|Nutrition Guidelines (MSF, 1995, 191 p.)|
|Part III Selective feeding programmes|
Treatment of severe PEM involves intensive medical and nutritional treatment. Care must be taken to chose suitable sites for the shelter of the participants (both and their carers), which need to be accessible to the population and near a health facility. Treatment of severe PEM is divided into two phases:
· In the 24-hour care unit medical treatment, including rehydration, is started to control infection and reduce risk of mortality. At the same time the careful introduction of a sustenance level diet will prevent nutritional deterioration and allow normalization of disturbed metabolic functions and to prepare them to manage the large amounts of food given later during the rehabilitation phase.
Children admitted without medical complications can be admitted directly to the second phase if resources are limited.
Treatment and surveillance is focused on the main causes of death and towards correcting metabolic imbalances and vitamin deficiencies.
Main Causes of Death in Severe PEM.
- Cardiac failure
- Severe anaemia
Severe malnutrition is almost always accompanied by diarrhoea, resulting in severe dehydration and malabsorption. Dehydration is the most important cause of death in severely malnourished children. The diagnosis of dehydration in children with PEM is difficult, especially for those with kwashiorkor.
Signs of severe dehydration in children with PEM
- Child limp, apathetic or unconscious
- Rapid weak pulse
- Skin pale and cold, with decreased turgor
- Sunken eyes and fontanelle
- Dry mouth
- Absence of tears when crying
- Urine volume decreased
Give oral rehydration whenever possible and if necessary by a nave-gastric tube. Intravenous fluids are not recommended for use in treating severely malnourished children because there is serious danger of overloading the circulatory system, leading to pulmonary oedema and death. It is only in cases of very severe shock that one can give Ringer's lactate (Hartmann solution) or isotonic saline (1Oml/kg/hr for the first 2 hours), with extreme caution. The respiratory rate should be monitored every 30 minutes, because faster breathing is the earliest sign of cardiac overload (see Ref. 7).
Malnourished children tend to have an electrolyte imbalance with a major excess of sodium. Oral rehydration solutions should be reduced in sodium content in order to prevent sudden death from cardiac failure. Therefore, severely malnourished children need a different ORS formula than the one generally used (WHO ORS) for well-fed and moderately malnourished children.
The classical WHO ORS should be diluted to half-strength (i.e. 1 sachet diluted in 2 litres rather than 1 litre), and sugar (25g/litre) and potassium (2g/litre) added. Due to the potential danger of potassium overloading, potassium supplementation requires strict supervision.
Children with severe PEM are deficient in both potassium and magnesium, as well as other minerals (zinc, copper, selenium, iodine). A well balanced mix of different minerals is therefore necessary to restore deficiencies and electrolyte imbalances. Pre-formated sachets of a special ORS are now available for the treatment of severely malnourished and dehydrated children (see Annex 15).
Almost all severely malnourished children are suffering from infection (Ref. 19). The most frequent problems are:
· Respiratory tract infections
· Urinary tract infections
· Gastrointestinal infections
· Skin infections
Respiratory, urinary and other infections are not easy to diagnose in severely malnourished children because the classical signs of infections (fever, pain, inflammation etc.) can be masked. Due to malnutrition, the immune systems are inhibited and the child does not have the normal defense mechanisms. A severely malnourished child can develop septicaemia without fever.
It is crucial to examine each child carefully on admission, and to keep examining them each day during the first phase of treatment. In the majority of cases, antibiotic treatment will be required (see Ref. 7 and 8).
The severe complications with measles for malnourished children leads to a very high case fatality rate (30%). Common complications with measles: bronchopneumonia, diarrhoea, stomatitis, otitis, laryngitis, vitamin A deficiency. As measles is so contagious, admission procedures should include systematic measles immunization for those who were not previously immunised. Severe malnutrition is NOT a contra-indication for measles immunization.
Malaria prophylaxis is not routinely given. However, in malaria endemic areas, during peak season, routine treatment for malaria for all children may be given. The choice of treatment will depend on the local pattern of drug resistance and national policy (see Ref. 7 and 8).
Persistent diarrhoea, which frequently accompanies severe malnutrition, is caused by atrophy of the intestinal mucosa and can only be treated by intensive nutritional rehabilitation itself.
