Management of Malnutrition in Children Under Five Years

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Management of Severe Acute Malnutrition in Children Under Five Years

In-patient Treatment Phase 1

1) Phase 1

Use only F75 Formula

Summary of key steps for Phase 1:

• Admitted patients should be registered and all information recorded in the Multichart including the target weight for discharge (WHO/NCHS table).
   
• Admitted patients should be provided with a systematic medical examination and given routine medicine
   
• Children in Phase 1 should be together in a separate room or space and NOT mixed with other patients because of their special diet requirements. Use identification bracelets if you do not have a separate room or space.
   
• It is important to provide mother/care givers with all necessary equipment at admission: blanket, mug, plate, etc.
   
• F75 is the starter formula to use during initial management. Severely malnourished children cannot tolerate usual amounts of protein and sodium at this stage, or high amounts of fat. They may die if given too much protein or sodium. They also need glucose, so they must be given a diet that is low in protein and sodium and high in carbohydrate. F-75 is specially made to meet the child's needs without overwhelming the body's systems in the initial stage of treatment. Use of F-75 prevents deaths.
   
• Children in Phase 1 need to receive daily surveillance:
   
  • Weight is measured, entered and plotted on the Multichart.
     
  • The degree of oedema (0 to +++) is assessed and noted in the Multichart.
     
  • Body temperature is measured twice a day and noted in the Multichart.
     
  • Standard clinical signs (stool, vomiting, dehydration, cough, respiration and liver size) are assessed and noted in the Multichart.
     
  • A record is taken if the patient is absent, vomits or refuses a feed and whether the patient is fed by naso-gastric tube or is given I-V infusion or transfusion (e.g. under "Observation" or other appropriate spaces in the Multichart).
     
• Breastfeeding children should always get the breast milk before the diet and on demand.
   
• Preparation of feeds:
   
  • Amounts of F75 to give during Phase 1 is based on the class of weight (Kg)
     
  • Frequency of feeds per day needs to be based on the functionality of the service. If there is no sufficient staff to prepare and distribute the feeds at night, it is advisable to consider 6 feeds during the day only and not at night.
     
  • Use the WHO Feeding Table
     
  • Preparation of feeds: Pre-packaged F75 or On-site prepared F75
     
  • Organization of feeds: Daily instructions need to be left for the staff in charge of preparing and distributing the feeds with the required amount for each child. Individual milk cards are a good practice for this. F75 can not be kept in liquid form at room temperature for more than a few hours before it is consumed.
     
• Supervision of feeding: Sharing of the mother's meal with the child can be very dangerous for the malnourished child. Peer supervision among mothers should be encouraged to promote appropriate feeding practices. The meals for mothers should never be taken beside the patient because it is almost impossible to stop a child demanding some of the mother's meal. If the mother's meal has added salt or condiment it can be sufficient to provoke heart failure in the malnourished child.
   
• Feeding technique: The child should be on the mother's lap against her chest, with one arm behind her back. The child should never be force fed. Naso-gastric tube (NGT) feeding is used when a patient is not able to take sufficient diet by mouth (that is defined as an intake of less than 75% of the prescribed diet). Other reasons for using NGT include: 1) Pneumonia with a rapid respiration rate; 2) Cleft palate or other physical deformity; 3) Painful lesions of the mouth and 4) Disturbances of consciousness. The use of NGT should not normally exceed three days and should only be used in Phase 1.
   
• Treatment of medical complications for severely malnourished children should follow standard WHO protocols for the seven steps of initial phase care taking into account national policy.
  
  Note 1: Careful diagnosis of dehydration (history and clinical signs) need to be done BEFORE using a rehydration solution like Resomal and should be accompanied by hourly monitoring.
  
  Note 2: The routine use of IV fluids is discouraged and should only be used to resuscitate severely acutely malnourished children from shock.
   
• Criteria to progress from Phase 1 to Transition
  
  Follow the two criteria:

1. Return of appetite

and

2. Evidence of loss of oedema (this is normally judged by an appropriate and proportionate weight loss as the oedema starts to subside).

Children with gross oedema (+++) should wait in Phase 1 until their oedema has reduced to moderate oedema (++).

In-patient Treatment Unit - What you need at a glance

Resources for Management of Malnutrition in Children Under Five Years  - In-patient Treatment Guidelines for the Management of the Severely Malnourished  119 pages 3.3mb Michael Golden & Yvonne Grellety – September 2006 Protocol for the Management of Severe Acute Malnutrition  122 pages 2.9mb Ethiopia - Federal Ministry of Health - March 2007 Interim Guidelines for the Management of Acute Malnutrition in Adolescents and Adults     21 pages 253kb -  Government of Malawi, Ministry of Health, UNICEF This document addresses malnutrition management in adults and adolescents Outpatient Care of Children with Acute Malnutrition - Trainers' Manual     69 pages 902kb – Republic of Uganda, Ministry of Health Severe Malnutrition: Report of a Consultation to Review Current Literature 52 pages 356kb – Nutrition for Health and Development, World Health Organization WHO Training Manuals

02 January, 2009