This is the process of caring for a child presenting with oedematous and non-oedematous features of acute malnutrition. This is a common life threatening condition occurring in children less than 5 years and it is characterized by protein, carbohydrate, fat, vitamins and minerals deficiencies. The child presents with very low weight for height/length, visible severe wasting, or bilateral pitting oedema.
Aims
· Correct the nutritional deficiency
· Correct fluid and electrolyte imbalance
· Treat/manage underlying conditions and associated infections
· Prevent complications and recurrence of malnutrition
· Restore health and development
· Counsel parents/caregivers on the importance of nutrition
Types
· Management of Oedematous Severe Acute Malnutrition (Kwashiorkor)
· Management of Non-Oedematous Severe Acute Malnutrition (Marasmus)
Requirements
a. Tray containing:
· F-75 specially formulated milk
· F-100 specially formulated milk
· Dil F-100 specially formulated milk
· Water
· ReSoMal (Rehydration Solution for Malnutrition)
· Cup and Spoon
· Graduated jug/container or measuring cup
b. Storage bowl with lid
c. Napkins/tissue paper
d. NG tube set (if necessary)
e. Age-appropriate weighing scale
f. Tape measure
g. MUAC tape
h. Stadiometer/infantometer
i. Alcohol rub
j. Child health record card/medical record
k. Pen/note pad
l. Percentile/standard deviation charts
m. Disinfectant
n. Examination gloves
o. Cotton swabs
p. Emergency tray
q. Vital signs tray
r. Drip stand
s. Oxygen apparatus
Steps
1. Receive child into a comfortable bed with caregiver support
2. Perform five moments of hand hygiene
3. Establish rapport (refer steps)
4. Explain procedure to child/caregiver (refer steps)
5. Provide privacy
6. Incorporate developmentally appropriate strategies in dealing with the child
7. Assist caregiver to remove the child’s diaper and clothing and other accessories (completely undress if the weather is conducive, is ethically sound and culturally acceptable)
8. Perform ABCD (Anthropometry, Biomedical Investigation, Clinical Signs and Symptoms, Dietary intake/history) nutritional assessment
9. Perform anthropometric measurement (refer to anthropometric measurement)
10. Assist to conduct Biomedical Investigation /diagnostic investigation (FBC, stool R/E for worm infestation, HIV testing and tuberculosis test, urinary tract infections)
11. Assess Clinical Signs and Symptoms /head to toe/systemic assessment
12. Gather information on Dietary intake or take nutritional history
13. Classify type of malnutrition after assessment and intervene accordingly
· Weight -for- height/length (Z Scores < −3)
· MUAC < 115 millimeters
· Bilateral pitting oedema
14. Manage child under the three phases:
15. Initial treatment/stabilization phase (in-patient care)
· Assess for Hypoglycemia, infections, and electrolyte imbalances and manage child accordingly
a. Assess for Airway, Breathing, Circulation, Dehydration and manage accordingly
b. Assess and manage for shock, and monitor closely
c. Manage dehydration with ReSoMal
d. Monitor closely for other danger signs
e. Monitor vital signs every 15-30 mins.
f. Keep child warm with clothing, warmed blanket or on caregiver’s chest (skin-to-skin)
g. Pass NG tube to feed critically ill children to prevent the risk of aspiration
h. Assemble items for preparing F-75 in the stabilization phase of inpatient treatment
i. Monitor strict feeding/intake and output chart
j. Feed child with F-75 80–100 kilocalories per kilogram per day (kcal/kg/d) spread over 8–12 meals per day for three to seven days
k. Feed child less than 6 months with Dil-F 100
l. Explain to the caregiver that F-75 is not designed for weight gain
m. Give frequent feeds to prevent both hypoglycemia and hypothermia but with caution because of the fragility of the child’s physiological state
n. Give F-75 every 30 minutes for two hours, followed by F-75 every two hours, day and night. Support mother to continue breastfeeding
o. Perform appetite test using Ready-to-use therapeutic foods (RUTFs) in the transition phase
p. Prepare for rehabilitation phase if child passes appetite test and is clinically stable
q. Provide sensorial stimulation to promote emotional and cognitive development
r. Feed with F-100/RUTF (Plumpy nut/BP – 100)
s. Give child feed consisting of 100–200 kcal/kg/d and 4–6 g protein/kg/d at least every 3-4 hours daily over for three to four weeks
t. Support mother to continue breastfeeding if child is still breastfeeding
u. Maintain close observation
v. Administer broad spectrum antibiotics to treat underlining infections
w. Administer vitamin A (200,000 international units [IU] for children older than age 12 months, 100,000 IU for children ages 6–12 months, and 50,000 IU for children ages 0–5 months) to treat micronutrient deficiencies.
x. Administer daily multivitamins and folic acid as prescribed
y. Assess child and discharge if: a. MUAC is ≥ 125 millimeters for at least two weeks OR b. Z is ≥ −2 for at least two weeks
16. Rehabilitation Phase
· Follow up phase
a. Teach caregiver how to feed child frequently with energy- and nutrient-dense foods and educating on 4-star diet
b. Educate caregiver on the need to continue provide sensorial stimulation to promote emotional and cognitive development
c. Educate caregiver on the need to bring child for regular follow-up visits
d. Follow up child routinely to avoid relapse
e. Provide Vitamin A supplementation and immunizations
f. Prepare child and caregiver for discharge by contacting public/community health nurse
g. Express appreciation to child/caregiver for their cooperation
h. Encourage follow up/refer if necessary/conduct home visits as appropriate
i. Document procedure in nurse’s note
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