Matias H.

Aznar Memorial College of Medicine

Presented to
Vicente Sotto Memorial Medical Center
Department of Pediatrics

IMCI:
Malnutrition

GROUP1A:
Aljas - Nuňez – Oliva – Orquin – Sicat – Silvestre – Estares – Ordeniza
NOVEMBER 18-20, 2020
Table of Contents

1 INTRODUCTION

2 ASSESS & CLASSIFY

3 TREATMENT

COUNSELLING &
4 FOLLOW- UP
INTRODUCTION TO
MALNUTRITION
ORQUIN, Rainbow Ramel Y.
 MALNUTRITION
‐ Pathological state secondary to
relative or absolute deficiency or
excess of one or more essential
nutrients

‐ Encompasses both ends of the

nutrition spectrum, from
undernutrition to overweight
 SEVERE ACUTE MALNUTRITION
‐ Defined as severe wasting and/or bilateral edema
‐ SEVERE WASTING – is extreme thinness diagnosed by weight – for
– length (or height) below -3 SD of the WHO Child Growth
Standards
‐ BILATERAL EDEMA
‐ Children usually had a diet insufficient in energy and nutrients relative
to their needs
‐ 2 forms
‐ Marasmus
‐ Kwashiorkor
 CAUSES OF MALNUTRITION
‐ Inappropriate dietary choices
‐ Low income
‐ Difficulty obtaining food
‐ Various physical and mental health conditions

‐ TAKE NOTE! It varies from country to country

 MALNUTRITION IN THE PHILIPPINES
‐ According to FNRI (Food and Nutrition Research
Institute) Philippines (February 2019)
‐ – malnutrition rate among Filipino children remains high
with 26.2% of all children aged 0 to 2 years old and
highest among children up to 10 years of age.
PATHOPHYSIOLOGY OF MALNUTRITION
REDUCTIVE ADAPTATION

INSUFFICIENT FOOD INTAKE

PHYSIOLOGIC AND METABOLIC • Fat stores are mobilized to provide energy

CHANGES • Later protein in muscle, skin and GI tract is
mobilized

• Reduction in physical activity and growth

CONSERVE ENERGY AND • Reduction in basal metabolism and functional
PROLONG LIFE reserve of organs and by reducing inflammatory
and immune response
 PATHOPHYSIOLOGY OF MALNUTRITION

LIVER HEART KIDNEYS

Glucose less readily Smaller and weaker Less able to excrete

available = and has a reduced excess fluids and
HYPOGLYCEMIA output sodium and fluids
easily accumulate in
CARDIAC FAILURE the circulation =
Albumin, Transferrin
and other transport FLUID OVERLOAD
proteins production
are reduced
Less able to cope with
excess dietary protein
and to excrete toxins
 PATHOPHYSIOLOGY OF MALNUTRITION
OTHERS
• Heat production is less, making the child more vulnerable to
hypothermia
• Sodium builds up inside cells due to leaky cell membranes and
reduced activity of the sodium/potassium pump, leading to excess
body sodium, fluid retention and edema
• Potassium leaks out of cells and is excreted in urine, contributing
to electrolyte imbalance, fluid retention, edema and anorexia
• Loss of muscle protein is accompanied by loss of potassium,
magnesium, zinc and copper
 CLINICAL MANIFESTATIONS
• Severe wasting – thighs, buttocks and upper arms and over the ribs and scapulae
• Poor skin turgor
• Eyes may appear sunken
• Edema – feet and lower legs
ASSESSMENT FOR
MALNUTRITION
OLIVA, Oshin Mae C.
HOW DO YOU CHECK FOR MALNUTRITION?

ASSESS FOR SAM

WHEN SAM, ASSESS FOR COMPLICATION

 PART 1: ASSESS FOR SAM
S S S
T T T
E E E
P P P
1: 2: 3:
 STEP 1:
LOOK AND FEEL FOR EDEMA OF BOTH FEET
WHAT IS EDEMA?
• Edema is when an
unusually large amount
of fluid gathers in the
child’s tissues.

