EXPANDED PROGRAM

ON
IMMUNIZATION (EPI)
 Learning objectives

At the end of this lesson the students will be able to:

• Define immunization, immunity and vaccine

• Discuss about classification of immunity.

• Identify immunization schedule.

• Recognize C/I, S/E, and their measure to be taken

 Introduction
• Immunity:- is the resistance of the body against a
disease producing agent.
• Immunization:- The production of immunity by
artificial means or the process of becoming immune.
• Vaccines :- is an antigen design to induce immunity
against the particular pathogen / production of Abs/.
• Toxiod :- is a modified bacterial toxin that has been
rendered nontoxic, and retains the ability to stimulate
the formation of antibodies to the toxin
 Why immunization?
 The most successful and cost effective health
intervention
 2 to 3 million deaths averted annually by vaccination
 The immune system
 The main function of the immune system is to prevent
or limit infections by microorganism such as bacteria,
virus, fungi and parasites
 The foetal immune system develops in a sterile and
protected environment, and therefore lacks antigenic
experience
 Soon after birth, the newborn is exposed to the "hostile
world" of bacteria, viruses, fungi, and parasites, and
must immediately defend itself
 The immune system
 The immunologic competence of the neonate progresses rapidly
in the first three months of life, as the cells involved in acquired
immunity mature and gain antigenic experience
 During this period, the neonate mainly depends upon components
of the innate or antigen-independent immune system’
 The overall performance of the immune system in the neonatal
period is diminished in several important respects
 As a result, very young infants are more susceptible than older
infants to serious bacterial infection, as well as some viral and
fungal infections
Classification of immunity

7
 Immunity divided in to two
I. Congenital or innate II. Acquired
 Non-specific immunity.  specific immunity
 It is the natural resistance of  Active acquired immunity
body o The child body makes its own
 The natural imuune process antibodies.
have no memory ex. Skin,
o Long lasting immunity.
mms, WBC etc.
o Characterized by long term memory
 Passive acquired immunity
o The child gets ready-made antibodies (Ab).
Short live immunity.
Active acquired immunity divided in to two.
A. Naturally acquired B. Artificial acquired
active Immunity. active Immunity.
The child makes The child makes anti
immunity after bodies after
Exposure to a administration of
disease. antigen vaccine .
 Passive acquired immunity

A. Natural-acquired B. Artificial acquired

passive immunity passive immunity.
• Trans-placentally • Formed antibodies are
transferred Maternal administered to the child.
antibodies in the body of e.g T.A.T
the child. E.g TT vaccine
for the mother.
 Active immunity
 Is acquired when a person’s own immune system
generates the immune response
 lasts for many years or for a lifetime
 This long-term protection is the result of immunologic
memory
 This immunity can occur after exposure to natural
pathogens or after exposure to vaccines
 Vaccines mimic the characteristics of the natural antigen
 The immune system mounts a response and establishes
an immunologic memory as it would for an infection
 Passive immunity
 Is produced when the immunoglobulins of one person
are transferred to another.

 This immunity lasts only weeks or months

 Passive immunity can be obtained by injection of

exogenous immunoglobulin

 It can also be transferred from mothers to infants via

colostrum or the placenta
Introduction to EPI Program
 Innovation of vaccination/immunization
• On May 14,1796, Edward Jenner, performed
an experiment that would revolutionize
public health.
 He made two small cuts on the arm of an
eight-year-old boy and inserted material
taken from a sore on a woman infected with
cowpox, a mild disease common to dairy
workers.
 Six weeks later, Jenner injected the boy with He called this process
fluid from a smallpox lesion, and James did “vaccination”, derived
not contract smallpox.
from the Latin name
• Inoculation of a person with relatively for cowpox, vaccinia.
harmless disease material could protect the
person from a more dangerous disease.
 Milestones in Vaccine Development
• 1885: First use of live attenuated viral vaccine
(rabies) in humans
• 1909: First live attenuated bacterial vaccine (Bacillus
Calmette Guerin, or BCG) created for use against
tuberculosis.
• 1921: Diphtheria toxoid developed
• 1924: Tetanus toxoid produced
• 1930: Pertussis vaccine developed
• 1932: Yellow fever vaccine developed
 Cont…
• 1940s: Diphtheria-tetanus-pertussis (DTP)
combination introduced
• 1955: Inactivated polio vaccine introduced
• 1963: Live attenuated oral polio vaccine introduced
• 1963: Measles vaccine introduced
• 1986: First recombinant vaccine (hepatitis B)
introduced
• 1990: First polysaccharide conjugate vaccine
(Haemophilus influenzae type b) introduced PCV
(2011) & Rota 2012
 EPI in Ethiopia

• EPI was launched in 1974 by the WHO to control

vaccine preventable diseases

• The objective of the National Immunization Policy

was to reduce mortality and morbidity in children
from the EPI target diseases through the
immunization of all children under the age of one.
 EPI in Ethiopia …
• The Ethiopian immunization policy was updated in
2007.
Children of under-one year of age and women of
reproductive age group (15-49 years age) are the
targets for the EPI vaccines.
• There are no booster doses recommended in routine
EPI for childhood immunization
• However, there are periodical supplemental doses
for measles and polio.
• The policy recommends the use of static sites,
outreach sites and mobile teams as appropriate
strategies for delivering immunization services.
 EPI in Ethiopia …
• Health Facilities conducting Routine Immunization
– Health Posts
– Health Centers
– Hospitals
– (NGO clinics – if appropriate)
– (Private Clinics – if appropriate)
• EPI Staff
– All HEWs
– All HWs who have pre-service training on conducting
EPI are responsible to conduct/lead EPI program in the
assigned Health Facility.
 EPI Delivery Strategies
 Static: immunization performed as part of routine activity of the Health
units.

 Outreach: an immunization approach in which the staffs of health unit go

out and administer vaccine to mothers and children in their catchments areas.

 Mobile: an immunization approach only for single dose vaccination

(measles, BCG) in nomadic, settlement areas and mostly used for controlling
epidemics of measles.

 Campaign: an immunization approach conducted by mobilizing the

community, example polio and measles vaccination.

20
The Vaccines
 Introduction
Common observed Problems:
A. Inappropriate dose and route of administration.

B. Misunderstanding of schedules for routine EPI.

C. False contraindications to vaccination

Nature and Type of vaccines
DTP-HepB-Hib
(Pentavalent)
 DTP-HepB-Hib combination vaccine
 Type of vaccine – Fully liquid vaccine
 Number of doses/child – Three (DTP-HepB-Hib)
 Schedule - 6, 10, 14 weeks of age
 Dosage - 0.5ml
 Injection site - Outer mid-thigh
 Injection type – Intramuscular
 Storage - Store between 2°C to 8°C. Never
freeze
 SAFETY AND SIDE EFFECT- Pentavalent vaccine
(DPT-HepB-HIB)
• 95% effective for Hep B, Hib, Diphtheria, 80% for Pertussis
• Mild reactions following immunization are common
– Pain and swelling, redness at the site of injection,
– Fever, irritability, malaise
– Self- limiting, hardly requiring even symptomatic treatment
• Reassure parents about such events so that they know about it
• Side effects are not contraindications for vaccination
• Contraindications – There are no contraindications to DTP except that
• It should not be given to children who have suffered a severe reaction
to a previous dose.
Measles Vaccine
 Measles vaccine
 Type of vaccine - Live attenuated
 Number of doses - two dose,
 Second opportunity should be given in campaigns/Routine
 Schedule - At 9 –11 months of age
 Dosage - 0.5ml
 Injection site - Outer upper arm
 Injection type - Subcutaneous
 Storage - Store between 2°C–8°C (vaccine will not be
damaged by freezing but the diluent should never be frozen).
 Soreness and pain at injection site- 24 hours
 5% - fever 5-12 days after injection
 5% mild rash 5-12 days after injection –last 2 days
Measles vaccine …
 85% Efficacy
 Contraindications
 Severe reaction to previous dose
 Adverse reactions
 Malaise, fever, rash 5–12 days later; idiopathic
thrombocytopenic purpura; rarely, encephalitis, anaphylaxis
 Severe reactions are rare:
 Anaphylaxis 1/1,000,000 doses
 Encephalitis :1/1,000,000 doses
Oral Polio Vaccine
(OPV)
Oral polio vaccine (OPV)
 Type of vaccine - Live attenuated
 Number of doses -Four in endemic countries (including
birth dose)
 Schedule - At birth, 6, 10, 14 weeks
 Additional dose: given in campaigns
 Adverse reactions
 Headache , diarrhea muscle pain- <1%
 VAPP very rare (approximately 2 to 4 cases per
million children vaccinated)
 Dosage - 2 drops into the mouth
 Storage - Store between 2°C–8°C ( maybe frozen for
long-term storage).
 Oral Polio Vaccine (OPV)

• Contraindications – There are no

contraindications to polio vaccination
However, if a child has diarrhea when OPV is
given, an extra dose should be administered
If the OPV0 dose is not given within 14 days of
birth, it should not be given at all, and the primary
series should begin with OPV1 at six weeks of age.
 Inactivated polio vaccine
• On 16 December 2015 Ethiopia introduce
Inactivated Polio Virus (IPV) vaccine against
poliomyelitis.
• The introduction of IPV in Ethiopia is a step
forward towards global polio eradication efforts
• Combining IPV and OPV provides stronger
protection to the current oral polio vaccine (OPV)
against polio.
 Inactivated polio vaccine
• The IPV will help provide additional
protection to children against polio disease –
and will give the child the benefits of both
vaccines.
• IPV strengthens immunity in the blood while
OPV strengthens immunity in the gut.
• Administered by IM, at 14 weeks, 0.5 ml
Tetanus Toxoid Vaccine
(TT)
 TT vaccine
 Type of vaccine - Toxoid
 Contraindications - Anaphylactic reaction to previous
dose
 Adverse reactions –
 Soreness, swelling at the injection site 1-3 days
 Mild fever -10%
 Dosage - 0.5ml
 Injection site - Outer upper arm(left arm)
 Injection type – Intramuscular
 Storage - Store between 2°C–8°C.
 Tetanus Toxoid vaccination schedule and period of protection

Dose When to give Level of Period of protection

protection
TT1 First contact Nil None

TT2 At least 4 weeks 80% 1-3 years

after TT1
TT3 At least 6 months 95% At least 5 years
after TT2
TT4 At least 1 year after 99% At least 10 years
TT3
TT5 At least 1 year after 99% For all child bearing yrs
TT4 and possibly longer
 TT vaccine
• Women who have received three doses of DTP
during child hood or additional doses of tetanus
toxiod containing vaccine during their school
years don’t need all five doses of TT in adult
hood for protection
• They must retain their vaccination card for health
workers to determine additional doses needed
BCG Vaccine
 BCG vaccine
 Type of vaccine - Live attenuated bacterial
 Number of doses - One
 Schedule - At or as soon as possible after birth
 Contraindications –
 Symptomatic HIV infection
 Adverse reactions –
 Local abscess, regional lymphadenitis;
 Rarely, distant spread to osteomyelitis,
disseminated disease
 BCG vaccine
 Special precautions –
 Correct intradermal administration is essential.
 A special syringe and needle is used for the administration
of BCG vaccine
 Dosage - 0.05ml
 Injection site - Outer upper right arm
 Injection type – Intra-dermal
 Storage - Store between 2°C–8°C. (vaccine
may be frozen for long-term storage but not the
diluents)
 Protection: variable, 90% only for disseminated
disease
 Safety and side effects- BCG

• Most children will have :

– Small raised lump at site of injection- disappear
within 30 min
– Red sore appear for two weeks.
– Leaving a scar
• Generalized infection: 5/1,000,000 in immuno-
compromised
Pneumococcal Conjugate Vaccine
(PCV)
 Pneumococcal Conjugate Vaccines (PCV)
 Streptococcus pneumoniae (pneumococcus) is the
most common cause of pneumonia, sepsis,
meningitis, and otitis media in young children
 The two available pneumococcal vaccines are
 Pneumococcal conjugate vaccine (PCV) and
 Pneumococcal polysaccharide vaccine (PPSV).
 PPSV contains 23 strains of S. pneumoniae.
 It does not provoke an immune response in children
younger than 2 years of age
 PPSV is given to children older than 2 years of age
who are at high risk for pneumococcal sepsis
 Pneumococcal Conjugate Vaccines (PCV)
 Conjugated to protein carrier to increase immunogenicity in
infants
 PCV presentations:
 7-valent: 4, 6B, 9V, 14, 18C, 19F, 23F
 10-valent: 7-valent + 1, 5, 7F
 Fully liquid in 1-dose and 2-dose vial without
preservative
 13-valent: 10-valent + 3, 6A, 19A
 Fully liquid in 1-dose vial
 13 strains of S. pneumoniae
PCV 10 - Synflorix™
• 2 dose vial • Administration at 6, 10
• No preservative and 14 weeks
• VVM on cap; VVM 30 • Intramuscular injection
• Storage temp: + 2° to in right upper outer
+ 8°C (Do not freeze!) thigh
• Pentavalent injection
first in left thigh
followed by PCV
injection right upper
thigh
 Pneumococcal vaccine reactions:
 Vaccine Reactions
 Mild reactions
 Local reactions
Swelling and tenderness at injection site are common (50%)
 Systemic reactions
Irritability and crying are very common; and transient fever >39˚C (5%).
 Severe reactions:
 Rare allergic reactions (dermatitis) which occur in 0.1%
 Contraindications:
 PCV should not be administered to children with a known severe
hypersensitivity reaction to a previous dose of the vaccine
 Infants with moderate or sever illness( temperature above 39 ºC) should
not be vaccinated until their condition improves
 Rotavirus Vaccine (Rotarix)
VIAL = ONE DOSE

Cardboard boxes of x50; Standard 1.5ml tube

Rotarix...
 Efficacy of Rotarix Vaccination
• 50% efficacy in preventing significant deaths
from diarrhea,

• 85% protection against severe rotavirus

gastroenteritis and

• 100% protection against most severe

dehydrating rotaviral gastroenteritis
episodes
 Absolute contraindications to Rotarix
 Hypersensitivity after previous administration of rotavirus
vaccines

 Severe immune deficiency

 Administration of RotarixTM should be postponed in subjects

suffering from diarrhea or vomiting and in need of rehydration
therapy

 Mild illness such as an upper respiratory tract infection or mild

diarrhea is not a contraindication
Conditions which are not contraindications to immunization
 Allergy or asthma (except if there is a known allergy to a specific
component of the vaccine mentioned above);

 Any minor illness, such as respiratory tract infections or diarrhoea with

temperature below 38.5°C;

 Family history of adverse events following immunization;

 Family history of convulsions, seizures, or fits;

 Treatment with antibiotics;

 Suspected HIV infection with no signs and symptoms of AIDS;

 Cont…
 Child being breastfed;
 Chronic illnesses such as chronic diseases of the heart, lung,
kidney, or liver
 Stable neurological conditions, such as cerebral palsy or Down’s
Syndrome;
 Premature or low-birth weight (vaccination should not be
postponed);
 Recent or imminent surgery;
 Malnutrition; and
 History of jaundice at birth.
 Absolute Contraindications to Immunization
There are only three contraindications to vaccination:
 Do not give BCG or yellow fever vaccine to a child with
symptomatic HIV infection or AIDS, but give the other
vaccines
 Do not give DPT-2 or -3 to a child who has had convulsions or
shock within 3 days of the most recent dose
 Do not give DPT to a child with recurrent convulsions or an
active disease of the central nervous system
 A child with diarrhoea who receive oral polio vaccine should
be given a dose, but this dose should not be counted in the
schedule
 Make a note on the child’s immunization record that it
coincided with diarrhoea, so that the health worker will give
the child an extra dose.
 Immunization schedule for children under one of age, Ethiopia

The EPI schedule focuses on provision of immunization services

against the EPI target diseases.
 Strategies to Boost immunization coverage

Vaccinate children who come for other illness.

