Case ReportSEVERE MALNUTRITION

Presentator:Andika Pradana 070100071Ira Nola Lingga 070100109

Deprtment of Pediatrics FK USU, July 4th 2011

SUPERVISOR:Dr. SRI SOFYANI, Sp.A(K)

SEVERE MALNUTRITION

LEVEL OF COMPETENCE

DEFINITION

World Health Organization:

Malnutrition is the cellular imbalance between the supply of nutrients and energy and the body's demand for them to ensure

growth, maintenance, and specific functions

CLINICAL FINDINGS

Three types of clinical findings in severly malnourished children:

1.Marasmus2.Khwarsiorkor

3.Marasmus - Khwarsiorkor

Clinical Features

Feature Kwarshiorkor Marasmus

Growth failure Present Present

Wasting Present Present, marked

Oedema Present Absent

Hair Changes Common Less common

Mental Changes Very common Uncommon

Dermatosis, flaky-paint Common Does not occur

Appetite Poor Good

Anemia Severe (sometimes) Present, less severe

Subcutaneous fat Reduced but present Absent

Face May be oedematous Draw in, monkey-like

Fatty infiltration of liver Present Absent

CLINICAL FINDINGS: Marasmus

CLINICAL FINDINGS: Marasmus

Marasmus:- Old man face- Extreme wasting- Prominent ribs- Baggy pants- Muscle hypotrophy- No edema

CLINICAL FINDINGS: Khwarsiorkor

CLINICAL FINDINGS: Khwarsiorkor

KHWARSIORKOR:- Moon face- Pale and sparse hair- Enlarged liver- Edema- Peeling skin (crazy

pavement dermatosis)

CLINICAL FINDINGS: Marasmus Khwarsiorkor

MARASMUS KHWARSIORKOR:

The patient appears like a marasmus child, combined with signs of khwarsiorkor such edema and enlarged liver

PATHOPHYSIOLOGY

• Decrease Imune System

• Enlarged Liver and accumulation

of triglyserides• Tachypnea• Malabsorbtion• Anemia

• Developmental delay•etc

• Decrease Imune System

• Enlarged Liver and accumulation

of triglyserides• Tachypnea• Malabsorbtion• Anemia

• Developmental delay•etc

DIAGNOSIS

WHO, 1999:Severe Malnutrition if:

BW / BL is below 70% BW / BL is between 70 – 79% but with

edema presents

Based on Body weight according to Body

length

BW/BL

very low low normal high70 80 90 110 120 %-3SD -2SD +2SD +3SD

PEM severe mod mild overweight obese

-Kwashiorkor -Marasmus -M-K

DIAGNOSIS

HISTORY TAKING

• Usual diet before current episode of illness• Food and fluids taken in past fiew days• Duration and frequency of vomiting or diarrhoea,

appearance of vomit or diarrhoea stool• Time when urine was last passed• Birth weight, birth length and growth chart• Breastfeeding history• Milestones reached• Immunization

Tests that may be useful

Blood glucose Glucose concentration <54 mg/dl is indicative of hypoglycaemia

Examination of blood smear

by microscopy

Presence of malaria parasites is indicative of infections

Haemoglobin or packed-cell

volume

Haemoglobin <40 d/l or packed-cell volume <12% is indicative of very

severe anemia

Examination and culture of

urine specimen

Presence of bacteria on microscopy is indicative of infections

Examination of faeces by

microscopy

Presence of blood is indicative of dysentry

Chest X-Ray Pneumonia causes less shadowing of the lungs in malnourished

children that in well-nourished children

Bones may show rickets or fractures of the ribs

Skin test for tuberculosis Often negative in children with tuberculosis or those previously

vaccinated with BCG vaccine

LABORATORY FINDINGS

LABORATORY FINDINGS

Tests that are of little or no value

Serum proteins Not useful in management, but may guide prognosis

Test for human

immunodeficiency virus (HIV)

