A SUMMARY OF NUT4301 (DIET THERAPY AND HOSPITAL

PRACTICE)

BY

YAYA
 FACILITY BASED MANAGEMENT OF SEVERE ACUTE
MALNUTRITION
• Background:
o Childhood undernutrition is a significant global health issue with wide-
ranging consequences, including morbidity, mortality, impaired
intellectual development, poor academic performance, and increased risk
of non-communicable diseases in adulthood.
o Malnutrition plays a critical role in childhood mortality, with conditions
like pneumonia, diarrhea, and malaria causing the majority of child
deaths, often exacerbated by malnutrition.
o Severe acute malnutrition (SAM) remains a leading cause of child
mortality globally. Around 50% of deaths among children under 5 in
developing countries are linked to nutrition-related factors, and 4.4% of
these deaths can be attributed specifically to severe wasting.

• Outpatient Therapeutic Program (OTP):

o Community health workers and community members play a role in early
SAM identification by measuring mid-upper arm circumference and
checking for bilateral pitting edema.
o Infants and children aged 6–59 months with a mid-upper arm
circumference <11.5cm or any degree of bilateral edema should be
referred immediately to an outpatient treatment program (OTP) for
comprehensive assessment and management of severe acute
malnutrition.
• RUTF (Ready-to-Use Therapeutic Foods) is increasingly used in outpatient
treatment to provide high-energy, fortified, ready-to-eat foods for children with
severe acute malnutrition.
• Inpatient Facility (IPF):
o Some children with SAM present with complications such as anorexia,
lethargy, severe edema, hypoglycemia, heart failure, fever, anemia, and
various infections, necessitating specialized care.
o These complex cases cannot be managed as outpatients and require
specialized care in inpatient facilities (IPF) to stabilize their condition and
mitigate potential dangers.
o To address these challenges, Nigeria developed a national guideline for
inpatient management, specifically focusing on stabilization care for
infants and young children with SAM, drawing from subsequent WHO and
UNICEF publications.

• Assessment of Severe Acute Malnutrition:

• Definition of Severe Acute Malnutrition (SAM):
o SAM is characterized by the presence of bilateral edema and/or severe
wasting, which can be indicated by a weight-for-height/length score
below -3 standard deviations (SD), or a mid-upper arm circumference
(MUAC) less than 115 mm.
• Inpatient Admission Criteria for Children 6 to 59 Months:
o Children falling within the age range of 6 to 59 months are admitted to
inpatient facilities for SAM if they meet any of the following criteria:
o MUAC less than 115 mm.
o Weight-for-height/length (WFH) score below -3 SD based on WHO 2006
standards (unisex table).
o Bilateral edema classified as (+++).
o Body weight below 3.5 kg.
o Presence of medical complications, including severe lack of appetite.
•
• Infants < 6 months:
o Treatment needed if the infant is too weak to breastfeed, has WL < -3SD,
bilateral edema, or body weight < 3kg.

• Patients > 6 months with SAM:

o Outpatient treatment for those without complications and a good
appetite.
o Inpatient care for those with complications or a failed appetite test.
o Infants < 6 months with these features also need inpatient care.

• Nutritional Assessment/Signs of SAM:

o Admission criteria rely on MUAC, weight, height, weight-for-height/length
Z score, and bilateral edema assessment.

• Measuring MUAC:
o Quick method for children aged 6-59 months to assess malnutrition.
o Procedure: Measure left arm, find midpoint, wrap tape, and record.

• Measuring Weight:
o Weigh on arrival and daily after admission, one hour before/after feeding.
o Recommended scale features: electronic, 0.01 kg precision, allows tared
weighing.

• How to Measure Weight:

o Remove clothing, place cloth in the pan, adjust to zero, place child gently,
wait to stabilize, measure, record, and re-wrap.

• Length/Height Measurement:
o Length for children under 2 or less than 87cm, and standing height for
those 2 or older or 87 cm and above.
o Adjust measurements if needed (add 0.7 cm for standing height, subtract
for recumbent length).

