Inpatient Management of Malnourished Children

• The integral health care of all children between 1 and 59 months of age consists of five fundamental elements:
  • Diagnosing the existence and severity of malnutrition
  • Determining the presence of acute concurrent complications or comorbidities
  • Defining and planning the priorities in initial clinical and nutritional care
  • Establishing prognosis
  • Selecting a suitable scenario to continue and consolidate the established management

Inpatient Management in Children Aged 6-59 Months

• Children aged 6-59 months meeting hospital management criteria will receive treatment once identified in their home, community, or institutional setting
• Hospitalization is needed to stabilize conditions and complications that could lead to death
• The management plan follows the therapeutic ABCD approach

Stabilization Phase

• The goal of inpatient management is to prevent, treat, and monitor complications
• Initiate specific management approaches
• Address altered carbohydrate and energy metabolism that affects blood glucose levels and body temperature regulation, as well as hydroelectrolytic balance

Controlling Hypoxemia and Respiratory Effort

• Assess for hypoxemia and tissue hypoxia signs: irritability, drowsiness, stupor, coma, cyanosis, earthy appearance, slowed fingertip refill, oliguria, abdominal distension, and increased respiratory effort
• Evaluate respiratory rate (greater than 50 breaths per minute), nasal flaring, inter- or subcostal retractions, expiratory grunting, or accessory muscle use
• Assess oxygen saturation using pulse oximetry
• If any of the above conditions are present, begin supplemental oxygen with an appropriate inspired fraction above 90% to improve saturation and respiratory pattern
• Ensure a continuous oxygen supply with portable or fixed sources is available as needed

Preventing, Checking For, and Treating Hypoglycemia

• Detect shock signs and cautiously correct dehydration

• All children with moderate to severe acute malnutrition are at risk of hypoglycemia, defined as a blood glucose level below 54 mg/dL, which can be fatal if untreated

• Hypoglycemia signs vary depending on severity and include decreased body temperature (less than 36.5°C), lethargy, flaccidity, loss of consciousness, or somnolence

• Hypoglycemia treatment depends on whether consciousness is altered.

• For patients without altered consciousness or lethargy:

  • Administer a bolus of 10% dextrose at 5 ml/kg orally or via a nasogastric (NG) tube
  • Check blood glucose levels after 30 minutes
  • If hypoglycemia continues, repeat the 10% dextrose bolus at 5 ml/kg
  • If there is improvement, continue with F-75 at 3 ml/kg per feeding every 30 minutes for 2 hours orally or via an NG tube

• For patients with altered consciousness, lethargy, or convulsions:

  • Administer a bolus of 10% dextrose at 5 ml/kg via an NG tube or intravenously over five minutes
  • Check blood glucose levels after 15 minutes if given intravenously or after 30 minutes if given enterally
  • If hypoglycemia continues, repeat the 10% dextrose bolus at 5 ml/kg
  • Repeat blood glucose check
  • If there is improvement, continue with F-75 via an NG tube every 30 minutes at 3 ml/kg per feeding for 2 hours
  • Check blood glucose levels every hour
  • If hypoglycemia persists, hypothermia develops, or consciousness deteriorates, continue individualized management and rule out infectious conditions like sepsis, necrotizing enterocolitis, pneumonia, or refeeding syndrome

• Hypoglycemia can result from a severe infection or prolonged fasting in children with acute malnutrition

• Regularly providing breast milk or F-75 every two hours, orally or via an NG tube, day and night, is the most effective measure for preventing hypoglycemia

• Assume that a child with diarrhea, vomiting, or hyporexia has dehydration associated with acute malnutrition, which is a predictor of mortality

• Evaluating dehydration in children aged 6-59 months with severe acute malnutrition using clinical signs alone is challenging, especially in those with edema

• Initial anthropometric measurements may lead to inaccurate nutritional classification; re-evaluate anthropometrics and nutritional status after correcting dehydration

• Clinically assume that all children with moderate or severe acute malnutrition and comorbidities have some degree of dehydration, approximately 5% of their body weight, unless clinical signs suggest a higher degree of dehydration

• Use the DHAKA scale to assess dehydration and calculate fluids to administer

• Correct dehydration over 6-12 hours, but you may wait up to 24 hour

• Prefer enteral hydration by mouth or gastroclysis unless contraindicated

• Electrolyte and metabolic stabilization will occur within the first 48 hours with hydration and the following regimens, as dictated by their level of conciousness

• If the patient is conscious:

  • Monitor for hypoxemia, and supplement with oxygen if necessary
  • Prefer oral hydration, but use an N/G tube if they can not take food orally
  • In cases of moderate malnutrition, administer 75 ml/kg of SRO-75 over 4-6 hours
  • In cases of severe acute malnutrition, prepare one liter of SRO-75, plus 10 ml of potassium chloride and administer 10 ml/kg/hr, to a max of 12 hours
  • Check urine output, level of conciousness, heart rate, and respiratory rate every 15 minutes for 2 hours, then every hour
  • Once the patient is rehydrated, continue breastfeeding if possible
  • Replace SRO-75 losses (with potassium chloride in the case of severe malnutrition), at a rate of 50-100ml.

