Management of Malnutrition in Children under five year
Management of Severe Acute Malnutrition in Children under five years
The Appetite Test
Why do the appetite test?
- Malnutrition changes the way infections and other diseases express themselves – children severely affected by the classical IMCI diseases, who are malnourished, frequently show no signs of these diseases. However, the major complications lead to a loss of appetite. Most importantly, the signs of severe malnutrition itself are often interpreted as dehydration in a child that is not actually dehydrated. The diagnosis and treatment of dehydration are different in these patients. Giving conventional treatment for dehydration to the severely malnourished is very dangerous.
- Even though the definition and identification of the severely malnourished is by anthropometric measurements, there is not a perfect correlation between anthropometric and metabolic malnutrition. It is mainly metabolic malnutrition that causes death. Often the only sign of severe metabolic malnutrition is a reduction in appetite. By far the most important criterion to decide if a patient should be sent to in- or out- patient management is the Appetite Test. A poor appetite means that the child has a significant infection or a major metabolic abnormality such as liver dysfunction, electrolyte imbalance, cell membrane damage or damaged biochemical pathways. These are the patients at immediate risk of death. Furthermore, a child with a poor appetite will not take the diet at home and will continue to deteriorate or die. As the patient does not eat the special therapeutic food (RUTF) the family will take the surplus and get used to share it.
- A short training video on the RUTF appetite test (following the WHO guidelines) is also available here.
How to do the appetite test?
- The appetite test should be conducted in a separate quiet area.
- Explain to the mother/caregiver the purpose of the appetite test and how it will be carried out.
- The mother/caregiver, where possible, should wash her/his hands.
- The mother/caregiver should sit comfortably with the child on her/his lap and either offer the RUTF from the packet or put a small amount on her/his finger and give it to the child.
- The mother/caregiver should offer the child the RUTF gently, encouraging the child all the time. If the child refuses then the mother/caregiver should continue to quietly encourage the child and take time over the test. The test usually takes a short time but may take up to one hour. The child must not be forced to take the RUTF.
- The child needs to be offered plenty of water to drink from a cup as he/she is taking the RUTF.
The result of the appetite test
- A child that takes at least the amount shown in the table below passes the appetite test.
- A child that does not take at least the amount of RUTF shown in the table below should be referred for in-patient care.
- Even if the caregiver/health worker thinks the child is not taking the RUTF because s/he doesn't like the taste or is frightened, the child still needs to be referred to in-patient care for least a short time. If it is later found that the child actually takes sufficient RUTF to pass the test then they can be immediately transferred to the out-patient treatment.
The following table gives the MINIMUM amount of RUTF that should be taken.
- The appetite test should always be performed carefully. Patients who fail their appetite tests should always be offered treatment as in-patients. If there is any doubt then the patient should be referred for in-patient treatment until the appetite returns (this is also the main criterion for an in-patient to continue treatment as an out-patient).
- The patient has to take at least the amount that will maintain body weight. A patient should not be sent home if they are likely to continue to deteriorate because they will not take sufficient therapeutic food. Ideally they should take at least the amount that children are given during the transition phase of in-patient treatment before they progress to Phase 2 (good appetite during the test).
- Sometimes a child will not eat the RUTF because he is frightened, distressed or fearful of the environment or staff. This is particularly likely if there is a crowd, a lot of noise, other distressed children or intimidating health professionals (white coats, awe-inspiring tone). The appetite test should be conducted a separate quiet area. If a quiet area is not possible then the appetite can be tested outside.
- The appetite test must be carried out at each visit for out-patients. Failure of an appetite test at any time is an indication for full evaluation and probably transfer for in-patient assessment and treatment.
- During the second and subsequent visits the intake should be very good if the patient is to recover reasonably quickly.
- If the If the appetite is good during the appetite test and the rate of weight gain at home is poor then a home visit should be arranged. It may then be necessary to bring a child into in-patient care to do a simple "trial of feeding" to differentiate i) a metabolic problem with the patient from ii) a difficulty with the home environment; such a trail-of-feeding, in a structured environment (e.g. TFU), is also frequently the first step in investigating failure to respond to treatment.
14 September, 2019