1. family and parenting
2. children

MOYO HOUSE Case-­‐management of Severely Malnourished Children Preamble Considering that presently close to 50% of the Malawian children under the age of five are stunted, 10 % are wasted, and HIV and TB infection are malnutrition’s common co-­‐
morbidities, many children admitted to whatever QECH paediatric ward are malnourished. The child’s nutritional status, in anthropometric terms (and not in fair or good) is an essential clinical sign requiring adequate attention and treatment. While other morbidity is often the reason for admission, the child’s malnourished status should be reckoned with; too many children when discharged are not referred for nutritional rehabilitation in CTC or OPT, both of which could improve or even safe their lives! Over the last 5 years MoH has made fast strides in the successful Community Treatment of malnourished children (CTC) by introducing MUAC as a universal screening tool and the widely distributed RUTF (Chiponde) as therapy, with the result that NRUs like our MOYO HOUSE wards have more become metabolic wards addressing the chronic malnourished children synergistically affected by HIV and TB infection and persistent other infections. All of which are challenging us as the application of the classical WHO therapeutic guidelines (1999) neither result in the suggested low case-­‐fatality rates during admission (suggested < 5%), and nor is only a small percentage of these children exhibiting catch-­‐up growth or in case HIV infected even survive (overall CFR 70%). As a result, there is a need for ongoing studies in MOYO House to determine improved diagnoses and treatment in these severely, almost invariably, chronically malnourished children. As a consequence and on the basis of new evidence, Moyo guidelines and hence this Departmental Protocol Book are frequently revised. The present MOYO guidelines reflect the experiences from peer reviewed and published studies undertaken in MOYO HOUSE, and other units in Sub-­‐Saharan Africa, and the WHO-­‐UNICEF updates to the case-­‐management of severely malnourished children. (Hyperlinks to WHO reference new guidelines and WHO Blue Pocket Book). Used Acronyms and/or Abbreviations • ARTMAM: present study (PI Dr. Phiri) enrolling all HIV infected severely malnourished children, • CCP: Critical Care Pathway, • CFR: Case Fatality Rate, • Chiponde: Chichewa vernacular for Ready to Use Therapeutic Food, • CMV: Combined Mineral Vitamin mixtures, 1 | Draft GTH (06/03/10): Malnutrition in Departmental Protocol Book 2010
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COT-­‐Clinic (also: Staging Clinic at QECH): paediatric HIV staging clinic at under 5 clinic, CTC: Community-­‐based Therapeutic Care, F75: Milk Formula food with 75 kcal/100ml, F100: Milk Formula food with 100 kcal/100ml, HAART; Highly Active Antiviral Therapy, HCW: Health Care Worker, Kwashiorkor: WfA < 80% plus oedema (Wellcome Classification), Marasmus: WfA < 60% (Wellcome Classification), MUAC : Mid-­‐Upper Arm Circumference, NVP: nevirapine, NRU: Nutritional Rehabilitation Unit (MOYO HOUSE), OTP: Out-­‐patient Therapeutic Programme, ReSoMal: ORT for malnourished children and different from WHO-­‐ORS, RCT: Routine Counselling and Testing for HIV, previously Voluntary CT, SFP: Supplementary Feeding Programme, S-­‐SA: sub Sahara Africa, Stunting expressed as Height/Length for Age (HfA) (Waterlow Classification), Wasting expressed as Weight for Height/Length (WfH/L) (Waterlow Classification), Phase I: Resuscitation/Stabilisation phase in which life-­‐threatening problems are identified and treated, Transition phase: phase of gradual increase in intake of energy and protein, Phase II: Rehabilitation/Catch-­‐Up phase, prior to discharge to an OTP/CTC. Moyo House Nursing & Medical Management Severely (sick) malnourished children are initially admitted to Ankie Borgstein Ward for their clinical and nursing management and start in the Resuscitation Phase (= phase 1) and when appetite returns and oedema has been lost go over in the Transition Phase. When stabilised, have a good appetite and if entering Catch-­‐Up Growth (= phase 2) they are transferred to, and spend the last few days of their stay in Moyo House, to Grace Malenga Ward. Pre-­‐ward round activities All children are weighed daily, temperature taken and the CCP symptoms recorded by the patient attendants / nursing staff. Children should be assessed to check if they are acutely sick, in which case they should be identified to the nurse, and seen early in or after the clinician’s round (or earlier). Ward rounds 2 | Draft GTH (06/03/10): Malnutrition in Departmental Protocol Book 2010
Clinicians review all children at least on Mondays, Tuesdays and Fridays. All children in resuscitation-­‐ and in the start of transition phase are seen every day (including weekends and public holidays!). Sick and unstable children in HDU are reviewed twice a day by the ward clinician (& the clinicians on call) and registrar (24/7). Discharging rounds of children who successful in catch-­‐up phase (II) should be(come) routine and done in the review corner of Ankie Borgstein or Grace Malenga Wards on Tuesdays and Friday mornings. Admission to High Dependency Unit in Ankie Borgstein ward All severely malnourished children are at risk of hypoglycaemia, particularly after an unknown time of travel our A&E, or to our admissions room at night. Ideally after triage, whilst waiting to be seen by a HCW or latest on arrival on Ankie Borgstein Ward, they should immediately be given a feed or 10% glucose or sucrose and transitioned immediately to F75 to avoid life threatening hypoglycaemia. Likewise severely malnourished children with purging diarrhoea awaiting admission should receive F75 and ReSoMal to avoid hypoglycaemia and hypovolaemia and shock. Children critically and clinically ill, requiring fluid charts (for diarrhea), on IV infusions and/or Oxygen, admitted with 3+ oedema, or whom the nurses and/or doctors are concerned about, should be admitted to the Ankie Borgstein Ward HDU beds. All other non-­‐critically sick children in resuscitation/phase 1 should ideally be admitted to Ankie Borgstein ward. Children with shock and/or diarrhoea, admitted to the HDU should be weighed and clinically reviewed twice daily at 08.00 am and 4.00 pm. Their observations (vomits, stools, weights [on electronic weight scales] and inputs) should be recorded on their fluid charts, as any actions required (e.g. ReSoMal and amount) be charted! Indications, and Transfer into Ankie Borgstein Ward from other departmental wards If sick (and apparently malnourished) children, initially admitted to one of our other wards, are recovering from the disease and warrant an admission to MOYO House, clinicians can at any time of the day refer this child for anthropometric assessment to Ankie Borgstein Ward. Upon those results, the originally referring clinician can transfer the child for Nutritional Rehabilitation to MOYO HOUSE, provided an appropriate transfer is documented in its CCP/file! Especially severely malnourished infants from Paediatric Nursery should, with a low threshold, be referred and admitted into Ankie Borgstein Ward. Transfer to Out Patient Treatment (OPT) at MOYO HOUSE and CTC in Blantyre District Transfer to OPT and CTC takes place on the basis of 1) resolved oedema, 2) a regained appetite, 3) gaining weight over >3 days, and 4) no need for IV/IM medication. In addition mothers or guardians should be familiar with the causes of the child’s initial condition and how through nursing, dietary and medical means this can be prevented and addressed. On discharge, information should be provided to the caretaker to which Health Centre on which date and time to present for OTP and CTC, and where to get 3 | Draft GTH (06/03/10): Malnutrition in Departmental Protocol Book 2010
