INTEGRATED APPROACH TO UNDER 5:

MALNUTRITION
DR. NOR AZAM KAMARUZAMAN KK ROMPIN
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UN
MILLENIUM DEVELOPMENT GOAL

To reduce by 2/3 the under 5 mortality

Major causes of death under five, 2002

Other 25% ARI 18%

Deaths assoc. with malnutrition 54%

Diarrhoea 15%

Perinatal 23% HIV/ AIDS 4%

Malaria 10% Measles 5%

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% OF POPULATION UNDERNOURISHED

IMCI
Management of sick children

Nutrition

Immunization

Other disease prevention Promotion of growth and development

Integrated Management of Childhood Illness (IMCI)

MALNUTRITION
ACUTE VS. CHRONIC
Acute malnutrition is a medical emergency. Chronic also called stunting > begins in infancy > develops in the first 2 years
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"We are guilty of many errors and many faults, but our worst crime is abandoning the children, neglecting the foundation of life. Many of the things we need can wait. The child cannot. Right now is the time his bones are being formed, his blood is being made and his senses are being developed. To him we cannot answer "Tomorrow". His name is "Today"."

Gabriela Mistral, 1948

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Causes of malnutrition
1. Protein-energy malnutrition
Severely wasted (marasmus*) Develop oedema (kwashiorkor**) Not grow well (stunted)

2. Lack specific vitamins or minerals

Vitamin A deficiency risk of death from measles,
diarrhoea, blindness

Iron Anaemia
*Greek = consumption
**Ghana = the sickness the baby gets when the new baby comes
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MALNUTRITION
All children should be assessed for nutritional status
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Check for Danger Signs

Then Ask About Main Symptoms

Cough or difficult breathing? Diarrhoea?

Fever?
Ear problem? .

Then Check for Malnutrition and Anaemia

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(1) Look for visible severe wasting

Remove all the childs clothes to check for wasting.

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 A child has visible severe wasting if the child looks all skin and bones.

The outline of ribs is easily seen.

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 Wasting of the muscles of the shoulder and arms.

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 The arms and legs of a severely wasted child look like sticks.

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 The buttocks are wasted and there are skin folds (baggy pants).
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 Face may still looks normal. Abdomen may be large or distended.

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(2) Check for oedema of both feet

With your thumb, press gently for a few seconds.

Swelling is present if there is depression left in the place where you pressed. This should be checked on the other foot also.
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Check for swelling (Oedema) of both feet

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(3) Determine weight for age

Weight for age chosen as a screening indicator for malnutrition.
Weight for height assessments most accurate but not routinely performed. Weight for age Z-score can be viewed as a proxy estimate for weight for height.
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Growth indicators
Z-score Weight for age Height for age BMI for age

<-2
<-3

Low weight
Very low weight

Stunting
Severe stunting

Wasting
Severe wasting
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Taking the Weight

Beam / Spring types Stable Flat Easy

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Taking the Weight

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Taking the Height

Pengukur tinggi

Bodymeter

Infantometer Alat pengukur panjang Seca 31

x Very low weight

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x Not Very low weight (low weight for age)

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x Low weight for age

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Classify nutritional status:

Visible severe wasting or Oedema of both feet Very low weight for age Not very low weight for age and no other sign of malnutrition SEVERE MALNUTRITION VERY LOW WEIGHT NOT VERY LOW WEIGHT
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Management

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Follow-up
After 14 days:
Weigh the child and determine if the child is still VLWA. Reassess feeding.
If the child is no longer VLWA - praise the mother and encourage her to continue.
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Follow-up
Treatment:
If the child is still VLWA counsel the mother about any feeding problem found. Ask the mother to return again in 14 days. Continue to see the child 2 weekly until the child is feeding well and gaining weight regularly or is no longer VLWA.

Exception: If you do not think that feeding will

improve, or if the child has lost weight, refer the child.
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ANAEMIA

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ANAEMIA
Reduced number of red cells or a reduced amount of Hb in each RBC.

Causes:
Iron deficiency Infections Parasites e.g. Hookworm Malaria
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Check for palmar pallor

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Why palmar pallor?

Simple Less traumatic to the child Less transmissions of eye pathogens Conjunctiva hyperaemia can obscure anaemia
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 Shown in studies to have good performance as a SINGLE SIGN to detect anaemia clinically.

Sensitivity of severe palmar pallor similar to or better than conjunctival pallor.

Specificity about the same for both; OK to be less specific because overtreatment usually not harmful.
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Severe palmar pallor

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No palmar pallor
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Some palmar pallor

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Severe palmar pallor

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Classification:

Severe palmar pallor Some palmar pallor No palmar pallor

SEVERE ANAEMIA ANAEMIA NO ANAEMIA

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Management

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Give Iron
Give one dose daily for 14 days.

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Follow-up
After 14 days: Give iron. Advise mother to return in 14 days for more iron. Continue giving iron every 14 days for 2 months. If the child has palmar pallor after 2 months, refer for assessment.
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Give Albendazole
ROUTINE WORM TREATMENT

Give every child Albendazole every 6 months from the age of one year. Record the dose on childs card.

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 Give Albendazole 400mg as a single dose in clinic if the child: > 1 years of age, and has not had a dose in the previous 6 months.
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FEEDING ASSESSMENT

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Management

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For all children < 2 years:

Feeding assessment and nutrition counselling as preventive measures.

Low weight for age in these children often indicates current under-nutrition.
Case management CAN reverse stunting.
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For children > 2 years:

Low WFA generally reflects stunting due to past under-nutrition.

Feeding assessment and nutrition counselling only if very low WFA.

Stunting is not reversible.
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Feeding assessment
ASK: How are you feeding your child? If the infant is receiving any breast milk, ASK: How many times during the day? Do you also breastfeed during the night?
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Does the infant take any other food or fluids? What food or fluids? How many times per day? What do you use to feed the child? If very low weight for age, ASK: How large are servings? Does the child receive his own serving? Who feeds the child and how? During this illness, has the childs feeding changed? If yes, how?
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FEEDING RECOMMENDATION

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Up to 6 months of age

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6 months up to 12 months

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12 months up to 2 years

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2 years and older

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QUESTION?

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