Malnutrition And Fluids

MALNUTRITIONMALNUTRITION

http://crisbertcualteros.page.tlhttp://crisbertcualteros.page.tl

COMPUTATIONSCOMPUTATIONS

• Weight for Age (WFA) Weight for Age (WFA) = = actual wt actual wt x 100 x 100 wt at p50wt at p50

• Height for Age (HFA)Height for Age (HFA)== actual htactual ht x 100x 100 ht at p50ht at p50

• Weight for Height (WFH)Weight for Height (WFH) = = actual wtactual wt x 100x 100 wt at p50 of ht at p50wt at p50 of ht at p50

InterpretationInterpretation

WFA (PEM)WFA (PEM)

A+CA+C

>90 N>90 N

75-90 Mild75-90 Mild

60-74 Mod60-74 Mod

<60 <60 SevereSevere

HFA HFA (stunting)(stunting)

CC

>95 N>95 N


85-90 Mod85-90 Mod

<85 Severe<85 Severe

WFH WFH (wasting)(wasting)

AA

>95 N>95 N


85-90 Mod85-90 Mod

<85 Severe<85 Severe

EXAMPLEEXAMPLE

• 15mos15mos

• boyboy

• wt = 6.6kgwt = 6.6kg

• length = 70cmlength = 70cm

WATERLOW WATERLOW CLASSIFICATIONCLASSIFICATION• Weight for Age (WFA) Weight for Age (WFA)

= = actual wt actual wt x 100 x 100

wt at p50wt at p50

e.g. 15 mos. Old baby boy e.g. 15 mos. Old baby boy

Ht = 70 cm, wt = 6.6 kgHt = 70 cm, wt = 6.6 kg

WFA = WFA = 6.6 kg6.6 kg x 100 = 59 % severe PEM x 100 = 59 % severe PEM

11.1 kg11.1 kg

• Height for Age (HFA)Height for Age (HFA)

== actual htactual htx 100x 100

ht at p50ht at p50e.g. HFA= e.g. HFA= 70 cm70 cm x 100 = 89% mod stunting x 100 = 89% mod stunting

79 cm79 cm

• Weight for Height (WFH)Weight for Height (WFH)

== actual wtactual wt x 100x 100

wt at p50 of ht at p50wt at p50 of ht at p50

e.g. e.g. 6.6 kg6.6 kg x 100 = 79% mod wasting x 100 = 79% mod wasting

8.4 kg8.4 kg

COMPUTATION FOR TOTAL CALORIC COMPUTATION FOR TOTAL CALORIC REQUIREMENT (TCR)REQUIREMENT (TCR)

Required Daily Allowance (RDA)Required Daily Allowance (RDA)• AGEAGE WEIGHT WEIGHT CALORIES CALORIES CHON CHON

(kg) (kg) (kcal/kg) (kcal/kg) (g/kg)(g/kg)

• 0 - 5 mo0 - 5 mo 3 - 63 - 6 115115 3.53.5

• 6 -11 mo6 -11 mo7 - 97 - 9 110110 3.03.0

• 1-2 y1-2 y 10 - 1210 - 12 110110 2.52.5

• 3-6 y3-6 y 14 - 1814 - 18 90 - 10090 - 100 2.02.0

• 7-9 y7-9 y 22 - 2422 - 24 80 - 9080 - 90 1.51.5

• 10-12 y10-12 y 28 - 3228 - 32 70 - 8070 - 80 1.51.5

• 13-15 y13-15 y 36 - 4436 - 44 55 - 6555 - 65 1.51.5

• 16-19 y16-19 y 48 - 5548 - 55 45 - 5045 - 50 1.21.2

EXAMPLE: 1 yr old baby weighing 10kg

A. Solve for TOTAL CALORIC A. Solve for TOTAL CALORIC REQUIREMENT (TCR)REQUIREMENT (TCR)

• TCR = Actual body weight (kg) x Calories TCR = Actual body weight (kg) x Calories

(kcal/kg)(kcal/kg)

