Course 3: Management of malnutrition

•  :4 hrs 30 min
• : National Guidelines for integrated management of acute
malnutrition
• : Power point handouts
•  Case studies: Management of malnutrition: OTP and in
patient care
• : Reductive adaptation notes

1
 MANAGEMENT OF MALNUTRITION

• Content overview
– definitions
– patho - physiology of malnutrition
– causes of malnutrition
– categories of malnutrition
– diagnosis of acute malnutrition
– nutrition education and counseling
– nutrient – based interventions

2
 Objective

• To equip health service providers with

knowledge and skills through:
– enhancing understanding on best practices
– prevention of malnutrition by early identification
– Effective management of malnutrition in order to
improve treatment outcomes including morbidity
and mortality

3
 Course 3a : Introduction to Management of
acute malnutrition

4
 Definitions
• Malnutrition is defined as any nutritional disorder. It may
result from an unbalanced, insufficient, or excessive diet
or from impaired absorption, assimilation, or use of
foods
• Over-nutrition – a condition of excess nutrient and
energy intake over time. Over nutrition may be regarded
as a form of malnutrition when it leads to morbid
obesity.
• Obesity – an abnormal increase in the proportion of fat
cells, mainly in the visceral and subcutaneous tissues of
the body.
• Under-nutrition – malnutrition caused by an inadequate
food supply or an inability to use the nutrients in food.

5
 Continued…
• Oedema – the abnormal accumulation of fluid in the
interstitial spaces of tissues such as the pericardial sac, intra-
pleural sac, peritoneal cavity, or joint capsules.
• Food security refers to physical and economic access to food
of sufficient quality and quantity
• Nutrition security refers to secure access to food coupled
with sanitary environment, adequate health services, and
knowledgeable care to ensure healthy life.
• Z score – a normalized value created from a member of a set
of data by expressing it in terms of standard deviations from
the median.

6
 Causes of malnutrition
• Food: Inadequate household food security (limited
access or availability of food)
• Nutrition: Inadequate access to food coupled with
unsanitary environment, inadequate health
services, and lack of knowledgeable care to ensure
healthy life.
• Health: Limited access to adequate health services
and/or inadequate environmental health
conditions.
• Care: Inadequate social and care environment in
the household and local community, especially in
regard to women and children.

7
 Conceptual framework of malnutrition (UNICEF 1991)

8
 Pathophysiology of Undernutrition

Reductive adaptation
Reductive adaptation is defined as the
physiological response of the body to under
nutrition i.e. Systems slow down and do less in
severe acute under nutrition in order to allow
survival on limited nutrient resources
especially calories.

9
 Pathophysiology of undernutrition

•reduced cellular metabolism

•reduction of protein/enzymes synthesis
•reduced cardiac output
•reduced kidney function - Limited capacity
of excretion,
•Electrolyte imbalance - Concentration K+ ↓;
Na+ ↑
•Iron - anaemia
•low transferrin
•Immune system-Inflammatory responses
absent or severely weakened
•Thermoregulation altered; poikilothermia:
hypothermia/pyrexia

10
 INTRODUCTION TO PATHO-
PHYSIOLOGY OF MALNUTRITION

11
 PHYSIOLOGICAL BASIS FOR TREATMENT
OF MALNUTRITION

12
 Cardiovascular system (1)
• Cardiac output and stroke volume are
• reduced
• Infusion of saline may cause an
• increase in venous pressure
• Any increase in blood volume can easily
produce acute heart failure;
• Any decrease will further compromise tissue
perfusion

13
 Cardiovascular system (2):

• Blood pressure is low

• Renal perfusion and circulation time
are reduced
• Plasma volume is usually normal and
• red cell volume is reduced

14
 LIVER (1)

• Synthesis of all proteins is reduced

• Abnormal metabolites of amino acids
are produced c
• Capacity of liver to take up, metabolize
and excrete toxins is severely reduced
• Energy production from substrates
such as galactose and fructose is much
slower than normal
15
 LIVER (2)

• Gluconeogenesis is reduced, which

increases the risk of hypoglycaemia
during infection
• Bile secretion is reduced

16
 GENITOURINARY SYSTEM (1)

• Glomerular filtration is reduced

• Capacity of kidney to excrete excess
acid or a water load is greatly reduced
• Urinary phosphate output is low
• Sodium excretion is reduced
• Urinary tract infection is common.

