PROTEIN CALORIE PROTEIN CALORIE MALNUTRITIONMALNUTRITION

PresentationPresentation byby

Professor Jalal AkberProfessor Jalal Akber

What is nutrition?What is nutrition?

The world health organisation (WHO) The world health organisation (WHO) defines nutrition as “A process where defines nutrition as “A process where living organisms utilise food nutrients for living organisms utilise food nutrients for the maintenance of life, maturation, and the maintenance of life, maturation, and normal functioning of organs and tissues normal functioning of organs and tissues and the production of energy.”and the production of energy.”

MALNUTRITIONMALNUTRITION

Is defined as a pathological Is defined as a pathological state resulting from state resulting from relative or absolute relative or absolute deficiency of one or more deficiency of one or more essential nutrients.essential nutrients.

Primary:Primary: When there is When there is deficiency of food availability. deficiency of food availability.

Secondary:Secondary: When food is When food is available but body can’t available but body can’t assimilate it for one or another assimilate it for one or another reason. reason.

ETIOLOGYETIOLOGY

Primary Malnutrition:Primary Malnutrition:1.1. Failure of lactation.Failure of lactation.2.2. Ignorance of weaning.Ignorance of weaning.3.3. Poverty.Poverty.4.4. Cultural patterns and food fads.Cultural patterns and food fads.5.5. Lack of immunization and primary Lack of immunization and primary

care.care.6.6. Lack ofLack of family planning.family planning.

Secondary MalnutritionSecondary Malnutrition

1.1. Infections.Infections.

2.2.Congenital disease.Congenital disease.

3.3.Malabsorption.Malabsorption.

4.4.Metabolic disorder.Metabolic disorder.

5.5.Psychosocial deprivation.Psychosocial deprivation.

CLASSIFICATIONSCLASSIFICATIONS

KWASHIORKORKWASHIORKORKwashiorkorKwashiorkor is is

characterized by characterized by oedema, apathy and oedema, apathy and low body weight. In low body weight. In addition, there may addition, there may be dermatosis, hair be dermatosis, hair changes, changes, hepatomegaly, hepatomegaly, diarrhoea and mental diarrhoea and mental changes.changes.

MARASMUSMARASMUSMarasmus Marasmus is is

characterizedcharacterized

by very low body by very low body weight, loss of weight, loss of subcutaneous fat, subcutaneous fat, muscle wasting muscle wasting and absence of and absence of oedema. oedema.

MARASMIC MARASMIC KWASHIORKORKWASHIORKOR

Combined forms with clinical signs Combined forms with clinical signs of both marasmus and of both marasmus and kwashiorkor are included here. kwashiorkor are included here. They show gross wasting as well They show gross wasting as well as oedema.as oedema.

WELLCOME CLASSIFICATIONWELLCOME CLASSIFICATION

Malnutrition Body weight OedemaMalnutrition Body weight Oedema (% of standard)(% of standard) Underweight 60- 80 _ Underweight 60- 80 _

Marasmus <60 _Marasmus <60 _

Kwashiorkor 60 – 80 +Kwashiorkor 60 – 80 +

Marasmic Kwashiorkor Marasmic Kwashiorkor <60 +<60 +

GOMEZ CLASSIFICATIONGOMEZ CLASSIFICATION

Malnutrition Body weightMalnutrition Body weight

of standard) of standard)

First degree 75 - 90 First degree 75 - 90

Second degree 60 - 75 Second degree 60 - 75

Third degree <60 Third degree <60

MODIFIED GOMEZ CLASSFICATIONMODIFIED GOMEZ CLASSFICATIONGrade 1 (Mild) 70 – 80%Grade 1 (Mild) 70 – 80%