• e.g. 1 yr old baby weighing 10 kge.g. 1 yr old baby weighing 10 kg

10 kg x 110 kcal/kg = 1100 kcal10 kg x 110 kcal/kg = 1100 kcal

B. Determine TCRB. Determine TCRCHON CHON in grams, in grams, then convert to caloriesthen convert to calories

• TCRTCRCHON CHON = CHON (g/kg) x ABW (kg) = CHON (g/kg) x ABW (kg)

• e.g. 2.5 g CHON/ kg x 10 kg = 25 e.g. 2.5 g CHON/ kg x 10 kg = 25 gg CHON CHON

• recall conversion factor to calories :recall conversion factor to calories :

1 g CHON = 4kcal/g1 g CHON = 4kcal/g

1 g CHO = 4kcal/g 1 g CHO = 4kcal/g

1g fat = 9kcal/g1g fat = 9kcal/g

e.g. 25 g CHON x 4kcal/g CHON = 100 e.g. 25 g CHON x 4kcal/g CHON = 100 kcalkcal CHON CHON

C. Subtract TCRC. Subtract TCRCHON CHON from TCRfrom TCRtotaltotal

then get fraction of CHO & fats then get fraction of CHO & fats (usual ratio 60:40)(usual ratio 60:40)

e.g. 1100 kcal - 100 kcal CHON = 1000 e.g. 1100 kcal - 100 kcal CHON = 1000 kcalkcal

60% of 100060% of 1000 == 600 kcal 600 kcal CHOCHO

40% of 100040% of 1000 == 400 kcal fats400 kcal fats

D. Convert back to gramsD. Convert back to grams

e.g. e.g. 100 kcal CHON = 100 / 4 = 100 kcal CHON = 100 / 4 = 25 g25 g

600 kcal CHO = 600/ 4 = 600 kcal CHO = 600/ 4 = 150 g150 g

400 kcal fats = 400 / 9 = 400 kcal fats = 400 / 9 = 45 g45 g

E. Write final prescriptionE. Write final prescription

• e.g.e.g.

1100kcal1100kcal == 25g25g 150g150g45g45g

TCRTCR CHON CHON CHOCHO fatsfats

Catch-up CaloriesCatch-up Calories

• Ex: 13yo, girl, ABW = 29kgEx: 13yo, girl, ABW = 29kg• IBW (p50)= 48kgIBW (p50)= 48kg• Compute for TCR = IBW x CaloriesCompute for TCR = IBW x Calories

48kg x 80cal/kg = 3840cal/day48kg x 80cal/kg = 3840cal/day60% of 3840cal/day = 2304cal/day60% of 3840cal/day = 2304cal/day

• Protein requirement Protein requirement = ABW kg x protein g/kcal x 4 kcal/g= ABW kg x protein g/kcal x 4 kcal/g= 29kg x 1.5g/kcal x 4cal/g = 232 kcal= 29kg x 1.5g/kcal x 4cal/g = 232 kcal

• CHO = (TCR - CHON) x .6 = 1243.2 kcalCHO = (TCR - CHON) x .6 = 1243.2 kcal• Fat = (TCR - CHON) x .4 = 828.8 kcal Fat = (TCR - CHON) x .4 = 828.8 kcal

COMPUTATION FOR TOTAL CALORIC COMPUTATION FOR TOTAL CALORIC REQUIREMENT (TCR)REQUIREMENT (TCR)

Required Daily Allowance (RDA)Required Daily Allowance (RDA)• AGEAGE WEIGHT WEIGHT CALORIES CALORIES CHON CHON

(kg) (kg) (kcal/kg) (kcal/kg) (g/kg) (g/kg)

