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Summarized CPG and PFC

The document discusses clinical practice guidelines for treating pediatric patients under 5 years old presenting with malnutrition. It outlines the guidelines, incidence rates of malnutrition by age group, and principles of management including maximum coverage, timeliness, appropriate medical care, and continued care as needed. It then presents a hypothetical case of a 6-month-old male patient presenting with failure to thrive and signs of kwashiorkor. The patient's history, exam findings, assessment, and a PFC matrix for developing a patient-centered, family-focused, and community-oriented management plan are discussed.

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0% found this document useful (0 votes)
36 views62 pages

Summarized CPG and PFC

The document discusses clinical practice guidelines for treating pediatric patients under 5 years old presenting with malnutrition. It outlines the guidelines, incidence rates of malnutrition by age group, and principles of management including maximum coverage, timeliness, appropriate medical care, and continued care as needed. It then presents a hypothetical case of a 6-month-old male patient presenting with failure to thrive and signs of kwashiorkor. The patient's history, exam findings, assessment, and a PFC matrix for developing a patient-centered, family-focused, and community-oriented management plan are discussed.

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CPG and

PFC matrix
of under 5
malnutrition
Deshmukh, Kanchan C
Fahim Ameer
Objectives of this discussion

1. To discuss the Clinical Practise Guidelines that help physicians make decisions about
appropriate healthcare for Pediatric patient under the age of 5 presenting with malnutrition
2. To discuss a hypothetical case of a Pediatric patient presenting with malnutrition
3. To present and discuss the PFC matrix for the said index patient in our hypothetical case.
Clinical Practice Guidelines
MUAC- Mid upper arm circumference
WFL/H- Weight for length/ height
The highest incidences within this population are among children below 6 months (10.9 %),
children 6-11 months (11.6 %) and children 12 to 23 months (9.2 %). Approximately, a million
children aged 0-5 years are affected by acute malnutrition and more than 700,000 are suffering
from moderate acute malnutrition.
PIMAM has four principles:
● maximum coverage – to bring to treatment as many people as possible, with
the most affordable and accessible services available;
● timeliness – to detect acute malnutrition early and start treatment before the
onset of life threatening conditions;
● appropriate medical care and nutrition rehabilitation – to ensure efficiency of
programs and services on nutrition, it is important to provide the proper
treatment of cases by the proper providers; and
● care as long as needed – to reduce barriers to access and ensure that children
stay in the program until they recover.
Step 1. First locate the tip of the shoulder (1) of the left arm.
Step 2. From the tip of the shoulder (2), with the elbow bent, find the tip of the elbow (3).
Step 3. Place the tape at the tip of the shoulder and extend it to the tip of the elbow (4 and
5).
Step 4. Mark the midpoint between the two (6).
Step 5. Then, slide the tape around the midpoint and take the reading.
Step 6. Feed the end of the tape down through the first opening and up through the third
opening. Read the measurement from the middle window where the arrows point inward.
Read the number in the box that is completely visible in the middle window
Step 7. Use enough tension to hold the tape against the skin but not pull the skin (7). If the
tape is too tight where the skin in pinched (8) or too loose where the tape isn’t touching the
skin (9), the measurement will be inaccurate.
Step 8. Immediately record the measuremen
Hypothetical case
General Data:
Name - A.B.
Age- 6 month old
Gender - Male
Religion - Catholic
Birthday: June 01 2022
Address: Gen T De Leon, Valenzuela
First consult at our institution

