CENTRE NUTITIONNEL THERAPEUTIQUE INTERNE (CNTI) POUR LES MALNUTRIS

SEVERE AVEC COMPLICATION MEDICALE

Les principes de prise en charge (PEC) de la malnutrition Aigue Severe (MAS) ;

quel que soit le type de programme ; comprend trois phases :

La phase Aigue ou Phase 1

Les patients anorexiques avec ou sans complications medicales majeure

ANGLAIS

The taking over of a case of severe and acute malnutrition no matter the case
has three stages:

Stage 1 or Chronic phase

Anorexic patients with or without serious medical complication are hospitalized

throughout this chronic stage treatment. The therapeutic product used
throughout this stage is F75 which helps restore metabolic functions and foster
electrolytic nutritional balance. Any weight gain during this stage is detriment
explaining why F75 is administer to the patient to avoid any weight gain.

Transitional Phase

This phase aims at preventing the patient to hastily eat large gulp of food
before his or her physiological functions be restored however; this can be
disastrous and lead to electrolytic imbalance and renutrition syndroms. The
patient starts putting on weight during this phase after having taken F100 or
ATPE. This gives a 30% energy and weight gain moves up to 6kg/day. Energy
intake and expected weight gain are lesser than that of the rehabilitation phase

Rehabilitation Phase ( )

As soon as the patients regain their appetite and show no signs of major medical
complications, ATPE is administered and they are transferred to CNAS. This
product help them put on weight faster (from 8kg/day and above). The weight
structured table could be used irrespective of the patients age.

Admission formalities

Table 30: Anthropometric criteria for Severe and acute Malnutrition (SAM) and
admission in

RECENT ENTRIES
SAM syntoms From PEC to CNT
Children below P/T < -3 z- These children were
6months never taken care of in
and/or CNAS but were
weighing less consistently checked
than 3kg in CNT
Children from 6 Signs of medical
to 59 months complications and /or
loss of appetite and/or
bilateral oedem
Definition and other admissions
rechute Readmission of a patient formerly treated and well
taken care of but who comes back suffering from
severe malnutrition
readmission Revisiting the two months lapse after abandoning
treatment from CNTI
Transfer of.. Patient discharged from CNAS who still show signs of
medical complications or still lack appetite

Admission procedures

If diagnostics are carried out, give vital first aid and enter it into the follow up
form.

Take the weight, height, blood pressure (BP), calculate the indice P/T, verify
the presence of oedem, carry out an appetite test and check criteria for
admission.
Give water to drink to patient from time to time during every visit upon
arrival, a glass of water 10% sweetened (10g of sugar in 100ml of water)
or a F75 to 5ml/kg/ per hour
Carry out medical test to diagnose the nature of the complications, fill in
the presence fiche antecedents form and test.
Enter all admitted into the register
Fill in the follow up form of the patient

Acute stage or phase 1

Serious forms of complications are given priority as far as routine

treatment is concerned and this can alter the consistent treatment is
administered. This explains why nutritional and medical treatments must be read
alongside that of its complications.

Nutritional treatment

F75 Milk this milk should be used within the first days of treating severe
malnutrition. It purpose is not to fatten the child but rather to balance and to
sustain the patients functional organisms. It helps recover lost biochemical,
physiological and immunological organism before the stressful rebuilding of new
tissues.

NB: therapeutic Milk F75 (and (100) are medicinal. They are only prescribed to
patients suffering from severe and acute malnutrition.
Therapeutic milk prepared must only be used within the context of the hospital or
CTN. The dilution must be clinically done in hospitals or CTN.

These milks should not be kept for more than two hours under ambient
temperature for risk of being contaminated and consequently unfit for
consumption.

During the acute stage, 8 meals are recommended within 24 hours (both night
and day) for:

Patients very seriously sick

Patients who develop re-nutrition diarrhea from 5 to 6 meals per day
Patients who have taken very little amount of milk ( e.g. new comers)
Patients who have thrown up once or many times a day
Patients who have once been diagnosed with an increase in the level of
sugar
Patients who have had hypothermia

Milk Preparation

The quantity of F75 milk that a SAM child must take is 130ml/kg/daily.
Calculate the amount of F75 milk to be prepared according to the number of
patients, their weight and the number of meals per day (refer to table X).

Prepare the quantity of portable water under good temperature (boiled and later
warmth) and the F75 milk needed for the meal.

Add a larger sachet of red F75 (410g) to a 2 litre of water or a smaller sachet of
F75 (102,5g) to 500ml of water in a bucket or recipient de couleur rouge.

For a limited number of patients, it is advisable to prepare small amount of milk

from dossete rouges Nutriset

NB: for children still receiving Brest milk, they should be Brest fed 30 minutes
before meal and also make sure their mothers receive a balanced diet.

