10. Severe Malnutrition

8/3/2019 10. Severe Malnutrition

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Dr. Emmanuel AmeyawDepartment of Child Health

Kath, Kumasi


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INTRODUCTION CLASSIFICATION

SIGNS

HYPOTHESIS REDUCTIVE ADAPTATION

MANAGEMENT

STATISTICS


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About 20 million children are affected bysevere acute malnutrition globally,

Leading cause of death in children indeveloping countries,

contributes to 5060% of all child deaths,

Mortality rates for children with SAM are 5 to20 times higher compared to well-nourished

children


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1 million to 2 million preventable child deathseach year

Only about 15% get hospital admission

28% of children under 5 years of age areunderweight.


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Malnutrition is defined as the failure of cells toperform their physiological functions due toinability receive and use the energy andnutrients needed, (in terms of amounts, mix

and timeliness).Severe malnutrition is characterized by

Severe wasting ( weight for height < 70% or


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Primary malnutrition refers to malnutritionresulting from inadequate food intake

Secondary malnutrition refers to malnutritionresulting from increased nutrient needs,decreased nutrient absorption, and orincreased nutrient losses.

Micronutrient malnutrition

Macronutrient malnutrition


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Weight for height of


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Syndromic classification Kwashiokor

Marasmus

Marasmic Kwashiokor

Gomez 1st degree .. .. Wgt between 90% and 75%

2nd drgree .. .. 75% and 60%

3rddegree.. Below 60%


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Wellcome Weight between 80% and 60% (expected weight)

EdemaKwashiokor

No edemaundernutrition

Weight below 60% Edema marasmic kwashiokor

No edema marasmus

Jelliffe

1st degree wgt between 90 and 80% (expected wgt) 2nd degree wgt between 80 and 70% (expected wgt)

3rd degree wgt between 70 and 60% (expected wgt)

4th degree below 60% (expected wgt)


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McLareen Mild: wgt between 90 and 80% (expected)

Moderate: wgt between 80 and 70% (expected)

Severe: wgt below 70% (expected)

Waterloo Acute: wasted but not stunted

Wgt for height is low, height for age is normal

Chronic: wasted and stunted

Wgt for height low, height for age low


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1. Severe wasting: Loss of fat and muscle (skin and bones)

Front view: ribs easily seen and skin of upperarm and thighs look loose.

Back view: ribs and shoulder bones easily seen,flesh missing from the buttocks, folds of skinson buttocks and thighs (wearing baggy pants)


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2. Oedema of both feet: The retained addedto the weight therefore weight for height > -3SD.

Rating of oedema:

+ mild: both feet++ moderate: both feet + lower legs + hand

or lower arms

+++ severe: generalised (moderate + face)


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3. Dermatosis Occurs in oedematous malnutrition than wasted

child.

Range from patches of abnormal pigmented skin

(light and dark) to shedding, ulceration andweeping lesion.

Affects perineum, groin, nappy areas, limbs, behindears, armpit and face


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4. Eye Signs: Vit. A deficiency

Night blindness Conjunctivitis xerosis

Bitot spot Corneal xerosis Cornea ulceration Cornea scar

Infection Pus


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In severe malnutrition, the systems almostshut down or slow down in order to allowfor survival on the barest minimum energyrequirements.

Almost all the major organs are affected


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HISTORY Frequency of feeding

Recent appetite

Usual diet before current illness When last child ate normally

Breastfeeding history

Birth history

Social/Family history


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MEDICAL HISTORY Vomiting & diarrhea Episodes of fever Chronic cough Birth weight Birth rank and intervals Immunizations Milestones reached before current illness


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Typical signs of malnutrition Signs of shock

Signs of infections or heart failure

Temperature, pulse, and respiratory rate Eye signs,

Mouth; sore tongue, thrush etc

Skin lesions

ENT, Chest Organomegaly, especially the liver, spleen

Lymph nodes


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Blood film for Mps Full blood count

Chest x-ray

Urine RE & Culture Stool RE & Culture

VCT-where the suspicion is there


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Weight for height of


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Prevent or Treat Hypoglycemia Prevent or Treat Hypothermia Prevent or Treat Dehydration Correct Electrolyte Imbalance

Treat and Prevent Infections Correct Micronutrient deficiencies Start Cautious feeding Give Catch-up diet Provide TLC and play and stimulation Prepare for Follow-up and discharge


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Phases Initial phase

Stabilization phase(1-2)

Transition phase (3-7)

Rehabilitation phase(2-6wks)

Follow ups (7-26 wks)


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MINERALS Potassium 2340mg

Magnesium 146mg

Zinc 40mg Copper 5.6g

Iodine 154mcg

Selenium 94mcg


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Vitamin A 3000mcg Vitamin D 60mcg

Vitamin E 44mg

Vitamin C 200mg Vitamin B1 1.4mg

Vitamin B2 4mg

Vitamin B6 1.4mg

Vitamin B12 2mcg


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Vitamin K 80mcg Biotin 0.2mg

Folic acid 700mg

Patothenic acid 6mg Niacin 20mg


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F 75 F 100

Suji

RUTF


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Treat infections and other medical problems Provide sufficient energy and nutrients to

stop further loss of muscle and fat

Revive the cells and organs that are almostdormant


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Provide extra energy and nutrients for rapidweight gain

Start stimulating the child to improve mentaland motor development

Start educating carer on how to continuecaring for the child after discharge


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Starter formula (F 75 here) Must contain milk, sugar and oil

Must be low in sodium and protein and highin sugar

Must be fed in small amounts every 3 hoursday and night. Feed very ill children 2hrly.


