Management of Severe Malnutrition

8/2/2019 Management of Severe Malnutrition

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1 Running Head

World Health Organization

Geneva

MANAGEMENT OF SEVEREMALNUTRITION:

A MANUAL FOR PHYSICIANS

AND OTHER SENIOR HEALTH

WORKERS


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1 Running Head

The World Health Organization was established in 1948 as a specialized agency of the UnitedNations serving as the directing and coordinating authority for international health matters andpub lic hea lth. One of WHOs constitutional functions is to provide ob jective and reliable informa-tion and advice in the field of human health, a responsibility that it fulfils in part through its

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i Running Head

Managementof severemalnutrition:

a m anual forphysician s and

other sen ior

health workers

World H ealth Organ izationGeneva

1999


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ii Management of severe malnutrition: a manual for physicians and other senior health workers

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World Health Organization 1999

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Typeset in Hong Kong

Printed in England

97/ 11527Best-set/ Clays8500

WHO Library Cataloguing in Publication Data

Managem ent of severe malnu trition: a man ual for ph ysicians and oth er senior health workers.

1.Child nutr i tion disorders therapy 2.Nutri tion disorders therapy 3.Manuals 4.Guidelines

ISBN 92 4 154511 9 (NLM Classifica tion : WD 101)


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iii Running Head

Contents

iii

Preface v

Ackn owledgem ents vi

1. Introduction 1

2. Treatment facilities 3

3. Evaluation of the malnourished child 4

3.1 Assessm ent of nutritional status and criteria for adm ission 43.2 History and physical exam ination 5

3.3 Laboratory tests 5

4. Initial treatment 7

4.1 Princip les of m anagem en t 7

4.2 Hypoglycaem ia 7

4.3 Hypotherm ia 8

4.4 Dehydration and sep tic shock 8

Diagnosis 8

Treatm ent of dehydration 9

Treatm ent of sep tic shock 12

4.5 Dietary treatm ent 12

Form ula diets for severely m aln ourished children 13

Feeding on adm ission 13

Nasogastric feeding 14

Feeding after the appetite im proves 15

Milk in toleran ce 16

Recording food in take 16

4.6 Infections 16

Bacterial in fections 16

Measles an d other viral in fection s 17

4.7 Vitam in deficiencies 17

Vitam in A deficiency 17

Other vitam in deficiencies 18

4.8 Very severe an aem ia 18

4.9 Congestive heart failu re 184.10 Derm atosis of kwashiorkor 19

5. Rehabilitation 20


5.2 Nutritional rehabilitation 20

Feeding children un der 24 m on ths 20

Feeding children over 24 m onths 21

Folic acid and iron 21

Assessing p rogress 22

5.3 Em otional and physical stim ulation 22

The environm en t 23

Play activities 23

Physical activities 23


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iv Management of severe malnutrition: a manual for physicians and other senior health workers

5.4 Teaching paren ts how to preven t m alnu trition from recurrin g 24

5.5 Preparation for discharge 24

Criteria for discharge 24

Appropriate diets 24

Im m unization 25

Plan n ing follow-up 25

6. Follow-up 26

7. Failure to respond to treatment 27

7.1 General p rinciples 27

7.2 Problem s with the treatm ent facility 27

Type of facility 27

Staff 28

In accurate weigh ing m achin es 28

Problem s with preparing or givin g food 28

7.3 Problem s with individual ch ildren 29

Feeding 29

In fection 30Serious u nd erlying disease 33

7.4 Learn ing from failure 34

8. Management o f malnutrition in disas ter s ituations and re fugee camps 35

8.1 General considerations 35

8.2 Establishing a therapeutic feedin g cen tre 35

Location an d capacity 35

Water supply and san itation 35

Cooking facilities and supp lies 35

Staff 35

8.3 Criteria for enrolm en t and discharge 35

8.4 Princip les of m anagem ent 36

8.5 Evaluation of the therapeu tic feeding cen tre 36

9. Malnutrition in adolescents and adults 37


9.2 Classification of m alnu trition 37

Adults (over 18 years) 37

Adolescen ts (1018 years) 38

9.3 History and physical exam ination 38

9.4 In itial treatm en t 38

9.5 Rehabilitation 39

9.6 Criteria for discharge 39

9.7 Failure to respond to treatm en t 39

References 40

Appendices 41

1. NCHS/ WHO norm alized reference values for weight-for-height andweight-for-length 41

2. Sam ple recordin g form 43

3. Physiological basis for treatm ent of severe m aln utrition 50

4. Com position of m ineral and vitam in m ixes 53

5. Desirab le d aily n utrien t in take du rin g in itial p hase of treatm en t 54

6. Drug dosages for treatm en t of in fection s 55

7. Toys for severely m alnourished ch ildren 58

8. Sam ple curricu lum for p lay therapy 59


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v Running Head

v

Preface

Malnutrition remains one of the most common causes of morbidity and mortality

among children throughout the world. Approximately 9% of children below 5 years of

age su ffer from wasting (weight-for-height b elow 2 standard deviations (2 SD) of

the Nationa l Cente r for Health Statistics (NCHS)/WHO reference values) and are at risk

of death or severe imp airment of growth an d psychological developm ent.

This ma nua l is based on The treatment and management of severe proteinenergy

malnutrition, which was published by WHO in 1981. Since then, many advances havebeen ma de in th e treatm ent of severe m alnutrition. An improved oral rehydration salts

(ORS) solution has been developed for the treatment of dehydration. Advances in

knowledge of the physiological roles of micronutrients have led to improved dietary

management during the initial phase of treatment. It has been shown that physical

and psychological stimulation, as well as care and affection, are necessary during the

rehabilitation phase in order to prevent retardation of growth and psychological

development.

This m anu al provides guidelines for the trea tm ent o f severely malnou rished children

(below 5 years of age) in hospitals and health centres. The treatment of severely mal-

nou rished adolescents an d ad ults is also b riefly considered. The m anu al is inten ded for

health personnel working at central and district level, including physicians, nurses,

m idwives an d a uxiliaries.


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vi Management of severe malnutrition: a manual for physicians and other senior health workers

Acknowledgements

vi

The World Health Organization is p articularly grateful to Dr M.H.N. Golden , University

of Aberd een , Aberd een , Scotland , for his exten sive con tribution to the d evelopm ent o f

the final draft of this manual. It also thanks Professor J. Waterlow, London School of

Hygiene a nd Tropical Medicine, Lon don , England , for his assistance in th e developm ent

of the initial draft. The World Health Organization also acknowledges the valuable

contributions of the many experts who assisted in the development of the manual,

including: Dr A. Ashworth , Lon don Schoo l of Hygiene an d Tropical Medicine, Londo n,Englan d; Dr M. Behar, Gene va, Switzerlan d; Ms R. Bhat ia, Office of th e Un ited Na tions

High Commissioner for Refugees (UNHCR), Geneva, Switzerland; Dr M. Bolaert,

Mdecins sans frontires, Brusse ls, Belgium ; Dr F. Chew, Institu te of Nutrition of Cen tral

Am erica an d Pan am a (INCAP), Guate ma la; Dr S. Grantha m -McGregor, Institute of Child

Health, London, England; Dr G. Lopez de Romana, Institute of Nutritional Studies,

Lima, Peru; Dr V. Reddy, National Institute of Nutrition, Hyderabad, India; Dr B.

Sch rch, Inte rnation al Dietary Energy Con sultancy Group (IDECG), Lausan ne, Switzer-

land; Dr N. Scrimshaw, United Nations University, Boston, MA, USA; and Dr B. Torun,

INCAP, Guatem ala. It is also grate ful to the st aff of hosp itals in Banglade sh, Brazil, India

and Viet Nam and Action contre la faim, Paris, France, who provided many valuable

practical comm ents on the fin al draft.

The following WHO staff m em bers provided su bstan tial techn ical cont ributions an d

com m ents: Dr K. Bailey, Programm e of Nutrition, WHO, Geneva, Switzerlan d; Dr D.

Benbouzid, Programme of Nutrition, WHO, Geneva, Switzerland; Dr G. Clugston,

Programm e of Nu trition, WHO, Geneva, Switzerland; Dr B. de Beno ist, WHO Region al

Office for Africa, Brazzaville, Congo; Dr M. de Onis, Programme of Nutrition, WHO,

Geneva, Switzerlan d; Dr O. Fontain e, Division of Child H ealth a nd Developm ent , WHO,

Geneva, Switzerland; Dr S. Khanum, WHO Regional Office for South-East Asia, New

Dehli, India; and Dr N.F. Pierce, Division of Child Health and Development, WHO,

Geneva, Switzerlan d.

The finan cial support of IDECG and UNHCR towards the developm ent and pub lica-

tion of this ma nu al is also gratefully acknowledged .


