Home-immediately access 800+ free online publications. Download CD3WD (680 Megabytes) and distribute it to the 3rd World. CD3WD is a 3rd World Development private-sector initiative, mastered by Software Developer Alex Weir and hosted by GNUveau_Networks (From globally distributed organizations, to supercomputers, to a small home server, if it's Linux, we know it.)ar.cn.de.en.es.fr.id.it.ph.po.ru.sw

CLOSE THIS BOOKClinical Guidelines and Treatment Manual (MSF, 1993, 319 p.)
Chapter 1 - A few symptoms and syndromes
VIEW THE DOCUMENTFatigue
VIEW THE DOCUMENTPain
VIEW THE DOCUMENTFever
VIEW THE DOCUMENTAnaemia
VIEW THE DOCUMENTConvulsions
VIEW THE DOCUMENTShock
VIEW THE DOCUMENTSevere protein-energy malnutrition

Clinical Guidelines and Treatment Manual (MSF, 1993, 319 p.)

Chapter 1 - A few symptoms and syndromes

Fatigue

Fatigue is one of the commonest presenting complaints. The term includes various subjective symptoms (lassitude, lack of energy etc), that are both physical and mental. In most of cases there is no pathological basis to be found, however it must not be forgotten that many diseases may present as fatigue. The symptom, as much as any other, requires a full, methodical clinical assessment.

Clinical features

The history and physical examination must define:

- Mode of onset: sudden or progressive, old or recent, isolated or associated with other symptoms, life situation (work, intense activity, recent illness, refugee displacement...).

- Nature of the fatigue: physical, intellectual, sexual...; whether it comes on in the morning (often psychosomatic) or evening (more usual).

- Any associated clinical features:

· Systemic features: anorexia, weight loss, fever, anaemia, all of which suggest a probable organic basis.

· Localizing features linked to a particular organ system, eg cough and haemoptysis in TB, dyspnea in cardiac failure or anaemia, abdominal pains in parasitoses, jaundice in hepatitis.

· Physical findings: the examination must be comprehensive:

· Nutritional status: weight (signs of recent loss), anaemia, signs of vitamin deficiency diseases...

· Cardiopulmonary: pulse, BP, chest auscultation...

· Abdomen: including liver, spleen...

· Lymph nodes

· Skin and mucus membranes

· Affect: anxiety, depression.

Diagnosis and Treatment (dispensary)

- If the fatigue is part of a syndrome, treat the cause.

- If there seems to be no organic basis, assume the complaint is psychosomatic. Advise the patient to consult a traditional healer, who is usually in a far better position to help. Depending on national recommendations, a placebo may be prescribed, give:
multivitamins: 1 tab x 3/d x 5 days.

Pain

Pain is a common presenting symptom and of course may be caused by a range of conditions. Pain is a subjective experience. The same degree of pain will be expressed differently from patient to patient. There are also cultural differences. The assessment of the severity of pain in a given patient is thus difficult. The solution is to address the problem with a clinical approach that is both methodical and comprehensive.

Clinical features

The history of the pain elicited from the patient must define:

- Onset: sudden, subacute or progressive.

- Duration.

- Localization and radiation.

- Nature of the pain: colicky, burning, sharp, constricting, like a weight; and whether intermittent or continuous.

- Factors that induce or relieve the pain: posture, coughing, deep breaths, meals, specific foods, movement etc.

- Associated systemic features: fever, fatigue, weight loss, etc.

- Associated focal features: cough, diarrhea, vomiting, burning during micturition...

The physical examination should be oriented towards the organ system or region where the pain seems to be localized. The synthesis of the clinical data provides the diagnosis and orients therapy, both etiological and symptomatic.

Treatment

ETIOLOGICAL

That is, treatment of the cause of the pain.

SYMPTOMATIC (dispensary)

According to the nature of the pain.

