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Berhanu Ebisa (MD)

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Definition Epidemiology Causes Pathophysiology Clinical manifestations Laboratory tests Complications Principle of management

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Why nutritionmatters?

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Low immunity Illness Death Mental impairment Reduced productivity

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Neonatal 25%

Malaria 20%

Pneumonia

28%

Diarrhea 20%

AIDS 1%

Measles 4%

Other 2%

Malnutrition

53%

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18%

412,000 died between 2000-2005

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50,000

infant

deaths

every yearU

NICEF/93-COU-0173/Lemoyne

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Defined as pathological states resulting fromrelative or absolute deficiency of one or moreessential nutrients.

Clinical syndrome results from micro ormacro nutrient deficiency

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A) Primary cause : 1.Failure of lactation.

2.Ignorans of weaning

3.Poverty. 4.Cultural patterns.

5.Lack of immunization & primary care.

6.Lack of family planning.

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B ) Secondary cause : 1.Infections.

2.Congenital diseases.

3.Malabsorption. 4.Metabolic causes.

5.Psycho social deprivation.

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1.Clinical

2. Anthropometric 3. Bio chemical

4. Dietary

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The process of determining thenutritional status of individuals or

population through collection andinterpretation of data fromdietary, laboratory,

anthropometric and clinicalstudies

14

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Nutrition indices are a combination ofmeasurements compared to a reference

15

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16

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Interpretation of MUAC measurement for age group 6 month-18 years

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Classification

18

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Wt-for- age = Wt. of subject x 100Wt. of normal child of same age

Wt. for age Degree ofmalnutrition

90-100% normal

75-89% mild (grade I)

60-74% moderate (grade II)< 60 severe (grade III)

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Edema WFA ( Harvard)

60-80 % < 60 %

Absent Underweight Marasmus

Present Kwashiorkor Marasmic-

kwashiorkor

20

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WFH Nutritional status HFA Nutritional

status

90-100% Normal > 95% Normal

80-90% Mild wasting 90-95% Mild stunting

70-80% Moderate 85-90% Moderate

< 70 % * Severe wasting < 85% Severe stunting

21

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22

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Ask the mother toremove all the cloth

and look the arms, thighs

and buttocks for loss ofmuscle bulk and

sagging of skin

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Admission criteria for SAM:( >6 month)

1.MAUC < 11cm.

2. Wt /Ht < 70% . 3.Bilateral pitting edema.

4.Serious medical complications

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Different proposed mechanisms :1. Protein-energy deficiency

2. Mal adaptation

3.

Free radical theory ( imbalance betweenoxidants and antioxidants)

No adequate explanation so far why somechildren develop edematous malnutrition

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Body Composition- TBW and ECF increased- Increased ICF Na+- Decreased body K+ and Mg+- Marked loss of fat and muscle

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GIT- Villi atrophy and reduced dissachardase- small intestinal bacterial overgrwth- Decreased biliary secretion- chronic pancreatic inssuficiency-fatty liver

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Defense against infection- All aspects of immunity are impaired but CMIprofoundly affected:- Reduced secretory IGA

- Impaired phagocytic function- Impaired acute phase response- WBC do not migrate to area of infection- Non-specific defense is weakened

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CVS and renal- Atrophied myocardium- Reduced cardiac output and stroke volume.- Blood pressure is lowDecreased renal blood flowPoor concentrating and filtration capacity

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kwash marasmusUnder weight Extremely under weight(

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RBS U/A and/or U/C

Serum Albumin

B/C

Serum electrolyte

CBC

S/E ,S/C

CXR

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Treatment approaches for SAM contains threephases :

1.phase I

2. transition phase

3. phase II

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Feeding Routine medicine Surveillance Rx complications

48

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How to diagnose and treat?

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Malnourished children are SENSITIVE toexcess sodium intake!

All the signs of dehydration in a normalchild occur in a severely malnourished childwho is NOT dehydrated only a HISTORY of

fluid loss and very recent change inappearance can be used

Giving a malnourished child who is notreally dehydrated treatment for dehydration

is very dangerous

Misdiagnosis of dehydration and givinginappropriate treatment is the commonest

cause of death in severe malnutrition. 50

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The treatment of dehydration is different inthe severely malnourished child from thenormally nourished child

Infusions are almost never used and areparticularly dangerous

ReSoMal must not be freely available in theunit but only taken when prescribed

The management is based mainly onaccurately monitoring changes in weight

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The next two slides show that severelywasted patients cannot excrete excesssodium and retain it in their body.