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1 Running Head

Table 1. Time-frame for the management of a child with severe malnutrition

Activity Initial treatment: Rehabilitation: Follow-up:

days 12 days 37 weeks 26 weeks 726

Treat or prevent:hypoglycaemia hypothermia dehydration

Correct electrolyte imbalance

Treat infection

Correct micronutrient deficiencies

Begin feeding

Increase feeding to recover lost weight(catch-up growth)

Stimulate emotional and sensorialdevelopment

Prepare for discharge

This manual provides practical guidelines for the management of patients with severe

malnutrition.1

It seeks to prom ote the b est available thera py so as to reduce th e risk of

deat h, shorten th e length of time spen t in hospital, and facilitate reha bilitation an d full

recovery. Emph asis is given here to th e ma na geme nt of severely m alnou rished children;

the m anagem ent of severely malnourished ad ults and adolescents is also con sidered

briefly.

Severe malnutrition is both a medical and a social disorder. That is, the medicalproblems of the child result, in part, from the social problems of the h ome in which the

child lives. Malnutrition is the end result of chronic nutritional and, frequently, emo-

tional deprivation by carers who, because of poor understanding, poverty or family

problems, are una ble to provide th e child with the n utrition a nd care he or she requires.

Successful m anagem ent of the severely ma lnourished child requ ires that both med ical

an d social problem s be recognized an d corrected . If the illness is viewed as being on ly a

med ical disorder, the child is likely to relapse when he o r she return s hom e, and other

children in th e family will remain a t risk of developin g the sam e prob lem.

1.

Introduction

1

1 Malnutrition and malnourished are used as synonyms of undernutrition and under-

nourished, respectively.

without iron with iron


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2 Management of severe malnutrition: a manual for physicians and other senior health workers

Management of the child with severe malnutrition is divided into three phases.

These are:

Initial treatment: life-threatening problems are identified an d treated in a h ospital

or a residen tial care facility, specific deficiencies are corrected, m etab olic abn orm ali-ties are reversed an d feeding is begun .

Rehabilitation:intensive feeding is given to recover most of the lost weight, emo-

tional and p hysical stimulation are increased, the m other or carer is trained to con-

tinue care at h ome, an d p reparations are mad e for discharge of the child.

Follow-up:after discharge, the ch ild an d th e childs family are followed t o pre vent

relapse an d assure the continued physical, men tal and em otional developmen t of the

child.

A typical time-frame for the management of a child with severe malnutrition is

shown in Table 1.

Successful man agem ent of the severely m alnou rished child does not requ ire soph is-

ticated facilities and equ ipm en t or highly qu alified p ersonn el. It does, however, require

that each child be treated with proper care and affection, and that each phase of treat-men t be carried out p roperly by approp riately trained and dedicated health workers.

When this is done, the risk of death can be substantially reduced 1 and the opportunity

for full recovery greatly improved.

1 For the p urpo ses of this ma nu al, a case-fatality rate of>20% is considered unacceptable, 1120%

is poor, 510% is mod erate, 14% is good a nd39.5 C or 103 F), an tipyretics should

be given.

4.7 Vitamin deficiencies

Vitamin A deficiency

Severely m alnou rished children a re at high risk of developin g blind ness du e to vitamin

A deficiency. For this reason a large dose of vitam in A shou ld be given routin ely to all

malnou rished children on day 1, un less there is definitive evidence that a dose has b een

given during the past month. The dose is as follows:1

50000 International Units (IU)

orally for infan ts 12 mon ths o f age. If there are an y clinical signs of vitam in

A de ficien cy (e.g. nigh t blind ne ss, conjun ctival xerosis with Bitots spots, corn eal xerosis

or ulceration , or keratom alacia), a large dose sho uld b e given on the first 2 days, followed

by a third d ose at least 2 weeks later (see Table 10). Oral treatm en t is preferred, except a t

the beginning in children with severe anorexia, oedematous malnutrition or septic

shock, who should b e given IM treatment. For oral treatmen t, oil-based p reparations are

1 The international standard (or reference preparation) of vitamin A has been discontinued.However, the international units for vitamin A are still used extensively, particularly in the

labelling of capsules and injectable preparations.


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preferred, but water-miscible formulations may be used if oil-based formulations are

not a vailable. Only water-m iscible form ulations shou ld be used for IM treatm ent .Great care must be taken during examination of the eyes, as they easily rupture in

children with vitamin A deficiency. The eyes should be examined gently for signs of

xerophth almia, corneal xerosis and ulceration , cloud iness and kerat om alacia. If there is

ocular inflammation or ulceration, protect the eyes with pads soaked in 0.9% saline.

Tetracycline e ye drop s (1%) shou ld be instilled four tim es da ily un til all signs of inflam -

m ation or u lceration resolve. Atropin e eye drops (0.1%) should also be app lied an d the

affected eye(s) shou ld be ban daged , as scratching with a finger can cau se ruptu re of an

ulcerated cornea. More details on the management of vitamin A deficiency are given

elsewhere (5, 6).

Other vitamin deficiencies

All m alnou rished children sh ould receive 5m g of folic acid orally on d ay 1 an d the n 1 m g

orally per day thereafter. Many malnourished children are also deficient in riboflavin,

ascorbic acid, pyridoxine, thiamine and the fat-soluble vitamins D, E and K. All diets

shou ld be fortified with th ese vitam ins by addin g the vitamin m ix (see App en dix 4).

4.8 Very severe anaemia

If the haemoglobin concentration is less than 40g/l or the packed-cell volume is less

than 12%, the child has very severe anaemia, which can cause heart failure. Children

with very severe anaemia need a blood transfusion. Give 10ml of packed red cells or

whole blood p er kg of bod y weight slowlyover 3 hou rs. Where testing for HIV an d viral

hepatitis B is not possible, transfusion should be given only when the haemoglobin

concentration falls below 30g/l (or packed-cell volume below 10%), or when there aresigns of life-thre aten ing he art failure. Do notgive iron du ring the initial phase o f treat-

m ent, as it can have toxic effects and m ay reduce resistance to infection.

4.9 Congestive heart failure

This is usu ally a com plication of overhydration (especially when an IV infusion or stan -

dard ORS solution is given ), very severe an aem ia, blood or p lasma tra nsfusion, or giving

a diet with a high sodium content. The first sign of heart failure is fast breathing (50

breaths per m inute or m ore if the child is aged 2 month s up to 12 mon ths; 40 breaths per

m inute o r mo re if the ch ild is aged 12 m ont hs up to 5 years). Later signs are respiratory

distress, a rapid pulse, engorgement of the jugular vein, cold hands and feet, and

cyanosis of the fingertips and under the tongue. Heart failure must be differentiated

Table 10. Treatment of clinical vitamin A deficiency inchildren

Timing Dosagea,b

Day 1:12 months of age 200 000 IU

Day 2 Same age-specific dose

At least 2 weeks later Same age-specific dose

a For oral administration, preferably in an oil-based preparation, except in children withsevere anorexia, oedematous malnutrition or septic shock.

b See footnote on page 17.


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19 4. Initial treatment

from respiratory infection and septic shock, which usually occur within 48 hours of

adm ission, whereas he art failure usually occurs som ewha t later.

When heart failure is caused by fluid overload, the following measures1

should be

taken:

1. St op alloral inta ke and IV fluids; the treatm ent of heart failure takes preced en ce over

feeding the child. No fluid shou ld be given u ntil the hea rt failure is impro ved, even if

this takes 2448 hours.

2. Give a diuretic IV.2 The most a pprop riate choice is furosemide (1 mg/ kg).

3. Do no t give digitalis un less the d iagnosis of heart failure is un equ ivocal (jugular

venou s pressure is elevated ) andthe p lasma potassium level is normal. In that case,

5 g/ kg of bo dy weight o f digoxin m ay be given IV as a sin gle dose, or o rally, if th e IV

preparation is not available.

4.10 Dermatosis of kwashiorkor

This is characterized by hypo- or hyperpigmentation, shedding of the skin in scales or

sheets, and u lceration of the skin of the perineum , groin, limbs, behind the ea rs and

arm pits. There m ay be widesp read weep ing skin lesions which ea sily becom e infected.

Spontaneous resolution occurs as nutrition improves. Atrophy of the skin in the

perineum leads to severe diaper dermatitis, especially if the child has diarrhoea. The

diape r area should be left unco vered. If the diap er area becom es colon ized with Candida

spp., it should be treated with nystatin ointment or cream (100000IU (1g)) twice daily

for 2 weeks and the ch ild sh ould b e given oral nystatin (100000 IU four tim es daily). In

other affected areas, application of zinc and castor oil ointment, petroleum jelly or

paraffin gauze dressings helps to relieve pain and prevent infection. The zinc supple-

men t contained in the mineral mix is particularly imp ortant in these children, as they

are u sually severely deficient.

