Management of Malnutrition in Children Under Five Years
Management of Severe Acute Malnutrition in Children Under Five Years
Failure to Respond
It is usually only when children fulfil the criteria for "failure to respond" that they need to have an extensive history and examination or laboratory investigations conducted. Most patients are managed by less highly trained staff (adequately supervised) on a routine basis. Skilled staff (nurses and doctors) time and resources should be mainly directed to those few children who fail to respond to the standard treatment.
Failure to respond to standard treatment is a "diagnosis" in its own right. It should be recorded on the chart as such and the child then seen by more senior and experienced staff. For out-patients this diagnosis usually warrants referral to a centre for full assessment; if inadequate social circumstances are suspected as the main cause in out-patient management a home visit can be performed before transfer to the in-patient treatment facility.
When a child fails to respond then the common causes must be investigated and treated appropriately according to the manual.
Every child with unexplained primary failure to respond should have a detailed history and examination performed. In particular, they should be checked carefully for infection as follows:
- Examine the child carefully. Measure the temperature, pulse rate and respiration rate.
- Where appropriate, examine urine for pus cells and culture blood. Examine and culture sputum or tracheal aspirate for TB; examine the fundi for retinal tuberculosis; do a chest x-ray. Examine stool for blood, look for trophozoites or cysts of Giardia; culture stool for bacterial pathogens. Test for HIV, hepatitis and malaria. Examine and culture CSF.
Secondary failure to respond (deterioration/regression after having progressed satisfactorily to Phase 2 with a good appetite and weight gain in Transition Phase for in-patients and deterioration after an initial response in out-patients), is usually due to:
- Inhalation of diet into the lungs. There is poor neuro-muscular coordination between the muscles of the throat and the oesophagus in malnutrition. It is quite common for children to inhale food into their lungs during recovery if they are: 1) force fed, particularly with a spoon or pinching of the nose; 2) laid down on their back to eat, and 3) given liquid diets. Inhalation of part of the diet is a common cause of pneumonia in all malnourished patients. Patients should be closely observed whist they are being fed by the caretaker to ensure that the correct technique is being used. One of the advantages of RUTF is that it is much less likely to be force fed and inhaled.
- An acute infection that has been contracted in the centre from another patient (called a "nosocomial" infection) or at home from a visitor/ sibling/ household member.
- Sometimes as the immune and inflammatory system recovers there appears to be "reactivation" of infection during recovery; acute onset of malaria and tuberculosis (for example sudden enlargement of a cervical abscess or development of a sinus) may arise several days or weeks after starting a therapeutic diet.
- A limiting nutrient in the body that has been "consumed" by the rapid growth and is not being supplied in adequate amounts by the diet. This is very uncommon with modern diets (F100 and RUTF) but may well occur with home-made diets or with the introduction of "other foods". Frequently, introduction of "family plate", UNIMIX or CSB slows the rate of recovery of a malnourished child. The same can occur at home when the child is given the family food (the same food that the child was taking when malnutrition developed) or traditional "weaning" foods.
- With out-patients, traditional medicines, other treatments and a change in home circumstances can significantly affect the recovery of the malnourished child.
Action required when failure to respond is commonly seen in a programme.
- The common causes listed in the box should be systematically examined to determine and rectify the problems.
- If this is not immediately successful then an external evaluation by someone with experience of running a programme for the treatment of severe malnutrition should be involved in the organisation and application of the protocol.
- Review staff performance with refresher training if necessary.
For out-patient treatment:
- Follow-up through home visits by outreach workers/volunteers to check whether a child should be referred back to the in-patient facility between visits.
- Discuss with mother/caregiver on aspects of the home environment that may be affecting the child's progress.
- At health facility carry out medical check and Appetite test
- A follow-up home visit is essential when:
- Mother/caregiver has refused admission to in-patient care despite advice
- Patient fails to attend appointments at the out-patient programme
Source: Protocol for the management of Severe Acute Malnutrition, Ethiopia Federal Ministry of Health, February 2007 (based on the Guideline for the management of the severely malnourished, Michael Golden and Yvonne Grellety, September 2006)
14 September, 2019