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Steps to Child Health: Malnutrition Management Pathways

Explore the journey of a 1-year-old girl with malnutrition, including symptoms, treatment, and management strategies, emphasizing community involvement. Learn about CMAM, WHO guidelines, micronutrient deficiencies, and the global impact of malnutrition. Uncover the road to child health through effective patient care and community interventions.

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Steps to Child Health: Malnutrition Management Pathways

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  1. The Steps Yet To Be Taken THE ROAD TO CHILD HEALTH

  2. INVOLVES IN PATIENT CARE COMMUNITY MANAGEMENT OF MALNUTRITION RCH CLINIC

  3. M.R • 1 yr 9 months old • Female • Admitted on 14/03/2016 • Referral from Gonja Lutheran Hospital

  4. M/C • Skin rashes for 3/12 • Mouth ulcers for 2/12 • Swollen lower limbs for 1/12 • Right eye discharge for 2/7 • Diarrhea for 2/7

  5. HPI • Seen as outpatient and given symptomatic treatment • Admitted with anasarca and treated for 3/52 • While in ward developed pus discharge right eye and wound in peri anal region

  6. Other history • Natal hx: Born via C/S weighed 3.9kg. • Post-natal hx: exclusively breastfed for 6 months • Immunization: up to date • Developmental milestones: normal

  7. Nutritional history • Positive history of poor appetite from 8 months of age • Weight loss since 1 year of age.

  8. Clinically

  9. Anasarca Flaky paint dermatitis

  10. Anthropometric measurements • MUAC – 13cm • Length – 68.5cm • Weight – 7kg • Weight for length -1 and -2 SD

  11. Systems

  12. Local Examination

  13. Provisional diagnosis

  14. Investigations

  15. Medical Treatment • IV Antibiotics • Cloxacillin • Metronidazole • Ceftriaxone • Management for malnutrition • Vitamin A • Ped Zinc • Cod Liver Oil • Multivitamins • 140mls of whole blood

  16. Nutritional support • Feeding: via NGT • F75 125mls PO 2hourly • ReSoMal 50mls PO after each loose motion

  17. Supportive • Kept warm • Regular skin care with potassium permanganate soaks • Sitz baths with Dettol • 2 hourly turning

  18. Multidisciplinary team • Ophthalmology review • Recommended evisceration RE when stable • Added • Ciprofloxacin eye drops QID • Chloramphenicol eye drops TDS • Normal Saline eye irrigation 4 hourly • Surgical review • Recommended fecal diversion as soon as possible • Anaesthesia review • ASA Grade IV, prepare for surgery

  19. Progress in the ward

  20. So what went wrong in general • Child wasn’t picked up early in clinic • RCH card failed • Management pitfalls • CMAM in place but failed • Plumpy nut isolated to hospitals only • Delayed referral

  21. Where the story started

  22. Undernutrition • Consequence of deficiency of nutrients in the body • Types of undernutrition: • Acute malnutrition (wasting and bilateral pitting oedema) • Stunting • Underweight (combined measurement of stunting and wasting) • Micronutrient deficiencies

  23. Epidemiology • Under nutrition • Causes > 50% of all childhood mortality in resource-poor settings • Major contributor of morbidity • Late diagnosis, untimely and improper treatment can be fatal

  24. Risk factors • Food insecurity • Maternal undernutrition • Low birth weight,prematurity • Deficiencies of specific nutrients (iodine, vitamin A, iron, zinc) • Infection and duration of breastfeeding WHO 2005, Victora et al 2016

  25. Initially starts here Healthy baby Failure to thrive

  26. Community Management of Malnutrition (CMAM)

  27. CMAM • One of World Vision’s core project models in nutrition • Used as a methodology for treating acute malnutrition in young children using a case-finding and triage approach. • Enables community volunteers to • Identify • Initiate treatment for children with acute malnutrition using Ready-to-Use-Therapeutic Foods (RUTF) and routine medical care.

  28. Key components CMAM approach

  29. Community Mobilisation Supplementary Feeding Programme

  30. Outpatient Therapeutic Programme

  31. Key Principles of CMAM • Maximum access and coverage • Timeliness • Appropriate medical and nutrition care • Care for as long as needed Following these steps can ensure maximum public health impact!

  32. Treatment guidelines • Mainly focus on in-patient management through 10 steps for malnutrition • Very little on CMAM • All treatments centralised to certain centres • Peripheral sites have none

  33. WHO 10 Steps • Prevent/treat hypoglycemia • Prevent/treat hypothermia • Prevent/treat dehydration • Correct electrolyte imbalances • Treat/prevent infections • Correct micronutrient deficiencies • Start cautious feeding • Give catch-up diet • Sensory stimulation • Discharge and follow-up

  34. Micronutrient deficiencies Pellagra

  35. Feeds

  36. Opposite end of spectrum OBESITY

  37. Statistics • Globally • Increased from 32 million in 1990 to 42 million in 2013 • WHO African Region • Increased from 4 to 9 million over the same period. • Majority live in developing countries • Current trends • Estimate globally will increase to 70 million by 2025

  38. Both spectrums fall under malnutrition

  39. CMAM & KCMC • 3 components • RCH clinic • Regular nutrition counselling and teaching to mothers • Outreach programmes by Paediatric department

  40. Take home message • Strengthening of CMAM programs • Clinicians • Always assess the RCH card of every child <5years • Always take a good, detailed history and examination • Emphasis on good nutrition • Educate peripheral health centres on the importance of early referrals

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