17
 GASTROINTESTINAL SYSTEM (2)

• Production of gastric acid is reduced

• Intestinal motility is reduced
• Pancreas is atrophied and production
of digestive enzymes is reduced
• Small intestinal mucosa is atrophied;
secretion of digestive enzymes is reduced
• Absorption of nutrients is reduced
18
 IMMUNE SYSTEM (1)
• All aspects of immunity are diminished
• Lymph glands, tonsils and the thymus are
atrophied
Cell-mediated (T-cell) immunity is severely
depressed
• IgA levels in secretions are reduced
• Complement components are low
• Phagocytes do not kill ingested bacteria
efficiently
19
 IMMUNE SYSTEM (2)
 Tissue damage does not result in inflammation or
migration of white
cells to the affected area
 Acute phase immune response is diminished
 Typical signs of infection, such as an increased white
cell count and fever,
are frequently absent
 Hypoglycaemia and hypothermia are both signs of
severe infection and are
usually associated with septic shock
20
 ENDOCRINE SYSTEM

• Insulin levels are reduced and the child has

glucose intolerance
• Insulin growth factor 1 (IGF-1) levels
are reduced
• Growth hormone levels are increased
• Cortisol levels are usually increased

21
 CIRCULATORY SYSTEM

• Basic metabolic rate is reduced by about 30%.

• Energy expenditure due to activity is very low
• Both heat generation and heat loss are
impaired; the child becomes hypothermic in a
cold environment and hyperthermic in a hot
environment

22
 CELLULAR FUNCTION

• Sodium pump activity is reduced and cell

membranes are more permeable than normal,
• which leads to an increase in intracellular
sodium and a decrease in intracellular
potassium and magnesium
• Protein synthesis is reduced

23
 SKIN,MUSCLES AND GLANDS

• THE skin and subcutaneous fat are and glands

atrophied, which leads to loose folds
• Many signs of dehydration are unreliable; eyes may
be sunken because of loss of subcutaneous fat in the
orbit
• Many glands, including the sweat, tear and salivary
glands, are atrophied; the child has dryness of the
mouth and eyes and sweat production is reduced
• Respiratory muscles are easily fatigued; the child is
lacking in energy

24
 Categories of Under nutrition
• Acute and Chronic under nutrition.
• Children can have a combination of both acute and
chronic under nutrition.
• Acute under nutrition is categorized into Moderate
and Severe acute under nutrition, determined by the
clients degree of wasting (is an indicator of acute
undernutrition, the result of more recent food
deprivation or illness).
• All cases of bi-lateral oedema are categorized as
severe acute under nutrition.
25
 Categories of under nutrition continued…

• Chronic under nutrition is determined by a patient’s

degree of stunting (the result of prolonged food
deprivation and/or disease or illness), i.e. when a
child has not reached his or her expected height for a
given age.
• To treat a patient with chronic under nutrition
requires a long-term focus that considers household
food insecurity in the long run; home care practices
(feeding and hygiene practices); and issues related to
public health.
26
 Assessment

• Anthropometry
• Biochemical
• Clinical
• Dietary
• Economic (social-economic status)

