Berhanu Ebisa (MD)

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

Why nutrition matters?

Low immunity Illness Death Mental impairment

Reduced productivity

Other 2% Measles 4% AIDS 1% Diarrhea 20%

Malnutrition 53%

Neonatal 25%

Malaria 20%
Pneumonia 28%

18%

412,000 died between 2000-2005

50,000
deaths
UNICEF/93-COU-0173/Lemoyne

infant

every year

9/28/2013

Defined as pathological states resulting from relative or absolute deficiency of one or more essential nutrients.
Clinical syndrome results from micro or macro nutrient deficiency

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.

B ) Secondary cause : 1.Infections. 2.Congenital diseases. 3.Malabsorption. 4.Metabolic causes. 5.Psycho social deprivation.

1.Clinical 2. Anthropometric 3. Bio chemical 4. Dietary

The process of determining the nutritional status of individuals or population through collection and interpretation of data from dietary, laboratory, anthropometric and clinical studies
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Nutrition indices are a combination of measurements compared to a reference

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Interpretation of MUAC measurement for age group 6 month18 years

 Classification

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

Wt. for age malnutrition

90-100% 75-89% 60-74% < 60

Degree of
normal mild (grade I) moderate (grade II) severe (grade III)

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Edema

WFA ( Harvard)

60-80 %

< 60 %

Absent

Underweight

Marasmus

Present

Kwashiorkor

Marasmickwashiorkor

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WFH

Nutritional status

HFA

Nutritional status Normal Mild stunting

90-100% 80-90%

Normal Mild wasting

> 95% 90-95%

70-80% < 70 % *

Moderate Severe wasting

85-90% < 85%

Moderate Severe stunting

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Ask the mother to remove all the cloth and look the arms, thighs and buttocks for loss of muscle bulk and sagging of skin

Admission criteria for SAM: ( >6 month) 1.MAUC < 11cm. 2. Wt /Ht < 70% . 3.Bilateral pitting edema. 4.Serious medical complications

Different proposed mechanisms : 1. Protein-energy deficiency 2. Mal adaptation 3. Free radical theory ( imbalance between oxidants and antioxidants) No adequate explanation so far why some children develop edematous malnutrition

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 CMI profoundly affected: - Reduced secretory IGA - Impaired phagocytic function - Impaired acute phase response - WBC do not migrate to area of infection - Non-specific defense is weakened

CVS and renal - Atrophied myocardium - Reduced cardiac output and stroke volume. - Blood pressure is low Decreased renal blood flow Poor concentrating and filtration capacity

kwash
Under weight

marasmus
Extremely under weight(<60 %)

Edema is always present Thin lean muscles, fat is present Puffy, moon face Hair changes are present

Edema is absent Muscle wasting and loss of subcutaneous fat Appearance old man face Hair are normal

Miserable looking apathetic

Face alert

Poor appetite and anorexic

Appetite is better

Flaky paint dermatitis

Skin is normal

RBS U/A and/or U/C Serum Albumin B/C Serum electrolyte CBC S/E ,S/C CXR

Treatment approaches for SAM contains three phases : 1.phase I 2. transition phase 3. phase II

Feeding Routine medicine Surveillance Rx complications

48

How to diagnose and treat?

Malnourished children are SENSITIVE to excess sodium intake! All the signs of dehydration in a normal child occur in a severely malnourished child who is NOT dehydrated only a HISTORY of fluid loss and very recent change in appearance can be used Giving a malnourished child who is not really dehydrated treatment for dehydration is very dangerous Misdiagnosis of dehydration and giving inappropriate treatment is the commonest cause of death in severe malnutrition.