Educate mother very well to reduce the no of
defaulters.
Mass Immunizations
 Used in regions or countries where the
immunization rate is low.
 Control an unexpected out-breaks.
Summary of common minor vaccine reactions
The Cold Chain

- -
 The Cold Chain
Cold chain is The system used for keeping &
distributing vaccines in good condition
 Vaccines are sensitive to:
Heat
Freezing
Light
 So vaccines must be kept at a correct temperature.
The system used for keeping (storing ) and
transporting (distributing) them in good condition
(correct temp) is called cold chain.
 Cold Chain
Manufacturer

Cold chain = system to ensure the potency, Central Cold room

the safety of vaccines during distribution
to the point of use.

Mobile strategy
Regions /
Zone/District

Out reach strategy

Health facility - -
 Major Cold Chain Equipments
1. Refrigerator
2. Cold boxes
3. Vaccine Carrier
4. Ice-Packs (0.6 lit & 0.4 lit)
5. Foam Pads
 Refrigerator in a HF should be able to hold

 A one-month supply of vaccines and diluents;

 Frozen ice-packs in the freezer compartment; bottles of water or

unfrozen ice packs in the refrigerator compartment(bottom)

 Half the total space in the refrigerator should be left empty to

allow air to circulate.
 Cold boxes
 An insulated container
 Used to collect vaccines during transportation,
refrigerator break
 Its cold life is from two to seven days
 Vaccine carriers

 Are insulated containers

 Its cold life is maximum for 48 hours with the
lid closed
 Used to transport vaccines and diluents to
outreach sites
 Foam pads
 Is a piece of soft foam that fits on top of the ice-packs in
a vaccine carrier

Serves as a temporary lid to keep unopened vaccines

 To hold, protect and keep cool opened vaccine vials
 Foam pad

During an immunization session, vials are protected

from heat for a longer period of time if they are inserted
in a foam pad.
 Ice-packs
 Are flat, square plastic bottles that are filled with water
and frozen
 Used to keep vaccines cool inside the vaccine carrier or
cold box
 Every health facility should have sets of ice-packs for
each of their cold boxes and vaccine carriers:
 Cold Chain Monitoring Equipment

Vaccine vial monitors

Vaccine cold chain monitor card
Thermometers
Freeze indicators (Freeze Watch, Freeze-tag)
Fridge Tag
 Temperature Monitoring Device

VVM
Vaccine Vial Monitors (VVMs)
How it works?
• VVMs show the heat
exposure only for the vial to
which it is attached
• The VVM on liquid vaccine
is on the label(but PCV),
while the VVM on
reconstituted vaccine is on
the caps (measles, BCG, YF,
some formulations of Hib)

70
How To Read A Vaccine Vial Monitor (VVM)
 Category of VVM
Category: No. days to end No. days to Time to end
(Vaccines) point at +37°C end point at point at +5°C
+25°C
VVM30
HIGH STABILITY 30 193 > 4 years

VVM14 14 90 > 3 years

MEDIUM STABILITY

VVM7 7 45 > 2 years

MODERATE STAB.

VVM2 2 NA* 225 days

LEAST STABILITY

*VVM reaction rates determined at two temperature points

72
Arrangement of vaccines
Vaccines in Inclined refrigerator
Correct conditions for storing EPI vaccines
 Sensitivity to Heat
• All vaccines are sensitive to heat to some extent, but
some are more sensitive than others.
• All freeze-dried vaccines becomes much more heat
sensitive after they are reconstituted.
Heat sensitivity

77
 Sensitivity to cold (Freezing)

Some vaccines are

sensitive to cold and
loss potency at
temperature below 0oc.
 Sensitivity to light
Some vaccines are also very sensitive to strong light
(Ultraviolet light) loss of potency.

BCG, Measles, (supplied in dark brown glass)

Actions to take when temperature is incorrect

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 Shake test and contingency plan
Whenever it is suspected that vaccine has been
frozen, at least one member of the duty staff
should know how to perform and interpret a
‘shake test’
Most importantly, all responsible staff should
know when and how to respond in the event of
equipment failure (Contingency plan)

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Shake Test

82
The shake test

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Transportation freeze sensitive vaccines; Prevention of
Exposure to Freezing
 Chill the water packs in the bottom of the refrigerator at list for
24 hours and use the chilled water pack.
 If you only have frozen ice packs – condition it
 Don’t use ice for the storage or transportation of freeze sensitive
vaccines
 Remember the vaccines are both heat and freeze sensitive.

11/25/2019
Cont…
Vaccine Transportation
• Freeze sensitive vaccines be transported in separate
cold boxes with conditioned ice packs/chilled water
from center to regions and zones
• Freeze sensitive vaccines be transported with
conditioned ice packs/chilled water from zonal to
Wereda, health facility and outreach level in 2-8 °C.
 After vaccines reach the health facility you must:

Keep them between 2ºC and 8ºC in your health

facility refrigerator.
Carry them to the immunization session in a
vaccine carrier with chilled water packs or
conditioned ice packs
Keep the vaccines cool using a foam pad in the
vaccine carrier while you immunize the children.

11/25/2019
 Vaccine Cooling

For storage the vaccines, the temperature should be stable within a

range between +2°C and +8°C

Do not store any vaccines, until the appliance has performing the
required stable operation temperature.

Perform a daily check and record the temperature when the unit is
in operation.
 VACCINES STORAGE

IMPORTANT

 Store your vaccines such that air can circulate

between the individual packages.

Keep the appliance tidy and dry inside.

 IMMUNIZATION COVERAGE
 Immunization coverage is the proportion of the target population
that has been vaccinated
 The difficulty of calculating and interpreting immunization
coverage rates often stems from problems related to estimating the
size of the target population
 Thus, in turn, are the result of inaccurate or outdated census counts,
population migrants, and unforeseen changes in birth rates or infant
mortality
 At the end of the month, health staff add the daily tallies of
vaccinations and converts them into a percentage called coverage.

11/25/2019 8:10 PM
SOURCE: EMDHS 2019
 Calculating annual coverage for DPT1, DPT2, DPT3 and
measles vaccines 2010
 Penta1: coverage:
Number of immunized by 12 months with Penta1 in 2011 * 100
Number of surviving infants < 12 mos. Of age in 2011
 Penta 3 coverage:
Number of immunized by 12 months with Penta 3 in 2011 * 100
Number of surviving infants < 12 mos. Of age in 2011
 Measles coverage :
No of immunized by 12 months with measles in 2011* 100
Number of surviving infants < 12 mos. Of age in 2011
 Estimating the number of surviving infants
• Total population : 5,500, 000
• Crude birth rate ( CBR): 30/1000
• Infant mortality rate (IMR): 80/1000
• Number of surviving infants= Total population * CBR *
( 1- IMR)
• = 5, 500,000 * 30/1000-* ( 1- 0.080)
• = 5,500, 000 * 0.03 * 0.920
= 151, 800

11/25/2019 8:10 PM
 If coverage rates indicates that people are not using
immunization services, health workers and their
supervisors need to find the causes and take
appropriate action
 Comparing coverage rates for different vaccines
sometimes points toward the likely problem as well as
possible solutions
 Eg, the data coverage shows BCG 80%, penta1 60%,
penta3 55% measles 55%
 What is the issue here? Why the decrease between BCG
and penta1 vaccines?
 What is the possible reasons?
 Vaccine Wastage
• Some causes of Vaccine wastage
– Poor reconstitution practices
– Cold chain failures
– Small session size
– Lack of knowledge how to read and interpret
VVMs
– Contamination
 Calculating Vaccine usage and wastage Rates

VUR = ___CI____ *100

Vaccine Usage Rate/VUR/
(BB+RDM)- EB
To Calculate usage rate /UR/ we Vaccine Wastage Rate/VWR/
should have the following
VWR= 100-VUR
1. Children Immunized= CI
2. Beginning Balance= BB
3. Received during the month= RDM

4. Ending Balance =EB

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 Calculating Vaccine usage and wastage……
Examples
Vaccine Usage Rate/VUR/ for PCV
CI = 200 BB= 100
RDM = 200 EB= 90
VUR = ___200____ *100
(100+200)- 90
VUR = 200 * 100= 95.2 %
210
Vaccine Wastage Rate
VUR= 95.2% (PCV)
Calculation
VWR= 100-95.2= 4.8%

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 Calculating Vaccine Wastage Factor
Indicate how much additional vaccine should be ordered in order to
allow for the given wastage rate Example:
Wastage rate: 30%
To Calculate Wastage
Factor/WF/ we should have WF = ___ 100_______
wastage rate (100 - Wastage rate)

“wasted rate” – is the number of doses WF = ___ 100_______

(in %) wasted
(100 - 30)
WF= 1.43
WF = ___ 100_______ 1.43 times more vaccine should be ordered so as
(100 - Wastage rate) to cover the estimated 30% wastage vaccine

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 Calculate coverage, Drop out rate and unimmunized children;

e.g. Children receiving Penta1, Penta2, Penta3 and Measles

are 288, 250, 192 and 160 respectively and 800 doses of
penta vaccine was used. If SI of the kebele is 320;
1. What is Penta1, Penta3 and Measles coverage?
2. What is Penta1 –penta3 and Penta1 – Measles drop out
rate?
3. What is unimmunized children with Penta3 and Measles?
 Calculate vaccination coverage, Drop out rate and unimmunized
children;

A. Penta1, Penta3 and Measles coverage (%)

%Penta1 = 288/320*100 = 90%

%Penta3 = 192/320*100 = 60%

%Measles =160/320*100 = 50%

Calculate vaccination coverage, Drop out rate and
unimmunized children;
B. Dropout Rate
Penta1-Penta3 dropout rate -
(Penta 1-Penta 3) x 100
Penta 1
(288-192)/288*100 = 33%

Penta1-Measles dropout rate -

(Penta 1-Measles) x 100
Penta1
(288-160)/288*100 = 44%
 Calculate vaccination coverage, Drop out rate and
unimmunized children;
C. Un-immunized children
 No. of unimmunized children with DPT- HepB-Hib3 =
Surviving infants-No. of children vaccinated with DPT-
HepB-Hib3
 320 – 192 = 128
 No. of unimmunized children with measles = Surviving
infants - No. of children vaccinated with measles
 320 – 160 = 160
 EPI TARGETED DISEASES
(Vaccine Preventable Disease/VPD)
 TARGETED DISEASES FOR EPI

LEARNING OBJECTIVES
At the end of this lesson the students will be able to:
 Describe vaccine preventable diseases

 Prevention methods of these diseases

 Goals for eradication or elimination of some EPI target diseases covered

 Discuss the definition ,c/m and the management of EPI target disease.

 Recognize the Case definitions

 Introduction
 Globally, each year 130 million children are born, 91 million of
which are in the developing countries
 However, around 10 million children under the age of five years
die every year
 Over 27 million infants in the world do not get full routine
immunization
 About 41% of these were in Sub-Saharan Africa and 34% in
South Asia.
 Introduction

 Immunization being one of the most cost effective

public health interventions which is directly or
indirectly responsible to prevent the bulk of mortalities
in under-fives

 WHO estimates 29% of deaths among children birth to

59 months of age are vaccine-preventable
 Diseases for which vaccination is routinely recommended
1. Tetanus
11. Meningococcal disease
2. Diphtheria
12. Mumps
3. Pertusis
13. Rubella
4. Polio
5. Measles 14. Varicella (chickenpox)
6. Pneumococcal diseases 15. Hepatitis A
7. TB 16. Herpes zoster (shingles)
8. Hepatitis B 17. Human papillomavirus
9. Haemophilus influenzae type b (HPV)
(Hib) 18. Influenza
10. Rota
1. Tetanus
 It is an acute, spastic paralytic neurotoxin illness.
 Greek words -“tetanos and teinein”, meaning rigid and
stretched, which describe the condition of the muscles
affected by the toxin, tetano spasmin,
 Tetanus was first described in Egypt over 3000 years ago
(Edwin Smith Papyrus)
 Causative agent: clostridium tetani
 It produces a powerful toxin that affects the nervous system
 Incubation period : typically is 2–14 days, but it may be
as long as months after the injury.
 Epidemiology

 Potent neurotoxin produced during the growth of

bacteria in dead tissue such as the umbilical cord.
 The disease is common and serious in newborns
 Most babies who get the disease die
 Neonatal tetanus is common in rural areas where the
deliveries are at home
 Epidemiology

 Tetanus spores are found throughout the

environment, usually in soil, dust, and animal waste.

 Tetanus is acquired through contact with the

environment
The usual locations for the bacteria to enter the body

 Contaminated wounds: major or minor

 Deep puncture wounds, crush wounds(such as those caused
by rusty nails, splinters, or insect bites.
 May follow elective surgery, burns,, otitis media , dental
infection, animal bites, abortion,IV drug access sites are also
potential entryways for the bacteria.
 Mode of spread
 Not transmitted from person to person
 A person becomes infected when dirt enters a wound
or cut
 Grows in deep cut wounds
 Women have additional risk due to child
birth/abortion
 A new baby may get infected when the umbilical cord
is contaminated with dirty hands, knives, razor,
application of substances on stamp ( e.g. cow dung,
soil), etc.
 Clinical manifestations
 Muscular stiffness of the jaw(‘trismus’) is the first symptom
 Stiffness of the neck, abdominal muscles, sweating,
headache, fever, etc.
 Seizure
 Sardonic smile/risus sardonicus
 Opisthotonos
 Airway obstruction and asphyxiation - laryngeal and
respiratory muscle spasm
Clinical manifestations

Trismus

• In generalized tetanus, the

presenting symptom in
about half of cases is
trismus (masseter muscle
spasm, or lockjaw
 Clinical manifestations

• Risus sardonicus
• Sardonic smile of
tetanus (risus sardonicus)
results from intractable
spasms of facial and
buccal muscles
 Clinical manifestations
Opisthotonos
• Opisthotonos is an equilibrium
position that results from
unrelenting total contraction of
opposing muscles, all of which
display the typical board like
rigidity of tetanus.
• The smallest disturbance by sight,
sound, or touch may trigger a
tetanic spasm
 Neonatal tetanus

• Neonatal tetanus (tetanus neonatorum), When a

newborn is infected by tetanus during the first 28 days of
life.
• When a woman delivers her baby in unsanitary
conditions, a newborn baby may become infected.
• Newborn babies are normal at birth but stop sucking
between 3 – 28 days
 Neonatal tetanus

 Stop sucking and bodies become stiff and death often

occurs

 Typically, an apparently healthy baby will stop

sucking after a couple of days due to lockjaw,
developing stiffness, arching of the body and
convulsions.
 Case definition

• Suspected case: Any neonatal death between three

and 28 days of age in which the cause of death is
unknown; any neonate reported as having suffered
from neonatal tetanus between three and 28 days of
age and not immunized
• Confirmed case: Any neonate with normal ability to
suck and cry during the first 2 days of life and-cannot
suck normally between 3 and 28 days of age, and
becomes stiff and/ or has spasms (i.e. jerking of the
muscles)
 Maternal Tetanus
• Maternal tetanus is When tetanus strikes a woman during
pregnancy or within 42 days following the delivery
• Commonly occurs when a woman delivers her baby in
unsanitary conditions, for example, on soil or a dirt floor
or during unsafe abortion practices.
• It is most prevalent where poverty, lack of education and
poor living conditions exist and where babies are delivered
by untrained attendants.
 Diagnosis

• Diagnosis is based on clinical findings and the immunization

history

 Nonimmunized or partially immunized patient.