- Headache

acetylsalicylic acid(PO): 3 g/d divided in 3 doses x 3-5 days
or
paracetamol (PO): 1.5 g/ d divided in 3 doses x 3-5 days

- Psychosomatic pains: consider this diagnosis if pains are multiple, fleeting, or shifting. Treat as for headache or refer to a traditional healer.

- Joint pains

acetylsallcyllc acid (PO):
Adult: 3 g/ d divided in 3 doses x 3-5 days
Child: 50 mg/kg/d divided in 3 doses x 3-5 days

- Inflammatory: tends to be worse at night. Look for an infectious cause (may require surgical drainage and antibiotics).

If acetylsalicylic acid is ineffective, treat with:

indomethacin (PO):
Adult: 50 to 150 mg/d divided in 3 doses x 3-5 days

- Joint pain (especially monoarticular): exclude septic arthritis.
Note that periarticular and bone pains with swelling and loss of function of the limb may be due to scurvy: look for bleeding from the gums and treat with:

Ascorbic acid (vitamin C) (PO):
Adult: 500 to 1,000 mg/d divided in 3 doses until recovery
Child: 100 to 300 mg/d divided in 3 doses until recovery
Give dietary Advice.

- Colic

· Gastrointestinal: exclude a parasitic infection. Do not give acetylsalicylic acid (possibility of ulcer).
Depending on severity:

N-butylhyoscine (PO):
Adult: 30-60 mg/d divided in 3 doses x 3-5 days
or
atropine (SC):
Adult: 0.5 to 1 mg by injection
Child: 0.01 to 0.02 mg/kg by injection

· Renal or biliary colic: same as above. If necessary: noramidopyrine (IM or IV):

Adult: 500 mg by injection

- Very severe pain

noramidopyrine (IM or PO)
Adult: 500 mg as necessary
Or, if ineffective: pentazocine (IM or PO): 30 mg IM or 50 mg PO as necessary

Fever

Fever is common, and usually, related to an infection of viral, bacterial or parasitic origin. The type and duration of fever helps determine the diagnosis. Note that fever in the newborn has its own complications.

Fever may be defined as a rectal temperature above 37°C in the morning, and above 37°5C in the evening.The corresponding axillary temperature would be above 37°5C and 38°C. This definition is practical in hospital but not as satisfactory in a dispensary. Several factors have to be considered in taking a patient's temperature: the technique (axillary, oral, rectal), the quality of measurement, the patient compliance, and the time available. One usually considers that axillary temperature under estimates the core temperature by 0°5C.

- Clinically: any hyperthermia, even if it is only slightly above normal, could be significant (e.g. nocturnal febrile stage in tuberculosis). On the other hand, at dispensary and primary health care level, a higher threshold only should be considered (ea. axillary temperature > 38°C after 5 mins).

At hospital level, a finer thresh-holds can be adopted.

In all cases, it is essential to define these thresholds.

- Fever to be treated:

· In the infant and new born: over 38°C rectal temperature, and/or if there are signs of intolerance.

· In the adult: above 38°5C and/or if the patient is uncomfortable.

Clinical features

- The following complications can be brought about by fever in newborns and infants:

· Convulsions
· Dehydration
· Malignant hyperthermia (collapse and coma)

They should be investigated and treated but moreover they should be prevented (see treatment).

- Clinical assessment is the main method of investigating the cause of fever. Epidemiological environment should also be considered. If available, a laboratory could be useful. The following guidelines are helpful. They should be adapted to the epidemiological context, level of medical staff and diagnostic methods.

FEVER AS A SERIOUS SYMPTOM OF INFECTION

- High fever, shivering, sweating, malaria endemic area (falciparum), headache, consciousness desorders (even minor) indicate severe malaria. Without treatment, it can cause death.Take a malaria smear and treat.

- High fever with general health impairement, with or without other signs indicates typhoid fever.

- High fever, stiffness and neurological signs indicate meningitis or meningocephalitis.

