MODULE VIII. Nutrition and Malnutrition in Humanitarian Emergencies

Transcription

1 MODULE VIII Nutrition and Malnutrition in Humanitarian Emergencies

2 The Invisibility of Malnutrition ¾ of children who die Are mild-moderately undernourished Have no outward signs of illness or vulnerability

3 Malnutrition the silent killer Short term consequences: morbidity, mortality, disability 35% of the disease burden in U5 s Poor immune response to common illness Underlying cause of 3.5 million deaths/yr Long term consequences: Limited adult size Limited intellectual capacity Economic productivity Reproductive performance & NCD

4 NUTRITION IN HUMANITARIAN EMERGENCIES Need: Adequate nutritional status Protects from acute food deprivation Improved pregnancy and newborn outcomes Avoid: Malnutrition Impaired host defenses Wound healing Loss of compensatory mechanisms

5 VULNERABLE GROUPS Children < 5 y (esp < 2 yr) Children removed from their family or community Pregnant or lactating women Families supported only by women Physically or emotionally disabled Chronic disease Elders

6 ANTHROPOMETRIC EVALUATION Size, weight, and proportions, compared to normal standards (lengths & heights whenever possible) Systematically collected data in a community to characterize overall nutritional status Data from children < 5 years reflect the nutritional status of the community

7 MOST FREQUENT ANTHROPOMETRIC MEASURES Weight for age Height for age Weight for length/height Body mass index (BMI) (> 2 yr olds) Mid-upper arm circumference (MUAC) reflects wasting (w/o height)

8 BMI Interpretation: Children (> 2 yr) & Adolescents BMI for age & sex PERCENTILE < 5 % Underweight / wasted 5% - 85% Normal range 85% - 95% Overweight > 95% Obese

9 RISKS AND VULNERABILITIES Risks: Death Disease Disability Vulnerabilities: Shortage of food Quality of food Access to food Right food (calories vs nutritional quality)

10 CONSEQUENCES OF MALNUTRITION IN DISASTER SITUATIONS Increase diseases incidence Delayed wound healing Growth retardation: physical/ mental Immunity impairment Miscarriage & still birth Congenital anomalies / intrauterine growth retardation

11 MALNUTRITION / DISORDERS Macronutrient Micronutrient Multiple nutrient deficiencies

12 MICRONUTRIENT DEFICIENCIES (in order of prevalence: I, Fe, Zn, Vit A) Vitamin A Zinc Iron Thiamine (important for re-feeding) Niacin Vitamin C Riboflavin Vitamin D (chronic) Calcium (chronic)

13 DIETARY FACTORS MICRONUTRIENT DEFICIENCiES Niacin (pellagra): maize-based diet; animal foods Thiamin (beri-beri): polished rice-based diet; refeeding Vitamin A: lack of fresh fruits & green/orange leafy vegetables; fat intake Vitamin C (scurvy): lack of fresh fruits/veg Zinc: diarrhea, chronic inflammation; animal foods Iron: poor birth endowment, animal foods; chronic inflammation Riboflavin: lack of dairy/animal food Vitamin D (rickets): poor sunlight exposure/dark skin Calcium: lack of dairy products, green leaf vegetables, bony fish

14 PHYSICAL FINDINGS ASSOCIATED w/ SPECIFIC DEFICIENCIES Hair: protein-energy, Zn, biotin, essential fatty acids Eyes: vitamins A & riboflavin Mouth: B-vitamins + Vit C Tongue: B complex Gums: Vitamin C Teeth: Vitamin C, Fl -, Ca

15 PRIORITIES IN HUMANITARIAN EMERGENCIES Protein energy malnutrition (SAM & MAM) Zinc deficiency Thiamine (refeeding) Vitamin A deficiency Iron deficiency

16 VITAMIN A DEFICIENCY Worldwide epidemics: 190 M preschool children; 19 M pregnant women 2M annual deaths in early childhood; particularly associated with morbidity/mortality from measles Vitamin A supplementation is associated with up to 35% reduction in child mortality, and almost total eradication of blindness, in developing countries

17 VITAMIN A DEFICIENCY CLINICAL FINDINGS Eyes (chronic) Dryness (xerophthalmia) Night blindness Conjunctival xerosis Bitot`s spots Keratomalacia Impaired immune function & epithelial integrity

18 EFFECTS OF VITAMIN A DEFICIENCY Xerophthalmia Bitot s spot Corneal ulceration

19 EFFECTS OF VITAMIN A DEFICIENCY

20 VITAMIN A INTERVENTIONS Give supplements to children 6 mo-5 years Treat all symptomatic individuals Repeat every 3-6 months, if adequate intake is not provided by available food resources Distribute fortified food

21 IRON DEFICIENCY Most common micronutrient deficiency worldwide Mostly children and women of reproductive age Most frequent cause of anemia

22 ANEMIA : RISK FACTORS Diet lacking animal products Pregnancy Prematurity, low birth weight, premature cord clamping Accelerated growth Animal milk use Impaired absorption due to high phytates (plant staples) Menstruation Intestinal parasites & chronic inflammation

23 ANEMIA: CLINICAL IMPACT Impaired development Increased morbidity associated with infections Decreased physical activity, productivity, attention span Increased mortality (severe anemia)

24 CLINICAL FINDINGS: SEVERE ANEMIA Pale skin, mucous membranes, nail beds Resting dyspnea and tachypnea Laboratory: hemoglobin and/or hematocrit

25 IRON DEFICIENCY PROPHYLAXIS Full-term infants: exclusive breast-feeding 6 months Premature infants: early iron supplementation Iron supplementation Breast-fed infants: after 6 months of age Formula-fed infants n/a if standard IF) If at risk, Rx antihelmintics to population over 2 years old Iron supplementation in iron replete individuals, esp in malaria endemic settings, is contraindicated.