Bath e the affected area s in 1% pota ssium perm an ganat e solution for 1015 m inute s

daily. This dries the lesions, helps to prevent loss of serum, and inhibits infection.Polyvidone iodine, 10% ointment, can also be used. It should be used sparingly, how-

ever, if the lesions are e xtensive, as the re is significan t systemic ab sorption .

All children with kwashiorkor-related derm atosis shou ld receive systemic an tibiotics

(see section 4.6).

1 There is no reported experience in malnourished children of angiotensin-converting enzymeinhibitors or other drugs used to treat con gestive heart failure.

2

Diuretics sh ould neverbe used to reduce oedema in malnourished children.


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20

5.

Rehabilitation

The child is deem ed to h ave entered the rehabilitation phase when his or her appetite

has returned. A child who is being fed by NG tub e is notconsidered ready to enter the

rehabilitation pha se.

5.1 Principles of management

The principal tasks during the rehabilitation phase are:

to encourage the child to eat as much as possible;

to re-initiate and/ or encourage breastfeeding as necessary;

to stimulate emotional and physical developmen t; and

to prepare the m other or carer to continue to look after the child after discharge.

The child shou ld remain in hospital for the first part of the reha bilitation pha se.

When allthe criteria in the box below have been met (usually 23 weeks after admis-

sion), the ch ild can be tran sferred to a n utrition rehabilitation centre.

Criteria for transfer to a nutrition rehabilitation centre Eating well

Mental state has improved: smiles, responds to stimuli, interested in surroundings Sits, crawls, stands or walks (depending on age) Normal temperature (36.537.5C) No vomiting or diarrhoea No oedema Gaining weight: >5 g/kg of body weight per day for 3 successive days

5.2 Nutritional rehabilitation

The most impo rtant determ inant of the rate of recovery is the am oun t of energy con-

sumed. However, at the start of the rehabilitation phase, the child is still deficient in

protein an d various m icronu trients, including potassium , magnesium, iron an d zinc.

These must also be given in increased amou nts. Infants und er 24 month s can be fedexclusively on liquid o r sem i-liquid formu las. It is usua lly app ropriate to intro du ce solid

foods for older ch ildren .

Feeding children under 24 months

During reha bilitation, F-100 diet shou ld be given e very 4 hou rs, night a nd day. Tran si-

tion to the reh abilitation p hase involves increasing the am oun t of diet given at each feed

by 10m l (e.g. if the first feed is 60m l, the second should be 70m l, the th ird 80m l, and so

on) un til the ch ild refuses to finish the feed.

When a feed is not finished, the same am oun t should be offered at th e next feed. If

that feed is finished, the amount offered for the following feed should be increased by

10 m l. Continu e this process un til som e food is left after most feeds. The am oun t being


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21 5. Rehabilitation

offered should th en b e dispensed for the child at each feed on subsequen t days. The

amo unts of each feed offered an d taken shou ld be recorded on the feeding chart (Ap-

pend ix 2) and any food not taken shou ld be discarded; neverreuse it for the n ext feed.

During rehabilitation mo st children take between 150 and 220 kcalth/ kg (630920 kJ/ kg)

per d ay. If inta ke is below 130kcalth or 540kJ/kg per d ay, the child is failing to resp on d

(see section 7).

The attitud e of those feeding the ch ild is crucial to success. Sufficien t time m ust be

spent with th e child to enab le him or h er to finish each feed. The child m ust be actively

encouraged to eat while sitting comfortably on the mothers or nurses lap. Children

must neverbe left alon e to take what th ey want.

During the first few days of reha bilitation, children with oede m a m ay not gain weight,

despite an adequate intake. This is because oedema fluid is being lost while tissue is

being restored. Thus, progress in these children is seen as decreased o edem a rather than

rapid weight gain. If the ch ild is neither gaining weight n or showing decreased oed em a,

or if there is increa sing oedem a, the child is failing to respo nd (see section 7).

F-100 should be continued until the child achieves 1 SD (90%) of the median

NCHS/ WHO referen ce values for weight-for-height (see App end ix 1). When this occu rsappetite dim inishes an d increasing amou nts of food a re left un eaten. The child is now

ready for the discharge ph ase of treatment.

Feeding children over 24 months

Children over 24 months can also be successfully treated with increasing quantities of

F-100; it is not essential to u se a d ifferent d iet. This has p ractical value in refugee cam ps

where it is important to keep the num ber of different diets to a m inimum . For most older

children, however, it is app ropriate to int rodu ce solid food, especially for tho se who wan t

a m ixed d iet. Most traditiona l mixed d iets have a lower energy conten t tha n F-100. They

are also relatively deficient in minerals, particularly potassium and magnesium, and

contain sub stances which inhibit the absorption of zinc, copper an d iron. Moreover, the

diets are u sually deficient in various vitam ins. Thu s, local food s shou ld be fortified to

increase their content o f energy, minerals and vitamins. Oil should be added to increase

the en ergy content, an d the mineral and vitamin m ixes used in F-100 should be add ed

after cooking (see section 4.5 and Appen dix 4). Other ingred ients, such a s dried skimm ed

milk, may also be a dded to increase the protein an d m ineral conten t. The en ergy content

of mixed diets shou ld be at least1kcalth or 4.2kJ/ g.

To avoid the effects of food substances which reduce the absorption of minerals,

F-100 should b e given between feeds o f the m ixed d iet. For examp le, if the m ixed d iet

is given th ree tim es da ily, F-100 should also b e given three times d aily, ma king six feeds

a day. Water intake is not usually a problem in children over 2 years because they can

ask for it when they are th irsty.

At the b eginning of rehabilitation , the children sho uld be fed every 4 hou rs, day and

night (six feeds p er 24 hou rs). When th ey are growing well an d a re no longer at risk ofdeveloping hypotherm ia or hypoglycaem ia, one of the n ight-time feeds can be om itted,

making five feeds per 24 hours. This allows the child longer undisturbed sleep and

m akes it much easier to m ana ge the child as a day-pa tient. It is also less taxing for those

caring for the child.

Folic acid and iron

Nearly all severely malnourished children have anaemia and should be given supple-

mentary folic acid and iron. They should also continue to receive the vitamin and

mineral mixes in their food throughout rehabilitation.

Iron should neverbe given during the initial phase of treatmen t, but m ust be given

during the rehabilitation phase. It should only be given orally, never by injection.


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Children with m oderate or severe anaem ia should be given elemental iron, 3 mg/ kg per

day in two divided doses, up to a maximum of 60mg daily, for 3 months ( 7). It is

preferable to give iron sup plements between meals using a liquid preparation.

All children must be given 5mg of folic acid on day 1 and then 1mg per day

thereafter.

Assessing progress

The child should be weighed daily and the weight plotted on a graph (see Fig. 1 and

App end ix 2). It is useful to ma rk the p oint th at is equivalent to 1 SD (90%) of the m edian

NCHS/ WHO referen ce values for weight-for-height on the grap h, which is the ta rget

weight for discharge. The usua l weight gain is abou t 1015 g/ kg per da y. A child who

does not gain at least 5 g/ kg per day for 3 consecu tive da ys is failing to respon d to

treatment (see section 7). With high-energy feeding, most severely malnourished

children re ach their target weight for discharge a fter 24 weeks.

5.3 Emotional and physical stimulation

Severely malnourished children have delayed mental and behavioural development,

which, if not treated, can becom e the most serious long-term result of malnutrition.

Emotional an d p hysical stimulation through p lay programm es that start du ring reha-

bilitation and continue after discharge can substantially reduce the risk of perman ent

men tal retardation and emotional imp airment.

Fig. 1 An example of a weight chart for a severely malnourished boy


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Care must be taken to avoid sensory deprivation. The childs face must not be

covered; the child m ust be able to see and h ear what is happen ing around h im or her.

The child should neverbe wrapped or tied to prevent him or her moving around in

the cot.

It is essential that the mother (or carer) be with her child in hospital and at the

nutrition rehabilitation centre, and that she be en couraged to feed, hold, comfort and

play with h er child as mu ch as p ossible. The num ber of other ad ults who interact with

the ch ild sho uld be a s few as possible. Each a du lt should talk, smile and show affection

towards the child. Medical procedures, such as venepu ncture, should be done by the

m ost skilled p erson a vailable, preferably out o f earsho t an d sight of the ot her ch ildren .

Immed iately after any un pleasant procedure th e child shou ld be held an d com forted.

The environment

The austerity of a traditional hospital has n o place in th e treatm ent of m alnourished

children. Rooms should be brightly coloured, with decorations that interest children.

Colourful mobiles should be hung over every cot, if possible. The staff should wearnorm al clothing rather than uniforms. Brightly coloured a prons m ay be used to protect

their clothing. A radio can provide background music. The atmosphere in the ward

should be relaxed, cheerful and welcoming.