27
 Severe acute under
Indicator Moderate acute under nutrition Mild acute under nutrition
nutrition
Children 6 months to 59 months
Weight for height /
< - 3 Z score Between – 3 to < -2 Z score Between -2 to < -1 Z score
Length Z scores
Weight for height /
< 70% W/H Between 70 – 80 % W/H Between 80 – 90%
Length % of median
MUAC < 11 cm ( under 5s) 11 –13 cm (under 5 s)
Bilateral pitting
Oedema (+) present Oedema absent Oedema absent
Oedema
Children 5 – 9 years
BMI for age Z scores < - 3 Z score Between – 3 to < -2 Z score Between -2 to < -1 Z score
MUAC < 13.5 cm Between 13.5 – 14.5 cm
Bilateral pitting
Oedema (+) present Oedema absent Oedema absent
Oedema
Adolescents 10 – 17 years
BMI for Age Z score < - 3 Z score Between -3 and -2 Z score Between -2 to < -1 Z score
MUAC <16 cm Between 16 – 18.5cm
Bilateral pitting
Oedema (+) present Oedema absent Oedema absent
Oedema
Adults 18 years and above
BMI < 16 cm Between 16 – 17 kg/m2 Between 17 – 18.5 kg/m2
- <16 cm
- 16-18.5cm plus one of
the 16 - 18.5cm with no relevant
MUAC following: clinical signs.
1. Inability to stand Few relevant social criteria
2. Apparent
dehydration
Oedema Oedema (+) present Oedema absent
Pregnant or postpartum women
28 MUAC < 22 cm Between 22 - 23 cm Between 23 – 24 cm
Oedema Oedema (+) present Oedema absent
 Course 3b: Severe malnutrition 1–

recognition and early treatment

29
 Objectives

• Learn to recognise severe malnutrition

• Learn to manage ALL the problems present in
these children
• Understand new approaches to feeding and
recognise it as the primary treatment.

30
 Definitions of Severe PEM (1)
WHO Classification:

+ Oedema No oedema

Severe wasting
(WHZ <-3) Severe wasting
+ oedema*

* If there is severe oedema the weight may appear

reasonable initially.

31
 Definitions of Severe PEM (2)
WHO Classification:
+ Oedema No oedema

Severe wasting
WHZ <-3 Severe wasting
+ oedema*

Two simple signs are useful

for classification
32
 Clinical Diagnosis / Definition

• Presence of visible severe wasting

– Buttocks, thighs, shoulders
• Presence of symmetrical oedema with
supporting evidence for kwashiorkor:
– Skin changes
– Hair changes
• Weight for age (Road to Health Card Chart)
• Should be the minimum form of assessment

33
 Clinical Diagnosis

Source: KEMRI /Wellcome Trust

But you have to look…..it is

often missed
34
 Why is detecting malnutrition
important?
• In many hospitals the commonest reason for
death of a child in hospital is PEM
• Case fatality of severe malnutrition in hospital
in Africa is 30-40% (3 or 4 out of 10 die in
hospital)
• If it is not recognised it is not treated properly
and deaths are not prevented.

35
 Kwashiorkor – where logic fails

Protein
deficiency

Treatment
with a high
protein diet

Source: KEMRI /Wellcome Trust

36
 Kwashiorkor – where logic fails

Protein
deficiency

Treatment
with a high
protein diet
Source: KEMRI /Wellcome Trust

37
 Severe malnutrition

Protein –
Energy
Malnutrition

38
 Severe malnutrition

Micronutrient
Protein – Electrolyte and and Vitamin
Energy mineral deficiencies
Malnutrition deficiencies

39
 Electrolyte / Mineral Deficiencies

• Potassium:
– Potassium supplements help reduce
oedema
– Muscle weakness / apathy
– Reduced cardiac output.
• Magnesium (convulsions / arrhythmias)
• Zinc (diarrhoea / skin disease)
• Copper (anaemia)
• Selenium (heart failure)
Source: KEMRI /Wellcome Trust

40
 Electrolytes / Minerals – What about Sodium?

• Total body sodium is often increased

– Expansion of extracellular fluid volume
– Leakage of sodium into cells – sick cell
syndrome
• Giving sodium (iv fluids / salty foods) can
be dangerous

