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What should you worry about in the middle of the night?

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Areas to think about

InfectionRespiratory StatusCardiac StatusFluid StatusRe-feeding Syndrome

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Malnutrition happens over a long period of time something has pushedthem over the edge to come into the Emergency Department.

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Sepsis Pneumonia

Occult infection TB HIV

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Malnutrition has a tremendous impact onrespiratory functions.

Diaphragm mass & thickness reduced Respiratory muscle strength and endurance

reduced Increased risk of respiratory failure Prolonged mechanical ventilation if intubated

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Avoid IV fluids unless in shock

Fluid boluses significantly increased 48-hour

mortality in critically ill children. NEJM June 2011 Oral rehydration

5 cc/kg every 30 minutes for first two hours

5-10cc/kg/hour x 4-10 hours based on level ofdehydration

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What steps will you take?

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Give judicious Fluid

Remember no IV Fluids

Start empiric antibiotics Treat Hypoglycemia Treat Hypothermia

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Mid - Upper Arm Circumference(MUAC) is relatively easy to measure and agood predictor of immediate risk of death. It is

used for rapid screening of acute malnutritionfrom the 6-59 month age range (MUACoverestimates rates of malnutrition in the 6-12month age group). MUAC can be used forscreening in emergency situations but is nottypically used for evaluation purposes.

Mdecins sans Frontries (MSF). Nutrition Guidelines. Coordinated by M.Boerlart, A. Davis, B. Lelin, M.J. Michelet, K. Ritmeijer, Svan der Kamand F. Vautier. MSF, Holland, 1995

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After a few hours of fluids begin a slowprocess of refeeding

How can you tell refeeding can go to fullvolume? They want to eat! Vitamins to use right away

Zinc, thiamin, vitamin D, vitaming A

Do not use iron right away as it can increaserate of infection.

Deparasite treatments as needed

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Marasmus

The signs of marasmus areloose, folded skin and aprotruding rib cage .

This photo is taken from theCDC Public Health Image

Library and was provided byDr. Edward Brink

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Kwashiorkor

This late 1960s photographshowed four Nigerian children whowere in a refugee relief campduring the Nigerian-Biafran civilwar. Note one of the children onthe left has light hair, which is asymptom indicative of

kwashiorkor, a disease brought ondue to severe dietary proteindeficiency. Symptoms include:changes in skin pigment, hairchanges, lethargy, loss of musclemass, edema, and severeinfections.

CDC Public Health Image Library

provided by Dr. Lyle Conrad.

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Refeeding syndrome (RFS) is the result ofaggressiveenteral or parenteral feeding in a malnourishedpatient, with hypophosphatemia being the hallmark of thisphenomenon. Other metabolic abnormalities, such as

hypokalemia and hypomagnesemia, may also occur, alongwith sodium and fluid retention. The metabolic changes thatoccur in RFS can be severe enough to causecardiorespiratory failure and death. This article reviews thepathophysiology, the clinical manifestations, and the

management of RFS. The key to prevention is identifyingpatients at risk and being aware of the potentialcomplications involved in rapidly reintroducing feeds to amalnourished patient.

Pediatric Clinics of North America 2009 56(5) 1201-10

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Pediatric Clinics of North America 2009 56(5) 1201-10

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Dureuil B, Matuszczak Y. Alteration in nutritional status and diaphragmmuscle function. Reprod Nutr Dev. 1998 Mar-Apr;38(2):175-80 Fuentebella, J and Kerner, JA. Refeeding syndrome. Pediatr Clin of NorthAm 2009 Oct;56(5): 1201-12 Maitland, K, et. al. Mortality after fluid bolus in African children with

severe infection. N Engl J Med 2011 Jun 30;364(26):2483-95.