 History of skin wound.

 Spasms of jaw muscles (trismus).

 Stiffness of neck, back, and abdominal muscles, with

hyperirritability and hyperreflexia.

 Episodic, generalized muscle contractions.

 Management

 General measures: IV fluid, O2, quite dark room,

 Antibiotics: to eradicate the source of tetanus toxin
 Antitoxin (TIG or TAT): to neutralizes circulating toxin
 Control of muscle spasms: Diazepam
 Respiratory care: gentle suctioning, tracheostomy
 Control of muscle spasms
 The patient should be admitted to a quiet, darkened room
where all possible auditory, visual, tactile, or other
stimuli are minimized.
 Diazepam controls spasms better and safer than other
options (The initial dose of 0.1–0.2mg/kg every 3–6 hr
given intravenously is subsequently titrated to control the
tetanic spasms);
 Control of muscle spasms

 Other drugs which can be used in combination with

diazepam include:
Chlorpromazine (1-5mg/kg/dose q8hr)
Phenobarbitone (loading dose 20mg/kg, then
2.5mg/kg/dose q12hr, increased to max
5mg/kg/dose q12hr)
 Antitoxin therapy
 Tetanus immunoglobulin ( TIG)/human tetanus
immunoglobulin should be given intramuscularly in a
single dose (3,000 to 6,000 IU)
 If human serum immunoglobulin is unavailable,
tetanus antitoxin ( TAT) should be given, assuming
sensitivity reactions to horse serum are negative
 The antitoxin is given intravenously and
intramuscularly (half of the dose via each route)-
NEONATE
 Antimicrobial therapy

• Metronidazole (30 mg/kg/day, given at six hour

intervals; maximum 4 g/day) or
• Parenteral penicillin G (100,000 U/kg/day) is an
alternative.
• Treatment for 10 to 14 days is recommended
Wound treatment
• After the patient has been sedated and received
antitoxin, the - Wound should be thoroughly cleansed
and debrided
 Supportive treatment
 Oxygen should be available.
 During early stages, oral feeding should be
avoided because of the danger of aspiration
 A continuous intra- venous infusion can
provide fluid
 Respiratory care

 Meticulous nursing care is imperative

 Gentle suctioning of or pharyngeal suctions is done
although tracheotomy need not be considered a
routine procedure, it should be done prior to the
development of severe asphyxia
 Prognosis
 Mortality is about 90%
 Bad prognostic signs include
I. Onset in the first week of life
II. Interval between lock jaw ( trismus) and onset of
muscle spasms less than 48 hrs
III. High fever
IV. Tachycardia
 An attack of tetanus does not confer immunity so
active immunization following recovery is a must
 Prevention
 Universal immunizations of pregnant mothers between 16 and 36
weeks of pregnancy with 2 doses of tetanus toxoid can prevent
neonatal tetanus
 The second dose should be given at least 2 weeks before the
expected date of delivery
 Immunization of infants with three doses of pentavalent
 Immunizing women of child bearing age women
 Those who recover from infection don’t develop natural
immunity and therefore, should be immunized
• Wound Management
 Tetanus toxoid (TAT) 3,000-5,000 U may be given
intramuscularly after testing for hypersensitivity.
 Prevention
 Additionally, sterile delivery practices need to be
Emphasized such as
 Conducting delivery in a clean room
 Sterile gloves to be worn while conducting delivery
 Cutting the umbilical cord with sterile equipment
 Sterile cord ties are to be used to the cord
 Not to apply anything over the umblical stump
 These are also known as the following 5 cleans: clean
surface, clean hands, clean blade, clean cord and
clean cord tie
 2. DIPHTHERIA
 It is an acute bacterial infection mainly disease of the
tonsils, pharynx, larynx & nose.
• Diphtheria is Greek for leather
• Causative Agent: Corynebacterium species
 Typically Corynebacterium diphtheriae
 Rarely toxigenic strains of Corynebacterium ulcerans.
Both toxigenic and nontoxigenic C. diphtheriae cause
skin and mucosal infection, and rarely can cause focal
infection after bacteremia.
 Case definition
WHO-Recommended Case Definition:
Diphtheria
 Clinical description: An illness characterized by
laryngitis or pharyngitis or tonsillitis and the
presence of an adherent membrane of the tonsils,
pharynx, and/or nose
 Laboratory criteria for diagnosis: Isolation of
Corynebacterium diphtheriae from a clinical
specimen
Source: WHO, 1998
 Mode of spread

• Person to person through close physical and

respiratory contact
• Droplets and secretions from the nose, throat, and
eyes of an infected person
• Skin diphtheria is spread through direct contact with
diphtheria ulcers or through clothing and other
articles that have been contaminated with fluid from
the ulcers.
• Diphtheria can also be transmitted through
unpasteurized milk products.
 Clinical manifestations

• The manifestations of C. diphtheriae infection

influenced by :
 Anatomic site of infection
 Immune status of the host, and
 Production and systemic distribution of toxin
• Incubation period - Average 2–4 days
Respiratory tract diphtheria
TONSILLAR AND PHARYNGEAL DIPHTHERIA
• The primary focus of infection is the tonsils or pharynx
(94%)
 Sore throat is the universal early symptom:
• Within the 1st few days of respiratory tract infection
(usually in the pharynx) a gray-brown, leather-like
adherent pseudomembrane
 Removal is difficult and reveals a bleeding edematous
submucosa
 Malaise & mild fever
 Paralysis of the palate and hypopharynx
 A bull-neck appearance
Diphtheria: This is a picture of
the throat of a child who has
diphtheria. Notice the thick
gray coating over the back of
the throat. If not treated, this
child could die from
suffocation.
Diphtheria: This child has bullneck diphtheria.
 Nose and larynx

 Next 2 most common sites

 Common among infants
 Local signs and symptoms of inflammation develop
 Infection of the anterior nares, causes purulent,
erosive rhinitis with membrane formation.
 Shallow ulceration of the external nares and upper lip
Diagnosis :- C/m
Throat swab for culture & smear
 Management

• Antitoxin : Diphtheria antitoxin

• Antibiotics: Erythromycin is marginally superior to
penicillin for eradication of nasopharyngeal carriage.
• 40–50 mg/kg/day QID PO or IV
• Fluid diet
• Bed rest usually for ≥2 wk
• I.V fluid
• Cutaneous wounds are cleaned thoroughly
• Cases are isolated
 COMPLICATIONS.
• Respiratory tract obstruction
• Cardiomyopathy, and/or demyelination of nerves.( Most
common )
• Kidney tubule necrosis
• Thrombocytopenia
Prevention
• Vaccination
• Droplet precautions and contact precautions.
• Mgt of carrier : contact with diphtheria patients should
also be given antibiotics
• Diphtheria toxiod can also be used to immunize adults
during out break
 3.Pertussis (whooping cough)

 Pertusis or Whooping cough is a disease of the respiratory

tract caused by bacteria
 Many children that contract pertusis have coughing spells
that lasts for six weeks
 The disease is most dangerous in infants
 Is an acute contagious respiratory tract infection involving
the mucous membrane lining the air passage .
ETIOLOGY
 Bordetella pertussis is the sole cause of epidemic pertussis
 Case definition
• WHO-Recommended Case Definition:

Pertussis
 Clinical description: A person with a cough lasting at least two weeks with

at least one of the following: Fits of coughing ,Intake of breath accompanied

by a whooping sound,Vomiting immediately after coughing and without any

other apparent cause

 Laboratory criteria for diagnosis: Isolation of Bordetella pertussis or

detection of genomic sequences by polymerase chain reaction (PCR).

Source: WHO, 1998

 Mode of spread
 Spreads very easily from child to child by droplets
produced by coughing or sneezing, close contact

 In many countries the disease occurs in regular epidemic

cycles of three to five years

 The disease spreads easily among susceptible people who

live in crowded conditions.
 Clinical manifestation

• Incubation period is 5 -10 days

• Classically, pertussis is a prolonged disease, divided
into
Catarrhal : 1-2 weeks
Paroxysmal ( Cough stage): 2-6 weeks
Convalescent stages: weeks to months
I. The catarrhal stage (1–2 wk)
 Begins insidiously after an incubation period
ranging from 3–12 days .
 Characterized by the insidious onset of coryza
(runny nose), sneezing, low-grade fever, and a
mild, occasional cough, similar to the common
cold
The cough gradually becomes more severe,
and after 1–2 weeks
 II. Paroxysmal stage (2–6 wk)

 Coughing marks the onset of the stage

 Cough begins as a dry, intermittent, irritative hack and evolves
into the inexorable paroxysms that are the hallmark of pertussis.
• Beginning a machine-gun burst of uninterrupted coughs, chin
and chest held forward
• Tongue protruding, eyes bulging and watering, face purple, until
coughing ceases and a loud whoop follows as inspired air
traverses the still partially closed airway.
III. Convalescent stage
 Exhaustion is universal.
 At the peak of the paroxysmal stage, patients may
have more than 1 episode hourly
 As the paroxysmal stage fades into the convalescent
stage, the number, severity, and duration of episodes
diminish.


Pertussis: This child has
pertussis (whooping cough).
He has severe coughing
spasms, which are often
followed by a “whooping”
sound. It is difficult for him to
stop coughing and catch his
breath.
Pertussis: This child has broken blood vessels in his
eyes and bruising on his face because of coughing
from pertussis.
 Complication
 The most common complication, and the cause
of most pertussis-related deaths, is secondary
bacterial pneumonia
 Young infants are at highest risk for acquiring
pertussis
 Management

• Goals of therapy are to limit the number of paroxysms

• Antibiotics. Macrolides are preferred agents
• An antimicrobial agent is always given when pertussis is
suspected or confirmed primarily to limit the spread of
infection and secondarily for possible clinical benefit.
• Provide mental & physical rest
• Provide warm humidity.
• Sedative
• Good nutrition
 PREVENTION.

• Universal immunization of children with pertussis

vaccine, beginning in infancy with periodic
reinforcing doses, is central to the control of pertussis
4. Poliomyelitis
• Poliomyelitis, literally meaning “gray spinal cord
inflammation
• Causative agent:poliovirus (Genus Entero Virus)
• Type-1, 2, & 3 ;- all types can cause paralysis
• Type -1 most frequently for epidemics
Transmission
• Feco-oral
• It is contagious: usually spread from person to person.
• Incubation period: ranges from 6 to 20 days
Polio: This child has a
severely deformed leg
caused by polio.
 Case definition
• WHO-Recommended Case Definition:

• Clinical case definition: Any child under fifteen years

of age with acute flaccid paralysis (AFP)/floppiness of
one or more of the extremities or any person with
paralytic illness at any age when polio is suspected.

Source: WHO, 1998

 Clinical manifestation
 Acute stage: Generally lasts 7 to 10 days.
 Many include fever, pharyngitis, headache, anorexia,
nausea, and vomiting.
 Illness may progress to aseptic meningitis and
menigoencephalitis in 1% to 4% of patients.
 These patients develop a higher fever & sever
headache with stiffness of the neck and back.
 Clinical manifestation
 Paralytic disease occurs 0.1% to 1% of those who become
infected with the polio virus.
• Flaccid paralysis of muscles
• Paralytic is asymmetrical leg, arms, trunk in that
order.
 Paralysis occurs twice as often in the lower extremity as in
upper extremity
 Weakness is clinically detectable only when more than
60% of the nerve cells supplying the muscle have been
destroyed.
 Paralysis of the respiratory muscles or from cardiac arrest
if the neurons in the medulla oblongata are destroyed.
DX
• Isolation of the virus from stool or throat swab
 Management
• No specific Rx
• Close monitoring of respiratory and cardiovascular
functioning is essential during the acute stage of
poliomyelitis along with fever control and pain
relievers for muscle spasms.
• Mechanical ventilation, respiratory therapy may be
needed depending of the severity of patients
• Bed rest
• Nutrition
• Change position frequently
• Physiotherapy
• Avoid urine retention
Prevention

A. Immunization against polio: The two vaccines

B. Isolation of cases

C. proper disposal of excreta

D. Active surveillance
 5. MEASLES
 Measles is one of the communicable diseases still causing
preventable mortality and morbidity in the country
 Is a highly infectious disease caused by a virus
(paramyxovirus).
 Kills more children than any other vaccine preventable
diseases
 Tends to occur in epidemic form causing more
complications among malnourished children

• ETIOLOGY:Measles virus
• Incubation period - 7–18 days

RISK FACTORS

 Severe malnutrition

 Low serum retinol levels

 Immuno compromised persons are associated with

increased morbidity and mortality
 Mode of spread
 Measles is extremely infectious
 Airborne droplets
 Contact with nose and throat secretions
 Cases can infect others for several days before and
after they develop symptoms
 Spreads easily in over crowded areas (schools,
military barracks, health facilities, etc)
 Clinical manifestations

1. Prodromal phase
2. Exanthemataus phase
3. Complete recovery
 Clinical manifestations
1. Prodromal phase
– Follows an incubation period of 10-12 days
– Lasts 3-5 days
– Characterized by:
• Fever, cough, coryza, conjuctivitis
• Malaise, myalgia, photo-phobia and peri-orbital
edema
• Koplik spot appear as 1 to 2 mm grayish white
spots (discrete), is the pathognomonic sign of
measles and appears 1 to 4 days prior to the onset
of the rash
 Clinical manifestations
 Koplik spots appear & disappear rapidly, usually
with in 12-18 hours.
 Koplik spots have been reported in 50–70% of
measles cases but probably occur in the great
majority
Clinical manifestations
2. Exanthemataus phase
– Characterized by:
• High grade fever
• Rash – begins at the hair line posteriorly and
spreads caudally over the next 3 days with
resolution of prodromal symptoms
• Rash lasts 6 days and fades from head
downwards (desquamations may be present)
 Clinical manifestations

3. Complete recovery – usually within 7-10

days from the onset of rash
 Case definition
 Clinical case definition: any person in whom a clinician
suspects measles infection or any person with = fever
+maculopapular rash + one ofthe following:
• Cough
• Coryza (runny nose) The 3 c’s
• Conjunctivitis
 At least a fourfold increase in antibody titer,
or isolation of measles virus, or the presence of
measles – specific IgM antibodies
 Complication
 Otitis media -the most common complication
 Hemorrhagic measles-into GIT, mms,and CNS
 Thrombocytopenia
 Myocarditis
 Croup ,tracheitis, and bronchiolitis are common
complications in infants and toddlers
 Reactivation of underlying mycobacterium tuberculosis
 Malnutrition
 Pneumonia
 Diarrhea
 Corneal scaring causing blindness
 Management

• Hydration

• Antipyretics

• Antibiotics (for secondary bacterial infection)

• Vitamin A (therapeutic dose): 1st ,2nd, and 14 days

• Admission for those with severe complications

 Management
 Vitamin A in Measles Case Management
 Measles seriously depletes vitamin A in children, making them
more susceptible to complications.
 For example, until recently, half of the blindness in children in
one East African country resulted from corneal scarring
following measles infection.
 Vitamin A supplementation for these children would have
prevented this outcome.
 Strategies For Reduce Measles Morbidity And
Mortality Reduction

• Routine immunization of > 90% of children aged 9 to

11 months
• Provide a second opportunity for measles vaccination
• Case-based measles surveillance
• Improved case management including provision of
vitamin A.
Since 2002, Ethiopia adopted these regional goals and
strategies and has been taking important steps to
control and ultimately to eliminate measles by 2020.
 Prevention
• Isolation – for infectious period
• Routine immunization
• Immunization campaigns
 6. Pneumococcal Diseases
• A group of diseases caused by Pneumococcus
• Main pneumococcal diseases
– Severe forms: Pneumonia, Meningitis &
Bacteremia
– Less severe forms: Otitis media, Sinusitis,
Bronchitis,
– Less common: arthritis, osteomyelitis, peritonitis,
sinusitis
 Streptococcus Pneumoniae (Sp)
(Pneumococcus)
• SP is an exclusively human pathogen
that colonizes the nasopharynx of
normal hosts.
• The noses and throats of up to 70% of
healthy people contain pneumococcus
at any given time.