Table 31: Quantity of F75 milk to be given under the various classes of
weight
SNG is used when the patient is does not sufficiently take F75 orally. This is
defined by a contribution of less than 75% prescribed diet (less than 2/3 of the
recommended ratio)

The indications for prescribing how SNG should be taken are as follows:

Food intake of less than 75% of the volume required in 24hrs in phase 1
Pneumonia with increased respiratory rate
Painful lesions in the mouth
Harelip or other physical deformity
Troubled conscience

The use of SNG is done exclusively in phase 1 and must not exceed 3 days
without being replaced by another, observing a pause for a day to see if the child
can be fed orally.

The use of SNG most often causes reluctance and concern from mothers.

The nurse must not yield to the refusal of carers but must persuade them of the
merits of its use. Community awareness of the benefit of the NSE for the
treatment of severe acute malnutrition is needed to increase the acceptability of
carers for its use.

Routine medical treatment

Systematic Anti-bio therapeutic

Antibiotics should be consistently given to the patient suffering from MAS, even if
the patient does not present clinical signs of sepsis. This is not a prophylactic
treatment. Although clinical signs of infection are absent, they should always be
treated in when passing.

Treatment 1st intention for patients with no apparent signs of infection:

Oral amoxicillin (if there are no high resistance in the region)

or

When there is amoxicillin resistance:

Cefotaxime in a daily injection of Intra Muscular (IM) for two days (50mg /
kg)
Or a combination of amoxicillin-acid clavullanique
And / or treating bacterial overgrowth of the small intestine with
metronidazole (10mg / kg / day)

Treatment 2ndia apparent intention for signs of systemic infection

Add gentamicin IM (continue the amoxicillin or replace with parental ampicillin)

throughout the chronic stage.

OR
Replace for Cefotaxime (50mg/kg) IM injection and oral ciprofloxacine
(30mg/kg/per day for three days. Continue as long as the patients still show signs
of infection

If a staphylococcus infection is suspected add cloxacillin 59 (100-200mg/kg/ and

to be taken times a day.

Another common treatment medically recommended

Nystatine : 100.000 UI oral intake four times a day and for candid doses cases

Another common treatment: medically recommended

Nystatin 100,000 IU in case of oral use 4 times a day, oral candidiasis and
routinely in cases of high prevalence of candidiasis ( > 20s%) or HIV

Fluconazole (3mg / kg / once daily 1): all children with signs of severe sepsis or
systematic candidiasis should be treated with fluconazole doses as indicated by
physician although there could be a light liver risks.

NOTE: Co-trimoxazole has an inactive bacterial growth in the small intestine: it is

not recommended for patients suffering from SAM. If it is given to patients with
HIV / AIDS as a prophylactic treatment for pneumocystis pneumonia, it should be
given alongside other antibiotics in addition to the doses of co-trimoxazole as it is
a prophylactic treatment (not curative)

Duration of antibiotic therapy:

Starts giving from the beginning of the treatment: that is (Acute Phase) till
patient is transferred to the CNAS; each day throughout the acute phase plus
an additional 4 days.

Administering antibiotics:

Whenever possible, administer antibiotics orally or NSE. In case of complications

due to severe infections such as septic shock, antibiotic parenterally should be
used. Infusions containing antibiotics should not be used because it can cause
heart failure. Catheters must be rarely used- and only in severely ill patients and
not regularly. It is imperative to keep the sterile catheter.

NB: during the drug prescription for patients with MAS, we must be very careful;
in fact, the majority of drug dose recommended for a normal patient to be toxic
or ineffective in these patients. The drug affecting the central nervous system
such as antiemetics, liver, pancreas, kidney, heart or intestinal function and
those which cause anorexia should not be used or only in very specific
circumstances.

Is advised
 Begin treatment of SAM on at least more than a week for diseases that are
not rapidly lethal (eg, HIV AIDS, until the nutritional therapy restores the
metabolism of the patient) before the dose standards are administered.
Avoid giving many drugs, until we were on their safety for the treatment of
SAM, and their dosage should be adjusted for malnutrition states. Drugs
such as paracetamol is ineffective for most patients with SAM and can
cause serious liver damage.
Leave reduced doses of drugs if they have not been tested in patients with
MAS.
Give normal doses to patients in rehabilitation phase or CNAS or have
lesser degrees of malnutrition.

Monitoring

During this support phase, patient monitoring should include the following:

Make each weighing every day at the same hour, transcribe the weight on
the sheet and chart the growth curve
Assess the degree edema every day (0 to )
Take the body temperature twice daily.
Write down every detail of every day clinical signs standards (numbers
stool, vomiting, hydration status, cough respiratory rate
Measure the arm circumference (PB) once a week.
Measure the size once at admission.
Note consistently on the plug any absence of the patient during a meal.
Each note has taken the quantity of meals eaten by the patient, refusals
and use of SNG.

Passing criteria in Phase 1 was the transition phase

There is no time limit for phase Aige- each patient differs. In general,
most affected remains longer than average and the least reached more
quickly respond to treatment.
Patients passage criteria of acute phase of the transition phase are:
The return of appetite
The onset of melting edema (generally evaluate according to a
proportional loss of weight loss edema)
The patient has recovered clinically