Toys shou ld always be a vailable in th e childs cot an d roo m , as well as in th e play

area; they should be changed frequently. Toys should be safe, washable and app ropriate

for the childs age and level of development. Inexpensive toys made from cardboard

boxes, plastic bottles, tin cans an d similar m aterials are best, becau se moth ers can copy

them . Examp les of suitable toys are described in App end ix 7.

Play activities

Malnou rished children ne ed interaction with oth er children d uring rehab ilitation. After

the initial phase of treatment, the child should spend prolonged periods with other

children on large play mats, and with th e m other or a play guide. The ch ild can also be

fed in the p lay area. These activities do n ot increase the risk of cross-infection a pp re-

ciably an d the b ene fit for the ch ild is sub stantial.

One person, usually a nurse or volunteer, should be responsible for developing a

curriculum of play activities and for leading the play sessions. Activities should be

selected to develop both motor and language skills, and new activities and materials

shou ld be introdu ced regularly. One aim sho uld be to p lay with each ch ild, individu ally,

for 1530 minu tes each d ay, in add ition t o informal group p lay. A sam ple curriculum of

play activities, arran ged b y level of developm ent , is provided in App end ix 8. Mothers can

be train ed to su pervise play session s.

Learn ing throu gh play shou ld be fun for children . A childs efforts to p erform a t ask

shou ld always be p raised an d n ever criticized. When a ch ild is taught a skill, the n urse orvolun teer shou ld dem on strate the skill first, then help th e child do it, an d fina lly let the

child d o it alone. This sequence should be repeated un til the ch ild h as m astered the skill.

Physical activities

Physical activities promote the development of essential motor skills and may also

enhance growth during rehabilitation. For those children who are unable to move,

passive limb m ovements an d splashing in a warm b ath a re helpful. For other children,

play should include su ch activities as rolling on a m attress, runn ing after an d tossing a

ball, climbing stairs, and walking. The duration and intensity of physical activities

shou ld increa se as the childs nut rition al status and gen eral condition im prove. If there

is sufficient space, an outdoor p layground sho uld be developed.


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5.4 Teaching parents how to prevent malnutrition from recurring

All parents should know how to prevent malnutrition from recurring. Before the child

is discharged, ensure th at the p arents or carers und erstand the causes of malnutrition

and how to prevent its recurrence, including correct feeding and continuing to stimulatethe childs mental and emotional development. They must also know how to treat,

or obtain treatmen t for, diarrhoea and other infections, and un derstand the importance

of regular (every 6 months) treatment for intestinal parasites. The parents have much

to learn; teaching them should not be left until a few days before the child is

discharged.

The moth er (or carer) should spend as mu ch time as possible at the n utrition reha -

bilitation centre with her child. This may be facilitated by providing the mother with

money for transportation and meals. The mother, in turn, should help prepare her

childs food, and feed and look after her child. A rotation of mothers may also be

organized to h elp with general activities on th e ward, includin g play, cooking, feedin g,

bathing an d ch anging the children, under supervision. This will enab le each m other to

learn ho w to care for her child at ho m e; she will also feel that sh e is contributin g to the

work of the cen tre. Teach ing of mo thers shou ld includ e regular sessions at which impo r-

tant p arenting skills are dem onstrated an d p ractised. Each m other should be taught the

play activities that are a pp ropriate for her child, so that she a nd o thers in th e fam ily can

continue to make toys and play with the child after discharge.

The staff must be friendly and treat the mothers as partners in the care of the

children. A mother should never be scolded, blamed for her childs problems, humili-

ated or m ade to feel un welcome. Moreover, helping, teaching, counselling and b efrien d-

ing the moth er are an essential part of the long-term treatm ent of the child.

5.5 Preparation for discharge

During rehabilitation, preparations should be made to ensure that the child is fully

reintegrated in to the fam ily and com m un ity after discha rge. As the childs hom e is the

environment in which severe malnutrition developed, the family must be carefully

prep ared to preven t its recurrence. If possible, the childs hom e shou ld be visited by a

social worker or nurse before discharge to ensure that adequate home care can be

provided. If the ch ild is aban doned or conditions at the childs hom e are u nsuitable,

often b ecause of death or absen ce of a carer, a foster hom e should be sou ght.

Criteria for discharge

A child may be con sidered to h ave recovered and be read y for discharge when the ch ilds

weight-for-height ha s reached 1 SD (90%) of the m edian NCHS/ WHO referen ce values

(see Appendix 1). To achieve this goal, it is essential that the child receives as many

meals as possible per day. In some instances, a child m ay be discharged before he or sh e

has reached the target weight-for-height for discharge; however, since the child is notyet recovered, he or she will need continuing care (as an outpatient). To en sure that

relapse does n ot occur, it is imp ortant tha t allthe criteria listed in Table 11 have been

m et before the child is discharged.

Appropriate diets

During rehabilitation the child should be fed at least five times daily. After reaching

1 SD of the m edian NCHS/ WHO reference values, the child should be fed at least three

times da ily at hom e. Adjustm ent to th is chan ge in frequen cy of feeding should take place

un der sup ervision before discharge. This is don e by gradually redu cing and e ventua lly

stopping the supplemen tary feeds of F-100 and adding or increasing the m ixed d iet until

the ch ild is eating as he or she will at ho m e.


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Table 11. Criteria for discharge from non-residential care

Criteria

Child Weight-for-height has reached 1 SD (90%) of NCHS/WHO median

reference values

Eating an adequate amount of a nutritious diet that the mother canprepare at home

Gaining weight at a normal or increased rate

All vitamin and mineral deficiencies have been treated

All infections and other conditions have been or are being treated,including anaemia, diarrhoea, intestinal parasitic infections, malaria,tuberculosis and otitis media

Full immunization programme started

Mother or carer Able and willing to look after the child

Knows how to prepare appropriate foods and to feed the child

Knows how to make appropriate toys and to play with the child

Knows how to give home treatment for diarrhoea, fever and acuterespiratory infections, and how to recognize the signs that mean shemust seek medical assistance

Health worker Able to ensure follow-up of the child and support for the mother

Before discharge, the m other (or carer) must p ractise preparing the recomm ended

foods an d feeding them to the child. It is essential that the m other dem onstrates that she

is able an d willing to d o these tasks, and that she und erstands the im portance o f con-

tinued correct feeding for her child. Appropriate mixed diets are the same as those

normally recommended for a healthy child. They should provide at least 110kcal th or

460 kJ/ kg per day and also sufficient vitamins an d m inerals to supp ort continued

growth. Breast-feeding should be con tinue d; anima l m ilk is also an imp ortan t source of

energy and protein. Solid foods should include a well-cooked staple cereal, to which

vegetable oil should be added (510ml for each 100g serving) to enrich its energy

cont ent. The cereal shou ld be soft and m ashed ; for infants u se a thick pap . A variety of

well-cooked vegetab les, including oran ge and dark-green leafy ones, shou ld be given. If

possible, includ e fruit, meat, eggs or fish. The m oth er shou ld be enco uraged to give the

child extra food between meals.

Immunization

Before discharge, the ch ild shou ld be imm un ized in accordance with n ational guide-lines. The mother should be informed of where and when to bring the child for any

required booster doses.

Planning follow-up

Before discharge, m ake an a pp ointm en t to see the ch ild 1 week after discharge. Follow-

up visits shou ld preferably take place at a spe cial clinic for malnou rished children , not at

a gene ral paed iatric clinic.

If possible, arrange for a health worker or field nurse trained to provide practical

advice on health and nutrition to visit the family at home. Also arrange for a social

worker to visit the family, in order to find a way of solving the familys social and

economic problems.


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26

6.

Follow-up

Although m uch im proved at the tim e of discharge, the child usually rema ins stunte d an d

men tal developm ent is delayed. Management of these conditions an d p reventing the

recurrence of severe malnutrition requires sustained improvement in feeding of the

child and in oth er paren ting skills. Plann ed follow-up of the ch ild at regular intervals

after discharge is essential. This shou ld include an efficient strategy for tracing children

who fail to atten d follow-up app ointm ents. Such children are at increased risk of recur-

rence of ma lnutrition or o f developing other serious illnesses.As the risk of relapse is greatest soon after discharge, the child shou ld be seen a fter 1

week, 2 weeks, 1 m ont h, 3 mon ths an d 6 m ont hs. Provided th e childs weight-for-height

is no less than 1 SD (90%) of the m edian NCHS/ WHO reference values, p rogress is

considered satisfactory. If a problem is foun d, visits shou ld be m ore frequen t un til it is

resolved. After 6 months, visits should be twice yearly until the child is at least 3 years

old. Children with frequent problems should remain under supervision longer. The

moth er should know the location and regular opening hou rs of the nearest nutrition

clinic and be en couraged to b ring her child witho ut an app ointm ent if the child is ill or

a previous app ointmen t was missed.