• The tissues become filled

with the fluid and look
swollen or puffed up.
HOW WILL YOU ASSESS FOR EDEMA?
• LOOK and FEEL to determine if the
child has edema of both feet.

• Using your thumbs, press the topside

of both feet simultaneously for 3
seconds on the top side of each foot.

 The child has edema if a dent remains

in the child’s foot when you lift your
REMEMEBER!!! thumb.
Edema both feet = Severe Acute Malnutrition
 STEP 2:
MEASURE WEIGHT-FOR-HEIGHT OR LENGTH
WHAT IS THE DIFFERENCE BETWEEN LENGTH
AND HEIGHT?
NOTE: Height of a child is 0.7
cm shorter than length
LENGTH
• Measured when the child is lying down.
• Children below 2 years of age or if the
child is too weak to stand.
HEIGHT
• Measured when the child is standing
upright.
• Used for all other children.
 LENGTH
• One assistant should hold the child’s head over the ears
and with straight arms.

• The measurer hold one hand on the child’s knees

keeping the legs straight and the other on the foot-place
to read the length.

• The child should lie flat on the board.

• Pull footboard against the child’s feet with both soles are
flat against the footboard and toes are pointing upwards.
 HEIGHT
• Assistant holding the child’s knees to keep the legs straight
with one hand, and the other hand on the shins to keep the
heels against the back and base of the board.

• The measurer should hold one hand the child’s chin and
the other on the head-piece to read the height.

• The child’s eyes should be in horizontal level and the body

flat against the board.

• Pull down the moveable headboard to rest firmly on top of

the head.
HOW DO YOU CALCULATE A CHILD’S Z-SCORE?

1. Choose the appropriate chart

2. Plot the measurement
3. Determine the z-score
4. Interpret
Choose the appropriate chart
Plot the measurement
Mark the intersection of the
child’s weight and height
• Weight (kg) run up the chart
• Height (cm) are along the bottom of the
chart

Example:
Ben is 10.5 kg and 82 cm
 Interpretation
Z SCORE Interpretation
Higher than 3 Above 3 (z-score>3) Obese
Between 2 to 3 Above 2 (z-score>2) Overweight
Between 1 to 2 Above 1 (z-score>1) Possible risk of
overweight
Between 1 to -1 0 (median) Normal
Between -1 to -2 Below -1 (z-score <-1) Normal
Between -2 to -3 Below -2 (z-score <-2) Wasted
Lower than -3 Below -3 (z-score <-3) Severe wasted
 STEP 3:
MEASURE MUAC
(only for children 6–59 months)
 WHAT IS MUAC?
• Mid-upper arm circumference (MUAC)

• The measurement around the middle of a

child’s upper arm is an important indicator of
acute malnutrition in a child.
•
• The MUAC strip is a flexible measuring tape
that measures in millimetres (mm).

• MUAC can only be used for children

6–59 months.
115 to <125 mm Moderate Acute Malnutrition
<115 mm Severe Acute Malnutrition
 HOW DO YOU MEASURE THE CHILD’S MUAC?

• Find the mid-point of the child’s upper arm between the shoulder and
elbow.
• Use MUAC tape to mark the midpoint on the child’s arm.
• Hold the large end of the strap against the arm at the midpoint of the
arm.
• Put the other end of the strap around the child’s arm. Thread the end up
through the second small slit in the strap. The end will come from behind.
• Pull both ends until the strap fits closely. It should not be so tight that it
makes folds in the skin. It should also not be too loose.
• Gently press the window. At the marks note the measurement and colour.
SIGNS OF SEVERE ACUTE MALNUTRITION
THE SIGNS OF A CHILD LESS THAN 6 MONTHS WITH SAM:
‐ Infant has edema of both feet
‐ Weight-for-length is less than 3 z-score

THE SIGNS OF A CHILD 6 MONTHS AND OLDER WITH SAM:

‐ Child has edema of both feet
‐ Weight-for-height/length is less than 3 z-score
‐ MUAC is 115 mm or below
 PART 2:
WHEN SAM, ASSESS FOR
COMPLICATIONS
ALJAS, Vida
 IF CHILD IS UNDER 6 MONTHS:
1. Check the child for medical complications. If the child has the following
complications, it must be noted for their assessment:

- general danger sign or sign of severe illness, done at the beginning

of ASSESS
- any severe (red) classification
- pneumonia with chest indrawing

2. Check the child for a breastfeeding or feeding problem. Refer to the

sick young infant assessment chart for FEEDING PROBLEM.
 IF CHILD IS 6 MONTHS AND OLDER:

1. Check the child for medical complications

2. Conduct an appetite test with RUTF (Ready-to-use Therapeutic Food)

• given for children > 6 months

with severe acute malnutrition
(SAM)
• safe to use at home and ensure
rapid weight gain in severely
malnourished children
 APPETITE TEST

WHEN WILL YOU CONDUCT AN APPETITE TEST?

• if a child is 6 months or older, and shows signs of severe acute
malnutrition, you should conduct an appetite test.
• you will assess appetite by giving the child some Ready-to-use
Therapeutic Food (RUTF)
 APPETITE TEST

HOW WILL YOU PREPARE TO GIVE A CHILD AN APPETITE TEST?

• A child may refuse to eat RUTF because it is unfamiliar and because
the child is in a strange environment.
• In this case, the caregiver should move to a quiet, private area and
slowly encourage the child to take the RUTF.
HOW WILL YOU CONDUCT AN APPETITE TEST?
 HOW DOES A CHILD ‘PASS’ THE
APPETITE TEST?
• To pass the test, the child must eat the RUTF quantities in table
below within 30 minutes.
ARE THERE ANY TIMES WHEN AN APPETITE TEST
SHOULD NOT BE CONDUCTED?

• If a child has any general danger signs, the appetite test is

not done.
• The appetite test is also not done in children who have
pneumonia, persistent diarrhea, dysentery, measles, or
malaria.
• If RUTF is not available for an appetite test, refer.
CLASSIFY
SILVESTRE, Ped
CLASSIFY MALNUTRITION
 COMPLICATED ACUTE SEVERE
MALNUTRITION (RED)

At least one medical

At least one medical No appetite A feeding
A feeding problem
complication
complication No appetite problem
•Including any •In children under
•Determined
general danger 6 months
• Including any general danger failed appetite according to the
sign, any severe • Determined failed appetite test
sign, any severe classification,
classification, or
test in a child
in a child 6 months or older
FEEDING
or pneumonia with chest
6 months or PROBLEM
indrawingpneumonia with classification for
chest indrawing older the young infant
CLASSIFY MALNUTRITION
 COMPLICATED ACUTE SEVERE MALNUTRITION

• If the child has at least one sign of severe acute malnutrition, but
passed the appetite test or does not other signs of complication, they
are classified as UNCOMPLICATED SEVERE ACUTE
MALNUTRITION.
 MODERATE ACUTE MALNUTRITION

• If the child’s weight for age is between -3 and -2 Z-score or MUAC

between 115 and 125, classify as MODERATE ACUTE
MALNUTRITION.
CLASSIFY MALNUTRITION
 CLASSIFY MALNUTRITION

Remember that signs of severe acute malnutrition that

you have assessed for include MUAC less than 115 mm,
weight-for-height lower than -3 Z, or include edema of
both feet.
 NO ACUTE MALNUTRITION ( GREEN )

• If the child has a weight-for-age over -2 Z-scores, and has no

other signs of malnutrition, classify as NO ACUTE MALNUTRITION.
TREATMENT FOR
MALNUTRITION
NUŇEZ, Martin Phyl
SICAT, Geraldine
Classify Malnutrition
Decision Flowchart for OTC or ITC: 6-59 mos. old
 OTC Treatment

Choose appropriate medical management

Choose appropriate nutritional management according

to age

Demonstrate how to orient caregiver on OTC treatment.

