Malnutrition 2

8/18/2019 Malnutrition 2

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Management of Severe AcuteMalnutrition JFK pediatric core curriculum

MGH Center for Global HealthPediatric Global Health Leadership Fellowship

Credits:Brett Nelson, MD, MPH

Rebecca Bell, MD



Discussion Overview

•Defining malnutrition

•Physiologic effects of malnutrition by

system•Management of severe malnutrition byproblem

•Integrating outpatient management ofsevere malnutrition



Causes of MalnutritionSection 1Section 1

3

From ICH/UNHCR Handout



Defining Malnutrition

•Malnutrition is diagnosed if one of the following criteriais met:–Weight-for-height < 70% or <-3 SD

–Bilateral pedal oedema

–Clinical signs of severe malnutrition

•Differentiating betweenmarasmus (characterized bysevere wasting) andkwashiorkor (characterized byoedema) is not necessary for treatment as many children

display symptoms of both conditions.•It is important to identify the presence or absence ofoedema, as those children tend to do worse thanmalnourished children without edema.



From the WHO “Management of Severe Malnutrition”



Signs of Marasmus

Children with marasmus have severe wasting, particularly of thearms, shoulders, thighs and buttocks. The lack of adipose tissuecauses skin to hang loosely.

http://www.wikieducator.org/images/9/95/Marasmuschild.jpg



Signs of Kwashiorkor / OedematousMalnutrition

This child has oedema of the hands and feet as well asdermatosis, most prominently on the legs and groin.

http://www.wikieducator.org/images/8/88/Kashiakorchild.jpg



Gently press with the thumb, applying pressure to both feet at the same time.Pitting oedema leaves a small indentation which can be seen and felt



Other Anthropometric Indicators ofMalnutrition

•Mid Upper Arm Circumference (MUAC)

–Some studies have shown MUAC to be the single bestpredictor of mortality in children between 1 and 5

years.–Community volunteers can be easily trained tomeasure MUAC.

–MUAC is currently recommended for screening in the

community. Children who meet criteria formalnutrition are referred to a clinic or hospital forfurther evaluation.



Measuring

MUAC



Physiological Effects ofMalnutrition By System

•Cardiovascular

•GI

•GU

•Immune•Liver

•Endocrine

•Cellular function

•Circulatory/Temperature regulation•Skin, muscles, glands



Cardiovascular SystemEffects:

•↓ cardiac output and stroke volume•↓ blood pressure•↓ renal perfusion

Concerns:•An increase in blood volume can produce acute heartfailure

•A further decrease in blood volume will compromise tissueperfusion

Management:•If dehydrated, give ReSoMal or F-75•Do not give IV fluids unless child is in shock•If blood transfusion is necessary, restrict to 10 ml/kg and

give a diuretic



Gastrointestinal System

Effects:•↓ production of gastric acid•↓ intestinal motility•↓ production of digestive enzymes secondary topancreatic atrophy

•↓ secretion of digestive enzymes secondary to smallintestinal mucosa atrophy•↓ absorption of nutrients when large amounts of foodingested

Management:•Give small, frequent feeds•If fat malabsorption, can give pancreatic enzymes



Genitourinary SystemEffects:• ↓ glomerular filtration• ↓ ability for renal excretion of acid or water load• ↓ sodium excretion• ↓ urinary phosphate output• ↑ incidence of UTI

Concerns:• A large protein load may not be well tolerated by the kidneys• Further protein deprivation will lead to continued tissue breakdown

Management:• Caloric intake should be targeted at 80-100 kcal/kg/day• Avoid nutrients that can lead to an acid load, such as magnesiumchloride

• Restrict sodium intake• Avoid excessive water intake



Immune System

Effects:• ↓ cell-mediated immunity• ↓ secretion of IgA• ↓ levels of complement components• ↓ efficacy of phagocytes• Atrophy of lymph glands, tonsils, and thymus• ↓ inflammatory response and migration of white cells to areas of

tissue damage

Concerns:• Typical signs of infection (↑ WBC count, fever) are often absent• Hypoglycemia and hypothermia are signs of severe infection

Management:• Although efficacy has been questioned in some studies, currentrecommendation is to treat all inpatients with broad-spectrumantibiotics

• In order to decrease risk of cross infection, arrange ward so that

newly admitted children and those with diarrhea are segregated



Liver

Effects:• ↓ synthesis of all proteins• ↓ bile secretion• ↓ ability of liver to take up, metabolize, and excrete toxins• ↓ gluconeogenesis• ↓ transferrin levels

Concerns:• Risk of hypoglycemia is high, particularly with infection

Management:• Protein intake should be about 1-2 g/kg/day so as to supportsynthesis of proteins but not to exceed metabolic capacity of liver