Should not be done routinely; if done, should be accompanied by

counselling of the child’s parents and result should be confidential

Electrolytes Rarely helpful and may lead to inappropriate therapy

TREATMENT

Five General Principles:

1.Ten Principal Steps2.Treatment of Comorbidities3.Failure of Treatments4.Patient discharges before end of treatment5.Emergency Case

TreatmentStabilization Transition Rehabilitation Follow Up

Day1-2

Day3-7

Week 2Week

3-6Week7-26

1 Hypoglycemia2 Hypothermia3 Dehydration4 Electrolyte Correction5 Treatment of Infection6 Micronutrition

Defficiency CorrectionWithout Iron

SupplementationWith Iron

Supplementation7 Initial Refeeding Formula 75 Formula 75

to Formula 100

8 Correctional Refeeding (Catch Up Growth)

9 Stimulation10 Prepare for Discharge

________________________ The Ten Principal Steps

Ten Principal Steps:1. Hypoglycemia

Hypoglycemia if blood glucose level below 3 mmol/l or 54 mg/dl

- Loss of consciousness- Lethargic- Weak arterial pulse- Sweating

If it is difficult to test blood glucose level, consider all severely malnourished children are

hypoglycemic

Ten Principal Steps:1. Hypoglycemia

Signs and Symptomps Treatment

Alert (not lethargic) Give 50 ml of Dextrose 10% per oral or via NGT

Loss of consciousness

(lethargic)

Give Dextrose 10% intravenous as much as 5 ml per each

kilogram body weight, followed by 50 ml of Dextrose

10% orlaly

Shock

Give Dextrose 10% intravenous as much as 5 ml per each

kilogram body weight, followed by Ringer Lactat +

Dextrose 10% (1:1) for 15 ml each kilogram body weight,

sould be given in 1 hour

Ten Principal Steps:2. Hypothermia

Hypothermia if rectal temprature is below 36oCelcius

Treatment:- Kangoroo technique skin to skin contact- Radiant warmer- Follow the fluctuation of body temp every

30-60 minutes

Ten Principal Steps:3. Dehydration

Evaluate the general condition, sunken eye, thirsty and skin pinch

Treatment: Give ReSoMal• 5 ml/kg bodyweight every 30 minutes for the

first 2 hours• Followed by another Resomal for as much as 5-

10 ml/kg body weight/hour, given alternately with Formula 75 as the early diet

Ten Principal Steps:4. Electrolyte Correction

Hyponatremia and Hypokalemia are frequently found particularly if

diarrhea and vomitting are present

Treatment: Give ReSoMal

ReSoMal (Rehidration Solution for

Malnutrition)

ReSoMal Modification

WHO-Oral rehydration solution : 1 sachet

Sugar : 50 gr

Potassium powder : 4 gr (40 ml)

Water added until : 2 liter

26

Ten Principal Steps:5. Treatment of Infection

No clear evidence of infection:Cotrimoxazole (TMP 5 mg/kgBW + SMZ 25 mg/kgBW

orally twice daily for 5 days.

Infection• Ampicillin, 50 mg/kgBW IM or IV for the first 2

days, followed by Amoxicillin 15 mg/kgBW orally every 8 hours for the next 5 days), along with

• Gentamycin 7,5 mg/kgBW IM or IV once daily for 7 days.

Ten Principal Steps:6. Micronutrient

Stabilization and Transitional Phase:Multivitamin supplementation - Folic Acid 1 mg/day ( 5mg on day 1 ) - Zn 2 mg/kgBW/day - Cu 0,2 mg/kgBW/day