Spreads mainly by coughing or

sneezing with air droplets
 Distribution of Pneumococcal Deaths by
Syndrome

Other Invasive
Meningitis
Pneumococcal Diseases 4% 7%

89% Pneumonia
 Other causes of Pneumonia and Meningitis
 Pneumococcal infection is the leading cause of
pneumonia death
 Pneumococcus is not the only cause of pneumonia
and meningitis among children
 Hib (Haemophilus influenzae type b) is another
important cause of meningitis and pneumonia
 Other causes of pneumonia among children may be:
viruses (Respiratory Syncitial Virus, influenza virus)
or bacteria (S. aureus, or Klebsiella pneumoniae)
 Pneumonia: Leading Child Killer
Pneumococcal disease
• Pneumococcus is the leading cause of child pneumonia
deaths (~40%)
• About 1 in 10 child deaths is due to pneumococcal
disease
• Ethiopia ranks 3rd among the top 10 countries with the
largest number of pneumococcal deaths
 Strategies For Preventing And Treating
Pneumonia
• Protection
– Breastfeeding promotion
– Hand washing promotion
– Zinc supplementation
– Adequate nutrition
– Reduce indoor air pollution
• Prevention
– Vaccination
• New: Pneumococcal, Hib
• Routine: Measles, pertussis
– HIV prevention
• Treatment
– Improve health care seeking behaviour
– Community case management ( ICCM)
– Health facility case management ( IMNCI)
– Antibiotics
 Key Points To Remember
• One bacteria, many diseases- Pneumococcus can cause:
– Pneumonia
– Meningitis
– Bacteraemia
– Other: middle ear infection (otitis media), sinusitis & bronchitis.
• One disease, many causes - Pneumonia is caused by:
– Bacteria e.g. Streptococcus, Staphylococcus, Haemophilus
– Viruses e.g. RSV, influenza
• One vaccine, many diseases – Pneumococcal vaccines will prevent
– Pneumonia
– Meningitis
– Bacteraemia
– Other: middle ear infection (otitis media), sinusitis & bronchitis
 7. Hepatitis B

• Hepatitis B is a viral infection of the liver.

• Acute infection either resolves or progresses to chronic
infection, which may lead to cirrhosis or liver cancer
several decades later
• When it resolves, patients develop lifelong immunity.
• Caused by a virus that affects the liver
• Adults who get hepatitis B usually recover
• Infected infants and adolescents become chronic carrier
Mode of transmission
– Unsafe injection or needle stick
– Mother to child during birth
– To children during contacts through cuts, scratches, bites
etc.
– Sexual intercourse
Sign and symptoms
– IP: 6 weeks mostly ( but can be up to 6 months)
– Jaundice, bleeding symptoms with Hepatic failure &
death
– Complications
• Chronic hepatitis, cirrhosis, liver cancer
Prevention
Vaccine: Hep B, Pentavalent Vaccine
 Hepatitis B Vaccine
Management of an infant born to Hep B positive mother:
• Infants born to HBsAg-positive mothers should be immunized
within 12 hours after birth with hepatitis B vaccine and hepatitis B
immune globulin (HBIg) at separate sites, regardless of gestational
age or birth weight;
• The birth dose in such infants should not be counted in the series
of three hepatitis B vaccines, and the full three-dose series should
be administered starting at age of 6 wks
 Summary : VPD
Disease Agent reservoir Spread Duration of Risk factors for
Immunity by infection in
infection Developing countries
Diphthe Toxin Humans Close Usually life long Crowding
ria producing respirato
bacterium ry
corynebac contact
terium or
diphteria contact
with
infectious
material
Mening Hempphil Humans Close Usually life long Not being
itis and us respirato breastfeeding
pneumo influenza ry Crowing
nia type b, contact
caused bacterium
by Hib
 Summary : VPD
Meas Virus Human Close respiratory contact Lifelong Crowding
les s and aerosolized droplets

Pert Bordetell humans Close reparatory contact Usually Crowding

usis a pertuis lifelong

TB M. Human Airborn droplets Not known; crowding,

Bacterum s reactivation immune
Tb of old deficiency ,
infection is malnutrition
common
 Summary : VPD
Hepa Virus Humans Mother to Newborn, child If infection Infected mother
titis to child, blood, sexual resolves, life Unsafe injections
B Transmission at birth or long Unsafe blood
early childhood is immunity; transfusions
dominant otherwise Multiple sexual
life long partners
carrier
status

Polio Poliomylit humans Fecal- oral Life long Poor

is virus – Close repiratory contact type specific environmental
serotypes immunity hygiene
1, 2, 3)

Tetan Toxin Soil, Spores enter body None Home delivery

us producing animal, Umblical cord of Unsafe birth
bacterium intestine newborns Exposure to
/c. Tetani) animal feces,
untreated wounds
Integrated Management of newborn & Childhood
Illnesses (IMNCI)

Muhammed D.
(BSc, in Paediatrics and Child Health
Nursing)
Email: ouseid867@gmail.com
 Objectives
At the end of this session, students will be able to:
 Describe the advantage of IMNCI
 Assess, classify and treatment of common childhood
illness
 Recognize general danger signs
 Introduction to IMNCI
 Children who come to health institutions are often
suffering from more than one condition
 Making it impossible to give a single diagnosis.
 IMNCI is an integrated strategy and is based upon the
combined treatment of the major childhood illnesses
 The IMNCI guidelines are designed for the management
of sick children from birth up to five years old
 IMNCI
• What is it?
A strategy to provide comprehensive &
continuous care to a sick child

• Purpose • To improve quality of care

• To reduce mortality among under
five children

• Approach? • Targets major killer diseases

• Use simple and effective tools

• Commitment
• Prerequisites? • Skilled and motivated personnel
• Priority diseases selected
 IMNCI ...

 More than 70% of these child deaths are due to five

diseases namely
Pneumonia
Diarrhoea
Malaria
Measles
Malnutrition
 IMNCI...

 These diseases are also the reasons for seeking care for at
least three out of four children who come to health
facilities.
 As children usually present with more than one of these
conditions, it was recognised that there was a need for an
integrated approach in order to manage the child in a
holistic manner
 This lead to the development of the IMNCI strategy
 IMNCI...
• IMNCI is an integrated approach to child health that
focuses on the wellbeing of the whole child
• IMNCI aims to reduce death, illness and disability,
and to promote improved growth and development
among children under five years of age
• IMNCI includes both preventive and curative
elements that are implemented by families and
communities as well as by health facilities
 IMNCI....

 IMNCI strategy includes three main components:

1. Improving case management skills of healthcare staff

2. Improving the health systems

3. Improving family and community health practices

 IMNCI...

 In health facilities, the IMNCI strategy:

 Promotes the accurate identification of childhood illnesses

in out-patient settings

 Ensures appropriate combined treatment of all major

illnesses

 Strengthens the counselling of caregivers

 Speeds up the referral of severely ill children.

 IMNCI...

 In the home setting, IMNCI:

 Promotes appropriate care-seeking behaviours
 Helps to improve nutrition and preventative care
 Supports the correct implementation of prescribed
care
 IMNCI...

 The IMNCI case management process is presented on

two different sets of charts:

Managing sick young infants aged from birth up to

two months and

Managing sick children aged from two months up

to five years
 IMNCI...

 First decide which chart to use depending on the age of

the child
 Up to five years means the child has not yet had his or
her fifth birthday
 If the child is not yet two months of age, the child is
considered a young infant
 A child who is two months old would be in the group
two months up to five years, not in the group birth up
to two months
 The IMNCI case management process

 The charts describe the following steps:

 Assess the young infant or child
 Classify the illness
 Identify treatment
 Treat the young infant or the child
 Counsel the mother
 Give follow-up care
 Assess---Classify---Treatment----Counsel + follow up
 Assessment

 Assess a child by checking first for general danger

signs (or possible bacterial infection in a young
infant)
 Asking questions about common conditions
 Assessment ( 2-59 months)
 Look for general danger signs
 Check for cough or difficult breathing
 Check for diarrhoea
 Check for fever
 Check for ear problem
 Check for acute malnutrition
 Check for Anemia
 Check for HIV infection
 Assessment ( birth – 2 months)
 Check for very severe diseases and local bacterial
infection
 Check for jaundice
 Check for diarrhoea
 Check for HIV infection
 Check for feeding problem or low weight for age
 Classification
 Classify a child’s illnesses using a colour-coded
classification system

 Because many children have more than one condition,

each illness is classified according to whether it requires:

◦ Urgent pre-referral treatment and referral (pink), or

◦ Specific medical treatment and advice (yellow), or

◦ Simple advice on home management (green).

 Classification
• Pink row needs urgent attention and referral or
admission for inpatient care.
• This is a severe classification
• A classification in a yellow row means that the young
infant or the child needs an appropriate antibiotic or
other treatment.
• The treatment includes teaching the mother how to
give the oral drugs or to treat local infections at home.
 Classification
• The HCPs advises her about caring for the
young infant or child at home and when she
should return
• A classification in a green row means he
young infant or child does not need specific
medical treatment such as antibiotics.
 Identify treatment
 After classifying all conditions, identify specific
treatments for the child
 If a child requires urgent referral, give essential
treatment before the patient is transferred
 If a child needs treatment at home, develop an
integrated treatment plan for the child and give the
first dose of drugs in the clinic
 If a child should be immunized, give immunizations
 Follow-up care

 When a child is brought back to the health institution

as requested, give follow-up care and
 If necessary, reassess the child for new problems
 If this is the child’s first visit for this episode of an
illness or problem, then this is an initial visit
 If the child was seen a few days before for the same
illness, this is a follow-up visit
 A follow-up visit has a different purpose from an
initial visit
 General danger signs (GDS)
 Since IMNCI takes a holistic approach to assessing,
classifying and treating childhood illnesses;
 It is important to look for general danger signs as well
as symptoms and signs of specific childhood illnesses
 The general danger signs are signs of serious illness
that are seen in children aged two months up to five
years and
 Will need immediate action/urgent attention to save
the life of the child
 General danger signs (GDS)
• There are five general danger signs
1. Unable to drink or breastfeed
2. Vomit every thing
3. Had convulsing/ history of convulsions
during the current illness
4. Lethargic or unconsciousness
5. Convulsing now
General danger signs (GDS)
 General danger signs (GDS)

 A child with a general danger sign has a serious

problem

 Most children with a general danger sign need urgent

referral to hospital

 They may need life saving treatment with injectable

antibiotics, oxygen or other treatments that may not
be available in the health post
 ASK: Is The Child Able To Drink Or Breastfeed?

 A child has the sign ‘not able to drink or breastfeed’ if

the child is not able to suck or swallow when offered a
drink or breast milk
 When you ask the mother if the child is able to drink,
make sure that she understands the question
 If the mother replies that the child is not able to drink
or breastfeed, ask her to describe what happens when
she offers the child something to drink.
 For example, is the child able to take fluid into his
mouth and swallow it?
 Cont...
 If you are not sure about the mother’s answer, ask her
to offer the child breast milk or a drink of clean water
 Look to see if the child is swallowing the breast milk
or water.
 A child who is breastfed may have difficulty sucking
when his nose is blocked
 If the child’s nose is blocked, clear it
 If the child can breastfeed after the nose is cleared,
the child does not have the danger sign, ‘not able to
drink or breastfeed’.
 ASK: Does The Child Vomit Every Thing?

 A child who is not able to hold anything down at all

has the sign ‘vomits everything’.
 A child who vomits everything will not be able to
hold down food, fluids or oral drugs
 A child who vomits several times but can hold
down some fluids does not have this general danger
sign
 When you ask the question, use words the mother
understands
 Give her time to answer
 Cont...
 If the mother is not sure if the child is vomiting
everything, help her to make her answer clear.