• Reduce dosage of meds that are dependent on hepatic metabolism• Ensure sufficient carbohydrate intake to avoid need forgluconeogenesis

• Do not give iron supplements



Endocrine System

Effects:

•↓ insulin levels, leading to glucose intolerance

•↓ levels of IGF-1

•↑ levels of growth hormone

•↑ levels of cortisol

Management:•Do not give steroids



Cellular Function

Effects:

•↓ synthesis of proteins•↓ activity of sodium pump

•↑ permeability of cell membranes

Concerns:

•This leads to anincrease in intracellular sodium and adecrease in intracellular potassium and magnesium

Management:

•Restrict sodium intake

•Give potassium and magnesium to all children



Circulatory System andTemperature Regulation

Effects:•Heat generation as well as heat loss are impaired

•↓ energy expenditure and basic metabolic rate

Concerns:•Child becomes hypothermic in cold environment andhyperthermic in hot environment

Management:•Keep child dry and warm

•Room temperature should be at 25-30 °C

•If child has fever, cool with tepid water



Skin, Muscles, Glands

Effects:•Skin and subcutaneous fat are atrophied

•Atrophy of sweat, tear, and salivary glands

•Respiratory muscles are fatigued easily

Concerns:

•Typical signs of dehydration (sunken eyes, abdominalskin pinch) are unreliable due to the loss ofsubcutaneous fat

Management:

•Rehydrate with ReSoMal when necessary (see protocol)



Inpatient Management Overview

•Management phases:–Stabilization phase: defined as the treatment period fromadmission to the point where the child’s appetite hasreturned. Typically lasts 2-7 days.

–Rehabilitation phase***: goals for this phase are weightgain, emotional development, family education, and lackof oedema, vomiting, diarrhea and fever. Typically,children are discharged 2-3 weeks after admission.

***Recent advances in outpatient management have led to asignificant decrease in the length of the rehabilitation phase, andin some cases, a complete elimination of the phase. Someinstitutions instead have a “transitional phase” where the childis prepared for discharge after stabilization.



Evaluation at Presentation

•Medical history:–Usual diet

–Breastfeeding history

–Food and fluids in last few days

–Time when last urine passed–Duration, frequency, appearance of vomit and diarrhea

–Recent sinking of eyes

–Contact with TB or measles

–Birth weight–Developmental milestones reached

–Immunizations



Evaluation at Presentation

•Physical exam:–Weight, length

–Temperature

–Edema

–Hepatomegaly, jaundice

–Abdominal distension, bowel sounds

–Pallor

–Signs of circulatory collapse

–Thirst

–Corneal lesions–Signs of infection in ears, mouth, throat

–Inspect skin for signs of infection, dermatosis, purpura

–Appearance of stool



Goals for Management of aMalnourished Child at Admission

•Treat or prevent hypoglycemia

•Treat or prevent hypothermia

•Treat or prevent dehydration•Treat infection or septic shock, if present

•Begin feeding

•Identify and treat vitamin deficiency, severe anemia, and

heart failure



Hypoglycemia

•Important cause of death during first 48 hoursafter admission

•Signs include low body temperature, lethargy,limpness, loss of consciousness

•Do not wait for lab results before treating:

–give first feed of F-75 diet–If F-75 not immediately available, give 50 ml of 10%glucose or sucrose orally or via NG tube–If unconscious, give 5ml/kg of 10% glucose IV–Give 2-3 hourly feeds, day and night



Hypothermia

•Defined as rectal temp less than 35.5°C

•Keep child clothed, including head, limit exams and

washing, dry immediately after washing, keep heater orlamp nearby

•Check for hypoglycemia any time a child is found to be

hypothermic



Dehydration and Septic Shock

•Malnourished children often do not displaytypical signs and symptoms of dehydration andseptic shock.

–Salivary and lacrimal glands are atrophied so childrenwill have dry mouth and lack of tears regardless offluid status.

–Loss of subcutaneous fat makes the skin thin and

loose so a slow skin pinch does not necessarily meanthe child is dehydrated.



Reliable Signs of Dehydration in aMalnourished Child

•History of diarrhea

•Thirst

•Recent development ofsunken eyes

•Weak or absentperipheral pulses

•Cold hands and feet

•↓ urine flow

Marasmic child with sunken eyes



Rehydration Solution for MalnourishedChildren (ReSoMal)

•High sodium and low potassium levels inmalnourished children make standard OralRehydration Salts (ORS) unsuitable.

•ReSoMal is commercially available, but can also be made by diluting one ORS packet in 2 liters of

water instead of 1 and adding 25 g/l of sucroseand 20 ml/l of mineral mix.