help if the child deteriorates. Further, mothers of HIV infected children are encouraged to undergo HIV testing themselves; and those known to be HIV positive are encouraged to attend staging clinics at their Health Centre, and start Co-­‐trimoxazole prophylaxis or ARVs accordingly. Studies from numerous countries have shown the increased risk of mortality in children of HIV positive mothers. Over the last years we have seen a gradual increase in the prevalence of HIV (60% at present) and other chronic co-­‐morbidity (CP, TB) in admitted severely malnourished children. Simultaneously, the national CTC program has expanded and intensified, and as a result we don’t follow up “normal” severely malnourished children any more but restrict our OTP to HIV and or TB infected children initially admitted to Moyo House. There is a follow up form filled by the PAs and a HCWs indicating progress since last visit. These are filed in their NRU folder. Children are followed in an OTP register, which allows reporting. All discharges are recorded in this (deaths are only in the admissions book, and deaths book on sisters desk). MOH through DHO is facilitating OTP/CTC in Blantyre district, and gives dates for OTP clinics so referrals can be made directly on discharge for uncomplicated follow ups. Transfer is through the Health Passport, and the NRU stamp, in which routine and important therapies should be recorded, as well as clinical details. This will ensure additional-­‐ and dangerous-­‐ doses of routine drugs (e.g. Vitamin A) are not given. Supplementary Feeding Programmes (SFP) is operating in 18 clinics in the Blantyre district. 1. EVALUATION OF THE SEVERELY MALNOURISHED CHILD During the triaging process important decisions are made concerning where, how, and through which case-­‐management process of nutritional and clinical rehabilitation the child be enrolled: in a CTC or OTP MOYO programme or in the MOYO HOUSE NRU & metabolic ward. An assessment of the child’s nutritional status (chapter 1.1) alone is not adequate anymore: the child’s history -­‐especially in case of chronic disease-­‐ (1.2), its clinical condition and physical examination (1.3), needs to be supplemented by relevant and possible (laboratory) investigations (1.4). Especially, the synergism between severe malnutrition with HIV and Tuberculosis (2) are critical aspects determining the type of treatment and where it should be commenced in the Moyo wards, OPT or CTC (3), its failure to respond (4), as well as the child’s short-­‐ and long-­‐term prognosis (5). 1.1 Assessment of Nutritional Status and Criteria for Admission Classically, the different types of nutritional assessment have been risk related and the most commonly used criterion for clinical institutional rehabilitation has long been, and is still, based on the Wellcome Criteria (Weight for Age!) defining kwashiorkor and marasmus as life threatening metabolic conditions requiring medical interventions. 4 | Draft GTH (06/03/10): Malnutrition in Departmental Protocol Book 2010
Stunted (HfA) and moderately wasted (WfH/L) children can effectively be treated by CTC programme and should be referred to the HCs and Clinics running these (see list in Moyo House wards and A&E’s room 4). Referral to our MOYO HOUSE OTP only takes place via the MOYO House staff. Nutritional admission criteria to Ankie Borgstein Ward-­‐Moyo House are: • Bipedal (or more) oedema present, or • Persistent Anorexia, or • Weight/Height <70%, MUAC less than 11.5 cm is NOT an admission criterion per se for Moyo, but for certainly for CTC/OPT. The advent of HIV infection and rate of success and failure of PMTCT programmes have led to an increased incidence of severely malnourished infants; posing us with therapeutic challenges as dietary therapeutic guidelines for these severely wasted, often stunted, and sick malnourished infants have not been developed yet (let alone standardised by WHO). It is therefore important that young wasted infants be well evaluated in A&E, Paediatric Nursery and Ankie Borgstein Ward, and that both nutritional-­‐ and HAAR-­‐Therapies offered by us. There should be a low threshold for severely malnourished infants to be admitted to Ankie Borgstein Ward. 1.2 History relevant in malnourished children The child’s history, aside from the routine medical-­‐, should especially focus on dietary history and the child’s appetite, recurrent and different infections, and always be cross-­‐
referenced by an assessment of the documented medical history and Road to Health in the child’s Health Passport. We expect that on the CCP and child’s admissions file the following aspects are referenced: • Age of child, and number and age of sibs, orphaned? • Length of the history: ask presenting complaint and complaints from the preceding 3/12 period? • Feeding history: Breast Fed (exclusive for how long), weaning (age and by what?) and energy density and frequency of present diet? • Availability (and type) of food at home? • Anorexia or lack of appetite (< 75% of expected food intake in 20 minutes)? • Vomiting or diarrhoea (and if so duration, aspect, quantity and frequency)? • Previous Illnesses: especially chronic cough (duration & contacts), and persistent diarrhoea? • RTH chart in passport: please copy onto CCP and MOYO CCP! • Mothers HIV status and that of other members of the nucleus family and compliant to Co-­‐trim and HAART? • Other symptoms of chronic illness e.g. chronic otitis media, night sweats, thrush? • Oedema distribution and duration; when did it start and what did precede it? 5 | Draft GTH (06/03/10): Malnutrition in Departmental Protocol Book 2010
