8. PLAN ECONÓMICO – FINANCIERO
8.2. I NVERSIÓN EN ACTIVOS ( FIJOS E INTANGIBLES ). D EPRECIACIÓN Y AMORTIZACIÓN
Mild and moderately malnourished (underweight or stunted) children account for the major burden of malnutrition in any developing country. Management of these children is, therefore, very important from a public health perspective. These children are managed at the household and community levels. The focus is on counselling of parents on health and nutrition education, care during common illnesses including diarrhoea, micronutrient supplementation, and in many countries periodic deworming. A commonly used strategy in developing countries is growth monitoring and promotion (GMP) where under-five children are weighed at regular intervals and a package of interventions provided at the contacts. Potential strengths of GMP are that it provides frequent contact with health workers and a platform for child health interventions. However, the success of GMP depends on how sincerely the programme is carried out.
FACILITY-BASED MANAGEMENT OF SEvERE ACUTE MALNUTRITION
According to the World Health Organisation, a death rate of greater than 20% is unacceptable in the management of severely malnourished children, 11–20% is poor, 5–10% is moderate, 1–4% is good and less than 1% is excellent. The reason for the high death rates among severely malnourished children is believed to be faulty case management.
Appropriate feeding, micronutrient supplementation, broad- spectrum antibiotic therapy and judicious use of rehydration fluids (particularly intravenous fluids) are factors that can reduce death, morbidity and cost of treatment of these children. A severely malnourished child having any of the following features should be admitted to a nutrition unit having appropriate facilities and trained staff or referred to a hospital. But these criteria are flexible and may be modified according to local conditions, such as availability of trained staff and facilities. Criteria for referral of a child with SAM to a hospital include:
• Signs of circulatory collapse—cold hands and feet, weak radial pulse, not alert (may be due to severe dehydration or septic shock)
• Convulsion/unconsciousness
• Cyanosis of lips, tongue or finger tips • Inability to drink
• Chest indrawing
• Fast breathing (60 breaths/min or more in an infant < 2 months, > 50/min in a child 2 months to 1 year, > 40/ min in a child 1–5 years old)
• Wheezy breathing
• Hypothermia (body temperature < 35.5°C) • High fever (> 39.0°C)
• Very severe pallor or anaemia (haemoglobin < 5 g/dl) • Persistent diarrhoea (diarrhoea for > 14 days) • Persistent vomiting (> 3 episodes per hour) • Bloody mucoid stools
• Loss of appetite
• Severe vitamin A deficiency (VAD) or keratomalacia • Jaundice
• Purpura
• Distended, tender abdomen • Age less than 1 year.
Evaluation of the Severely Malnourished Child If the child with SAM is acutely ill and requires immediate treatment, details of the history and physical examination should be delayed. History-taking should include the following:
• Usual diet given before the present illness • History of breastfeeding
• Food and fluids taken in the past few days
• Duration, frequency and nature of diarrhoea or vomiting • Time when urine was last passed
• Recent sinking of the eyes • Duration and nature of cough • History of fever
• Contact with measles or tuberculosis • Major past illness
• Milestones reached (sitting, standing, etc.) • Immunisations
• Socioeconomic history.
A thorough physical examination should be done, that includes:
• Temperature (for diagnosing fever and hypothermia) • Respiratory rate and type of respiration (for diagnosing
pneumonia and heart failure)
• Signs of circulatory collapse (cold hands and feet, weak/ absent radial pulse, not alert)
• Weight and height or length. Length is measured for children aged less than 2 years, less than 85 cm tall or those who cannot stand
• Hydration status • Pallor
• Oedema
• Abdominal distension and bowel sounds • Enlarged or tender liver, jaundice • Vitamin A deficiency signs in eyes • Pus in eyes
• Signs of infection in mouth, throat and ears • Signs of infection in and around the genital organs • Appearance of stools (consistency, presence of blood,
mucus or worms).
Laboratory Investigations
Laboratory tests are not essential for management. The following tests should be done if facilities are available: • Blood glucose if the child is not alert
• Haemoglobin if the child is severely pale
• Urine for pus cells if urinary tract infection is suspected • X-ray chest if severe pneumonia or if tuberculosis (TB)
is suspected
• Mantoux test if TB is suspected (an induration of > 5 mm indicates a positive test in a severely malnourished child). Reductive Adaptation in Severe
Acute Malnutrition
Children with SAM undergo physiological and metabolic changes to conserve energy and preserve essential processes. This is known as reductive adaptation. If these changes are ignored during treatment, hypoglycaemia, hypothermia, heart failure, untreated infection can cause death. This can be illustrated by the reasons for not giving iron during the initial acute phase treatment of SAM. The child with SAM makes less haemoglobin than usual. Giving iron early in treatment leads to ‘free iron’ that can cause problems:
• Free iron is highly reactive and promotes formation of free radicals which can damage cell membranes
• Promotes bacterial growth and can make infections worse
• The body tries to convert it into ferritin, the storage form of iron. This uses up essential energy and amino acids. Therefore, iron should not be given during the acute phase of management of SAM.
