guidelines for the integrated management of severe acute malnutrition

More documents

Recommendations

Info

ACF-In Guidelines for the integrated management of SAM In-patient: SAM and HIV/AIDS 96 pharmacokinetics have not been assessed in the severely malnourished child 155 . They particularly affect mitochondrial function [111] 156 , which is already compromised in the severely malnourished child [109,112]; the degree of dysfunction is related to mortality and any further mitochondrial insult is likely to have serious effects. Furthermore, there is excessive mortality of patients shortly after commencing ART, that appears to be related to nutritional status [107,113]; initiation of ART and other long-term treatment of illnesses that are not immediately lethal should be delayed until the metabolism of the major organs has improved through nutritional therapy. Other drugs used in HIV/AIDS patients with opportunistic infections are particularly toxic to the malnourished patient (e.g. Amphotericin B). There are also major interactions between ARV drugs and some of the drugs that may be used in severe malnutrition. For example co-artem and rifampicin should be avoided at the same time as some of the ARVs. These interactions are likely to be even more serious in the malnourished patient who already has a compromised hepatic function. This is another cogent reason why the treatment of HIV with ARVs should be delayed until the drugs used in malnutrition have been administered. In areas where there is a high prevalence of HIV there is a danger of patients being enrolled in both programmes where either the nutrition team or the staff of other programme is unaware of the potential drug interactions in the malnourished patient; with ARVs then alternative anti-malarial and TB drugs may be indicated. Rifampicin-isoniazid appears to have a particular hepato-toxicity in the malnourished patient and should be avoided until the nutritional status of the children has improved [114]. � The treatment of malnutrition should be started at a minimum two weeks before the introduction of anti-retroviral drugs to diminish the risk of serious side effects from the antiretroviral drugs. Preferably anti-retroviral treatment should be delayed until the recovery phase is well established in OTP. Children with HIV should be given co-trimoxazole prophylaxis against pneumocystis pneumonia. This is inadequate antibiotic cover for the severely malnourished patient; amoxicillin should be given in addition to prophylactic doses of co-trimoxazole. � Once the patient’s SAM is being treated satisfactorily and s/he have had adequate amounts of the essential nutrients to resist the toxic effects of the drug treatment HIV and TB, treatment should be started and should follow the national guidelines. Children with SAM and TB should not be immediately transferred to a TB centre where they have little experience in treating SAM; the treatment of the SAM takes precedence in view of the respective mortality rates. The treatment of TB can be carried out within the IMAM programme more easily and efficiently than the treatment of SAM at a TB centre. There are major opportunity costs for families to attend clinics, particularly if the clinic is distant from their home. This is one of the main reasons for promoting out-patient management of severe malnutrition. If the child has HIV then it is extremely likely that the mother also is infected. The clinic that looks after the mother should also care for the child; the parent should not have to make two visits to the clinic, one for herself and the other for her child. The care and treatment centres that have been established for HIV should not only see both the mother and child together, they should also be able to provide treatment for severe malnutrition and TB, on an out-patient basis according to this protocol. There should be access to in-patient facilities 155 In moderately malnourished children in Malawi the pharmacokinetics of Nevirapine is not abnormal. Toxicity was not assessed [110]. 156 The nucleoside reverse transcriptase inhibitors (NRTI) which are the backbone of ART treatment are associated with mitochondrial toxicity in children comparable to children with congenital mitochondrial disorders and NRTI-exposed adults; they may develop serious lactic acidosis, pancreatitis, cardiomyopathy and neuropathy. Children with severe malnutrition already have mitochondrial abnormalities making them much more vulnerable than well-nourished children.
ACF-In Guidelines for the integrated management of SAM In-patient: SAM and HIV/AIDS 97 where the complicated cases and those without appetite can undergo acute phase treatment in association with the HIV care and treatment team/centre. Similarly, TB programmes should always also screen for nutritional status and offer treatment along with the DOTS and other TB programmes. Indeed, HIV, TB and SAM services in most regions should be integrated administratively and operationally.
Page 1 and 2:
�� ACF INTERNATIONAL GUID
Page 3 and 4:
ACF-In Guidelines for the integrate
Page 5 and 6:
Page 7 and 8:
Page 9 and 10:
Page 11 and 12:
Page 13 and 14:
Page 15 and 16:
Page 17 and 18:
Page 19 and 20:
Page 21 and 22:
Page 23 and 24:
Page 25 and 26:
Page 27 and 28:
Page 29 and 30:
Page 31 and 32:
Page 33 and 34:
Page 35 and 36:
Page 37 and 38:
Page 39 and 40:
Page 41 and 42:
Page 43 and 44:
Page 45 and 46: ACF-In Guidelines for the integrate
Page 95: ACF-In Guidelines for the integrate
Page 147 and 148:
Page 149 and 150:
Page 151 and 152:
Page 153 and 154:
Page 155 and 156:
Page 157 and 158:
Page 159 and 160:
Page 161 and 162:
Page 163 and 164:
Page 165 and 166:
Page 167 and 168:
Page 169 and 170:
Page 171 and 172:
Page 173 and 174:
Page 175 and 176:
Page 177 and 178:
Page 179 and 180:
Page 181 and 182:
Cover photography: © ACF, Anne-Dom
show all

guidelines for the integrated management of severe acute malnutrition

Create successful ePaper yourself

Delete template?

Save as template?