41
 What other problems do these children
commonly have?

42
 10 Step Approach
Hypoglycaemia
Hypothermia
Dehydration Monitoring
Electrolytes
Infection
Micronutrients
Initiate feeding
Catch-up growth
Sensory stimulation
Discharge preparation
43
 Hypoglycaemia and Hypothermia

• All new admissions with malnutrition

should be kept warm until there are signs of
recovery.
• iv or ngt glucose for those who are
unconscious or very severely ill with no
glucose measurement.
• Immediate ngt feeding for conscious
children with blood glucose < 3mmol/l
44
 Dehydration

• Shock is treated with special fluid plans and

Half-Strength Darrow’s with 5% dextrose.
• Oral rehydration is with ReSoMal.
• Feeding must be started by 12 hours.

45
 Oral re-hydration in Severe Malnutrition.
All concentrations are in Osmolarity
Na+ K+ Osmolarity
mmol/l Glucose

New WHO /
75 20 111
UNICEF ORS
Rehydration Solution ~ 200
for Malnutrition – 45 40 Glucose
ReSoMal*. &saccharose

*Add 2 WHO ORS ‘500ml’ sachets to 2 litres water rather then 1

litre, then add 50g (5 teaspoons) sugar and 60 mmols Potassium
Chloride (3 10ml iv vials of strong potassium, 20mmols/10mls)

46
Composition
of RESOMAL

47
• Note
use of
2 liters
of
water

48
 Oral re-hydration in Severe Malnutrition

• Resomal 5ml/kg every 30 mins for 2 hours.

• Use an ngt early.
• Then 5 – 10 mls/kg each hour for a maximum of
10 hours
– Give 10 if the child thirsty / severe dehydration, 5 if
not.
• Introduce starter milk (F-75) at 4 hours and slowly
replace Resomal with starter milk over 12 hours.
• Continue breast feeding throughout.

49
 Electrolytes & Minerals

• All severely malnourished children have

potassium deficiency.
• All should receive an extra 4mmol/kg/day of
oral potassium (after stopping ReSoMal).
• Ideally should receive Mg, Zn, Cu and Se as
part of mineral mix – added to milk feed.

50
 Infection
• Up to 1/3rd children with malnutrition who die
have septicaemia / bacteraemia
• Fever and other signs of infection are not helpful
in identifying these children when there is severe
malnutrition.
• ALL children with severe malnutrition sick enough
to be in hospital should be started on Penicillin (or
Ampicillin) and Gentamicin for at least 5 days.
• In addition they receive oral metronidazole and
treatment for thrush if present.

51
52
Vitamin A deficiency

Source: KEMRI /Wellcome Trust

 Vitamins

• Vitamin A:
– With Eye signs: 200,000 iu on admission, on Day 2
and on Day 14 (100,000 iu if aged < 12 months).
– Without Eye signs: stat dose appropriate for age
• Multivitamins – 1 tablet twice daily for 14
days.

53
 First feeding.

• Feeds need to be prescribed – they are

treatment!

54
 Questions?

55
 Course 3c: Severe malnutrition 2-

nutritional treatment

56
 Objectives

• Understand the link between observed

pathophysiological abnormalities and
treatment.
• Consider the priorities and aims of immediate
nutritional management.
• Non-nutritional management is considered
elsewhere.

57
What are the problems faced in

Source: KEMRI /Wellcome Trust

providing acute nutritional
therapy?

• Reduced appetite and willingness to feed

• Fatty liver with reduced synthetic functions
• Absorption of nutrients is probably adequate but
may be reduced by diarrhoea and small bowel
bacterial overgrowth
• Reduced renal ability to excrete sodium
• Impaired cardiac contractility
A state of physiological ‘standby’ – awaiting gentle re-
awakening
58
 Gentle nutritional rescue – the process of
feeding

• Immediate feeding
• Small volume / frequent feeding because of small
stomach capacity and precarious physiology
• Vomiting is NOT a contraindication to feeding
• Routine insertion of a naso-gastric tube should be
considered
• Feeds are the ‘drug’ to cure malnutrition, they are
a priority (after correction of dehydration if
required).