 For example, ask the mother how often the child vomits

 Also ask if each time the child swallows food or fluids,

does the child vomit? If you are not sure of the mother’s
answers, ask her to offer the child a drink. See if the child
vomits
 Ask: Has The Child Had Convulsions?
• During a convulsion, the child’s arms and legs stiffen
because the muscles are contracting or if the child has
repeated abnormal movements
• The child may lose consciousness or not be able to
respond to spoken directions
• Ask the mother if the child has had convulsions during
this current illness.
• Use words the mother understands.
• For example, the mother may know convulsions as ‘fits’
or ‘spasms’. See also if the child is convulsing now.
 Look If The Child Is Lethargic Or Unconscious

 A lethargic child is not awake and alert

 The child is drowsy and does not show interest in what is

happening around him

 Often the lethargic child does not look at his mother or watch
your face when you talk

 The child may stare blankly and appear not to notice what is
going on around him
 Cont...
 An unconscious child cannot be wakened

 He does not respond when he is touched, shaken or spoken

 Ask the mother if the child seems unusually sleepy or if she

cannot wake the child

 Look to see if the child wakens when the mother talks or

shakes the child or when you clap your hands
 Cont...
 However, if the child is sleeping and has cough or
signs of difficult breathing, you must count the number
of breaths first before you try to wake the child
because it is easier to count the exact breathing rate
when the child is calm
 When you have completed the above steps, you should
record what you have found on the sick child case
recording form
 You must circle any general danger signs that are
found, process for general danger signs in practice.
Yes__ No___
Cont...
SICK CHILD AGE 2 MONTHS UP TO 5 YEARS
Does The Child Have Cough Or Difficult Breathing?
Does The Child Have Diarrhea
 Plan A: Treat Diarrhoea At Home
• Counsel the mother on the 4 Rules of Home Treatment:
• Give Extra Fluids, Give Zinc Supplements, Continue
Feeding, When to Return
• GIVE EXTRA FLUIDS (as much as the child will take)
• Tell the mother:
• Breastfeed frequently and for longer at each feed.
• If the child is exclusively breastfed, give ORS in addition to
breast milk.
• If the child is not exclusively breastfed, give one or more of the
following: ORS
• Solution, food-based fluids (such as soup, rice water and
yoghurt drinks), or clean water.
 Cont…
• It is especially important to give ORS at home when:
• The child has been treated with plan B or plan C during this
visit.
• The child cannot return to a clinic if the diarrhoea gets worse.
• Teach the mother how to mix and give ors.
• Give the mother 2 packets of ors to use at home.
• Show the mother how much fluid to give in addition to the
usual fluid in-take 10 ml/kg
• Up to 2 years 50 to 100 ml after each loose stool
• 2 years or more 100 to 200 ml after each loose stool
 Cont…
Give zinc supplements :
• Tell the mother how much zinc to give:
– 0-6 months- 1/2 tablet for 10 days
– 6 months or more - 1 tablet for 10 days
• Show the mother how to give zinc supplements
• Infants- dissolve tablet in a small amount of
expressed breast milk, ors or clean water in a cup
 Plan B: Treat Some Dehydration With ORS
• Give in clinic recommended amount of ORS over 4
hour period
• Use the child’s age only when you do not know the
weight.
• The approximate amount of ORS required (in ml) can also
be calculated by multiplying the child’s weight (in kg)
times 75
• If the child wants more ORS than shown, give more.
• For infants under 6 months who are not breastfed, also
give 100-200 ml use the child’s age only when you do not
know the weight.
 Plan B: Treat Some Dehydration With ORS
• Show the mother how to give ors solution:
• Give frequent small sips from a cup.
• If the child vomits, wait 10 minutes.
• Then continue, but more slowly.
• Continue breastfeeding whenever the child wants.
 Plan B: Treat Some Dehydration With ORS
After 4 hours:
• Reassess the child and classify the child for dehydration.
• Select the appropriate plan to continue treatment.
• Begin feeding the child in clinic.
If the mother must leave before completing treatment:
• Show her how to prepare ors solution at home.
• Show her how much ors to give to finish 4-hour treatment at
home.
• Give her enough ors packets to complete rehydration.
• Also give her 2 packets as recommended in plan a.
• Explain the 4 rules of home treatment:
Does The Child Have Fever?
Does The Child Have An Ear Problem?
Then Check For Anaemia
Acute Malnutrtion, In Infants < 6 Months
Check For Acute Malnutrition, In Children 6 - 59 Months
HIV Exposure And Infection, In Children 2 - < 18
Months
HIV Exposure And Infection, In Children 18 - 59
Months
Assess And Classify The Child For Tuberculosis
SICK YOUNG INFANT AGE UP TO 2
MONTHS
Check The Newborn For Birth Asphyxia
Assess The Newborn For Birth Weight And
Gestational Age
Check For Very Severe Disease And Local
Bacterial Infection
Check For Jaundice
Does The Young Infant Have Diarrhoea?
Then Check For HIV Infection
Check For Feeding Problem Or Low Weight For Age
Check For Feeding Problem Or Low Weight For Age
 Summary
 IMNCI aims to reduce death, illness and disability, and
to promote improved growth and development among
children under five years of age
 The IMNCI case management process involves a
stepwise approach consisting of the following
elements: assessment, classification, treatment,
counselling and follow-up
 Summary
 After checking the general danger signs, you should
assess the child for cough/difficult breathing, diarrhoea,
fever, ear problems, malnutrition, anaemia and HIV.
 The presence of any one of the general danger signs
indicates a severe classification
 A child with a general danger sign or a severe
classification should be referred immediately after
giving appropriate pre-referral treatments
 Follow Up Visits For 2 Months Up To Five Years
If the child has: Return for Follow-up in:

• Pneumonia
• Some dehydration
• Dysentery
• Malaria, if fever persists
• Fever, if fever persists 2 days
• Fever no malaria, if fever persists
• Measles with eye or mouth complications
• Persistent diarrhea
• Acute ear infection
• Chronic ear infection 5 days
• Feeding problem
• Any other illness, if not improving
• MAM, if feeding problem
 Follow Up Visits For 2 Months Up To Five Years
If the child has: Return for follow-up in:
•Uncomplicated severe acute malnutrition 7 Days

•Anemia 14 Days
•Moderate acute malnutrition 30 Days
 Follow Up Visits For Young Infants
2 days
• LBW/preterm
• Local bacterial infection
• Low body temperature
• some dehydration
• Feeding problem
• Thrush
14 days
• underweight

254
Return Immediately If The Young Infant Has Any
Of These Signs
• Breastfeeding or drinking poorly
• Vomiting after each feeding
• Convulsion
• Reduced activity
• Fast or difficult breathing
• Develops a fever or feels cold to touch
• Blood in stool
• Becomes sicker
• Palms and soles appear yellow
 Return Immediately
• Advise the mother to come immediately if the child has any
of these signs.
• Any sick child
• Not able to drink or breastfeed
• Becomes sicker
• Develops a fever
If child has COUGH OR COLD, also return if:
• Fast breathing
• Difficult breathing
If child has diarrhoea, also return if:
• Blood in stool
• Drinking poorly
MALNUTRITION
 Contents
• Learning Objectives
 Overview of malnutrition
 Prevalence of malnutrition
 Types of malnutrition
 Risk factors for malnutrition
 Determinants of malnutrition
 Nutritional Assessment
 PEM ( kwashiorkor, marasmus)
 Management of SAM
 Warm up questions
 What are the causes of under-five mortality?
 How can you define malnutrition?
 Why children are at risk for malnutrition?
 How do you assess nutritional status?
 kwashiorkor VS Marasmus
 Learning Objectives
At the end of this topic, students will be able to:
Describe the epidemiology of malnutrition among
children
Explain the risk factors of malnutrition among
children
Analyze the causes malnutrition
Describe nutritional assessment methods
Explain classification of malnutrition
 Learning Objectives
Describe PEM ( kwashiorkor an marasmus)
Recognize the complication of malnutrition
Analyze the effect of malnutrition on the body
Recognize the signs of SAM
Outline the admission and discharge criteria of
SAM
Manage a child with SAM
 Overview Of Malnutrition

• WHO defines malnutrition as "the cellular imbalance

between supply of nutrients and the body's demand for them
to ensure growth, maintenance, and specific functions”
 Malnutrition is one of the most common causes of
morbidity and mortality among children under the age of
5 years worldwide.
 Early onset of malnutrition can also have lasting effects on
growth and functional status.
 Overview Of Malnutrition
 Severe acute malnutrition (SAM), often
associated with infection contributes to high
child mortality in underprivileged
communities.
 Prevalence
 More than one-fourth of under-five children
worldwide (about 150 million) are underweight;
27% are stunted while 10% are wasted.
 2019 EMDHS shows

Stunted (37%)
Wasted (7%)

Underweight 21 %
 Prevalence...
 Stunting is highly prévalent in sub-saharan Africain and
in South Asia
 Increasingly, many countries are witnessing increasing
public health problems posed by the double burden of
malnutrition – both under- nutrition and over weight
In the Ethiopian context, the commonest nutritional
problems are deficiency diseases
Malnutrition is the underlying cause of 57- 60% of child
deaths in Ethiopia
 Types Of Malnutrition

Malnutrition includes:
• Macronutrient deficiency
• Micronutrient deficiency ( Hidden Hunger )
• Over nutrition-obesity
Children with acute malnutrition appear wasted,
whereas
children with chronic malnutrition have stunted
linear growth
 Types Of Undernutrition

Based on UNDERNUTRITION
duration

ACUTE CHRONIC
UNDERNUTRITION UNDERNUTRITION

•Wasting
•Kwashiorkor Stunting
•Marasmus Underweight
•Marasmic- kwash
 Types…

 Malnutrition also classified in to ( based on etiology)

 Primary malnutrition resulted from inadequate food

intake

 Secondary malnutrition resulted from increased nutrient

needs, decreased nutrient absorption, and/or increased
nutrient losses
 Risk Factors Of Malnutrition
There is high nutritional needs of infants and young
children as;
– More energy expenditure (i.E., Basal metabolism,
metabolic response to food, and physical activity),
– Rapid rate of growth
– New growth of tissues
– Physiological changes (e.G., Puberty).
– Infection is common during child hood period
(particular at early age)
leads to nutritional disruption
 Determinants Of Child Malnutrition

Generaly:
No Single cause:
Can have many causes
Basic causes
Underlying causes
Immediate causes
 Underlying causes
 Lack of knowledge about diet
Parents often withhold food supplements/fluids during episodes of
diarrhea
Affluent families may also have irrational beliefs about the nutritional
needs of infants and
 Economic factors (poverty)
 Social factors
Repeated pregnancies, inadequate child spacing, food taboos, broken
homes and separation of a child from his parents `
 Biologic factors maternal malnutritionLBW(prematurity)
Malnourished mothers have a high incidence of LBW and
growth retarded babies with poor nutritional reserve
Underlying causes
 Feeding habits :
Lack of EBF for first 6 months makes the child
prone to early onset malnutrition
Artificial feeding is disastrous for the baby
because of the poor quality of the substitute
milk, excessive dilution and use of unhygienic
feeding bottles and nipples
Delayed introduction of complementary
feeding
 Underlying causes
 Infections:
Diarrhea, pneumonia, malaria, measles, and tuberculosis precipitate
acute malnutrition and aggravate the existing nutritional deficit
During infections, child’s appetite is impaired
The patient catabolizes his own tissues to produce the additional
heat energy
Metabolic demands for protein during infections are higher
Protein may be lost because of tissue breakdown and in pus and
exudates.
Also, malnutrition may adversely affect the immune status and make
the malnourished individuals more vulnerable to infections
This sets up a vicious cycle of malnutrition-infection malnutrition
 Underlying causes
 Religious customs (people of certain religions avoid
non-vegetarian diet which has high-quality proteins)
 Environmental factors such as overcrowded and
unsanitary living conditions, drought, earthquakes.
 Insufficient health services
 Inadequate care for children and women
 Wars and civil unrest exaggerate pre-existing
malnutrition in the community
 Natural disasters such as floods, earthquakes, and
droughts
Strategies to Prevent and Control Under nutrition
 Improve household food security.
 Improve diversity of diet.
 Improve maternal nutrition and health care.
 Improve child feeding practices.
 Ensure child health care (immunization, medical
care, growth monitoring).
 Provide nutrition rehabilitation.
 Intergenerational cycle/effect of malnutrition
Child growth failure

Low birth Early Adolescents with Low

weight babies pregnancy weight and height

Small adult women

How can we break the cycle?
 Can we conclude that teenage pregnancy is likely to play a
big role in the cycle of growth failure and stunting?
Nutritional Assessment
 Definition
Nutritional assessment is an interpretation of
anthropometric, biochemical (laboratory), clinical
and dietary survey data to tell whether a person/
group of people is well nourished or malnourished
(Over nourished or under nourished).
INTRODUCTION
The nutritional status of an
individual is often the result of
many inter-related factors.

It is influenced by food intake,

quantity & quality, & physical
health.

The spectrum of nutritional status

spreads from severe under
nutrition to obesity
 Nutritional Assessment -Why?
The purpose of nutritional assessment is to:
Identify individuals or population groups at risk of
becoming malnourished
Identify individuals or population groups who are
malnourished
To develop nutrition and health care programs that meet the
community needs which are defined by the assessment
To measure the effectiveness of the nutritional programs &
intervention once initiated
 Nutritional Assessment
 There are direct and indirect methods of assessing
Nutritional status
 Direct: involve the direct measurement of body
dimensions and proportions, dietary intake, appearance
of the clinical symptoms and signs related to a specific
nutrient.
Abbreviated as the ABCDs
A=Anthropometry
B= biochemical/Biophysical,
C= Clinical
D= Dietary
 Cont…
• Anthropometry: height, weight, BMI-for - age, MUAC
• Biochemical: analysis of blood, urine, and other body
tissues
• Clinical: complete physical examination, and a medical
and psychosocial history
• Dietary: foods and quantities eaten, eating habits,
accessibility of food, and cultural and socioeconomic
factors that affect selection of food
 Anthropometric Assessments
 Assessment of nutritional status by anthmpometry is
the simplest and most useful tool for assessing the
nutritional status of children
 Weight, height, and mid-arm circumference should
be compared to the reference norms for the
corresponding age in the well nourished and healthy
children of the community
 International references for anthropometric
measurements have been advocated
 Anthropometric Assessments
 These include Harvard standards (UK),
NCHS/CDC standards (US). WHO
 However, the recent reference values provided
by WHO provide the most recent and widely
acceptable international growth standards for
comparison
 Purposes of Anthropometric measurements

 Anthropometric measurements are performed

with two major purposes in mind:
IN CHILDREN: to assess physical growth
IN ADULTS: to assess changes in body
composition or weight
Anthropometric Measurements Of Growth #1
Growth performance of children is an excellent
reflection of their underlying nutritional status.
 Children adapt to the chronic nutritional insult by
either reducing their rate of growth or by totally failing
to grow.
Therefore, assessment of growth performance of
children is one very important purpose of
anthropometric measurements.
The following body measurements are good indicators
of growth performance of children at different ages
when combined with the cut-off points.
 Head Circumference (HC)

Measured using flexible measuring tape

It is the circumference of the head along the supra orbital
ridge anteriorly and occipital prominence posteriorly.
HC is useful in assessing chronic nutritional problems in
under two children.
 But after 2 years as the growth of the brain is sluggish it is
not useful.
 Length

A wooden measuring board (also called sliding board)

is used for measuring length.
It is measured in recumbent position in children <2 yrs
old
It is always > height by 1-2cm.
One assistant is needed in taking the measurement
Measurement is read to the nearest mm
Length…
 Height
Is measured in children > 2 yrs and a adults in standing
position
The head should be in the Frankfurt plane
During measurement, knees should be straight and the
heels buttocks and the shoulders blades, should touch the
vertical surface of the stadiometer ( anthropometer) or
wall.
Stadiometer or portable anthropometer can be used for
measuring.
There is also a plastic instrument called acustat
Stadiometer that is cheaper than the conventional
Stadiometer.
Height…
 Weight
Weighing sling (spring balance) also called salter
scale is used for measurement of weight in
children < 2 years.
 In adults and children >2 years, beam balance is
used
Weight…
What
INDICES
is anDERIVED
index? ItFROM THESE of two
is a combination
MEASUREMENTS
measurements or a measurement plus age.
The following are few of them:
Head circumference-for age
Weight -for-age
Height-for age
Weight for height
 Meanings Of The Indices Derived From
Growth Measurements
Weight for Age = Weight of the child x 100
Weight the normal child of
the same age

Weigh for height = Weight of the child x 100

Weight of the normal child of
the same height

Height for age = Height of the child . X 100

Height of the normal child of
the same age
 Mid Upper Arm Circumference (MUAC)

 Used to screen for malnutrition - time and equipment

are very limited, such as famines and refugee crises

 Used to identify children for further evaluation

 It is independent of age and gender

 Between six month and five years of life

 MUAC…
 MUAC is measured on the upper left arm
 To locate the correct point for measurement,
 The child's elbow is flexed to 90°, with the palm facing upwards
 A measuring tape is used to find the midpoint between the end of
the shoulder (acromion) and the tip of the elbow (olecranon);
 This point should be marked
 The arm is then allowed to hang freely, palm towards the thigh, and
the measuring tape is placed snugly around the arm at the midpoint
mark
 The tape should not be pulled too tight or too loose
 Read the measurement to the nearest 0.1 cm.
Indicator

• An indicator is an index + a cut-off point.