Hypothermia is a frequent cause of death, especially early in the morning. Severely malnourished children cannot regulate their body temperatures adequately and they <<cool>> very quickly when there is a drop in external temperature. Even in tropical climates, temperatures at night can fall very low in an open ward. Body temperature should be measured once or twice daily and the child should be kept warm: let the mother keep the child close and provide adequate supplies of blankets. Never wash a hypothermic child, not even with warm water.
Death by hypoglycaemia occurs frequently and most often at night. For this reason it is essential that there is regular feeding during day and night (at least 1 - 2 meals).
Cardiac failure can result from electrolyte disturbances, overload of fluids or severe anaemia.
The first two causes should not occur when a proper oral rehydration and nutritional rehabilitation scheme is followed. For the treatment of severe decompensated anaemia, see below.
Malnourished children seem to tolerate anaemia remarkably well. Blood transfusions should not be given, because of the danger of over-loading the heart and transmission of HIV and other infections. Transfusion is only required in exceptional cases, when the child presents with symptoms of decompensation (see Ref. 7 and 16).
Folic acid (5 mg/day) should be given from the day of admission. Iron, however, should NOT be given during the first two weeks after admission. Iron repletion has an adverse effect on the course of some infections (by promoting bacterial growth and free radical formation). Iron overload carries a serious risk of death, especially in young children.
Mebendazole should be given routinely, since most severely malnourished children suffer from worms. Do not give mebendazole to children younger than 12 months.
· Vitamin A:
Vitamin A deficiency is clearly associated with increased mortality. PEM is usually associated with low vitamin A body stores and often with frank vitamin A deficiency. Furthermore, vitamin A requirements are greatly increased during nutritional rehabilitation.
An oral therapeutic dose should be given (see Ref. 8). Children younger than 6 months should not be given vitamin A because of possible toxicity; supplements should also be given to mothers within 1 month of delivery and for those breastfeeding.
Be aware of possible excess (toxic) doses given to children who recently received a mass-dose of vitamin A: re-admissions, children referred from a SFP or children admitted shortly after a mass measles immunization campaign where vitamin A was distributed (see Ref. 17).
· Vitamin C:
In areas where the diet is limited in Vitamin C, or wherever cases of scurvy are reported, a curative dose of Vitamin C should be given on admission to each child followed by regular prophylaxis (see Ref. 7).
· Other Vitamin and micronutrient deficiencies:
Other vitamin and micronutrient deficiencies are common in some areas:
- Vitamin B1 (beriberi)
- Vitamin B6/PP (pellagra)
- Vitamin D (rickets)
- Iodine (goitre and cretinism)
If you face these kinds of deficiencies in the feeding centre they should be treated in accordance with MSF Clinical Guidelines (Ref. 7). In addition, a real control strategy should be formulated: active surveillance, treatment of cases, prevention through supplementation with tablets or food fortification and advocacy.
The specific pattern of medication for a child entering the TFC will depend on the locally defined essential drugs and any other medication prescribed after clinical examination.
Initiation of Nutritional Therapy
It takes time for the metabolic mechanisms of a severely malnourished child to readjust to food intake. Therefore, do not give too much protein and energy too early: because of its osmotic value, absorbed food increases body water, and therefore can cause cardiac failure and sudden death.
Feeds must be given in small amounts and frequently. Children should never be force fed: use the child's appetite as a guide.
FEEDING: COMPOSITION AND FREQUENCY
To allow readjustment of metabolic mechanisms, the child should stay in Phase I for a maximum of one week on a diet providing just enough energy and protein for maintenance: 100 kcal/kg/day and not more than 3g protein/kg/day.
During Phase I, food requirements have to be calculated individually, according to bodyweight and required meal frequency, and marked on the child's individual patient card. However, a ration providing 100 kcal/kg/day is not enough to allow weight gain and therefore should not be given for more than one week.
For practical purposes, use high energy milk (HEM) formula with an energy density of 1 kcal/ml. Aim to give 100 ml HEM/kg bodyweight/day; this is equivalent to providing 100 kcal and 2.9g protein/kg/day.