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Photophobia? Lethargy & apathy/irritability? Developmental delay (both as a cause and effect of malnutrition)? Vaccinations up to date (especially measles)? Social, Economic and Family History (clues of immune suppression), deaths of other sibs, orphaned, disruption of family-­‐, economic-­‐ or care provision, other difficulties? 1.3 Important issues during initial and ongoing daily examination Remember that severely malnourished children are, by their poor nutritional status, already immune compromised, and hence show limited or no signs of infection and inflammation, and their reductive adapted state makes them “sluggish” in their vital signs and brittle (to therapeutic interventions)! • Assess ABC, and Blantyre Coma Score, • Weight and Height/Length, and MUAC, • Severe wasting (and realise that <50% of under fives are stunted), • Hypothermia (common) or fever (rare in severe malnutrition), • Oedema (and its distribution) and Capillary Refill Time (<2 sec. normal), • Flaky paint dermatitis, peri-­‐oral and peri-­‐orbital cheilosis, • Hair texture and colour, • Liver size and tenderness, liver disease (pale stools grave prognostic sign!), • Abdominal distension and Small Bowel Bacterial Overgrowth (distended tympanic abdomen), • Candidiasis: oral thrush and genitalia and or groin (weeping & exudative and/or fissures?), • Localising signs of infection (usually absent): evidence of focal or widespread infection e.g. pneumonia, GIT, Skin, ear infections, UTI and septicaemia, • Lymph nodes palpability is rare in malnutrition; hence, suspect EP-­‐TB and/or HIV • Pallor, • Evidence of eye disease: photophobia (measles and Vit A deficiency), corneal dryness, Bitot’s spots, corneal ulceration or keratomalacia, all suggesting vitamin A deficiency, • Dehydration vs. hypo-­‐volaemia (beware – may be difficult to assess CRT!), • Cardiac Failure (difficult to diagnose in an oedematous child, with (-­‐out) pneumonia and or with (-­‐out) chest-­‐PTB signs!), • HIV disease: lymphadenopathy, skin changes, Kaposi etc., • Renal disease (acidosis). 1.4. Investigations & laboratory tests relevant and meaningful in the malnourished In our low resourced setting, only a limited number of tests can be done and in addition the values and interpretation differ from well nourished children. Nonetheless, some are essential and ranked in below order: • Blood Sugar (if lethargic, irritable, low BCS, diarrhoea or vomiting, hypothermic), 6 | Draft GTH (06/03/10): Malnutrition in Departmental Protocol Book 2010
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2. MPS (malaria apparently not common in oedematous malnourished children), PCV and FBC, Urinalysis (if oedema and diagnosis uncertain check for protein, ery’s and nitrate), Blood Culture (low threshold in hypoglycaemia, hypothermia, hypovolaemia, low BCS), Analysis of faecal samples for ova and parasites, HIV testing should be done as soon as possible (Elisa & PCR in the <18/12 and Elisa [Determinant and confirming Unigold] in the child >18/12), as this will importantly influence the clinical decision making and determine to introduce HAART early during institutional nutritional recovery process, Mantoux test: suppressed in immune compromised state (severe malnutrition and HIV) like in HIV infection, >5 mm positive then suspicion for tuberculosis infection, Chest X ray; due to reduced inflammatory response limited value in diagnosing consolidations, often cardiomegaly due to reductive adaptation, watch out for Rickets. Synergism between severe malnutrition and HIV, TB and other chronic infections More than before are we confronted in admissions to MOYO HOUSE with multiple pathology accompanying, or determining, the child’s poor nutritional status. HIV has altered the epidemiology, pathophysiology, case presentation, and prognosis for malnourished children hence don’t always rely on traditional textbooks or guidelines; use your local common sense and experience of seniors! HIV infected severely malnourished children Presently, more than 60% of the malnourished children admitted to MOYO HOUSE are HIV infected and possibly co infected with other chronic or recurrent infections, making them eligible for early commencement on HAART. However, there are no evidence based guidelines as yet when to start with HAART; and our limited experiences when HAART was started in moderate to severely malnourished children is that it was associated with a high CFR and often presented as unmanageable kwashiorkor. HIV infection in itself increases the child’s nutritional requirements by at least 10% through an increased energy expenditure and co-­‐morbidity from opportunistic infections. In addition, persistent anorexia, malabsorption and diarrhoea result in additional energy and nutrient losses. Prompt HIV testing of admitted malnourished children All children admitted to MOYO should be tested for HIV as soon as possible. Admitted children failing to gain weight during the traditional WHO therapy should likewise be investigated for HIV as soon as possible. Therefore, the child should be sent to the RCT 7 | Draft GTH (06/03/10): Malnutrition in Departmental Protocol Book 2010
services (in Admissions Area). If the child is above 18 months old, two ELISA tests (Determine, and if positive Unigold) are performed and the results are given out the same day and stamped (and numbered) in the Child’s Health Passport and CCP admissions file. If below 18 months of age, a PCR test is done in addition, which result usually requires 4 weeks. Nonetheless, during which period these children should be started on Co-­‐trimoxazole prophylaxis. Commencement of HAART during admission Children can be started on ART treatment during their stay in the ward. To do this the guardian must be able to regularly come to our ART MOYO ARTMAM clinic on Monday & Tuesday. Hence, all these children can be enrolled in the ARTMAM study (PI Dr A Phiri). Staging and counselling is done by the ARTMAM team and there is no need to be sent for staging in the COT clinic. Further, the children should have other chronic conditions investigated and treated (e.g. TB) and be stable enough to tolerate the treatment (no fever, no new rash, no jaundice, no diarrhoea and no vomiting; weight loss is not an exclusion criteria). On discharge, all HIV + children are discharged via the OTP ARTMAM-­‐Clinic (Thursday afternoon 12.30-­‐15.00). During admission under the ARTMAM study they are staged, CD4% and viral loads taken, as well as liver and renal function tested and after starting on ART pharmacokinetics are determined. Children, who do not qualify to be started on ARVs, will be followed-­‐up fortnightly in OTP or COT clinic. All children receive Co-­‐trimoxazole supplies and RUTF for the next month and a follow-­‐up appointment. Under the to be started UFARTMAM study, all HIV reactive and HAART started children, and HIV non-­‐reactive initially severely malnourished children followed up in CTC will be followed for one year, and visited on months 6 and 12 post initial admission. Severely malnourished children infected with Tuberculosis with or without HIV At least a third of the HIV infected severely malnourished children appear to be co-­‐
infected with tuberculosis (a number far lower in non-­‐HIV infected admitted severely malnourished children). All admitted children failing to gain weight after one week in transition should be investigated for TB, like all those who are TB exposed by a close relative. Similarly those who present with signs or symptoms suggesting TB e.g. chronic cough or fever, enlarged lymph nodes, Gibbus, or pulmonary infections that don’t improve after a 7 days course with broad spectrum antibiotics.
