Download Chapter 7 Severe malnutrition

Chapter 7
Severe Malnutrition
Case study: Kobi
Kobi, 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.
Emergency treatment
3.
History and examination
4.
Laboratory investigations, if required
5.
Main diagnosis and other diagnoses
6.
Treatment
7.
Supportive care
8.
Monitoring
9.
Plan discharge
10.
Follow-up
What emergency and priority signs does
Kobi have
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
Does Kobe have signs of shock?
•
•
•
•
Emergency signs of shock
(Ref. p. 5)
Cold hands/feet
AND
Capillary refill longer than 3 s
AND
Weak and fast pulse
AND
Lethargic or unconscious
•
•
•
•
•
How to treat for shock in a
severely malnourished
child (Ref. p. 5, 14)
Give oxygen
Give glucose
Give IV Fluids
Initiate feeding with F75 or Full
Strength Sunshine milk
Give antibiotics
Kobe does not have emergency signs of shock.
If a child is in shock refer to the pages of the book as
listed above
History
Kobi 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 potatos and some vegetables.
From 5 months he had six episodes of diarrhoea. Each
lasted 5-6 days. 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.
Examination
Kobi was wasted, having loose 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 Kobi’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: sick looking; no neck stiffness
and no other focal signs
Differential diagnoses
• Severe malnutrition (marasmus, kwashiorkor)
• Severe malnutrition due to other organic disease:
-Tuberculosis
-HIV
-Malabsorption syndrome
-Micronutrient deficiency (Vitamin A, zinc)
(Ref. p. 198-199)
Additional questions on history
• Nutrition history from birth
• Duration and frequency of diarrhoea and vomiting
• Type of diarrhoea (watery / bloody/ mucous / pus)
• Family circumstances
• Chronic cough
• Contact with TB, measles
• Known or suspected HIV
Nutrition history
Kobi had been on formula feed since 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. He was given weaning food at six
months of age, mainly contained potato and 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. Kobi had to share his
plate of food with his other siblings.
Family circumstances
Kobi lives with his parents in a small house. 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. Kobi’s father works
as a farmer and his mother as a housemaid where they
can earn some more money for food. Because they are
busy, Kobi’s older siblings mostly take care of him.
Further examination based on differential
diagnoses
On examination, look for:
•
•
•
•
•
•
•
•
Severe palmer 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
(Ref. p. 199)
Further examination based on differential
diagnoses
• Palmer Pallor – indicates
anaemia (Ref. p. 166). In any
child with palmer pallor, check
the haemoglobin or haematocrit
level
• Check 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)
Look for signs of Kwashiorkor and skin
features of zinc deficiency
What investigations would you like to do
to make a diagnosis?
Investigations
• Blood glucose: 2.4 mmol/L (3-6.5mmol/L)
• Haemoglobin: 70 g/l (105-135)
• Chest x-ray: normal, no features of TB
• Stool microscopy shows trophozoites of giardia
• After counseling of parents, HIV PCR test negative
Diagnosis




Severe Malnutrition
Anaemia (not severe)
Giardia infection causing diarrhoea
Hypoglycaemia
How would you treat Kobi?
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 or Full Strength
Sunshine Milk (FSS). If it is not quickly
available give 50ml of 10% glucose solution
orally or by nasogastric tube
 give 3 hourly feeds
At least 6 feeds per day
Day and night for the first day
After day 1, give 6 feeds during day (e.g. 0600, 0900,
1200, 1500, 1800, 2100) and overnight if possible
Treatment: Step 2
□ Hypothermia (Ref. p. 202-203):
 immediate and 3 hour feeding reduces risk
of hypothermia and hypoglycaemia
 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
□ If there is Dehydration (Ref. p. 203-204):
 give rehydration solution orally or by
nasogastric tube, much more slowly than you
would when rehydrating a well-nourished
child
 if rehydration is still occurring at 6 hours
give the same volume of starter F-75 instead
of ORS at these times
 Refer to Ref. p. 203-204 or PNG
malnutrition guidelines for details
Treatment: Step 4
□ Electrolytes (Ref. p. 206):
If electrolytes are not added to the food, give:




zinc (10 mg/day if <10 kg ; 20mg/day >10kg)
potassium (3-4mmol/kg/day)
magnesium (0.4-0.6mmol/kg/day)
prepare food without salt
• Giving high sodium loads can be very dangerous in severe
malnutrition
• 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
broad-spectrum antibiotic (penicillin &
gentamicin)
 in this case treat also for giardia
(metronidazole: 5mg/kg, 3 times a day, for 5
days (Ref. p. 137)) or Tinidazole for 3 days
 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 multivitamins
 give vitamin A orally on day 1
- Do not need to repeat doses
 once gaining weight, give ferrous sulfate
 give iron only after the child gains weight,
because iron can make infections worse
Treatment: Step 7
□ Initiating feeding (Ref. p. 209-210):
 give F-75 or Full Strength Sunshine milk
 100kcal/kg/day (liquid: 130ml/kg/day;
protein: 1-1.5g/kg/day)
 3 hourly feeds
At least 6 feeds per day
Day and night for the first day
After day 1, give 6 feeds during day (e.g. 0600, 0900,
1200, 1500, 1800, 2100) and overnight if possible
 continue breastfeeding if possible in
addition
Treatment: Step 8
□ Catch-up growth (Ref. p. 210-215):
 replace the starter F-75 with F-100 or Milk
Oil Formula. Use RUTF also if the child is
older than 6 months
 use the same amount of F-100 as F-75 for
2 days
 then increase each feed until some food
remains uneaten (up to 220 ml/kg/day)
 continue breastfeeding if possible in
addition
Treatment: Step 9
□ Sensory stimulation (Ref. p. 215):
 provide loving care, a cheerful stimulating
environment and involvement of the mother
 provide toys for the child to play with or
books to look at
 physical activity as soon as the child is well
enough
What monitoring is required?
Monitoring
• Monitor for early signs of heart failure (Ref. p. 214):
fast or slow heart rate, tachypnoea, oxygen
saturation, oedema, chest crackles, large liver
• Monitor urinary frequency and frequency of stools
and vomit
• Note number and amounts of feed offered and left
over
•Standardize the weighing on the ward (Ref. p. 222223) Weigh the child the same time of the day, after
removing clothes
• Calculate weight change and plot weight on chart
(Ref. p. 215)
Monitoring
• Weigh every 2nd day
• Record the adequacy of weight gain:
– >10g/kg/day – good
– 5-10g/kg/day – moderate
– <5g/kg/day – poor
• E.g, a 6kg child should gain more than 6 x 10 x 7 g =
more than 420 g per week
• An 8.5kg child should gain more than 8.5 x 10 x 7 g
= 595 g per week
Monitoring
• If weight gain is poor check the following points:
– Inadequate feeding – give more, observe the child
feeding, consider need for a nasogastric tube
– Untreated infection?
– Another illness, such as HIV/AIDS?
– Emotional or psychological problems
Discharge and follow-up
(Ref. 219-222)
Before discharge the child should have:
• Completed antibiotic treatment
• Regained a good appetite, taking all feeds regularly
• Show good weight gain (weight gain >70g/kg/week and Z-score
> -2 SD)
The mother or carer should:
• Be available for child care
• Have received training on appropriate feeding
• Have enough resources at home to feed the child
Follow-up
• Make a plan for the follow-up of the child until
complete recovery
• The child should be weighed weekly after discharge.
• If the child does not gain weight over 2-week period
or it even lost weight, he should be referred back to
hospital.
Progress
• Kobi was discharged after gaining weight and regaining
appetite
• 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 encourage him to complete
each meal, to add micronutrient supplements to each
feed and to monitor his appetite and intake.
• His mother was encouraged to breastfeed him as often
as Kobi wants.
• Follow-up was arranged.
• Kobi still needs continuing care as an outpatient to
complete rehabilitation and prevent relapse.
Summary
• 12-month-old boy, youngest of family of 6. Early
weaning, diluted dirty formula, poorly nutritious
food, repeated infections, diarrhoea and anaemia
• Severe malnutrition with hypothermia,
hypoglycemia, anaemia, giardiasis
• HIV negative, no signs of TB
• Malnourished children have multiple medical,
social and psychological problems, and each need
to be identified and addressed