PHASES OF MANAGEMENT OF SEvERE ACUTE MALNUTRITION
The management of children with severe malnutrition can be divided into three phases.
Acute Phase
Problems that endanger life, such as hypoglycaemia (a low blood glucose level) or an infection, are identified and treated. Feeding and correction of micronutrient deficiencies are initiated during this phase. Broad-spectrum antibiotics are started. Small, frequent feeds are given (about 100 kcal/ kg and 1–1.5 g protein/kg per day). The main objective of this phase is to stabilise the child. Case fatality is highest during this phase of management, the principal causes being hypoglycaemia, hypothermia, infection and water-electrolyte imbalance. Most deaths occur within the first 1–2 days of admission. This phase usually takes about 4–5 days. Nutritional Rehabilitation Phase
The aim of this phase is to recover lost weight by intensive feeding. The child is stimulated emotionally and physically, and the mother is trained to continue care at home. Around 150–250 kcal/kg and 3–5 g protein/kg are provided daily during this phase. Micronutrients, including iron, are continued. Treatment remains incomplete without health and nutrition education of the mothers. This phase takes 2–4 weeks if the criterion of discharge is WHZ –2 without oedema.
Follow-up
Follow-up is done to prevent relapse of severe malnutrition, and to ensure proper physical growth and mental development of the child. The likelihood of relapse into severe malnutrition is more within 1 month of discharge. Follow-up visits should be fortnightly initially and then monthly until the child has achieved WHZ greater than –1. Nutritional status and general condition are assessed and the caregivers counselled. Commonly occurring illnesses are treated and health and nutrition education for the caregivers reinforced.
These phases of management can be carried out through the ten steps of treatment:
Step 1: Treat/Prevent Hypoglycaemia
Hypoglycaemia and hypothermia usually occur together and are signs of infection. The child should be tested
for hypoglycaemia on admission or whenever lethargy, convulsions or hypothermia are found. If blood glucose cannot be measured, all children with SAM should be assumed to be are hypoglycaemic and treated accordingly.
If the child is conscious and blood glucose is less than 3 mmol/L or 54 mg/dl give:
• 50 ml bolus of 10% glucose or 10% sucrose solution (5 g or 1 rounded teaspoon of sugar in 50 ml or 3.5 tablespoons water), orally or by nasogastric (NG) tube. Then feed starter diet F-75 (discussed in Step 7) every 30 minutes for 2 hours (giving one quarter of the 2 hourly feed each time).
• Two hourly feeds, day and night for first 24–48 hours (discussed in Step 7).
If the child is unconscious, lethargic or convulsing give: • IV sterile 10% glucose (5 ml/kg) or 25% glucose (2 ml/
kg), followed by 50 ml of 10% glucose or sucrose by NG tube.
• Then give starter F-75 as above. Step 2: Treat/Prevent Hypothermia
If the axillary temperature is less than 35.0°C or the rectal temperature is less than 35.5°C:
• Start feeding right away (or start rehydration if needed) • Rewarm the child by clothing (including head), covering
with a warm blanket or placing the child on the mother’s bare chest (skin-to-skin) and covering them. A heater or lamp may be placed nearby. During rewarming rectal temperature should be taken 2 hourly until it rises to greater than 36.5°C (half hourly if heater is used). The child must be kept dry and away from draughts of wind. Step 3: Treat/Prevent Dehydration
The WHO-ORS (75 mmol sodium/L) contains too much sodium and too little potassium for severely malnourished children. They should be given the special rehydration solution for malnutrition (ReSoMal) (Table 5.3). It is difficult to estimate dehydration status in a severely malnourished child. All children with watery diarrhoea should be assumed to have dehydration and given:
• Every 30 minutes for first 2 hours, ReSoMal 5 ml/kg body weight orally or by NG tube, then
• Alternate hours for up to 10 hours, ReSoMal 5–10 ml/kg per hour (the amount to be given should be determined by how much the child wants, and stool loss and vomiting). F-75 is given in alternate hours during this period until the child is rehydrated.
• After rehydration, continue feeding F-75 (discussed in Step 7).