HIV infection increases the risk of acquiring tuberculosis and likewise makes it difficult to diagnose, since the Mantoux/PPD skin-­‐test routinely remains negative despite a TB infection. Investigations in such malnourished children consist of a plain chest x-­‐ray and a Mantoux test (a form needs to be filled for the x-­‐ray and Mantoux testing is done every day at 14:00 hrs at Sobo-­‐Ward). (Currently the EU-­‐TB study helps us with the diagnosis of TB and all children are sent there for further diagnostic tests after a chest x-­‐ray has been taken). If suspicion is confirmed by the diagnostic tests, the child is send to the TB office to obtain the required treatment. HIV infected patients found to be TB positive 8 | Draft GTH (06/03/10): Malnutrition in Departmental Protocol Book 2010
can be started on HAART after being on TB treatment for 2 weeks (in the past this was only after 2 months!). Therefore, in order not to delay the start of HAART treatment, TB should be excluded timely while the patients are in Moyo Ward. Malnourished children with an open, proven sputum positive, pulmonary tuberculosis should be isolated (usually in the front of Ankie Borgstein ward behind the wall and passage be forbidden and with their own exit door). All guardians with symptoms suggesting pulmonary TB are isolated in another ward to avoid spreading the disease to the susceptible malnourished patients in Moyo ward. Other chronic infections Persistent diarrhoea (PD) is common in severely malnourished children, and dependent upon their original site of living, can be caused by pathogens like Giardia, Isospora Belli, Cryptosporidium et. al.. Latter are still hard to treat and only nutritional and mucosal recovery will enhance their elimination. Chronic Candidiasis is common in (HIV infected) severely malnourished children and often requires a course with Fluconazole as Nystatin and GV don’t often suffice. Skin infections can be started on Gentian Violet and Nystatin but, if persistent and weeping often require additional Fluconazole and if super infected Cloxacillin for common staphylococcal infection. PCJ (PCP) is, for reasons yet unknown, not commonly seen in severely malnourished HIV infected children. 3. Treatment, Monitoring and Supportive Care The treatment of severely malnourished children in MOYO HOUSE and the s-­‐SA region so affected by the (human) resources crisis and HIV/AIDS epidemic, in deviation from the traditional 1999 WHO guidelines and “Ten Steps”, and in the presence of a well functioning CTC programme, is determined by the child’s co-­‐morbidity. It is important to realise, therefore, that their treatment is still less protocollised, as one wishes us to believe and the 1999 WHO therapeutic guidelines (as yet less applicable to our region) do suggest. Most of the WHO therapeutic guidelines are based on extensive physiological studies and less on RTCs now required for guideline development, in addition almost all these studies on which WHO guidelines are built are done on non HIV infected securely malnourished children, an essentially different population from that admitted in Moyo House. Nonetheless, there are general experiences and deviations from normality in these children which could be anticipated, and therefore, strict and systematic monitoring and evaluation of the child’s altering clinical condition and anticipation of common problems is one of the best tools of our successful treatment. Acknowledgement, monitoring anticipation and careful management of the malnourished child’s reductive adaptation and brittle condition are prerequisites to a rational and empiric case-­‐management as are understanding of the different metabolic and nutritional rehabilitative phases are essential for success, and recognition of the different failures herein. 9 | Draft GTH (06/03/10): Malnutrition in Departmental Protocol Book 2010
Supportive Care is essential for achieving a successful recovery and survival. Psycho-­‐
social stimulation, as well as an adequate treatment of pain are elements in the daily care of these children, and cannot be replaced by attractive physical environments (light and cosy wards and music). 3.1. Empiric and rational treatment of severely malnourished children The empiric and rational treatment of severely malnourished children is determined, unlike almost all other admitted sick children, by their metabolic condition resulting from their nutritional compromised status: one of reductive adaptation (see table 1). These severely malnourished children able to adapt to their reduced dietary intake by a reduction of their organ’s and systems functioning, have survived. Rehabilitation of these brittle conditions requires a gradual reversal of this reductive adaptations; ignoring this physiological paradigm may be fatal to the child. The child’s overall metabolic derangements and resulting energy and protein metabolic derangements, altered body composition and related fluid & electrolyte derangements, vascular depletion and septicaemia to a large extent, determine the initial and two following phases of its clinical treatment. Frequent feeding (if necessary via NGT and essential if the child remains anorectic and/ or refuses more than 25% of its prescribed diet), at a three hour schedule guarantees the child a steady, and metabolic homoeostatic and homoeothermic improved, energy-­‐ and fluid intake. The diets F75 and F100 are designed to carefully manoeuvre through these metabolic abnormal states, while RUTF is primarily designed for rapid catch-­‐up growth. Therefore, latter two should not be used interchangeably (as we have done in the recent past)! 10 | Draft GTH (06/03/10): Malnutrition in Departmental Protocol Book 2010
The initial Resuscitation/Stabilisation Phase I is concerned with stabilising the brittle vital systems at a maintenance energy intake level while maintaining normo-­‐glycaemia, correcting electrolyte and fluid abnormalities, treating septicaemia and vascular depletion or shock. When the child’s appetite has returned and its vital functions are stable Transition phase can be commenced and dependent upon maintained stability and initial weight gain the Rehabilitative Catch-­‐Up Phase II can be started and if successful the child be prepared for discharge to CTC or OT-­‐Programme. Catch-­‐Up growth energy requirements are easily 20-­‐30 times as high as the normal growth requirements of a 1 year’s old child; hence, can only be met with increased frequency of feeding of a high energy dense complements like we offer in RUTF. During rapid catch-­‐up growth micronutrient deficiencies easily develop and need addressing like can be done through RUTF. While, certain micronutrients which can act as pro-­‐oxidant (like Fe) and hence should be avoided in Phase 1 and the beginning of Transition Phase, the reverse can be true later when these can become essential missing micronutrients if offered catch-­‐up diets are deplete of those (empty-­‐calorie catch-­‐up diets). 3.2 Monitoring the child’s condition and its therapeutic response Monitoring the clinical and nutritional rehabilitation process is essential for an efficient and effective case-­‐management. Otherwise, as seen in many NRUs, children stay undue long in the same phase or in the ward (and are at high risk of nosocomial infection, likewise the mother/guardian has to pay the high opportunity costs for their families these admissions carry). Like with all our CCPs, we monitor very sick malnourished children 6 hourly and sick malnourished children 12 hourly in the High Dependency Unit. When in the phase II of their rehabilitation daily measurements suffice. Normal monitoring of malnourished children entails: • Daily temperature, respiratory and heart rate as a minimum, • Fluid and dietary intake as prescribed to gauge appetite, • Daily weight and assessment of its growth rate (> 5g/kg/day), • Loss of oedema and weight, • Stool and urine output, diarrhoea, • Mood: apathy, irritability and appetite. Additional to that sick children monitored in HDU require regular (6 hourly) assessments of: • BCS, • Blood pressure and CRT, pulse rate, • Oxygen Saturation and respiratory rates, • Scleraema or other signs for septicaemia, • Fluid intake and Urine output, • And all other (chest and abdominal signs) as on specific MOYO HOUSE CCP. 11 | Draft GTH (06/03/10): Malnutrition in Departmental Protocol Book 2010