- High fever with:

· A hemorragical syndrome indicates meningococcemia, or hemorragic fever, or in an endemic area, relapsing fever, rickettsiosis, dengue...

· Icterus indicates a hepatitis...

· Associated icterus and renal signs (oliguria...) indicates yellow fever, leptospirosis...

- Fever with shock indicates septicemia.

- Fever with respiratory insufficiency indicates pneumonia, bronchiolitis, epiglottitis...

- Fever during last month of pregnancy (major risks to fetus and mother) indicates falciparum malaria, pyelonephritis...

- Fever in the new born is always serious.

- Fever in the young adult with general health impairement, adenopathies, chronic diarrhea... indicates a severe opportunistic infection in an AIDS patient.

FEVER ASSOCIATED WITH FOCAL SIGNS

Here, diagnosis is easier, for example:

- Pharyngeal signs in tonsillitis

- Pulmonary signs in pneumopathy

- Cutaneous rash or Koplick spots in measles

- Dysentery in shigellosis

- Urinary signs in pyelonephritis

- Painful swelling of an abcess or an osteomyelitis...

- Icterus in hepatitis...

- Painful large liver in amoebic abcess

FEVER WITH NO OBVIOUS FOCAL SIGNS

- Depending on the endemic area and associated clinical picture:

· Trypanosomiasis during blood stage
· Bilharzia during invasive stage
· Visceral leishmaniasis (Kala-Azar)
· Trichinosis during invasive stage
· Brucellosis
· Arbovirus infection: dengue, scrub typhus...

- Prolonged fever:

· Tuberculosis, Brucellosis, collagen disease...

"PUO" PYREXIA UNKNOWN ORIGIN

No sign leads to a diagnosis.

When there is a high rate of PUO, an epidemiological survey is necessary. However, it is recommended to take stock of the situation with the local health authorities, as they have experience of the local conditions and often have the answer to the problem.

Treatment (dispensary)

- Causative: cause of fever following the established diagnosis of the disease.

- Symptomatic

· Get the patient undressed.

· Either wet the skin with a tepid sponge (body temperature, not cold) and leave to cool by evaporation, or give a bath at 37°C for a few minutes.

· Antipyretic treatment (see table 1):
paracetamol (PO):

Adult: 2 g/d divided in 4 doses
Child: 30 mg/kg/d divided in 4 doses
or acetylsalicylic acid (A.S.A.) (PO):
Adult: 3 g/d divided in 3-4 doses
Child: 50 mg/kg/d divided in 3-4 doses

- Keep the patient well hydrated and breast fed.

- Maintain good nutrition, even if anorexic. Convince the mother to keep feeding.

- With convulsions: diazepam: 0,5 mg/kg to be given rectally (use the parenteral solution)

- With diarrhea, give same dose by slow IV injection. Repeat after
10 minutes if necessary.

Antipyretic Dosage


Table 1

Notes

- Acetylsalicylic acid (A.S.A.)

· When used as an anti-inflammatory, the maximum daily dose can be doubled:

Adult: 6 g
Child: 100 mg/kg

· In some countries, acetylsalicylic acid is contraindicated in children. Use paracetamol if available.

- Paracetamol

· Does not have an anti-inflammatory effect.
· Use in patients with a history of ulcer or gastric problems, in those allergic to acetylsalicylic acid (some asthmatics), in infants and pregnant women.

Anaemia

Anemia is defined as an abnormally low concentration of hemoglobin in the blood (below 12 g/lOOml in males, 11 g/lOOml in females). There are three mechanisms: impaired RBC production, RBC loss from bleeding, and increased RBC destruction (haemolysis).

- Three major causes:

· Malaria

· Nutritional deficiencies in iron and/or folic acid, especially in children and women of childbearing age.