If diarrhoea is severe then WHO-ORS (75 mmol sodium/L) may be used because loss of sodium in stool
is high, and symptomatic hyponatraemia can occur with ReSoMal. Severe diarrhoea can be due to cholera or rotavirus infection, and is usually defined as stool output greater than 5 ml/kg per hour.
Return of tears, moist mouth, eyes and fontanelle appearing less sunken, and improved skin turgor, are signs that rehydration is proceeding. It should be noted that many severely malnourished children would not show these changes even when fully rehydrated. Continuing rapid breathing and pulse during rehydration suggest coexisting infection or overhydration. Signs of excess fluid (overhydration) are increasing respiratory rate and pulse rate, increasing oedema and puffy eyelids. If these signs occur, fluids are stopped immediately and the child reassessed after 1 hour. Intravenous rehydration should be used only in case of shock, infusing slowly to avoid overloading the heart.
Step 4: Correct Electrolyte Imbalance
All severely malnourished children have excess body sodium even though serum sodium may be low. Deficiencies of potassium and magnesium are also present and may take at least 2 weeks to correct. Oedema is partly due to these imbalances and must never be treated with a diuretic, give: • Extra potassium 3–4 mmol/kg per day
• Extra magnesium 0.4–0.6 mmol/kg per day
• When rehydrating, give low sodium rehydration fluid (e.g. ReSoMal)
• Prepare food without salt.
The extra potassium and magnesium can be prepared in a liquid form and added directly to feed during preparation (Table 5.3 for a recipe for a combined electrolyte/mineral solution).
Step 5: Treat/Prevent Infection
In severe malnutrition the usual signs of infection, such as fever, are often absent, and infections often hidden. Therefore, give routinely on admission:
• Broad-spectrum antibiotics
• Measles vaccine if child is greater than 6 months and not immunised (delay if the child is in shock)
If the child appears to have no complications give: • Oral amoxycillin 15 mg/kg 8 hourly for 5 days.
If the child is sick looking or lethargic or has complications (hypoglycaemia, hypothermia, skin lesions, respiratory tract or urinary tract infection) give:
• Ampicillin 50 mg/kg IM/IV 6 hourly for 2 days, then oral amoxycillin 15 mg/kg 8 hourly for 5 days
• Gentamicin 7.5 mg/kg IM/IV once daily for 7 days. If the child fails to improve clinically by 48 hours or deteriorates after 24 hours, a third-generation cephalosporin,
e.g. ceftriaxone 50–75 mg/kg per day IV or IM once daily may be started with gentamicin. Ceftriaxone, if available, should be the preferred antibiotic in case of septic shock or meningitis. Where specific infections are identified, add: • Specific antibiotics if appropriate
• Antimalarial treatment if the child has a positive blood film for malaria parasites.
If anorexia still persists, reassess the child fully, checking for sites of infection and potentially resistant organisms, and ensure that vitamin and mineral supplements have been correctly given.
Step 6: Correct Micronutrient Deficiencies
All severely malnourished children have vitamin and mineral deficiencies. Although anaemia is common, do not give iron initially but wait until the child has a good appetite and starts gaining weight (usually by the 2nd week), as giving iron can make infections worse, give:
• Vitamin A orally on day 1 (for age > 12 months, give 200,000 International Unit (IU); for age 6–12 months, give 100,000 IU; for age 0–5 months, give 50,000 IU) unless there is definite evidence that a dose has been given in the last month. If the child has xerophthalmia, the same doses of vitamin A are repeated on days 2 and 14 or on day of discharge.
Give daily for the entire period of nutritional rehabilitation (at least 4 weeks):
• Multivitamin supplements
• Folic acid 1 mg/day (5 mg on day 1) • Zinc 2 mg/kg per day
• Copper 0.3 mg/kg per day
• Iron 3 mg/kg per day but only when gaining weight (start after the stabilisation phase is over).
A combined electrolyte/mineral/vitamin (CMV) mix for severe malnutrition is available commercially. This can Table 5.3: Rehydration solution for malnutrition
Ingredient Amount
Recipe for ReSoMal
Water (boiled and cooled) 2 L
WHO-ORS 1 L sachet
Sugar 50 g
Electrolyte/mineral solution (discussed below) 40 ml ReSoMal contains approximately Na less than 45 mmol/L, K 40 mmol/L and Mg 3 mmol/L. Recipe for electrolyte/mineral solution
Weigh the following ingredients and make up to 2,500 ml. Add 20 ml of electrolyte/mineral solution to 1,000 ml of milk feed.
g Molar content of 20 ml
Potassium chloride 224 24 mmol
Tripotassium citrate 81 2 mmol
Magnesium chloride 76 3 mmol
Zinc acetate 8.2 300 mmol
Copper sulphate 1.4 45 mmol
Water up to 2,500 ml
Note: Add selenium if available and the small amounts can be measured locally (sodium selenate 0.028 g) and iodine
(potassium iodide 0.012 g) per 2,500 ml.