Monitoring allows one to anticipate on physiological changes which in these brittle children can look trivial but also could be deadly. 4. Treatment of severely malnourished children The treatment of severely malnourished children is divided into three, physiologically determined (as referred to in chapter 3.1.), phases and in response to reversing the process of reductive adaptation and subsequently transitioning the diets to achieve a rapid Catch-­‐Up of growth and normalisation of the child’s psycho-­‐social development. 4.1. The Initial Resuscitation and Stabilisation phase: Phase I The initial phase, characterised by instability and resuscitation, is characterised by hypoglycaemia and hypothermia, electrolyte, fluid and intra vascular derangements and shock, bacteraemia or septicaemia. Severely malnourished children are often anaemic either due to chronic disease and or for dietary inadequacies. However, F75 contains CMV which will address these. Micronutrient deficiencies like anaemia can occur and should only be treated if causes CCF, never give Fe therapy, go for a full fresh blood transfusion. Vitamin A and folic acid deficiencies, but rarely under our conditions Vit. B1 deficiency (causing wet Beri-­‐Beri), do occur and if these occur need prompt treatment. This Resuscitation Phase transitions into the next one, the Transition Phase, if the child has regained appetite, is thermo stable and -­‐if present-­‐ has lost most of its oedema. 4.1.1 Resuscitation Severely malnourished children are brittle. Hence, we are generally more careful in resuscitating these children because of their reductive adaptive state, but at the same time cannot ignore their hypovolaemic state eventually resulting terminal shock, cardiac arrest and anuria (this is an area in need of further studies). Severely malnourished children, oedematous or not, do not easily tolerate fluid overloads, as they, a) easily go into Congestive Cardiac Failure, and b) are unable to clear fluids by an impaired GFR. Moreover, their body composition is characterised by high intracellular sodium, non functional membranes and their pumps, and low total body potassium. Therefore, the general guidelines for rehydration do not apply, and i.v. rehydration should only be considered in decompensated hypovolaemic shock. Usually there is a history of profound watery diarrhoea and/or vomiting and anorexia. Signs of hypovolaemic shock in severely malnourished children are: • reduced Blantyre Coma Score, and or • severe lethargy, • a rapid weak pulse, and • gallop rhythm, and 12 | Draft GTH (06/03/10): Malnutrition in Departmental Protocol Book 2010
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cold peripheries, with a prolonged capillary refill time >2 sec., or being obtunding. (N.B. there is a resuscitation chart at the wall near the resuscitation table with further instructions. Please be familiar with these instructions as resuscitation is a common procedure to be performed). 4.1.2 Hypoglycaemia and hypothermia Hypothermia and hypoglycaemia are common in the resuscitation phase, and less so in later phases. Both are invariably grave prognostic signs of metabolic derangement, and/or septicaemia, and require prompt treatment. 4.1.2.1 Hypoglycaemia (blood sugar < 3 mmol/l or 54 mg/dl) • Give 1ml/kg of 50% dextrose. If the child can drink this can be orally, if the child is alert but not drinking, this can be by NGT. If the child is lethargic/ unconscious give then dextrose IV. • Start feeding with F75 immediately (too avoid rebound hypoglycaemia on the therapeutically induced high Serum-­‐glucose), • Give 1/6 of the 3 hourly amount of F75 every half-­‐an-­‐hour, • Repeat a blood sugar after 30 minutes up to 3 hours; and if it is >3mmol/l change to 3 hourly feeds, • If it is still low, make sure antibiotics have been given, and continue half-­‐hourly F75. • Transition F75 feeds from half hourly to two hourly feeds, • Especially also through the night! 4.1.2.2 Hypothermia (an axillary temperature below 350C) On admission, all children are eligible to receive a warm blanket free of charge. Also all windows should be closed at night and washing of malnourished children in the early morning hours should be discouraged as this exacerbates/causes hypothermia. Children should be preferably washed just with a wet cloth at lunchtime in the sun, after a feed and immediately dried in a warm blanket. If the child has wet clothing change this promptly. 13 | Draft GTH (06/03/10): Malnutrition in Departmental Protocol Book 2010
As hypoglycaemia and hypothermia are strongly associated with increased CFR, all guardians should be advised to keep their children warm as malnourished children have lost the mechanism to regulate their body temperature and to shiver. Normal thermometers do not record below 35oC; hence low reading thermometers should be used but then rectally. Make sure that all windows are closed to avoid draft, and the heaters be switched on! Encourage all mothers to practice kangaroo care. If Hypothermia is detected children should be placed under a blanket plus radiant heat. All hypothermic children should also be treated for hypoglycaemia, and for serious systemic infection: hence fed every 2 hours and especially so at night and receive antibiotic cover against septicaemia! 4.1.3 Electrolyte & fluids, and intra-­‐vascular derangements: shock Brittle conditions and severe intra-­‐ and extracellular electrolyte derangements make clinical predictions of dehydration and hypovolaemia in the malnourished different from the usual APLS/ETAT approaches in well nourished (see Table 1). In severely malnourished children, Serum electrolyte measurements do not reflect the malnourished child’s body composition, and shifts in its fluids may cause suddenly, unexpected, hypernatraemic or hypokaleamic states, all potentially resulting in convulsions and/or arrhythmias. Nonetheless, also these children can become severely hypovolaemic due to purging galloping diarrhoea (hard to detect in over-­‐hydrated oedematous children with an altered body-­‐composition loaded > 80% water). 4.1.3.1 Dehydration The altered body-­‐ and intracellular composition of the malnourished child requires a different rehydrating approach and fluid of different electrolyte composition. As it is difficult to assess hydration, children with watery diarrhoea or vomiting should be assumed to be dehydrated and potentially hypovolaemic. We therefore use in these children only ReSoMal. • Give ReSoMal as follows (see acute gastroenteritis protocol for constituents) How often to give ReSoMal Amount to Give Every 30 minutes for first 2 hours 5ml/kg Alternate hours (with F75 at the usual volume) 5 – 10ml/kg for up to 10 hours • If the child has already received IV fluids for shock and is switching to ReSoMal, omit the first 2 hour treatment with ReSoMal and start with the amount for the next period of 10 hours. 14 | Draft GTH (06/03/10): Malnutrition in Departmental Protocol Book 2010