26 ZINC DEFICIENCY AND SUPPLEMENT Impaired immune function, growth, differentiation, and replication Recommended daily allowances: Infants: 3 mg Young children: 5 mg Women: 12 mg Diarrhea: 20 mg/d x days +ORS (10 mg/d < 6 mo)

27 MALNUTRITION Protein energy malnutrition (Severe Acute Malnutrition= SAM) Marasmus vs kwashiorkor

28 2 [CLASSICAL] TYPES OF MALNUTRITION

29 TYPES OF MALNUTRITION MARASMUS Most frequent in < 1 y Marked emaciation Irritability Marked loss of subcutaneous fat Weight/length or ht < 70% of median (50 th % wt/len); Wt/L Z-score < - 3 = SAM (MUAC < 11 cm) (N.B.: low wt/age malnutrition) Appetite preserved

30 TYPES OF MALNUTRITION KWASHIORKOR Edema Enlarged liver and spleen Water and electrolyte shifts Loss of appetite Skin and hair (discoloration) changes Metabolic dysregulation (higher mortality)

31 Kwashiorkor PE: Miserable Rash ( flaky paint ) Edema Moon facies

32 INITIAL NEEDS ASSESSMENT Prevalence of malnutrition/sam & micronutrient deficiencies Active nutritional programs in the community Identification of vulnerable groups (infants, WRA) Quantity and quality of readily available food resources

33 ASSESSMENT DURING RECOVERY PHASE Periodic reassessments until adequate nutritional resources are sustainable Quality and security of available nutritional resources Systematic assessment of nutritional status Target vulnerable groups

34 MANAGEMENT OF MICRONUTRIENT DEFICIENCY: RISK REDUCTION Assess prevalence of pre-existing deficiencies Assess usual food resources (potential pre-existing deficiencies) Estimate current risk Identify symptomatic individuals and treat them Periodic re-assessment (particularly high risk populations)

35 RESPONSE Global food fortification (commodities, biofortification ) RUTF (Ready to Use Therapeutic Food e.g. Plumpy Nut) Supplement high risk individuals Diversify diet (longer term) Nutritional education Supervise food rations Improve sanitation status

36 CASE MANAGEMENT : FEEDING PROGRAMS Acute malnutrition is a strong predictor of excess mortality in young children Timely arrival of food assistance contributes to prevention of mortality through impact on reducing malnutrition. General feeding program Supplementary feeding Therapeutic feeding

37 GENERAL FEEDING PROGRAM General distribution of standard ration of food commodities to everyone within crisis affected population, without distinction (+MNP/RUTF) Types Wet rations: congregate feeding for targeted individuals; assoc health care interventions; labor intensive, more costly, risk of infectious dis. Dry rations: lower cost, less labor, larger reach; e.g. fortified blended foods, oil, pulses, staple

38 SUPPLEMENTARY FEEDING PROGRAM Mild/moderate malnutrition Nutritional support targeted to vulnerable groups Provide intake required for recovery and catch-up growth Feedings according to individual requirements (MN) Proteins 3-5g/kg/day

39 THERAPEUTIC FEEDING Identify children with severe malnutrition: MUAC <11.0 cm (wasting/sam) W/H < 70% of median (marasmus) W/H Z Score < -3 (= SAM) Clinical edema (kwashiorkor)

40 THERAPEUTIC FEEDING PHASE 1 Hospitalized patient (recommended) Initial stabilization Fluids: oral (IV only if severe dehydration and/or shock) Progressive increase of calories and volume in 1-2 weeks Oral feeding (alternatively NGT) Frequent feedings Treat micronutrient deficiencies (MN powders/rutf) Treat associated disorders (infection) Iron supplements are contraindicated acutely

41 THERAPEUTIC FEEDING PHASE 2 Continue medical treatment Initiate nutritional rehabilitation: 4-6 feedings/day; kcal Transition to social environment Vary diet, incorporate age-appropriate local foods, provide psychosocial stimulation Progress to supplementary feeding program when W/H is at least at 80% of median x 2 weeks, edema resolved, medical problems treated

42 REFEEDING SYNDROME Most frequent/severe with Kwashiorkor Malnutrition results in functional redistribution of proteins, acidosis, and fluid and electrolyte shifts Rehydration and refeeding causes a rapid return to glucose as primary energy source Aggressive delivery of fluids and food can cause circulatory overload with hemodynamic failure, and hypothermia, hypoglycemia, hypokalemia, and hypophosphatemia, associated with increased morbidity and mortality.

43 REFEEDING SYNDROME THERAPEUTIC PLAN Cautious and progressive; close clinical monitoring Additional phosphorus, potassium, magnesium, thiamine, and glucose Treat infections and associated micronutrient deficiencies

44 NUTRITIONAL STATUS INFANTS 0-2 MONTHS WEIGHT LOSS Newborn: normal 10% of birth weight in the first week of life Greater loss after 7 days = severe nutrition problem hospitalization Feeding problems

45 INFANT AND YOUNG CHILD FEEDING Promote exclusive breast-feeding for infants < 6 months, and continued breast-feeding for children 6-24 mo (WHO) supplemented with adequate complementary foods Provide adequate nutrition to lactating mothers Supplemental feeding with formula or animal milk is not recommended Artificial feeding requires increased use of limited resources (water, fuel); sustainability?

46 FOOD SECURITY vs FOOD BASKET Access to food Right food 1900 Kcal/day Quality of food (fortification) Culture and norms of society Behavioral attention Sustainability of supply (central fortification vs home fortification) Non-food resources: clean water, meds, skilled care

47 IDENTIFY COMMUNITY RESOURCES

48 FOOD MUST BE ACCEPTED BY COMMUNITY

49 THANK YOU!