At each visit the mother should be asked about the childs recent health, feeding

practices and p lay activities. The child shou ld be examined , weighed and m easured, an d

the results recorded (see App end ix 2). Any n eeded vaccine shou ld be given. Trainin g of

the mother should focus on areas that need to be strengthened, especially feeding

practices, and mental and physical stimulation of the child. Attention should also be

given to feeding practices for other children in the fam ily, and for pregnan t or lactating

wome n, as these are likely to be ina dequ ate. If vitam ins or m edicines are needed , they

should be p rovided.


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27 7. Failure to respond to treatment

27

7.

Failure to respond to treatment

7.1 General principles

When the treatment guidelines in this manual are followed, a severely malnourished

child without comp lications should show definite signs o f imp rovemen t within a few

days and should con tinue to improve thereafter. Failure to achieve initial improvemen t

at the expected rate is termed primary failure to respond, whereas deterioration of the

childs condition, when a satisfactory respon se has been established, is term ed second-

ary failure to respond.

A child who meets any of the criteria in Table 12 should be diagnosed as failing to

respond. When this diagnosis is mad e it is essential that practices in the trea tm ent u nit

are carefully reviewed and the child is thoroughly re-evaluated. The objective is to

identify the cause for failure to respond and to correct the problem by making specific

changes to p ractices in the u nit or to th e childs treatmen t. Treatmen t should n ever be

changed blindly; this is more likely to be harmful than to help the child. The most

frequent causes of failure to respond are listed in the box below and considered in

section s 7.27.3.

Frequent causes of failure to respond

Problems with the treatment facility: Poor environment for malnourished children Insufficient or inadequately trained staff Inaccurate weighing machines Food prepared or given incorrectly

Problems of individual children: Insufficient food given Vitamin or mineral deficiency Malabsorption of nutrients Rumination Infections, especially diarrhoea, dysentery, otitis media, pneumonia, tuberculosis,

urinary tract infection, malaria, intestinal helminthiasis and HIV/AIDS Serious underlying disease

7.2 Problems with the treatment facility

Type of facility

Failure to respond is more likely when a malnourished child is treated in a general

paediatric ward than in a special nutrition unit. This is because the risk of cross-

infection is increased in a gen eral ward, it is mo re difficult to p rovide th e ne cessary care

and attention, and staff are less likely to have the essential skills and attitudes for

management of malnourished children. Wherever possible, malnourished children

should be managed in a special nutrition unit. If this is not possible, they should be

treated in a sp ecially designa ted area o f a paed iatric ward, by staff specifically trained in

the treatm ent of severe m alnutrition.


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Table 12. Criteria for failure to respond to treatment

Criteria Time after admission

Primary failure to respond:Failure to regain appetite Day 4Failure to start to lose oedema Day 4Oedema still present Day 10Failure to gain at least 5g/kg of body weight per day Day 10

Secondary failure to respond:Failure to gain at least 5 g/kg of body weight per day During rehabilitation

for 3 successive days

The special nutrition unit must, however, be well organized. If essential food sup-

plies or med ications are n ot available, weighing scales do n ot work prop erly, diagnostic

facilities or administrative procedures are inadequate, or there are insufficient trainedstaff, treatment failure and mortality will be high. An effective management system

shou ld ensure careful mon itoring of each ch ild, prop er training of nu rses and au xiliary

staff, use of the m ost experienced staff as sup ervisors, reliable supp lies of drugs an d food

supplemen ts, and reliable record-keeping.

Staff

Experienced staff (including junior staff) who understand the needs of malnourished

children and are familiar with the important details of their m anagem ent a re essential

for a well-functionin g treatm ent facility. It is imp ortan t, therefore, tha t loss of experi-

ence d staff be avoided whe rever possible. For th is reason, staff of the treat m ent facility

should nottake pa rt in the rou tine rotation of staff that is practised in m an y hospitals. If

staff must be changed, this should be done one person at a time so as to minimize

disruption of routines in th e facility.

The attitude of staff towards a p articular child can determine whether treatm ent of

the child will succeed or fail. If staff believe that a child is beyond helping, th ey ma y give

less attention to the ch ild. Such children often fail to respond to treatm ent, which seems

to con firm t he o pinion of the staff. This clinical prejudice ma y be difficult to correct,

especially when it reflects the views of the m ost experienced staff. It is essential tha t staff

are rem inded frequen tly that each childs well-being depen ds on their efforts and that

every child mu st be given th eir full attention .

Inaccurate weighing machines

Machine s used for weighing children ea sily becom e inaccu rate an d, thu s, give m islead-ing inform ation on the p rogress of children in th e facility. Weighing ma chine s mu st be

checked and adjusted daily following a standard procedure. Records of daily checks

shou ld be kept. Weighing mach ines used for preparing food or for mea suring the ingre-

dients of the m ineral mix should be checked and adjusted weekly.

Problems with preparing or giving food

Standa rd hygiene practices should b e used when storing, preparing and han dling food

in the kitchen of the hospital or nutrition rehabilitation centre. Hands shou ld be washed

with soap after defecation and before food is handled. Foods should be thoroughly

cooked an d served prom ptly. Any cooked food tha t will be stored for more tha n 2 hou rs

shou ld be refrigerated (after allowing it to cool to room tem pera ture) and re -hea ted un til


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it is thorou ghly hot (and t hen allowed to cool) before be ing served. Persons with infec-

tions on their hands should not han dle food.

Each p erson involved in p reparing food shou ld be checked to en sure that th ey are

following the co rrect proce du res for weighing, measu ring, mixing, cooking an d storing

the food. Observe the feeds being made; check that the recipes are correct and all

ingredients are added .

Ensure that sufficient time is allocated to feeding each child and that there are

eno ugh staff, day and n ight, for this task. Rem em ber th at feeding a malno urished ch ild

takes more time an d p atience than feeding a no rmal child. If it is assumed that it takes

about 15 minutes to feed ea ch child and that food is given every 3 hours, one person is

nee ded , day and n ight, to feed 12 children. When food is given every 2 hou rs, more staff

are ne eded . If there a re no t eno ugh staff, treatme nt of a child may fail because insuffi-

cient time is taken for feeding. Having the m othe r help with feeding her ch ild can relieve

this situation.

7.3 Problems with individual children

Feeding

Is enough food being given?

Recalculate the food requiremen t for the child. Ensure that the correct amoun t is being

offered at the required times, and that the a mou nt taken by the child is measured an d

recorded accura tely. Observe the m easurin g and giving of food. Check the ca lculation of

the daily energy inta ke of the ch ild. Review the feedin g guidelines in sections 4.5 and 5.2,

giving pa rticular attent ion to feeding du ring the n ight, as this is often d one less well tha n

during the day.

A child treated at a nutrition rehabilitation centre m ay fail to respond because th e

feeds p rovided at ho m e are too few or too small, or incorrectly prep ared . Such failures

usua lly ind icate th at th e family was not ad equ ately counselled initially. If, desp ite cor-

rective me asures, the child fails to respon d, the child should be read m itted to hosp ital.

Are sufficient vitamins and minerals being given?

Nutrient deficiency can result from the increased requ irements related to th e synthesis

of new tissue du ring rapid growth. When this hap pen s, there is usu ally an initial period

of rapid growth, after which growth slows or stops even thou gh food int ake is adeq uate .

Deficiencies of potassium, magnesium, zinc, copper or iron may be responsible. Diets

are often deficient in these m inerals and com mercial vitamin and mineral preparations

do not provide th em in sufficient am oun ts for severely malnou rished children. This

problem can be avoided by ensuring that th e m ineral and vitamin mixes described in

App end ix 4 are ad ded to th e childs food every day.

Is the child ruminating?

Rum ination is a condition tha t occurs in up to 10% of severely m alnou rished, emotion -

ally im paired ch ildren . It shou ld be susp ected wh en a child eats well, but fails to gain

weight. Children with th is condition regurgitate food from the stom ach into the m outh,

and then vomit part of it and swallow the rest. This usually happens when they are

igno red, so it ma y no t be observed. Such ch ildren are usu ally thought to h ave vom iting

without diarrhoea because they often smell of vomit, and may have vomit-stained

clothes or bedding. They are often unusually alert and suspicious, may make stereo-

typed chewing movemen ts, and do not ap pear distressed by vomiting.

Rum ination is best treated by staff m em bers who ha ve experien ce with this prob lem

and give special attention to the child. They need to show disapproval whenever the


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child b egins to rum inate, without being intimidating, and to encou rage other less harm -

ful beh aviours.