59
60
Contents of F-75. Note that this is
61
 The feed content – 1 litre of F75
Ingredient Amount
Dried skimmed milk 25g
Sugar 100g
Vegetable Oil 27mls
Mineral solution 20mls
Water make up to 1000mls

Mineral solution ideally contains minerals and trace

elements – if not available at least add 40mmols
potassium (2x 10mls iv KCl vials) to each 1000mls of
62 feed
 The feeding plan – a prescription

• What is the weight?

• Marasmus
– 130 ml/kg/day start-up feed
• Kwashiorkor / marasmic kwashiorkor:
– 100 mls/kg/day start-up feed
• Ideally given in 12 two hourly feeds, or, if not
possible, 8 three hourly feeds
• …..this means at night too!

63
 What would this provide?

Marasmus Kwashiorkor
130 mls/kg/day 100 mls/kg/day

Calories 100 kcal/kg/day 75 kcal/kg/day

0.75 – 1.3
Protein 1 – 1.5 g/kg/day
g/kg/day

64
 Why do we not give more?

• The body really cannot tolerate more

• Too vigorous re-feeding has been
associated with increased mortality.
• Too much sugar can cause an osmotic
diarrhoea
• Higher protein contents are usually
associated with higher sodium contents
that can make oedema worse and
precipitate heart failure.
65
 Feeding this child? –
10kg

• Total 24 hour feeds?

• 3 hourly feed volume?

66
 Feeding this child? –
10kg

• Total 24 hour feeds?

– 1300 mls
• 3 hourly feed volume?
– 165 mls

67
 Standard initial nutritional
prescription…age 3 yrs, 10 kg

F-75 165 mls 3 hourly

Potassium chloride 5mmol

2 tabs qds
tabs (crushed in feed)
200,000 iu stat, on day 2
Vitamin A (has eye signs)
and day 14

Multivitamin 1 tab twice daily

68
 When to change from
rescue feeding?

• Return of appetite:
– 2 to 3 days after admission in those with no oedema
and modest levels of activity
– 5 to 7 days after admission in those with severe
lethargy / severely ill at admission
• Oedema:
– You do not have to wait for resolution of oedema
before changing to recovery feeding if the child has a
good appetite.
• Feed with cup / cup and spoon
69
 Weight gain in the first week
• Rescue feeding is usually NOT associated with weight
gain
• Weight loss may even occur in children whose
oedema is improving
• Do not panic!
– Ensure at least 100 mls/kg/day of starter feed has been
given.
– Early recovery involves loss of body water (reducing weight)
and increases in cellular mass (increasing weight)
• Appetite and activity level denote recovery in the first
week, not weight change.

70
71
72 F100 : to be mixed with 2litres of water. Note it has vitamins &minera
Contains peanut paste, vegetable fat, dry skimmed milk, dry whey, sugar,
73 minerals & vitamin complex
74
 The feed content – 1 litre of F100
Ingredient Amount
Dried skimmed milk 80g
Sugar 50g
Vegetable Oil 60mls
Mineral solution 20mls
Water make up to 1000mls

Mineral solution ideally contains minerals and trace

elements – if not available at least add 40mmols
potassium (2x 10mls iv KCl vials) to each 1000mls of
75 feed
 What would this provide?