Preparation: Dissolve the ingredients in cooled boiled water. Store the solution in sterilised bottles in the refrigerator to retard deterioration. Make
fresh each month and discard if it turns cloudy. If the preparation of this electrolyte/mineral solution is not possible and if premixed sachets are not available, give K, Mg and Zn separately.
Potassium
• Make a 10% stock solution of potassium chloride (KCl), 100 g in 1 litre of water
• For oral rehydration solution, use 45 ml of stock KCl solution instead of 40 ml electrolyte/mineral solution • For milk feeds, add 22.5 ml of stock KCl solution instead of 20 ml of the electrolyte/mineral solution.
Magnesium
• Give sterile magnesium sulphate (50% w/v) intramuscularly once daily (0.1 ml/kg up to a maximum of 2 ml) for 7 days.
Zinc
replace the electrolyte/mineral solution and multivitamin and folic acid supplements mentioned in Steps 4 and 6, but still give the large single dose of vitamin A and folic acid on day 1, and iron daily after weight gain has started.
Step 7: Start Cautious Feeding
During the stabilisation phase a cautious approach is required due to the child’s fragile physiological state and reduced capacity to handle large feeds. Feeding should be started as soon as possible after admission. WHO-recommended starter formula, F-75, contains 75 kcal/100 ml and 0.9 g protein/100 ml (Table 5.4). Very weak children may be fed by spoon, dropper or syringe. Breastfeeding is encouraged between the feeds of F-75. A recommended schedule in which volume is gradually increased, and feeding frequency gradually decreased is:
Days Frequency Vol/kg per feed Vol/kg per day
1–2 2 hourly 11 ml 130 ml
3–5 3 hourly 16 ml 130 ml
6–7+ 4 hourly 22 ml 130 ml
If intake does not reach 80 kcal/kg per day despite frequent feeds, coaxing and reoffering, give the remaining feed by NG tube.
Criteria for increasing volume/decreasing frequency of F-75 feeds:
• If vomiting, lots of diarrhoea or poor appetite, continue 2 hourly feeds
• If little or no vomiting, modest diarrhoea (less than 5 watery stools per day), and finishing most feeds, change to 3 hourly feeds
• After a day on 3 hourly feeds—if no vomiting, less diarrhoea and finishing most feeds, change to 4 hourly feeds.
In case of SAM infants less than 6 months old, feeding should be initiated with F-75. During the nutritional rehabilitation phase, F-75 can be continued and if possible relactation should be done.
Step 8: Achieve Catch-up Growth
During the nutritional rehabilitation phase feeding is gradually increased to achieve a rapid weight gain of greater than 10 g gain/kg per day. The recommended milk-based F-100 contains 100 kcal and 2.9 g protein/100 ml (Table 5.4). Modified porridges or modified family foods can be used provided they have comparable energy and protein concentrations.
Readiness to enter the rehabilitation phase is signalled by a return of appetite, usually about one week after admission. A gradual transition is recommended to avoid the risk of
heart failure, which can occur if children suddenly consume huge amounts.
To change from starter to catch-up formula:
• Replace F-75 with the same amount of catch-up formula F-100 every 4 hours for 48 hours then
• Increase each successive feed by 10 ml until some feed remains uneaten. The point when some remains unconsumed after most feeds is likely to occur when intakes reach about 30 ml/kg per feed (200 ml/kg per day).
If weight gain is:
• Poor (5 g/kg per day), the child requires full reassessment for other underlying illnesses, e.g. TB
• Moderate (5–10 g/kg per day), check whether intake targets are being met, or if infection has been overlooked • Good (>10 g/kg per day), continue to praise staff and
mothers.
Step 9: Provide Sensory Stimulation and Emotional Support
In severe malnutrition, there is delayed mental and behavioural development. Just giving diets will improve physical growth but mental development will remain impaired. This is improved by providing tender loving care and a cheerful, stimulating environment. The play sessions should make use of toys made of discarded material.
Step 10: Prepare for Follow-up After Recovery
A child who has achieved WHZ –2 SD can be considered to have improved. At this point, the child is still likely to have a low WA due to stunting. Good feeding practices and sensory stimulation should be continued at home. Parents or caregivers should be counselled on:
• Feeding energy and nutrient-dense foods • Providing structured plays to the children
• To bring the child back for regular follow-up checks • Ensure that booster immunisations are given
• Ensure that vitamin A and antihelminthic drugs are given every 6 months.