· Hookworm

- Other causes:

· G6PD deficiency: crisis of haemolytic anaemia precipitated by certain drugs: chloroquine (perhaps), primaquine, sulfonamides, sulfones, nitrofurans, chloramphenicol, tetracyclines (perhaps), nalidixic acid, acetylsalicylic acid, noramidopyrine, probenecid, niridazole, vitamin K, quinidine...

· Sickle cell disease, thalassemia

· Leishmaniasis

· Bleeding (e.g. gastric ulcer)

Clinical features

- Pallor of conjunctivae and mucus membranes, fatigue, dizziness, dyspnea, tachycardia, edema, cardiac murmur...

- If possible, determine hemoglobin or hematocrit.

- A blood film will show red cell morphology (but this is difficult to interpret).

- Stool examination to exclude hookworm; or else in an endemic area treat presumptively with mebendazole.

Treatment

IRON DEFICIENCY ANEMIA (dispensary)

ferrous sulphate (PO)
Adult: 0.6 - 1.2 g/d divided in 3 doses x 2 months
Child: 15 to 30 mg/kg/d divided in 3 doses x 2 months

- Often associated with a nutritional deficiency in folate:
folic acid (PO)

Adult: 10-20 mg/d single dose x 15-30 days
Child: 5-15 mg/d single dose x 15-30 days

- Combination tablets can also be used, though the dose of folic acid is low:
ferrous sulphate + folic acid (PO): as for ferrous sulphate tabs.

- Deworming

mebendazole (PO): 200 mg in a single dose for all ages.

FOLIC ACID DEFICIENCY (rarely occurs on its own) (dispensary)

folic acid (PO)

Adult: 10-20 mg/d single dose x 15-30 days
Child: 5-15 mg/d single dose x 15-30 days

HEMOLYTIC ANEMIA (MALARIA, HAEMOGLOBINOPATHIES) (dispensary)

Give folic acid only. Do not give iron unless there is a proven associated deficiency (iron from haemolyzed RBCs remains in the body and is reutilized).

SEVERE ANEMIA WITH SIGNS OF DECOMPENSATION: HAEMATOCRIT LESS THAN
15% OR SIGNS OF CARDIAC FAILURE (hospital)

- Transfusion: avoid whenever possible because of risk of transmission of HIV and Hepatitis B viruses. If anaemia is very severe, however, transfusion is life-saving. Use grouped compatible blood; use packed cells rather than whole blood if possible.

Volume to be transfused:

Adult:

2 to 4 bags of packed cells (double volume if whole blood)

Child:

packed cells: increase in haematocrit desired x weight in kg. E.g. 13kg child with Hct of


14%: to bring Hct up to, say, 30%, need to transfuse (30 -14)


x 13 = approx. 200 ml packed cells = approx 400 ml whole blood.


whole blood: above volume x 2


Rate of transfusion: 2 drops/minute/kg

- Observe very closely (risk of pulmonary edema).

Note: Prevalence of HIV contra-indicates blood transfusion (in the absence of donor blood screening test). Before transfusing measure the risk. Quote: "Transfusions that are not absolutely indicated are contra-indicated".

Prevention

SHORT TERM

- Prophylaxis for pregnant women and malnourished children:

ferrous sulphate + folic acid (PO)
Adult: 200 mg + 15-30 mg/d single dose
Child: 60 mg + 2.5 mg/d single dose

- Dietary Advice

LONG TERM

- Malaria control

- Deworming

- Nutrition education

- Hygiene and sanitation, health and nutritional education, national and local nutrition policy.

Convulsions

- Paroxysmal involuntary movements of cerebral origin with loss of consciousness, often accompanied by biting of the tongue and urinary incontinence.

- Two priorities:

· Stop the convulsion.

· Make an etiological diagnosis quickly and treat the cause. This necessitates a good clinical examination, a blood slide for malaria and possibly a lumbar puncture.

Supportive Treatment

THE PATIENT HAS STOPPED FITTING

- Put in the coma position (lying on left side and upper leg flexed), maintain clear upper airway (remove any secretions or vomitus).