The total amount of 100 ml/kg/day should be provided through a high number of small feeds. An ideal distribution is:
· day 1 - 2: 12 feeds of 8 ml/kg (every 2 hours)
· day 3 - 7: 8 feeds of 12 - 15 ml/kg (every 3 hours)
If these frequencies are not possible, an absolute minimum is 6 feeds/day, of which at least 1 must be during the night.
Psychological stimulation of the child by its mother and by personnel is crucial in getting the child to eat again.
Guidelines for preparation of HEM are given in Annex 16.
Indications for nave-gastric feeding are:
- Complete anorexia
- Severe dehydration
- Child cannot drink (too weak)
- Repeated vomiting
Try to breastfeed or feed by spoon each time before resorting to feeding through the tube. If possible, try not to tube-feed for more than 3-4 days. The tube should be changed every 24 - 48 hours by trained health staff.
It is vital to take time to explain the necessity of tube feeding to the mother so that she accepts the feeding and does not take the child away.
A limitation of the HEM formula is that it does not contain sufficient potassium and other minerals which the malnourished child is depleted of. HEM should be supplemented with a sachet of the <<Mineral Mix>> (in development) (see Annex 15).
Until these mineral sachets are available, only potassium should be added to the HEM (2g KCL per 1000 ml HEM). The addition of potassium should be strictly controlled, because of the possible danger of potassium overloading. If fortification cannot be controlled, bananas should be added to the diet as a source of potassium.
FEEDING OF CHILDREN WITH DIARRHOEA
The idea that <<resting the gut>> is the best treatment for diarrhoea is not true. Milk in small frequent feeds stimulates the re-generation of the gut epithelium.
True lactose intolerance is rare, and only a small minority of children with true lactase deficiency will need to be given a lactose-free formula (K-Mix-II or fermented milk products).
DISCHARGE TO THE NEXT PHASE
Until medical complications (dehydration, systemic infections, risk of hypothermia or hypoglycaemia) are under control, the child will stay in the 24-hour intensive care unit for treatment and observation.
Once the medical complications are under control (which may even be within one day), the child can be transferred from the intensive care unit to day-care.
The indications for moving to the Second Phase of the TFP are recovery of appetite and a change of attitude/expression (i.e. the child loses his lethargy and becomes interested in the environment and may start to smile). (There does not have to be loss of oedema before movement to the Phase II).
Children should never stay in the First Phase for more than 7 days, since the 100 kcal/kg/day ration does not allow weight gain.
Once the child's appetite is recovering and medical complications are brought under control, he can be moved from the first to the second phase of treatment, which is a day-care treatment. Children arrive in the feeding centre early in the morning and return home in the late afternoon.
Children, when entering the second phase, have had acute infections treated and metabolic and electrolyte imbalances brought under control. They are now able to tolerate larger quantities of food and begin nutritional rehabilitation.
Whereas food intake is limited in the first phase (the objective being to restore metabolic functioning and control infections), the objective of treatment in the second phase is to restore normal weight-for-height as quickly as possible. Consequently, medical treatment is continued and larger quantities of food are provided to promote nutritional rehabilitation.
These children, if properly treated, can gain weight very quickly (up to about 20g/kg/day) which is 20 times the normal rate of weight gain at the age of one year. Almost all energy consumed above maintenance level (+ 90 kcal/kg/day) is used for building new body tissue (i.e. weight gain).
To achieve maximum weight gain, the recovery diet should provide a minimum of 200 kcal and 5g protein/kg bodyweight/day (= 10% protein calories). The increase in food intake should be smooth and progressive. Never force children to eat, children should be fed on demand and may consume up to 300 kcal/kg/day. Practically speaking, it may be impossible to calculate individual requirements based on body weight for each child, therefore one often distributes a standard large ration (i.e. 350 ml) for each meal to all children. Older/larger children, or those with a very good appetite, will need more than 350 ml per feed: therefore, always make a round for those who may want a second serving.
An important limitation to the amount eaten, is the capacity of the stomach, which puts an upper limit to the size of the feeds. Stomach volume has been estimated to be 3% of the total body weight. Thus, in a child weighing 6kg, the stomach capacity is approximately 180 ml. Therefore, the smaller the child, and the more malnourished, the smaller and more frequent the feeds should be.
COMPOSITION OF FEEDS
The aim is to devise a mixture, which, if fed in amounts which the children can take, will provide at least 200 kcal and 5g protein/kg bodyweight/day.