• 0 - 5 mo0 - 5 mo 3 - 63 - 6 115115 3.53.5

• 6 -11 mo6 -11 mo 7 - 97 - 9 110110 3.03.0

• 1-2 y1-2 y 10 - 1210 - 12 110110 2.52.5

• 3-6 y3-6 y 14 - 1814 - 18 90 - 10090 - 100 2.02.0

• 7-9 y7-9 y 22 - 2422 - 24 80 - 9080 - 90 1.51.5

• 10-12 y10-12 y 28 - 3228 - 32 70 - 8070 - 80 1.51.5

• 13-15 y13-15 y 36 - 4436 - 44 55 - 6555 - 65 1.51.5

• 16-19 y16-19 y 48 - 5548 - 55 45 - 5045 - 50 1.21.2

EXAMPLE: 13yo, girl, BW=29kg

FLUIDSFLUIDS

Fluid CompositionFluid Composition

GeneralitiesGeneralities

Three types of fluid therapy:Three types of fluid therapy:

• MaintenanceMaintenance

• ReplacementReplacement

• DeficitDeficit

Maintenance fluidMaintenance fluid

• Replaces the obligatory fluid losses both Replaces the obligatory fluid losses both measurable (urine and stool) and not measurable (urine and stool) and not measurable (insensible losses from the skin measurable (insensible losses from the skin and lungs) and lungs)

• Goals: Goals: – Prevent dehydrationPrevent dehydration– Prevent electrolyte disordersPrevent electrolyte disorders– Prevent ketoacidosisPrevent ketoacidosis– Prevent protein degradationPrevent protein degradation

• It is composed in general of a solution It is composed in general of a solution consisting of water, glucose, sodium and consisting of water, glucose, sodium and potassium; potassium;

Components of Maintenance Components of Maintenance waterwaterUrineUrine 60%60%

Insensible (skin and lungs)Insensible (skin and lungs) 35%35%

StoolStool 05% 05%

• It provides approximately 20% of the It provides approximately 20% of the normal caloric needs of the patient enough normal caloric needs of the patient enough to prevent ketoacidosis from starvation and to prevent ketoacidosis from starvation and protein degradationprotein degradation

• It does not provide adequate calories, It does not provide adequate calories, protein, fat, minerals ( calcium, phosphorus, protein, fat, minerals ( calcium, phosphorus, magnesium or bicarbonate) and vitamins.magnesium or bicarbonate) and vitamins.

• Calculation of maintenance fluidCalculation of maintenance fluid

Maintenance fluidMaintenance fluid

Body Weight Method for calculating Body Weight Method for calculating Maintenance Fluid VolumeMaintenance Fluid Volume

Holliday-Segar MethodHolliday-Segar Method

BW (kg)BW (kg) Total Fluid Total Fluid RequirementRequirement

1st 10kg BW1st 10kg BW

2nd 10kg BW2nd 10kg BW

BW > 20kgBW > 20kg

100ml/kg/day, plus100ml/kg/day, plus

50ml/kg/day, plus50ml/kg/day, plus

20ml/kg/day20ml/kg/day

The maximum total fluid per day is normally 2,400 ml

Eg. 25kg child (1000+500+100) = 1600ml/day

Maintenance fluid to Maintenance fluid to gtts/mingtts/min

1600ml1600ml x x 1 day1 day x x 1 hr1 hr x x 15gtts15gtts

day 24 hrs 60mins mlday 24 hrs 60mins ml

= 16gtts/min= 16gtts/min

Maintenance FluidsMaintenance Fluids

Ludan’s MethodLudan’s Method

Weight (kg)Weight (kg) Volume of Fluid in Volume of Fluid in 24h24h

(ml/kg/d)(ml/kg/d)

0-30-3

3-103-10

10-2010-20

20-3020-30

>30>30

7575

100100

7575

6060

5050Eg. 25kg child: 25kg x 60ml/kg/d = 1500ml/day

Maintenance FluidsMaintenance Fluids

Based on BSABased on BSA

TFR = IWL + urine outputTFR = IWL + urine output– where:where:

