Dr. Mariama MustaphaSHO III- Paediatrics and Child Health

Makerere UniversityMwanamugimu Nutrition Unit, Mulago Hospital

OutlineIntroduction/Background

Conditions seen in MNU needing Surgical Interventions

Nutritional Rehabilitation in MNU

Role of the Paediatric Surgeons and Paediatricians

Conclusion

Introduction/BackgroundThe WHO defines malnutrition as “the imbalance

between the supply of nutrients and energy and the body’s demand for them to ensure growth, maintenance, and specific functions”.

It is estimated that 34 million children under the age of 5 each year are affected by severe acute malnutrition (SAM).

UNICEF 2012

Background: Uganda DHS 2011

BackgroundWork by Cooper and colleagues showed that

18% to 40% of paediatric surgical patients have malnutrition.

Paediatric surgical patients respond to surgical stress differently from older children or adults.

The metabolism of children is markedly affected by operative stress.

Herman R et al, 2011.

Conditions seen in MNU needing Surgical Interventions

Cerebral Palsy

Congenital Heart Diseases

Massive Pleural Effusion/Empyema

Cleft Lip/Palate

Burns

Conditions seen in MNU needing Surgical Interventions

Hydrocephalus

Pyloric Stenosis

Hirschsprung’s Disease

Oesophageal Stricture

Summary of Nutritional Assessment and Classification

Nutritional Rehabilitation: Outpatient Therapeutic Care (OTC)

Admission CriteriaChildren with SAM who have appetite, are

clinically well and alert and have oedema grade +/++

For MAM with HIV or TB

Transfers in

Relapse or readmission

Nutritional Rehabilitation: OTCDietary Therapy

Ready-to-Use Therapeutic Food (RUTF):Contains 500 kcal per 92gNeed calculated based on

175-200kcal/kg/day

Breastfeeding on demand.

Adequate safe drinking water while on RUTF.

Nutritional Rehabilitation: Inpatient Therapeutic Care (ITC)

Admission CriteriaChildren with Severe Acute Malnutrition with:

Medical complications

Severe 0edema (+++)

Poor appetite

IMCI danger signs

Nutritional Rehabilitation: ITCDietary Therapy

F-75

F-100

RUTF

SDTM

Isomil

Preoperative NutritionIn malnourished adults, provision of enteral

feedings preoperatively for 2 to 3 weeks may reduce:Postop wound infections

Anastomotic leakage

Hepatic and renal failure

Length of hospital stay

Data for PN support are less clear!Herman R et al, 2011

Postoperative NutritionWhen used, postop nutrition should be started

early using a combination of PN and EN until the GIT fully recovers.

In the postop period, there are higher infection rates in patients on PN.

Postop PN should be restricted to:Infants who do not tolerate enteral feedings.Older children who probably cannot tolerate EN for

at least 5 to 7 days.Herman R et

al, 2011

How Can We Work Together?Role of the Paediatric Surgeons?

Identify patients needing nutritional interventions

Consult/Refer

Role of the Paediatricians?Identify patients needing surgical

interventionsConsult/Refer

ConclusionMaintaining adequate nutrition of paediatric

surgical patients is critical.

Close follow-up is critical to maintain a child on target for growth objectives.

Paediatric Surgeons and Paediatricians need to work together to provide optimal nutrition support to paediatric surgical patients.