• Measuring Length:
o Use an infantometer with a headboard and sliding foot piece.
 o Place the child on the board, securing the head and stretching the legs.
o Ensure the foot-plate is perpendicular to the board and read the
measurement to the nearest 0.1 centimeter.

• To measure standing height:

o Use a stadiometer on a level floor.
o Remove socks, shoes, and hair ornaments.
o Child stands against the board.
o Assistant aligns body parts.
o Measure to the nearest 0.1 cm.
• Edema Check:
o Edema is excess fluid causing swelling, often in feet and lower legs.
o Press the foot, if a pit remains, edema is present.
• Weight-for-Height SD-Scores:
o Helps identify severe acute malnutrition by comparing weight to average.
o Find length/height in the table and check SD-score.
• Appetite Test:
o Differentiates complicated from uncomplicated cases.
o Child eats RUTF, observed for quantity.
o Interpreting Appetite Test:
▪ Pass if child consumes moderate RUTF, fail otherwise.
• Initial Emergency Management:
o Focus on preventing death, follow ABCD steps.
o Assess airway, breathing, circulation, coma, convulsion, and dehydration.
• Airway and Breathing:
o Observe breathing, check for central cyanosis.
o Assess respiratory distress.
• Circulation, Coma, Convulsion:
o Check for signs of shock and neurological status.
• Coma Assessment:
o Wakefulness test if unsure.
• Dehydration Check:
o Look for specific signs with a history of diarrhea.
• Inpatient Care Principles:
o Treat SAM patients as emergencies.
o Conduct assessments, open an inpatient card, and admit to designated
ward.
• Stabilization Phase:
o Critical period in inpatient care, lasting 3-5 days (varies with severity).
o Addresses life-threatening issues and deficiencies.
o Focuses on correcting medical complications like dehydration, shock,
septic shock, heart failure, anemia, hypoglycemia, hypothermia, infection,
micronutrient deficiencies, therapeutic feeding, vitamin A deficiency,
tuberculosis, and HIV.
• Dehydration:
o Hard to diagnose accurately in malnourished children.
o Signs include lethargy, restlessness, sunken eyes, thirst, and slow skin
pinch.
o Administer ReSoMal rehydration fluid orally or via nasogastric tube.
o Continue breastfeeding during rehydration.
o Monitor for signs of overhydration.
• Shock:
o Identify through weakness, lethargy, cold extremities, and fast, weak
pulse.
o Keep the child warm and administer antibiotics if infection is suspected.
o Administer sugar-water to children who have traveled long distances.
o Feed every 3 hours, starting immediately, or rehydrate first if dehydrated.
• Hypothermia:
o Hypothermia is indicated by an axillary temperature below 35°C.
o Treat for hypoglycemia and infection.
o Keep the child warm (kangaroo technique, warm drinks, room
temperature).
o Feed immediately and every 3-4 hours.
o Rehydrate with warm fluids when necessary.
• Correcting Electrolyte Imbalance:
o Severe malnourished children typically lack potassium and magnesium.
o Correct through commercially prepared fluids like ReSoMal.
o For magnesium deficiency, administer magnesium supplements.
o Avoid adding extra potassium and magnesium to feeds unless necessary.
• Nutrient Correction:
o Do not give iron initially; wait until the child has a good appetite and
starts gaining weight, as iron can worsen infections.
o F-75, F-100, and ready-to-use therapeutic food packets contain essential
nutrients, including vitamin A, folic acid, zinc, and copper.
• Vitamin A Supplementation:
o Low-dose (5000 IU) daily vitamin A supplementation is effective for
children with severe acute malnutrition.
o High-dose vitamin A is only given if the child recently had measles or
shows eye signs of deficiency.
o
Micronutrient Supplementation:

o Severely malnourished children receiving F-75, F-100, or WHO-compliant

therapeutic food do not require multivitamins.
o If not on these foods, provide daily micronutrients like folic acid,
multivitamin syrup, zinc, and copper for at least 2 weeks.
•
• Therapeutic Feeding Including Breastfeeding:
o Start feeding cautiously with frequent, small amounts.
o Use a starter diet like F75 in the stabilization phase.
o F75 has different nutrient composition and is designed for patients with
severe complicated malnutrition.
o Gradually increase the number of feeds per day.
o Prepare F-75 according to patient weight and number of feeds.
o Ensure proper hygiene and monitor feed intake, vomiting, stool
frequency, and weight.
o Naso-gastric tube (NGT) feeding is used when the patient cannot take
sufficient diet by mouth; try oral feeding first.
o NGT use should not exceed 3 days and is mainly for the stabilization
phase.
• Addressing Associated Conditions:
• Vitamin A Deficiency:
o Treat with low-dose daily supplementation, unless there are recent measles or
eye signs, in which case high-dose vitamin A is given on day 1.
• Tuberculosis (TB):
o Confirm TB suspicions with tests and X-rays.
o Delay TB treatment, except for TB meningitis.
o Avoid transferring to TB centers if inexperienced with SAM.
o Be cautious with TB drugs if on ARVs; consider dose reduction.
o Use Isoniazid cautiously.
• Malaria:
o Test for malaria in all SAM children and treat per National protocol.
o Be cautious with malaria drugs in malnourished patients.
o Avoid quinine during the first two weeks of treatment.
 o Promote Long Lasting Insecticidal Nets (LLINs) for malaria prevention at
the facility and home.
• TRANSITION PHASE:
• Objective:
o Prepare the child for transitioning from stabilization care in the Inpatient
Facility (IPF) to the rehabilitation phase in the Outpatient Therapeutic
Program (OTP).
• Diet Transition:
o Change from F75 to RUTF (Ready-to-Use Therapeutic Food) or F100.
• Catch-Up Growth Feeding:
o Occurs during the transition phase in the IPF after medical complications
are resolved.
o Lasts 1-3 days.
o Transition the child from F-75 to RUTF once they show improvement and
appetite returns.
o Prioritize breastfeeding before RUTF feeds.
o Promote RUTF use to habituate children for take-home treatment.
o Give the daily RUTF amount according to the table.
o Instruct mothers on handwashing and water provision.
o Store RUTF safely.
o Monitor the amount given five times daily.
• Catch-Up Growth Feeding Issues:
o If a child doesn't take sufficient RUTF or doesn't gain weight, consider:
o Giving F100 for a few days before reintroducing RUTF.
o Returning the child to the acute phase for a day or two with F75.
o Do not give any other food during this period.
o Ensure caretakers don't eat in the same room as malnourished children.
o Some children may initially refuse RUTF and can be given F100 for a day
or two before reintroducing RUTF.
o Stimulate breast milk output using Supplementary Suckling (SS)
technique and initiate relactation if needed.
• Supplementary Suckling Technique (SST):
o Helps initiate relactation in mothers with lactation failure.
o Time-consuming but effective.
o Milk used can be generic infant formula or F100 diluted.
o Use an appropriately sized tube (NGT size 8) to transfer milk.
o Gradually lower the cup as the infant gets stronger.
o Encourage mothers to perform SST without assistance once confident.
o Promote group SST sessions for mothers.
o Maintain consistency in supplementary diet throughout treatment.
• Record Staff Responsibilities:
o Responsible for opening an inpatient file with a unique SAM number.
o Ensure proper identification of record forms like Critical Care Pathway
(CCP), multi-charts, and transfer forms.
• Medical Social Worker/Community Health Officer Responsibilities:
o Identify children needing home follow-up.
o Actively conduct follow-up visits for children.
o Follow-up at home is necessary for various reasons, including defaulters,
refusal of admission, missed appointments, and social problems.

• Failure to Respond to Treatment:

• Criteria for failure to respond to inpatient care:
o Failure to improve/regain appetite for 4 days.
o Failure to start losing edema for 4 days.
o Edema still present after 10 days.
o Failure to meet the criteria for recovery-phase (OTP) after 10 days.

• Management of patients failing to respond to inpatient care

involves:
o Detailed history and examination.
o Diagnostic tests such as chest X-ray, urine, blood culture, stool
examination, TB tests, HIV tests, and more.
o Discouraging the use of traditional medicines.
o Referring children with chronic diseases to appropriate pediatric wards
for specialized care.