Module 8. Small group discussion: Nutrition and Malnutrition. Module objectives

Transcription

1 Module 8. Small group discussion: Nutrition and Malnutrition Module objectives Section I- Assessment of global nutritional status and population needs Recognize the importance of assessing the nutritional status of the pediatric population affected by a disaster. Identify the vulnerable population groups in these situations. Know and use the different methods for anthropometric assessment of the pediatric population. Section II- Clinical presentation of malnutrition Identify through physical examination the main clinical findings of protein-energy malnutrition and those indicating severe malnutrition. Recognize the particular features and the clinical and pathophysiologic differences between marasmus and kwashiorkor. Describe the pathophysiology of the refeeding syndrome. Section III- Micronutrient deficiency List specific micronutrient deficiencies, their risk factors and clinical signs. Describe the epidemiology, pathophysiology, and clinical presentation of vitamin A, iron, and zinc deficiencies. Describe the general management for micronutrient deficiency prevention and treatment in acute emergency settings. Section IV- IMCI strategy for nutritional status assessment Assess and classify the nutritional status of children according to the Integrated Management of Childhood Illness (IMCI) guidelines and determine the appropriate management strategy. Identify anemia using IMCI tools and recommend the appropriate management strategy. Section V- Feeding programs in disaster situations Recognize the importance of breastfeeding as well as its nutritional and logistic benefits in an emergency context. Describe the different feeding program options in situations of disaster. 1

2 Identify the phases of a therapeutic feeding program. Section VI- Nutritional status of infants 0-2 months of age Assess nutritional status and rule out feeding problems. Counsel the mother on effective breastfeeding. Objectives of the station Plan and develop measures to assess the nutritional status of populations displaced by disasters, and to ensure the most optimal nutritional status in such context. Implement feeding programs adapted to cultural characteristics and to the nutritional status of displaced populations. Identify the clinical symptoms of the different types of malnutrition. Determine the severity of malnutrition. Calculate the anthropometric indexes in infants and older children. Identify the clinical symptoms of iron deficiency anemia. Identify the clinical symptoms of micronutrient deficiencies. Give appropriate treatments for the different types and levels of malnutrition. Give appropriate management to prevent and treat micronutrient deficiencies. Classify the nutritional status according to the variables included in the IMCI guidelines. Format of presentation Discussion of clinical cases Duration 60 minutes Material Classroom or conference room with a sufficient number of chairs in a semicircular arrangement. Enough blank sheets of paper, and pencils or pens for handing out to the participants. Scale for infants; scale for older children; measuring tape or similar. Measuring tape and/ or specific tape for measuring brachial perimeter using colorcoding. Graphs with weight- and height-for-age curves. Graphs with weight/height ratio curves. 2

3 Clinical scenario(s)/ case(s) for facilitator. Printed clinical scenario(s)/ case(s) for participants. If information from clinical cases will be shown (photos, data, etc.): - Slides/ audiovisual material on clinical cases - Slide equipment (projector, computer, etc.) - Screen - Poster illustrating the food pyramid. Optional: - Abridged nutritional status classification poster; - Slides or poster on measuring techniques. Cases Notes for the instructor Before starting the activity with each group, check that the material needed is available. Explain the educational objectives of the station. During the whole activity the facilitator must encourage the participation of all students in the group, and coordinate the discussion of cases being discussed. If necessary, the facilitator can make questions directly to those students that do not participate spontaneously. The instructor can use a board or flip chart to write the group s conclusions for each problem that has been discussed or appoint a recorder from the group to do this. Cases resolution Case 1 You have been selected by the Secretariat of Health to deliver health care to refugees from a region of the country affected by mountain rivers overflowing onto this region. A great number of houses built with mud and wood, were devastated by the flood, aggravated by intense rain. Over 5,000 people had to leave their homes and settle in different camps located on a dry, elevated area. Most of these people suffered previous shortages, due to a series of bad harvests, and the region s low economic level. An elevated prevalence of malnutrition and specific shortages can be predicted. 3