F75 – Starter F100 – Catch-up

100mls 100mls

Calories 75 kcal 100 kcal

Protein 0.9 g 3g

76
 A feeding plan

Admission

130 or 100 ml/kg/day

as 3 hourly feeds, for 2
-7 days

F75

77
 A feeding plan
Appetite
Admission recovers
130 ml/kg/day as
3 hourly feeds for
2 – 3 days

F100, same
volume as
F75
F75

78
 A feeding plan
Appetite Good appetite,
Admission recovers clinically stable

F100, volume
increasing until
F100, same
appetite satisfied
volume as
F75 F75

79
 A feeding plan
Good appetite,
clinically stable
Increase each feed by
10mls until some is not
eaten – usually achieve
180 – 200 ml/kg/day F100, volume
increasing until
appetite satisfied

80
 Preparation of small quantities of
resomal,F75 AND F100 therapeutic
milk

81
 OBJECTIVES
Be able to:
Adequately reconstitute small quantities
of ReSoMal,F75 and F100 therapeutic milk
Use appropriate household measures
while measuring volumes of ReSoMal,F75
and F100

82
 You can use the NUTRISET
measuring scoop to measure the
right quantity of powder to
prepare small quantities of
ReSoMal,F75 and F100

83
 WARNING

The following data is ONLY valid with the

NUTRISET measuring scoop
Nutriset measuring scoops are easily
recognisable.They are RED with the NUTRISET
logo embossed on the handle

84
 PREPARATION OF RESOMAL

• Mix 1 level scoopful of ReSoMal into 140ml of

water

PREPARATION OF F-75 THERAPEUTIC MILK

Mix 1 level scoopful of F-75 therapeutic milk
powder into 20ml of water

85
 PREPARATION OF F-100

• Mix 1 level scoopful of F100 therapeutic milk

powder into 18 ml of water

86
 Prescribing RUFT

• How many packets would you give a two years

old who weighs 10kg and has kwashiorkor
and is in the translation period?

87
 Then what?

88
 Rehabilitation
• Introduce solid foods and increase to 5
appropriate meals a day.
• Continue snacks in between
• Continue breast feeding
• Continue mineral supplements for 2 weeks
• Start oral iron and mebendazole therapy after 1
week
• Monitor progress
• Provide stimulation / play
• Educate the family and prepare for discharge

89
 Monitoring 1
Rescue
Fever / Recovery
Hypothermia
Fever /
Glucose Hypothermia
Respiration Respiration

Heart Rate Heart Rate

Weight Weight Rehabilitation

Oedema Oedema Weight

90
 Monitoring 2
• Intake of feed should be monitored
throughout
• If there is concern for heart failure (↑HR,
↑RR) in the rescue phase reduce feed volumes
for 24 hours.
• Weight gain in recovery / rehabilitation
phases:
– Poor, <5g/kg/day, full re-assessment
– Moderate, 5 – 10g/kg/day, check intake adequate,
is there untreated infection
– Good, >10g/kg/day

91
 When to discharge?
• Completed antibiotics
• Good appetite and gaining weight
• Lost any oedema
• Appropriate support in the community or home
• Mother / carer:
– Available
– Understands child’s needs
– Able to supply needs

92
 10 Step Approach
Hypoglycaemia
Hypothermia
Dehydration Monitoring
Electrolytes
Infection
Micronutrients
Initiate feeding
Catch-up growth
Sensory stimulation
Discharge preparation
93
 Questions?

94
 Summary

• The rescue phase of nutritional support

requires gentle introduction of calories and
small amounts of protein.
• Potassium, vitamins and ideally other minerals
should routinely be given
• Recovery feeding starts as the appetite returns
and is gradually scaled up.

95
• You are asked to see a 2 year old boy in OPD
who is said to have severe wasting and look
very unwell.

What do you do?

96
 Rx -1
1. Oxygen 1-2 l/min via nasal prongs.
2. IV HSD in 5%Dextrose120mls in 1 hr- 70 drops
per min.
3. IV 10% dextrose 35 mls over 5min
4. Keep warm.
5. KCl 10mmol added in tds feed
6. IV X-pen 700,000 IU 6 hrly.
7. IV Chloramphenicol 175 mg 6 hrly.
8. IM Quinine 105mg stat then 70 mg 12hrly.

