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INTRODUCTION
Severe malnutrition is a major health problem because is wide spread and common cause of mortality( 50% mortality in some cenetes). The malnourished child has clinically inapparent but serious health problems besides the malnutrition.
INTRODUCTION
Case management practice suitable for other children are HIGHLY DANGEROUS for the malnourished child. The severe malnourished child has abnormal physiology due reductive adaptation.
Rating of dermatosis + mild: discoloration or few patches of skin ++ moderate: multiple patches on arm and/or legs +++ severe: flaking skin, raw area and fissures
Infection
Pus
REDUCTIVE ADAPTATION
With severe malnutrition, the systems shut down or slow down and do less to allow survival on limited calories. With treatment, the systems gradually learn to function again. Rapid changes (feeding, fluid) would OVERWHELM the systems so feeding must be slowly and cautiously increased. This slowing down of the systems is called REDUCTIVE ADAPTATION.
Mx/Caution
- give just adequate protein - dose of drugs - feed CHO rich - no iron initially - give small feeds at a time
Organisation of Care
Adm is a must if criteria is fulfilled. Admit to separate ward (mal ward) Get specially trained staff Frequent assessment and monitoring Good organisation of feeding (small vol. large vol.) Special feeding formulas
F-75 & F -100, Suji, RUTF & resomal
How reductive adaptation affect care; 3 implications 1. Nearly all mal chn have bacterial infection (UTI, OM, pneumonia, septicaemia) assume infection and treat with broad spectrum antibiotic. 2. Dont give iron early in treatment Early iron excess free iron with 3 effects: Free radical Promote bacterial growth Utilises energy and amino acids ferritin.
3. Provide K+ but restrict Na+ Na+ - K+ pump runs slowly in sev mal due to reductive adaptative K + is lost in urine and stool as Na + is retained. This affects proper distribution of fluid oedema. Provide mg2+ as well (retains K+ in cells) . Resomal, F-75 & F-100 has require amount of electrolyte (mineral mix)
These account for most deaths in the first 48hrs of adm. Improper management of these complications similarly cause death in the first 48hrs. 1) Hypoglycemia RBS < 3mmol/L If RBS check not possible, assumed hypoglycemia and treat. Signs: hypothermia, lethargy, loss of consciousness.
Promptly change wet clothes or beddings. Dry the child thoroughly after bathing. Let the child sleep snuggled up to the mother and cover them with a blanket.
b) Actively re-warm the hypothermic child. Skin-to-skin contact between mother and child and covering both of them (kangaroo technique). Use lamp or bulbs (not too close).
Mx
Give O2 Give 10% glucose 5ml/kg IV Keep the child warm Give IV fluid 15ml/kg/hr. Repeat for another hour if pulse and RR improves () Give antibiotics.
small mucoid stools are common in sev. mal but do cause dehydration. Signs of dehydration misleading Assume dehydration if watery diarrhoea and vomiting present. do not give std ORS Give resomal 5ml/kg q 30min for 2hrs then 5 10ml/kg/hr to alternate with F-75 for 10hrs. Monitor RR & PR closely as HF may occur. Monitor urine freq. Stool, vomiting plus signs of dehydration for any improvement.
Rx
Signs of overhydration:
PR & RR engorged jugular vein oedema (eg. Puffi eyelid)
Assume infection and treat with ab straightaway. Selection of ab depends on presence or absence of complication
Mx
Zinc 2mg/kg/dy Copper (0.3mg/kg/dy) Once gaining weight (during rehabilitation phase), Ferrous salt 3mg/kg/dy. Give vit A po on day 1 Zn, Cu, K+ and Mg2+ all available in mineral mix or CMV
Common complications and their management 9) Severe Dermatosis (flaking, ulceration, fissures & raw areas)
Rx Bath in 1% potassium permagnate for 10min or dab with GV paint Apply Zinc oxide ointment to raw area (barrier cream)
10) Feeding
Critical in mx of the sev mal Should begin immediately after adm or soon after stabilization . Should however be started cautiously in small frequent amount Aggressive handling or high protein/Na+ diet could overwhelm system or kill child. Special Formulas; F-75 (75 kcal/100ml) as starter feed for stabilisation (usually 1st 2 - 7 dys) F-100 (100 kcal/100ml) as catch up formula during rehabilitation phase to rebuild waste tissue.
Discharged if wt for ht is >-1SD (90% of expected wt for ht) Identified home factor contributing to mal and tackle to prevent relapse. Employ community nurse for home follow-up Regular hospital review: 1wk, 2wk, 1mth, 3mth, 6mth. Prepare parents for home feeding using simple modification of home food aimed at providing high energy and protein + mineral, vit, & E.
Immunization: If not immunized then do so before discharge. Monitoring and records: Detailed management should be recorded on monitoring chart (monitoring record, critical care pathway, daily care, 24hr food intake chart). Review childs record daily to assess progress and problems.