• Signs of overhydration include increased heart and respiratory rates, new snoring sounds, an enlarged liver (hepatomegaly) and venous engorgement, all signs of refeeding syndrome

• If the patient is lethargic or otherwise has altered concious state:

  • Check for hypoxemia, and supplement with oxygen if necessary
  • Get venous access
  • If you cannot get venous access, use an N/G tube
  • Immediately administer a bolus of Ringer's lactate at 15 ml/kg over one hour by N/G tube or IV
  • Check heart rate and respiratory rate every 10 minutes in the first hour
  • If there are signs of improvement (urine production, decreased heart rate etc), continue with fluid therapy by either mouth or N/G tube
  • Keep the venous access open, but do not give additional fluids
  • Prepare a liter of low osmolarity SRO-75 with 10 ml Potassium Chloride
  • Administer 100 ml/kg a day for up to 12 hours
  • Continue to monitor conciousness, heart rate, respiratory rate, urine output, and number of poops

• If the patient is not improving:

  • Repeat the ringer's lactate bolus, and monitor their hemoglobin
  • Administer packed red blood cells at 10 ml/kg over 3 hours when hemoglobin count is either:
    • Under 4 g/DI
    • Under 6 g/DI with symptoms
  • Administer Furosemide, and remember that that the indication above is the only reason to give diuretics.
  • Give an IV fluid cocktail, being 500 ml in distiled water, 15ml Nacl solution and 7.5 ml KCL
  • Monitor respiratory and heart rate
  • Stop the transfusion if repsirations jump by 5 or more, or heart rate jumps by 25

• Stop transfusion if there is a fever, rash, dark-colored urine, change of conciousness, or shock, and do not repeat for 4 days

• Avoid administering, albumin, diuretics and sodium. Use SRO75 instead.

• Shock can appear simultaneously with severe dehydration

• A child with no diarrhea and dehydration should be treated like they are septic

• Desiccation of the mouth, tearless crying, or loss of skin turgor are not trustworthy signs of dehydration in childhood severe malnutrition

• In cases of severe acute malnutrition with dehydration:

  • Slow rehydration is prefered when teh patient is in shock or has severe dehydration and oral admin is not possible
  • A patient can have shock due to sepsis or dehydration
  • Refeeding can be mistaken for the above two
  • IV fluids are not effective when a patient is undergoing septic shock without dehydration
  • The amount of fluids to administer depends on the clinic. Do not over-hydrate.
  • Children with severe malnutrition who are not responding to fludis may be undergoing septic shock
  • A patient who shows signs of dehydration without a history of diaherra may be experiencing a lack of sodium/glucose

• Values for children with acute malnutrition may be abnormal

• Always treat dehydration and shock symptoms immediately

• The stabilization phase can begin on-site

• There are necessary supplies for first-level care that should be on-hand

Monitoring Renal Function

• Quantify the urine output from the start of diagnosis
• Decreased abdominal distension and other symptoms suggest a good start of F-75 via the nose or mouth
• A lack of diuresis is a sign of hypoperfusion as compensation and homeostasis resulting from trauma, infection, dehydration, or shock
• Hypoperfusion of the kidney and other organs can cause ischemia of the mesentery and electrical imbalance

Ensuring Intestinal Function

• Intestinal mucosa needs progressive amounts of fluids to maintain balance.
• Re-hydration should be given using SRO-75 via the mouth
• F-75 can be given once consciousness has improved and there is a passing of urine and normal bowel sounds
• SRO-75 should be given in small amounts to children with moderate malnutrition
• 10ml of potassium Cholride
• Breast milk and F-75 should be given as soon as possible
• Persistent diarrhea is defined as 3 or more poops a day for 14 days. Causes a delay for recovery. This is due to bad living conditions or infections. Treat with antibiotics.

Correcting Severe Anemia

• Severe anemia is defined as hemoglobin under 4, or 6 with symptoms and a low hematocrit
• Packed red blood ceels should be given over 3 hours
• Stop transfusion if there is a fever, rash, dark urine, bad mental state or shock
• Give 1mg/kg of Furosemide, the only acceptable reason

Controlling Hypothermia

• Define when a body temperature is under 35.
• Put the child in warm clothes, including the head
• Cover in a blanket
• Wrap the baby skin to skin with the mother
• Make sure the room is heated
• Treat skin injuries
• Do not put hot bottles near the child
• Keep child warm by covering them and limiting their contact

Starting Empirical antibiotic treatments.

