PROTEIN ENERGY MALNUTRITION SEVERE ACUTE MALNUTRITION · PROTEIN ENERGY MALNUTRITION & SEVERE ACUTE MALNUTRITION 1. IAP UG Teaching slides 2015-16 MAGNITUDE OF MALNUTRITION ‐ INDIA

IAP UG Teaching slides 2015-16

PROTEIN ENERGY MALNUTRITION & SEVERE ACUTE MALNUTRITION

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MAGNITUDE OF MALNUTRITION ‐ INDIA

• % <5yrs Moderate ‐ 47• % <5yrs Severe ‐ 18• % Wasting<5yrs ‐ 16

(moderate & severe)• % Stunting <5yrs ‐ 46

(moderate & severe)

(Data based on NFHS2 findings 1998‐99)

•Underweight ‐ 40.4%•Wasted ‐ 22.9%•Stunted ‐ 44.9%

(NFHS 3 DATA 2005‐2006)

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IAP UG Teaching slides 2015-16 33


Protein deficiency :resulting in KwashiorkorViteri’s Time bound theory: time to adapt marasmusToxic theory: Organ dysfunction kwashiorkorNiacin theory: deficiency dermatosis Increased ferritin level ADH like action & edemaDr. Gopalan’s dysadaptation theory effective catabolism & near normal anabolism in marasmus, failure of anabolism in kwashiorkor

THEORIES OF MALNUTRITION

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THEORIES OF MALNUTRITION‐NEW THEORIES

•Free radical theory

•Aflatoxin poisoning

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Free oxygen radicals are potentially toxic to cell membrane and are produced during various infections These oxides are normally buffered by proteins and neutralized by antioxidants such as Vit. A, C & E and selenium In malnourished child deficiency of these nutrients in the presence of infection or aflatoxin may result in the accumulation of toxic – free oxygen radicals These may damage liver cells giving rise to Kwashiorkor.

FREE RADICAL THEORY

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Inadequate protective pathway

Noxious agent (NoxA)

Free Radicals

Macro molecular damage

Fe Catalyzed

Inadequate Repair

Fatty Liver

Malnutrition

FREE RADICAL THEORY OF KWASHIORKOR

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Low protein diet growth stops Stunting

Very low protein Anorexia Marasmus

Insufficient diet weight loss wasting ,edema

(kwashiorkor/marasmic

kwashiorkor)

AFLATOXIN POISONING

NoXa

DIET

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CLINICAL FEATURES

• Hair changes• Skin changes• Muscle wasting• Oedema• Psychomotor changes

• Anaemia• Features of vitamin deficiencies• Dehydration• Hepatomegaly• Cardiac failure

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MARASMUS‐GRADE IV

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KWASHIORKOR‐ GRADE IV

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Marasmus Kwashiorkor

Age (Yr.) <1 1 – 3

Edema None Lower legs or generalized

Wasting Gross, loss of subcutaneous fat, skin

and bone

Hidden

Muscle wasting Obvious Hidden

Growth retardation Obvious Present

Mental change late feature Irritable, moaning, apathetic

Appetite Good Poor

Diarrhea May be present Usually present

KWASHIORKOR & MARASMUS

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Marasmus Kwashiorkor Hair & Skin

changeSeldom Often diffuse

depigmentation/ flag sign occasional flanky paint dermatosis of skin

Serum. Albumin Low Normal Low

Urinary Urea / Creatinine

Low Normal Low

Urinary Hydroxyproline /

Creatinine

Low Low

Serum Essential amino acid

Low Low

Anemia Uncommon Common

Hepatomegaly ‐ Fatty Liver

KWASHIORKOR & MARASMUS

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MARASMIC KWASHIORKOR

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POOR PROGNOSTIC CRITERIA IN PEM

• Age: infants• Wt/Ht >70%/ 3 SD• MUAC < 11.5 cm• Stupor or coma• Severe gram negative

sepsis• Hemorrhagic tendencies,

Thrombocytopenia • Signs of CCF/respiratory

distress

•Total serum protein <3 g/dl & Albumin <2 g/dl•Severe anaemia with clinical signs of hypoxia •Liver dysfunction, altered LFT•Extensive exudative or exfoliative dermatosis•Hypoglycaemia/hypothermia •Low gamma globulin fraction

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SEVERE ACUTE MALNUTRITION

• Severe Acute malnutrition is defined as the presence of severe wasting – Weight for height/length <‐3SD and or – MUAC <11.5 cm for children 6‐59 months and or – Presence of bilateral edema

• Children with severe acute malnutrition have nine times higher risk of death.