E.g.
W F A < 60% = is indicator of severe malnutrition
BMI < 16 kg/m2 = indicator of severe chronic energy
deficiency
W F H < 70% = is indicator of severe wasting
We use SD in Ethiopia
 Classification of PEM: WHO Classification
 WHO definitions — has developed criteria for
the classification of moderate or severe
malnutrition
• This classification is based on two anthropometric
indicators (stunting and wasting) and one clinical
indicator (edema).
 The child's weight for height, and the height for
age are expressed as Z-scores
 Wasting and stunting are defined by the following
 Classification: WHO Classification
 Wasting : measured by deficit in weight-for-height.
Indicates a deficit in tissue and fat mass and may result
either from failure to gain weight or from actual weight
loss
It usually signifies acute onset malnutrition
A child is considered wasted if the weight for height/
length is less than -2SD (Z) score or less than 85% of
the expected
Moderate wasting – wt/ht Z-score <-2 to -3
Severe wasting – weight/height /length Z-score <-3
or less than 70% of expected
 Classification: WHO Classification
 Stunting (deficit in height-for-age)
 Signifies accumulated consequences of retarded growth
over a prolonged period of time
 points towards a chronic course of malnutrition
 Lt may also be a residue of past malnutrition or could be
due to non-nutritional disorders like genetic short stature or
endocrinal disorders.
 The diagnosis of stunting is based on a height for age less
than -zsd (z) score or less than 90% of the expected
 Moderate stunting – height/length for age z-score <-2 to -3
 Severe stunting – height/length for age z-score <-3 or less
than 85% of expected
 Classification: WHO Classification
Children are classified as having
malnutrition:
Moderate malnutrition – moderate
wasting or stunting
Severe malnutrition – severe wasting,
severe stunting
Presence of edema along with stunting or
wasting indicates severe under nutrition.
 Classification: WHO Classification
 Underweight
Is a composite index of weight-for-height and
height-for-age and
Thus does not distinguish between acute
malnutrition (wasting) and chronic malnutrition
(stunting)
Children can be underweight for their age because
they are stunted, wasted, or both
Weight-for-age is an overall indicator of a
population’s nutritional health.
Classification
 Severe Acute Malnutrition (SAM)
 The term SAM has been coined by international agencies (WHO
and UNICEF) to identify malnourished children at highest risk of
death, and for the
Purpose of therapeutic feeding in the hospital or community
 SAM is defined by
A very low weight for height (below -3Z scores of the median
WHO growth standards)
By visible severe wasting or
By the presence of nutritional edema
Using mid-arm circumference, the cut-off point to define SAM is
11.5 cm for children aged between 6 months and 5 years
 Classification
• The severity of malnutrition can be calculated based on the
median/ average value and classified as;

Grade W/a Ht/age W/ht

( Gomez) (Waterlaw ) (Waterlaw)
Normal >90 >95 >90

Mild 75-90 90-95 81-90

Moderate 60-74 85-90 71-80

Severe <60 <85 <70

 Classification: Welcome
 This classification is also based on deficit in body weight for
age and presence or absence of edema
 Children weighing between 60-80% of their expected weight
for age with edema are classified as kwashiorkor.
 Those weighing between 60-80 percent of expected without
edema are known as having under weight.
 Those without edema and weighing less than 60 per cent of
their expected weight for age are considered to be having
marasmus.
 Marasmus- kiuashiorkor is applied to children with edema
and body weight less than 60 per cent of expected
 Classification

The Welcome Classification

Indicator: Weight-for-age and edema

% expected OEDEMA
Weight for Age
Present Absent
60 - 80 Kwashiorkor Underweight
< 60 Marasmic-Kwashiorkor Marasmus
Advantage: Useful for classifying more severe forms.
Limitations: Does not take account of height differences.
Age of the child must be known.
 Malnutrition Indicators
NUTRITION MEASUREMENT CLINICAL
INDICATOR INDICATOR INDICATOR

Acute Malnutrition (SAM Weight-for-Height

& MAM)
Mid-upper arm Wasting, kwashiorkor
circumference
Chronic Under nutrition Height-for-Age Stunting
Underweight (composite Weight-for-Age Underweight
indicator)
Over nutrition Body Mass Index Overweight/Obesity
(weight/Height)
Micronutrient Deficiencies Biochemical indicators Xerophthalmia, stomatitis
 Protein-energy Malnutrition (PEM)
• The term protein-energy malnutrition (PEM)
applies to a group of related disorders that include
marasmus, kwashiorkor, and intermediate
states.
• Nutritional deficiency of macronutrients is a
major health problem in the developing countries
• Usually associated with micronutrient
deficiencies.
 PEM
 Worldwide, severe protein energy malnutrition is a leading
cause of death among children younger than five years of
age
 Severe protein-energy malnutrition is associated with
1. Marasmus (wasting syndrome) and
2. Kwashiorkor, or
3. With manifestations of both
• Lack of protein in the diet is more often due to low
food intake, rather than a qualitative defect in the diet
• Nutritional marasmus and kwashiorkor are two extreme
forms of malnutrition.
 Kwashiorkor
• Cecilly Williams, a British nurse, had
introduced the word Kwashiorkor to the
medical literature in 1933.
• The word is taken from the Ga tribe in
Ghana & used to describe : ‘’The
sickness of weaning’’ “The sickness the
older child gets when the next baby is
born”
 Kwashiorkor ...

• In this form of severe undernutrition, the

child’s muscles are wasted, but the wasting may
not be apparent due to generalized oedema
(swelling from excess fluid in the tissues).
Kwashiorkor ...
• Incidence is more in:

 Low birth weight

 Age >6 months

 Broken families

 In children with whose parents are unemployed

 Large families
Clinical features
Essential features of kwashiorkor include
(I) Edema
(II) Markedly retarded growth
(III) Psychomotor changes
 Other features that help in making a diagnosis include
 Skin and hair changes
 Hepatomegaly
 Impaired appetite
 Associated nutritional deficiencies.
Clinical features
Edema and preserved subcutaneous tissues mask
muscle wasting which becomes apparent when the
child recovers from edema
Infections (eg, diarrhea, acute respiratory infections,
skin infection) and infestations (eg, scabies, lice) are
present in majority of cases
 Edema
 Is the clinical manifestation of expansion of
extracellular water (ECW) volume caused
By pre-renal diversion of fluid from the capillary
bed to extracellular space
 Edema may be caused by
I. Hypo-albuminemia
II. Retention of fluid and water due to increased
capillary permeability as a result of infection,
potassium deficiency
III. Free radical induced damage to cell membranes
 Edema
 The edema starts in the lower extremities and
progresses to involve the upper limbs and the face
 The face appears moon-shaped and puffy
 The trunk is affected to a lesser extent, and ascites is
rare unless there is a co-existent cause such as
tuberculosis
 In a previously malnourished child, edema is
precipitated by debilitating illnesses such as measles or
diarrhea
 Presence of edema may mask features of severe
dehydration secondary to diarrhea in a severely
malnourished child
 How To Check For Edema?

 Grasp both feet so that they rest in your

hand with your thumbs on top of the feet

 Press your thumbs gently for three seconds

or count 101,102,103

 The child has edema if a pit (dent) remains

in both feet when you lift your thumbs

 Edema must appear in both feet= sign of

severe malnutrition
Extent of edema
The extent of edema is commonly rated
Grade
Absent Absent
Grade + Mild: both feet/ankles
Grade ++ Moderate: both feet, plus lower legs, hands
or lower arms
Grade +++ Severe: generalized bilateral pitting edema;
including both feet, legs, arms and face
Edema
• Scale for grading edema
 Psychomotor change
 Child with kwashiorkor is lethargic,
listless, and apathetic
 Play activity and interaction with
others is reduced
 Child resists attempts to
examination by medical personnel
 Child loses appetite, and it is
difficult to feed him orally in the
initial phase of dietary management
 Child may need nasogastric feeding
for nutritional rehabilitation
 Appetite improves once co-existent
infection is controlled by antibiotics
 Skin changes
 A variety of skin changes have been described in
kwashiorkor
 Dry and scaly skin with cracking is apparent over large
areas of trunk and limbs giving mosaic appearance
 Most typical skin lesion is crazy pavement dermatosis
which is characterized by jet black patches over
pressure sites, especially of extremities which later
exfoliate to expose raw hypopigmented or reddish skin
 Peeling plaques of this dermatosis give appearance of
old paint peeling off the surface, and is termed flaky
paint dermatosis
 Multiple punctate pinkish areas over the legs are seen in
few cases
 Skin changes
 Perioral lesions occur frequently which are
caused by riboflavin deficiency and Zinc
deficiency
 Deep and indolent ulcerations and fissures in
flexures or over pressure points may also occur
 Skin changes regress rapidly following
successful dietary management of kwashiorkor
 Skin change
Dermatosis
 It is more common in children who have edema than in
wasted children
 A child with dermatosis may have patches of skin that is
abnormally light or dark in color
 Shedding of skin in scales or sheets, and ulceration of the
skin of the perineum, groin, limbs, behind the ears, and in
the armpits
Skin change
Dermatosis…
 There may be weeping lesions
 There may be severe rash in the nappy area
 Any break in the skin can let dangerous bacteria get
into the body
 When the skin is raw and weeping, the risk is very
high.
Skin change
Dermatosis…

 The extent of dermatosis can be described:

 Mild (+): discoloration or a few rough patches of skin

 Moderate (++): multiple patches on arms and/or legs

 Severe (+++): flaking skin, raw skin, fissures (openings

in the skin)
 Hair changes
 Hair become hypopigmented, lusterless, thin,
and easily pluckable
 The discoloration may be seen only in some
segments, often the growing ends
 During recovery, segmental discoloration (flag
sign) is more apparent as the growing part of the
hairs gets pigmented
 Changes In Body Composition And Function
Parameter Features
Growth Short statured
Mental faculties Irritable, lack of interest in surroundings, apathetic,
dull, lethargic, resents meddling
Hair Lack of luster, easily pluckable, sparse , loss of
natural curls, brownish discoloration, flag sign
Anterior Delayed closure
fontanel
Face Moon face, a full well-rounded somewhat
pendulous and blubbery cheeks
Eyes Conjunctival pallor, signs of vitamin-A deficiency
 Changes In Body Composition And Function
Parameter Features
Oral cavity Angular stomatitis: iron deficiency anemia, B-
complex deficiency; oral thrush
Tongue Oedema of tongue, scarlet and raw tongue (bright
red), magenta tongue (purplish red), atrophy of
papillae, geographic tongue (the tongue has
irregularly distributed patchy areas of denudation
and atrophy of epithelium
Teeth Caries, delayed dentition, enamel hypoplasia,
enamel erosion
Gums Spongy, bleeding gums, recession of gums
 Changes in Body Composition and Function

Parameter Features
Cheeks Baggy cheeks of Trowel
Neck Neck appears to be long due to wasting of
muscles and sub-cutaneous fat
Chest All the ribs and spinal processes are
prominently seen due to wasting of muscles
and sub-cutaneous fat
Abdomen Abdomen is distended due to intestinal atony,
hepatomegally, rarely ascites
 Changes in Body Composition and Function
Parameter Features
Skin Hypopigmented and hyperpigmented patches
(crazy pavement dermatosis), flaky pavement
dermatosis (peeling of skin), xerosis: generalized
dryness with branny desquamation, petechiae,
pellagrous dermatosis
Extremities Are thin due to wasting, pedal oedema,
CNS Patient is dull, lethargic, apathetic, hypotonia due
to nutritional myelopathy
 Changes in Body Composition and Function
Parameter Features

CVS Intensity of heart sounds is decreased due to

decrease of cardiac output
Respiratory Features of secondary infection
system
GIT Hepatomegaly
Rectal prolapse is common
Salivary glands atrophy
 Differential diagnosis
• Nephrotic syndrome
• Cirrhosis of liver
• Congestive heart failure
 Investigations
 Blood
• CBC
• Serum electrolytes, plasma protein estimation
• Blood culture & sensitivity for evaluation of septicaemia
 Urine
• Albumin, sugar, deposits, urine culture & sensitivity
 Stool
• Ova of parasite, culture & sensitivity if there is diarrhoea
 Chest X-ray: to r/o TB & other infections
 Mantoux test
Complications
• Hypothermia
• Hypoglycaemia
• Infections
• Electrolyte disturbances
• Dehydration
• Anemia
 Prevention

 Health and nutrition education

 Early identification and treatment of the diseases
 Exclusive breast feeding up to six months
 Complementary feeding at the age of six months
 Family planning
 Safe and adequate water supply
 Immunization
 Marasmus
• The term marasmus is derived from the Greek
marasmos, which means wasting.
• A nutritional disorder due to deficiency of protein
and calories, particularly calories, characterized
by:
 Growth failure
 Gross wasting
 Absence of oedema
 Age 2- 4 yrs
 Weight is more affected than height
• Marasmus represents the end result of starvation
where both proteins and calories are deficient.
 Marasmus
 Marasmus represents an adaptive response to
starvation, whereas kwashiorkor represents a
maladaptive response to starvation
 In Marasmus the body utilizes all fat stores
before using muscles
 Clinical features
 The most characteristic feature of marasmus is visible
severe wasting of muscle and subcutaneous tissues
 Child is usually alert, has an emaciated look, and has
no edema
 Skin is thin, dry, scaly, and wrinkled with loose folds
apparent over the gluteal region and thighs
 Subcutaneous fat gets depleted as it is used up for
providing energy
 Buccal pad of fat is the last to disappear because of
presence of saturated fats which are utilized at last
 Clinical features
 Atrophic muscles make a contour under the thin and
wrinkled skin
 Bones appear prominent giving a skeleton like look
 Hairs may become hypopigmented
 Abdomen appears distended because of hypotonia of
abdominal wall muscles
 Appetite may be voracious, especially in absence of
infection or a secondary cause of malnutrition
 Clinical features: severe wasting
 A child with severe wasting has lost fat and
muscle and has a “skin and bones” appearance.
 Severe wasting in infants of under 6 months is
marked by visible severe wasting
 Whereas for children >6 month severe wasting
is assessed objectively using anthropometric
measurements (WFL/H, MUAC).
 Severe wasting…
 Visible severe wasting is an important sign of
SAM for infants under 6 months of age
 It is used as a criteria to classify as SAM only for
infants below 6 months age.
 To look for severe wasting, remove the child’s
clothes.
 Look at the front view of the child:
 Is the outline of the child’s ribs easily seen?
 Does the skin of the upper arms look loose?
 Does the skin of the thighs look loose?
 Severe wasting..
 Look at the back view of the child:
 Are the ribs and shoulder bones easily seen?
 Is flesh missing from the buttocks?
 When wasting is extreme, there are folds of skin on
the buttocks and thighs
It looks as if the child is wearing “baggy pants”.
 Because a wasted child has lost fat and muscle, this
child will weigh less than other children of the same
height/length and will have a low weight-for-
height/Length
Clinical features
 Changes in Body Composition and Function
Parameter Features
Mental faculties If there is no infection:
•Patient is alert, playful, lovely look
•The cry is vigorous
•Appetite is vigorous
If there is an infection:
• The child is less active, apathetic, cries in a
low tone, refusal to food

