FEEDING A MALNOURISHED CHILD: A MODEL OF A DAY-CARE COMPREHENSIVE THERAPEUTIC FEEDING CENTER IN AN URBAN AREA

Endy P. Prawirohartono, Kurnia S. Lestari, Yati Soenarto Department of Pediatrics Medical School Gadjah Mada University, Yogyakarta, Indonesia

CAUSES OF DEATH AMONG UNDER 5 YEARS OF AGE 2000-2003 WORLDWIDE

Mller O, Krawinkel M. Malnutrition and health in developing countries. CMAJ 2005;173:279-85.

DEFINITION: Severe acute malnutrition (SAM)

WHO and UNICEF. WHO child growth standards and the identification of severe acute malnutrition in Infants and chidren. A Joint Statement by the World Health Organization and the United Nations Childrens Fund, 2009.

EDEMA

pitting edema

edema

KWASHIORKOR

visible severe wasting

MARASMUS

THE CONCEPT OF THE TREATMENT OF SAM

Nearly all physiological, biochemical, and immunological systems are changed in a malnourished individual Reductive adaptation to inadequate intake, nutritional imbalance and deficiency of specific nutrients Diet formulation and guidelines for the management of SAM and its complication should be based on pathophysiological changes and detailed studies of the metabolism of individual nutrients
Golden MH. Evolution of nutritional management of acute malnutrition. Indian Pediatr 2010;47:667-77.

WHO PROTOCOL

Stabilization phase
Compromised liver, renal and intestinal function Infections Small bowel bacterial overgrowth Very poor appetite Not allow to growth Very low levels of sodium, protein, iron Abundant potassium, magnesium Easily digested

Rehabilitation phase

Recovery

F75

Weight gain (normal Loose edema values) Resynthesis enzymes Physiology starts to Type II nutrients: ZINC to return to normal Regaining appetite Physiological process returns to normal: Promotes growth Renal concentrating Energy and protein ability dense Glucose tolerance Fortified with vitamins and minerals Insulin secretion Body composition: lean tissues Immune functions Stimulation of Na pump Correction of intracellular F100 electrolyte concentration

Golden MH. Evolution of nutritional management of acute malnutrition. Indian Pediatr 2010;47:667-77.

TFC versus CTC

Mode of managements Stabilization phase Rehabilitation phase Comments

In-patient, TFC

F75

F100

well trained personnel, costly, stabile situation

Unstable condition: Famine, war

In-patient, TFC Out-patient, CTC

F75 RUTF

RUTF RUTF

TFC = therapeutic feeding center, CTC = community based therapeutic care F75 = liquid, milk based, adding water/cooking, easily contaminated, 313 kJ, 0.9 g protein/100ml, fortified with vitamin and minerals F100 = liquid, milk based, adding water/cooking, easily contaminated, 414 kJ, 2.5 g protein/100 ml, fortified with vitamin and minerals RUTF = ready to use therapeutic food, paste/solid, energy dense 2281 kJ, 13.6 g/100 g, no added water/cooking, peanut butter
Diop EHI, Dosson NI, Ndour MM, Briend A, Wade S. Comparison of the efficacy of a solid ready-to-use food and a liquid, milk based diet for the rehabilitation of severely malnourished children: a randomized trial. Am J Clin Nutr 2003;78:302-7.

SEVERE ACUTE MALNUTRITION WITH COMPLICATIONS: 1. Bilateral pitting edema grade 3 (severe edema) OR 2. MUAC <110 mm AND bilateral pitting edema grades 1 or 2 AND One of the following: 1. Anorexia 2. LRI 3. Severe palmar pallor 4. High fever 5. Severe dehydration 6. Not alert INPATIENT CARE: WHO/IMCI protocol WITHOUT COMPLICATIONS: MUAC <110 mm OR MUAC 110 mm with bilateral pitting edema grades 1 or 2 AND Appetite Clinically well Alert

OUTPATIENT CARE: OTP protocol

Collins S. Treating severe acute malnutrition seriously. Arch Dis Child 2007;92:453-61.

F100 versus RUTF*

Daily energy intake (kJ/kg body weight/d)1 Average weight gain (g/kg body weight/d)1 Duration of rehabilitation (d)1 Relapsed or died (%)2

F100 573 201

10.1 15.6 16.7

RUTF 808 280

15.6 13.4 8.7

P <0.001
<0.001 <0.001 <0.001

Died (%)2

5.4

3.0

<0.001

* TFC, in-patient in Senegal (ref 1) and in Malawi (ref 2)

1. Diop EHI, Dosson NI, Ndour MM, Briend A, Wade S. Am J Clin Nutr 2003;78:302-7. 2. Ciliberto MA, Sandige H, Ndekha MJ, Ashorn P, Briend A, Ciliberto M, Manary MJ. Am J Clin Nutr 2005;81:864-70.

