10 Steps to Recovery
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Transcript of 10 Steps to Recovery
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10 Steps to Recovery
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Steps 1-2Treat/prevent hypoglycemia
and hypothermia
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STEP 1: Treat Hypoglycemia STEP 2: Treat Hypothermia• Usually occur together• Associated with some severe illnesses and
infection• Frequent feeding is important• Hypoglycemia: blood sugar < 3mmol/l • Signs and symptoms:
• Confusion, abnormal behavior, visual disturbances• Heart palpitations, tremor, anxiety, sweating,
hunger
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• If confirmed, give through mouth or NGT tube:• 50 ml of 10% glucose solution or sugar
water (1 rounded teaspoon of sugar in 3.5 tablespoon water)
• Feed every 2 hours, day and night. Start straightaway or rehydrate first, if needed.
STEP 1: Treat Hypoglycemia
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• Check for the blood sugar again: • After 30 minutes and again after 2
hours• If it is low on either occasion, repeat the
50 ml glucose solution or sugar water.
• If unable to test, assume all severely malnourished children have hypoglycemia.
STEP 1: Treat Hypoglycemia
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STEP 2: Treat Hypothermia
• Hypothermia• Temperature: 35 C (axillary), 35.5 (rectal)
• Children lose heat faster than adults do.• There is sympathetic nervous system
excitation• shivering, hypertension, tachycardia,
tachypnea, and vasoconstriction
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• Feed straightaway• Make sure the child is warm
• Put the child on the mother’s bare chest or abdomen and cover them
• Clothe the child and cover with a warmed blanket
• Place a heater or lamp nearby
STEP 2: Treat Hypothermia
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• Check: • the rectal temperature every 2 hours until it
rises above 36.5 C• The child is covered all times, especially at
night• For hypoglycemia
• Assume the child has hypothermia when the thermometer does not measure low temperatures and the child’s temperature is too low to register.
STEP 2: Treat Hypothermia
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• To prevent hypothermia and hypoglycemia: Feed the child every 2 hours, start
straightaway Always feed during the night Keep the child covered and away from
draughts Avoid exposure
STEP 1: Treat Hypoglycemia STEP 2: Treat Hypothermia
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Step 3Treat/Prevent Dehydration
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• Do not use the standard WHO oral rehydration salt solution
• Give modified solution instead.
• Do not use IV route except in shock, and then do so with care.
STEP 3: Treat/ Prevent Dehydration
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1. Modified ORS Solution
Ingredient Amount
Water 2 Liters
WHO-ORS One 1 Little Packed
Sugar 50 g
Electrolytes 40 mL
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2. Combined Electrolyte/mineral solution (for rehydration solution and feeds)
Ingredient Amount (g)
Potassium Chloride 224
Tripotassium Chloride 81
Magnesium Chloride 76
Zinc Acetate 8.2
Copper Sulfate 1.4
Water Make Up to 2500 mL
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New ORS FormulationReduced osmolarity
ORS grams/litre Reduced osmolarity ORS
mmol/litre
Sodium chloride 2.6 Sodium 75
Glucose, anhydrous 13.5 Chloride 65
Potassium chloride 1.5 Glucose, anhydrous 75
Trisodium citrate, dihydrate 2.9 Potassium 20
Citrate 10
Total Osmolarity 245
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Standard
ORS solution Reduced Osmolarity ORS solutions
(mEq or mmol/l)
(mEq or mmol/l)
(21)
(mEq or mmol/l)
(6, 14, 22-27)
(mEq or mmol/l)
(13, 15-18, 28-29)
Glucose 111 111 75-90 75
Sodium 90 50 60-70 75
Chloride 80 40 60-70 65
Potassium 20 20 20 20
Citrate 10 30 10 10
Osmolarity 311 251 210-260 245
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• Monitor progress of rehydration • every 30 minutes for the first 2 hours • every hour for the next 6-12 hours • Check pulse, respiratory rates, input
and output (urine, stool, vomitus)
STEP 3: Treat/ Prevent Dehydration
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Signs of TOO much Rehydration
• Increase RR• Increase PR
• Edema• Puffy eyelids
* If these signs occur, STOP fluids immediately and reassess the child’s condition after 1 hour.
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• When a child has watery diarrhea:• Start feeding straightaway• Replace the approximate volume of
stool losses with the modified rehydration solution.
• Encourage continued breastfeeding if the child is breastfed
STEP 3: Treat/ Prevent Dehydration
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Body Weight Method for Daily Maintenace Fluid
VolumeBody Weight Fluid Per Day
0-10 kg 100 mL/kg
11-20 kg 1,000 mL + 50 mL/kg for each kg > 10 kg
>20 kg 1500 mL + 20 mL/kg for each kg >20 kg*
* The MAXIMUM fluid per day is 2,400 mL
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Hourly Maintenance Rate
For Body Weight of:
0-10 kg 4 mL/kg/hr
10-20 kg 40 mL/kg/hr + 2 mL/kg/hr x (wt-20)
>20 kg 60 mL/kg/hr + 1 mL/kg/hr x (wt-20)*
* The maximum fluid rate is normally 100 mL/hr
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Step 4Correct Electrolyte imbalance
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• All severely malnourished children have TOO much sodium in their bodies.