• IWL: 400-600ml/m2/day x BSAIWL: 400-600ml/m2/day x BSA

•Urine: 600-1000ml/m2/day x BSAUrine: 600-1000ml/m2/day x BSA

– BSA = BSA = (ht in cm) x (wt in kg)(ht in cm) x (wt in kg) 36003600

Eg. 8y.o. girl, 25kg, 125cm

BSA = 0.931

TFR = 1488ml/day

ComparisonComparison

8y.o. girl, 25kg, 125cm8y.o. girl, 25kg, 125cm

• Holliday Segar = 1,600ml/dayHolliday Segar = 1,600ml/day

• Ludan’s Method = 1,500ml/dayLudan’s Method = 1,500ml/day

• Based on BSA = 1,488ml/day Based on BSA = 1,488ml/day

Maintenance ElectrolytesMaintenance Electrolytes

Sodium Sodium 2-3 meq /kg / 24 2-3 meq /kg / 24 hour hour

Potassium Potassium 1-2 meq /kg / 24 1-2 meq /kg / 24 hour hour

Composition of Intravenous Composition of Intravenous

solutionssolutions FluidFluid NaNa

++Cl+Cl+ K+K+ Ca+Ca+

++LactateLactate--

Normal saline Normal saline (0.9%NaCl)(0.9%NaCl)

154154 151544

½ Normail ½ Normail Saline (0.45% Saline (0.45% NaCl)NaCl)

7777 7777

¼ Normal Saline ¼ Normal Saline (0.225% NaCl)(0.225% NaCl)

38.38.55

38.38.55

Ringer lactateRinger lactate 130130 101099

44 33 2828

Adjustments in maintenance Adjustments in maintenance WaterWater Source Source Causes of Increased Causes of Increased

Water needs Water needs Causes of Decreased Causes of Decreased water needs water needs

Skin Skin •radiant warmerradiant warmer

•FeverFever

•SweatSweat

•BurnsBurns

mist tent mist tent

Lungs Lungs Tachypnea Tachypnea Humidified ventilator Humidified ventilator

Gastrointestinal Tract Gastrointestinal Tract •Diarrhea Diarrhea

•EmesisEmesis

•Nasogastric suctionNasogastric suction

Renal Renal Polyuria Polyuria Oliguria / anuria Oliguria / anuria

Miscellaneous Miscellaneous •Surgical drain Surgical drain

•Third spacing Third spacing Hypothyroidism Hypothyroidism

Replacement FluidReplacement Fluid • GI tract is potentially a source of considerable GI tract is potentially a source of considerable

water loss;water loss;

• GI losses are often associated with loss of GI losses are often associated with loss of potassium, leading to potassium, leading to hypokalemihypokalemia and a and bicarbonate, causing bicarbonate, causing metabolic acidosismetabolic acidosis which which maybe aggravated when there is maybe aggravated when there is hypoperfusion causing a concurrent lactic hypoperfusion causing a concurrent lactic acidosis; acidosis;

• emesis or losses from NG tube cause a emesis or losses from NG tube cause a metabolic alkalosismetabolic alkalosis..

Replacement FluidReplacement Fluid

• Losses should then be replaced as Losses should then be replaced as they occur using a solution with the they occur using a solution with the same approximate electrolyte same approximate electrolyte concentration as the GI fluid;concentration as the GI fluid;

• the losses are replaced every 1-6 the losses are replaced every 1-6 hour depending on the rate of losshour depending on the rate of loss

Adjusting Fluid therapy in Adjusting Fluid therapy in DiarrheaDiarrhea

Average composition of Diarrheal fluidAverage composition of Diarrheal fluid• Sodium: 55 meq / lSodium: 55 meq / l• Potassium: 25 meq / lPotassium: 25 meq / l• Bicarbonate: 15 meq / lBicarbonate: 15 meq / l

Approach to Replacement of Ongoing Approach to Replacement of Ongoing LossesLosses

• Solution: D5 ¼ NS + 15 meq / L Solution: D5 ¼ NS + 15 meq / L bicarbonate + 25 meq / L KClbicarbonate + 25 meq / L KCl

• Replace stool ml/ml every 1-6 hour Replace stool ml/ml every 1-6 hour

Adjusting Fluid Therapy for Emesis or Adjusting Fluid Therapy for Emesis or Nasogastric lossesNasogastric losses

Average composition of Gastric FluidAverage composition of Gastric Fluid

• Sodium: 60 meq / LSodium: 60 meq / L

• Potassium: 10 meq / LPotassium: 10 meq / L

• Chloride: 90 meq / LChloride: 90 meq / L

Approach to Replacement of ongoing Losses:Approach to Replacement of ongoing Losses:

• Solution: D5 ½ NS + 10 meq /L KCLSolution: D5 ½ NS + 10 meq /L KCL

• Replace output ml / ml every 1-6 hourReplace output ml / ml every 1-6 hour

THANK YOU!THANK YOU!