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Monitor the child carefully. If there are signs of “over” hydration, (re)emerging oedema especially around eyes, stop ReSoMal. If the hydration status improves, stop giving ReSoMal routinely, and offer only after loose stools: o For children <2 years, give 50 –100 ml. after each loose stool o For children >2 years, give 100 – 200 ml. after each loose stool 4.1.3.2 Hypovolaemic-­‐ and or septic shock Careful treatment of shock is required. Shock is defined in these children when lethargic, obtunding/unconscious, and having cold hands, plus either slow-­‐capillary refill (>2sec) or a weak or fast pulse, and gallop rhythm. If in shock: • Give Oxygen, • Keep the child warm, manage preferably on resuscitaire with overhead heater/lamp, • note the pulse and respiration rate as sensitive an effective monitor, • establish IV -­‐or if impossible IO-­‐ access, • Give a bolus of 15 ml/kg of ½ strengths Darrows or Ringers Lactate + 5 % Glucose over 1 hr and check pulse and respiration rate again, • If the pulse rate increases by 10/min, or the respiration rate is up by 5/min, the cause of the shock is most likely sepsis, and • Fresh Whole Blood should be given if available (15-­‐20 ml/kg in 6 hours plus halfway 1mg/kg Frusemide i.v.) (see anaemia) continue i.v. fluids at maintenance rate (4ml/kg/h) while awaiting the blood. If the pulse rate and/or respiration rate decrease after the first bolus but child remains still in shock, then • Repeat the bolus (15 ml/kg/hr) and then give ReSoMal by NGT 10/kg/hr for up to 10h. Then start phase I formula. If an infant is unable to tolerate oral feeds, continue i.v. at 2-­‐4 ml/kg/hr and try oral feeds at slower rate. If the child is not in shock or no longer in shock, oral rehydration via NGT is the preferred treatment option. • The standard rehydration protocol is 5 ml/kg of ReSoMal, 4 times every 30 min (over 2 hrs) and then 5-­‐10 ml hourly for the next 4-­‐10 hours, • If there is diarrhoea or vomiting during resuscitation add 30-­‐50 ml of ReSoMal per diarrhoea or vomiting. If the child is still dehydrated afterwards, repeat the treatment. 4.1.4 Bacteraemia and septicaemia in severely malnourished: empiric antibiotics Many children admitted to MOYO HOUSE have bacterial, parasitic and/or fungal infections complicating their immune-­‐compromised state, and are very susceptible to 15 | Draft GTH (06/03/10): Malnutrition in Departmental Protocol Book 2010
nosocomial and opportunistic infections. As they are often unable to mount an effective immune response to these infections, they often do not show the typical signs like redness, swelling, pus, or fever, tachycardia and tachypnoea. We assume these children to be infected until proven otherwise; hence, all requiring empiric antibiotic treatment. Therefore, all marasmic children without oedema admitted to the ward, and without obvious complications, appearing clinically well are put on first-­‐line antibiotics. Marasmic children who are clinically ill (lethargic, reduced appetite, febrile or hypothermic), and all children with Kwashiorkor or Marasmic-­‐Kwashiorkor are covered with second line antibiotic treatment as from their admission. IF GIVE No complications (rarely the case as admitted children are complicated by co morbidity) st
1 Line AB treatment Co-­‐trimoxazole 120 mg (1/4 Tab, if below 5 kg) BD or 240 mg (1/2 Tab, if above 5 kg) BD prophylaxis treatment. Complications: and usually the case 2nd Line AB treatment, prescribed to most on admission! (Shock, hypoglycaemia, admitted children hypothermia, dermatosis with raw Chloramphenicol 25 mg/kg t.d.s. i.v. and skin/ fissures, pneumonia, UTI, Gentamycin 7.5 mg/kg o.d. i.v. /i.m. lethargic, child appears unwell) If we are out of Chloramphenicol or Gentamycin Give Ciprofloxacin 10 mg/kg b.d .p.o as our 2nd line alternative drug. Failure to respond (if child fails to lose 3rd Line AB treatment oedema, remains anorectic, or/and is Ceftriaxon 100 mg/kg OD IV/IM for 7 days clinically septic and/or sick) Or if the child can swallow, and Gram Do a blood culture as well! Negative-­‐sepsis is suspected then Ciprofloxacine 10 mg/kg OD, orally times 7 days (and in case NTS infection for 14 days). 4.1.4.1 Conditions needing special antibiotic treatment Malnutrition affects all organs and systems and the reductive adaptation process makes clearance of pathogens slow or to be absent. The result is that bacterial overgrowth is common in these children without showing the classical signs of inflammation and infection. • For children presenting with extensive/infected skin lesions Cloxacillin 50mg/kg/day t.d.s. per os is indicated, as Staphylococcal (S. Aureus and S. Epiderdimis) infections are common. • In children with a distended abdomen bacterial overgrowth of the small gut, with gaseous distension, and often accompanied by anorexia is suspected. These children, as well as those with Persistent Diarrhoea with suspected protozoan infections of the gut (Cryptosporidium Parvum, Giardia intestinalis, Amoebiasis); require Metronidazole 7.5-­‐10 mg/kg p.o. t.d.s. for 7 days. 16 | Draft GTH (06/03/10): Malnutrition in Departmental Protocol Book 2010
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Also consider treatment with high dose Co-­‐trimoxazole (60 mg/kg b.d.) against other intestinal protozoa (Isospora, Cyclospora). For infected skin lesions or open sores GV paint is indicated, for the dermatosis of Kwashiorkor (scaling skin), zinc ointment is indicated. Candida infection of the perineum is best treated with removing diapers to dry the area and apply GV paint (Nystatin cream bd. if available). Oral Candidiasis, if mild, is treated with GV paint or Nystatin oral drops (100.000 IU t.d.s.), otherwise experience teaches us that it usually is insufficient and the need for Fluconazole arises. Acrodermatitis with further affection of the oral-­‐ and anal/vulvar-­‐penile mucosa mimics the congenital picture of Zn-­‐Deficiency Acro-­‐Dermatitis-­‐Entero-­‐Hepatica and resolves with oral and topical Zn. Oesophageal Candidiasis is suspected in HIV infected children who have extensive oral Candidiasis with persistent vomiting and anorexia. In this condition Fluconazole can be ordered. Remember that Ketoconazole interacts with NVP so if the child is already on ARVs Ketoconazole is contra-­‐indicated! 4.1.5 Micronutrient deficiencies The Severely Malnourished Child, traditionally described as suffering from Protein Energy Malnutrition, is now realised to be deficient in both macro-­‐ and micronutrients. A lack or loss in energy is manifested by wasting, and if this becomes chronic in marasmus. A (chronic) lack of protein and other type II nutrients (like N, Zn, K, Na, Ph, essential Amino Acids) leads to stunting. Kwashiorkor is associated with a condition in which overwhelming stressors like septicaemia and/or a high exposure to endo-­‐ & exotoxins, in the absence of anti-­‐oxidants (micronutrients: vitamins and minerals) results in the presence of oedema, apathy, hepatomegaly, dyspigmentation and the other classical features of kwashiorkor. A lack of micronutrients, minerals and/or vitamins, has been recognised as essential in most malnourished states, hence dietary therapies have to constitute most of these in more than recommended dietary allowances to make up for obvious and hidden deficiency diseases. 4.1.5.1 Anaemia Due to the compensated anaemia in the reductive adaptive state, we only transfuse children with a PCV<12%, and then preferably with fresh full blood. • If stable await senior review, • If unstable give a blood transfusion with Fresh Full Blood (10-­‐15 ml/kg in 6 hours), • Frusemide (1mg/kg) should be given to all children receiving a blood transfusion, • If there are no signs of cardiac failure, infuse 10-­‐15 mls/kg of blood over 3-­‐6 hours, 17 | Draft GTH (06/03/10): Malnutrition in Departmental Protocol Book 2010