- Treat any fever.

- Prepare a syringe of diazepam in case of further convulsions.

THE PATIENT IS STILL FITTING

- diazepam (IV)

Adult: 10 mg by slow IV injection (over 2-3 minutes).
Child: 0.5 mg/kg rectally (use the injectable form) and inject by means of a syringe without a needle, if possible with the help of a nasogastric tube cut to 2-3 cm length. If rectal route impractical because of diarrhea, give same dose by slow IV. If still fitting after 10 minutes, repeat same dose. Child may need to be ventilated if there is respiratory insufficiency secondary to IV diazepam.

Do not repeat dose if there is no means of ventilation

- Put in coma position, clear out upper airways.

- Treat any fever.

REPEATED GRAND MAL CONVULSIONS

Convulsions which follow each other rapidly or do not cease, carry the risk of respiratory arrest or serious neurological consequences.

- Try diazepam 10 mg by slow IV and continue with 40 mg in 500 ml 5 % glucose infused over 24 hours. Theoretically, barbiturates IV and assisted ventilation..

- Ensure adequate nutrition and hydration nursing.

REPEATED CONVULSIONS

These can be prevented by oral phenobarbital (possibly with gastric tube) or IM if available.

Adult and Child: 3-5 mg/kg/d in 1 or 2 doses without exceeding 200 mg/d.

Injectable phenobarbital must be given through a glass syringe.

Treatment of the Cause

(only causes amenable to treatment are discussed)

INFECTIOUS

· Hyperthermia: treat the fever.

· Cerebral malaria (falciparum).

· Meningitis.

· Meningo-ncephalitis (e.g. measles, arbovirus): supportive treatment as for coma: feeding-hydration, nursing.

METABOLIC

- Hypoglycemia: may occur in severe malnutrition, neonate or patient being treated with IV quinine. Treat with:

30-50 % solution of hypertonic glucose (IV): 1 g/kg stat followed by 5 % glucose infusion.

- Hypocalcemia: rickets, malnutrition, neonatal period. Treat with:
calcium gluconate (ampoule 10 ml = 1 g)

Adult: 1 g by slow IV injection (= 1 amp)
Child: 0.04 g/kg by slow IV injection (= 0,4 ml/kg)

Never use calcium chloride IV.

EPILEPSY

Once commenced, phenobarbital treatment must never be abruptly interrumpted: risk of grand mal convulsions. The longer the treatment has lasted, the more gradual it should be stopped.

In the ambulatory patient, it is often better to leave him with some attacks than risk abrupt interrumption.

phenobarbital (PO):
Adult and child: 3-5 mg/kg/d in 1 dose, to be reached gradullay.

If this is insufficient, but only it is available on the spot, the following can be added:

phenytoin (PO):
Adult: 2-6 mg/kg/d divided in 1-2 doses
Child < 10 years: 3-8 mg/kg/d divided in 1-2 doses

These doses are reached gradually, commencing with 2-3 mg/kg/d in 2 doses. The same risk with abrupt interrumption.

RECURRENT FEBRILE CONVULSIONS IN CHILDREN

Discuss preventive treatment with diazepam. Avoid phenobarbital. diazepam (PO): 0.25 to 0.5 mg/kg/d divided in 3-4 doses

ECLAMPSIA

- diazepam: 10 mg slowly IV, plus 40 mg in 500 ml 5 % glucose infused over 24 hours.

- Treatment of hypertension: hydralazine IV or infusion (see "Hypertension).

- Obstetrical management (see "Obstetrique en situation d'isolement", Medecins Sans Frontieres, 1992).

- Feeding, hydration, nursing.

Shock

Acute circulatory failure, characterized by a rapid fall in blood pressure which reduces perfusion of the vital organs, causing anoxic damage and preventing the elimination of metabolic waste.