Fluid Management of Specific Fluid & Fluid Management of Specific Fluid & Electrolytes Disturbance Electrolytes Disturbance Hyponatremia:Hyponatremia:• Initial goal is correction of intravascular volume depletion with Initial goal is correction of intravascular volume depletion with

isotonic fluid (NS or Ringer lactate)isotonic fluid (NS or Ringer lactate)

• Formula for computing sodium deficit:Formula for computing sodium deficit:– Sodium deficit = 0.6 x wt x ( {Na+} d – Na+} i )Sodium deficit = 0.6 x wt x ( {Na+} d – Na+} i )

* * Na + d= sodium desired (135 meq / l)Na + d= sodium desired (135 meq / l)* Na + i= initial sodium concentration* Na + i= initial sodium concentration

• It is not necessary to increase sodium level beyond 135 meq / It is not necessary to increase sodium level beyond 135 meq / L; overcorrection and rapid correction (12 meq / L) are L; overcorrection and rapid correction (12 meq / L) are associated with an increased risk of central pontine myelinosis associated with an increased risk of central pontine myelinosis (CPM).(CPM).

• D5 ½ NS + 20 meq / LD5 ½ NS + 20 meq / L KCl is effective; half of the fluid can KCl is effective; half of the fluid can be administered over the first 8 hours.be administered over the first 8 hours.

Management of Specific Fluid & Management of Specific Fluid & Electrolytes DisturbanceElectrolytes Disturbance

Hypernatremia: Hypernatremia:

• Decrease in sodium concentration should not be more than Decrease in sodium concentration should not be more than 12 meq / L; severe hypernatremia should be corrected over 12 meq / L; severe hypernatremia should be corrected over 2-4 days2-4 days

• Guide in the fluid treatment:Guide in the fluid treatment:– Restore intravascular volume:Restore intravascular volume:

• Normal saline: Normal saline: 20 ml /kg over 20 minutes20 ml /kg over 20 minutes• Repeat until intravascular volume is restoredRepeat until intravascular volume is restored

– Determine the time for correction based on theDetermine the time for correction based on the initial initial sodium concentrationsodium concentration• Na+:Na+: 145-157 meq / L = 24 hours145-157 meq / L = 24 hours• Na+:Na+: 158-170 meq / L = 48 hours158-170 meq / L = 48 hours• Na+:Na+: 171-183 meq / L = 72 hours171-183 meq / L = 72 hours• Na+:Na+: 184-196 meq / L = 84 hours184-196 meq / L = 84 hours

Assessment of State of Assessment of State of HydrationHydration Assessment of State of Assessment of State of HydrationHydration

1.1.Clinical Manifestations:Clinical Manifestations:– Look: Look:

• Look at the Look at the child’s general conditionchild’s general condition: : – Is the child lethargic or unconscious? Is the child lethargic or unconscious?

Restless and irritable?Restless and irritable?

• Look for Look for sunken eyes and tearssunken eyes and tears

• Look for Look for dry buccal mucosadry buccal mucosa

• Offer the child with fluidOffer the child with fluid– Does the child: Does the child:

Not able to drink or drinking poorly?Not able to drink or drinking poorly? Drink eagerly, thirsty?Drink eagerly, thirsty?

1.1. Clinical Manifestations:Clinical Manifestations:– FeelFeel

• PinchPinch the skin on the abdomen the skin on the abdomen– Does it go back:Does it go back:

Very fast ( < 2 seconds) or Very fast ( < 2 seconds) or Very slowly (longer than 2 seconds)? Very slowly (longer than 2 seconds)?