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If there are signs of congestive cardiac failure, infuse 7-­‐10 mls/kg of blood over 3-­‐6 hours and give Frusemide IV. Anaemia is often of a mixed picture and in our situation due to chronic infection hence Fe deficiency, but also due to folate and Vit B 12 deficiencies, latter of which can be replete immediately. Folic acid 5mg/day is given on day one, and 1 mg per day on subsequent days. Fe deficiency is often compensated by high Ferritine levels, hence by virtue free iron availability for oxidative stress. Therefore, Fe therapy (3 mg elemental Fe/kg/day) is only commenced when signs of kwashiorkor have disappeared and the recovering child is in its Catch-­‐Up growth phase. 4.1.5.2 Xerosis, Bitot’s spots, xerophtalmia and corneal ulceration As a result of IMCI and good vitamin A supplementation programmes in routine child health services, vitamin A deficiency has largely disappeared from environments where diets are still devoid of vitamin A. Nonetheless, famine and poor compliance to health services as during outbreaks of Measles the vitamin A deficiencies can re-­‐emerge. Malnourished children who are photophobic should be suspected as suffering from clinical vitamin A deficiency as night blindness in adults is. If the child has Xerosis, Bitot’s spots, or keratomalacia and corneal ulceration give vitamin A immediately and repeat at day 2 and 14 Child’s Age Vitamin A Oral Dose <6 months 50 000 IU 6 – 12 months 100 000 IU >12 months 200 000 IU In case of ulceration and or keratomalacia: •
One drop of Atropine 1% should be instilled into each eye, three times a day, • Chloramphenicol or tetracycline eye ointment 2-­‐3 hourly for 7/7 in each eye, • Eye pads be provided, • Seek ophthalmological advice as soon as possible, • Advice the mother to keep the child out of bright sunlight. 4.2 Therapeutic diets in the management of severely malnourished children Wasted children have undergone a reductive adaptation of most of their organs and systems, which results in a reduced handling capacity of on average 30% (i.e. of Cardiac output and stroke volume, GFR, Circulation time, but also membrane transport) of the normal organ and systems function. Hence, these children are very brittle and i.e. are hardly able to show the clinical signs of both dehydration and over-­‐hydration (for which one rather uses the word hypovolaemia in oedematous children). 18 | Draft GTH (06/03/10): Malnutrition in Departmental Protocol Book 2010
In these children the Basal Metabolic Rate is reduced by 30%, which therefore at the initiation of their rehabilitative therapy only require a maintenance energy and low protein intake. As many of the metabolic functions have to gradually increase their (metallo-­‐) enzyme function have to increase for which the body needs to be replenished by micronutrients. Maintenance means to maintain the child’s basic and vital body functions in rest and with reduced energy intake level not enabling the body to respond to stress or growth. If these vital systems and organs are adapted to these maintenance intakes, which are already an increase compared by the previous levels of too low intake giving rise to the child’s wasting (disease), then one can carefully transition to higher energy and protein intakes by moving from F75 to F100. If then the body becomes stabilised, homeostatic and homoeothermic than it will be able to grow in mass again provided the energy for this growth is available. High energy diets like RUTF, full of micronutrients as well, provide the means to catch-­‐up. The basic principles in Therapeutic Feeding: • Therapeutic diets are calculated for the child’s weight, condition and phase. Calculating, means that during daily clinical rounds the requirement of the child’s total intake is checked against its rehabilitative phase and appetite, if less than 75% of the prescribed intake is achieved a Naso Gastric Tube (NGT) is inserted. Prescribed volumes and types of Therapeutic Diets in these children are as crucial as prescribed doses of antibiotics for infected children. • An NGT is placed if the child finishes less than 75% of the formula milk for 2 consecutive feeds. Other reasons for inserting an NGT are reduced level of consciousness, lethargy or convulsions, pneumonia with rapid breathing, painful lesions in the mouth or cleft palate or deformity. The NGT should be removed when the child takes 75% of the day’s diet orally, or takes 2 consecutive feeds fully by mouth. • Therapeutic Diets are increased in a gradual manner, in volume, energy and protein content. Feeds should never be forced, as appetite is the most sensitive proxy for metabolic adaptations and conditions. The energy intake is the easiest guidance and used to calculate daily the child’s intake. All severely malnourished children are started with a diet matching their maintenance requirement which is 75 kcal/kg/day; hence F75. If the child has oedema this maintenance diet is continued until most of the oedema is gone; if the child has a good appetite (and is generally without oedema) it could commence on F100, which has 100 kcal/kg/day and a higher amount of protein than in F75. Both F75 and F100 have a high content of minerals and vitamins (anti-­‐oxidants). • If possible, breastfeeding should at all times be continued (also in HIV exposed children!). To ensure good lactation, the mother should breastfeed before the child is fed with F75. • During the Resuscitation/Stabilisation phase (phase I), the body has to adapt to the regular uptake of calories whilst other conditions like hypothermia, hypoglycaemia and infections are also treated. All children during admission to 19 | Draft GTH (06/03/10): Malnutrition in Departmental Protocol Book 2010
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Moyo ward are initially put on F-­‐75 feeds 8 times per day. This is a Formula based feed containing 75 kcal/100 ml and 0.9 g/100ml of proteins. The amount equals 130 ml/kg/24 hrs (children with kwashiorkor and gross oedema get 100 ml/kg/24 hrs) and provides the child with 100 kcal/kg/24 hrs, just enough not to lose more weight. After a few days the appetite usually returns, the child is more active and alert and complications are treated. In children with Kwashiorkor the oedema should also be visibly decreasing. When these conditions are met, the child can be changed to the transition phase. During the transition phase the child with a regained appetite is transitioned to F100 in the same frequency and volume as it was given with F75. F100 is a Formula based feed containing 100 kcal/100 ml and 2.9 g/100ml of protein. If the child takes this well one can increase the volume daily by 10% and if this is accepted for a period of 4 days without increase in stool frequency or diarrhea than one can assume that the small bowel mucosa can accommodate larger carbohydrate loads and only then can RUTF Chiponde be commenced and F100 is witched back to F75 in the same volumes. Chiponde is added to the F75 feeds to introduce a high caloric diet whilst avoiding fluid overload. The Chiponde should be taken prior to the F75 or mixed with F75 to make it more palatable. The amount of RUTF per day or per feed can be taken from the list in the blue folder. This diet should provide at least 175kcal/kg/day. One Chiponde bottle contains 1287 kcal and 100 g thus contains 520 kcal instead of 100 kcal in the usual 100 ml F100!! Chiponde/RUTF is a peanut-­‐butter based high caloric food containing all required minerals and vitamins to achieve catch up growths in malnourished children, and through its energy density may not give enough fluid to the child. Hence during dry warm days, children receiving high intakes of RUTF benefit from drinking additional water. Patients are moved to Rehabilitation and Catch-­‐Up Phase (II) feeds when consistently gaining weight and finishing at least 50% of Chiponde target amount, when they are active and alert, and their complications present at admission are being resolved. During this final catch-­‐up phase in the NRU, the child receives Likuni Phala at 6 a.m. and 6 p.m. instead of F75, and F75 & RUTF for the remaining 6 feeds. When to move back a phase? Children who clinically deteriorate (worsening of vomiting or diarrhoea) and/or children with increasing oedema or signs of fluid overload (increased liver size, gallop rhythm, raised JVP, bilateral crepitations), who loose appetite, refuse RUTF or have problems finishing 50 % of Chiponde/RUTF, should be moved back to phase I and be reviewed the same day. This is a group of children of high risk of cardio-­‐vascular compromise while appearing hypovolaemic. Transitioning to the family pot means often going back to diluted gruels of Likuni Phala and nzima. It is on this transition and improved and varied energy rich and frequent diet, the Nutrition Education Lessons should be aimed. 20 | Draft GTH (06/03/10): Malnutrition in Departmental Protocol Book 2010
