Nutrition

Nutrition is the intake of food, considered in relation to the body’s dietary needs. Good nutrition an adequate, well balanced diet combined with regular physical activity is a cornerstone of good health. Poor nutrition can lead to reduced immunity, increased susceptibility to disease, impaired physical and mental development, and reduced productivity.


recommended food for children in their very early years

Breast milk is the best food for the healthy growth and development of infants. Infants should be exclusively breastfed for the first six months of life to achieve optimal growth, development and health. After six months, they should be fed adequate and safe complementary foods while continuing breastfeeding for up to two years or beyond.
Complementary food is the additional nutrient-rich food and drink that is recommended for children from six months of life. The transition from exclusive breastfeeding to complementary feeding (which includes continued breastfeeding) typically covers the period from 6 to 18–24 months of age. This is a very vulnerable period as it is the time when malnutrition starts in many children. Thus it is essential that infants receive appropriate, adequate and safe complementary foods to ensure the right transition from breastfeeding to the full use of family foods.
These recommendations are made in the Global Strategy for Infant and Young Child Feeding, which was jointly developed by WHO and UNICEF in 2003.
The strategy is a guide for countries to develop policies and implement activities addressing feeding practices and the nutritional status, growth and health of infants and children. It is based both on the evidence that nutrition plays a crucial role in the early months and years of life, and on the importance of appropriate feeding practices in achieving optimal health.
Lack of appropriate feeding can set up risk factors for ill-health. The life-long impact may include poor school performance, reduced productivity, impaired intellectual and social development, or chronic diseases.

SELECTED ANTI-MALARIAL DRUGS: IMPORTANT INFORMATION

Quinine:

According to WHO, Quinine should only be used for uncomplicated malaria if alternatives are not available e.g. in areas of multi drug resistance and where P. falciparum does not respond to Chloroquine, sulphadoxine - pyremethamine etc. Quinine could be used as first line treatment for patients who fail to respond to Chloroquine and are hypersensitive to sulpha drugs.

Artesunate:

Use: Artesunate is a water soluble hemisuccinate derivative of dihydroartemisinin and is most widely used member of this family of dugs. It is effective against P. falciparum resistant to other operationally used anti-malarial drugs. It does not have hypnozonticidal activity. It also reduces gametocytes carriage rate. Artesunate is used for treatment of uncomplicated P. falciparum malaria. It should always be administered in combination with another effective blood Schizonticide to prevent recrudescence and delay the selection of resistant strains. The use of artesunate as monotherapy should be limited to specific indications, such as patient with a history of adverse reactions to the combination drug.  WHO does not recommended Artesunate for the treatment of vivax malaria since other effective anti-malarial drugs are available for this purpose.

 Dose:  for treatment of uncomplicated P. falciparum malaria, Artesunate should be used combination with other effective schizonticide. The recommended dose is: 4 mg/Kg body weight once a day for 03 days, plus sulphadoxine- pyremethamine as single adult dose of 1500 mg of sulpha drug + 75 mg of pyremethamine on first day (25 mg Sulphadoxine and 1.25 mg of pyremethamine per Kg body weight, as a single dose).

SELECTED ANTI-MALARIAL DRUGS: IMPORTANT INFORMATION

Primaquine:

Use:  Pramaquine is 8-aminoquinoline highly active against gametocytes of all malaria species. It is also effective against hypnozoites of the relapsing malarial parasites of P. vivax. It is the only drug currently used for treatment of relapsing malaria. It is used along with chloroquine in P. vivax infections as an anti-relapse therapy and in P. falciparum infections as a gametocytocidal drug (mature gametocytes of P. falciparum are unaffected by chloroquine).

Dose:  P. vivax: 0.25 mg base per Kg body weight per day for 14 days.
            P. falciparum: 0.75 mg / Kg body weight as single dose.

Primaquine may be given concurrently with an active blood Schizonticide, such as chloroquine.

Side Effects: it can cause a fatal hemolytic crisis in patients with glucose-6-phosphate dehydrogenase deficiency. The symptoms are dose related and are relatively rare at daily dose of 0.25 mg of base per Kg body weight (15 mg of base daily in adult). The symptoms include nausea, vomiting, abdominal pain and cramps. It can also cause granulocytopenia. Patients should be warned to stop treatment and seek medical advice if they have abdominal pain, become weak or pale or notice darkening of urine. Gastric intolerance can be avoided by administering the drug with food.

Contra-indications: Primaquine should not be used in children below 04 years of age and in pregnant women, due to risk of hemolysis. It should also not be used in conditions pre-disposing to granulocytopenia, including active rheumatoid arthritis and lupus erythematosus . Primaquine should not be administered with any other drug that may induce hematological disorders.

Over Dosage: Weakness, cyanosis, nausea, vomiting, hemolytic anemia, jaundice and bone marrow depression may occur with over dosage. There is no specific antidote and treatment is symptomatic.

