Transcript Slide 1

Chapter 7
Severe Malnutrition
Case study: Kanchha
Kanchha, a 12-month-old
boy brought to district
hospital from rural area. 8
day history of loose watery
stools. 2 days of increased
irritability and poor oral
intake.
What are the stages in the management
of any sick child?
Stages in the management of a sick child
(Ref. Chart 1, p. xxii)
1.
Triage
•
2.
History and examination
•
3.
Emergency treatment, if required
Laboratory investigations, if required
Differential diagnoses
•
Main diagnosis
4.
Treatment
5.
Supportive care
6.
Monitoring
7.
Plan discharge
•
Follow-up, if required
What emergency and priority signs have
you noticed from the history and from
the picture?
Temperature: <35.00C,
pulse: 130/min,
RR: 50/min, Weight: 6 kg,
Length: 69cm
Triage
Emergency signs (Ref. p. 2, 6)
• Obstructed breathing
• Severe respiratory distress
• Central cyanosis
• Signs of shock
• Coma
• Convulsions
• Severe dehydration
Priority signs (Ref. p. 6)
• Tiny baby
• Temperature
• Trauma
• Pallor
• Poisoning
• Pain (severe)
• Respiratory distress
• Restless, irritable,
lethargic
• Referral
• Malnutrition
• Oedema of both feet
• Burns
History
Kanchha Lama was well until 5 months of age. At 5 months
his mother became pregnant again. His mother had started
to wean him from the breast at 3 months, as her milk
supply was reduced. From 4 months he was fed formula
milk from a bottle with a rubber teat. He was given solid
food from four months of age, mostly rice with dahl (lentil
soup).
From 5 months he had six episodes of diarrhoea. Each
episode lasted for 5-6 days, which was treated locally from
a medical shop. During each episode of diarrhoea he was
given reduced amounts of fluid and feeds because his
mother thought this would reduce the severity of his
diarrhoea. On this last occasion he was taken to the
hospital, as he became irritable and was not drinking or
eating well.
Nutrition history
Kanchha was started on formula feed at 4 months of
age. The milk was diluted (one scoop of milk per whole
bottle of water). His mother would wash his bottles and
teats in tap water, and rarely would boil the bottles. He
was given weaning food at six months of age, mainly
contained rice with dal and only occasional vegetables.
He would get meat occasionally, but not for the past 2
months. He usually received two meals and two bottles
of milk each day. Kanchha always had to share his plate
of food with his other siblings.
Family circumstances
Kanchha lives with his parents in a small cottage. He
has three older sisters and two older brothers. They
have a small plot of land on which they grow crops, but
which is not sufficient to feed their family. Kanchha’s
father works as a farmer and his mother as a
housemaid where they can earn some more money for
food and beverages. Because they are so busy,
Kanchha’s older siblings mostly take care of him.
Examination
Kanchha was visibly wasted, having skin folds over his arms,
buttocks and thighs and visible rib outlines.
Vital signs: temperature: <35.00C, pulse: 130/min, RR: 50/min
Weight: 6 kg and Length: 69cm, MUAC 10.5cm
□ Use Table 35 p. 386 and assess Kancha’s weight-for-length
Chest: bilateral air entry was normal, no added sounds
Cardiovascular: both heart sounds were heard and there was
no murmur
Abdomen: soft, bowel sound was audible; no organomegaly
Ears-Nose-Throat: dry mucus membranes
Eyes: sunken, no tears and dry conjunctiva
Skin: decreased skin turgor
Neurology: irritable, sick looking; no neck stiffness
and no other focal signs
Differential diagnoses
• List possible causes of the illness
• Main diagnosis
• Secondary diagnoses
• Use references to confirm (Ref. p. 198-199)
Differential diagnoses (continued)
• Primary severe malnutrition (marasmus,
kwashiorkor)
• Secondary severe malnutrition in the course of:
-Tuberculosis
-HIV
-Pneumonia
-Measles
-Malabsorption syndrome
-Micronutrient deficiency (Vitamin A, zinc)
Additional questions on history
Concerning:
• Recent intake of food and fluids
• Usual diet (before the illness)
• Breastfeeding
• Duration and frequency of diarrhoea and vomiting
• Type of diarrhoea (watery/bloody)
• Loss of appetite
• Family circumstances (social background)
• Chronic cough
• Contact with TB, measles
• Known or suspected HIV
Further examination based on differential
diagnoses
On examination, look for:
• Severe palmar pallor
• Eye signs of vitamin A deficiency
• Skin changes of kwashiorkor
• Localizing signs of infection
• Signs of HIV
• Fever or hypothermia
• Mouth ulcers
• Signs of dehydration
• Shock
(Ref. p. 199)
Further examination based on differential
diagnoses
• Palmar Pallor – indicating
severe anaemia (Ref. p. 167). In
any child with palmar pallor,
determine the haemoglobin or
haematocrit level
• Check also conjunctiva and
mucous membranes
Further examination based on
differential diagnoses
Look for signs of vitamin A deficiency:
• Dry conjunctiva or cornea
• Bitot’s spots
• Corneal ulceration
• Keratomalacia
(Ref. p. 199)
Kwashiorkor and dermatosis of zinc
deficiency
What investigations would you like to do
to make your diagnosis?
Investigations
• Blood glucose
• Haemoglobin
• Chest x-ray
• Stool microscopy
Investigations (continued)
• Blood glucose: 2.4 mmol/L (3-6.5mmol/L)
• Haemoglobin: 70 g/l (105-135)
• Chest x-ray: normal
• Stool microscopy shows trophozoites of giardia
Diagnosis
Summary of findings:
• Examination: pale, irritable, and ill-looking. He was visibly
wasted, having skin folds over his arms, buttocks and
thighs. He had visible rib outlines, hypothermia, sunken
eyes with no tears and dry conjunctiva and decreased skin
turgor.