Management of Severe Malnutrition (WHO)

Time frame for the management of the child with severe malnutrition
Stabilization 10 STEPS Days 1-2 Days 3-7 Weeks 2-6 Rehabilitation

1. Hypoglycemia 2. Hypothermia 3. Dehydration 4. Electrolytes 5. Infection 6. Micronutrients 7. Initial feeding 8. Catch-up growth 9. Sensory stimulation 10. Prepare for follow-up

no iron

with iron

STEP 1

HYPOGLYCEMIA
Is quick blood glucose test (e.g. Dextrostix) available?

YES
Blood glucose normal Hypoglycemia*

NO Assume that the child has hypoglycemia

* < 3 mmol/l or < 54 mg/dl ** 1 teaspoon of sugar in 31/2 tablespoons water

Is the child conscious? YES Give: First feed of F-75 or: 50 ml of 10% glucose orally or: 50 ml of sucrose solution** NO (unconscious)

Give: i.v. 10% glucose 5ml/kg or: 50 ml of 10% glucose by NGT or: 50 ml of sucrose solution by NGT REPEAT TEST AFTER 30 MINUTES

STEP 2

HYPOTHERMIA
Is thermometer available? YES

NO
HYPOTHERMIA* Assume the child has hypothermia

NORMAL

* Axillar temperature < 35C or: Rectal temperature < 35,5C

Child clothed (including head) - Warm blanket Place a heater or lamp nearby or: Put the child on bare chest or abdomen of the mother (skin-to-skin) cover them with warm blanket and/or warm clothing Monitor temperature every 2 hour until it increases more than 36.5C or: Every hour if a heater is being used

STEP 3

DEHYDRATION

It is difficult to estimate dehydration status accurately in a severely malnourished child

Is the child suffering from watery diarrhea? YES Assume the child may has some dehydration Give: ReSoMal by oral or NGT - 5 ml/kg/30 minutes for first 2 hours - 5-10 ml/kg/hour for the next 4-10 hours Rehydration is still occurring at 6 and 10 hours Give: F-75 instead of ReSoMal use the same volume of F-75 as for ReSoMal NOTE: Do not use i.v. route for rehydration EXCEPT in cases of shock Overhydration may lead to heart failure check: - respiratory rate increases by 5/minute - pulse rate increases by 15/minute Stop ReSoMal immediately and reasses after 1 hour

NO

STEP 4

ELECTROLYTES

All severely malnourished children have deficiencies of potassium and magnesium takes 2 weeks or more to correct Do not treat edema with a diuretics Excess body sodium exists even though the plasma sodium may be low GIVING HIGH SODIUM LOADS COULD KILL THE CHILD! Give: -Extra potassium (3-4 mmol/kg/daily) -Extra magnesium (0.4-0.6 mmol/kg/daily) The extra potassium and magnesium should be added to the feeds during their preparation

STEP 5

INFECTION

All severely malnourished children should be assumed have infection during their arrival in hospital

Are there complications (hypoglycemia, hypothermia or the child looks lethargic or sickly)? NO YES Ampicillin 50 mg/kg/i.m./i.v. 6 hourly 2 days + gentamicin 7.5 mg/kg/i.m./i.iv. once daily 2 days Improvement? YES

Cotrimoxazole: 4 mg TMP + 20 mg SMX/kg 2 times/daily - 5 days

NO

NOTE Check for meningitis, malaria, tuberculosis pneumonia, dysentery, skin infection

Continue ampicillin and Gentamicin until 7 days Add: Chloramphenicol: 25 mg/kg/i.m./i.v. 8 hourly 5 days

STEP 6

MICRONUTRIENTS INITIAL FEEDING

Give daily for at least two weeks: a multivitamin supplement folic acid 5 mg on day 1, then 1 mg/day zinc 2 mg Zn/kg/day copper 0.3 mg/kg/day once gaining weight, ferrous sulfate 3 mg/kg/day vitamin A orally (aged < 6 mo: 50000 IU, aged 6 mo 12 months: 100.000 IU, older children 200.000 UI 20,.000 daily) on day 1

STEP 7

INITIAL FEEDING

All severely malnourished children have vitamin and mineral deficiencies

Essential features of initial feeding are: 1. Frequent small feeds 2. Oral or nasogastric tube (never parenteral preparation ) 3. 100 kcal/kg/day 4. Protein 1-1.5 g/kg/day 5. Liquid: 130 ml/kg/day (100 ml/kg/day if the child has severe edema) 6. If the child is breastfed, continue with this, but make sure the prescribed amounts of starter formula are given

