Dr NMT GumedePholela Community Health Centre

Malnourished Child-South Africa

South Africa-Malnutrion

The Situation Right now in SA

1.Poverty remains a problem in South Africa, 2. KwaZulu-Natal (KZN) bears a substantial part of the national burden of poverty.3.The District Health Barometer (HST, 2010) shows KZN being one of threeprovinces with the most deprived Districts 4. 63% to 82% of households live on less than R800 per month. 5. There is a synergistic effect between malnutrition, HIV and TB which has led theAcademy of Sciences of South Africa to conclude that `South Africa is in the gripof three concurrent epidemics: 6.Poor access to existing health services and inadequate knowledge on how toprevent illness and care for the sick children at community and household levelsare further factors contributing to high rates of death of mothers and children. 7.34% of children who die in KZN are malnourished and 50% have clinicalevidence of AIDS

What is Malnutrition?

Acute malnutrition is caused by a decrease in food consumption and/or illness resulting in bilateral pitting pedal oedema and/or a sudden weight loss. Anorexia or poor appetite and medical complications are clinical signs indicating oraggravating the severity of acute malnutrition.

There are two forms of acute malnutrition:

SAM - de ned by the presence of bilateral pitting pedal oedema or severe wasting(very low weight for length / height <-3 z-score) or MUAC <11.5cm (in children 6 – 59months). It is associated with other clinical signs such as a poor appetite. A child withSAM is highly vulnerable and at high risk of death.

MAM - de ned by moderate wasting (low weight for height/length z-score between -2and -3 SD). MUAC between 11.5 and 12.4cm.

Growth &

development

Household

Food

Security

Adequatecare

of childrenand women

Health

Health

Services

EDUCATION

Adequate Psychosocial

dietary well being Health

intake

Potentialresources

Immediatedeterminants

Manifestations

Source: UNICEF

Underlyingdeterminants

Recognising the malnourished child

Risk factors Growth monitoring:

Road to Health Card Feeding history Clinical signs: early

wasting, anemia, etc. Identifying early

wasting: wall charts,MUAC

Assessing the degree of severity (IntegratedManagement of Childhood Illness)

Visible severe wasting

Oedema of both feet

Severe palmar pallor

Low weight

Weight gainunsatisfactory

Some palmar pallor

Assessing the degree of severity (IntegratedManagement of Childhood Illness)

Visible severe wasting

Oedema of both feet

Severe palmar pallor

Low weight

Weight gainunsatisfactory

Some palmar pallor

Malnourished children in hospital(Mpumalanga Audit 2000: 26 hospitals)

• Nutrition & feeding practices in wards

1.no WFA charts/assessment, RTHC not used

2.breast/f promotion hampered by bottles & teats

3.no snacks between meals for infants <2 years

4.no meals at night for malnourished children

5.inconsistent lodger mother policies, no facilities

• Treatment guidelines– National pediatric EDL; IMCI; other (local)

Today I can confirm it to you that 16 years later this has not changed

Potential team members

Doctor

Nurse

Dietician

Mother / care-giver

Social worker

Physiotherapist / O.T.

Community care giver

Family Health Team

Extent of malnutrition

Tip of the ice-berg:severe malnutrition

Below the surface: mildto moderatemalnutrition

For every 1 SAM in the area, make sure to screen and aim to get 10 MAMs

WHO Guidelines: management of severemalnutrition (SAM)

Organisation of care Proper triage Stabilisation and

rehabilitation Prevent and treat

hypoglycemia Prevent and treat

hypothermia Treat dehydration

Treat electrolyteimbalance

Treat micronutrientdeficencies

Initial refeeding Catch-up growth Stimulation & support Prepare for follow-up Monitor and audit

Monitoring and Evaluation at the outpatient level will involve the PHC based IMCI Trained Nurses, PHC OutreachTeams / Family Health Teams, Nutrition Advisors and CCG’s.

The patient will be on the nutrition supplementation programme (> 5 years), outpatient supplementary programme(OSP) or (GMPs) facilitated from the PHC facility. Upon full recovery and exit from the NSP, OSP or GMPs, the child < 5years will attend GMP routine screening at PhilaMntwana Centres and all other categories will continue routinemedical check ups. The following tools will be used, and monthly data collection and reporting will be facilitated bythe PHC Operational Manager.

Nutrition Advisor Monthly Report

● The nutrition advisor monthly report collects data on the number of children identified as SAM / MAM, referrals toCCG’s, Adults with HIV & TB on therapeutic supplements, Pregnant and lactating women on therapeutic supplements.Nutrition Advisors should have dietitian referrals (down referrals) and CCG referrals (up referrals) within theirrecording system at the PHC. The NA will use the NSP register to track all patients being supplemented.

CCG Monthly Summary Sheet & CCG Weekly Tally Sheet

● The CCG Weekly Summary Sheet provides an indicator of how many children were identi ed as Red and / or Yellowon the MUAC tape. The Operational Manager needs to verify that this number of children were admitted into eitheroutpatient care for MAM or inpatient care for SAM. The monthly summary sheet will be used for monthly datacollection.