Grade 11 (moderate) 60 – 70%Grade 11 (moderate) 60 – 70%

Grade 111 (severe) <60%Grade 111 (severe) <60%

WATERLOW CLASSIFICATIONWATERLOW CLASSIFICATIONHeight Weight for age expressed as %Height Weight for age expressed as %

for age <80 80 – 120 >120for age <80 80 – 120 >120

<90 <90 Chronic Stunted but Stunted &Chronic Stunted but Stunted &

Malnutrition no MalnutritionMalnutrition no Malnutrition ObeseObese

>90 >90 Acute Normal Obese Acute Normal Obese

MalnutritionMalnutrition

GENERAL GENERAL CLASSIFICATIONCLASSIFICATION MID ARM CIRCUMFERANCEMID ARM CIRCUMFERANCE

Mid arm circumferance Degree ofMid arm circumferance Degree of MalnutritionMalnutrition 16.5 – 14 cm No malnutrition16.5 – 14 cm No malnutrition 14 – 12 cm 114 – 12 cm 1stst & 2 & 2ndnd degree degree malnutritionmalnutrition

<12 cm 3<12 cm 3rdrd degree degree malnutrition malnutrition

Skin foldSkin foldSkin fold thickness is assessed by the Skin fold thickness is assessed by the

Herpenden Caliper in the region of Herpenden Caliper in the region of triceps or back of shoulders;triceps or back of shoulders;

Normal: 9 -11 mm.Normal: 9 -11 mm.

Evaluation of the malnourished child:Evaluation of the malnourished child:HistoryHistory

• Breast feeding history.Breast feeding history.• Usual diet before current episode of illness.Usual diet before current episode of illness.• Foods & fluids taken in past few days.Foods & fluids taken in past few days.• Duration & frequency of vomiting or diarrhea.Duration & frequency of vomiting or diarrhea.• Appearance of vomit or diarrheal stools.Appearance of vomit or diarrheal stools.• Time when urine was last passed.Time when urine was last passed.• Contact with people with measles or tuberculosis.Contact with people with measles or tuberculosis.• Deaths of siblings.Deaths of siblings.• Birth weight.Birth weight.• Milestones.Milestones.• Immunization.Immunization.

EXAMINATION EXAMINATION WITHWITH

NUTRITIONAL ASSESSMENTNUTRITIONAL ASSESSMENT

SKINSKIN Anemia Dry skinAnemia Dry skin

Vitamin K deficiencyVitamin K deficiency

Zinc DeficiencyZinc Deficiency

PELLAGRA (NIACIN)PELLAGRA (NIACIN)

SEBORRHOEIC DERMATITIS SEBORRHOEIC DERMATITIS

WET BERI-BERIWET BERI-BERI(VITAMIN B1)(VITAMIN B1)

UPPER LIMPSUPPER LIMPSPulse Blood pressure clubbing Pulse Blood pressure clubbing

NailsNails

Palms Wrist ForearmPalms Wrist Forearm

HEAD AND NECKHEAD AND NECKFrontal & parietal prominence Frontal & parietal prominence

Hair:Hair:• Alopecia.Alopecia.• Dyspigmented.Dyspigmented.• Thinning.Thinning.• Pluckable.Pluckable.• DryDry

EYESEYES

Sunken (dehydration)Sunken (dehydration)

Ptosis (Vitamin B1)Ptosis (Vitamin B1)

ConjunctivaConjunctiva• Pallor (anaemia).Pallor (anaemia).• Xerosis (Vitamin A).Xerosis (Vitamin A).• Conjunctivitis (Vitamin B2, C).Conjunctivitis (Vitamin B2, C).

• Bitot spots (Vitamin A).Bitot spots (Vitamin A).

Scleral icterus (CLD).Scleral icterus (CLD).

Cornea:Cornea:

• Xerosis (Vitamin A).Xerosis (Vitamin A).

• Cloudy (Vitamin A).Cloudy (Vitamin A).

• Keratomalacia (Vitamin A).Keratomalacia (Vitamin A).

• Opacification (Vitamin A, Zinc).Opacification (Vitamin A, Zinc).

• Vascularisation (Vitamin B2).Vascularisation (Vitamin B2).

Retina:Retina:

• Optic neuritis (Vitamin B12).Optic neuritis (Vitamin B12).

