MUSCLE WAISTING

Doc Ailyn Agdeppa

WELCOME CLASSIFICATION:
- Evaluates the child for edema and with the Gomez Classification System

Weight for age With edema Without edema

60-80% Kwashiorkor Undernutrition
<60% Marasmic-kwashiorkor Marasmus
*MUAC <11cms (6months old- 18 years old)

CHANGES IN SEVERE CHILDHOOD UNDERNUTRITION (PEM)

Decreased energy requirement

Malnourished children are expected to have a higher energy requirement for each kilo of his body weight because
more of his body is made up of brain, liver, heart and lungs which require a lot of energy.
Whereas he has lost mainly muscle and fat which use very little energy
There must be very profound changes in the function of the main organ of his body to conserve energy

Decreased basal metabolic rate

The basal metabolic rate of a normal child is about 90 kilocalories per kilo
The basal metabolic rate in a non-infected child with chronic malnutrition who is fully adapted to his low intake is
about 60kcal/kilo.
The diet we used to treat James must have MORE than the BASAL requirement to allow for:
1. The amount that he does not absorb from the intestine (about 10%)
2. The amount that is spilt or left in the cup (about 10%)
3. Normal physical activity
4. The fact that most malnourished children have an infection
5. Some of the children have not fully adapted and they will need more
6. We want to TREAT the children by starting gradually to reserve the process.
Therefore, we normally give all malnourished children when they first come for treatment 80-100kcal/kg at 12
feedings/day at the beginning with the F75 diet.
A child who has a poor appetite and is offered 100kcal/kg should never be allowed to take less than 70kcal/kg
(Basal amount plus the amount that will be absorbed).
If he is taking less than this he will continue to become malnourished under your care!
There is no place for graded intake of food starting with half-strength feeds
Below 70kcal/kg is the action point for putting down a nasogastric tube to feed the child with loss of appetite.

Reduced activity
Malnourished children are inactive, only moving when really necessary
They do not smile, play or explore the environment
Actual energy expenditure is much closer to their basal metabolic rate than in normal child
Clinically they are lethargic and apathetic
They do not cry or complain

1
 MUSCLE WAISTING
Doc Ailyn Agdeppa
Heart function
The speed with which the blood circulates around the body is slower. The time it takes dye injected into a vein in
the arm to reach the ear is about 10 seconds in the normal child. When the child is malnourished it takes about
15 seconds. The blood flow is sluggish
What has happened to the heart?
o Each heart muscle fiber contracts less forcefully
o Each muscle cell is thinner than normal
o There are fewer muscle fibers
o The electrical conduction is slower

Therapeutic implication:
It is very easy to precipitate heart failure by overloading the circulation
Intravenous fluid and blood transfusion are dangerous in the malnourished child
True dehydration is treated orally with low sodium solution (ReSoMal is used and not ORS)
For very severe anemia use EXCHANGE transfusion in the same way that it is used for neonates- remove
blood and then give the same volume of blood and repeat the cycle
When edema is being mobilized and the cells are also correcting their electrolyte imbalance from 3 to 14
days after admission is the most dangerous time.

Renal function
The kidneys of the children also adapt to do less work
Renal blood flow is reduced
Glomerular filtration rate is reduced
The amount of acid that can be excreted is limited
The maximum concentration of the urine is limited
The excretion of sodium is impaired
Both the blood flow and the glomerular filtration rate are about half in the malnourished child
The malnourished childrens urine is less concentrated than normal plasma
Some malnourished children can hardly concentrate their urine
After recovery a few children reach the normal ability, but some have kidneys that recovery very slowly

Therapeutic Implication:
Renal solute load is the amount of solid coming from the diet that the kidney will have to excrete
If diets with a high solute load are given to the malnourished child, then the solute may build up in his body
because he cannot concentrate them into his urine
Sodium and potassium concentration in the plasma may increase to dangerous levels at the start of treatment
if sufficient water is not given
This is more likely to happen if the climate is hot and dry and water that is lost from the skin and lungs is not
available to make urine
This is more likely to occur when a child has a fever or a high respiratory rate

Small infants with a high surface area to weight are more likely to lose excess water
Urea, from protein, contributes a lot to renal solute load. High protein diets should not be used to treat
malnutrition
Children who retain excess solute get a skin that feels like dough and then develop hyperosmolar coma,
convulsions and death