97
 Rx- 2

8. Vit A 200,000IU stat. Eye changes ???

9. Multivit 1 tab BD for 2 weeks.
10. Folic acid 2.5 mg on alt days.
11. Zinc 20 mg OD for 2 weeks.
12. F75; 910 mls in 24 hrs – 115 mls 3hrly

98
 Fluid plan -Resomal 70mls hourly
Resomal 0800hrs – 70mls
Resomal 0900hrs- 70 mls
Resomal 1000hrs-70 mls Then F75; 115mls every
3 hrs
F75 1100hrs – 70 mls Resomal 70mls after
every loose stool
Resomal MD – 70mls
Resomal 1300hrs- 70 mls
Resomal 1400hrs-70 mls

F75 1500hrs – 70 mls

Resomal 1600hrs- 70mls

99
 Summary.

• The risk of death in children with severe

malnutrition is very high.
• The children have many problems and each
needs treating.
• The 10 steps approach allows each problem to
be treated
• Feeding should not be a high protein diet.

100
 OUT PATIENT CARE….

101
 OBJECTIVES

• Increase coverage and access to treatment

• Timeliness: Case finding and treatment before malnutrition

escalate

• Appropriate care: effective treatment for those who can be

treated at home

102
 WHO IS ELIGIBLE?

• Those with severe acute malnutrition (SAM)

with no medical complications are treated at
OTP and are given RUTF and routine
medicines to take home.

• Only applicable in a setting where OTP has

been established and RUTF available

103
 TRIAGE…ADMISSION CRITERIA
MEDICAL EXAMINATION AND APPETITE TEST

SAM with SAM without

complications complications Moderate Acute
•Nutritional oedema ++,+++ malnutrition
OR •WHZ<-3 without
•Marasmic Kwashiorkor complications
OR
(WHZ<-3 OR/MUAC<115mm with any
grade of oedema) •MUAC<115mm WHZ>-3 and <-2
OR OR Or
•WHZ<-3(OR WHM<70%)
•MUAC<115mm •Nutritional oedema + MUAC >115mm and
•Nutritional oedema + <125mm
AND
AND
No appetite and /or •Appetite Supplementary Feeding
complications(IMCI danger signs) •Clinically well
Infants
6months unable to suckle or visibly •Alert
wasted
Out Patient Care
In Patient Care
104
 APPETITE TEST (1)

Why to conduct one?

• Major medical complications lead to loss of appetite

• It is mainly metabolic malnutrition that causes death. Often

the only sign of severe metabolic malnutrition is a reduction
in appetite

 A poor appetite means that the child has a significant

infection or a major metabolic abnormality such as liver
dysfunction, cell membrane damage, electrolyte imbalance.
These children are at immediate risk of death and neeed
inpatient care.
105
 APPETITE TEST (2)

How to conduct one?

• In a separate area
• Explain to care giver how
• Care giver washes hands
• Care giver offers RUTF
• Child need to be offered plenty of water

106
 APPETITE TEST (3)

Result of the appetite test Kg Sachets

A child who takes the minimum <4 1/8 to ¼
amount for their weight as
indicated in the table has passed 4-6.9 ¼ to 1/3
7-9.9 1/3 to ½
A child that does not take at least the
amount of RUTF indicated in the 10-14.9 ½ to ¾
table has failed
15-29 ¾ to 1
>30 >1
107
 FOOD RATIONS (1)
Ready-to-Use Therapeutic Food (RUTF)
• This is a specialized food that is:
• developed specifically for the recovery of severe malnutrition
at home.
• energy-dense, mineral/vitamin-enriched product equivalent
to F100 with added iron.
• It contains the required energy and micronutrients to meet
the nutritional needs of the severely malnourished child.
• oil-based, ready-to-use product that has a low risk of
contamination. It provides approximately 530Kcal per 100g.
• Used for nutrition rehabilitation in the community and is
effective when the patient receives a weekly supply of take
home RUTF. Why?
•

108
 FOOD RATIONS (2)

Ration
• The ration given to a severely malnourished child
is based on the intake requirement of between
150-200 kcal/kg/day.