High energy milk (HEM) has suitable nutritional properties, providing 100 kcal and 2.9g protein per 100 ml.
HEM feeds can be alternated with porridge feeds, which are based on a blended food (e.g. CSM, WSB). A porridge should provide 100 - 150 kcal and 3 - 4g protein per
100 ml (10-12% protein calories). In order to prepare a semi-liquid porridge with required energy and protein density, DSM and oil should be added, as well as sugar for taste (recipe given in Annex 10). High-energy and -protein biscuits are also sometimes used as an easy (take home) meal.
Good weight gains have also been achieved on diets composed of local foods: local staples (cereal plus pulse) with meat/fish, vegetables and oil. These local meals will then replace the porridge meals. Experience has shown that local meals are very much appreciated by the children. A mixed diet is particularly preferred for older children from the second week on. A limitation to local meals is the energy density, which should provide enough energy to allow rapid growth, but should also be (semi)-liquid. Therefore, oil may be added to local foods to improve the characteristics.
All children should be able to eat a family-type diet when they leave the feeding centre. Transition to a family diet and meal frequency are therefore important aspects of nutritional rehabilitation. As the child improves, the diet should be replaced by local foods and meal frequency should be changed to come into line with family meal times.
A good diet will be composed of alternate HEM and porridge/local meal feeds.
Medical Treatment, Minerals and Vitamins
During the second phase, daily monitoring of the medical state is still necessary. Standard treatments and prophylaxis should continue to be given.
A supply of Iron is necessary to provide for an increase in red cell mass and may be given safely after the second week of treatment (ferrous sulphate 100 mg/day from day 15). Folic acid treatment (5 mg daily or the ferrous/folic complex) should be continued.
Other Vitamin supplements should preferably be supplied through a diet containing fresh vegetables and fruits, but may also be given by multivitamin tablets. If fresh vegetables and fruits cannot be given, supplementation with vitamin C tablets is necessary (125 mg per day).
In addition, if vitamin deficiencies are routinely found in new entrants, a real control strategy should be formulated: active surveillance, treatment of cases, prevention through supplementation with tablets or food fortification and advocacy.
It is recommended to include psycho-social stimulation sessions in conjunction with the medical and nutritional therapy. Psychosocial stimulation improves the prognosis for recovery. While it may be difficult in emergencies, group play and singing/music/story sessions should be introduced and carers should be encouraged to play with and stimulate children.
Infant feeding in a TFP
It should be clear that breast feeding should be promoted and continued during the whole treatment course. If it is possible, breastfeeding should even be continued over the first critical phase when the child is ill and being fed by nave-gastric tube. Breast feeding has a proven protective role against dehydration during diarrhoea and facilitates rapid recovery of digestive and absorption capacities of the gut. Even in the early phases of treatment, breastmilk is absorbed well.
In infants, breast milk should be the main (and best) source of energy and protein during rehabilitation, only supplemented with HEM if necessary.
Breast milk production of the mother should therefore be stimulated by:
- sufficient feeding and liquid intake by the mother, as well as
- HEM-milk formula feeds should be given ad libitum after each session on the breast.
Do not use artificial infant feeding formulas except for rare cases in which the mother is not able to breast feed (mother seriously ill or dead). Always try to look for a wet nurse. If the infant is given artificial milk, besides breastmilk, he is less motivated to suckle and therefore breastmilk production is decreased.
To inhibit the dangers of artificial feeding (diarrhoea, malnutrition), one has to strictly control the hygienic conditions and preparation (i.e. dilution) of the infant formula milk.
The young infant needs approximately 105 kcal and 2.8g protein/kg bodyweight/day. Energy content of the infant formula milk should be 70 kcal/100 ml milk. Therefore, the infant needs 150 ml/kg/day, divided over 5 - 6 meals given throughout the day.
An example for reconstituted and enriched milk formula for newborns (0 - 5 months) is seven below.
· Be sure that the DSM is vitamin A fortified.
· Reconstituted milk cannot be kept for more than 1 - 2 hours.
· Do not feed by bottle - bottles are forbidden in feeding centres. Feed children using a small spoon or syringe and teach the mother how to use a spoon.