• Optic atrophy (Vitamin B1).Optic atrophy (Vitamin B1).

Eye movements: Ophthamoplegia (Vitamin E).Eye movements: Ophthamoplegia (Vitamin E).

Photophobia (Vitamin A, Vit:B2, Zinc).Photophobia (Vitamin A, Vit:B2, Zinc).

Facial nerve: Facial nerve: Percuss for Chvostek’s sign Percuss for Chvostek’s sign (calcium).(calcium).

MOUTHMOUTH

Angular cheilosis and stomatitis.Angular cheilosis and stomatitis.

(iron, vitamin B2, niacin).(iron, vitamin B2, niacin).

TEETHTEETH

• Caries (fluoride).Caries (fluoride).• Loose (vitamin C).Loose (vitamin C).• Enamel defects (vitamin D).Enamel defects (vitamin D).

TONGUETONGUE• Glossitis, reddening and ulceration (vitamin B group).Glossitis, reddening and ulceration (vitamin B group).• Moisture (hydration).Moisture (hydration).• Cyanosis (CHD).Cyanosis (CHD).

BUCCAL MUCOSABUCCAL MUCOSA

• Reddened & ulcerated (vitamin B Reddened & ulcerated (vitamin B group).group).

• Petechiae (vitamin C).Petechiae (vitamin C).

GUMSGUMS

• Swollen,bleeding (vitamin C).Swollen,bleeding (vitamin C).

NECKNECK• Goitre (iodine).Goitre (iodine).

GAIT AND BACKGAIT AND BACKFull gait examination, looking for:Full gait examination, looking for:

• Cerebellar ataxia (vitamin E, zinc).Cerebellar ataxia (vitamin E, zinc).

• Peripheral neuropathy (vitamins B1, B6, Peripheral neuropathy (vitamins B1, B6, B12).B12).

• Romberg’s sign (vitamin E, B12).Romberg’s sign (vitamin E, B12).

• Examine back for scoliosis, kyphosis and Examine back for scoliosis, kyphosis and lordosis (vitamin D).lordosis (vitamin D).

LOWER LIMPSLOWER LIMPS

Palpate:Palpate:

• Muscle bulk (PCM).Muscle bulk (PCM).

• Ankle oedema (PCM, CLD).Ankle oedema (PCM, CLD).

• Long bone tenderness (vitamin C).Long bone tenderness (vitamin C).

• Calf tenderness (vitamin B1, selenium).Calf tenderness (vitamin B1, selenium).

• Power: decreased (PCM, vitamin C, Power: decreased (PCM, vitamin C, sodium, potassium, phosphate).sodium, potassium, phosphate).

• Tone: decreased (PCM).Tone: decreased (PCM).

Sensation:Sensation:•Peripheral neuropathy (vitamins B1, B6, B12, Peripheral neuropathy (vitamins B1, B6, B12, E).E).•Posterior column dysfunction (vitamins B12, Posterior column dysfunction (vitamins B12, E).E).

Reflexes:Reflexes:

• Decreased (vitamins B1, B6, B12, E).Decreased (vitamins B1, B6, B12, E).

• Increased (vitamin B12).Increased (vitamin B12).

• Slow return (iodine).Slow return (iodine).

INVESTIGATIONSINVESTIGATIONS

INVESTIGATIONSINVESTIGATIONS• CBC, ESRCBC, ESR• RBS.RBS.• Urine D/R and CultureUrine D/R and Culture• Stool D/R and CultureStool D/R and Culture• Chest X-ray.Chest X-ray.• MT.MT.• Serum proteins.Serum proteins.• Electrolytes.Electrolytes.• Urea/CreatininUrea/Creatinin• LFTLFT• MPMP

COMPLICATIONSCOMPLICATIONS

• Hypothermia.Hypothermia.

• Hypoglycemia.Hypoglycemia.

• Electrolyte ImbalanceElectrolyte Imbalance

• Cardiac failure.Cardiac failure.

• Infections.Infections.

