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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)
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2.) Acute Malnutrition -Wasting (MUAC / Weight for height) -Edema or ´Manasµ *** 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 .

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

Types of Acute malnutrition « Sever ´ Acute Malnutrition (SAM) « Moderate Acute Malnutrition (MAM) « Global Acute Malnutrition (GAM) = SAM = MAM .WHAT IS ACUTE MALNUTRITION ´ Cause by decreas in food consumption and/or illness leadin to bilatearl pitting edema (mana) or wasting (matinding pangangayayat).

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! ´ .

decentralized sites « Children with SAM and medical complications are treated as inpatients « Community outreach for community involvement and early detection and referral cases .WHAT IS CMAM? ´ CMAM = Community-Based management of Acute Malnutrition « Most children with SAM without medical complications can be treated as outpatients at accessible.

´ First pilot Progamme: 2000 (Africa) ´ Philippines: 2009 (Mindanao) .

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 . Maximum Access and Coverage -Bring treatment close to where people live 2. Timeliness -Treat before onset of complication 3.PRINCIPLES OF CMAM 1.

2.COMPONENTS OF CMAM 1. 4. 3. 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 ´ .

4.MEASURING AND CLASSIFYING ACUTE MALNUTRITION 1. 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 . 2. 3.

) Bilateral Pitting Edema .) Weight-for-Height or Weight-for-Length Or 2.) Wasting a.ACUTE MALNUTRITION ´ Defined by the presence of: 1.) MUAC b.

adjust until at ZERO before placing the child ´ Do not use the scale to weigh other objects (rice. supplies.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. 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.

5 cm to 12.5 cm (RED) 11.ACUTE MALNUTRITION MUAC WIGHT-FORHEIGHT/LENGTH Z-SCORE Less than -3 SD SAM Less than 11.5 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 manµ 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 pantsµ look ´ No bilateral pitting edema .

5cm X-Score <-3 SD These children have lost fat and muscle and will weight less than other children of similar height .MARASMUS INDICATOR SEVERE WASTING MUAC < 11.

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

5cm W/H <-3 Z Scores And one of the following: ² ² ² ² ² No appetite LRTI/Pneumonia Severe Dehydration Severe Anemia Not alert Inpatient care .ACUTE MALNUTRITION ´ Complicated acute malnutrition « « « « « +++edema Marasmic kwashiorkor OR MUAC <11.

5CM OR W/H <-3-Z scores OR Bilateral pitting edema.ACUTE MALNUTRITION ´ Severe acute malnutrition « « « « MUAC <11. AND Appetite « Clinically well « Alert Outpatient therapeutic Care .

5cm to <12.ACUTE MALNUTRITION ´ Moderate acute malnutrition MUAC 11.5cm 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 ² ORS vs ReSoMal « Liver and Kidney function are abnormal -> drugs are not eliminated normally (e.g. Paracetamol) .

UTI .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.

.PROVIDING IN-PATIENT CARE ´ Hospitals or Major health centers « 24-hour care available. ² Treatment at night is required for very ill children. ² 8 meals per 24 hours with full medical surveillance and treatment of complications (there needs to be adequate staff at night). those that get refeeding diarrhea and those that have not taken food during the day.

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 .USE OF DRUGS IN ACUTE MALNUTRITION ´ ´ ´ ´ ´ Drugs that cause appetite loss should not be used such as anti-emetics Drugs affecting liver. renal. pancreatic. cardiac or intestinal functions should not be used Malnutrition is treated first before standard doses of drugs are given If really needed.

000iu/ml 50mg/kg IM OD for 2 dyas 5mg/kg IM OD 25mg/kg/d BID 10-30mg/kg/d BID 100. Clav31) DOSAGES 20-100mg/kg/day BID 50-100mg/kg/day BID CEFTRIAXONE GENTAMYCIN CHLORAMPHENICOL CIPROFLOXACIN NYSTATIN 100.000iu PO QID .INPATIENT ANTIBIOTIC DOSAGES DRUGS AMOXYCILLIN Co-AMOXYCLAV PREPARATION 125mg/5ml 156 mg/5mg(Amox125mg.

3/4 3/4 .9 10 .1/4 1/4 .9 15 ² 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 .APPETITE TEST BODY WEIGHT Less than 4kgs 4 .9 7 .14.1/2 1/2 .1/3 1/3 .1 >1 Good >1/4 >1/3 >1/2 >3/4 >1 .9.6.

5 ² 10.5 ² 9.5 3.5 5.5 4.RUTF OTP RATION Weight of child (kg) 3.4 5.4 10.4 8.5 ² 3.0 ² 8.9 4.0 3.0 2.0 ² 5.5 ² 11.0 4.5 ² 6.9 >12 Sachets per week 11 14 18 21 25 28 32 35 Sachets per day 1.0 .4 9.5 2.9 7.

5 ² 2.2 ² 2.1 2.0 ² 4.2kg 1.0 ² 3.7L water OR 1 scoop in 20ml water) WEIGHT >=1.8 ² 2.9 4.9 3.FOR <6 ± MONTH OLD INFANTS SUPPLEMENTAL SUCKLING: Amounts of diluted F100 to give for 24 hours (456 gm of F100 in 2.6 ² 1.7 2.4 ml per feed (8 feeds/day) F100 dilute 25ml per feed 30 35 40 45 50 55 60 65 70 .8 ² 2.3 to 1.7 1.5 kg 1.9 3.5 ² 3.4 2.

1 2.9 3.0 ² 3.6 ² 1.7 2.9 4.9 ² 2.4 2.4 3.0 ² 4.8 ² 2.5 ² 3. 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 1.8 1.5 ² 2.4 .ACUTE PHASE (< 6 MONTHS OLD INFANTS) Amounts of infant formula.2 ² 2.