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INVESTIGATIONS

• Blood glucose• Peripheral smear• Hemoglobin• TC,DC,ESR • Urine Examination• Stool Examination • Chest X‐ray • RFT, LFT• Cultures• Mantoux Test

Other Tests:• Serum proteins, • Serum albumin• Electrolytes• Calcium, Magnesium, Phosphorus

• Immunoglobulin profile

• HIV

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• Hypoglycemia• Hypothermia• Infections (bacterial, viral & fungal)• Hypokalemia• Hyponatremia• Dehydration & shock• Heart failure

COMPLICATIONS

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• Age: > 6 months of age• Alert• Preserved appetite • Clinically assessed to be well

• Living in a conducive home environment.

UNCOMPLICATED

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• Age: <6 months or• > 6 months but not fulfilling the criteria for uncomplicated also considered "complicated".

• Institutional care is considered mandatory

CRITERIA FOR ADMISSION

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WHO GUIDELINES FOR IN‐PATIENT TREATMENT OF SEVERELY MALNOURISHED CHILDREN (SAM)

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A. General principles for routine care (the’10 steps’) B. Emergency treatment of shock and severe anemia

C. Treatment of associated conditions D. Failure to respond to treatment E. Discharge before recovery is complete

MANAGEMENT

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• These steps are accomplished in two phases: • an initial stabilization phase where the acute medical conditions are managed; and

• a longer rehabilitation phase.

• Note that treatment procedures are similar for marasmus & kwashiorkor.

GENERAL PRINCIPLES FOR ROUTINE CARE

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THE 10 STEPS

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Blood sugar level <54 mg/dl or 3 mmol/L

Assume hypoglycemia when levels cannot be determined.

CONSCIOUS CHILD‐ 50 ml bolus of 10% glucose by nasogastric (NG) tube.

UNCONSCIOUS CHILD, lethargic or convulsing ‐IV sterile 10% glucose (5ml/kg), followed by 50ml of 10% glucose or sucrose by NG tube.

Start two‐hourly feeds, day and night

STEP 1. TREAT/PREVENT HYPOGLYCAEMIA

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• If axillary temperature <35oC, take rectal temperature

• If the rectal temperature is <35.5oC (<95.9oF):‐ rewarm the child: 2 layer clothes, cover with

warmed blanket & place a heater or lamp nearby or put the child on the mother’s bare chest (skin to skin) and cover them – Kangaroo mother care

‐ feed straightaway

STEP 2. TREAT/PREVENT HYPOTHERMIA

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• Difficult to estimate dehydration using clinical signs alone

• Assume all children with watery diarrhea may have dehydration

• Do not use the IV route for rehydration except in cases of shock

• Continue feeding

STEP 3. TREAT/PREVENT DEHYDRATION

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Basic format remains the sameSome signs unreliable• Mental state• Mouth, tongue and tears• Skin turgor• Urine output: quantity/color/osmolarityEdema and hypovolemia can coexist

ASSESSMENT OF DEHYDRATION IN SEVERELY MALNOURISHED CHILDREN

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DIAGNOSIS OF DEHYDRATION IN SEVERELY MALNOURISHED CHILDREN

• History of diarrhea ( with large volume of stools)

• Increased thirst • Recent sunken eyes• Prolonged CFT, weak/absent radial pulse, decreased or absent urine flow

Difficult using clinical signs alone Best to assume that all with watery diarrhea have some dehydration

Treat with ORS unless shock is present30


REHYDRATION SOLUTION FOR MALNUTRITION (ReSoMal)

Std. WHOORS

WHO Reduced osmolarity

ORS

ReSoMal

Sodium 90 75 45

Potassium

20 20 40

Glucose 111 75 125

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Ingredient Mass (g) mmol per 20 mlPotassium chloride (KCl) 224 24Tripotassium citrate 81 2Magnesium chloride (MgCl2.6H20) 76 3Zinc acetate (Zn accetate.2H20) 8.2 0.3Copper sulphate (CuSO4.5H20) 1.4 0.045

• To be added to diet or oral rehydration salts solution.• Add 20 ml of the solution to a liter of diet or oral rehydration salts. However, appropriate Vitamin mineral mix is not available in India.