Pre-cautions: Primaquine should be used very carefully in known G6PD deficient patients. Patients should be warned to stop treatment and seek medical advice if they have abdominal pain, become weak or pale or notice darkening of urine.      

SELECTED ANTI-MALARIAL DRUGS: IMPORTANT INFORMATION

Sulfhadoxine-Pyrimethamine:

Use: it is used in combination with artisunate in co-blister packing for confirmed P. falciparum infections and during malaria epidemics.

Dosage:  Sulfhadoxine-Pyrimethamine is recommended as single adult dose of 1500 mg of Sulpha drug plus 75 mg of Pyrimethamine (25 mg Sulphadoxine and 1.25 mg of Pyrimethamine per Kg body weight, as a single dose). This comprises 03 tablets.

Side effects: The combination is generally well tolerated when used at the recommended doses for treatment of malaria. The Sulpha components may be associated with serious skin rashes and impairment of folic and metabolism. Rare side effects include Hepatitis, thrombocytopenia, megaloblastic anemia and leukopenia.

Contra-indication: it is contra-indicated during the first trimester of pregnancy and children below 02 months of age, in persons with known-hypersensitivity to Sulpha drugs or Pyrimethamine, in persons with severe hepatic or renal dysfunction. It is not recommended for chemoprophylaxis.

Over dosage: High doses of combination are highly fatal. Symptoms include headache, anorexia, nausea, vomiting, excitation and possibly convulsions and hematological changes. In case of acute intoxication, indication of emeses or gastric lavage is useful if undertaken with in few hours of ingestion. Convulsions can be controlled with diazepam.      

SELECTED ANTI-MALARIAL DRUGS: IMPORTANT INFORMATION

Chloroquine:

Use: Chloroquine is a 4-aminoquinoline that has marked and repaid schizonticidal activity against Chloroquine sensitive infection of P. falciparum and P. vivax. It is also gametocytocidal against P. vivax and immature gametocytes of P. falciparum. It is not effective against tissue stages (intrahepatic forms) of P. vivax and should therefore, be used with Primaquine to effect remedial cure of P. vivax. According to WHO Chloroquine can be given throughout pregnancy and to children of all ages if there is no specific contra-indication for it.

Dose: 25 mg of Chloroquine base per Kg body weight given over a period of 03 days. This consists of 10 mg per Kg body weight on the first and second day and 05 mg per Kg body weight on the third day.

Side effects: According to WHO, serious adverse reaction to Chloroquine are rare at the usual Anti-Malarial dosage, but some people may feel itchy after taking Chloroquine and you may see them scratching. Occasionally Chloroquine may cause transient headaches, nausea, vomiting, gastrointestinal symptoms and blurred vision. This may be avoided by taking the dose after meals. These effects are not dangerous, and they will disappear soon after the 03-day treatment.

Contra-indication: Chloroquine should not be used in persons with known hypersensitivity to Chloroquine, with a known history of epilepsy or suffering from skin disease like psoriasis.

Over-dosage: Chloroquine has a low safety margin. Acute Chloroquine poisoning is extremely dangerous and death may occur within a few hours. Symptoms and signs of poisoning include headache, nausea, diarrhea, dizziness, muscular weakness and blurred vision. The main effects in on the cardio-vascular system leading to hypotension and cardiac arrhythmias progressing to cardio-vascular collapse, convulsions, cardiac and respiratory arrest and death. If a patient is seen within few hours of administration of the event, emesis must be induced or gastric lavage undertaken as rapidly as possible. If not, treatment is symptomatic and directed particularly to sustaining cardiovascular and respiratory function.

Precautions:  There is very little difference between the therapeutic and toxic doses. Oral ingestion of 2-3 times the daily dose can be dangerous. All medicines, especially Chloroquine should be kept out of the reach of children. Intramuscular Chloroquine should be avoided if the patient is able to take medicines orally (as this may result in cardiac arrest).  

ADMINISTERING ANTI-MALARIAL DRUGS: ALWAYS REMEMBER

Anti-Malaria should be given by weight, especially in children.

Chemoprophylaxis is not recommended in Pakistan. 

While administering Chloroquine

P. vivax is fully susceptible to Chloroquine.

Intra-muscular or intravenous injections of Chloroquine should never be given. This

can cause sudden cardiac arrest. 

While administering Sulfadoxine +pyremethamine (SP)

SP is not recommended for children under 2 months and during first trimester of pregnancy.

SP is not effective against Plasmodium vivax malaria. 

SP is also not recommended in patients with known sensitivity to sulpha drugs. 

While administering Primaquine

            Primaquine should be given with Chloroquine only to microscopically confirmed vivax cases.

            Primaquine should not be given to pregnant women and children under 4 years of age. 

            Primaquine should not be given to patients known to have Glucose-6-Phosphate Dehydrogenase

            (G-6-P) deficiency. 

            Primaquine should not be given to patients who have received a complete dose of Artesunate + SP. 

Confirming Malaria Diagnosis:

The patient with suspected malaria (uncomplicated or severe) requires laboratory investigations (i.e. microscopy or rapid diagnostic test for MP) to confirm the diagnosis.

