Severe malnutrition in Bangladesh

Severe malnutrition is one of the most common causes of morbidity and mortality among children under the age of 5 years worldwide. Many severely malnourished children die at home without care, but even when hospital care is provided, case fatality rates may be high.

Nearly 20 million children under 5 suffer from severe acute malnutrition (SAM) globally, which contributes to an estimated 1 million deaths among children every year.

Most of these children live in South Asia and sub-Saharan Africa. In Bangladesh, according to new WHO GRS 2006, the proportion of children with severe Severely malnourished children often die because doctors unknowingly use practices that are suitable for most children but highly dangerous for severely malnourished children. In certain hospitals that have used these case management methods over a period of time, case fatality has been reduced from over 30% to less than 5% With appropriate case management in hospitals and follow-up care, the lives of many children can be saved, and severe malnutrition wards can dramatically lower case fatality rates.

National Guideline

The National Guidelines for the Management of Severely Malnourished Children in Bangladesh are intended for doctors, senior nurses and other senior health professionals responsible for inpatient therapeutic care of severely malnourished children in health facilities. They are based on the global guidelines of the World Health Organization (WHO), which have been adapted, where necessary, to the context of Bangladesh.

The guidelines are designed for circumstances where community-based management of severe acute malnutrition is not available and therefore include the complete protocol for management of severe acute malnutrition, including:

1. Assessment of SAM and admission criteria
2. General principles for management (the '10 Steps')
3. Treatment of associated conditions
4. How to address failure to respond to treatment
5. Guidelines for discharge before recovery is complete
6. Emergency treatment of shock and severe anaemia.

There are ten essential steps for management:

1. Step : Treat/prevent hypoglycemia
2. Step : Treat/prevent hypothermia
3. Step : Treat/prevent dehydration
4. Step : Correct electrolyte imbalance
5. Step : Treat/prevent infection
6. Step : Correct micronutrient deficiencies
7. Step : Start feeding cautiously including breast feeding
8. Step : Achieve catch-up growth
9. Step : Provide sensory stimulation and emotional support
10. Step : Prepare for discharge and follow-up after recovery

Assessment of severe acute malnutrition

Severe acute malnutrition is identified by the presence of severe wasting and/or bi-pedal oedema. A child aged 6-59 months is classified as severely malnourished if s/he has one or more of the following:

• 1. Mid-upper arm circumference110 mm
• 2. Weight-for-height median (WHM)70% mm
• 3. Weight-for-height z-score (WHZ) -3 SD
• 4. Bipedal oedema (kwashiorkor, marasmic kwashiorkor 'oedematous malnutrition')

IPHN developed National Guidelines for the Management of SAM

The National Guidelines for the Management of Severely Malnourished Children in Bangladesh were developed in 2008 and this course will teach how to implement these guidelines, which are intended for doctors, senior nurses and other senior health professionals responsible for inpatient therapeutic care of severely malnourished children in health facilities.

Assesment of natritional Status

Different forms of under nutrition, indicators for severe acute malnutrition and how to recognize a child with severe acute malnutrition. The severe acute malnourished child is likely to have many serious health problems in addition to malnutrition. In many cases these problems may not be clinically apparent. In some cases the usual treatment for a problem may be harmful or even fatal for a severely malnourished child. This module will describe how the physiology of the severely malnourished child is different, and how these differences affect care.

Assessment of Nutritional Status will assist you when observing and/or obtaining clinical practice with the following skills:

• 1.Definition of different forms of undernutrition
• 2.Understanding indicators for severe acute malnutrition
• 3.Recognizing signs of severe acute malnutrition
• 4.Anthropometric measurement (in practice session)
• 5.Determining a Z-score (SD)[1], based on weight and length/height.

In addition:

1. Recipes for therapeutic feeding formulas (F-75 and F-100)
2. Criteria for admission and discharge
3. A z-score is the number of standard deviations (SD) below or above the reference median value (WHO/UNICEF definition, 2009).

Undernutrition: Undernutrition is a consequence of a deficiency in nutrient intake and/or absorption in the body. The different forms of undernutrition that can appear alone or in combination are: acute malnutrition, stunting, underweight, and micronutrient deficiencies.

Underweight: Underweight is defined by a weight-for-age <-2 SD (WHO standards) and is a composite form of undernutrition including stunting and wasting. This indicator is commonly used in growth monitoring and promotion and child health and nutrition programmes aimed at the prevention and treatment of undernutrition.

Stunting: Stunting, or chronic undernutrition, is a form of undernutrition. It is defined by a height-for-age –2 SD (WHO standards). Stunting is a result of prolonged or repeated episodes of undernutrition often starting before birth. Stunting is best addressed through preventive maternal health programmes aimed at pregnant women, infants and children 2 years

Wasting: Wasting is a form of acute malnutrition. It is defined by a MUAC <125 mm or a weight-for-length/height Z-score <-2 SD (WHO growth standards)

Severe wasting (marasmus): Severe wasting is a sign of SAM. It is defined by a MUAC < 110 mm or a weight-for-height z-score <-3 SD (WHO standards) Severe wasting is also called marasmus. The child with severe wasting has lost fat and muscle and appears very thin, e.g., signs of “old man face” or “baggy pants” (folds of skin over the buttocks).

Acute malnutrition: Acute malnutrition is a form of under nutrition. It is caused by a decrease in food consumption and/or illness resulting in bilateral pitting oedema or sudden weight loss. It is defined by the presence of bilateral pitting oedema, wasting (low mid-upper arm circumference and/or low weight-for-height Z-score).

Severe acute malnutrition (SAM): SAM is defined by the presence of bilateral pitting oedema or severe wasting: MUAC <110 mm or weight-for-length/height z-score <-3 SD (WHO standards)

Management

This module describes and, to the extent feasible, will assist you when observing and/or obtaining clinical practice with the following skills:

Identifying and managing the severely malnourished child with:

1. Hypoglycaemia
2. Hypothermia
3. Shock
4. Very severe anaemia
5. Corneal ulceration
6. Watery diarrhoea and/or vomiting
7. Preparing ReSoMal