In this scenario, one may use combinations of various commercial preparations available

COMPOSITION OF RESOMAL

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OPTIONS

• Low osmolarity ORS with potassium supplements

• ReSoMal (not available in India)IAP endorses the use of LOW OSMOLARITY WHO ORS for all types of diarrhea and nutritional status for logistics and programmatic advantages.

WHICH ORS SHOULD BE USED IN SEVERE MALNUTRITION?

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ConsciousUnconscious

Resomal

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

IV fluid

Ringer lactate & 5% dextrose at 15ml/kg the first hr & reassess

5ml/kg /30min for first 2hrs

‐ If improving, 15ml/kg 2nd hr;

‐ If conscious, NGT: ReSoMal

‐ If not improving =Septic shock

TREATMENT OF DEHYDRATION

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• Plasma sodium may be low though body sodium is usually high. Sodium supplementation may increase mortality.

• Potassium & Magnesium are usually deficient and needs supplementation; may take at least two weeks to correct.

• Edema if present is partly due to these imbalances. Do NOT treat edema with a diuretic

STEP 4. CORRECT ELECTROLYTE IMBALANCE

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POTASSIUM

• In SAM children, there is too little potassium inside cells.

• All SAM children should be given potassium supplements (3‐4 mmol/kg/day) for 2 weeks.

• Potassium Chloride syrup is the most available medicine of which every 15ml contains 20 mmol potassium.

Give extra potassium daily for 2 weeksDo not treat oedema with diuretic since most diuretics increase loss of potassium and make electrolyte imbalance worse.

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MAGNESIUM

• In SAM children, there is too little magnesium inside cells.

• On 1st day 0.3 ml/kg of 50% magnesium sulphate (up to a maximum of 2ml) should be given IM once.

• After this from 2nd day onwards magnesium should be given orally (0.1ml/kg/day/0.4‐0.6 mmol/kg/day) X 2 weeks.

Give extra magnesium daily37


Usual signs of infection, such as fever, are often absent. Give broad spectrum antibiotics to all. Hypoglycemia/hypothermia usually coexistent with infection. Hence if either is present assume infection is present as wellNo complications ‐ Co‐trimoxazole / AmoxicillinSeverely ill ‐ Ampicillin + GentamicinIf the child fails to improve clinically within 48 hours, add: cefotaxime/ceftrioxone as per Facility based ‐ FIMNCI

STEP 5. TREAT/PREVENT INFECTION

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STATUS ANTIBIOTICSInfected child or complications* present

IV AMPICILLIN 50 mg/kg/dose q 6hrly and IV GENTAMICIN 2.5 mg/kg/dose q 8hrly/ once daily

Add IV CLOXACILLIN 100 mg/kg/day q 6hrly if staphylococcal infection is suspected.

For septic shock or No improvement or worsening in initial 48 hours

Add third generation cephalosporins i.e. IV CEFOTAXIME 100 mg/kg/day q 8hrly

Meningitis IV Cefotaxime 200mg/kg/day IV q 6hrly with IV amikacin 15 mg/kg/day q 8hrly

Dysentery CIPROFLOXACIN 30mg/kg/day in 2 divided doses.

IV ceftriaxone 50mg/kg/day in od or q 12 hourly if child is sick or has already received nalidixic acid

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• All severely malnourished children have vitamin and mineral deficiencies

• Vitamin A orally on Day 1 • Give daily :

– Multivitamin supplement– Folic acid 1 mg/d (give 5 mg on Day 1)– Zinc 2 mg/kg/d– Iron 3 mg/kg/d after first week

STEP 6. CORRECT MICRONUTRIENT DEFICIENCIES

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HOW TO CORRECT VITAMIN A DEFICIENCY ?