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ReSoMal Protocol(Rehydration solution for marasmicchildren)DO NOT use for oedematous children

To be used ONLY after careful diagnosis ofdehydration (history and clinical signs).

For children with OEDEMA, do not giveReSoMaL in an outpatient setting, use 10%sugar water only.

Monitor regularly. If respiratory rateincreases or there is increasing oedema(e.g. of eyelids) or neck veins becomedistended, stop ReSoMaL. Reassess afterthe 1st hour. If there is improvement in

symptoms advise carer to continue breastfeeding and to give extra water athome (small quantities every hour) untilchild is no longer thirsty.

If no improvement or further deteriorationrefer to inpatient facility.



Signs of Septic Shock in aMalnourished Child

•Incipient septic shock:–Limpness, apathy, anorexia, hypothermia, cold handsand feet, weak peripheral pulses, ↓ urine flow

•Developed septic shock:–Dilated superficial veins (scalp and external jugularveins), dilated pulmonary veins leading to grunting,shallow cough, difficulty breathing

–Development of renal, cardiac, liver, and intestinalfailure–Hematemesis, melena, abdominal distension withabdominal splash



Infection in the Malnourished Child

•Malnourished children often have no signs ofinfection. Therefore, on admission, all childrenshould receive antibiotic treatment according to

local resistance patterns.

•Suggested regimen:

–If no signs of infection and no complications•Cotrimoxazole (25/5) PO BID x 5 days



Antibiotic Treatment in Children withComplications

•Complications include:–Septic shock–Hypoglycemia–Hypothermia–Skin infection–UTI–Lethargy

•Suggested regimen:–Ampicillin 50mg/kg IM/IV every 6 hours x 2 days,followed by amoxicillin 15mg/kg PO every 8 hours x5 days



More on Infections

•If child fails to respond in 48 hours, add:–Chloramphenicol 25mg/kg IM/IV every 8 hours x 5days

•Follow WHO or local treatment protocols formanagement of dysentery, candidiasis,helminthiasis

•All children should be tested for malaria upon

admission and treated accordingly•All children should receive a measles vaccine onadmission



Vitamin A Administration

•All children should receive vitamin eye on admissionaccording to age-specific guidelines.

•If the child has oedema, severe anorexia, or septic shock,give IM dose.

•If child has evidence of Vitamin A deficiency (eyecomplications), follow table below:



Eye Care

•Eyes should be examined gently for signs ofxerophthalmia, corneal xerosis and ulceration,cloudiness and keratomalacia

•Management of ocular inflammation orulceration:

–Cover eyes with pads soaked with 0.9% saline

–Apply 1% tetracycline eye drops 4 times a day



Complications of Vitamin A Deficiency

Keratomalacia with Bitot's Spots:discrete, foamy-appearing spots onthe conjunctiva

Copyright © Online Journal of Ophthalmology

Corneal ulcer: small ulcer withclouding of the central cornea

http://www.atlasophthalmology.com/atlas/login.jsf

http://www.atlasophthalmology.com/atlas/login.jsf



Severe +nemia

•WHO recommends blood transfusion when the

haemoglobin drops below 30g/l (or packed-cell volume below 10%), or if child is showing signs of life-threatening heart failure.

•Give 10 ml/kg slowly over 3 hours.

,almar -allor in a .everel anemi0 0hild



Dermatosis of Kwashiorkor

• Characterized by hypo- or hyperpigmentation, shedding and

ulceration of the skin especially in legs, perineum, and groin.• Bathe affected areas in 1% KMnO4for 10-15 daily

• Apply zinc and castor oil ointment, petroleum jelly, or paraffin gauzedressings

• All children with dermatosis should receive antibiotics. If areas show

signs of candida infection, treat with topical and oral nystatin.



Formula Diets Used in the Treatment ofMalnourished Children

•F-75–75 kcal/100 ml

–Used during initial treatment

•F-100–100 kcal/100 ml

–Used during rehab phase, once appetite has returned

•RUTF(Ready-to-use therapeutic food)

–Mixture of peanut paste, sugar, oil, powdered milk,and vitamin/mineral mix

–Similar composition as F-100, but non-water based sodoes not spoil

–Can be given at home



Feeding Tips

•Strictly follow feeding tables that determine volumeand frequency of feeds for weight.

•Feeding by mouth is always better, but if a child will

not take food, an NG tube must be placed.•Children should continue to breastfeed.

•Children should be fed with cup and spoon, ordropper – never with a bottle as these can be sources

of infection.•Carefully record food intake. Standard recordingforms are available.