- Vitamin A on the 1st day

Rehabilitation Phase• Iron added. Sulfas Ferrosus 10 mg/kgBW/day

Ten Principal Steps:7. Initial Refeeding

WHO Formula 75

- Give a small portion but frequent feeding- Hypoosmolar and low in lactose- Energy: 80-100 kal/kgBW/day- Protein: 1-1,5 gr/kgBW/day- Fluid: 130 ml/kgBW/day, or 100 ml/kgBW/day if

edema presents

Nutrients

Treatment Phase

Stabilization Transitional Rehabilitation

Energy 100 kcal/kg/day 150 kcal/kg/day 150-200

kcal/kg/day

Protein 1 – 1,5 g/kg/day 2-3 g/kg/day 4-6 g/kg/day

Fluid intake 130 ml/kg/day or

100 ml/kg/day if

edema presents

150 ml/kg/day 150 – 200

ml/kg/day

Ten Principal Steps:8. Correctional Refeeding

WHO Formula 75 – 100 – 135

Transitional Phase:Correctional refeeding should be given alternatingly from F

75 to F 100 in the transitional phase

Rehabilitation Phase- Energy: 150-220 kkal/kgBW/day- Protein: 4-6 g/kgBW/day- Family food

32

Ten Principal Steps:9. Stimulation

- Interaction to other children- Structured game designed for suitable age- Love and care from parents- Motor and language skills

Ten Principal Steps:10. Discharge

Treatment Evaluation:

• If weight gain is less than 5 gr/kgBW/day, the child should be reassesed

• If weight gain is between 5 to 10 gr/kgBW/day, an undetected infection should be suspected

• If weight gain is more than 10 gr/kgBW/day, then the therapeutic program has reached its target.

Ten Principal Steps:10. Discharge

Discharge Criteria:

1.BW/BL has no longer been below 70%2.Edema, vomitting and diarrhea are no longer

present3.Normal body temprature4.Adequate weight gain5.Patient can eat the whole diet prepared6.General condition improvement, skill and

motoric development are suitable to age

SEVERE MALNUTRITION

CM, Female, 14 year old, with the body weight and body height of 25 Kg and 144 cm respectively, was admitted to the non infectious unit of Haji Adam Malik General Hospital on June, 4th 2011 with the main complaint bulging of the lower abdomen for the last 3 months before admission. The bulging was previously 7 x 8 cm in size, and getting bigger day by day until now it has already been approximately 15 x 16 cm in size, immobile, soft in consistency and smooth surface, and well marginated with pain on palpation.

Interrupted flow of micturition (+) for the last 3 months, with micturition frequency was more than 6 times a day, volume less then 50 – 60 cc each time. Previously, the urine was transparent yellowish in colour, but for the last 2 weeks, she complained that the urine colour had been yellowish to brown. History of flank pain while urinating (-), no stones. Defecation (+) normal.

`

Pallor (+) during the last 3 months, without any previous history of reccurent pale. History of bleeding (-).

Weight loss for as much as 6 kg in the past 3 months. This problem has actually been occuring since 2 years ago, and was getting worse for the last 3 months. Loss of appetite (+) for as long as 3 months, but previously eating poorly was found since the patient was 6 years old, and she had never eaten more than half of the food served for her. Fever (-), cough (-), night sweating (-), history of contact to tuberculosis patient (-).

Leg swelling (+) for the last 2 weeks, both in the right and the left one. Previous history of swollen leg was denied. Pain on palpation (-).

Menstruation delay (+) for the last 3 months. This patient got menarche on 13 years old and got menstruation regularly before. The duration of menstruation was 7 days per month.

• She was born spontaneously, aided by midwife, with birth body weight was 3500 grams and body length was 50 cm, crying spontaneously, with APGAR score was not recorded. There was no pregnancy complication for both mother, nor child. History of immunization was incomplete. • Feeding history: within the normal limit, • History of growth and development: within the

normal limit • History of previous illness and medications :

unclear

PHYSICAL EXAMINATIONGeneralized status

BW: 25 kg, BL: 144 cm, Upper arm circumference: 16 cm, Head circumference: 57 cmBW/BL : 78,13% (moderate malnutrition)BW/age : 49,02% (severe malnutrition)BL/age : 88,9% (normoheight)

Presens status

CM, Body temperature: 37,2oC. Anemic (+). Icteric (-). Cyanosis (-). Edema (+). Dyspnea (-). Thristy and drink eagerly was not found.