Vitamin A orally IMMEDIATELY on Day 1‐ unlessthere is definite evidence that a dose has beengiven in the last month or if bilateral edema < 6 months ‐‐ 50,000 IU or 0.5 ml 6‐12 months ‐‐ 100,000 IU or 1 ml > 12 months ‐‐ 200,000 IU or 2 ml In edematous patient, give one dose once edema has subsided.Repeat dose on day 2 and day 14 if there is any sign of xerophthalmia, as children can go

blind very quickly – WITHIN HOURS!

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HOW TO CORRECT ANEMIA?

DO NOT give iron initially

Giving iron too early is DANGEROUS because the blood may have too little

protein to bind the iron and keep it safe.

Unbound iron can stimulate the growth of bacteria and make infections

worse.

Start iron supplements in the catch‐up/rehabilitation phase when there has

been time for iron to be bound and antibiotics to reverse the infection.

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HOW TO CORRECT ANEMIA ? Cont…

Fe 3mg/kg body weight per day.

If the anemia is very severe (i.e. severe pallor of the

palms of the hands) and there is a risk of heart

failure, then treat with a very carefully administered

small blood transfusion.

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To correct deficiencies of riboflavin, ascorbic acid, pyridoxine, thiamin and fat soluble vitamins –ADEK‐ give Multivitamin Supplement (without Iron)

Folic acid orally: On 1st day 5 mg and from 2nd day onwards 1mg/day daily in > 6 mo. old .

Zinc: 2 mg / kg / day. Copper: 0.2 ‐ 0.3 mg / kg / day. Continue giving nutritious mixed diet**All these micronutrients may be available together in a premixed packet,

ready to add to formula.

HOW TO CORRECT OTHER MICRONUTRIENT DEFICIENCY?

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• Readiness to enter the rehabilitation phase is signaled by a RETURN OF APPETITE, usually about one week after admission

• Do appetite test & plan phase II• Recommended milk‐based F‐100 contains 100 kcal & 2.9 ‐3 g protein/100 ml

• In rehabilitation phase vigorous approach to feeding is required to achieve very high intakes & rapid weight gain of >10 g gain/kg/d

STEP 8. ACHIEVE CATCH‐UP GROWTH

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• Replace starter F‐75 with the same amount of catch‐up formula F‐100 for 48 hours then,

• Increase each successive feed by 10 ml until some feed remains uneaten.

• The point when some remains unconsumed is likely to occur when intakes reach about 30 ml/kg/feed (200 ml/kg/d & 6 g/kg protein/day)

• Daily record weight & plot (Tick sign may be seen in edematous SAM due to initial weight loss)

TO CHANGE FROM STARTER TO CATCH ‐ UP FORMULA

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RECIPIES FOR STARTER AND CATCH‐UP FORMULAS

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F75

Full Cream milk‐ 30 ml/ 5 g powder 10 g sugar ½ tsp MCT Oil Water up to 100 ml 75 – 80 Kcals. & 1 g protein RUTF, 20 g = 100 ml of F100 100 g = 500 Cal. & 15 g protein

Full Cream milk‐ 90 ml/ 15 g powder 5 g sugar ½ tsp MCT Oil Water up to 100 ml 100 kcals. & 3 g protein F100 with Skimmed Milk 10 g SM powder 10 g sugar +1/2 tsp oil

LOCALLY PREPARED PREPARATIONS

F100

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• Phase I– Patients without an adequate appetite and /or– Medical complications

• Transition phase– Introduced when appetite improves & edema decreases

• Phase II– Good appetite and no major medical complications– Patients with good appetite are admitted directly into phase

II– RUTF (ready to use therapeutic food ) peanut based – 20 g = 100 kcal. & 3 g protein– ARF (Amylase Rich Food) – usage of germinated cereals &

pulses

PRINCIPLE OF MANAGEMENT

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• Delayed mental and behavioral development is present• Provide:

– Tender loving care (TLC)– Cheerful, stimulating environment– Structured play therapy 15‐30 min/d– Physical activity as soon as the child is well enough– Maternal involvement when possible (e.g. Comforting, feeding, bathing, play, skin to skin, eye to eye contact)

