Growth charts and PEM

Question 1

Why is it NB to plot patients

Answer 1

opportunity to check growth
idea of how well baby is doing
opportunity counselling on feeding and development
high malnutrition rate in our country
pick up poor growth early to intervene early

Question 2

Criteria for SAM and MAM

Answer 2

SAM
Weight for height z score < -3 or
MUAC < 11.5cm or
Bilateral pitting oedema of nutritional oedema

MAM
-3 < Weight for height z score < -2
11.5cm < MUAC < 12.5cm
NO bilateral pitting oedema of nutritional origin

AGE = 6m - 5 years

Question 3

when to treat inpatient?

Answer 3

pneumonia
diarrhoea with shock
sepsis
metabolic - hypothermia or hypoglycaemia

Question 4

When to worry

Answer 4

severe infection 
hypothermia
collapse due to dehydration 
jaundice 
hypoglycaemia

Question 5

Features of Kwashiorkor

Answer 5

flag sign
moon face
pot belly
Oedema
Dermatosis - dry scaly pigmentation, crazy paving, pseudopurpura - due decreased platelets, bulluous desquamation, angular cheilitis
decreased cell mediated immunity
liver enlarged fatty changes
hypokalaemia - ileus, anaemia, poor contractility
MEALS - malnutrition, oedema, anaemia, liver malfunction, skin lesions

Growth failure 
Oedema 
Dermatosis 
Immune suppression infections - measles, HSV, TB, Gastroenteritis  
Other 
     Mental and neurological changes 
     Atrophic bowel - diarrhoea 
     Liver changes - fatty 
     Glucose intolerance - hypoglycaemia 
     Anaemia 
     Purpura due thrombocytopaenia

Question 6

Step 1: Prevent and treat hypoglycaemia

Answer 6

prevent - feed two hourly start straight way or if necessary rehydrate first
always give feed throughout night

treat
1. conscious + destrostix < 3mmol/l
immediate feed of DF 75
OR 10% sugar solution oral 5ml/kg - 10ml/kg
OR dextrose 10% ivi bolus - 5ml/kg
2. monitor BG if this was low - repeat hourly, once treated most stabilise in 30min
3. Continue feeds
4. If BG remains < 3 mmol/L give ivi bolus 10% dextrose water 5ml/kg

Question 7

Step 2: Prevent and treat hypothermia

Answer 7

axillary T < 36 or rectal T < 35.5
feed straight away
rewarm by
- clothing child including head
- cover warmed blanket and place a heater or lamp nearby
- pit child on mother bare chest - skin to skin and cover them
- do not use hot water bottle - scolding

Question 8

Step 3: Prevent and treat dehydration

Answer 8

do not use IV route except in cases shock
1. Assume all children watery diarrhoea may have dehydration
2. SOROL 5ml/kg every 30min for 2 hours orally/NGT
3. 5-10ml/kg/h for next 4-10 hours
exact amount determines - child wants, stool loss, vomiting
oral rehydration safe - assume
4. replace SOROL doses at
4,6,8,10 Hours with F-75 if rehydration is continuing at these times
continue feeding starter F-75
5. observe half hourly for 2 hours then hourly for next 6-12 hours
= PR, RR, urine F, stool/vomit F

Question 9

Signs of over hydration

Answer 9

increasing RR
increasing PR
increasing oedema
puffy eyelids

Question 10

Step 4: Correct electrolyte imbalances

Answer 10

excess body sodium
deficiency potassium and magnesium
causes oedema = NOT diuretic
KCl 25-50mg/kg/dose oral 3x daily until oedema subsides
- < 10kg = 250 mg
- > 10kg = 500 mg
Mg 0.4-0.6 mmol/kg/d (0.2ml/kg of 50% IVI solution orally)

Question 11

Step 5: Prevent and treat infection

Answer 11

infections often hidden 
Broad-spectrum AB 
- ampicillin AND aminoglycoside: gentamicin, amikacin 
ADD specific AB if appropriate 
antimalarial treatment 
GIT - metronidazole - flagyll 
Dysentery - cefotaxime or ceftriaxone

Question 12

Step 6: Correct micronutrient deficiencies

Answer 12

Vit A orally - > 12m = 200 000 IU 
6-12 m = 100 000 IU 
0-5 m = 50 000 IU 
MVT supplement 5ml daily - if not available additional Mg 0.2ml/kg 
FA - 2.5mg daily po 
Zinc - 2mg/kg/d 
Copper - 0.3mg/kg/d 
Iron 3-6 mg/kg/d - only when gaining weight or from second week in divided doses

Question 13

Step 7: Start cautious feeding

Answer 13

begin feeding immediately
if hypoglycaemia or danger signs - 2 hourly
refused or no taken via NGT
DF-75 = lower fat and protein content
130ml/kg/day
monitor - amount offered and left over, vomiting, frequency watery stool, daily BW
increase up to 150ml/kg/day

Question 14

Step 8: Achieve catch up growth

Answer 14

return of appetite
replace starter DF-75 with same amount catch-up formula DF-100 for 48 hours
increase each successive feed by 10ml until some feed remains uneaten
usually when about 30ml/kg/feed (200ml/kg/d)

Question 15

Step 9: Provide sensory stimulation and emotional support

Answer 15

delayed mental and behavioural development
TLC
cheerful stimulating env
structured play therapy 15-30min/day
physical activity as soon child well enough
maternal involvement when possible

Question 16

Step 10: Prepare for discharge and follow up

Answer 16

ready for discharge when 
- no oedema 
- good appetite 
- good weight gain 
- no infection 
- playful and alert 
weight for age at least -2 Z score = considered recovered 
still low 
educate parents 
regular follow up - 2 weekly 
booster immunisations 
vit A - every 6m