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The treatment of dehydration is different in the severely malnourished child from the normally nourished child
Infusions are almost never used and are particularly dangerous ReSoMal must not be freely available in the unit but only taken when prescribed The management is based mainly on accurately monitoring changes in weight

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The next two slides show that severely wasted patients cannot excrete excess sodium 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 as pneumonia

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Fasting Urine Osmolarity (mOsm/l)

300

600

900

0
Malnourished Recovered
Post-Pitressin Urine Osmolarity (mOsm/l)

300

600

900

0 Malnourished Recovered

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Sodium excretion (% of sodium filtered)

10

12

0
Normal ECF Expanded ECF

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History of recent change in appearance of eyes

History of recent fluid loss

NO OEDEMA - Oedematous patients are over-hydrated and not dehydrated (although
they are often hypovolaemic from septic shock)

Check the eyes lids to see if there is lidretraction a sign of sympathetic over-activity Check if the patient is unconscious or not
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Eyes Sunken

Not Recent onset recent Not dehydrated

Conscious
Awake
Eye-lid retracte d Eye-lid normal

Unconscious

Sleeping
Eyes not closed Eyes closed

Eyes not closed

Eyes closed

Dehydration Hypogly

dehyd ration

Dehydration Hypogly

dehyd ration

Dehydration hypoglycae mia

dehydrati on 56

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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Conscious

ONLY Rehydrate until the weight deficit (measured or estimated) is corrected and then STOP DO not give extra fluid to prevent Unconscious recurrence
IV fluid

Resomal

- 5ml/kg /30min first 2hrs

Darrows solution or 1/2 saline & 5% glucose or Ringer lactate & 5% dextrose

- 5 to 10ml/kg/hr 10 hrs

at 15ml/kg the first hr & reassess .if improved repit - If conscious, NGT: ReSoMal - If not improving =>Septic shock
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If there is no weight gain, then:

Increase the rate of administration of ReSoMal by 10ml/kg/hour Formally reassess in one hour Increase the rate of administration of Resomal by 5ml/kg/hour Formally reassess every hour

If there is continued weight loss, then:

If there is clinical improvement but there are still signs of dehydration

continue with the treatment until the appropriate weight gain has been achieved.

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If there is weight gain and deterioration of the childs 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 of the child or reversal of the clinical signs
Then the diagnosis of dehydration was probably wrong: either change to F75 or F75 and Resomal.

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Weight

Gain

Stable

Loss

Clinical Improv ed
continue

Targ et wgt F75

- STOP ALL rehydration fluid - Give F75 - Re-diagnose & assess

Clinical Not improved

- Increase ReSoMal: 5ml/kg/h r Reassess every hr

- Increase ReSoMal by 10ml/kg/ hr - Reassess every hr 61

Signs of Septic shock present

Fast weak pulse, cold peripheries, pallor, drowsiness

No History of recent eyes sinking No history of major fluid loss

Eye-lid drooping/normal or closed when asleep/unconscious

Eye-lid retracted or slightly open when asleep/ unconscious

Septic shock

Septic shock with Hypoglycaemia

Note: Lid retraction without shock treat immediately for hypoglycaemia

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Diagnosis = Septic shock to be present

a fast weak pulse with cold peripheries Pallor Disturbed consciousness

- 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. -

Treatment

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Septic shock

Conscious

Unconscious Loosing conscious

F 75 by mouth or 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, without ; anything else. - If conscious, NGT: F75

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What is the diagnose of this child?

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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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Diagnosis Physical deterioration with a gain in weight

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 during treatment

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Examine daily weights

Weight Increase

Weight decrease

Weight stable

Fluid overload Heart failure

Pneumonia Aspiration

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Stop all intake of fluids or feeds (oral or IV) No fluid or food should be given until the heart failure has improved or resolved (even 24-48 hours.) Small amounts of sugar-water can be given orally if worried about hypoglycaemia Give frusemide (1mg/kg) usually not very effective. Digoxin can be given in small single dose
(5 mcg/kg note 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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- 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 suspicion of anaemia

- Hb >= 4g/dl or -Packed cell vol>=12%

-or between 2 and 14 days after admission No acute treatment

ONLY during the first 48 hours after admission: Give 10ml/kg whole or packed cells

- Hb < 4g/dl or - Packed cell vol<12%

Iron during phase 2

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The good results of day-care show that significant 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 they also have hypoglycaemia

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Check for eye-lid retraction Check if the patient is loosing consciousness 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
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Check the T of the patient:T rectal<35 - T axi. <35.5 C Check the temperature (T) of the room (28 32C) Warm the patient using the kangaroo technique for children with a caretaker Put a hat on the child and wrap mother an child together Give hot drinks to the mother Monitor body temperature Treat for hypoglycaemia and give second-line antibiotic treatment.