• You can expect that a child with malnutrition is infected because of weak immune barriers.
• Conduct antibiotic therapy right away. An early treatment will improve nutrition, protect from shock, and limit symptoms.
• Anorexia is the most sensitive symptom for infection
• Signs of infection are delayed in malnourished children

Antibiotic treatments available

• Ensure the patients are protected from infection
• Isolate the child with the least amount of patients
• Wash hands
• Treat with first-line antibiotic treatments, such as Amoxicillin

Administer Micronutrients

• All children with poor nutrition have trace deficiencies
• F-75 covers the vitamin A, Zinc, and cooper amounts.
• They wont need this unless they are in certain bad conditions like measles.

Definition and nutrition mangement.

• Stabilizing complications will help them begin again and lower mortality

• Children can not process proteins and salts as normal

• Do NOT put a feeding tube up their nose.

• When diuresis is proven, start F-75 in the amounts described, for children with acute malnourished conditions or refeeding syndrome.

• Administer F-75 every 3 hours

• For severe malnutrition with oedema, administer every 3 hours

Transition phase of F-75 after diuresis occurs:

• Offer the formula or breast milk with a spoon or cup. Do not use a pacifier.

• Strict vigilance in:

  • Breast milk quantity, vomit, bowel movements, body weight, heart rate, respiratory rate, and urination frequency.

• For any child weighing less than 4 kg it is important to identify nutrition management as it is high-risk. Breast feeding is important for the mother.

• For those kids, the goal is to increase their weight

• If the child is active, stimulate breast feeding. Should be given after F-75.

• Nutrition must be provided orally, be cautious

• The nutrition needs to be introduced so that a reverse of the acute malnutrition is possible.

• Watch out for heart rate and breathing

Final points of transition phase:

• P: Look at the commitment of the skin. Observe and document
• You need to set the damage based on the amount of the surface of the skin that is damaged.
• The damaged zones need to be kept clean
• Children should be put in a proper weight phase to grow

Transition phase of malnutrition.

• Apply a cover cream over the affected part.

In the transition phase, it consists of moving from F-75

• Happens for 3 to 7 days depending on the condition of the child

• The consumption needs to be monitored.

• Slowly reduce them volumes of F-75 and gradually increase the amount of FTLC

• After this process, the patient is on FTLC for diet

Option 1

• A FTLC formula will be released.

• If it is too much work to offer more than F-75, it may be offered before breastfeeding.

• Offer fresh water in an amount of food demand

• If FTLC needs to supplement calories will be F-75

• If the child receives supplements daily then the child may be able to rehabilitate nutritionally.

• It can be offered more as an additional component with care.

Option 2:

• Make sure to show the kids the formulas of the formula
• It is an obligation to create a formula to the malnourished children to get them better

If the child consumes the amount necessary for this portion, revert back to F-75

• Then you can offer complementary food

• M. Administer micronutrients: Start folic acid to treat and keep it in a diluted amount.

• Diarrhea may appear when too many nutrients are given at once. It has symptoms of hydration and indicate the need for hospital patient check

• You should make sure the feeding of the patient continues to be low and proper to prevent harm

R. Refeeding

• In a refeeding syndrome there are signs of heart and renal failure, change in levels.

• Treatment needs to be carefully managed for care, the important signs of the situation.

• Heart Rate: increase of breaths per minute will effect the child

• There are signs of not getting enough heart function

• Blood is not stable from this

• Change or high blood is going on to change

• The signs should be monitored for 24 hours

• The increase in calories needs to be slowly put in.

• There will be some control of all liquids

• Weigh the weight everyday. Be suspicious of high amounts of weight each day. If needed, use K, p and Mg.

• The process of providing the nutrient over IV must be correct

• The patient is monitored for all important processes

• You must show attention that the clinical is proper or not.

Fase de rehabilitacion

• In this phase one must verity properly body function

Reccomendations of FTCLI:

• Should be known with an alterered stater and be given.

• There should be no diseases. If processes should be there it has a controller

• Is the disease controlled

• There are some important signs. What you should do

• It should be done in two days and 135 k day

• If here is swelling, give it

• Gain body weight after two days

• Acceptence by some

• Make sure that is some follow ups set to plan to manage them

• Complete what all can to the children

• Provide albenzaol to all people who are in nutrition.

• Take a look after weeks

• Collect and provide the info necessary

• Make sure you have communication

• Prevent problems for nutrition.