This leads to volume overload and

compromise of the cardiovascular system The resulting heart failure can be very acute

(sudden death)or be misdiagnosed aspneumonia

52

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Malnourished Recovered

0

300

600

900

FastingUrineOsmolarity(mOsm/l

Malnourished Recovered

0

300

600

900

Post-PitressinUrineOsmolarity

(mOsm/l

53

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Normal ECF Expanded ECF0

2

4

6

8

10

12

Sodiume

xcretio

n

(%o

fsodiumf

iltered)

54

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History of recent change in appearance of

eyes

History of recent fluid loss

NO OEDEMA - Oedematous patients areover-hydrated and not dehydrated (althoughthey are often hypovolaemic from septic shock)

Check the eyes lids to see if there is lid-retraction a sign of sympathetic over-activity

Check if the patient is unconscious or not

55

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56

Conscious UnconsciousSleeping Awake

Eyes notclosed

Eyes closed

Dehydration

Hypogly

dehyd

ration

Eye-lidretracted

Eye-lidnormal

DehydrationHypogly

dehyd

ration

Eyes notclosed

Eyes closed

Dehydration

hypoglycaemia

dehydrati

on

Eyes Sunken

Notrecent

Recent onset

Not dehydrated

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Monitor every hour the liver edge marked on the skin before any

rehydration treatment starts

the weight, the respiration and pulse rate

the heart sounds

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58

ConsciousUnconscious

Resomal

ONLY Rehydrate until theweight deficit (measured or

estimated) is corrected andthen STOP DO not giveextra fluid to preventrecurrence

IV fluid

Darrows solution

or 1/2 saline & 5% glucose

or Ringer lactate & 5% dextrose

at 15ml/kg the first hr &reassess .if improved repit

- 5ml/kg /30min first2hrs

- 5 to 10ml/kg/hr 10 hrs

- If conscious, NGT: ReSoMal

- If not improving =>Septicshock

If there is continued weight loss then:

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If there is continued weight loss, then: Increase the rate of administration of ReSoMal by

10ml/kg/hour

Formally reassess in one hour If there is no weight gain, then: Increase the rate of administration of Resomal by

5ml/kg/hour Formally reassess every hour

If there is clinical improvement but thereare still signs of dehydration continue with the treatment until the appropriate

weight gain has been achieved.

59

If there is weight gain and deterioration of the

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If there is weight gain anddeterioration of thechilds condition with the rehydration therapy Then the diagnosis of dehydration was definitely wrong.

Stop and start the child on F75 diet.

If there is no improvement in the mood and look ofthe child or reversal of the clinical signs Then the diagnosis of dehydration was probably wrong: either change to F75 or F75 and Resomal.

60

Weight

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61

e g t

Gain

ClinicalImproved

ClinicalNotimproved

StableLoss

- Increase

ReSoMalby10ml/kg/hr

- Reassessever hr

-Increase

ReSoMal:5ml/kg/hr

-Reassessevery hr

F75

- STOP ALL

rehydrationfluid

- Give F75

- Re-diagnose

& assess

Targetwgt

continue

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62

Eye-lid drooping/normal orclosed whenasleep/unconscious

Septicshock

Septic shock withHypoglycaemia

No History of recent eyessinking

No history of major fluid loss

Eye-lid retracted or slightly openwhen asleep/ unconscious

Signs of Septic shock present

Fast weak pulse, cold peripheries, pallor,drowsiness

Note: Lid retraction without shock treat immediately for

hypoglycaemia

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Diagnosis = Septic shock to be presenta fast weak pulse withcold peripheriesPallorDisturbed consciousness

Treatment- Give second and first line antibiotics together- Kept warm to prevent or treat hypothermia,- Give sugar-water by mouth or NGT as soon as the

diagnosis is made.-

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Septic shock

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64

p

Conscious UnconsciousLoosing conscious

F 75 by mouthor NGT

- Darrows solution,or 1/2 saline & 5% glucose,

or Ringer Lactate & 5%glucose

at 15ml/kg the first hr- Reassess every 10min- If possible, Blood transfusion:10ml/kg in 3 hours, withoutanything else.

;

- If conscious, NGT: F75

Wh t i th di f thi

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What is the diagnose of thischild?