4 There is a common initial scenario for all cases or problems posed in the practice station. Students will have to solve each one of the situations and explain their diagnoses and interventions. Clinical situations must be used to perform the anthropometric measurement techniques if material needed is available. 1) What information do you need to get from health professionals within the area to implement feeding programs in this population? Demographic data from the population living in the region affected by the disaster. Prevalence of malnutrition and specific deficiencies detected in the population before the disaster. Active previous feeding programs. Food products that were most frequently included in the diet before the disaster. Identification of most vulnerable populations (children less than 5 years old; children separated from their families or communities; pregnant or breast-feeding women; families economically supported by women; physically or mentally disabled individuals; chronically ill individuals; and elderly people). Immediate availability of food, as well as other necessary resources for the feeding process (fuel, kitchen tools, etc.). Cultural preferences regarding different food types. Safety guaranteed within the region and camps. Description of the previous general sanitary and vaccination status of the population. 2) How is the population s current nutritional status determined? The nutritional status in children less than 5 years old can be used to estimate the global nutritional status of the affected population, thus determining the population s nutritional needs. Therefore, a rapid assessment can be performed measuring the middle upper arm circumference (MUAC) in a significant number of children less than 5 years old. Those children identified as undernourished using this method should undergo further assessment using other anthropometric measurements and indexes (weight/ age; weight/ height) to establish a precise diagnosis. 3) What initial interventions may be applied? Encourage breast-feeding. WHO suggests mothers to breast-feed their children at least until they are 2 years old. This is even more important during disaster situations in which food resources are limited. Moreover, artificial feeding in infants during these 4

5 situations require elements that are limited, such as fresh water, fuel, containers, clean areas to prepare bottles, as well as the continuous supply of artificial milk. Give nutritional supplements to vulnerable groups, particularly mothers who are breastfeeding. Provide fresh, safe water and appropriate sanitation services. 4) You must implement a feeding program for the area you have been assigned to. You have been informed that due to shortage, many warehouses have been sacked. Some women and children have been hurt during those incidents. What kind of feeding program would you implement according to this information? Initially, a wet ration program for people in shelters and surroundings should be implemented. This intervention guarantees that food rations are consumed by the targeted population, and allows other health-care interventions (e.g., immunizations) to be performed in the distribution center. Moreover, no resources are required for preparing meals in the places where refugees are living. Unfortunately, these programs are more expensive, require more staff, are more timeconsuming for mothers, allow appropriate feeding for less people, and increase the risk of epidemic outbreaks compared to dry food rations. 5) The information obtained regarding food products typically eaten by the population affected by the flood shows a predominance of corn, and milled rice in the daily diet, with a poor intake of dairy products, meat, and fresh fruit. Due to the poor conditions prior to the current disaster, families ate the few farm animals that they had from previous seasons. What micronutrient deficiencies would you expect to find in the pediatric population? A poor intake of protein can be associated with a protein-energy malnutrition, and some cases of kwashiorkor can occur. In addition, poor meat or egg intake can be associated with iron deficiency (ferropenic anemia) and zinc deficiency. It is possible to find patients with signs of beri-beri or peripheral neuropathy due to the predominance of corn or milled rice in their diet. No vegetables or fruits in a patient s diet can be associated with vitamin C and vitamin A deficiencies. It is also possible to observe calcium deficiency due to the lack of available dairy products. 5

6 Case 2 You receive at the health care center a 3 years old boy. His mother says that her son drinks fluids, but refuses to eat the corn porridge that she prepares for him. The patient is pale, and shows no interest in what surrounds him. His hair is reddish and sparse. His abdomen is distended. His palms are very pale. There is edema in both feet. Arm circumference is cm. His weight is 7.9 kg, and his height is 80 cm. 1) What is the most probable diagnosis? Severe malnutrition, Kwashiorkor type. Severe anemia. Despite the weight/height index is 72%, indicating no severe malnutrition, the presence of edema affects the use of this index to determine the severity of malnutrition. The physical findings consistent with Kwashiorkor establishes the severity of malnutrition. The marked paleness in both palms determines the diagnosis of anemia. 2) What other clinical signs would be observed? Skin changes, Cushingoid facies, hepatomegaly. Signs of other micronutrient deficiencies (vitamin A). Tachycardia, if anemia is severe. 3) What is the immediate next step? This patient should be referred to a hospital. If referral is not possible, it is necessary to maintain appropriate hydration and normal blood glucose level, and investigate and treat associated pathologies (particularly infections). Start the refeeding process very slowly: frequent (8-12/ day) and small with low osmolarity and low lactose content, food rations, basal calories. If the child refuses to eat or does not tolerate oral feeding, NGT feeding should be used. Daily intake should be 100 kcal/ kg; no more than 3 g/day of protein; total fluid: 100 ml/kg/day, due to the presence of edema. Different formulations and adequate recipes can be used. This initial phase can last 1-2 weeks. Phase 2 starts when associated complications have been resolved, and the child shows an improved clinical status and recovers his/ her appetite. The goal is to feed the child with 300 kcal/kg/day. Usual foods used by the family are progressively incorporated. Micronutrient supplements (zinc, vitamin A, copper) must also be given. Daily increase should be kcal/kg/day. During this whole process it is important that the child is sensorialy stimulated and emotionally supported. Once the child has recovered his/her weight, and has reached 80% of his/her weight/height ratio, and the edema and associated pathologies have resolved, the patient will be changed to a 6