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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

Return of appetite

Beginning of loss of edema

No IV line, no NGT

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/

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,IV medication

Good appetite No edema No NGT,IV medication No complication

Diet is F-100 or RUTF Expect wt gain to achieve our target weight Add iron supplementation, de-worming Educate the family

Weight and edema 3 times per week Temperature every morning Standard clinical sign every day MUAC every week Height every 3 week

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

In patients
Primary failure Failure to regain appetite Day 4

Failure to start to loss edema

Edema still present Failure to enter phase II and gain more than 5g/kg/day Secondary failure Failure to gain more than 5g/kg/day for 3 successive days

Day 4
Day 10 Day 10

During phase II

Out patients
Primary failure Failure to gain any weight Failure to start to loss edema Edema still present Secondary failure Failure of appetite test Weight loss of 5% of body wt Failure to gain more than 2.5g/kg/day for 21 days At any visit At any visit During OTP care 21 days 14 days 21 days

Wt loss for two successive visit During OTP care

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

PROGNOSIS OF SEVERE MALNUTRITION MR ~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 <3gm/dl

9.
10. 11.

12.

Severe anemia ( Hb <4gm/dl) Extensive skin lesion Hypoglycemia or hypothermia Clinical Jaundice or high serum bilirubin

Diluted F- 100 Why Should be diluted? Because babies of that age need more water and they are wasted, they need 100kcal/kg

Breastfeed every 3 hours, at least for 20 minutes, more often if the child ask for more. One hour after breast-feeding, complete with F100 diluted 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 sachet in to 2.7 liters of water In order to prepare small amount use already prepared 100ml of F100 and add 35 ml of water to make it diluted and you will get 135 ml diluted F100

-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 too small) -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 nipple and the infant is offered the breast. -When the infant sucks on the breast with the tube in is mouth, the milk from the cup is sucked up through the tube and taken by the infant. -The beaker is placed at least 10cm below the level of the breast so the milk does not flow too quickly and distress the infant.

*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 with ferrous you need in phase II. Add 1/3 of water to obtain the correct dilution. * Antibiotics:- Amoxicillin (from 2kg): 30mg/kg 2 times a day (60mg/day) with - Gentamicin(5mg/kg/d IM) - Dont use Chloramphenicol

Weigh infant daily and see if his weight is increasing. The scale should have a 10 to 20g precision. If the infant is taking the same quantity of F100D and is increasing, it means that the breast-milk quantity is increasing.

When the infant is gaining weight at 20g per day (what ever his weight), decrease the quantity of F100 diluted to one half of the maintenance intake, -If the weight gain is maintained (10g per day what ever his weight) then stop ss feeding completely, -If weight gain is not maintained then increase the amount by 75% of the maintenance amount. -Keep the child in the centre for a further 5 days on breast milk alone to make sure that he continues to gain weight.

Admission criteria

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

Counsel the mother/carer on the following Key education messages:

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

Amount of RUTF to give for a week

1.ASK ABOUT - Diarrhoea, Vomiting, fever, or any other complaint or problem - If the child is finishing the weekly RUTF ration 2.CHECK FOR
Complication Temperature, Respiratory Rate (RR) Weight, MUAC, and oedema Do appetite test

3. DECIDE ON ACTION

- Develop complication - Fail appetite test - Increase/development of oedema - Weight loss for 2 consecutive weeks/visits - Failure to gain weight for 3 consecutive weeks/visits - Major illness or death of the main caretaker

Refer if there is any one of the following

DISCHARGE CRITERIA
For those who were admitted based on oedema: discharge if there is no oedema for 2 consecutive visits (14 days). For those who were admitted without oedema: discharge when the patient reaches discharge target weight for 2 consecutive visits If the child fails to reach the discharge criteria after 2 months(8 weeks) of OTP treatment, refer for inpatient care.

On discharge

Counsel on child feeding and care Give discharge certificate Refer the child to SFP if available Complete registration book