Decision Flowchart for OTC or ITC: 6-59 mos. old
A. Choose the appropriate medical management for
the infant/child with SAM.

ALL cases admitted to OTC should be treated according to the

following routine treatment schedule in order to treat probable
and potential underlying illnesses that may not always show
classical signs and symptoms.
 Treatment upon OTC Admission

• Check child’s immunization status. Refer to the BHS

for any vaccinations due (including for measles
vaccination).
• Check date of the child’s last deworming. Refer to
BHS.
• Diagnose and treat malaria, per national guidelines.
 Treatment upon OTC Admission
• Diagnose and treat tuberculosis, per national guidelines.
• Record any supplementation/ treatment given on child’s
ECCD chart if they have one.
• Treat other medical conditions/symptoms – eye
infections, ear discharge, mouth ulcers, fungal infections,
minor skin infections and lesions – per CB-IMCI
guidelines.
 Treatment upon OTC Admission
• Additional medication should be prescribed
conservatively.
• Do not give iron and folic acid routinely.
• Severe anemia: Refer to ITC, according to CB-
IMCI guidelines
• Moderate anemia: Start treatment only after 14
days in OTC; not before, because high doses
may increase risk of severe infections. (CB-IMCI
protocol one dose daily for 14 days)
 DO NOT GIVE!

• Zinc to patients taking RUTF.

• Medicines against vomiting (anti-emetics) in OTC.
• Cough suppressants.
• Paracetamol routinely (toxic in a malnourished child).
• Aminophylline in OTC.
• Metronidazole in normal/high dosages.
• Reduce dosage as indicated.
• Ivermectin in any edematous child.
B. Choose the appropriate nutritional
management for the infant/child with Severe
Acute Malnutrition.

1. Determine amount of RUTF required by child based

on their current weight, as indicated in RUTF ration
table.
 RUTF Ration Table
Body Weight Ready-to-use therapeutic food (RUTF)
Range (kg)
Sachets per day Sachets per week

3.0-3.4 1 ¼ sachet 8 sachets

3.5-4.9 1 ½ sachet 10
5.0-6.9 2 15
7.0-9.9 3 20
10.0-14.9 4 30
15.0-19.9 5 35
20.0-29.9 6 40
Values are round off
How to prepare RUTF to eat?

1. Massage packet for 30 seconds

 One half One third

2. Measure
the portion

One fourth
 4. Fingers mark the portion
as the child eats
3. Tear RUTF packet
5. Or caregiver gives a small amount on her finger
2. Do NOT give RUTF if:

a) Infant is less than 6 months old.

Provide intensive breastfeeding counseling
to the mother/ caregiver (C-MAMI Tool, Nov 2015*).

b.) Child has known peanut allergy.

Refer to ITC for treatment with therapeutic milk
(F75/F100).
C. Orient the mother/ caregiver on the
treatment.
‐

1. Explain how much RUTF to give each day.

Ask to repeat.
2. Discuss simple key messages on RUTF use:
a) For breastfeeding infants older than 6 months, advise
mother to continue breastfeeding as before and give the
RUTF after each feeding.
b) For older children, always give plenty of safe water with
RUTF as it doesn’t contain any itself. But do not mix
RUTF with water.
C. Orient the mother/ caregiver on the
treatment.
c) RUTF is all the food needed to recover.
Give no other foods until full daily ration is consumed.

• Adhere to proper timing/amount of RUTF ration so that it

won’t be consumed immediately.
• Report improved infant/child’s appetite to health worker to
evaluate if increased RUTF ration needed.
• May give fresh fruits/ vegetables once ration consumed &
infant/child requests.
C. Orient the mother/ caregiver on the
treatment.