Head •Hair is normal, delayed closure of anterior

fontanel may be present
 Changes in Body Composition and Function
Parameter Features
Face •Eyes: no signs of vitamin A deficiency
•Mild to moderate anemia may be present
•Sunken cheeks are present due to loss of buccal fad
of fat
•Child appears as a wizened little old man or monkey
face
Oral cavity •Oral thrush may be present
•Stomatitis and angular stomatitis may be present
Chest All the ribs and spinal processes are prominently seen
due to wasting of subcutaneous fat & muscles
 Changes in Body Composition and Function
Parameter Features
Abdomen •Abdomen is distended due intestinal atony
•No hepatomegaly
Skin •Thin
•No skin changes
Extremities Thin due to wasting of muscles & sub-
cutaneous fat. There is no oedema
CVS Size of heart decreased. Decreased intensity of
heart sounds due to low cardiac output
Respiratory Features of secondary infection may be present
system
Investigations
• CBC
• Urine and stool culture
• Chest X-ray
• Mantoux test
Complications
1. Immediate complications
• Hypoglycaemia
• Hypothermia
• Septicaemia
• Electrolyte imbalance
2. Late complications
• Intellectual sub-normality
• Growth retardation
 Mixed (marasmus-kwashiorkor)
 Mixed marasmus-kwashiorkor (edematous malnutrition)
may occur:
In a child who has inadequate dietary intake of all
nutrients and is triggered by a common infectious
illness of childhood
 Children with mixed marasmus-kwashiorkor often have
Anorexia
Dermatitis and
Sometimes neurological abnormalities (depression and flat
affect) and hepatic steatosis
 Mixed (marasmus-kwashiorkor)
 The transition from marasmus to mixed marasmus-
kwashiorkor is associated with particularly high
morbidity and mortality
 Perhaps because of
 The frequent association with acute infection or
 Children with this clinical course are less well adapted
metabolically than children with pure marasmus
 End organ effects of malnutrition
• Body composition
– Total body water increases(ECF)
– Increased Na+
– Decreased K+ and Mg++
– Muscle and fat loss
• GIT
– Villus atrophy
– Reduced enzymes
– Bacterial over growth
 End organ effects of malnutrition
• Liver
– Reduced synthesis of protein
– Impaired gluconeogenesis
– Decreased metabolism of toxins and substances
• Cardiac
– Myocardial atrophy, reduced cardiac out put , decreased BP
• Hematology
– Anemia
• Metabolic
– Hypoglycemia
– Reduced metabolic rate
 End organ effects of malnutrition
Renal impairment
Glomerular filtration rate and renal plasma
flow are reduced in severe PEM
Capacity of the kidneys to excrete excess acid
or water is greatly affected
Urinary phosphate and sodium excretion are
reduced.
 End organ effects of malnutrition
Central nervous system
 Growth and development of the brain ; is adversely
affected especially if malnutrition sets in first two years
of life which is a period of rapid brain growth
 Associated micronutrient deficiencies (eg, iron,
thiamine, vitamin B12, zinc, iodine) further impair the
brain function resulting in lower developmental scores.
 There is impairment of sensory coordination and
recognition of figures and shapes
 Lag in development and intelligence (IQ) may persist
even after recovery from malnutrition.
 End organ effects of malnutrition
Skin, Muscles, Exocrine glands
• The skin and subcutaneous fat are atrophied
which leads to loose folds of skin and sunken eyes
• Many exocrine glands including the sweat,
lacrimal (tear), salivary, and pancreatic glands are
atrophied
• Many signs of dehydration (decreased skin turgor,
dry oral mucosa, absent tears, sunken eyes) are
unreliable in the severely malnourished child.
 End organ effects of malnutrition
• Immune System
– Immunity
• Impaired especially the Cell mediated
• Reduced IgA
• Reduced phagocytosis
– Inflammatory response
• Impaired acute phase response
• Reduced chemotaxis of WBC to site of infection/
inflammation
• Prone to infectious agents/subtle signs
 End organ effects of malnutrition
• All aspects of immunity are diminished;
Cell-mediated immunity is depressed, IgA
secretions are reduced, phagocytosis is
impaired, lymph glands, tonsils and thymus are
atrophied.
• Typical signs of infection like fever are
frequently absent
• Relying on the presence of fever to suspect
infection could therefore be misleading
 End organ effects of malnutrition
 Severe malnutrition is a state of relative immuno-
deficiency
 These children are more prone to infection: b/c of
There is impaired cell mediated immunity due to atrophy
of thymus and lymphoid tissues
Sensitization to antigens and recognition of earlier
sensitization is impaired
There is impaired fungicidal and bactericidal capacity of
leukocytes
 End organ effects of malnutrition
 Secretory IgA may be reduced resulting in increased
severity, prolonged infectivity, and delayed recovery from
infections
 Leukocyte count is generally normal in severe
malnutrition, leukopenia may occur
 Physical barriers against infection such as skin and
mucosal membranes are breached
 Skin is thin and ulcerated which is easily penetrated by
microbes
 Mucosa are atrophic resulting in increased risk of
gastrointestinal and respiratory tract infections
 Management of Acute Malnutrition
• The comprehensive management of acute malnutrition,
which is also called Community-Based Management
of Acute Malnutrition (CMAM), consists of four main
components:
1. Community outreach/mobilization
2. Inpatient Treatment/ care
3. Outpatient Treatment Program (OTP)
4. Targeted supplementary feeding program (TSF)
 Inpatient Treatment/ care

 Children who are acutely malnourished with associated

medical complications

 Poor appetite

 Infants less than 6 months with SAM need to be treated in

inpatient care facility until they are well enough

To continue nutritional rehabilitation in OTP

 Outpatient Treatment Program (OTP)
Outpatient care is intended for children presenting
SAM
 Without medical complications
 Children that have recovered in inpatient care after they
have recovered appetite
 They receive ready-to-use therapeutic food (RUTF) and
routine medicines, which are taken at home, and the child
attends the outpatient care site every week
 Recommended criteria for SAM and
Admission to TFP
• All children who have SAM should be admitted to a
Therapeutic Feeding Program (TFP)

In-patient care (TFU) or

Out-Patient Treatment Program (OTP)

 Recommended criteria for SAM and
Admission to TFP
 Children with SAM are treated as in-patient or OTP
 Depends on
The age of a child
Presence or absence of medical complications
Result of the appetite test determine whether a child
with SAM should be treated in OTP or in-patient
care (TFU, or stabilization center or SAM ward)
Criteria for SAM
1. Infants less than six months or less than 3 Kg:
 WFL less than 70% or < -3Z score
OR
 Presence of pitting Edema of both feet
OR
 Visible Severe Wasting if it is difficult to determine
WFL
• Note: Infants below six months of age with SAM can
be treated as in patient
Criteria for SAM
Note:
 Visible severe wasting is an important sign of
SAM for infants under 6 months of age
 It is used as a criteria to classify as SAM only
for infants below 6 months age.
 Criteria for SAM
2. Children 6 months to 5 years:
 (WFL) / WFH less than 70 % or < -3 Z score OR
 Presence of pitting Edema of both feet OR
 MUAC <11.5cm
 Note: edema +3, WFL/H < 70% with edema +1,+2 or
with medical complication, MUAC < 11.5cm with
edema +1,+2 or with medical complication, failed
appetite test can be treated as in- patient
 Admission Criteria (In- patient)
Complicated Severe Acute Malnutrition
 WFL/H
< 70% of median OR
< -3Z score OR
MUAC <11.5 cm OR
 Edema of both feet (+, ++) OR
 +++ Edema OR
 Marasmic - Kwashiorkor (WFL/H < 70% with edema OR
 MUAC <11.5cm with edema)
Assessment and Classification of Children for SAM
 Admission Criteria (In- patient)
 If they fulfil any one of the following:
1. Infants below six months of age with SAM OR
2. Children 6 months to 5 years with SAM who have any one of
the medical complications or failed appetite test OR
3. Children with SAM and referred from OTP for in-patient care
OR
4. When OTP is not available in
 Your working area or
 Where the care taker lives or
 If the care taker’s choice is inpatient care, all SAM children
need to be admitted for in-patient care even if they do not
fulfil the in-patient admission criteria
 List of common medical complications:
1. Unable to breast feed, drink or
feed 10. Dysentery
2. Vomiting everything 11. Persistent diarrhoea
3. Convulsions 12. Hypoglycaemia
4. Very Weak, Lethargic or 13. Severe anemia (severe
unconscious palmar pallor)
5. Hypothermia: axillary temp 14. Jaundice
<35 0C or rectal < 35.5 0C 15. Bleeding Tendencies
6. Fever ≥ 38.5 0C0C
16. Dermatosis +++
7. Pneumonia/severe pneumonia 17. Corneal clouding or
8. Shock ulceration
9. Dehydration (watery diarrhea 18. Measles (now or with
with recent sunken eye balls.) eye/mouth complication)
 Medical complications
 Edema grading: bilateral edema below ankles (+); below the
knees & the elbows (++); generalized edema involving the
upper arms & face (+++)
 Dermatosis grading: few discolored or rough patches of skin
(+); multiple patches on arms and/or legs (++); flaking skin,
raw skin or fissures (openings in the skin) is grade +++
dermatosis
 Measles: If a child has generalized rash with one of the
following: cough, runny nose or red eyes
 Measles with eye or mouth complications: If a child with
measles has pus draining from the eye, clouding of cornea or
mouth ulcers (deep or extensive ulcers)
 Note
 Children with severe acute malnutrition that need in-patient
care are in danger of death from
Hypoglycemia
Hypothermia
 Fluid overload and
Undetected infections
They cannot be treated like other children
Their feeding and fluids must be carefully controlled, or
they could die
 Note
To ensure the proper feeding and treatment routines, it is
critical to keep these children in TFU/SC or separate rooms
with in a ward
Other health problems and infections should be treated in
these rooms
 Appetite Test
 An appetite test is done to children ages 6 months to 5
years who have no medical complications
 In order to determine whether the child can eat the
RUTF (Plumpy’Nut)
 The test shows whether the child has appetite, accepts
the RUTF’s taste and consistency and can swallow
 If a child fails the appetite test, it reflects a severe
disturbance of the metabolism and this child needs to
be treated as an in-patient
 Appetite Test

 A poor appetite shows that the child has significant

infection or a major metabolic abnormality such as liver
dysfunction, electrolyte imbalance, etc

 Such children with SAM are at immediate risk of death

 If a child passes the appetite test, he/she should be

treated as out-patient if OTP service is available
 Appetite Test
Why do we do appetite test?
 No signs of clinical infection in children with SAM
 No perfect correlation between metabolic malnutrition &
anthropometric malnutrition
 Metabolic malnutrition is the common cause of death and
often its sign is loss of appetite
 Appetite test is the most important criteria to admit SAM
either to inpatient or OTP
B
How Does The Physiology Of Severe Malnutrition
Affect Care Of The Child?
 The child with severe malnutrition must be treated
differently because
The physiology is seriously abnormal due to
reductive adaptation
 What is reductive adaptation?
 The systems of the body begin to “shut down” with severe
malnutrition
 The systems slow down and do less in order to allow survival on
limited calories
 This slowing down is known as reductive adaptation
 As the child is treated, the body's systems must gradually "learn"
to function fully again
 Rapid changes (such as rapid feeding or fluids) would overwhelm
the systems, so feeding must be slowly and cautiously increased
How Does Reductive Adaptation Affect Care
Of The Child?
 Reductive adaptation affects treatment of the child in a
number of ways.
 Three important implications for care reductive
adaptation for care includes:
1. Presume and treat infection
2. Do not give iron early in treatment
3. Provide potassium and restrict sodium
 Presume And Treat Infection
 Nearly all children with severe malnutrition have
bacterial infections

 However, as a result of reductive adaptation,

The usual signs of infection may not be
apparent, because the body does not use its
limited energy to respond in the usual ways,
such as inflammation or fever
 Presume and treat infection
 Examples of common infections in the severely
malnourished children are
 Ear infection
 Urinary tract infection and
 Pneumonia
 Assume that infection is present and treat all severe
malnutrition admissions with broad spectrum
antibiotics
If a specific infection is identified (such as Shigella),
add specific appropriate antibiotics to those already
being given.
 Antibiotics for Severely Malnourished
Children
• Give all severely malnourished children antibiotics for
presumed infection even if they do not have clinical sign of
systemic infections.
• Selection of antibiotics depends on the presence or absence
of complications
Complications include septic shock, hypoglycemia,
hypothermia, skin infections or dermatosis, respiratory or
urinary tract infections....
 Antibiotics for Severely Malnourished Children
IF: Give
No Medical Complications Oral Amoxicillin
or If Amoxicillin is not available, give Cotrimoxazole for 5
Only failed appetite test days
Medical Complications ( Gentamycin IV or IM once daily for 7 days, plus:
Unable to feed , Vomiting Ampicillin IV every 6 hours for 2 days followed by
everything, pneumonia...) oral Amoxicillin for 5 days
If child is not seriously sick looking and can take oral
medication, avoid IV Ampicillin and start with oral
Amoxicillin and IM Gentamycin.
If the child has medical Oral Amoxicillin and IM Gentamicin for 7 days.
complications other than If child is seriously sick looking, instead of oral
mentioned above, Amoxicillin & IM Gentamycin start with IV Ampicillin
(dehydration, dysentery, and IV Gentamycin
persistent diarrhea, malaia...
 Antibiotics for Severely Malnourished Children
IF: Give
If child fails to Chloramphenicol IV or IM every 8 hours for
improve within 48 5 days. (Give IV every 6 hours if suspect
hours, ADD: meningitis.) or ceftriaxone 100 mg/kg
divided into 2 doses IV or IM + Gentamicin
once daily for a total of 10 days.
If a specific infection
requires an additional
antibiotic, ALSO Specific antibiotic as indicated.
GIVE:
Antibiotics And Oral Dose
 Do Not Give Iron Early In Treatment
 Due to reductive adaptation, the severely malnourished
child makes less hemoglobin than usual
 Iron that is not used for making hemoglobin is put into
storage
 Thus, there is “extra” iron stored in the body, even though
the child may appear anemic
 Giving iron early in treatment will not cure anemia, as the
child already has a supply of stored iron
 Do not give iron early in treatment
 Giving iron early in treatment can also lead to “free iron” in the
body
 Free iron can cause problems in three ways:
1. Free iron promotes bacterial growth and can make some
infections worse
2. Free radical formation
3. The body tries to protect itself from free iron by converting it to
FERRITIN (a blood cell protein that contain iron)
 This conversion requires energy and amino acids and diverts
these from other critical activities
 Later, as the child recovers and begins to build new tissue and
form more red blood cells, the iron in storage will be used and
supplements will be needed.
 Provide Potassium And Restrict Sodium
 Normally the body uses a lot of energy maintaining the
appropriate balance of potassium inside the cells and
sodium outside the cells.
 This balance is critical to maintaining the correct
distribution of water inside the cells, around the cells
and in the blood
 In reductive adaptation, the “pump” that usually controls
the balance of potassium and sodium runs slower
 As a result, the level of sodium in the cells rises and the
potassium leaks out of the cells and is lost (for example,
in urine or stools)
 Provide Potassium And Restrict Sodium
 Fluid may then accumulate outside of the cells (as in
edema) instead of being properly distributed through the
body.
All severely malnourished children should be given
potassium to make up for what is lost
They should also be given magnesium, which is essential
for potassium to enter into the cells and be retained
The commercially prepared F-75 and F-100 have enough
potassium and magnesium and there is no need to
supplement.
 Note