Microscopy is cost effective, fairly sensitive and highly specific. Microscopic examination of blood smear for MP, where found feasible, is still considered a gold standard for diagnosing malaria. Microscopy can estimate parasite density and differentiates between parasites and its species, provides information about platelets and leukocytes and help diagnose many other conditions. Giemsa stained thick and thin blood smears should be examined in all malaria suspected patients. A thick smear should be examined in all suspected cases of malaria because of its ability to detect parasites even with the low parasitemia. A thin film is used for identification of species and stages of parasites. High parasitemia, growing stages of parasites (trophozoites and schizonts) and pigment-laden neutrophils indicate poor prognosis. If any of the above are detected the doctor should be informed to help in making the decision about referral of the patient to hospital. In case of uncertainty of identification of parasite species in severe malaria patients, it should always be considered as P. falciparum.

The laboratory staff examines the blood smear for malaria parasite (MP) and records the results in the laboratory register. On the same day he/she reports the results to the doctor on the patient OPD ticket. The result is reported on OPD ticket as follows:

1.       Plasmodium vivax seen.

2.       Plasmodium falciparum seen.

3.       Plasmodium vivax and falciparum seen.

4.       Malaria parasite not seen.

Rapid diagnostic tests (RDT) for diagnosing malaria are fairly sensitive and specific. These tests are fast and simple. The rapid diagnostic tests are based on detection of parasite-derived proteins circulating in the whole blood. They are particularly helpful in diagnosing partially treated cases and those with very low parasitemia, when the microscopy is negative, or microscopy services are not available or not reliable. The rapid diagnostic tests are able to detect the presence of plasmodium falciparum and vivax in malaria patients.  

How to do the Rapid Test for Malaria

SEVERE MALARIA:

Severe Malaria is defined as severe manifestation of malaria that may contribute to major organ dysfunction or failure (e.g. coma, renal failure or pulmonary edema) or even death if treatment is not proper or urgent. Severe malaria is mainly caused by Plasmodium falciparum but not all cases of P. falciparum are severe. The treatment of this condition requires hospitalization and specialist care.

                                  

In case of P. falciparum infection the symptoms usually begin 10 to 35 days after mosquito injects the parasite. Initial “prodromal” symptoms are followed by the paroxysms. Unlike other forms of malaria the paroxysms are not regular and patients often do have fever between the paroxysms. The parasite load is high in falciparum infection because this type can infect red blood cells of any age. This is one of the reasons for severity of malaria caused by P. falciparum. The most important and potentially fatal complication is cerebral malaria that occurs commonly in infants, pregnant women and non-immune travelers to high-risk areas. Untreated P. falciparum malaria is fatal in about 20% of people and prompt and adequate treatment is required to prevent fatalities.

The case of severe malaria mainly presents with history of fever (in the last 03 days) with one or more of the following manifestations:

v  Cerebral manifestations

·         Altered consciousness and/ or behavior.

·         Convulsions (more than two generalized seizures in 24 hours)

·         Coma (Unrousable coma, not attributable to any other cause)

v  Circulatory manifestations:

·         Dehydration

·         Circulatory overload (Bilateral basal crept, raised JVP, dependent edema)

·         Circulatory collapse (systolic BP < 80 mm Hg in adults, with cold clammy skin)

v  Acute renal manifestations:

·         24 hours urine output < 400 ml in adults or 2 ml/kg body weight in children or anurea.

·         No improvement with dehyderation

·         Serum creatanine > 03 mg/dl or 265 mmol/L

·         Hemoglubinuria

v  Respiratory manifestations:

·         Pulmonary edema or difficult breathing

·         Acute respiratory distress syndrome.

v  Blood related manifestations:

·         Severe anemia (hemoglobin < 05gm/dl or hematocrit less 15%)

·         Significant bleeding / disseminated intra-vascular coagulation

v  Metabolic manifestations:

·         Hypoglycemia (blood glucose less than 2.2 mmol/L or < 40 mg/dl)

·         Metabolic acidosis (Arterial ph < 7.25 or plasma bicarbonate < 15 mmol/L, venous blood lactate > 6 mmol/L)

v  Other manifestations:

·         Jaundice

·         Hyperparasitemia (parasite count > 10,000 parasites / micro litter of blood)

These severe malaria manifestations can occur singly or, more commonly, in combination in the same patient. Severe malaria can mimic many other diseases. The most important of these are all types of meningitis, typhoid fever and septicemia. Other differential diagnosis include influenza, dengue and other arbovirus infections, hepatitis, the relapsing fevers, hemorrhagic fever, all types of viral encephalitis (including rabies) and gastroenteritis.

In pregnant women malaria must be distinguished from sepsis arising in the uterus, urinary tract or breast. In children convulsions due to severe malaria must be differentiated from febrile convulsions. In febrile convulsions patients regain consciousness in 30-60 minutes.

Malaria Parasites Detail View