 Encourage child to take small amounts of RUTF frequently during

the day directly from the packet.
 NOT to share RUTF with other family members (RUTF -
medicinal food for thin and swollen children)
 Return to health center weekly for monitoring; receive the next
weekly RUTF ration.
 Return empty RUTF packets to the health center each week.
 C. Orient the mother/ caregiver on the
treatment.
 Explain how to give home medicines. Ask to
repeat.

 Explain importance of hygiene and sanitation.

Wash child’s hands/face before eating and after
stooling.

 Explain that malnourished children need to be

kept warm (ensure adequate clothing).
C. Orient the mother/ caregiver on the
treatment.
 Inform of local volunteer/ health worker support.

 Inform those who refused transfer to inpatient care facilities of

home visit by local BHW and/or BNS

 Inform that if concerned about the child’s condition, they should

bring child straight back to health facility for medical review/advice.

C. Orient the mother/ caregiver on the
treatment.
 Encourage them to ask questions.
Give them sufficient time.

 On later visits, additional counseling:

 IYCF topics based on IMCI guidelines

 Handwashing with soap and water

 Growth monitoring
Discharge
 Steps for OTC Discharge
‐ Identify patients for discharge from
OTC.

‐ Classify outcome of OTC treatment and

‐ record in registration book and chart.
Decision Flowchart
for OTC or ITC:
6-59 mos. olds
A. Identify patients for discharge from the OTC.
Discharge criteria: Cured
PATIENT GROUP DISCHARGE CURED CRITERIA
Children 6- Admitted on MUAC > 125mm (12.5 cm) for 2 consecutive visits
59 months MUAC, edema or AND
No edema for 14 days
both MUAC and AND
WFH/WFL Z- Clinically well
scores
Admitted on WFH or WFL > -2 Z-scores for two consecutive visits
WFH/WFL Z- AND
No edema for 14 days
scores only AND
Clinically well

Infants < 6 months Breastfeeding effectively

AND
Has adequate weight gain (5g/kg/d)
AND
WFL > -2 Z-scores for consecutive visits (where capacity exists
to measure)

OR
Reaches 6 months of age21
 B. Classify the infant/child’s outcome of
treatment
OUTCOME DESCRIPTION
Cured The patient has reached the criteria for discharge cured.
Dead The patient died during treatment in the OTC or in transit to the ITC.
Defaulter The patient has not returned for three consecutive visits and a home
visit, neighbor, village volunteer, or other reliable source confirms that
the patient is not dead.
Discharged as The patient does not reach the discharge criteria within four months
non-cured and all referral and follow-up options have been tried (e.g. home visit
and household situation assessed), they may be discharged as non-
cured. In these cases, ensure that the child is refeered for assessment
of possible medical complications if not yet done (e.g. TB) and linked
with the MAM program where possible and to social support systems.
 Do the following Steps for
Discharge..

A. Explain to the mother/caregiver that the child has recovered

sufficiently to be discharged and congratulate them.
Do the following Steps for
Discharge..
B. Refer if vaccination is required:

 If the child has reached 9 months of age during treatment

in OTC and has not yet received vaccination against
measles (follow up to BHC or RHU)

 Children admitted at age 6 to 8 months should get a

follow-up appointment for the second measles vaccination
(booster) after 1 month.
 Do the following Steps for
Discharge..
C. All children will get a last ration for seven sachets
of RUTF.
 Do the following Steps for Discharge..
D. The mother/caregiver should receive counseling
on IYCF practices, care practices, hygiene feeding
practices, food preparation for children, and so on, in
line with standard IYCF counseling.
Do the following Steps for Discharge..

E. Link to dietary
supplementation programs
and/or other services available.
 Do the following Steps for Discharge..

F. Fill in the patient record in

the register with the
discharge details.
 Do the following Steps for Discharge..

G. Caregivers should be linked

with any other appropriate
services for which they are
eligible, and which support the
on-going rehabilitation of the
child.
Decision Flowchart for presence of MAM: 6-59 mos. old
Thank you!