• Vitamin A deficiency.Vitamin A deficiency.

• Severe anemia.Severe anemia.

TREATMENTTREATMENT

DEFINITIONPresence of severe wasting ( <70% weight – for –height or – 3SD) and/or edema.

General Principles for ManagementThere are 10 essential steps. 1)Treat hypoglycemia.2)Treat hypothermia3)Treat dehydration4)Correct electrolyte imbalance5)Treat infection6)Correct micronutrient deficiencies7)Start cautious feeding8)Achieve catch-up growth9)Provide sensory stimulation and emotional support10)Prepare for follow-up after recovery

These steps are accomplished in two phases.

1. Stabilization Phase (within 7 days) 2. Rehabilitation Phase (2-6 weeks)

TREAT HYPOGLYCEMIAHypoglycemia is present when blood glucose is <54mg/dl (<3mmol/l )

Treatment:

If child is conscious, give:• 50ml bolus of 10% glucose (1 round tsf of sugar in 3.5 tbsp of water) orally or by N/G tube. Then feed starter F-75 every 30 minutes for 2 hours. (give 1 quarter of the 2 hourly feed each time)• Keep warm• Antibiotics

If child is unconscious or convulsing, give:• IV 10% Glucose (5ml/kg) or, if unavailable, 50ml 10% Glucose by N/G tube.• Starter F-75 every thirty minutes for 2 hours (give 1 quarter of the 2 hourly feed each time)• Keep warm• Antibiotics

Monitoring:

• Repeat RBS 2 hour.• Rectal temperature; if this falls to <30.5 *C, repeat RBS• Level of consciousness

TREAT HYPOTHERMIAIf axillary temperature is <35.0*C, or Rectal <35.5*C

Treatment:• Re-warm the child either, clothe the child (including head), cover with a warm blanket and place a heater or lamp nearby. Or Put child on mother’s bare chest, skin to skin, and cover them.• Give antibiotic• Feed straight away (or start rehydration if needed)

MONITORING:

• Rectal temperature 2 hourly, until it rises to >36.5*C• Feel for warmth• Check for hypoglycemia whenever hypothermia is found.

TREAT DEHYDRATION

Do not use the IV route for rehydration, except in shock, Infusing slowly to avoid flooding the circulation and overloading the heart.

• Standard WHO ORS contains too much Sodium and too little potassium for severely malnourished children. Instead give special Rehydration Solution for Malnutrition (ReSoMal).

• ReSoMal 5ml/kg every 30 minutes for 2 hours, orally for by N/G tube. Then;• 5-10 ml/kg per hour for next 4-10 hours. Replace the ReSoMal doses at 6 hours and 10 hours with an equal amount of F-75. If rehydration is continuing at these times.• Begin feeding with starter F-75

During treatment, rapid respiration and pulse rate should slow and child will begin to pass urine.

TREATMENT

MONITOR PROCESS OF REHYDRATION• Observe half hourly for 2 hours. Then hourly for next 4-10 hours regarding.

1)Pulse rate2)Respiratory rate3)Urine frequency4)Stool/Vomit frequency

Continuing rapid respiratory and pulse rates during rehydration suggest coexisting infection or overhydration

Signs of over hydration are:

• Increased respiratory rate (>5 breaths per minute or more)

• Increased pulse rate (>25 beats per minute or more)

• If these signs occur, stop fluid immediately and re-assess after one hour.

CORRECT ELECTROLYTE IMBALANCE

All severely malnourished children have excess body Sodium and low Potassium and Magnesium. Edema is partially due to these imbalances. (DO NOT treat edema with diuretic) give• Extra potassium 3-4 milimoles per kg per day,• Extra magnesium 0.4-0.6 milimoles per kg per day,• Give ReSoMal • Prepare food without salt.

TREAT INFECTIONAssume all malnourished children have an infection and give routinely on admission:

• Broad spectrum antibiotics AND• Measles vaccine if child is >6 months and not immunized.• In addition, some experts recommend Metronidazole (7.5mg/kg 8 hourly for 7 days) to hasten repair of the intestinal mucosa and reduce the risk of oxidative damage and systemic infection arising from the overgrowth of anaerobic bacteria in gut.