 Malnourished children already have excess

sodium in their cells, so sodium intake should
be restricted
 If a child has diarrhea, a special rehydration
solution called ReSoMal should be used
instead of regular WHO ORS
 ReSoMal has less sodium and more potassium
than regular WHO ORS.
 The NOT TO DOs

1. Do NOT give DIURETICS to treat Edema

2. Do NOT give IRON during the Initial feeding phase-add
iron only after the child has been on F100 for 2days
3. Do NOT provide high protein formula, over
1.5gm/kg/day in initial phase
4. Do NOT give IV Fluids routinely
5. Don’t give deworming tablets during phase I
 The NOT TO DOs
Do not give diuretics to treat edema
 The edema is partly due to potassium and magnesium
deficiencies that may take about 2 weeks to correct
 The edema will go away with proper feeding including a
mineral mix containing potassium and magnesium
 Giving a diuretic will worsen the child’s electrolyte
imbalance and may cause death
Do not give iron during phase 1 and transition phase
 Add iron only when the child is in phase 2
 Giving iron early in treatment can have toxic effects and
interfere with the body’s ability to resist infection
 The NOT TO DOs
Do not give high protein formula (over 1.5 g protein per
kg body weight daily)
 Too much protein in the first days of treatment may be
dangerous because the severely malnourished child is
unable to deal with the extra metabolic stress involved
 Too much protein could overload the liver, heart, and
kidneys and may cause death
Do not give IV fluids routinely
 IV fluids can easily cause fluid overload and heart failure
in a severely malnourished child
 Only give IV fluids to children with signs of shock
 Treatment will be described in Initial Treatment
 A. Inpatient care

In-patient care has three important phases of

treatment
 Phase 1 (Stabilization phase)

 Transition phase

 Phase 2 ( rehabilitation phase)

 Phase I (Stabilization phase)
 Children with complicated SAM are initially admitted to an
in-patient facility for stabilization
 These children are admitted to phase I room.
Life-threatening medical complications are treated
Routine drugs are given to correct specific deficiencies (
antibiotics, folic acid, vit A..)
Feeding with f-75 milk (low caloric and sodium)
The children in phase 1 should be together in a separate
room or section of the ward and not mixed with other
patients
 Transition Phase
 This phase is important for slow transition as the introduction
of large amounts of RUTF or F100 could lead to
Imbalance of body fluids and severe medical complications
Important to avoid electrolyte disequilibrium.
The diet used is f100(100ml=100kcal)
Quantity of f100 given is equal to the quantity of f75 given
in phase 1 or an equivalent amount of rutf
Expected weight gain should be around 6 g/kg/day.
Transition takes 3 days, during which f-100 or RUTF should
be given
Transition Phase
In this phase:
Routine drugs are continued
Feeding with RUTF or F100 is started
 Phase 2 (Rehabilitation Phase)
 Whenever patients have good appetite and no major
medical complication they enter Phase 2
 Many patients with a good appetite can be admitted
directly into Phase 2
 Give RUTF or F100 according to look-up tables.
 Expected weight more than 8 g/kg/day.
 Start deworming and iron supplementation
During phase 2:

During phase 2:
Routine drugs, deworming tablets and iron, are
started
Feeding with RUTF or F100 is increased in
amount
Child starts gaining weight
Criteria to move from Phase I to transition phase
 Return of appetite (easily finishes the F-75 feeds)
 Reduced edema or minimal edema (++ or less)
 Main medical complications are under control
 No IV line, no NGT
 The child may also smile at this stage.
Children with +++ edema should wait in phase I at
least until their edema has reduced to ++ edema
These children are particularly vulnerable to fluid
overload and heart failure
 Move the child back to Phase 1
• If the patient gains weight more rapidly than 10g/kg/d
• If there is increasing edema
• If a child who does not have edema develops edema
• If there is a rapid increase in the size of the liver
• If tense abdominal distension develops
• If the patient gets significant re-feeding diarrhea - weight loss
• If patient develops medical complication
• If Naso-Gastric Tube is needed
• If patient takes less than 75% of the feeds
 Criteria To Progress From Transition Phase To
Phase II
• A good appetite, taking at least 90% of the RUTF or
F100 prescribed for Transition Phase.
• Edematous patients (kwashiorkor) should remain in
Transition Phase until there is a definite and steady
reduction in oedema (now at + level).
 Move Back From Phase II To Phase I
 Develops any signs of a complication
 Increase/development of edema
 Development of refeeding diarrhea sufficient to lead
to weight loss
 Weight loss for 2 consecutive weighing
 Static weight for 3 consecutive weighing
 Fulfilling any of the criteria of “failure to respond to
treatment”
 Failure to respond
 A child is failing to respond if he or she:
 Does not improve initially (primary failure); or
 Deteriorates/regress after having progressed
satisfactorily to phase 2 with a good appetite
and
 Weight gain in transition phase for in-patients and
deteriorates after an initial response in out-patients
(secondary failure).
Failure to Respond to Treatment
 Failure to Respond to Treatment

 Possible causes :
Inadequate feeding
Specific nutrient deficiencies
Untreated infection
Underlying systemic disorder
 A child may have a primary or secondary
failure to respond to treatment.
 Outpatient Treatment Program (OTP)
 Outpatient care is intended for children
presenting SAM
Without medical complications
Passed appetite test and
For children that have transferred from
inpatient care
 Most children with SAM have no medical
complications and can be treated in outpatient
care
 Outpatient Treatment Program (OTP)
During the OTP, the children with SAM receive:
Ready-to-use therapeutic food ( RUTF)
which are taken at home
Routine medicines which are taken at home,
Follow up care at the outpatient care site
every one week
During follow up their progress in appetite
and weight and presence or absence of
complication will be assessed.
 The 10 Steps for Management of Severe
Malnutrition
Sequential management of severe SAM recommended
The two main aspects of management are
1) Treatment of complications
2) Dietary management and rehabilitation
WHO describes the 10 steps of management of severe
malnutrition
These steps are accomplished in two phases:
 An initial stabilization phase where the acute medical
conditions are managed (steps 1-6);and
 A longer rehabilitation phase (steps 7-10)
 The 10 Steps for Management of Severe
Malnutrition
The first six steps (Steps 1-6) are related to treatment of
complications, and can be remembered with the mnemonic
SHIELDED.
1. S - Sugar deficiency-ie, hypoglycemia
2. H - Hypothermia
3. I -Infection and septic shock
4. EL -Electrolyte imbalance
5. DE - Dehydration
6. D -Deficiencies of folic acid, vitamins, and other micro-
nutrients
 The 10 Steps for Management of Severe
Malnutrition
Steps 7-10 are related to dietary management
which can be remembered by the mnemonic BEST
as described below:
7. B-Beginning of feeding: F-75
8. E-Energy dense feeding: F- 100
9. S-Stimulation of emotional and sensorial
development
10 .T- Transfer to home-based diets before discharge
or transfer to nutritional rehabilitation centers
 Common Incorrect Practices in Initial
Common Incorrect Practices in Initial Correct Practice
Treatment – These cause deaths:

During initial treatment ensure that

Child not fed at night the child is fed every 3 hours at night.

IV fluids given even though child Give IV only if signs of shock (cold hand
is not in shock plus slow capillary refill or weak/fast pulse).

Do not give. Edema will resolve with

Diuretics given to treat edema correct initial treatment using F-75
with correct minerals and vitamins.

High protein diet given immediately Give F-75 until the child stabilizes; then start
F-100.
 Monitor case management practices
Common Incorrect Practices in Initial Correct Practice
Treatment – These cause deaths:

Antibiotics not given because no Presume infection and give

clinical signs of infection antibiotics to all severely
malnourished children as described in
the manual.
Standard ORS used instead of Give ReSoMal to severely
ReSoMal malnourished children with diarrhea.

Child left uncovered at night Provide blanket and ensure the child
is covered at night.
Anemia treated with iron from Wait to start iron until the child has
admission been on F-100 for 2 days.
 F-75, F- 100, & RUTF
FEEDING
Learning Objectives
Preparing F-75 and F-100
Planning feeding for a 24-hour period for a child who is
in:
Phase I
Transition Phase and
Phase II
Measuring and giving feeds to children
Recording intake and output
Planning feeding for a ward
 Introduction
 Feeding is obviously a critical part of managing severe
malnutrition
 Feeding must be started cautiously, in frequent, small
amounts
 If feeding begins too aggressively, or if feeds contain
too much protein or sodium,
The child’s systems may be overwhelmed, and the
child may die
 F-75
 F-75 is the "starter" formula to use during phase 1
 Beginning as soon as possible and continuing for 2-7 days
until the child is stabilized
 Severely malnourished children cannot tolerate usual
amounts of protein and sodium at this stage,
 They may die if given too much protein or sodium
 They also need glucose, so they must be given a diet that
is low in protein and sodium and high in carbohydrate
 F-75
 F-75 is specially made to meet the child’s needs without
overwhelming the body’s systems in the initial stage of
treatment
 Use of F-75 prevents deaths
 F-75 contains 75 kcal and 0.9 g protein per 100 ml
 F-100 Formulas

 As soon as the child is stabilized on F-75

F-100 is used as a "catch-up" formula to
rebuild wasted tissues during transition phase
and phase 2
F-100 contains more calories and protein: 100
kcal and 2.9 g protein per 100 ml.
 RUTF
 Is high-energy, nutrient-dense food
Used for nutrition rehabilitation during phase 2 of
in-patient care and outpatient care (OTP)
 Good for out-patient or home management of SAM
 It is similar in composition to F100 (except RUTF
contains iron)
 The RUTF plumpy’nut has a caloric value of 500 kilocalories
(kcal) and 12.5 gm of protein per one sachet of product (92 gms)
 There are two types:
Soft lipid-based paste (plumpy’nut®) or crushable
nutrient bar (BP100).
 RUTF
 The principle behind the recipes is to provide the energy
and protein needed for catch-up
Note:
 The commercially manufactured F75 and F100 have all
the necessary minerals and vitamins.
 Thus, there is no need to add mineral mix or vitamins or
CMV in to these feeds.
 Discharge Criteria
 The national protocol recommends that children with
SAM should be discharged
As cured from therapeutic feeding program (TFP) if
the child attains the following criteria:
Age 6 months to 5 years:
A weight-for-length or height >=85% on more than one
occasion
Two days for in-patients
Two weeks for out-patients and
No edema for 10 days (in-patient) or 14 days (out-patient) or
A target weight gain reached for two consecutive measurements or
visits if the child is admitted with MUAC
Discharge Criteria
Age less than 6 months or less than 3 kg being breast fed:
If he/she is gaining weight on breast milk alone after the
Supplemented Suckling technique has been used
Age less than 6 months with no prospect of being breast-
fed:
When they reach ≥85% weight for length and switched to
infant formula or other animal milk
 Discharge Criteria
 It usually requires about 2 – 6 weeks for a child to
achieve the target weight
 If the principles of care for SAM are followed
 If a child leaves the TFP before achieving 85 % weight-
for-height/length, he/she is likely to get worse and have to
return, or h/she may die at home
 If the caretaker decides to go home before fulfilling the
discharge criteria and there is no OTP in the area, many
preparations must be made to ensure that the caretakers
can continue care at home
 Follow-up visits are essential
Managing Of Medical Complication
Learning Objectives
Identifying and managing the severely malnourished
child with:
Hypoglycemia
Hypothermia
Shock
Severe anemia
Corneal clouding and ulceration
Watery diarrhea and/or vomiting and dehydration
Heart failure
Infections
Abdominal distension
Introduction
The focus of managing medical complication
Is to prevent death while stabilizing the child.
The first step is to check the child for serious medical complications
and provide emergency treatment as necessary
Any child presenting to the hospital or health center should be
checked for serious medical complications as part of standard
procedure
If serious medical complications are present, many procedures must
be done very quickly, almost simultaneously
Practice and experience is needed to perform efficiently in an
emergency room as a team.
Daily Care

Handle the child gently

Give Routine medicines and other medications
Give antibiotics as prescribed
Give vitamin A
Give Measles Vaccine
Give Deworming tablets
Give Iron
Care for skin and bathe the child
Care for the eyes
 Handle the child gentle
 Children with SAM must be handled very gently,
especially at the beginning of their care
 The body of a child with SAM is fragile and bruises
easily
 The child needs all his energy to recover, so he
must stay calm and not become upset
 It is important to speak quietly and handle children
as little as possible at first
 Hold and touch children with loving care when
feeding, bathing, weighing, and caring for them.
 Folic Acid

• Folic acid is a vitamin important for treating and

preventing anemia and repairing the damaged gut
• There is sufficient folic acid in commercially
manufactured F75, F100 and RUTF to treat mild
folate deficiency
• Folic acid: On the day of admission, one single
dose of folic acid (5 mg) can be given to children
with clinical signs of anemia.
 Vitamin A
 Vitamin A should be given orally to all children with
SAM on the day of admission (on day 1)
Except those with edema or those who received
vitamin A in the past 6 months
However, for children with edema, it should be given
once the edema subsides.
Children with measles and any clinical signs of
vitamin a deficiency should be given vitamin a on
admission even if edema is present
 Give a second dose on discharge if the child finishes the
treatment in in-patient care
Timing and oral dosages of vitamin A
 Measles vaccine
 All children from 9 months who are not vaccinated should
be given measles vaccine both on admission and discharge
after Phase 2
 The first measles dose often does not give a protective
antibody response
 It is given because it ameliorates the severity of incubating
measles and partially protects from nosocomial measles
 The second dose is given to provoke protective antibodies.
 Give Deworming tablets

 Worms are common in older children who play outside,

and they can be a problem in severely malnourished
children
 They can cause dysentery and anemia
 Albendazole or Mebendazole is given at the start of phase
2 for children greater than 1 year that will remain as in-
patient
 For those transferred to outpatient Albendazole or
Mebendazole is given at the second outpatient visit (after 7
days).
 Iron
 Even if the child is anemic, he/she should not be given iron
until he is recovering and he/she is in phase 2
 If given earlier, iron can have toxic effects and reduce
resistance to infection
 Provide iron to a child who is in phase 2
 Add 1 crushed tablet of ferrous sulphate (200 mg) to each
2 to 2.4 liters of F100
 Don't give iron to a child who is taking RUTF because it
already has the required amount of iron.
 Eye care

• Chloramphenicol or tetracycline eye drops are

given for eye infection or possible eye
infection
• Atropine eye drops are used to relax the eye
when there is corneal involvement (i.e.,
corneal clouding or ulceration)
• In some cases both types of eye drops may be
needed