmation u m c i n
a l n a e c t r m i
mthe childly c p e s te
llIf og is - s
losing y
consciousness, cannot be
AIf theppatient
OFTEN,y o a
THE dis conscious
u s
ONLYs or
SIGN can be
BEFORE roused
h isor
aroused
and b rhas to
able r i o
convulsions,
drink, givegive505 ml ml/kg of of
10% body
weight it h
DEATH
of s
sterilee 10%IS DROWSINESS
glucose intravenously
w
glucose or sucrose, or give F-75 diet(IV),
followed by 50 ml of 10% glucose or sucrose
by mouth
by nasogastric (NG) tube 7
 HYPOTHERMIA
Infants underkangaroo technique
12 months, and those with marasmus,
large areas of damaged skin or serious infections are
clothehighly
the child well (including
susceptible the head),
to hypothermia
cover with a warmed blanket and place an
theincandescent lamp
rectal temperature over°C
< 35.5
or
The rectal temperature
the underarm must <be35.0
temperature measured
°C
every 30 minutes during rewarming with
a lamp
8
DEHYDRATION AND
SEPTIC SHOCK
Dehydration and septic shock are
difficult to differentiate in a child
with severe malnutrition

9
Comparison of clinical signs of dehydration
and septic shock in the severely
malnourished child

10
 Treatment of dehydration
Whenever possible, should be
rehydrated orally
Because severely malnourished children are
deficient in potassium and have abnormally
high levels of sodium, the oral rehydration
salts (ORS) solution should contain less
sodium and more potassium

Magnesium, zinc and copper

11
12
 Amount of ReSoMal to give
70 -100 ml / kg is usually enough to restore
normal hydration

5 ml/kg every 30 min. The 1st 2 h, orally/NGT

12 h
5 – 10 ml/kg/h

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 ReSoMal should be stopped if:
the respiratory and pulse rates increase

the jugular veins become engorged

there is increasing oedema

SIGNS
OF
OVERHYDRATION
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Rehydration is completed when :
the child is no longer thirsty

urine is passed

Any other signs of dehydration have

disappeared

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 Fluids given to maintain
hydration should be based on :
the child’s willingness to drink

the amount of ongoing losses in the stool

< 2 y : 50–100 ml
after each loose stool
older : 100–200 ml
until diarrhoea stops

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How to give ReSoMal ?

oral

NGT

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 Intravenous rehydration
circulatory collapse caused by severe
dehydration or septic shock

• Ringer’s lactate solution with 5% glucose

15 ml/kg !!! Over
• 0.45% (half-normal) saline NGT
with
1h hydration
5% glucose 10 ml/kg/h

18
Feeding during rehydration

breastfeeding should not be interrupted

give the F-75 diet as soon as possible

Oral/NGT

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 Treatment of septic shock
severely septic shock
•should
abdominalimmediately
IVFD 15 ml/kg/hdistensionbe given
Observe
or broad-
every
vomits 5-10min.
repeatedly
malnourished
spectrum antibiotics
•be kept warmgive to prevent
the diet more orslowly
treat
•hypothermia
signs
the
Sign ofofdehydration,
radial CHF
pulse(+)
becomesbut
/ not without
improve a history
strong /conscious
after 1h
•should not be of handled
watery diarrhoea
any more than is
• hypothermia not resolve
or hypoglycaemia
essential for treatment
Blood transfusion
• oedema orally
and or byof
signs 10
NGT
ml/kg, 3 h
dehydration
stop feeding and IVFD 2–4 ml/kg/h + 2 ml
of 50% magnesium sulfate solution IM
F-75 diet by NGT 20
Formula diets for severely
malnourished children

F-75 Initial phase

80 – 100kcal/kg/d

F-100 rehabilitation phase

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22
23
24
25
 NGT
• very poor appetite
• weakness
• painful stomatitis

26
Vitamin A deficiency

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28
 Other vitamin deficiencies
• all malnourished children should receive
5 mg of folic acid orally on day 1 and
then 1mg orally per day thereafter

• deficient in riboflavin, ascorbic acid,

pyridoxine, thiamine and the fat-soluble
vitamins D, E and K

29
 Very severe anaemia
Hb< 40 g/l Very severe anaemia

HEART FAILURE

10 ml/kg of packed red cells or whole blood

slowly over 3 hours
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REHABILITATION PHASE

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:

32
 Principles of management
• to encourage the child to eat as much as
possible
• to re-initiate and/or encourage
breastfeeding as necessary
• to stimulate emotional and physical
development
• to prepare the mother or carer to
continue to look after the child after
discharge 33
F-100 150 - 220 kcal/kg/d, every 4 h

Transition to the rehabilitation phase

involves increasing the amount of diet given
at each feed by 10 ml

F-100 should be continued until the child

achieves -1 SD (90%) of the median NCHS/
WHO reference values for weight-for-height

Folic acid 5 mg on dayIron

1st 3 mg/kg/d, 2 doses,
and than1 mg/d thereafter
max.60 mg/d for 3 mo 34
 Assessing progress
-1 SD (90%) of the median NCHS/WHO
reference values for weight-for-height

weight gain : 10–15 g/kg/d

2–4 weeks
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36
MALNUTRITION IN
ADOLESCENTS
AND ADULTS

37
38
 Criteria for discharge

Adults :BMI is >18.5

Adolescents : BMI-for-age >5th percentile

of the median
NCHS/WHO reference values

39
40
• Initial treatment: life-threatening problems are
identified and treated, specific deficiencies are
corrected, metabolic abnormalities are reversed and
feeding is begun.
• Rehabilitation: intensive feeding is given to recover
most of the lost weight, emotional and physical
stimulation are increased, the mother or carer is
trained to continue care at home, and preparations
are made for discharge of the child.
• Follow-up: after discharge, the child and the child’s
family are followed to prevent relapse and assure the
continued physical, mental and emotional
development of the child.
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Thank you 42