STEP 9. PROVIDE SENSORY STIMULATION AND EMOTIONAL SUPPORT

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•Target weight for discharge: > 15% of baseline weight•A child who is 90% weight‐for‐length (equivalent to ‐1SD) can be considered to have recovered •Show parent or caregiver how to:

– Feed frequently with energy ‐ and nutrient‐dense foods– Give structured play therapy •Advise parent or caregiver to:

– Bring child back for regular follow‐up checks– Ensure booster immunizations are given– Ensure vitamin A is given every six months

STEP 10. PREPARE FOR FOLLOW‐UP AFTER RECOVERY

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Measure CutoffBilateral edema absent for last 10 days And/orWeight‐for‐height 15% weight gain from the weight on admission or weight

on the day free of oedemaAnd/or

Medical complications None

SAM < 6 months of age need special regimen

WHEN TO DISCHARGE THE CHILD (6‐60 MONTHS) FROM PROGRAM ?

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Phase 1 –INFANTS YOUNGER THAN 6 MONTHS

• Breastfeed every 3 hours, duration at least 20 minutes to ensure hind milk,

more often if the child ask for more, at least 8 times/day.

• One hour after breast‐feeding, complete with F100 diluted using the

supplementary suckling technique:

• F‐100 diluted: 130ml/kg/day 100 kcal/kg/day & 3 g protein/kg/d in 8

feeds.

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ROUTINE MEDICINE

• Vitamin A: 50.000UI at admission only• Folic acid: 5mg (1tab) in unique dose• Ferrous sulphate: when the child sucks well and starts to grow. Take the quantity of F100 enriched with ferrous you need in phase II. Iron can be given separate also

• Antibiotics: Amoxicillin (from 2kg): 20mg/kg 3 times a day (60mg/day)

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EMERGENCY TREATMENT OF SHOCK AND SEVERE ANEMIA

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Fluid therapy in severe dehydrationUse intravenous or intraosseous routeRingers Lactate with 5% dextrose or ½ normal saline with 5% dextrose

at 15 ml/kg/hour for the first hour * do not use 5% dextrose alone

Continue monitoring every 5-10 min.

Assess after 1 hour

If no improvement or worsening If improvement(pulse slows/fasterconsider capillary refill /increase in blood pressure)septic shock consider severe dehydration with shock

Repeat Ringers Lactate 15 ml/kg over1 h

Assess

If accepts orally start ORS Clinically better but not accepting orally give 10ml/kg/h till accepts

orally 58


• Blood transfusion is required if:– Hb < 4 g/dl or if there is respiratory distress

& Hb 4‐6 g/dl• Give:

– Whole blood 10 ml/kg slowly over 3 hours– Furosemide 1 mg/kg IV at start of transfusion

• If CARDIAC FAILURE present, transfuse packed cells (5‐7 ml/kg) rather than whole blood

• Monitor RR & HR every 15 minutes. If either of them rises, transfuse more slowly.

• Give oral iron for two months to replenish iron stores

SEVERE ANAEMIA

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HOW TO DIAGNOSE AND TREAT ANAEMIA?

Check Hb at admission if any clinical suspicion of anaemia

‐ Hb >= 4g/% or ‐Packed cell vol>=12%‐ or between 2 and 14 days after admission

- Hb < 4g/% or ‐ Packed cell vol<12%

No acute treatment

Iron during phase 2

ONLY during the first 48 hours after admission:Give 10ml/kg packed cells 3hours ‐ No food for 3 to 5 hrs 60


TREATMENT OF ASSOCIATED CONDITIONS

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If eye signs of deficiency, give orally:vitamin A on days 1, 2, 14

>12 months ‐200,000 IU 6‐12 months ‐100,000 IU < 6 months ‐50,000 IU

If corneal clouding/ulceration, give additional eye care to prevent extrusion of the lens:

instill chloramphenicol or tetracycline eye drops (1%) 2‐3 hourly for 7‐10 daysinstill atropine eye drops (1%), 1 drop three times daily for 3‐5 days