– Ask:Ask:• For frequency of urinationFor frequency of urination

• For the color of the urineFor the color of the urine

Assessment of State of Assessment of State of HydrationHydration Assessment of State of Assessment of State of HydrationHydration

Classify DehydrationClassify Dehydration

Not enough signs to classify as Not enough signs to classify as some or severe dehydration:some or severe dehydration:

NO DEHYDRATIONNO DEHYDRATION Treatment Plan Treatment Plan AA

(Group A)(Group A)

Volume loss: <3-6%Volume loss: <3-6%

Additional Clinical Parameters of Additional Clinical Parameters of Dehydration Dehydration Additional Clinical Parameters of Additional Clinical Parameters of Dehydration Dehydration

Some signs of Dehydration: (Group B)Some signs of Dehydration: (Group B)

• Mild dehydration (3-6%):Mild dehydration (3-6%):– Volume loss:Volume loss: 30-60 ml / kg 30-60 ml / kg

•Average:Average: 50 ml / kg 50 ml / kg

•Clinical Manifestations:Clinical Manifestations:– Normal pulseNormal pulse– decreased urine outputdecreased urine output – thirstythirsty– normal physical examination normal physical examination

Some signs of Dehydration: (Group B)Some signs of Dehydration: (Group B)

• Mild dehydration (3-6%):Mild dehydration (3-6%):– Volume loss:Volume loss: 30-60 ml / kg 30-60 ml / kg

•Average:Average: 50 ml / kg 50 ml / kg

•Clinical Manifestations:Clinical Manifestations:– Normal pulseNormal pulse– decreased urine outputdecreased urine output – thirstythirsty– normal physical examination normal physical examination

Additional Clinical Parameters of Additional Clinical Parameters of Dehydration Dehydration Additional Clinical Parameters of Additional Clinical Parameters of Dehydration Dehydration

Some signs of DehydrationSome signs of Dehydration: (Group B): (Group B)

• Moderate dehydration (7-10%):Moderate dehydration (7-10%):– Volume Loss:Volume Loss: 70-100 ml / kg 70-100 ml / kg

• Average:Average: 80 ml / kg80 ml / kg

– Clinical Manifestations:Clinical Manifestations:• TachycardiaTachycardia - dry mucous - dry mucous

membranesmembranes• irritable / lethargic irritable / lethargic - little or no urine - little or no urine

outputoutput• sunken eyes and fontanelsunken eyes and fontanel - mild tenting of - mild tenting of

the skinthe skin• decreased tearsdecreased tears - delayed capillary refill- delayed capillary refill• Mottled skinMottled skin

Some signs of DehydrationSome signs of Dehydration: (Group B): (Group B)

• Moderate dehydration (7-10%):Moderate dehydration (7-10%):– Volume Loss:Volume Loss: 70-100 ml / kg 70-100 ml / kg

• Average:Average: 80 ml / kg80 ml / kg

– Clinical Manifestations:Clinical Manifestations:• TachycardiaTachycardia - dry mucous - dry mucous

membranesmembranes• irritable / lethargic irritable / lethargic - little or no urine - little or no urine

outputoutput• sunken eyes and fontanelsunken eyes and fontanel - mild tenting of - mild tenting of

the skinthe skin• decreased tearsdecreased tears - delayed capillary refill- delayed capillary refill• Mottled skinMottled skin

Additional Clinical Parameters of Additional Clinical Parameters of DehydrationDehydrationAdditional Clinical Parameters of Additional Clinical Parameters of DehydrationDehydration

Severe Dehydration ( > 11-15%): Shock Severe Dehydration ( > 11-15%): Shock (Group C)(Group C)

– Volume Loss:Volume Loss: >110 ml – 150 ml / kg >110 ml – 150 ml / kg

– Clinical manifestations:Clinical manifestations:• rapid and weak pulserapid and weak pulse• decreased blood pressuredecreased blood pressure• no urine outputno urine output• very sunken eyes and fontanelsvery sunken eyes and fontanels• no tearsno tears• parched mucous membranes parched mucous membranes • tenting of the skintenting of the skin• very delayed capillary refill (>2 seconds)very delayed capillary refill (>2 seconds)• cold and mottled skincold and mottled skin