• Choice of broad spectrum anti-biotic a) If the child is with no complications give

• Co-trimoxazole 5ml orally twice daily for 5 days (2.5ml if weight <4kg).

b) If the child is severely ill or has complications give,

• Ampicillin 50mg/kg IM/IV 6 hourly for 2 days, then oral amoxycillin 15mg/kg 8 hourly for 5 days, and gentacin 7.5mg/kg IM/IV once daily for 7 days.

If the child fails to improve clinically within 48 hours, ADD:

• Chloramphenicol 25mg/kg IM/IV 8 hourly for 5 days.

Where specific infection are identified, ADD:• Specific antibiotics if appropriate• Antimalarial treatment if the child has a

positive blood film for malaria parasite.

CORRECT MICRONUTRIENT DEFICIENCIES

All severely malnourished children have vitamin and mineral deficiencies. Anemia is common, do NOT give iron initially but wait until the child has a good appetite and starts gaining weight. As giving iron can make infection worse.

Give:• Vitamin A, orally on day 1 ( >1 year 200000 IU , 6-12 months 100000 IU, 0-5 months 50000 IU)• Give daily for at least 2 weeks:

1) Multivitamin Supplement2) Folic acid 1mg/day3) Zinc 2mg/kg per day4) Copper 0.3mg/kg per day5) Iron 3mg/kg per day but only when gaining weight.

ZINC DEFICIENCYZINC DEFICIENCY

START CAUTIOUS FEEDING

Feeding should be started as soon as possible and should be designed to provide just sufficient energy and protein to maintain basic physiological processes. The essential features of feeding in the stabilization phase are:• Small/frequent feeds of low osmolarity and low lactose. • Oral or N/G feed (never par enteral preparations)• 100kCal/kg per day • 1-1.5gm Proteins/kg per day• 130ml/kg per day of fluid (100ml/kg per day if the child has severe edema)• If the child is breastfed, continue to breastfeed but make sure the prescribed amount of starter formula is given.

WITHOUT EDEMA

F-75:130 ml/kg/day2 hourly

WITH EDEMA

F-75:100 ml/kg/day2 hourly

A recommended schedule in which volume is gradually increased, and feeding frequency gradually decreases is as follows.

Days FrequencyVol/Kg/feed Vol/Kg/Day

1 -- 2 2-hourly 11ml 130ml3 --5 3-hourly 16ml 130ml6 --7 + 4-hourly 22ml 130mlMonitor and note:• Amount offered and leftover• Vomiting• Stool frequency and consistency• Daily weight gain

ACHIEVE CATCH-UP GROWTHWeight gain of >10g gain/kg per day. The recommended milk based F-100 contains 100KCal and 2.9g Proteins/100ml

To change from starter to catch-up formula:

• Replace starter F-75 with small amount of Catch-up formula F-100 for 48 hours then• Increase each successive feed by 10ml until some feed remains uneaten.

After the Transition, give

• Frequent feed (at least 4 hourly) of unlimited amount of catch-up formula • 150-220KCal/kg per day

• 4-6gm Protein/kg per day

• If Child is breastfed, encourage to continue, also give F-100 as indicated

•Monitor progress by assessing the rate of weight gain.

• If weight gain is – Poor (<5gm/kg per day) child requires

full reassessment – Moderate (5-10gm/kg per day) check

if intake targets are being met or if infection has been overlooked.

– Good (>10gm/kg per day) continue to praise staff and mother

TREATMENT OF ASSOCIATED CONDITIONS

1. Vitamin A deficiency

If the child has any eye signs of deficiency, give orally:-

• Vitamin A on days 1, 2 and 14 (if aged >1 year give 200,000iu; if aged 6-12 months give 100,000iu, if aged 0-5 months give 50,000iu). If first dose has been given in referring centre, treat on days 1 and 14 only.