2
 MUSCLE WAISTING
Doc Ailyn Agdeppa
The renal solute loads from various diets are as follows:
o Human Milk 80 mOsm/l
o F75 145 mOsm/l
o F100 325 mOsm/l
o F100 (diluted to 75 kcal/100ml) 245 mOsm/l
The low renal solute load from human mild is why extra water never has to be given with human milk but
we must be careful with other diets, and F100 should be used only under your supervision
If F75 is not used at the start of treatment, then F100 should be diluted or extra water should be given this
is especially important in hot dry climates and for all infants and small children less than 5kg
More concentrated diets than F100 are not necessary and should never be used

The malnourished children are only able excrete about half as much acid as the recovered children
This is partly due to the very low of phosphorus than the children have in their tissues
The children cannot tolerate any additional acid in their diet
Magnesium chloride if given alone to treat magnesium depletion provokes a severe acidosis
Potassium citrate is incorporated into the mineral mix to balance magnesium chloride

A high protein diet gives an additional acid load

The low phosphate status is an important reason to use diets based upon cows milk, which is high in
phosphorus
if local diets are used which do not milk then an additional source of phosphorus should be given or some of
the potassium in the mineral mix provided as potassium phosphate but calcium has to be given at the same
time to maintain the calcium phosphorus balance

a normal child can excrete 10 times as much sodium as he is given after treatment of dehydration with normal
ORS the malnourished child is given the same amount of sodium he will get fluid overload
to give the same volume of solution it would need to be given as one fifth normal saline for him just keep
up and not become overloaded
ReSoMal has half the sodium or ORS: even ReSoMal should be given in less quantities than are used to treat
normal children with diarrhea. If the rehydration solution is stronger, or if it is given more quickly, then the
fluid may accumulate until he goes into heart failure

Intestinal Function
The long finger-like villae covered with the cells that absorb food disappear in some cases of marasmus
In malnutrition there is a reduction in the activity of all enzymes to digest carbohydrate by between one third
and one half
In malnutrition, the sucrose was absorbed as well as the glucose. Lactose was absorbed nearly as well as the other
sugars
Because there is twice as much energy in 10% sucrose as in 5% glucose (at the same osmolarity) it is better to give
sucrose or even lactose than glucose.

Therapeutic implications

If you give more than the capacity to absorb then you will provoke diarrhea.
This can come about by either giving too high a volume or high concentration.
Isotonic diets can give diarrhea if too much is given at one time: this even applies oto glucose solutions. Thye
have a reduced CAPACITY for absorption.

3
 MUSCLE WAISTING
Doc Ailyn Agdeppa
High concentration, hyperosmolarity and large volumes of feed, that exceed the capacity of the child will all
cause re-feeding diarrhea.
The malnourished child needs to be fed small amounts of the diet every frequently.
If a child gets diarrhea with the feed then give twice as many feeds with half of the amount in each feed. With
very sick children the diet can be dripped in slowly though a nasogastric tube so that the intestine is
continuously absorbing and the capacity is not exceeded.
You can get more energy in from 10% sucrose than 5% glucose: they are absorbed to similar amounts. It is
better to give ordinary sugar than glucose.

LACTOSE INTOLERANCE AND REFEEEDING DIARRHEA

Many people think that lactase deficiency is a common problem in malnutrition because the children get
diarrhea at first when they are given large meals of milk.
This is a problem of overloading the capacity to absorb, and will occur with large amounts of any sugar.

ELECTROLYTE METABOLISM

Therapeutic implications:

Giving oral rehydration solution while the adaptation is reversing is particularly dangerous.
This applies to marasmus and kwashiorkor, but is more likely to occur in kwashiorkor because the sodium pump
is already active.
If high sodium diets, rehydration solutions or transfusions are given during this time when the children may die
from heart failure.
Be very careful with high sodium solutions, diets or drugs after the start of the treatment, particularly after 72
hours or more.
Re-feeding diarrhea should not be treated with rehydration solutions change the diet and put the child back
to phase one.
Heart failure due to refeeding can be treated with digoxin to slow the sodium pump anf allow some of the
sodium to pass into the cells again.
The plasma sodium concentration is usually normal this does not mean that there is a normal amount of
sodium in the body it is greatly increased.
If the cells are very leaky the plasma sodium concentration can fall as the sodium enters the cells.
This is a very bad prognostic sign and means that the cell membrane are damaged.
A low plasma sodium must never be treated by giving extra sodium this will lead to death.
As the circulation expands and the child goes into heart failure, the hemoglobin level drops (and the liver
enlarges).
This is because there is a fixed amount of red cells but the quantity of plasma increases.
The expansion of the circulation can be measured by the fall in hemoglobin or hematocrit.
This must NEVER be treated with transfusion. One doctor in Angola monitored hemoglobin and transfused these
children as they became more anemic. Of the first 26 children they ALL DIED from heart failure.
If anemia is severe it should be treated within 48h of admission. After that time is should not be treated by
transfusion at all. If possible, give blood by exchange transfusion and also start treatment for heart failure
The normal body temperature of the malnourished children is less than the recovered children.
At 38C the body temperature in malnutrition rises steadily until there is fever. This is due to a failure of the
sweating response where much less sweat is produced by the malnourished child.
4
 MUSCLE WAISTING
Doc Ailyn Agdeppa
In hot environments fever can be due to the malnutrition itself and not necessarily infection.
The treatment is to cover the patient with a wet towel. The towel should be tepid and not cold (cold water
makes les blood come to the skin so that heat is lost more slowly than with ordinary water).
The malnourished person needs extra water, or breast milk, to lose heat and excrete the renal solute load as
well.
The diet should not be cooled this makes the skin feel cooler but the core temperature rises.
Rubbing alcohol should never be used it is very dangerous.
Aspirin or paracetamol should not be used the liver enzymes cannot metabolize them. Paracetamol makes
liver function worse in malnutrition ad aspirin can give acidosis.

TEMPERATURE REGULATION:

The malnourished children had a decrease in energy consumption as the environmental temperature dropped.
They were producing less heat in their body. This means that they would not have been able to maintain their
temperature and would become hypothermic.
THERAPEUTIC IMPLICATIONS

Hypothermia is common in malnutrition.

The patients need a temperature which is often unpleasantly warm (28-32C) for fully clothed adults that are
active as a nurse. The attendants should know that only when they feel warm it is the correct temperature for
their child if they feel normal it is too cold for the malnourished in their care.
The children are vulnerable until they have been gaining weight rapidly for some days and not just during the
first few days after admission. Rapidly growing children are also vulnerable if they miss a meal, the temperature
drops to less than 25C or they are wet.
Open skin lesions make it much more difficult to maintain heat these patients are very vulnerable to
hypothermia.
All windows must be closed at night.
The children should all have clothes, blankets and their heads should be covered at night.
The patients should sleep with their mothers, or together, at night and not alone.
Very ill malnourished children should not be washed unless it is above their thermoneutral range.
All malnourished children should be dried carefully after washing.
The diet should be warmed to 30-40C (but no more) before it is given to sick patients.
Hypothermia is best treated by putting the patient on the bare chest of the caretaker and wrapping them both
together in warm blankets (Kangaroo style). Hot drinks to the caretaker increase her skin blood flow and warms
the child much more quickly.

IMMUNE AND INFLAMMATORY SYSTEM

The child has almost no inflammatory response to bacterial invasion.

There is little migration of cells to the sites of injury.
Cells that ingest bacteria have difficulty in killing them.
Immune function tests show that all aspects of both the immune and inflammatory systems are reduced.
The thymus, tonsils, lymph nodes and other tissues of the immune system are atrophic.
The cell mediated responses are diminished or absent.
The response to vaccines is diminished.
The intestinal secretion of antibodies is decreased.
Over 95% of children with severe malnutrition have a systemic infection.

5
 MUSCLE WAISTING
Doc Ailyn Agdeppa
The common bacterial infections are bronchopneumonia, urinary tract infection, blood, skin, small and large
intestine, middle ear, joints and bone.
There is frequently candidiasis of mouth, esophagus, stomach, large intestine, lung and blood.
Many different viruses have been isolated.
There are usually worms in the intestine. Disseminated scabies and lice are very frequent. Malaria is almost
universal in endemic areas. Other protozoa and filarial worms are common.
We diagnose infections by the way that the body reacts to the invading organism. Because the reactions may be
absent we do not recognize when a child has a severe infection. YOU CANNOT TELL CLINICALLY THAT A CHILD
HAS INFECTION.
An increased shadow on chest X-ray is very faint and diffuse and easily overlooked only well-nourished
children get lobar pneumonia. The marasmic child cannot restrict the infection to only one lobe of the lung.
One sided lesions are either an inhaled foreign body or tuberculosis.
Broncho-pneumonia may not be accompanied by a fast respiratory rate.
Skin tests for tuberculosis may be negative in patients with active TB,
Urine tests that look for white cells may be negative in the presence of significant infection.
The blood white cell count is not a reliable test for septicaemia.
All malnourished children should be treated blindly with broad spectrum antibiotics from admission.
There is always small bowel bacterial overgrowth this is because of
a) the reduction in stomach acid, IgA, lysozyme and bile salts and,
b) the slow movement of the intestine (reduced peristalsis) which can act like a partial
obstruction.