Severe Dehydration ( > 11-15%): Shock Severe Dehydration ( > 11-15%): Shock (Group C)(Group C)

– Volume Loss:Volume Loss: >110 ml – 150 ml / kg >110 ml – 150 ml / kg

– Clinical manifestations:Clinical manifestations:• rapid and weak pulserapid and weak pulse• decreased blood pressuredecreased blood pressure• no urine outputno urine output• very sunken eyes and fontanelsvery sunken eyes and fontanels• no tearsno tears• parched mucous membranes parched mucous membranes • tenting of the skintenting of the skin• very delayed capillary refill (>2 seconds)very delayed capillary refill (>2 seconds)• cold and mottled skincold and mottled skin


Two of the following signs:Two of the following signs:• Restless, irritableRestless, irritable• Sunken eyesSunken eyes• Drinks eagerly, thirstyDrinks eagerly, thirsty• Skin pinch goes back slowlySkin pinch goes back slowly

– goes back immediately: Normalgoes back immediately: Normal– < 2 seconds:< 2 seconds: Some signs of dehydration Some signs of dehydration– > 2 seconds:> 2 seconds: Severe Dehydration Severe Dehydration

SOME DEHYDRATIONSOME DEHYDRATION Treatment Plan BTreatment Plan B (Group B)(Group B)


Two of the following signs:Two of the following signs:• Lethargic or unconsciousLethargic or unconscious• Sunken eyesSunken eyes• Not able to drink or drinking poorlyNot able to drink or drinking poorly• Skin pinch goes back very slowly (>2 Skin pinch goes back very slowly (>2

secondsseconds

SEVERE DEHYDRATIONSEVERE DEHYDRATION Treatment Plan CTreatment Plan C(Group C)(Group C)

Deficit TherapyDeficit TherapyORTORT

• Treatment Plan A: Treat Diarrhea at Home:Treatment Plan A: Treat Diarrhea at Home:– Three rules of home treatment:Three rules of home treatment:

• Give extra fluids (as much as the child will take)Give extra fluids (as much as the child will take)

– Tell the motherTell the mother:: Breastfeed frequently and for longer at each feedBreastfeed frequently and for longer at each feed If the child is exclusively breastfed, give ORS or clean water in If the child is exclusively breastfed, give ORS or clean water in

addition to BMaddition to BM If the child is not exclusively breastfed, give one or more of If the child is not exclusively breastfed, give one or more of

the following: ORS solution, food-based fluids (such as soup, the following: ORS solution, food-based fluids (such as soup, rice water, and yoghurt drinks or clean waterrice water, and yoghurt drinks or clean water

– Teach the mother how to mix and give ORS, give the Teach the mother how to mix and give ORS, give the mother 2 packets of ORS to use at home.mother 2 packets of ORS to use at home.

– Show the mother how much fluid to give in addition to the Show the mother how much fluid to give in addition to the usual fluid intake:usual fluid intake:

up to 2 years:up to 2 years: 50-100 ml after each loose stool50-100 ml after each loose stool 2 years of more:2 years of more: 100-200 ml after each loose stool100-200 ml after each loose stool

Treatment Plan A: Treat Diarrhea at Treatment Plan A: Treat Diarrhea at HomeHome

• Continue feedingContinue feeding

• Follow-upFollow-up

Treatment Plan B: Treat Some Treatment Plan B: Treat Some DehydrationDehydration with ORS with ORS

• Give in clinic recommended amount of Give in clinic recommended amount of ORS over 4-hour period ORS over 4-hour period

• Determine amount of ORS to give during Determine amount of ORS to give during the first 4 hours: the first 4 hours:

AgeAge Up to 4 Up to 4 mosmos

4 mos – 4 mos – 12 mos 12 mos

12 mos 12 mos – 2 yrs – 2 yrs

2 yrs-5 2 yrs-5 yrs yrs

WeighWeightt

< 5kg< 5kg 6-<10 6-<10 kg kg

10-<12 10-<12 kg kg

2 yrs-5 2 yrs-5 yrs yrs

In mlIn ml 200-200-400400

400-400-700 700

700-700-900 900

900-900-1400 1400

Treatment Plan B: Treat Some Treatment Plan B: Treat Some Dehydration with ORSDehydration with ORS