Etiology and Pathophysiology

There are three main mechanisms, more than one may be active in a shocked patient: hypovolaemia, cardiogenic shock, and vasodilatation.

HYPOVOLAEMIA

- Hemorrhage: trauma, peptic ulcer, ectopic pregnancy, antepartum or postpartum hemorrhage, uterine rupture, etc.

Loss of up to 10-20% of the blood volume may be well tolerated.

Loss of more than 20% of the blood volume does not permit maintenance of adequate blood pressure to perfuse the vital organs.

- Dehydration: prolonged diarrhea and vomiting, cholera, burns, intestinal obstruction, diabetic coma, etc.

- Burns

- Hemolytic crises: malaria, G6PD deficiency and certain medications (see anaemia).

CARDIOGENIC SHOCK

- Myocardial infarction, terminal congestive cardiac failure.

- Compromised left ventricular filling or emptying: tachyarrythmias, haemopericardium, pericardial tamponade, tension pneumothorax, massive pulmonary embolism.

VASODILATATION

- Septic shock: septicemia, release of bacterial endotoxins.

- Anaphylactic shock: release of histamine and other vasodilators.

Clinical features

HYPOVOLEMIC OR CARDIOGENIC SHOCK

- Patient usually conscious, but apathetic.

- Palor, marbled skin, cold and clammy extremities.

- Rapid thready pulse (rate >120), blood pressure low or undetectable.

- Rapid breathing.

- Oliguria or anuria.

SEPTIC SHOCK

- Early: fever, chills, warm extremities.

- Rapid pulse, variable BP.

- Hyperventilation.

SIGNS RELATED TO SPECIFIC ETIOLOGIES

- Loss of skin elasticity: dehydration.

- Chest pain: infarction, pulmonary embolism.

- Abdominal guarding: peritonitis, distension due to obstruction.

- Melaena: GIT hemorrhage.

Management (hospital)

- Lie patient down, keep warm, elevate legs.

- Establish IV line: large vein, large bore needle (16 or 18G for adult).

- Cardiac arrest: extemal cardiac massage.

- Respiratory arrest: endotracheal intubation, manual ventilation.

- Close monitoring of vital signs: pulse, BP, respiratory rate, urine output.

Treatment of the cause (hospital)

HYPOVOLEMIA

-Hemorrhage

Rapid transfusion of as many units of crossmatched blood (which has been HIV tested) has necessary to maintain a stable blood pressure. Meanwhile, prepare to surgically treat the cause of the hemorrhage.

Note: the absence of HIV testing, refer to note.

- Acute dehydration

Infusion of Plasmion or Haemacel: 1 to 2 bottles (child: 10 to 20 mg/kg), given in a jet thann: ringer lactate solution

Adult and child: 100 ml/kg over 4 hours, then 100 ml/kg in the next 20 hours.

CARDIOGENIC SHOCK

- Cardiac failure and acute pulmonary edema

· half-sitting position, legs lower than body.

· furosemide: 40 to 80 mg IV stat. Higher doses sometimes needed. Observe pulse, BP and urine output.

· digoxin (only if no cardiac arrythmia):

Adult: 0.25 mg IV stat
Child: 0.01 mg/kg IV stat

· Beri-Beri may be a cause of cardiac failure. Treat with
Thiamine (IM):

Adult: 200 mg IM or IV /d for a few days then PO
Child: 50 -100 mg IM or IV /d for a few days then PO

· If furosemide not available, rapid blood letting through basilar vein (300-400 ml in the absence of a severe anaemia) in severe cases.

- Tamponade (due to acute constrictive pericarditis, often tuberculous). Requires urgent pericardial tap.

- Myocardial infarction: rare in tropical countries.

· Treat the pain with pentazocine: 30 mg IM.
· Nitrite derivatives if available.

- Tension pneumothorax: urgent pleural aspiration.

VASODILATATION

- Septic shock

· Find the focus of infection: abscess, RTI, digestive system, gynaecology).