This enormous numbers of normal bacteria in the lumen of the intestine damage the intestinal lining, produce
toxins that impair liver function and frequently invade the body.
The broad spectrum antibiotics may reduce their numbers, if there is abdominal distension then metronidazole
should be added to the regimen.
Metronidazole will also treat giardiasis and amoebae.
There is diminished response to vaccines. Measles vaccine should be given both on admission (to abort
incubation infection and prevent nosocomial infection) and also on discharge when the child has recovered.
It is only with the second dose that good immunity will develop and protect the child. Two doses of measles
vaccine are not harmful.
Fever is more likely to be due to environmental temperature than an infection 0 it should not be treated with
aspirin or paracetamol.
Hypothermia and hypoglycemia frequently accompany very severe infection. If these occur, then second line
antibiotics should be used.

MUSCLE FUNCTION

The muscle of the throat and gullet are weak and not well coordinated so that his swallowing is poor: he is much
more likely to choke and inhale food or medicine than a normal child.
Do not force feed malnourished children by filling their mouths and then holding the mouth closed.
Do not try to get the child to swallow by pinching this nose so that he needs to swallow before he can take a
breath.
Most children find it much easier to swallow liquid than solid food.
Do not have ingredients in the diet that cause chemical inflammation in the lungs (for example, groundnut
products are notorious for giving a chemical pneumonia when inhaled and should not be used in the diet).
The smooth muscle of the stomach and intestine is slow and sluggish. This is the main reason for the small
bowel bacterial overgrowth.

6
 MUSCLE WAISTING
Doc Ailyn Agdeppa
The smooth muscle of the bladder is weak and the bladder does not empty completely. This is why urinary tract
infection is so common unlike normal children it is just as common in malnourished boys and girls.
The heart muscle is weak and easily over stretched. This is why heart failure is very common during early
recovery.

LOSS OF RESERVE

The loss of tissue mass and the reduction in the chemical composition of the remaining tissue, together with the
remarked reduction in the physiological and biochemical capacity means that there is a loss of reserve to
withstand any stress that is put on the system
Loss of appetite is a cardinal feature it means that the child has a type 2 nutrient deficiency, altered liver
function or a serious infection and should also be used to decide if the child needs special treatment.
Other features such as the general appearance and regression of milestones in children (for example, no longer
being able to crawl whereas the child used to crawl), or the inability to stand in older children and adults are
important sign of failure of function.
When the malnourished child loses his appetite and reduces his intake he has entered a downward spiral that
will lead to death if the cycle is not broken. Anorexia is a major danger sign.

LOSS OF HOMEOSTASIS

The childs inability to respond to stress means that he cannot maintain the normal concentrations of
substances in his blood or tissues, electrolyte gradients, or body temperature.
A relatively mild stress, that would be well within the capacity of the normal child to homeostatically control
may kill a severely marasmic child.
DEATH

In many hospitals about one third of marasmic children who reach hospital alive, die during treatment.
When standard protocols are used, based upon the concepts in this module, the mortality rate is about 5% or
less. The children that do not die can come completely back to normal.

TABLE 43-3 COMPOSITION OF F75 AND F100 DIETS

AMOUNT 100 mL
CONSTITUENT F75 F100
Energy 75 kcalth (315 kJ) 100 kcalth (420 kJ)
Protein 0.9 g 2.9 g
Lactose 1.3 g 4.2 g
Potassium 3.6 mmol 5.9 mmol
Sodium 0.6 mmol 1.9 mmol
Magnesium 0.43 mmol 0.73 mmol
Zinc 2.0 mg 2.3 mg
Copper 0.25 mg 0.25 mg
Percentage of energy from:
Protein 5% 12%
Osmolarity 333 mOsmol/L 419 mOsmol/L