InfectionUnrecognized infections are a frequent cause of failure to respond. Those most often

overlooked include pneumonia, urinary tract infection, otitis media and tuberculosis.

Others includ e m alaria, dengue , viral hepatitis B an d HIV infection. Children who fail to

respon d to treatm ent sh ould be investigated for infection as follows:

1. Exam ine the child carefully. Measure the ch ilds temp erature, pulse rate and respira-

tion rate every 3 hou rs. As already men tioned , infection in a m alnou rished child often

causes hypothermia.

2. If possible, obtain a ch est X-ray. Exam ine the u rine for pus cells. Examine a nd cu lture

the sputum or a tracheal aspirate for tubercle bacilli. Examine the stool for signs of

blood, Giardiatroph ozoites or cysts and Strongyloides stercoralislarvae, and cu lture

for bacterial path ogens. Culture th e blood an d test for the p resence of viral hep atitis

B and m alaria. Exam ine and culture the cerebrospinal fluid.

Specific infections are d iscussed below.

Persistent diarrhoea

This is diarrhoea that occurs every day for at least 14 days. Weight loss is common.

ReSoMal shou ld be given to p revent or tre at d ehydration (see section 4.4). If the stool

cont ains visible blood, treat th e child with an oral antim icrobial that is effective against

most local strains ofShigella (see treatment guidelines for dysentery below). If cysts

or trophozoites ofGiardia are found in the stool, treat the ch ild with m etronidazole,

5 m g/ kg orally three times d aily for 5 days. Blind an timicrobial therap y, however, is

ineffective and should not be given. Every child with persistent diarrhoea should be

examined for non-intestinal infections, such as pneumonia, sepsis, urinary tract infec-

tion and otitis media. Antimicrobial treatment of these infections should follow stan-

dard guidelines. Antidiarrh oeal drugs shou ld neverbe u sed. Such dru gs are not effective

in children an d some m ay be dangerous.

Feeding guidelines are th e sam e as for severe malnu trition. Breast-feeding should be

cont inued as often and for as lon g as the ch ild wan ts. Milk into lerance is rare when th e

recommended feeding guidelines for malnutrition are followed. However, if it occurs

(see section 4.5), replace the animal milk with yoghurt or a commercial lactose-free

formula. Persistent d iarrhoea u sually resolves when the ch ild be gins to gain weight.

Further d etails of treatmen t of diarrhoe a are available elsewhere (8).

Dysentery

This is diarrhoea with visible blood in the stool. Shigella is the most frequent cause,

especially of cases that are severe. Treatment is with an oral antibiotic to which most

local strains ofShigella are sensitive. Unfortunately, the choice of antimicrobials for

treatm ent o f shigellosis has narro wed con siderably in recen t years as the p revalence of

antimicrobial resistance has increased. Resistance to ampicillin and cotrimoxazole

(sulfamethoxazole + trimethoprim), formerly the drugs of choice, is now widespread.

Nevertheless, cotrimoxazole (25mg of sulfamethoxazole + 5mg of trimethoprim/kg

orally twice daily for 5 d ays) and, in a few areas, am picillin (25m g/ kg four times d aily for

5 days) ma y still be effective against m ost en dem ic strains. Nalidixic acid (15m g/ kg four

times d aily for 5 da ys), which was formerly reserved for th e treatm ent of resistant cases

of shigellosis, is now th e dru g of choice in m an y areas. If there is no im provem ent (less

blood in the stool or passage of fewer stools) after 2 days, the antibiotic should be


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changed to another to which local strains ofShigella are sensitive (see Appendix 6).

Accordingly, health facilities in a reas whe re the re is a high inciden ce of bloody diarrho ea

should ensure that several antimicrobials known to be effective against most local

strains ofShigellaspp. are kept in stock.

Amoebiasis. Am oeb iasiscan cau se dysentery, liver abscess and oth er system ic comp lica-

tions, but is rare in children under 5 years. Treatment for amoebiasis should be given

when motile trophozoites ofEntamoeba histolyticacont aining ingested erythrocytes are

found in a fresh stool sample or when bloody diarrhoea continues after successive

treatment with two antibiotics that are usually effective for Shigella. The finding of

am oeb ic cysts in the stools is not sufficien t for a diagnosis of am oebiasis. Treatm ent is

with me tron idazole oral suspen sion, 10m g/ kg three times d aily for 510 days (see Ap-

pen dix 6).

Giardiasis. Intestinal infection with Giardia is common and usually has no adverse

effect on well-nourished children. However, in severely malnourished children, treat-

m ent for giardiasis should be given wh en cysts or troph ozoites ofGiardiaare seen in the

stool. Treatme nt is with m etron idazole, 5m g/ kg orally three times da ily for 5 days (seeAppendix 6).

Further d etails of treatme nt for children with dysent ery are available elsewhere (9).

Otitis media

Otitis media occurs frequently in children, often in connection with hospital-acquired

upper respiratory infection. There are no specific clinical signs, except when the ear-

drum has ruptured, causing drainage from the ear. The diagnosis usually requires ex-

am ination of the ears with an otoscop e, looking for loss of the tym pa nic light reflex or

perforation of the eardrum . Typical signs of inflam ma tion m ay not be present. Treat-

m ent is with cotrimoxazole (25m g of sulfam etho xazole + 5m g of trimeth oprim/ kg twice

daily), amp icillin (25m g/ kg four tim es daily) or am oxicillin (15m g/ kg three tim es daily)for 5 days (see Appendix 6). A cotton wick should be used to dry any drainage from

the ear.

Pneumonia

Pneum onia is ma nifested by fast breathing and, som etimes, chest indrawing. Cough,

crackly breat h soun ds and a bn orm alities on chest X-ray are frequ ently absent. The cut-

off for fast brea thing is 50 tim es per m inute or m ore if the child is aged 212 mon ths, or

40 tim es per m inute or m ore if the ch ild is aged 12 mon ths to 5 years. Children with fast

breathing should be d iagnosed a s having pn eum onia an d given a n o ral antimicrobial for

5 da ys. Cotrimo xazole (sulfameth oxazole + trimeth oprim ), amp icillin or a m oxicillin is

usua lly effective (see ab ove). Children with fast breathin g and chest ind rawing shou ld be

treated with ben zylpen icillin, 50000 IU/ kg IM four times d aily for at least 5 days, unt il

they imp rove, and then with oral am picillin o r am oxicillin (see ab ove). Oxygen shou ld

also be given if the breat hing rate is over 70 breath s per m inute .

For further d etails of treatment for children with otitis media an d p neum onia, see

reference 10.

Urinary tract infections

Urinary tract infections occu r frequen tly, with a similar inciden ce in b oys and girls. Such

infections are usually asymptomatic and are diagnosed using dip-stick tests or by

finding large numbers of leukocytes on microscopic examination of fresh urine (at

least 10 leukocytes p er m icroscope field (X40 ma gnification)). Cotrimoxazole (25m g of

sulfamethoxazole + 5 m g of trim etho prim / kg twice da ily for 5 da ys) is usually effective.


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Alternatively, amp icillin (25 m g/ kg four times d aily for 5 d ays) can b e given (see App en-

dix 6).

Skin infectionsBacterial infections. These in clude p ustu les, imp etigo, infected fissures (especially be-

hind the ears) and indolent ulcers. Treatmen t should include washing the affected area

with soap and water, and gently removing deb ris and crusts by soaking in warm saline or

clean warm water. Dry the ch ild carefully and a pp ly polyvidone iod ine, 10% ointm ent , or

chlorhexidine, 5% lotion, to the affected area. Widespread superficial and deep-seated

infections sh ould b e treated with ben zylpen icillin, 50000 IU/ kg IM four tim es daily for at

least 10 days. If abscesses are p resent, th ey should b e drain ed su rgically.

Candidiasis. Oral candidiasis causes creamy-white lesions in the mou th an d m ay be

pain ful, making feeding difficult. The d iagnosis is confirm ed b y the pre sence o f typical

yeast form s on Gram staining of scrapings from the lesion. Cand idiasis can a lso involve

the oesophagus, stomach, rectum and moist tissues (e.g. axillae, groin). In systemic

can didiasis, the respiratory tract and blood m ay be involved. Nystatin oral suspen sion,

100000 IU four times daily is recom m end ed for oral, oesop hageal an d rectal cand idiasis.

Nystatin cream (100000IU (1g)) should be applied to affected areas of skin twice

daily for 2 weeks. Children over 2 years with systemic candidiasis should be given

ketocon azole, 5 m g/ kg orally daily un til rem ission is obtained .

Scabies. Scabies is caused by a mite tha t burrows sup erficially into the skin an d cau ses

inten se itching; the scratch ed lesions often beco m e second arily infected. Linda ne, 0.3%

lotion , should b e ap plied to affected areas o nce daily for 2 days. If this is not a vailable,

benzyl benzoate, 25% lotion, may be used. Although cheaper, it is more irritating; it

should be avoided in malnourished children, unless there is no alternative available.