OUTPATIENT MONITORING & EVALUATION

Supervision and Support at PhilaMntwana centres

● The CCG supervisors and Community Health Facilitators (CHF’s) will supervise and monitor theactivities conducted by the CCGs at the PhilaMntwana Centres. In the municipal wards with Family HealthTeams (FHTs), the team will support the CCGs with all the activities. At district level, Maternal Child andWomen’s Health (MCWH) coordinator will be responsible for compiling reports on the status of all thesites in the district

● The District Manager remains overall responsible

● Other key team members include: the District Nutrition Coordinator, the PHC and Paediatric Nurse,District Clinical Specialists (DCS), Family Physician – DCS an CCG coordinator. The Deputy Manager –Clinical and Programmes is the team leader.

Dietitian Visits to PHC

● Every PHC facility should be visited by a Dietitian at least twice over a year to conduct Moni- toring andEvaluation of the Integrated Nutrition Programme at the PHC. A review of the M & E reports by Dietitianswill provide an indication to the districts and provincial of ce on the gaps in the nutrition services at PHCthat require further support. Dietitians should also estab- lish a referral system with the PHC’s linked totheir hospital for follow up of SAM discharges by the PHC based Nutrition Advisor.

Individual Monitoring at outpatient care

During Follow-up VisitsIndividual monitoring of the child’s progress should be carried out by the health care providerupon monthly (or as circumstances dictate) return visits to the health facility or outreach point.The following parameters are monitored and recorded on the Road to Health Booklet (RtHB) dur-ing the follow-up visit:Anthropometry● MUAC● Weight● HeightPhysical examination● Weight gain:- The weight is marked and compared to the weight of the previous weeks.age and weight for length / height at every visit. Assess growth velocity on RtHB growth curves.- Children who lose weight or have no weight gain following 2 consecutive visits or have theirweight fluctuating receive special attention during the medical examination and according to theevaluation a decision is taken to continue treatment in outpatient care or refer.- Investigate reasons for weight loss / static weight.● Body temperature● Standard clinical signs: stool, vomiting, dehydration, cough, respiration, liver size, eyes, ears,skin condition and peri-anal lesions are assessed● Any illness suffered by the child since the last visit● Any action taken or medication given in response to a health condition

Very important

Home Visits

The CCG covering the geographical area of a child’s place of origin should be assigned to con- duct home visits forchildren requiring special attention during the treatment process. Home visits should include assessing thenutrition and health condition of the child, compliance with feeding practices for RUTF and home caring practices.The CCG should provide individual counselling to the caregiver and provides feedback to the health care provider.

Home visits for children with SAM are essential in the following high-risk or problem cases

WHO: organisation of care

Admit mother/carer

Team involvement

Ward care: hi-care bed

2-3 hourly monitoringand feeding (72 hours)

Keep warm (KMC,adjust routines eg.bathing time)

WHO: triage and resuscitation

Screen children forsigns of severe PEM

Assess dehydration inmalnourished childrenusing additional signs

Children wthkwashiorkor andmarasmus must begiven IV fluid withcaution

WHO: Stabilisation phase

Hypoglycaemia (prevent, monitor & treat):– 2-3 hourly fortified milk feeds (60-130ml/kg/d)

Hypothermia (prevent, monitor and treat):– 3 hly temp, warm skin-to-skin, use hat, no baths

Dehydration: (prevent and treat):– Treat shock cautiously, rehydrate orally

Suspect and treat infection:– Assume infection, give broad spectrum antibiotics– Monitor appetite, weight: if not better, change

antibiotics after 48 hours

WHO: Stabilisation phase (cont.)

Correct electrolyte imbalances:– Hypokalemia: oral K, if K<2.5, add IV KCl (!)– Hyponatremia: do not give Na supplements

Treat micronutrient deficiencies:– Vit A stat – reduces morbidity and mortality– Multivitamins, Zink sulphate, Phosphate, Folic

acid, copper– Give Fe later – once infection is controlled

WHO: Stabilisation phase (cont.)

Initial Refeeding:– Frequent small feeds orally/nasogastrically

– 100 kcal/kg/day; protein: 101.5g/kg/day; liquid:100-130ml/kg/day

Monitor:– 3 hourly temperature and dextrostix for first 72 hours

– Daily weight (same conditions)

Audit outcome– Weight gain (good: >10g/kg/day), mortality ( <5% )

WHO: Rehabilitation phase

Catch-up growth:– Return of appetite then gradual transition– Frequent feeds, up to 200ml/kg/day (!)– 150-200 kcal/kg/day; protein 4-6 gram/kg/day

Stimulation and support– Visual and emotional stimulation– Social support: child care grant application, etc.

Prepare for follow-up– Follow IMCI feeding recommendations

20/04/16

Time frame for the managementof a child with severe malnutrition

Stabilization Rehabilitation

Days 1-2 Days 3-7 Weeks 2-6

1. Hypoglycaemia

2. Hypothermia

3. Dehydration

4. Electrolytes

5. Infection

6. Micronutrients no iron with iron

7. Initiate feeding

8. Catch up growth

9. Sensory stimulation

10. Prepare for follow-up

Source: WHO

Basically what I want to say is:

Malnutrition is a multifactorial condition. It can only be addressed if themultidisciplinary team works together towards a common goal.

Usually Malnutrition presents at very late stages in hospitals and clinics

It is then critical to make use of our resources: ie CCG's Family Health Teams,Dietician

DSD plays a social role in prevention of this condition, OSS is a strong framework weshould all try to understand and utilize to solve this problem.

Every child you see dont forget to look at the growth pattern and immunizationupdate.

Good luck in identifying MAM's and I hope we can never loose a child due toMalnutrition.