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The target weight-increase has been achieved The visible veins become full The development of oedema The development of prominent neck vein An increase in the liver size The development of tenderness over the liver. An increase in the respiration rate The development of grunting The development of crepitations in the lungs The development of a triple rhythm

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DiagnosisPhysical deterioration with a gain iweight An increase in liver size. Tenderness over the liver tachypnea Grunting . Crepitations in the lungs Prominent superficial and neck veins Heart sounds - Development of triple rhythm Increasing or reappearance of oedema duringtreatment

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Weight Increase Weight decrease

68

Pneumonia Aspiration

Fluid overload Heart

failure

Weight stable

Examine daily weights

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Stop all intake of fluids or feeds (oral or IV)

No fluid or food should be given until the heartfailure has improved or resolved (even 24-48 hours.)

Smallamounts of sugar-water can be given orallyif worried about hypoglycaemia

Give frusemide (1mg/kg)usually not very effective.

Digoxin can be given in small single dose

(5 mcg/kgnote that this is lower than the normal dose of

digoxin).

Even if very anaemic do not transfuse

Heart Failure treatment takes precedence

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70

- Weight

- Respiration rate & sound

- Liver size

- Pulse rate

- Jugular vein or visible veins engorgement

- Heart sounds

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Check Hb at admission if any clinical suspicionof anaemia

- Hb >= 4g/dl or

-Packed cellvol>=12%-or between 2 and 14 days after

admission

- Hb < 4g/dl or

- Packed cellvol

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The good results of day-care show thatsignificant hypoglycaemia is very uncommon

Best prevented by regular feeding

Often there are no clinical signs at all

Treatment has no adverse effects

Always treat children with septic shock as if theyalso have hypoglycaemia

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Give the patient:

- If Conscious: about 50 ml of 10% sugar

water or F-75 by mouth- If Loosing consciousness: 50 ml of

10%sugar water by NGT.

- If Unconscious: Give sugar water by NGT

AND glucose as a single IV injection Start second-line and first line antibiotics

together

Reassess after 15 minutes

Check for eye-lid retraction

Check if the patient is loosing

consciousness

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Warm the patient using the kangaroo

technique for children with acaretaker

Put a hat on the child and wrap motheran child together

Give hot drinks to the mother

Monitor body temperature

Treat for hypoglycaemia and give

second-line antibiotic treatment.

Check the T of the patient:T rectal

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Body temperature twice daily Weight ,degree of edema ,standard clinical

sign every day

MUAC every week

Height every 21 day

Look for signs of primary failure

Record if pts absent,vomits,refuse,use of NGT

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Return of appetite

Beginning of loss of edema

No IV line, no NGT

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It prepare the patient for phase II Lasts b/n 1and 5 days usually 2 or 3 days

Diet is F_100

Surveillance is similar in phase I

Routine medication continued

Expected rate of wt gain is 6g/kg/

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Weight gain more than 10g/kg/day Increasing edema

New onset edema

Increase in liver size rapidly

If sings of fluid over load occurs If tense abdominal distention develops

Significant re-feeding diarrhea

Development of complication, need of NGT,IVmedication

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Good appetite

No edema

No NGT,IV medication

No complication

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Diet is F-100 or RUTF Expect wt gain to achieve our target weight

Add iron supplementation, de-worming

Educate the family

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Weight and edema 3 times per week Temperature every morning

Standard clinical sign every day

MUAC every week

Height every 3 week

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Failure of appetite test Increase/development of edema

Re-feeding diarrhea leads to wt loss

Weight loss for 2 consecutive weighing

Weight loss of more than 5% of body wt

Static weight for 3 consecutive weighing

Major illness

Death of main caretaker

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In patientsPrimary failureFailure to regain appetite Day 4

Failure to start to loss

edema

Day 4

Edema still present Day 10

Failure to enter phase II andgain more than 5g/kg/day

Day 10

Secondary failureFailure to gain more than5g/kg/day for 3 successivedays

During phase II

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Out patientsPrimary failureFailure to gain any weight 21 days

Failure to start to loss edema 14 days

Edema still present 21 days

Secondary failureFailure of appetite test At any visit

Weight loss of 5% of body wt At any visitWt loss for two successive visit During OTP care

Failure to gain more than2.5g/kg/day for 21 days

During OTP care

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W/H >= 85% No edema for 10 days (in pts) & 14 (out pts)

Or target weight gain reached

Education completed

Mother supplied with vitamins

Cheek vaccination completed

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PROGNOSIS OF SEVERE MALNUTRITIONMR ~40% :mostly immediate cause is sepsis

Poor Prognostic indicators

1. Age ( < 6 months)

2. Mental change ( stupor/coma) at presentation

3. Deficient of WFH> 30%

HFA >40%

4. Infections

5. Petichae or hemorrhagic tendencies

6. DHN & electrolyte disturbances

7. Tachycarida with CHF

8. TSP

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9. Severe anemia ( Hb

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Diluted F- 100Why Should be diluted?