5. Failure to respond to treatment During the rehabilitation/catch-­‐up phase (phase II) the child’s expected weight gain is about 10-­‐15 g/kg per day. Hence, a child who does not gain at least 5g/kg per day for 3 consecutive days should be reviewed carefully for failure. The most common causes for not reaching the expected weight gains are • Inadequate dietary intake (insufficient amount of F75, F100 or Chiponde, the prescribed (night-­‐) feeds are not given as prescribed, spillage [easily 10% of prescribed volume], vomiting, anorexia), • Glossitis due to thrush or folate deficiency, • Chronic diarrhoea, and malabsorption, • Lack of supervisory staff, and/or exhausted guardians from feeding every 3 hours, • Inaccurately or faulty recording/plotting and weighing, • Review the exact amount of food that the child is taking and calculate the caloric intake per day (should be > 150 kcal/kg/d). • Specific micronutrient deficiencies, empty calories: is the child receiving a catch-­‐
up diet which not containing adequate amounts of micronutrient as per requirement for catch-­‐up (K, Fe etc.), • HIV infection should be investigated for in the first days of admission, • Underlying infections (e.g. TB, HIV, bacteraemia due to UTI, Otitis, Thrush), • TB infection should be suspected in any child who does not gain weight for more than 7 days on AB, who has a TB contact, or symptoms or signs suggestive of TB. Treat the treatable conditions leading to poor weight gain and increase the caloric intake, which can easiest be done by increasing the daily amount of F100 and or RUTF/Chiponde. Never forget to consider the classical reasons for failure to thrive under affluent conditions like: • Congenital Cardiac Disease, • Celiac disease, • Other malabsorptive GI-­‐diseases, • CP, • Social and parental deprivation, • Metabolic disease, • Renal Disease, • Liver Disease. 6. Supportive and stimulating care is vital 21 | Draft GTH (06/03/10): Malnutrition in Departmental Protocol Book 2010
Emotional-­‐, social-­‐ and physical stimulation form all aspects of tender loving care, and are essential for normal and catch–up growth and development, and should be provided if the child is in a stable condition. Severely malnourished children often have a delayed mental and behavioural development as the same micro/family environments causing inadequate dietary intakes and easy transmission of infections also are devoid of stimulation. The poor nutritional state as such is not causatively related to above delays, but sensory deprivation at home and in the ward is. Hence a cheerful, stimulating and inviting environment should be available during the last phase of institutional rehabilitation. We therefore have, thankfully supported by Umodzi, developed Alice Assani room into a play room. Half an hour, focussed and well directed, play per day has proven to significantly increase catch-­‐up growth in height and the child’s cognitive development. Play activities don’t need fancy equipment and examples how to make simple, but effective, toys from daily household cleaning materials can be found with the nursing or Umodzi staff. 6.1 A malnourished child in pain Many children in Ankie Borgstein-­‐ or Grace Malenga-­‐ (Moyo House) wards experience pain due to their illness and complications while admitted. The whole team should recognise, prevent when possible and adequately treat pain in children. Pain and discomfort has clearly shown to be detrimental to recovery e.g. by causing anorexia, withdrawal, impaired respiration. Relieve includes minimal handling and adequate dressing of open wounds, NGT feeds for children with oral sores as well adequate pain relief with medication. Because of the impaired liver function of malnourished children, the use of hepatotoxic drugs like Paracetamol is best avoided. If children are in pain, involve the Umodzi palliative care team early on in their management, and be liberal with Morphine. (There are special forms to inform them about patients in the ward that should be completed and given to the palliative care team). 6.2 When a hospitalised malnourished child dies Mortality is high in severely malnourished children especially when accompanied by other diseases or complications. The mortality in malnourished children with HIV-­‐
infection is even higher. Many of the children admitted in Moyo ward are in the latest stage of HIV infection and even with the best treatment available their prognosis is very poor. Families should be aware of the severity of the illness and the palliative care team should be involved early on in their management. If a child dies in Moyo ward, try to comfort the guardians and if possible give them some privacy to be with the child. 7. Short-­‐ and Long-­‐Term Prognosis of our treatment 22 | Draft GTH (06/03/10): Malnutrition in Departmental Protocol Book 2010
Like in any disease it is important for patient, family/guardian and nursing and medical staff alike to know what presently the short and long term prognoses are for the admitted children. While 25 years ago the population severely malnourished children in Moyo House was mainly the result of food insecurity, malabsorptive disease and inadequate treatment, nowadays these are mainly and well treated in the community and are we left in Moyo with children with extensive or longstanding co-­‐morbidity and or serious metabolic derangements. The first group with adequate treatment (WHO guidelines, 1999) usually has a 95% survival after admission and negligible CFR afterwards during follow up. Under our recent circumstances as shown by Kerac (2009) in the ProNUT study, the case management of severe malnutrition uncomplicated by HIV has an in-­‐hospital CFR of less than 10%, and if these are followed up for one year little additional mortality. However, the same study showed that if these severely malnourished children were HIF infected their CFR during admission was as high as close to 30% and if discharged and followed up for one year only another 65% of the survivors died. Hence, HIV-­‐Severe Childhood Malnutrition carries an enormous overall mortality of 75%. Solutions to these appalling high mortality figures have to be found in a 100% effective PMTCT programme, Exclusive Breastfeeding during the first 6 months and both situations of this exclusive BF and later complimentary feeding the infant’s mother should receive HAART. The CHER study has shown that early start of HAART in non malnourished infants is significantly improving their survival and likely to reduce the chances for infantile malnutrition. 23 | Draft GTH (06/03/10): Malnutrition in Departmental Protocol Book 2010