• History: several risk factors for malnutrition such as poor
socioeconomic status, a large family, non-nutritious family
food, early weaning from breast milk, diluted, dirty
formula feeding
• Weight-for length: <70% or -3SD
• Low haemoglobin
• No contact with TB
• No signs of HIV
• Stool microscopy shows trophozoites of Giardia lamblia
Diagnosis (continued)
 Severe Malnutrition
 Anaemia (not severe)
 Giardiasis
How would you treat Kanchha?
Treatment
includes 10 steps in 2 phases: initial stabilization
and rehabilitation
(Ref. p. 201)
Treatment: Step 1
□Hypoglycaemia (Ref. p. 201):
give the first feed of F-75 if it is not quickly
available give 50ml of 10% glucose solution
orally or by nasogastric tube
give 2-3 hourly feeds, day and night, at
least for the first day
Treatment: Step 2
□Hypothermia (Ref. p. 202-203):
feed the child immediately
make sure the child is clothed (including
the head), use warmed blanket or put the
child on the mother's bare chest or abdomen
Treatment: Step 3
□Dehydration (Ref. p. 203-204):
give ReSoMal rehydration fluid orally or by
nasogastric tube, much more slowly than you
would when rehydrating a well-nourished
child
if rehydration is still occurring at 6 and 10
hours give the same volume of starter F-75
instead of ReSoMal at these times
Treatment: Step 4
□Electrolytes (Ref. p. 206):
If electrolytes are not added to the food:
give extra potassium (3-4mmol/kg)
give extra magnesium (0.4-0.6mmol/kg)
prepare food without salt
Giving high sodium loads could kill the child
Consider if F-75 is provided there is no
need to add electrolytes to food
Treatment: Step 5
□Infection (Ref. p. 207-208):
give all severely malnourished children a
broad-spectrum antibiotic
in this case give also treatment for
giardiasis (metronidazole: 5mg/kg, 3 times a
day, for 5 days (Ref. p. 137))
give measles vaccine if the child is not
immunized
Treatment: Step 6
□Micronutrients (Ref. p. 208-209):
If micronutrients are not added to the food:
give daily a multivitamin supplement, folic acid,
zinc, copper
give vitamin A orally on day 1
once gaining weight, give ferrous sulfate
give iron only after the child gains weight, because
iron can make infections worse
Consider if F-75 is provided there is no need to
add electrolytes to food
Treatment: Step 7
□Initiate feeding (Ref. p. 209-210):
give F-75
100kcal/kg/day (protein: 1-1.5g/kg/day;
liquid: 130ml/kg/day)
continue breastfeeding if possible, but
make sure the prescribed amounts of starter
formula are given
Treatment: Step 8
□Catch-up growth (Ref. p. 210-215):
replace the starter F-75 with F-100 for 2
days or use RUTF, if the child is elder than 6
months
then increase each feed by 10ml until some
feed remains uneaten
continue breastfeeding if possible and give
F-100 as indicated
Treatment: Step 9
□Sensory stimulation (Ref. p. 215):
provide tender loving care, a cheerful
stimulating environment and maternal
involvement as much as possible
provide structured play therapy for 15-30
minutes a day
physical activity as soon as the child is well
enough
Treatment Step 10: Prepare for discharge
and follow-up
What monitoring is required?
Monitoring
• Monitor for early signs of heart failure (Ref. p. 214):
 Pulse
 RR
• Monitor urinary frequency and frequency of stools
and vomit
• Note amounts of feed offered and left over and
daily body weight
• Standardize the weighing on the ward (Ref. p. 222223)
• Weigh the child the same time of the day, after
removing clothes
• Calculate weight gain (Ref. p. 215)
Monitoring (continued)
• Note the weight gain:
– poor: <5g/kg/day
– moderate: 5-10g/kg/day
– good:>10g/kg/day
• If weight gain is poor check the following points:
– Inadequate feeding
– Untreated infection
– HIV/AIDS
– Psychological problems
Discharge home
(Ref. 219-221)
If you discharge the child home before the full recovery:
The child :
•
•
•
•
Should
Should
Should
Should
have completed antibiotic treatment
have a good appetite
show good weight gain
at least be losing oedema
The mother or carer:
• Should be available for child care
• Should have received specific training on appropriate feeding
• Should have resources to feed the child
Mothers should understand that it is essential to give frequent
meals with a high energy and protein content
Follow-up
• Make a plan for the follow-up of the child until
recovery
• Contact the outpatient department (or nutrition
rehabilitation centre, local health clinic, health
worker) who will take responsibility for continuing
supervision of the child.
• The child should be weighed weekly after discharge.
• If the child does not gain weight over 2-week period
or it even losts weight, it should be referred back to
hospital.
Progress
• Kanchha was discharged before full recovery.
• His parents were told to feed him at least 5 times per
day. They had to give him high-energy snacks between
meals (e.g. milk, banana, bread, biscuits).
• His parents were told to assist and to encourage him to
complete each meal, to add electrolytes and
micronutrient supplements to each feed and to monitor
his intake as well.
• His mother was encouraged to breastfeed him as often
as Kanchha wants.
• Follow-up was arranged.
• Kanchha still needs continuing care as an outpatient
to complete rehabilitation and prevent relapse.
Kanchha
Summary
• 12-month-old boy, youngest of family of 6. Several
episodes of gastroenteritis since he was five
months of age. For the last 8 days he had been
having frequent loose watery stools.
• Early weaning, diluted dirty formula,
nutritious food, repeated infections
poorly
• Alert but severely wasted, with palmar pallor
• Severe
malnutrition
with
hypoglycemia, anaemia, giardiasis
hypothermia,