Family mem bers should also be treated to prevent infestation or reinfestation.

Tuberculosis

Tubercu losis is an imp ortan t cause of failure to respo nd . The diagn osis is m ade b y chest

X-ray and e xaminat ion or culture of sputu m o r trachea l secretions. Occasionally, typical

tuberculous lesions can be seen in the fundus of the eye. The Mantoux test is often

negative owing to anergy, but may become positive as the childs nutritional status

improves.

Antituberculosis drugs should be given only when tuberculosis is diagnosed, and

treatm ent sh ould follow guidelines pub lished by WHO (11) or n ationa l guidelines. Chil-

dren with HIV infection are at increased risk of tuberculosis and should be treated if

tuberculosis is suspected. As the recomm ended drugs are hep atotoxic, they should b e

used with caution in any child with an enlarged or tender liver. The recommended

treatment schedule is described in Appendix 6.

Helminthiasis

Ascariasis, hookworm infection and trichuriasis. Infection with Ascaris lumbricoides

(roundworm), Ancylostoma duodenale or Necator americanus (hookworm), and

Trichuris trichiura (whipworm) is comm on in children who play outside. Whipworm

infections can cause dysentery, anaemia and, occasionally, prolapse of the rectum.

Hookworm infections can cause severe anaem ia. Treatmen t of these infections sho uld

be delayed until the rehabilitation phase of treatment for severe malnutrition.

Albend azole (400m g in a single do se) and m eben dazole (100 m g twice daily for 3 days

for inpatient treatment or 500mg in a single dose for outpatient treatment) are both

effective in ch ildren over 2 years. If these drugs are n ot available or the ch ild is un der 2


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years, hoo kworm can be treate d with pyrante l (10m g/ kg in a single dose) and ascariasis

with pyran tel or pipe razine. Piperazine is also effective in wh ipworm infection s. Chil-

dren aged 212 years should be given 75mg/kg of piperazine in a single dose to a

maximum of 2.5g, while those under 2 years should receive 50mg/kg in a single dose

administered under medical supervision (see Appendix 6).

Strongyloidiasis. Infection with Strongyloides stercoralisis also comm on in ch ildren who

play outside. The diagnosis is made by detectin g typical larvae in th e faeces. In p atients

whose imm un e systems are depressed by disease, the larvae m ay become widely dis-

seminated, giving rise to life-threatening pulmonary, cerebral and hepatic complica-

tions. Albend azole is the dru g of choice for children over 2 years; 400 m g should b e given

in a single oral dose. If albendazole is unavailable or the child is under 2 years,

iverm ectin sho uld be given; the dosage is 200g/ kg in a single oral dose. Tiabend azole

is effective, bu t causes severe ano rexia, which is dangerou s for m alnou rished children .

Malaria

Malaria is diagnosed by microscopic examination of a blood smear for malarial para-sites. Malaria often appears during the rehabilitation phase of treatment for malnutri-

tion. Malnourished children with malaria should receive a full course of antimalarial

therapy with th e dosage based on body weight.

Non-falciparum malaria. Infections with Plasmodium ovale, P. malariaeor susceptible

form s ofP. vivaxm ay be treated with chloroq uine. The total daily dose of chloroquine is

25 m g of base/ kg orally given o ver 3 days as follows (see App end ix 6):

Days 1 and 2: 10m g of base/ kg in a single dose

Day 3: 5 mg of base/ kg in a single dose.

Falciparum malaria. A single drug should be given following national recommenda-

tions. Drugs that m ay be recomm ended for children include ch loroquine (see above),

quinine and pyrimetham ine + sulfado xine. The d ose of quinine is 8 m g of base/ kg orallyevery 8 hou rs for 7 days. The d ose of pyrim etha m ine + sulfado xine is adjusted a ccording

to th e bod y weight of the ch ild as follows:

510kg: 12.5mg + 250m g orally in a single do se

1120kg: 25m g + 500m g orally in a single do se.

HIV infection and AIDS

Children with acquired immunodeficiency syndrome (AIDS) are likely to present with

severe malnu trition. In som e coun tries up to half of the ch ildren p resentin g with severe

m alnutrition h ave AIDS. Treatm ent of m alnut rition in ch ildren with HIV infection or

AIDS is the sam e as in ch ildren who a re HIV-negative. Interstitial lymp hocytic pn eum o-

nia is specifically associated with HIV infection. If findings on X-ray are typical of inter-

stitial lymphocytic pneumonia, an HIV test should be performed. Treatment is with

steroids.

Severely m alnou rished children shou ld notbe tested routin ely for HIV. Knowledge o f

HIV status plays no role in management of the child, except to diagnose interstitial

lym ph ocytic pn eum on ia. When an HIV test is don e, the results shou ld notbe revealed to

the staff. Otherwise, a po sitive test may cause th em to ne glect the ch ild.

Serious underlying disease

Malnutrition may result from unrecognized congenital abnormalities, inborn errors

of metabolism, malignancies, immunological diseases and other diseases of the major

organs. Examina tion of a child who fails to respon d to treatm en t should include a search

for serious und erlying disease. Any problem identified sho uld be treated a pp ropriately;


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however, the associated ma lnutrition should b e m anaged a ccording to th e guidelines in

this man ual.

7.4 Learning from failureAccurate records should be kept of all children who fail to respond to treatm ent a nd of

all deaths. These should include, as a minimum, details of the childs age, sex, date of

admission, weight-for-height (or length) on admission, principal diagnoses, treatment

and, where app ropriate, date an d time of death, and ap parent cau se of death. Periodic

review of these records can help to iden tify areas where case m anagem ent p ractices

should be carefully exam ined an d im proved. For example, deaths that occur within the

first 2 days are often due to hypoglycaemia, un recognized or m isman aged septic shock,

or other serious infection, whereas death s that occur a fter day 2 are often d ue to heart

failure. An increase in de ath s occurring at night or at weekends suggests that mo nitoring

and care of children at tho se times should b e reviewed an d im proved. The o bjective

shou ld be to ach ieve a case-fatality rate of


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35 8. Management of Malnutrition in Disaster Situations and Refugee Camps

35

8.

Management of malnutritionin disaster situations andrefugee camps

8.1 General considerations

Health workers in disaster situations an d refugee camps may h ave to m anage a large

num ber of severely malnou rished ch ildren. Although the principles of mana gement are

the sam e as in other situations, treatment mu st follow a routine, rather than an ind i-

vidual, approach. This often requires that a therapeutic feeding centre be established.

This is usually necessary when a cluster survey shows over 10% of children aged 6

m ont hs to 5 years with low weight-for-height (below 2 SD of the m edian NCHS/ WHO

reference values) (12).

8.2 Establishing a therapeutic feeding centre

Location and capacity

If possible, the therapeutic feeding centre should be in or near a hospital. It may be

located in simp le buildings or tents. One cen tre can serve up to 50 children. If there a re

more than 50100 children, a second cen tre should b e established. Each centre shou ld

include a special care unit, to provide roun d-th e-clock care du ring initial treatm ent , an d

a day-care unit, to provide care during rehabilitation.

Water supply and sanitation

A m inimu m of 30 litres of water shou ld be a vailable p er child per d ay. If less than 10 litres

of water are available pe r child per da y, the cen tre will be un able to fun ction. A latrine

and a bath ing area are required for every 20 persons.

Cooking facilities and supplies

A collective kitchen should be organized and a reliable supply of fuel for cooking en-

sured. The food requirement should be based on the estimated number of severely

malnourished children plus their mothers or carers. Secure storage facilities are re-quired for food and med ical supplies.

Staff

Each centre shou ld include, as a minimum , one part-time doctor, three nurses and 10

nu rsing aides. The moth ers or carers of the ch ildren m ay also provide assistance .

8.3 Criteria for enrolment and discharge

The criteria for admission d epen d on the ob jectives of the programm e and the resources

available. In general, children whose weight-for-height is below 3 SD or 70% of the

med ian NCHS/ WHO reference values, or who have oedem a, should be adm itted to the


44/68


therapeutic feeding centre. Discharge usually takes place when the childs weight-for-

height has reached at least 2 SD or 80% (pre ferably 1.5 SD or 85%) of the N CHS/WHO

m edian referen ce values on two con secutive weighings, 1 week ap art. In som e situations

the circum ference of the m id upper arm (13) is used as a criterion for adm ission. The

criteria can be m odified in accordan ce with national guidelines, resources of the centre

an d cap acity for follow-up, bu t shou ld always be clearly defin ed.


The principles of man agement are the same a s in a ho spital setting. The d octor should

evaluate each child daily. Initial treatment should include vitamins, minerals,

an thelm inthics (see page 32) an d an timicrobials (see section 4.6).