LABORATORY RESULT

Parameters Value Normal Value

Hemoglobin 4,76 gr% 12,0 – 14,4 gr%

Hematocrite 14,9 % 38 – 44%

Erithrocyte 1,82 x 106 /mm3 4,2 – 4,87 x 106 /mm3

Leucocyte 3530 /mm3 4500 – 11000 /mm3

Platelet 226.000 /mm3 150000 – 450000 /mm3

MCV 82 fl 85 – 95 fl

MCH 26,2 pg 28 – 32 pg

MCHC 32 gr% 33 – 35 gr%

RDW 16,6 % 11,6 – 14,8 %

Diftel 0 / 0 / 78 / 9 / 13

WORKING DIAGNOSIS

Suspect Tumor Abdomen e.c dd/ - Wilms Tumor- Neuroblastoma

Severe Malnutrition Marasmic - Khwarsiorkor Type

TREATMENT• Bedrest, threeway and urinary catheter inserted• IVFD D5% NaCl 0,45% 20 gtt/i micro• Diet Formula 75 280 cc / 2 hours (stabilization phase)• Multivitamin without Fe 1 x cth II• Folic acid tab 1 x 5 mg• Cotrimoxazole tab 2 x 480 mg• Vitamin A 1 x 200.000 IU• Packed red cell transfusion 75 cc / 12 hours

Needed: 4 x ( 11-4,76 ) x 25 kg = 624 ccTransfusion ability: 3cc x 25 kg = 75 cc

DIAGNOSTIC PLANNING

• Complete blood count post transfusion • Liver Function Test and Renal Function Test• Serum Electrolytes, Serum Albumin• Blood Glucose ad random• Abdominal CT Scan• Urinalysis• Fluid Balance per 6 hours

SEVERE MALNUTRITION

June 5th-7th, 2011

S Bulging of the lower abdomen (+), Pallor (+), Abdominal pain (-)

O Sens: CM, Temp: 36,7 – 36,9oC. Anemic (+), Edema (+). BW: 25 kg, BL: 144 cm. UOP: 3,4 – 6,1 cc/kg/hour, Urine colour : yelowish to brownIn the abdomen: Bulging (+) in regio hypogastrium, 8 x 9 cm in size, immobile, soft and well marginated. Pain on palpation (-)

Laboratory Findings: SGOT: 11 U/L Na: 131 mEq/L Ureum: 64,50 mg/dlSGPT: 3 U/L K: 3,9 mEq/L Kreatinin: 2,32 mg/dlAlbumin: 2,7 gr/dl Cl : 113 mEq/L Dipstick urine:Leu / Nit / Uro / Protein / pH / Blood / SG / Ket / Bil / Glu+2 / + / - / + / 6,5 / +3 / 1,01/ - / - / -

A Suspect Tumor Abdomen e.c dd/ - Wilms Tumor + Severe Malnutrition Marasmic- - Neuroblastoma Kwarshiorkor Type

P Management:Bedrest, threeway and urinary catheter insertedIVFD D5% NaCl 0,45% 20 gtt/i microDiet Formula 75 270 cc / 2 hours (stabilization phase)Multivitamin without Fe 1 x cth IICotrimoxazole tab 2 x 480 mgTransfusion PRC 75 cc / 12 hoursFolic acid 1 mg/day (the following day) Vitamin A was no longer given (no deficiency sign found)

Diagnostic Planning:Complete blood count post transfusion Abdominal CT ScanUrinalysis

June 8th-11th, 2011

S Bulging of the lower abdomen (-). Pallor (-). Abdominal pain (-).The patient ate the whole diet provided.

O Sens: CM, Temp: 37,0 – 37,6oC. Anemic (-), Edema (-). BW: 25 kg, BL: 144 cm. UOP: 3,4 – 5,5 cc/kg/hour, Urine colour : yelowish to brownIn the abdomen: Bulging was not found after urinary catheter insertion.