Chief complaint:
Failure to thrive
Hypothetical case
HISTORY OF PRESENT ILLNESS
4 months prior to consult, during his regular check up in the clinic, it was noted that
patients weight continued to rise through the second month but began to fall below the -2SD in
the third month and below -3SD in the fifth month. Over this period, he was assumed to be
thriving, as neither parent noticed any physical changes. He had a poor appetite and normal
bowel function.
Hypothetical case
PAST MEDICAL HISTORY
A. Perinatal History: Patient was born full term at 38 weeks 2 days via NSD with a
birthweight of 2.42kg at a private institution to a 23 year old G1P1 (1001). The mother
claimed that she was compliant with her prenatal check up as well as in taking the
prescribed supplements for pregnancy. The rest of the pregnancy was unremarkable and
also not exposed to any radiation and teratogens. There were no complications during the
delivery. APGAR score was unrecalled. Both mother and baby were discharged after one
day hospital stay and were advised for sunlight exposure early in the morning.
B. Feeding History: He was breastfed exclusively until he reached two months, at which
point the mother stopped breastfeeding due to inadequate milk supply. He was then fed
sweetened condensed milk, water, and occasionally plain rice and the patient would eat 3
to 4 times a day.
Hypothetical case
C. Developmental and Behavioural History: Patient’s mother denies any developmental
abnormalities or delays.The baby was able to hold the head without head lag, had
unclenched hands, was alert to human voice, at 3 months old and just started to roll over
a few days ago. No monosyllabic babbling was exhibited.

D. PAST ILLNESSES: The patient has no history of childhood diseases reported. No history
of past hospitalizations. Patient's mother denies any history of surgery and blood
transfusion. Patient has experienced episodes of allergic rhinitis a couple of times. No
history of trauma and accidents as claimed by the father. Newborn screening and hearing
tests were performed which were both normal.

E. IMMUNIZATION HISTORY: The patient’s mother claimed that the patient received BCG
hepatitis B vaccines at birth. No other immunizations given.
Hypothetical case
Family history: SOCIOECONOMIC/ ENVIRONMENTAL
HISTORY
(+) HTN (maternal grandparents) The patient’s father is the main provider of the family
(+) DM (maternal grandparents) and is a jeepney driver. Mother is a housewife.. The family
(-) TB lives in a small 2 room house well-ventilated and
well-lighted. The source of drinking water is mineral water.
(-) Heart disease
Garbage is disposed once or twice a week. Both parents do
(-) Malignancy
not smoke and do not drink.
(-) Thyroid disease
Hypothetical case
REVIEW OF SYSTEMS:
General: (-) Chills (-) Weight gain (-) Weakness
Cutaneous: (-) Pigmentation (-) Hair loss, (-) Petechiae (-) Rash (-) Pigmentations
HEENT: (-) Headache (-) Dizziness (-) Visual difficulty (-) Hearing difficulty (-) Lacrimation
(-) Epistaxis (-) Salivation (-) Swollen gums (+ tooth eruption
Cardiovascular: (-) Orthopnea (-) Cyanosis (+) Easy fatigability (-) Fainting spells
Respiratory: (-) Anosmia
Gastrointestinal: (-) Constipation (-) Passage of worms (-) Diarrhea (-) Abdominal pain
Genitourinary: (-) Polyuria (-) Frequency (-) Hematuria (-) Dysuria (-) Discharge
(-) Discoloration of urine (-) Discharge
Endocrine: (-) Heat Intolerance (-) Cold Intolerance (-) Polyuria (-) Polydipsia (-) Polyphagia
Nervous/Behavioral: (-) Seizures (-) Changes in Consciousness (-) Tremors (-) Sleep problem (-) Convulsion
Musculoskeletal: (-) Joint Stiffness (-) Joint Swelling (-) Bone Deformity (-) Limitation of motion (-) Stiffness
Hematopoietic: (-) Easy Bruisability (-) Pallor
Hypothetical case
Physical examination:

General Survey: Awake, alert, not in cardiopulmonary distress


VITAL SIGNS:
HR: 140 bpm
RR: 22cpm
Temperature: 36.5C
O2 Sat: 98% at RA

Anthropometric measurements:
Weight: 4.5kg
Length: 59.5cm
MUAC: 11cm
Physical examination
Skin: Brown in color, flaky skin, warm to touch, good skin mobility and turgor, no mass, no scaling, no abrasions, no
rash, no cyanosis, black short hair, equally distributed.
HEENT: Head is normocephalic, symmetric head, closed anterior and posterior fontanelles with no mass, no bulging,
no abrasions or lesions. Sparse hair, brown in colour, evenly distributed. Prominent cheeks, anicteric sclera, pinkish
palpebral conjunctiva, non sunken eyeballs, midline nasal septum, no alar flaring, no neck mass, no cervical
lymphadenopathy, (-)NAD,no active gum bleeding.
Chest and Lungs: Symmetrical chest expansion, no retractions, no rales on both lung fields, clear breath sounds
Heart: Adynamic precordium, with normal heart rate and regular rhythm, no murmur.
Abdomen: flat, soft, distended abdomen, normal bowel sounds, non tender
Extremities: Grossly normal extremities, (+) edema on both lower extremities, no cyanosis. No involuntary
movements with full and equal pulses, cold extremities, CRT <2 seconds.
Neurologic exam: No motor and sensory deficit

Motor Sensory Deep Tendon Reflexes

5 5 100% 100% ++ ++
5 5 100% 100% ++ ++
Reference: case report
Malaysian Family Physician 2020; Volume 15, Number 2
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7430309/
Clinical impression
SEVERE ACUTE MALNUTRITION
KWASHIORKOR

Basis:
● (+) growth retardation
● (+)protruding abdomen
● (+)moon facies
● (+)sparse hair
● (+)symmetrical peripheral edema
Assessment
Management
PFC matrix
Patient centered
Family focused
Community oriented
Patient centered
Components Patient - Centre

Data ● 6 month old male


● CC: unsatisfactory serial weight gain
● Birthweight - 2.42 kg
● Current Weight - 4.5kg, Length: 59.5cm BMI: 12.5 kg/m3 under weight
● The mother reported to have breastfeed exclusively only for 2 months. After that sweetened
condensed milk, water and plain rice was introduced.
● poor appetite, pitting edema,
● developmental assessment showed that he is able to lie prone in the supine position and able to
bear weight while standing. He exhibited no monosyllabic babbling.

Analysis / Diagnosis / 6 month old male, failure to thrive, underweight, severely malnourished
Conclusions / Assumptions Diagnosis:- Kwashiorkor

Management / Interventions ● Prevent and treat the following:


Hypoglycemia
Hypothermia
Dehydration
Electrolyte imbalance
Infection
Micronutrient deficiencies
● Provide special feeds for the following:
Initial stabilization
Catch-up growth
Provide loving care and stimulation
Prepare for follow-up after discharge
● Complete vaccinations.
Family focused
Components Family focused

Data Family History


Family genogram
● Has closely-knit family, nuclear type of family
● Patient is living together with mother and father
Family life cycle stage
● Parenting

Analysis Family Systems Assessment


Family Circle
● The Patient has a good relationship with family.
● Highly functional family (APGAR SCORE 9) with good relationship with each other.
Impact of illness
● The illness does not disrupt normal family relations. The patient is not performing daily
Activities well. The other family members can still perform daily activities without hindrances.

Diagnosis / Conclusions / Assumptions There is no hereditary and co morbidity in the family.

Management / Interventions The family could be counselled by the doctors to help in preventing complications in the future.
Advice for routine check up.
We should also encourage the family to have an annual check up by the doctor.
● Family Wellness Plan
● Periodic Health Assessment
● Counselling on prevention strategies
Ecomap Family Map
Community oriented
Components Community oriented

Data Patient is living in Valenzuela City. He is actively playing with mother and
father overall, their community fighting poverty has poor sanitation and is
lacking nutritional education for newborns and children.

Analysis Patient growth and development has not achieved to normal extent. He lives
in a community where he has no access to healthy foods but have good
access to pharmacy, clinics, and health centers. Thus, medical care is
accessible.

Diagnosis / Conclusions / Assumptions Early detection of the diagnosis may help the community be aware of the
diagnosis in order to seek help as well.

Management / Interventions ● Achieving coverage


● Community sensitization
● Case finding and referral
● Follow up of children with malnutrition
Thank you!!
Mission
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Milestones reached

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