8.5 Evaluation of the therapeutic feeding centre

A med ical team should m onitor the hea lth an d n utritional status of the entirepopulation

of the refugee cam p or disaster area by:

calculating m ean daily mortality rates at weekly intervals;

mo nitoring the availability of food, and its macro- and micronutrient conten t, at

m on thly intervals; an d

condu cting anth ropom etric (weight an d height or length) surveys every 3 mon ths.

The rates of coverage, success an d m ortality of the cen tre shou ld be regularly evalu-

ated by th e following criteria:

Coverage rate: The n um ber of severely malnourished children en rolled at the centre

divided by the total number of severely malnourished children in the population,

based on the m ost recent survey.

Recovery rate: The number of children reaching criteria for discharge divided by the

total number of discharges, deaths, defaulters and transfers.

Mortality rate: The num ber of deaths amon g children at the centre divided b y the total

nu mb er of children en rolled at the centre.

The interpretation of these figures dep ends on local conditions, resources and com -

peting health priorities. Most programmes can achieve coverage rates of at least 80%,

with recovery rates of>50%, and m ortality rates of


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37 9. Malnutrition in adolescents and adults

37

9.

Malnutrition in adolescentsand adults

Severe m alnutrition occurs as a primary disorder in adolescents and adults in cond itions

of extrem e privation and fam ine. It also occurs in situation s of dep end ency, for examp le,

in the elderly, those with m ental illnesses and emo tional problems, and in prisoners.

Malnutrition in adolescents and adults is commonly associated with other illnesses,

such as chronic infections, intestinal malabsorption, alcohol and drug dependence,

liver disease, endocrine an d auto imm un e diseases, cance r and AIDS. In such ca ses both

the m alnutrition a nd the un derlying illness m ust be treated.


The physiological changes and principles of management of adolescents and adults

with severe malnu trition a re the sam e as those in ch ildren . In gene ral, the guidelines for

management of children should be followed. There are, however, differences in the

classification of malnutrition, the am oun t of food requ ired and the d rug dosages.

Except in famine conditions, adolescents and adults rarely associate wasting or

oede m a with their diet. As a conseq uen ce, they do not b elieve that altering their diet will

help them. Even in famine conditions, they are often very reluctant to eat anything

except trad ition al foods, which th ey view as perfectly satisfactory. Moreover, the foods

they are allowed are often restricted by cultural and religious beliefs. They are often

reluctant to take formu la feeds un less they can b e persuad ed th at such feeds are a form

of medicine. This prob lem is one of the m ost difficult aspects of treating adolescents an d

adults.

9.2 Classification of malnutrition

Adults (over 18 years)

Body mass index

The degree o f thinne ss is assessed u sing the b ody m ass index (BMI) as the indicator. BMI

is defined as the body weight (in kg) divided by the square of the height1

(in metres).

Table 13 gives th e BMI cut-off values for defin ing grades of m alnut rition in ad ults.

When an adu lt is too ill to stan d or has a spina l deform ity, the half arm sp an sh ould

be m easured. This is the distance from the m iddle of the sternal notch to the tip of the

middle finger with the arm held out horizontally to the side. Both sides should be

measured. If there is a discrepancy, the measurements should be repeated and the

longest one taken . The h eight (in m etres) can then be calculated as follows:

Height = ( )[ ]+0 73 2 0 43. .half arm sp anThe BMI is then comp uted from th e calculated h eight an d m easured weight.

1 Short height, in adults, usually represents chronic malnutrition in childhood. As there is notreatment available, short adult height is mainly of theoretical interest, except that stuntedwomen have an increased risk of complications d uring delivery and are likely to have low-birth-

weight an d short ch ildren them selves.


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Oedema

Exam ine the a nkles and lower legs for pitting oedem a. If symm etrical oede m a is present,

its cause m ust be d etermined. In add ition to ma lnutrition, causes in ad ults include pre-

eclamp sia (in p regnant wom en), severe proteinuria (neph rotic syndrome), nep hritis,

acute filariasis (the limb is hot and painful), heart failure and wet beriberi. Non-

nu tritional causes of oede m a can rea dily be iden tified by the history, ph ysical exam ina-tion an d urina lysis.

Adu lts with a BMI below 16.0 or with oed em atou s malnu trition shou ld be adm itted

to hospital.

Adolescents (1018 years)

A WHO Expert Com m ittee has recom m end ed BMI-for-age as the b est indicator of thin-

ness for use in adolescence, the cu t-off value b eing


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39 9. Malnutrition in adolescents and adults

Table 14. Dietary requirements for initial treatment ofseverely malnourished adolescents and adults

Age Daily energy Volume of diet(years) requirementa required (ml/kg

per hour)

(kcalth/kg) (kJ/kg) F-75 F-100

710 75 315 4.2 3.01114 60 250 3.5 2.51518 50 210 2.8 2.01975 40 170 2.2 1.7>75 35 150 2.0 1.5

a Individual needs may vary by up to 30% from these figures.

9.5 Rehabilitation

An imp roving app etite indicates the be ginning of reha bilitation. During reha bilitation it

is usual for adolescents and adults to become very hungry, often refusing the formula

feed an d dem and ing enormous am oun ts of solid food. When this happen s, a diet should

be given th at is based on trad ition al foods, but with ad ded o il, mineral mix and vitamin

m ix. Provide a wide variety of foods an d allow the pat ients to eat a s mu ch as th ey want.

If possible, continue to give the formula feed with the vitamin and mineral mixes be-

tween m eals and at night. If necessary, present the formu la feed as a med icine.

9.6 Criteria for discharge

Adolescent s and ad ults can be discha rged when th ey are eating well an d gaining weight,

they have a reliable source of nu tritious food ou tside the hosp ital, an d an y othe r health

problems have been diagnosed and treatm ent begun . Adults should continue to receive

a sup plemen ted d iet as outpa tients until their BMI is 18.5; for a dolescents, th eir diets

should be supplemented until their BMI-for-age is 5th percentile of the median

NCHS/ WHO referen ce values.

9.7 Failure to respond to treatment

Failure to respond to treatmen t in adu lts and adolescents is usually due to an u nrecog-

nized underlying illness (see page 37), a nutrient deficiency or refusal to follow the

treatment regimen.


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40

References

1. Physical status: the use and interpretation of anthropometry. Report of a WHO Expert

Committee. Geneva, World Health Organization, 1995 (WHO Technical Report

Series, No. 854).

2. Waterlow JC. Note on th e assessmen t and classification of prote inenergy malnu tri-

tion in ch ildren. Lancet, 1973, i:8789.

3. Waterlow JC. Classification an d de finition of protein calorie ma lnutrition. Britishmedical journal, 1972, 3: 566569.

4. Gomez F et al. Mortality in second - and third-degree m alnutrition.Journal of tropi-

cal pediatrics and African child health, 1956, 2:77.

5. Somm er A. Vitamin A deficiency and its consequences. A field guide to detection and

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vitamin A deficiency and xerophthalmia, 2nd ed. Geneva, World Health Organiza-

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9. The management of bloody diarrhoea in young children. Geneva, World H ealth Orga-

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Division of Child Health a nd Developme nt, World Health Organization, 1211 Gen eva

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10. Acute respiratory infections in children: case management in small hospitals in devel-

oping countries. Geneva, World Health Organization, 1990 (unpublished documentWHO/ARI/90.5; available on requ est from Distribu tion a nd Sales, World Hea lth

Organization, 1211 Geneva 27, Switzerland).

11. Treatment of tuberculosis: guidelines for national programmes, 2nd ed . Geneva,

World He alth Organization, 1997 (unp ub lished docu m ent WHO/TB/ 97.220; avail-

able on request from Global Tuberculosis Programme, World Health Organization,

1211 Geneva 27, Switzerland).

12. The management of nutrition in major emergencies, 2nd ed .Geneva, World Health

Organization, in press.

13. de Onis M, Yip R, Mei Z. The developm ent of MUAC-for-age reference data recom -

men ded b y a WHO Expert Comm ittee. Bulletin of the World Health Organization,

1997, 75:1118.


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41 Appendix

41

Appendix 1NCHS/ WHO n orm alized referen ce values forweight-for-height an d weight-for-len gth

Boys weight (kg) Lengtha(cm) Girls weight (kg)

4 SD 3 SD 2 SD 1 SD Median Median 1 SD 2 SD 3 SD 4 SD

1.8 2.1 2.5 2.8 3.1 49 3.3 2.9 2.6 2.2 1.81.8 2.2 2.5 2.9 3.3 50 3.4 3.0 2.6 2.3 1.9

1.8 2.2 2.6 3.1 3.5 51 3.5 3.1 2.7 2.3 1.91.

Documents

Management of Severe Malnutrition