Role Of IAP In Advancing the Right Role Of IAP In Advancing the Right of All Children with SAM to Timely of All Children with SAM to Timely

and Quality Treatment In India and Quality Treatment In India (New Guidelines) (New Guidelines)

deepak ugra email: deepakugra@hotmail.com

IAP’s Mission Statement IAP’s Mission Statement

The Academy shall strive for the achievement of the optimum growth, development and health in the physical, emotional, mental, social and spiritual realms of all children irrespective of diversities of their backgrounds

SAM Management Guidelines SAM Management Guidelines

• IAP Guidelines on Hospital Based Management of Severely Malnourished Children (Adapted from the WHO Guidelines) – Indian Pediatr 2007; 44: 443-461

• National Workshop on “Development of Guidelines for Effective Home Based Care and Treatment of Children Suffering from Severe Acute Malnutrition”– Indian Pediatr 2006; 43: 131-139

• Consensus Statement: National Consensus Workshop on Management of SAM Children through Medical Nutrition Therapy

– Indian Pediatr 2010; 47: 661-665

SAM Management Guidelines SAM Management Guidelines

National Consultative Meeting on Guidelines by the Indian Academy of Pediatrics (IAP) for Management of Severe Acute Malnutrition

16th, 17th October 2010, Mumbai

Key areas of SAM consultation Key areas of SAM consultation

• Definition and active detection• In Patient Care• Out patient Care• Organizational issues• Training• Research priorities• Public and media participation• Role of IAP

Definition of Severe Acute MalnutritionDefinition of Severe Acute Malnutrition (Anyone of the following Criteria)(Anyone of the following Criteria)

• Weight/height or Weight/length < -3z score,

using the WHO Growth Charts

• Visible severe wasting

• Bipedal edema

• Mid-upper arm circumference (MUAC) < 115

mm

Active Detection of Children with SAM Active Detection of Children with SAM

• Early detection - before medical complications

• Health care providers to use every opportunity

• Undertaken at every health facility

MUAC is a simple measure- Good quality, non-stretchable, long lasting MUAC tapes to be available at every health facility.

Indications for Inpatient Care Indications for Inpatient Care

• Presence of a medical complication

• Reduced appetite (based on failed appetite

test)

• Presence of bilateral pitting edema

• Age < 6 months

In Patient care of SAM ChildrenIn Patient care of SAM Children

Day 1-2 Days 3-7 Weeks 2-6

Hypoglycemia

Hypothermia

Dehydration

Electrolytes

Infection

Micronutrients no iron with iron

Cautious feeding

Catch-up growth

Sensory stimulation

Prepare for follow-up

Ten Essential StepsTen Essential StepsStabilization

Rehabilitation

Appropriate Feeding above 6 moAppropriate Feeding above 6 mo

• F-75 can be used as an initial starting formula in the acute phase,

• F-100  in the rehabilitation phase.

If the child’s appetite is poor, nasogastric/ gavage feeding should be given initially

F 75 and F 100 formulaF 75 and F 100 formula

 IAP recommends F-75 and F-100 equivalents both milk and cereal based

NB: Full cream cow’s milk can be also be used

Indian Pediatr 2007; 44: 443-461

Composition of Conc. electrolyte-mineral Composition of Conc. electrolyte-mineral solsolnn Ingredient Mass(g) mol per 20mlPotassium chloride(KCl) 22424Tripotassium citrate 81 2Magnesium chloride (MgCl2.6H20) 76 3Zinc acetate (Zn accetate.2H20) 8.2 0.3Copper sulphate (CuSO4.5H20) 1.4 0.045

* To be added to dietUse water to make up to 2500 ml. If available, also add selenium (0.028 g of sodium selenate, NaSe4.10H20) and iodine (0.012 g of potassium iodide, KI) per 2500 ml.

Add 20 ml of the solution to a litre of diet

Feeding below 6 moFeeding below 6 mo

• Breastfeeding should be encouraged if there is prospect of continuing/reinitiating BF.

• Supplemental suckling technique can be used to support and enhance breastfeeding.