Days
1-2 3-5 6 onwards

Frequency
2-hourly 3-hourly 4-hourly

Vol/kg/feed
11 ml 16 ml 22 ml

Vol/kg/day
130 ml 130 ml 130 ml

STEP 8

CATCH-UP GROWTH

Signs that a child has reached this phase are: return of appetite most/all of the edema has gone

Replace F-75 with an equal amount of catch-up F-100 for 2 days The increase each successive feed by 10 ml until some feed remains uneaten After a gradual transition give: frequent feeds, unlimited amounts 150-220 kcal/kg/day 4-6 g of protein/kg/day Assess progress: poor: < 5 g/kg/day requires a full re-assessment moderate: 5-10 g/kg/day check whether the intake targets are being met, or infection has been overlooked good: > 10 g/kg/day

STEP 9

SENSORY STIMULATION

Provide: tender loving care a cheerful stimulating environment structured play therapy for 15-30 minutes a day physical activity as soon as the child is well enough maternal involvement as much as possible (e.g. comforting, feeding, bathing, play)

STEP 10

PREPARE FOR FOLLOW-UP

A child who is 90% weight for length (equivalent to 1 SD) can be considered to have recovered The child is still likely to have a low weight for age because of stunting

Show the parents how to: feed frequently with energy-rich and nutrient-dense foods give structured play therapy ask the parents to bring the child back for regular follow-up (at 1, 2 and 4 weeks, then monthly for 6 months) and make sure the child receives booster immunizations and 6-monthly vitamin A

TREATMENT OF ASSOCIATED CONDITION: EYE PROBLEM

VITAMIN A DEFICIENCY Vitamin A on days 1, 2, and 14 CORNEAL CLOUDING or ULCERATION Chloramphenicol or Tetracycline eye drops 4 times a day 7-10 days Atropine eye drops 1 drop 3 times a day 3-5 days Cover with saline-soaked eye pads Bandage Note Examine the eyes gently to prevent rupture

TREATMENT OF ASSOCIATED CONDITION: SEVERE ANEMIA

BLOOD TRANSFUSION Hb is <4g/dl or 4-6 g/dl and the child with repiratory distress Whole blood 10 ml/kg slowly over 3 hours Furosemide 1 mg/kg iv at the start of transfusion

Pack red cell 10 ml/kg if child has hart failure Monitor pulse and breathing rate every 15 minutes during transfusion If breathing increases by 5 breath/minute or pulse by 25 beats/minute transfuse more slowly
Note If Hb is still low do not repeat the transfusion within 4 days Kwashiorkor may indicate redistribution of fluid leading to apparent low Hb which does not require transfusion

TREATMENT OF ASSOCIATED CONDITION: SKIN LESION

Bath or soak the affected areas for 10 minutes/day in 0.01% potassium permanganat solution Apply barrier cream (zinc and castor oil ointment or petroleum jelly or tulle gras) to the aw areas

Apply gentian violet or nystatin cream to the skin sores

Omit using nappies/diapers so that the perineum can stay dry

TREATMENT OF ASSOCIATED CONDITION: CONTINUING DIARRHEA

GIARDIASIS Metronidazole 7.5 mg/kg 8 hourly for 7 days LACTOSE INTOLERANCE Substitute milk feeds with yoghurt or lactose free infant formula Reintroduce milk feeds gradually in the rehabilitation phase OSMOTIC DIARRHEA Use a lower osmolar cereal-based starter F-75 Introduce catch-up F-100 gradually

Thank you so much

A model of therapeutic feeding center (TFC) in Yogyakarta city

Background
Relatively low prevalence of SAM

Limited bed capacity at the referral hospital

Continuation of care intermediate unit Educated mothers transfer of knowledge and skills Accessible Need to a comprehensive care: growth and development,

play group Less impact of regular feeding program Training and research

REFERRAL SYSTEM

Referral/ Teaching hospital

Health Centers

Private Hospitals

District Hospital

TFC
Health Posts

regular emergency non regular

Home

TFCs daily schedule

Time 08.00-08.15 08.15-09.00 Activities Registration, anthropometry, dietary recall F75 / F100

09.00-10.00

Play group, class session for parents

10.00-11.00 11.00-12.00

F75 / F 100, supplements Physical examination

12.00-14.00
14.00-15.00

Lunch
F75 / F100

TFCs ACTIVITIES

Screening

Nutritional care

Home visit

In-service training

Play group

Research

TFCs ACTIVITIES

Pre-service training (Pediatric-resident)

Training for mothers

Training for mothers (F100)

Nutrition consultation (dietitian)

TFCs FACILITIES

Kitchen (common)

Outdoor playground

Dining room

Meeting room

Ward

Play room

Outcome
43

45 40 35 30 25 20 15

34

20 13 15 14

19

admission discharge

10
5 0 severely wasted

9 10 2
total severely wasted

4 3 0
wasted normal total

0
wasted normal

2010

2011