Because babies of that age needmore water and they are wasted,they need 100kcal/kg

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Breastfeed every 3 hours, at least for 20 minutes,more often if the child ask for more.

One hour after breast-feeding, complete with F100diluted using the supplementary suckling technique:complete

F-100 diluted: 130ml/kg/day(100kcal/kg/day),divided in 8 meals

To prepare F-100 diluted : dilute F100 one sachetin to 2.7 liters of water

In order to prepare small amount use alreadyprepared 100ml of F100 and add 35 ml of water to

make it diluted and you will get 135 ml diluted F100

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-The mother holds the tube at the breast with one hand

and uses the other for holding the beaker.

-The supplementation is given via an NGT n8 (n5 is toosmall)

-F-100 diluted is put in a beaker. The mother holds it.

-The end of the tube is put in a cup.-The tip of the tube is put on the breast at the nippleand the infant is offered the breast.

-When the infant sucks on the breast with the tube in ismouth, the milk from the cup is sucked up through thetube and taken by the infant.

-The beaker is placed at least 10cm below the level ofthe breast so the milk does not flow too quickly anddistress the infant.

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*Vitamin A:50.000 IU at admission only* Folic acid:2.5mg (1/2tab)* Ferrous sulphate: when the child sucks well and starts

to grow. Take the quantity of F100 enriched withferrous you need in phase II. Add 1/3 of water toobtain the correct dilution.

* Antibiotics:- Amoxicillin (from 2kg):30mg/kg 2 times a day (60mg/day)with

- Gentamicin(5mg/kg/d IM)- Dont use Chloramphenicol

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Weigh infant daily and see if his weight isincreasing.The scale should have a 10 to 20g precision.If the infant is taking the same quantity ofF100D and is increasing, it means that the

breast-milk quantity is increasing.

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When the infant is gaining weight at 20g perday (what ever his weight), decrease thequantity of F100 diluted to one half of themaintenance intake,

-If the weight gain is maintained (10g perday what ever his weight) then stop ssfeeding completely,

-If weight gain is not maintained thenincrease the amount by 75% of the

maintenance amount.-Keep the child in the centre for a further 5days on breast milk alone to make sure thathe continues to gain weight.

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Admission criteria

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RUTF ( Plumpy Nut or B 100 biscuit) ration for week

Routine medicines - Amoxicillin for 7 days- Folic Acid 5 mg PO stat- Vitamin A at admission

( except for edematous children& who received in the past 6

months)- Albendazole at 2nd week- Measles vaccination at 4th week,- Malaria treatment when needed

Weekly follow up

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Counsel the mother/carer on the following Key educationmessages:

RUTF is a food and medicine for malnourished children only. It should not be shared For breast-fed children, always give breast milk before the

RUTF RUTF should be given before other foods. and encourage the child to eat often, every 3-4 hours Always offer plenty of clean water to drink while eating RUTF Use soap and water for the caretaker to wash her/his hands

before feeding Keep food clean and covered Sick children get cold quickly, always keep the child covered

and warm

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Amount of RUTF to give for a week

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1.ASK ABOUT- Diarrhoea, Vomiting, fever, orany other complaint or problem

- If the child is finishing the

weekly RUTF ration2.CHECK FOR Complication Temperature, Respiratory Rate (RR)

Weight, MUAC, and oedema Do appetite test

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3. DECIDE ON ACTION Refer if there is any one of the following

- Develop complication- Fail appetite test

- Increase/development of oedema- Weight loss for 2 consecutive weeks/visits- Failure to gain weight for 3 consecutiveweeks/visits

- Major illness or death of the maincaretaker

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DISCHARGE CRITERIAFor those who were admitted based on oedema: -discharge if there is no oedema for 2 consecutivevisits (14 days).

For those who were admitted without oedema: -discharge when the patient reaches discharge targetweight for 2 consecutive visits

If the child fails to reach the discharge criteria after2 months(8 weeks) of OTP treatment, refer forinpatient care.

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On discharge

Counsel on child feeding and care

Give discharge certificate

Refer the child to SFP if available

Complete registration book

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