• The amount of RUTF to be consumed per day is

based on the weight of the child

109
 FOOD RATIONS (3)

Class of weight (kg) RUTF

sachet per day sachet per week

3.5 - 3.9 1 .5 11
4.0 – 5.4 2 14
5.5 – 6.9 2.5 18
7.0 – 8.4 3 21
8.5 – 9.4 3.5 25
9.5– 10.4 4 28
10.5 – 11.9 4.5 32
≥ 12 5 35

110
 ROUTINE MEDICATION
Medication Direct admission to out-patient community
nutrition care
Vitamin A One (1) dose on the fourth week (fourth visit)
One (1) dose at health facility on admission, if
Folic Acid
signs of anaemia
Give first dose at the health facility and
give remainder of treatment to the
Amoxicillin
parent/caregiver with instructions to give twice
daily for seven days at home
Malaria According to national protocol
Measles
(children 6 months and 1 vaccine on the fourth week (fourth visit)
older)
Iron None: sufficient iron is in RUTF

De-worming
111 1 dose on the second week (second visit)
(children >1 year old)
 MONITORING

Task Frequency
Patient attends health facility weekly
Patient receives replacement RUTF weekly
Health worker checks weight weekly
Health worker checks MUAC weekly
Health worker checks height monthly
Health worker checks vital signs:
weekly
temperature, pulse & respiration rate
Health worker conducts Appetite Test weekly
Health worker does medical check weekly
Health worker fills in patient card and ration
weekly
card

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 HOME CARE

Community health workers and Care givers are playing a key role
in the recovery of the child (!!!)

• Ensure food eaten (only RUTF)

• Give safe water to drink
• Wash hands
• Do not share RUTF with other members
• Seek CHW if concerned with patient’s condition
• Give routine medicine
• Attend health facilities for weekly visits
• Keep child warm
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 TRANSFER TO INPATIENT CARE

If the outpatients develops any of the following, the patient is

transferred to the in-patient facility:

• Failure of appetite test

• Increase or develop oedema
• Re-feeding diarrhea that leads to weight loss
• Weight loss for 3 consecutive weighing, or 2 weeks
• Weight loss of more than 5% of body weight at any visit
• Static weight for 3 consecutive weighing
• Fulfilling any criteria of ‘failure to respond’ (next slide)
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 FAILURE TO RESPOND

᥈ Out Patient Community Nutrition Care

Criteria for failure to respond After
Primary failure to respond
Failure to gain any weight (non-oedematous children) 21 days
Failure to start to lose oedema 14 days
Oedema still present 21 days
Weight loss since admission to program 14 days
(non-oedematous children)
Secondary failure to respond

Failure of Appetite test At any visit

Weight loss of 5% of body weight At any visit
Weight loss for two successive visits 14 days

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 POSSIBLE CAUSE OF FAILURE

• Community care is inappropriate for patients to go directly to

out-patient care
• Poorly conducted appetite test
• Inadequate instructions given to mothers
• Inaccurate quantity of RUTF dispensed to child
• Health facility long distance
• Share of food with siblings…or caregivers
• Micronutrients deficiency
• Mal-absorption
• Unwilling or too busy care giver
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 DISCHARGE CRITERIA FROM OTP TO SFP

 W/H >80% (where there is SFP) or W/H >85% (in the

absence of SFP) for two consecutive measurements and
 MUAC >11.0cm and
 No oedema for two consecutive visits.
Cured  W/H -2 Z-score (where there is SFP)
 W/H -1 Z-score where there is no SFP
 Children admitted on MUAC, or stabilised from an in-
patient facility, are discharged from the outpatient
community nutrition care after a minimum of two
months.
Defaulted Absent for two consecutive visits
Died while registered in the out-patient community nutrition
Died
care
Has not achieved discharge criteria within four months.
Non-recovered Link the child to other programmes e.g. IMCI, OVC, HBC, ART
Clinics, or targeted food distributions.

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