RUTF1 e.igned 3 Fren0h .0ienti.t +ndre 4riend in $### and

manufa0tured under the 3rand name ,lum-5nut 3Nutri.et

1 In Mala6i7 RU8F i. -rodu0ed in"0ountr u.ing lo0al

ingredient. mi9ed 6ith vitamin/mineral -a0:. from

Nutri.et



Plumpy’nut® (RUTF)

Paste of groundnut composed of vegetable fat, peanut butter, skimmed milkpowder, lactoserum, maltodextrin, sugar and mineral and vitamin complex.

Instructions for use: Clean drinking water must be made available tochildren during consumption of ready-to-eat therapeutic spread. Theproduct should only be given to children who can express their thirst.Contra-indicated for children who are allergic to cows milk, proteins or

peanuts and asthmatic people (risk of allergy).

Recommendations for use: In the management of severe acute malnutritionin therapeutic feeding, it is recommended to use the product in phase 2 (two)in the dietetic management of severe acute malnutrition. In phase 1 (one) use

milk based diet (F75).

Storage of Plumpy’nut: Plumpy’nut has a shelf life of 24 months frommanufacturing date. Keep stored in a cool and dry place.

Packaging: Plumpy’nut is presented in sachets of 92 g. Each carton (around15.1 kg) contains 150 sachets. One sachet = 92 g = 500 Kcal.



RUTF in the Field

Child being fed locallyproduced RUTF in Malawi

Zambian child eatingimported Plumpy’nut



Transitioning toRehabilitation Phase

•When a child’s appetite has returned, replaceF-75 with an equal volume of F-100 for 2 days.Then increase volume.

•If RUTF is available, this can be given in place ofF-100.



Management Models

•Malnutrition is the result of a combination ofmedical and social problems. A managementmodel that addresses all aspects of malnutrition

will lead to a faster recovery and reduce thechances of relapse.



Community-Based Therapeutic Care (CTC)

• In 2007, a joint statement was issued by the WHO, WFP, andUNICEF, promoting community-based management of severe acutemalnutrition.

• Countries are encouraged to adapt national policies to address:– training for community health workers in identifying malnourished

children–ensuring competency in IMCI at the facility level

– establishing referral arrangements for complicated cases

– making RUTF available to children with severe malnutrition

• The CTC approach to malnutrition management has been shown to

be more successful than traditional methods that focus on inpatientmanagement.

• Malnutrition cases that were previously treated as inpatient can bemanaged on an outpatient basis, and severe complicated cases can be discharged home earlier.



Suggested Update of Management of SevereAcute Malnutrition Into IMCI Protocol

Andre Briend, WHO, September 2007

http://www.fantaproject.org/downloads/pdfs/D2.S5.Briend.pdf



Case Question #1

A two year-old boy presents with bilateral pedaloedema and hypothermia. On exam, you are unable toarouse him.

Your next step should be to:

a) Check a stat haemoglobin and transfuse if Hb < 30g/l.

b) Check a stat glucose and replete if necessary

c) Place the child near a heater to warm his body temperature

d) Give 10% glucose IV

e) Give IV ampicillin



Case Question #1

A two year-old boy presents with bilateral pedaloedema and hypothermia. On exam, you are unable toarouse him.


a) Check a stat haemoglobin and transfuse if Hb < 30g/l.

b) Check a stat glucose and replete if necessary

c) Place the child near a heater to warm his body temperature

d)Give 10% glucose IVe) Give IV ampicillin



Case Question #2

An 18 month-old girl whose mother recently died ofTB is admitted to the hospital for severe wasting andanorexia x 2 days. Her weight-for-height is -4 SD. Sheis alert but refuses food. Her vitals are stable.


– Give F-75 by NG tube

– Start anti-tuberculosis medicines

– Send for chest x-ray

– Give ReSoMal by NG tube

– Test for HIV



Case Question #2

An 18 month-old girl whose mother recently died ofTB is admitted to the hospital for severe wasting andanorexia x 2 days. Her weight-for-height is -4 SD. Sheis alert but refuses food. Her vitals are stable.


– Give F-75 by NG tube

– Start anti-tuberculosis medicines– Send for chest x-ray

– Give ReSoMal by NG tube

– Test for HIV



Resources

•WHO, Management of severe malnutrition: a manual forphysicians and other senior health workers.

–Available online at:http://whqlibdoc.who.int/hq/1999/a57361.pdf

•Valid International’s CTC Manual:http://www.validinternational.org/pages/

•Project Peanut Butter – RUTF factory and feedingprogram in Malawi:http://www.projectpeanutbutter.org/

http://whqlibdoc.who.int/hq/1999/a57361.pdf

http://www.validinternational.org/pages/

http://www.projectpeanutbutter.org/

http://www.projectpeanutbutter.org/

http://www.validinternational.org/pages/

http://whqlibdoc.who.int/hq/1999/a57361.pdf

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