Management of Malnutrition in Children Under Five Years
Management of Severe Acute Malnutrition in Children Under Five Years
Acutely malnourished children lack growth nutrients that are required to build new tissues. These nutrients aid weight gain after illness, repair damaged tissues and help replace the rapid turn-over of cells (intestine and immune cells). Correct replenishment of nutrients like essential amino acids (protein), potassium, magnesium and zinc (among other minerals) is essential for recovery from malnutrition.
This section addresses the treatment of Severe Acute Malnutrition (SAM) characterized by severe wasting (W/H < 70% NCHS median or Mid-Upper Arm Circumference (MUAC) < 11.0). Oedematous cases are always classified as severe.
Children with severe acute malnutrition need to be treated with specialized therapeutic diets (F75 and F100 formula; RUTF) alongside the diagnosis and management of complications during in-patient care.
The standard treatment for complications like dehydration or severe anaemia given to non-malnourished children can lead to death through heart failure if the patient is severely malnourished because of temporary electrolyte disequilibrium.
Note: Stunting is due to chronic malnutrition. Discharged children have to be adequately supported at home through an improved quality diet. Families that are not able to meet the minimum requirements for a healthy diet should be assisted through targeted food aid or cash-transfer safety-net programs.
The principles of management of Severe Acute Malnutrition, whatever the program setting, are based on three phases:
Patients that have not passed the appetite test and/or have a major medical complication should be admitted to an in-patient facility for phase 1 treatment. The F75 formula is used during this phase to promote recovery of normal metabolic function and nutrition-electrolytic balance. The duration in this Phase is 2-7 days until the child is stabilized.
A short training video on the RUTF appetite test (following the WHO guidelines) is also available here.
Rapid weight gain at this stage is dangerous, which is why F75 is formulated so that patients do not gain weight during this stage.
F-75 contains 75 kcal of energy and 0.9 g protein per 100ml.
Transition Phase: In-patients transferred from Phase 1 are introduced to F100 formula or RUTF and start to gain weight. The Transition Phase is crucial to monitor an in-patient's adjustment capacity to a sudden change of diet as this may lead to electrolyte disequilibrium. The expected weight gain should be around 6g per kg per day. The duration in this phase is 1-3 days.
F-100 contains 100 kcal of energy and 2.9g proteins per 100ml.
Phase 2: In-patients transferred from Transition Phase may continue to use F100 formula or RUTF in the facility-setting until discharged or they may be transferred to out-patient treatment where they are given
Patients that have passed the appetite test and/or do not have a major medical complication can be admitted directly to an out-patient facility for Phase 2 treatment using RUTF. The expected weight gain should be 8g per kg per day.
Program settings may depend on national guidelines and facilities available. The following are the most common types of services for treatment:
In-patient treatment: Management of severe malnutrition in facilities should ideally be only for Phase 1 and the Transition Phase.
Patients that are admitted can be treated on a 24 hour basis with full medical surveillance and treatment of complications. They would receive 6-12 meals of F75 per day during Phase 1 followed by 6 meals of F100 per day during the Transition Phase.
Patients may also be treated on a Day Care basis. In this case they would have to receive the 5-6 meals of F75 within 12 hours making this option not one that is recommended for Phase 1. Day Care is suitable for in-patient treatment during Phase 2 but it places a burden on the caregiver who has to come in on a daily basis. In general, the continuation of this treatment as in-patients for Phase 2 may increase the economic burden on the caregivers as well as on the facility.
All in-patients that regain their appetite and have successfully passed the Transition Phase should continue treatment as out-patients if there is a service in place and if the caregivers agree.
Out-patient treatment is normally organized from the same facilities that have in-patients. However, out-patient treatment can also be arranged from peripheral health units bringing the service closer to the community. Most patients can be admitted directly as an out-patient and can receive the treatment on a weekly basis. For each in-patient facility there should be many satellite sites providing out-patient treatment programs.
A strong communication and referral system needs to be in place to allow in-patients to move from in-patient (Phase 1 and Transition Phase) to out-patient treatment (Phase 2). The opposite applies if out-patients do not respond appropriately or if they develop complications. If this occurs they should be transferred immediately from out-patient to in-patient treatment.
Patients attending TB and ART services are at high risk of malnutrition and should be systematically screened for severe malnutrition using the Mid-Upper Arm Circumference (MUAC) tape and checking for oedema so that they can be promptly referred and admitted if needed.
Mobile clinics should incorporate the management of severe acute malnutrition. Screening could be done using Mid-Upper Arm Circumference (MUAC) tape and checking for oedema. Enrolled patients based on admission criteria are given a weekly RUTF ration if they pass the appetite test and/or do not have medical complications. Transport is important for patients referred for in-patient care.
Note: The link between malnutrition and HIV/AIDS is acknowledged. For this reason, it is recommended to make available HIV Individual Counselling and Testing (ICT) services at in-patient and out-patient treatment sites. If this is done so HIV-exposed or HIV-positive children can access appropriate support and care at an early stage.
11 April, 2013