VITAMIN A DEFICIENCY

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• Signs: hypo‐or hyper pigmentation• desquamation, ulceration, exudative lesions

• ZINC DEFICIENCY is usual in affected children. Skin quickly improves with zinc supplementation

• > 6 mo. 20 mg/day X 14 days & 2‐6 mo. 10 mg/day• In addition:

• apply barrier cream (zinc & castor oil ointment, or petroleum jelly or paraffin gauze) to raw

areas• omit nappies so that the perineum can dry

DERMATOSIS

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• Common feature but it should subside during the first week of treatment with cautious feeding. In the rehabilitation phase, loose, poorly formed stools are no cause for concern provided weight gain is satisfactory.

• Mucosal damage & giardiasis – Stool microscopy– Give: metronidazole (7.5 mg/kg 8‐hourly for 7 days)

CONTINUING DIARRHEA

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• Lactose intolerance. – Only rarely due to lactose intolerance. – Treat only if continuing diarrhea is preventing general improvement

– Starter F‐75 is a low‐lactose feed. In exceptional cases: • substitute milk feeds with yogurt or lactose‐free infant formula

• reintroduce milk feeds gradually in the rehabilitation phase

CONTINUING DIARRHEA – Cont..

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• Suspected if diarrhea worsens substantially with hyperosmolar starter F‐75 and

• Ceases when the sugar content is reduced and osmolarity is <300 mOsmol/l.

• In these cases: use isotonic F‐75 or low osmolar cereal‐based F‐75. Introduce F‐100 gradually

PARASITIC WORMS• Give mebendazole 100 mg orally, twice daily for 3 days

OSMOTIC DIARRHEA

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If strongly suspected (contacts with adult TB patient, poor growth, despite good intake, chronic cough, chest infection not responding to antibiotics):– Mantoux test (false negatives are frequent)– Chest X‐ray if possible– If test is positive or strong suspicion of TB,

treat according to national TB guidelines

TUBERCULOSIS (TB)

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• Good wt gain (>10 g/kg/day): continue same

• Mod. wt gain (5‐10 g/kg/day), check intake & infection

• Poor wt gain (<5 g/kg/day), • Inadequate feeding, • Untreated infection, • Specific nutrient deficiencies, • Tuberculosis & HIV/AIDS • Psychological problems

FAILURE TO RESPOND TO TREATMENT

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PRIMARY FAILURE TO RESPOND•Failure to regain appetite by day 4•Failure to start losing edema by day 4•Presence of edema on day 10•Failure to gain at least 5g/kg/day by day 10

SECONDARY FAILURE TO RESPOND •Failure to gain at least 5g/kg/day for 3 consecutive days during rehabilitation

FAILURE TO RESPOND TO TREATMENT

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• Recovered when reaches 90% weight‐for‐length / 1SD & no edema

• Absence of infection • Eating at least 120‐130 cal/kg/day & receiving

adequate micronutrients • Consistent weight gain • (of at least 5 g/kg/day for 3 consecutive days) on

exclusive oral feeding• Completed immunization appropriate for age• Caretakers sensitized to home care

CRITERIA FOR DISCHARGE

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• Recovery complete if 90% W/L/ Wt/Ht; • But can be discharge early for domiciliary if‐• The child: > 1yr; good appetite & wt gain; no edema, antibiotic treat completed.

• The mother: available at home, motivated & trained to look after; have resources; reside near hospital.

• Local Health Worker/ anganwadi/nutrition rehabilitation center : Can provide support; trained; motivated

CHILDREN DISCHARGED EARLY: WHAT TO DO

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• Monitoring Feeding at Home Essential:

• Feed frequently at least 5 times a day

• Modify home food to suit F‐100• High energy snacks between meals• Assistance to complete each meal • Give electrolyte/ mineral solutions• Breastfeeding should continue

CHILDREN DISCHARGED EARLY: WHAT TO DO

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Thank You

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PROTEIN ENERGY MALNUTRITION SEVERE ACUTE MALNUTRITION · PROTEIN ENERGY MALNUTRITION & SEVERE ACUTE MALNUTRITION 1. IAP UG Teaching slides 2015-16 MAGNITUDE OF MALNUTRITION ‐ INDIA