If there is corneal clouding or ulceration, give additional eye care to prevent extrusion ofthe lens:-

• instil chloramphenicol or tetracycline eye drops (1%): 1 drop 4 times daily for 7-10 days in the affected eye.

• instil atropine eye drops (1%), 1 drop three times daily for 3-5 days

• cover with saline-soaked eye pads and bandage

2. DermatosisSigns:-

• hypo- or hyper-pigmentation• desquamation• ulceration (spreading over limbs, thighs, genitalia, groin, and behind the ears)• exudative lesions (resembling severe burns) often with secondary infection, including CandidaZinc deficiency is usual in affected children and the skin quickly improves with zinc supplementation

IN ADDITION:-

• Dab affected areas with gauze soaked in 0.01% potassium permanganate solution

• Apply barrier cream (zinc and castor oil ointment, or petroleum jelly or tulle gras) to raw areas

• Omit nappies so that the perineum can dry

3. Parasitic worms

• give Mebendazole 100mg orally, twice daily for 3 days

Mucosal damage and Giardiasis are common causes of continuing diarrhea.

Where possible examine the stools by microscopy.

Give:-• Metronidazole (7.5mg/kg 8-hourly for 7 days) if not already given

Lactose Intolerance.

Only rarely is diarrhea due to lactose intolerance. Treat only if continuing diarrhea is preventing general improvement. Starter F-75 is a low-lactose feed.

In exceptional cases:-• substitute milk feeds with yoghurt or a lactose-free infant formula• reintroduce milk feeds gradually in the rehabilitation phase

If TB is strongly suspected (contacts, poor growth despite good intake, chronic cough, chest infection not responding to antibiotics):-

• Perform Monteux test (NB false negatives are frequent)• Chest x-ray

If positive test or strong suspicion of TB, treat according to national TB guidelines.

TUBERCULOSIS

A fall in hemoglobin concentration during treatment is normal as intracellular sodium moves out into the plasma causing an expansion of the plasma volume. Avoid giving transfusions after the first 24h.A blood transfusion is required on day 1 if:• Hb is less than 4g/dl• or if there is respiratory distress and Hb between 4 and 6g/dlGive:-• whole blood 10ml/kg bodyweight slowly over 3 hours• furosemide 1mg/kg IV at the start of the transfusionIf the severely anemic child has signs of cardiac failure, transfuse packed cells (5-7ml/kg) rather than whole blood.

SEVERE ANEMIA IN MALNOURISHED CHILDREN

Ingredient Amount•Water (boiled & cooled) 1.7 liters•WHO-ORS 1 liter-packet•Sugar 40g•Electrolyte/mineral solution 33ml

ReSoMal contains approximately

• 45mmol/l Na• 40mmol/l K • 3mmol/l Mg.

Recipe for ReSoMal oral rehydration solution (using the new ORS formulation)

Weigh the following ingredients and make up to 2500ml. Add 20ml of electrolyte/mineral solution to 1000ml of milk feed.

Potassium Chloride: 224gm Tripotassium Citrate: 81gm Magnesium Chloride: 76gmZinc Acetate: 8.2gm Copper Sulphate: 1.4gmWater: make up to: 2500ml

Recipe for Electrolyte mineral solution

The H.D.D-I HIGHDENSITY - DIET

• The HDD-I can be given to all malnourished children. The diet is of semi solid consistency which can also be fed through an NG tube.

The HDD-I diet provides approximately 45 calories/ oz or 1.5 calories/ ml.

• (HDD-I has been developed by the Nutrition Support Programme- a Government Assisted programme.).