– If the child wants more ORS than shown, give moreIf the child wants more ORS than shown, give more– For infants < 6 months who are not breastfed, also give For infants < 6 months who are not breastfed, also give

100-200 ml clean water during this period100-200 ml clean water during this period

• Show the mother how to give ORS solutionShow the mother how to give ORS solution– Give frequent small sips from a cupGive frequent small sips from a cup– If the child vomits, wait 10 minutes, then continue, but If the child vomits, wait 10 minutes, then continue, but

more slowlymore slowly– Continue BF whenever the child wantsContinue BF whenever the child wants

Treatment Plan B: Treat Some Treatment Plan B: Treat Some DehydrationDehydration with ORS with ORS

• After 4 hours:After 4 hours:– Reassess the child and classify the child for dehydrationReassess the child and classify the child for dehydration– Select the appropriate plan to continue treatmentSelect the appropriate plan to continue treatment– Begin feeding the child in clinicBegin feeding the child in clinic

• If the mother must leave beforeIf the mother must leave before completing completing treatment:treatment:– Show her how to prepare ORS solution at homeShow her how to prepare ORS solution at home– Show her how much ORS to give to finish the 4-hour Show her how much ORS to give to finish the 4-hour

treatment at hometreatment at home– Give her enough ORS packets to complete rehydration. Also Give her enough ORS packets to complete rehydration. Also

give her 2 packets as recommended in Plan Agive her 2 packets as recommended in Plan A

Treatment Plan C: Treat severe Treatment Plan C: Treat severe Dehydration QuicklyDehydration Quickly

• Start IVF immediately. If the child can drink, give ORS by Start IVF immediately. If the child can drink, give ORS by mouth while the drip is set up. Give mouth while the drip is set up. Give 100 ml / kg 100 ml / kg Ringer’s Lactate SolutionRinger’s Lactate Solution (or if not available NSS), (or if not available NSS), divided as follows:divided as follows:

Age Age First give 30 First give 30 ml / kg in:ml / kg in:

Then give 70 Then give 70 ml / kg in:ml / kg in:

Infants (under Infants (under 12 mos) 12 mos)

1 hour* 1 hour* 5 hours 5 hours

Children (12 Children (12 mos-5 yrs) mos-5 yrs)

30 minutes* 30 minutes* 2 ½ hours 2 ½ hours

* Repeat once if radial is still very weak or not detectable* Repeat once if radial is still very weak or not detectable

Treatment Plan C: Treat severe Treatment Plan C: Treat severe Dehydration QuicklyDehydration Quickly

• Reassess the child every 1-2 hours. If hydration is Reassess the child every 1-2 hours. If hydration is not improving, give the IV drip more rapidly.not improving, give the IV drip more rapidly.

• Also give ORS (about 5 ml /kg / hour) as soon as Also give ORS (about 5 ml /kg / hour) as soon as the child can drink: usually after 3-4 hours the child can drink: usually after 3-4 hours (infants) or 1-2 hours (children).(infants) or 1-2 hours (children).

• Reassess an infant after 6 hours and a child after Reassess an infant after 6 hours and a child after 3 hours. Classify hydration. Then choose the 3 hours. Classify hydration. Then choose the appropriate plan (A, B, C) to continue treatment.appropriate plan (A, B, C) to continue treatment.

FOOD GUIDESFOOD GUIDES

Primary Role of Food Guides Primary Role of Food Guides

To communicate an To communicate an optimal dietoptimal diet for foroverall health of the population, whetheroverall health of the population, whethera pyramid, star, pagoda, rainbow, circle isa pyramid, star, pagoda, rainbow, circle is

used, to used, to improve quality of lifeimprove quality of life and and nutritional well beingnutritional well being in a simple and in a simple and

understandable way.understandable way.

• Thank you…Thank you…

Health & Medicine

Malnutrition And Fluids