• F-75 if there is no prospect of continuing or re-initiating breastfeeding

Outpatient CareOutpatient Care

Before After

Experience shows it is feasible

Outpatient Care at (OTP) centreOutpatient Care at (OTP) centre

• Integration with existing health program: as a part of ICDS/ RCH-II/ IMNCI-ANM, NRHM-ASHA

• Health promotion: Counseling on breastfeeding, hygiene, immunization, nutrition Supplementation

• Nutrition therapy with high energy food - Home based food

- Ready to use therapeutic food (RUTF)

Ready to Use Therapeutic Food (RUTF)Ready to Use Therapeutic Food (RUTF)

• RUTF is anhydrous version of F 100 in semisolid form

-Long shelf life -less chance of contamination• Several RUTF preparations tried world over;

There are Indian versions of RUTF with varied composition

10% of 17 million SAM children worldwide received RUTF in 2010

Cautionary Note on RUTFCautionary Note on RUTF

• Use exclusively for SAM children

• Duration of use for 4-8 weeks only

• Prescribed product, restricting free

availability

• Public health system as sole procurement

agency

• Involvement of multiple producers, including

public sector

Outcome of treatment can be defined as Outcome of treatment can be defined as

Non-responder or Primary Failure (i) Failure to gain any weight for 21 days, (ii) Weight loss since admission to program for 14

days Secondary Failure or Relapse (i) Failure of Appetite test at any visit (ii) Weight loss of 5% body weight at any visit

Non-responders and children developing danger sign during first 4 weeks, should be referred to a hospital

Provide Sensory Stimulation Provide Sensory Stimulation and emotional Supportand emotional Support

• Tender Loving Care• Cheerful Stimulating Environment• Structured Play Therapy

(15-30 Min Daily)• Gradual Physical Activity• Maternal Environment

(comforting, bathing, feeding, play)

Criteria for discharge from facility > 6 moCriteria for discharge from facility > 6 mo

• Good appetite (eating at least 120-130 Cal/kg/d) along with micronutrients

• Lost edema• Consistent weight gain (>5gm/kg/d) on 3

consecutive days• Completed anti-microbial treatment• Appropriate immunization initiated• Mother or Care-taker: trained to prepare and

provide appropriate feeding

Criteria for discharge from facility < 6 moCriteria for discharge from facility < 6 mo

• Consistent weight gain on oral feeds and has no medical complications. Babies on breastfeeding should be showing this weight gain

• Training and involvement of the mother/ caretaker is an important aspect of inpatient care

• After discharge the child should be referred for further care to the appropriate OTP center

Discharge of SAM Cases from Program Discharge of SAM Cases from Program

All of the following criteria's need to be fulfilled

•Weight/Height by WHO growth charts: at least -2z score of WHO standard • MUAC >120mm   Thereafter, the child can be referred for usual health care program and growth promotion activities can be ensured by Health Care Workers and Providers  

Organizational Issues about ProgramOrganizational Issues about Program

• In- & Out patient care: One Integrated Program 

• Integrated with other existing health programs

• Trial in high-risk areas; scaling up the program

• Monitor no. of beneficiaries, mortality reduction

• It is necessary to encourage indigenous commercial production of RUTF/F75/F100 with strict quality control

Training in the Management of SAMTraining in the Management of SAM

• Health professionals and medical teachers should be enrolled as trainers for the program

• Training of healthcare providers; should be integral component of IMNCI training

• Pediatricians motivated and trained for taking a leadership role at national/state/district level

• Assessment of the effectiveness of training

• The Universities/MCI to include Management of SAM in the pediatric curriculum

Research PrioritiesResearch Priorities

• Appropriate starter diet, catch-up diet  and ready-to-use therapeutic food need to be encouraged

• Programmatic Research for assessing the cost-effectiveness of various interventions used in the program

Public and Media Participation

Public and Media Participation

Role of IAPRole of IAP

• Providing technical advice to the government regarding appropriate interventions and in formulating management guidelines and training modules

• Assisting by conducting training programs

• Public awareness and media participation

• Recommend MCI/Universities to include management of SAM in the medical curriculum