• They also have potassium and magnesium deficiencies which may take at least 2 weeks to correct.
• Edema is partly due to this deficiencies
STEP 4: Correct Electrolyte
imbalance
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• Give• Extra potassium 2-4 mmol/kg/day• Extra magnesium 0.3-0.6 mmol/kg/day• Modified ORS solution (see step 3)• Prepare food without salt
• Extra potassium and magnesium can be prepared in liquid form and added directly during preparation
STEP 4: Correct Electrolyte
imbalance
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IVF CompositionFluid Na Cl K Ca Lactate
Normal Saline (0.9% NaCl)
154 154
½ Normal Saline (0.45%
NaCl)
77 77
0.2 Normal Saline (0.2%
NaCl)
34 34
Ringers Lactate 130 109 4 3 28
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Step 5Treat Infections
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STEP 5: Treat Infection
• Severe malnutrition: No Fever• Given routinely to ALL admission:
• Broad spectrum antibiotics• Measles vaccine to unimmunized• Metronidazole (7mg/kg tid for 7 days)*• Mebendazole: Children > 2 years
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Treat Infections: Antibiotics
• No complications Co-trimoxazole• Given for 5 days, twice daily
• If < 4 kg, give 2.5 ml • If > 4kg, give 5 ml
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Treat Infections: Antibiotics
• If severely ill + complications (lethargic, hypoglycemic, hypothermic, skin lesions) Gentamicin + Ampicillin• Gentamicin: 3.5 mg/kg IM or IV q12h for 7
days• Ampicillin: 50 mg/kg IM or IV q6h for 2 days
then shift to oral for 5 days
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Treat Infections: Antibiotics
• If fails to improve within 48h Gentamicin + Ampicillin + Chloramphenicol• Gentamicin: 3.5 mg/kg IM or IV q12h for 7
days• Ampicillin: 50 mg/kg IM or IV q6h for 2 days
then shift to oral for 5 days• Chloramphenicol: 25mg/kg IM q6h for 5
days
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• Poor appetite continues after 5-7 days of antibiotic, complete 10 day course.
• If still anorexic, fully RE-ASSESS the patient
STEP 5: Treat Infection
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Step 6Correct Micronutrient
deficiencies
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STEP 6: Correct micronutrient deficiencies
• Give• Multivitamin supplement• Folic acid 1mg/day• Zinc 2mg/kg/day• Copper 0.2 mg/kg/day
• Do NOT give Iron (3mg/kg/day) until the child starts gaining weight (2nd week of treatment
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Step 7Start cautious feeding
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Start cautious feeding in the stabilization phase (days 1-7)
• The amount and type of food given is important.
• Feeds should be started as soon as possible and provide just sufficient energy and protein to maintain basic physiological processes.
STEP 7:Start Cautious feeding
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Give:• Small, frequent feeds of a milk-based starter formula• 100kcal/kg/day• 1-1.5g protein/kg/day• 130mL/kg/day (100mL/kg/day if the child has
edema)• If the child is breastfed, encourage continued
breastfeeding (give starter formula first)
STEP 7:Start Cautious feeding
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• Very weak children may be fed by spoon, dropper, syringe (remove needle) or nasogastric tube
• During this phase, diarrhea should gradually diminish and children with edema should lose weight
STEP 7:Start Cautious feeding
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• A typical schedule for feeding is:
DAYS FREQUENCY VOL/KG/FEED VOL/KG/DAY1-2 2 hourly 11 mL 130 mL3.5 3 hourly 16 mL 130 mL
6-7+ 4 hourly 22 mL 130 mL
STEP 7:Start Cautious feeding
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Step 8Rebuild Wasted Tissues
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STEP 8: Rebuild Wasted Tissues• Rebuild wasted
tissues
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Frequent feeds (every 4 hours) of a catch-up diet with unlimited amounts150-220kcal/kg/day4-6g protein/kg/day
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Step 9Provide TLC
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Step 9: TLC• Stimulation, play, and loving
care
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Starting from admission, provide:1. tender, loving care2. structured play and physical activity as soon as the child is well enough3. a cheerful, stimulating environment4. mother’s involvement
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Step 10Preparation for follow up after
discharge
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Involve parents in feeding and playing with their child
Child= 90% weight-for-length can be considered to be ready for discharge
Good feeding practices and stimulation should continue at home
SOME POINTERS:
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The family should…
Give energy and nutrient dense foods at least 5x per day
Establish play time with the child so that mental development may improve
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Thank you!!