7 supplementary feeding program, with approximately kcal/day and g/day of protein to maintain his/her nutritional status. It is important to incorporate food products that guarantee an appropriate intake of all micronutrients. Iron supplements should not be given initially to avoid complications. Once the initial phase is over, 25 mg/day of iron (plus 0.4 mg/day of folic acid) must be given for 3 months. If possible, check progress using Hb level. Case 3 An 18-month-old girl is brought to the shelter s health care center to be evaluated after an upper airway infection. She has no fever, serous rhinorrhea is the only positive physical finding. The patient does not complain of earache. She feeds well. There are no signs of dehydration. Her weight is 7 kg, and her height is 73 cm. Both conjunctives are dry, and show gray spots. Her palms are slightly pale. 1) What is the diagnosis? The girl presents moderate malnutrition (weight/height ratio under 80%), mild anemia, and likely vitamin A deficiency (Bitot s spots). 2) What other manifestations can be associated with the diagnosis? Xerophthalmia; corneal xerosis; altered night vision; melting cornea; corneal rupture. The patient must also have immunological and hematopoietic abnormalities. The latter can contribute to mild anemia. 3) What treatment should be indicated? The girl s feeding must be assessed, and adequate protein-energy intake should be provided through a supplementary feeding program. Ferrous sulphate: 25 mg/day (or 3 mg/kg/day) for 3 months. If possible, check using Hb and/or Ht. Vitamin A: 200,000 IU; repeat dose the day after, and after 4 weeks. Follow-up at 15 days to monitor weight progress. Case 4 A 45-day-old infant is brought to the health care center. The infant was born via an uneventful vaginal delivery after a full-term gestation. Birth weight: 3,200 kg; birth height: 49 cm. She is exclusively breast-fed. Her mother is worried because she has to 7

8 breast-feed her baby every 2 hours. Her current weight is 4,500 kg, and her height is 53 cm. Her physical exam is normal. 1) What is the diagnosis? The nutritional status of the infant is normal. Height and weight are progressing well (increase in weight is close to 30 g/day). 2) What is the appropriate next step? The mother should be reassured and counseled that the frequency of feedings is normal. The baby is well nourished, and does not require artificial milk. Assess breastfeeding technique. Counsel against the use of bottles and, if possible, of pacifiers. The latter, at least until breast-feeding is well established. Recommend that the mother eat as well as possible, and to drink plenty of fluids. Prescribe a multivitamin supplement (vitamin A, C, and D). No prescription for ferrous sulphate is needed because the infant is breast-feeding exclusively, and human milk provides iron with high bioavailability. Case 5 A 4-year-old boy is brought to the health care center. He was diagnosed with tuberculosis by means of a positive skin test, and contact with an infected adult; however, he has not been treated due to lack of medication. Upper arm circumference is 12.0 cm. 1)What is the appropriate immediate step in the management of this boy? Weight and height should be determined to establish the weight/height ratio. 2) The boy weighs 10 kg and his height is 91 cm. Weight/ height ratio is 75%. What is the most appropriate immediate step? The best treatment for this boy probably is supplementary feeding, because if the administration of drugs cannot be guaranteed, incomplete therapy can result in the emergence of antimicrobial resistance. If therapy against tuberculosis is started, it is necessary to guarantee that the patient is taking pyridoxine-rich food products (whole grains, nuts, meat, dairy products, eggs), because isoniacid is a pyridoxine-antagonist, so there would be an increase in the risk of pyridoxine deficiency. 8

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