· Antibiotics:
ampicillin: 100 to 200 mg/kg/24 hours, divided in 3-4 IV injections/24 hours

· Plus, if available:

gentamicin: 3 mg/kg/24 hours, IM, without exceeding 180 mg/24 hours or 3 IM injections/24 hours

· Controversial: corticosteroids.

- Anaphylactic shock

Determine and remove the cause (e.g. insect sting, drug).
epinephrin (adrenaline):

Adult: 0.5 to 1 mg diluted in 10 ml isotonic solution (glucose, normal saline, ringer lactate) by slow IV infusion.

Child: 0.25 mg diluted in 10 ml isotonic solution (glucose, normal saline, ringer lactate) by slow IV infusion.

Note that the management of a shocked patient must always include very close monitoring of vital signs and clinical progress. All parameters should be noted on an observation form.

Severe protein-energy malnutrition

Malnutrition occurs because of a prolonged discrepancy between food consumption and nutritional needs.

To understand malnutrition requires first a knowledge of the prevalence in the childhood population and second a study of the individual causes (pathology, weaning problems) or collective causes (famine, drought, economic problems) in order to determine appropriate treatment measures.

How to determine nutritional state

CLINICAL SIGNS

Marasmus

Muscle wasting and loss of sub-cutaneous tissue.
Loss of appetite.
Reduced growth.
Irritability.

Kwashiorkor

Weight loss,
Œdema of extremities (and the face).
Loss of appetite.
Skin changes. Apathy.
Changes of the heir and nails.

Maras-Kwashiorkor

Two classes of signs: muscle wasting and oedema.

CLASSIFICATION

There are several types of classification. It is helpfull to use anthropometric measurements to determine the severity of the malnutrition.
The most frequently used indicators are:

- Classification of weight/age

Weight of the subject / Normal weight of a child of the same age.
80 - 60 %: moderate malnutrition
< 60 %: severe malnutrition

- Classification of weight/height

Weight of the subject / Normal weight of a child of the same height.
80 - 70 %: moderate malnutrition
< 70 %: severe malnutrition

- Arm circumference
Measure the arm circumference in the middle of the upper arm of a child aged 1 to 5 years.
13,5 cm -12,5 cm: moderate malnutrition
< 12 cm: severe malnutrition

- Presence of tibial oedema
This indicates severe malnutrition.
Beyond their use to study the prevalence of malnutrition in the population, anthropometric indicators establish the criteria for entry to and exit from the feeding center.

Example (weight/height):

· criteria for entry = < 70 % W/H

· criteria for exit = > 85 % W/H for two consecutive measurements, improving general state and disappearing oedema.

Different types of treatment

FEEDING CENTER FOR THE SEVERELY MALNOURISHED

First establish a system adapted to needs which depends on the number of cases: establish a specific structure = center of therapeutic recuperation (intensive), or indeed a pediatric service if the numbers are not too large.

Treatment continues on a 24 hour cycle 7 days a week. The treatment center is essential and depends on the active participation of the mothers under the supervision of trained personnel. A medical center is indispensable.

The principle of treating the malnourished persons is to progressively give calories and protein at appropriate stages of treatment:

- Acute phase

· reanimation and initiation of dietary cure
· maintenance

- Recuperahon phase

· enhanced growth
· return to family meals

ACUTE PHASE

- Reanimation and initiation of dietary cure

Reanimation is the medical treatment of the complications of malnutrition, in particular dehydration.

Initiation of a cure leads at the same time to reanimation.

Nutrition must be progressive and not agressive. Give small frequent meals because these reduce the risk of diarrhea, vomiting, hypoglycemia and hypothermia. Always adapt treatment to the individual.

Infants are given oral nourishment (by spoon, never by bottle) or by nasogastric tube if anorexic or there is severe vomiting.

The regime should be max 80 to 100 Kcal/kg body weight in the first days with a minimum of protein.