Weight Calories Protein

Rice flour 40 gm 143 3.00

Dal 30 gm 105 6.75

Milk Powder 20 gm 100 7.50

Sugar 90 gm 432

Oil 90 ml 750

Water 900 ml

1530 17.25

F-75 feed volumes by feeding frequency, and body

weight and for nasogastric feeding

Childs Weight 2-hourly 3-hourly 4-hourly

Switch to NG Feeding if

intakes (ml) fall below:-

Kg (ml/feed) (ml/feed) (ml/feed)  

2.0 20 30 45 2102.2 25 35 50 2302.4 25 40 55 2502.6 30 45 55 2702.8 30 45 60 2903.0 35 50 65 3203.2 35 55 70 3403.4 35 55 75 3603.6 40 60 80 3803.8 40 60 85 4004.0 45 65 90 420

4.2 45 70 90 4404.4 50 70 95 4604.6 50 75 100 4904.8 55 80 105 5105.0 55 80 110 5305.2 55 85 115 5505.4 60 90 120 5705.6 60 90 125 5905.8 65 95 130 6106.0 65 100 130 6406.2 70 100 135 6606.4 70 105 140 6806.6 75 110 145 7006.8 75 110 150 7207.0 75 115 155 7407.2 80 120 160 7607.4 80 120 160 7807.6 85 125 165 8107.8 85 130 170 8308.0 90 130 175 850

8.2 90 135 180 8708.4 90 140 185 8908.6 95 140 190 9108.8 95 145 195 9309.0 100 145 200 9509.2 100 150 200 9809.4 105 155 205 10009.6 105 155 210 10309.8 110 160 215 1040

10.0 110 160 220 1060

F-75 feed volumes for children with severe edema

edematous weight

2-hourly 3-hourly 4-hourly

Kg

(ml/feed)

(ml/feed)

(ml/feed)3.0 25 40 503.2 25 40 553.4 30 45 603.6 30 45 603.8 30 50 654.0 35 50 654.2 35 55 704.4 35 55 754.6 40 60 754.8 40 60 805.0 40 65 85

5.2 45 65 855.4 45 70 905.6 45 70 955.8 50 75 956.0 50 75 1006.2 50 80 1056.4 55 80 1056.6 55 85 1106.8 55 85 1157.0 60 90 1157.2 60 90 1207.4 60 95 1257.6 65 95 1257.8 65 100 1308.0 65 100 1358.2 70 105 1358.4 70 105 140

8.6 70 110 1458.8 75 110 1459.0 75 115 1509.2 75 115 1559.4 80 120 1559.6 80 120 1609.8 80 125 165

10.0 85 125 16510.2 85 130 17010.4 85 130 17510.6 90 135 17510.8 90 135 18011.0 90 140 18511.2 95 140 18511.4 95 145 19011.6 95 145 19511.8 100 150 19512.0 100 150 200

RECOVERYRECOVERY

Recovery takes place in two stages:Recovery takes place in two stages:

• Initial recovery occurs in 2-3 weeks Initial recovery occurs in 2-3 weeks when edema disappears and other when edema disappears and other signs improve.signs improve.

• Consolidation phase: In next 2-3 Consolidation phase: In next 2-3 months child regains normal weight months child regains normal weight & is considered clinically recovered.& is considered clinically recovered.

Criteria for discharge from hospitalCHILD

•Weight gain is adequate.•Eating an adequate amount of

nutritious diet that the mother can prepare at home.

•All vitamin & mineral deficiencies have been treatd.

•All infections have been treated.•Full immunization programme

started.

MOTHERMOTHER

•Able and willing to look after the child.

•Knows how to prepare appropriate food & to feed the child.

•Knows how to make appropriate toys & to play with the child.

•Knows how to give home treatment for diarrhoea, fever & ARI .

HEALTH WORKERHEALTH WORKER

Able to ensure follow up of the child & support for the mother.

FOLLOW UP

After discharge the child & the child family are followed to prevent relapse & assume the continued physical, mental & emotional development of the child.

• Planned follow up of the child at regular intervals after discharge is essential.

• As the risk of relapse is greatest soon after discharge, the child should be seen after 1 week, 2 weeks, 1 month, 3 months & 6 months.

• If a problem is found visits should be more frequent until it is resolved.

• After 6 months, visits should be twice yearly until the child is atleast 3 years.

THANK YOU !