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Role Of IAP In Advancing the Right of All Children with SAM to Timely and Quality Treatment In India (New

Guidelines)
deepak ugra
email: deepakugra@hotmail.com

IAPs 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


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


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


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 Malnutrition (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


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


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 Children

Ten Essential Steps


Stabilization
Day 1-2 Days 3-7

Rehabilitation
Weeks 2-6

Hypoglycemia
Hypothermia Dehydration

Electrolytes
Infection Micronutrients
no iron with iron

Cautious feeding
Catch-up growth Sensory stimulation

Prepare for follow-up

Appropriate 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 childs appetite is poor, nasogastric/ gavage feeding should be given initially

F 75 and F 100 formula

IAP recommends F-75 and F-100 equivalents both milk and cereal based
Indian Pediatr 2007; 44: 443-461
NB: Full cream cows milk can be also be used

Composition of Conc. electrolyte-mineral soln


Ingredient Mass(g) Potassium chloride(KCl) 224 Tripotassium citrate 81 Magnesium chloride (MgCl2.6H20) 76 Zinc acetate (Zn accetate.2H20) 8.2 Copper sulphate (CuSO4.5H20) 1.4

mol per 20ml 24 2 3 0.3 0.045

* To be added to diet Use 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 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 Care

Before

After

Experience shows it is feasible

Outpatient 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)


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 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


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 and 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 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 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


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 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 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 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

Role 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

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