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Feed by NGT if a child; Is lethargic and refuses to eat

Has refused or vomited the last 2 consecutivefeeds

Is taking


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Child is active and smiling Edema resolving or resolved

Increased appetite

Continue with F 100 or RUTF


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Catch-up diets are high in energy and proteinand some micronutrients

It contains more milk and oil and less sugarthan starter formula

Rapid weight gain Give high energy snacks such as bread and

margarine, banana between feeds

Avoid salty foods

Weight gain should be aimed at 10g/kg/day


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In severe malnutrition, theres delayedbehavioral and mental development.

These can be improved by giving;

TLC

A cheerful stimulating environment

Structured play therapy,15-30min/day

Physical activities as soon as well enough

Maternal involvement as much as possible


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Counselling Bringing child back for regular follow-up

checks

Ensure they complete immunizationschedules


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HYPOGLYCAEMIA Blood sugar


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When axillary temperature


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Difficult to rely on usual signs to tell severity

of dehydration

Assume all children with watery diarrhea may

have some dehydration No IV fluids except in shock

ReSoMal-ideal solution in malnutrition; giveorally or by NGT.


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ReSoMal: 5ml/kg every 30mins for the 1st 2hours, then 5-10ml/kg/hr for the next 4-10hours

Start starter feeds after 4 hours

Continue breastfeeding


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Look out for signs of over hydration Puffy face

Engorged jugular vein

Pulse

Respiratory rate

HR

Crackles


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Assume all malnourished children have aninfection

Hypoglycemia & hypothermia are signs ofsevere infections

Give broad-spectrum antibiotics Keep warm Check RTHC for at least measles vaccine,


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All severely malnourished children have vitamin& mineral deficiencies

Do not give iron within the first 2 weeks Give;

Vitamin A Multivitamin supplement

Folic acid Zinc

Copper


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Haemotransfusion required if Hb


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Common causes Misdiagnosis of dehydration with consequent

inappropriate hydration

Very severe anemia

Overloading due to blood transfusion High Na diet using conventional ORS or

excess ReSoMal

Inappropriate treatment of refeeding

diarrhea with rehydration solutions


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First fast breathing 2-12 months: RR>50 cpm

1-5years: RR>40cpm

Later

Cyanosis or pulse oximetry,SaO2 2cm

Engorged jugular veins

Increased pulse rate

Lung crepitations

Respiratory distress


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Stop all oral intake and IV fluid No fluid should be given until cardiac

function improves

A diuretic-IV lasix,1mg/kg stat


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TB can be a cause of failure to gain weight Signs are often non-specific

Asymmetric chest signs or lymph nodes areusually TB

The mantoux test can be negative Take a chest x-ray

To treat as soon as the suspicion is there


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Nutritional treatment of HIV/HIV-suspectedpatients is the same as for any severelymalnourished patient

They require the same dietary and medical

treatment HIV-positive patients usually respond well to

the nutritional treatment and gain weight


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Children can be allowed to go home if they; Have completed the transition to catch-up diets and are

eating well

Have no edema

Have completed antibiotic treatment

Have received extra electrolytes and micronutrients for atleast 2 weeks

Have been gaining weight well for at least 1week

Are up to date with their immunizations

W-f-h of >85%,if theres good follow-up services; w-f-h

of >95% without good follow-up services


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MONTH KWASHIOKOR MARASMUS MK TOTAL FATALITY

January 7 15 2 24 2

February 0 15 2 17 3

March 1 13 1 15 4

April 1 20 3 24 0

May 5 20 4 29 5

June 2 18 3 23 1

July 0 15 4 19 4

August 3 16 3 22 4

September 4 12 0 16 2

October 1 14 3 18 3

November 10 20 8 38 9

December 10 17 4 31 2

TOTAL 44 195 37 276 39


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MONTH KWASHIOKOR MARASMUS MK TOTAL FATALITY

January 2 24 4 30 1

February 3 35 6 44 3

March 5 30 1 37 6

April 9 24 1 34 4

May 1 17 0 18 3

June 3 15 2 20 5

July 4 19 2 25 1

TOTAL 27 164 16 207 23


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14.13% for 2008 11.11% for 2009

Both primary and secondary

WHO accepts between 5-10%

Resources available: 1-5%


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Part of Ward B4 Four nutritionist

3 pediatricians

1 resident

3/4 house officers

Nurses

Health care assistants


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Over crowding Nocturnal feedings

No office and store for feeds

Funds for alternate feeds

Hospital bill


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Case management practices suitable for the

non malnourished child may be highlydangerous for the PEM child

A malnourished child can be likened to apremature neonate

Very delicate and fragile, but when given thenecessary care and treatment, can surpriseeven you


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