Laboratory Findings:Hb: 13,5 gr% WBC: 10470/ mm3 MCV : 76,6 flHt: 39,5 % PLT: 263000/ mm3 MCH : 26,2 pgRBC: 5,16 x 106 / mm3 RDW: 19,6% MCHC : 34,2 gr% LED : 14 mm/hours Dipstick urine:Leu / Nit / Uro / Protein / pH / Blood / SG / Ket / Bil / Glu+ / - / 0,2 / ± / 5 / +3 / 1,01/ - / - / -

A Hydronephrosis bilateral e.c (?) + severe malnutrition marasmic khwarsiorkor type + suspect urinary tract infection

P Management: Bedrest, threeway and urinary catheter insertedIVFD D5% NaCl 0,45% 20 gtt/i microDiet Formula 75 270 cc / 2 hours (stabilization phase)Multivitamin without Fe 1 x cth IIFolic acid 1x1 mgInjection Ceftriaxone 1 gr / 12 hoursCotrimoxazole tab 2 x 480 mg

Diagnostic Planning:Abdominal CT ScanUrinalysis and urine culture + sensitivity test

June 12th-18th, 2011

S Fever (+). Bulging of the lower abdomen (-). Pallor (-). Abdominal pain (-).

O Sens: CM, Temp: 37,3 – 38,1oC. Anemic (-), Edema (-). BW: 25 kg, BL: 144 cm. (BW/A: 50,9) UOP: 2-3,1cc/kg/hour, Urine colour : transparent yellowishIn the abdomen: Bulging was not found after urinary catheter insertion.

CT Scan Reports:No mass in the abdomen could be identifiedThere is a hyperthrophy of the urinary bladder wallMuscle hypertrophy due to urinary retention should be suspected. Suggestion: Cystoscopy

Urine Culture:Pseudomonas aeruginosa was found, with concentration more than 105 CFU/mlSensitive to Meropenem

Dipstick urine:Leu / Nit / Uro / Protein / pH / Blood / SG / Ket / Bil / Glu+ / - / - / + / 5 / +3 / 1,01/ - / - / -

A Hydronephrosis bilateral e.c. Retensio Urine + Severe Malnutrition Marasmic – Khwarsiorkor type + Urinary Tract Infection

P Management:Bedrest, threeway and urinary catheter insertedIVFD D5% NaCl 0,45% 20 gtt/i microDiet Formula 100 470 cc / 3 hours (transition phase)Injection Meropenam 250 mg / 8 jamMultivitamin without Fe 1 x cth IIFolic acid 1x1 mg/day

Planning:Urinalysis

SEVERE MALNUTRITION

Loss of appetite since 3 months,pallor, weight loss, old man face, thinning of subcutaneous fat, muscle

hypotrophy, prominent ribs, edema dorsum pedis,

Antropomethric measurement: BW/BL below 70% with edeme presents

Dx: SEVERE MALNUTRITION Marasmus-Khwarsiorkor

IVFD D5% NaCl 0,45%, Diet Formula 75, Multivitamin, Antibiotic, Transfussion PRC

AMENORRHEA and MALNUTRITION

STABILIZATION PHASE

STABILIZATION PHASE

STABILIZATION PHASE

TRANSITIONAL PHASE

Formula 75

Formula 100

Formula 135

Low calorieLow lactose

Frequent Frequency

Higher CalorieEvaluate toleranceEvaluate appetite

Family Food

Given in the rehabilitation phase only after weight gain is adequate

TREATMENT EVALUATION

INADEQUATE WEIGHT GAIN(below 5 gr/kg/day)

WHY??

Reanamnesis: Pain while urinatingLaboratory findings: Leukosituria, Nitrate in urine (+)Urine Culture: Pseudomonas aeruginosa

Urinary tract infection as a COMORBID Treat based on sensitivity MEROPENEM

Terima

KasihKapkun Kha Gracia

Xie xie SyukranArigato Gozaimasu

Mercie