- Maintenance

A phase of stabilisation occurs during treatment: at the stage, attempts should be made to "recuperate" the weight lost.

Note a reduction of the oedema or stagnation in kwashiorkor.

This phase continues until the appetite returns.

If the child is still being breast fed, it is necessary to continue and encourage this method of nutrition.

The following protocol can be used for example:

20 g (45 ml) DSM (dry skimmed milk)
100 g (100 ml) sugar
40 g (40 ml) oil

reconstitute with 1 liter of water:
100 Kcal and 0.6 g of protein/100 ml


Table

Meals are given every two hours. Gorging of food can be used, this is practiced on day 1 and 2, under the surveillance of a nurse or other health worker.

The acute phase lasts for 7 days with marasmus. For a child with oedema, the progression from initial treatment to cure must be slow and the maintenance phase prolonged. The oedema decreases and the general state improves with the stage of rehabilitation (about 15 days).

RECUPERATION PHASE

- Enhanced growth

The objective is to achieve no more weight for height as quickly as possible.

The speed of weight gain is directly proportional to alimentary consumption. Minimal requirement corresponds to 150-200 Kcal/kg/day and 4 to 5 g of protein/ kg / day.

The principle occupation at the stage is to institute concentrated high energy alimentation because a child of less than 5 years only absorbs illimited amount.

Use high energy concentrated alimentation: oil, sugar... and continue to give as many small meals as possible per day.

A possible formula for high energy alimentation is:

90 g (200 ml) DSM
60 g (60 ml) sugar
80 g (80 ml) oil
800 ml water


1000 ml

128 Kcal and 3.2 g of protein/100 ml
192 Kcal and 4.8 g of protein/100 ml

Many of the formulas are available, notably that of Oxfam

6 volumes of powder milk
2 volumes of oil
1 volume of sugar


premix

premix = dry mixture
H.E.M. = premix + water (H.E.M. = high energy milk)

1 volume of premix + 4 volumes of water-> H.E.M.
100 ml of H.E.M. = 100 Kcal + 4 g of protein (1 ml = 1 Kcal)

- Return to family meals

The move to family meals is an important step in recuperation.

Meals should be introduced progressively. Insist on the importance of the participation of mothers and their education in nutrition.

Medical feeding center

ASSOCIATED PATHOLOGIES

The associated pathologies must be treated:

- Diarrhea:
ORS

- Bacterial infections
antibiotics

- Buccal candidiasis
gentian violet

- Intestinal parasites
mebendazole: 200 mg/d x 3 days

- Anti-malaria prophylaxis
chloroquine: 10 mg/kg/week

- Skin lesions
zinc oxide ointment

- Look for tuberculosis.
Tuberculosis should always be suspected if, after several weeks of treatment, a child is not recovering.

SPECIFIC NUTRIENT DEFICIENCIES

These should be corrected if possible:

- Potassium:5mmol/kg/day

- Magnesium:2mmol/kg/day

- Zinc:2 mg/kg/day

- Multivitamin preparation and vitamin C

- Vitamin A: according to WHO recommendations

- Iron: from the reanimation phase

- Folic acid: 5 mg/day

FLUID REQUIREMENTS

- It is important to give water to the malnourished infant, several times a day, between meals, especially if the outside temperature is high, or if the infant has a fever, and educate the mother to this effect.

- It is necessary however to use ORS with discrimination: only if there is diarrhea and, if it is poorly tolerated, cut the volume to 1/2 or 1/3.

Surveillance

Pay particular attention to the changing state of each case, in particular by following the weight gain and by medical examination.

All personnel in the feeding center must be able to analyse cases and act appropriatly.

This surveillance must be organised:

- Control the allocation of meals and their preparation.

- Regularly gather information: register weight (especially during acute phase).

- Repeated medical consultations, register medications.

TO PREVIOUS SECTION OF BOOK TO NEXT SECTION OF BOOK