Severe Malnutrition MED

8/12/2019 Severe Malnutrition MED

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UpDate in Mx of Severe

MalnutritionDr. Emmanuel Ameyaw

KATH


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INTRODUCTION

Severe malnutrition is a major health

problem because is wide spread and

common cause of mortality(50%mortality in some cenetes).

The malnourished child has clinically

inapparent but serious health problemsbesides the malnutrition.


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INTRODUCTION

Case management practice suitable for other

children are HIGHLY DANGEROUS for

the malnourished child.

The severe malnourished child has

abnormal physiology due reductive

adaptation.


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DEFINITION AND

ADMISSION CRITERIA Severe malnutrition is defined as

severe wasting or oedema of both feet.

Admission criteria is either weight for

height


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Signs of severe malnutrition

1. Severe wasting:

Loss of fat and muscle (skin and bones)

Front view: ribs easily seen and skin of upper

arm and thighs look loose.

Back view: ribs and shoulder bones easily

seen, flesh missing from the buttocks, folds ofskins on buttocks and thighs (wearing baggy

pants)


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Recognizable signs of severe

malnutrition2. Oedema of both feet: The retained added

to the weight therefore weight for height > -

3SD.Rating of oedema:

+ mild: both feet

++ moderate: both feet + lower legs + handor lower arms

+++ severe: generalised (moderate + face)


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malnutrition3. Dermatosis

Occurs in oedematous malnutrition than wasted

child.

Range from patches of abnormal pigmented

skin (light and dark) to shedding, ulceration and

weeping lesion.

Affects perineum, groin, nappy areas, limbs,

behind ears, armpit and face


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malnutritionAny break in the skin can let dangerous bacteria

get into body especially raw and weepy lesion.

Rating of dermatosis+ mild: discoloration or few patches of skin

++ moderate: multiple patches on arm and/or

legs+++ severe: flaking skin, raw area andfissures


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malnutrition 4. Eye Signs:

Vit. A deficiency

Night blindnessConjunctivitis xerosis

Bitot spot

Corneal xerosisCornea ulceration

Cornea scar

Infection

Pus


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REDUCTIVE ADAPTATION

With severe malnutrition, the systems shut downor slow down and do less to allow survival onlimited calories.

With treatment, the systems gradually learn tofunction again.

Rapid changes (feeding, fluid) would

OVERWHELM the systems so feeding must beslowly and cautiously increased.

This slowing down of the systems is calledREDUCTIVE ADAPTATION.


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Abnormal physiology in selected

systemsSystem/Organ Effect Mx/Caution

CVS - C.O SV

- plasma vol N- red cell vol

- restrict Tx to

10ml/kg & givediuretics

Genitourinary - GF- acid & waterload excrete - Na+excretion- UTI common

- No moreprotein thanrequired formaintenance- Rx infection to

prevent tissuebreak down


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systemsSystem/Organ

Effect Mx/Caution

Liver - synthesis of protein

-

metabolic andexcretory capacity

- gluconeogenesis

- give just

adequate protein

- dose of drugs

- feed CHO rich

- no iron initially

GIT - gastric acid

- GI mortility

- atrophied mucusa &

glands

- give small feeds

at a time


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systemsSystem/Organ Effect Mx/Caution

Immune system - all aspect

- CMI, IgAComplement

- atrophied

lymph glands,

thymus & tonsils

- inflammatory

response

Hypoglycemia &

hypothermia areboth signs of

severe infection

associated with

septic shock.


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Organisation of Care

Adm is a must if criteria is fulfilled.

Admit to separate ward (mal ward)

Get specially trained staff

Frequent assessment and monitoring

Good organisation of feeding (small vol.large vol.)

Special feeding formulasF-75 & F -100, Suji, RUTF & resomal


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How reductive adaptation affect care; 3 implications

1. Nearly all mal chn have bacterial infection (UTI,

OM, pneumonia, septicaemia) assume infection

and treat with broad spectrum antibiotic.

2. Dont give iron early in treatment

Early iron excess free iron with 3 effects:

Free radical

Promote bacterial growthUtilises energy and amino acids ferritin.


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How reductive adaptation affect care; 3 implications

3. Provide K+but restrict Na+

Na+- K+pump runs slowly in sev mal due to

reductive adaptative K +is lost in urineand stool as Na +is retained. This affectsproper distribution of fluid oedema.

Provide mg2+as well (retains K+in cells) .Resomal, F-75 & F-100 has require amountof electrolyte (mineral mix)


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Common complications and their management

These account for most deaths in the first 48hrs ofadm.

Improper management of these complicationssimilarly cause death in the first 48hrs.

1) Hypoglycemia RBS < 3mmol/L

If RBS check not possible, assumed

hypoglycemia and treat.Signs: hypothermia, lethargy, loss of

consciousness.


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Treatment:

50mls of 10% glucose/sucrose (1 teaspoon in 50ml H2O)orally or po conscious and can drink. Or

5ml/kg of 10% dextrose IV followed by 50mls of 10%

glucose/sucrose. Then start feeding with F-75 in next 30min and every

30min for 2hrs.

2) Hypothermia: Rectal temp. < 35.5C or

axillary temp. < 35C.

Usually co-exist with hypoglycemia. Both indicate serioussystematic infections.


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Treatment:

a) Maintaining temperature to prevent hypothermia.

Cover the child, including the head

Maintain room temperature at 25 - 30C

Keep the child covered at night.

Warm your hands before touching the child.

Avoid leaving the child uncovered while beingexamined or weighed.


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Promptly change wet clothes or beddings.

Dry the child thoroughly after bathing.

Let the child sleep snuggled up to themother and cover them with a blanket.

b) Actively re-warm the hypothermic child.

Skin-to-skin contact between mother and child

and covering both of them (kangarootechnique).

Use lamp or bulbs (not too close).


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3) Shock: Either caused by D&V or sepsis

Signs may confuse with signs of severe malnutrition(prostration, lethargy, unconscious, cold extremities,

fast and weak pulse) give IV fluid only if criteriabelow is fulfilled:

i. Lethargic or unconscious

ii. Cold hands and feet

Plus eitheriii. Capi refil < 3sec Or

iv. Weak/fast pulse


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Mx

Give O2

Give 10% glucose 5ml/kg IV

Keep the child warm

Give IV fluid 15ml/kg/hr. Repeat for another

hour if pulse and RR improves ()Give antibiotics.


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Types of IV fluid to use

strength Darrows with 5% dextrose

R/lactate with 5% dextrose (add KCL 20mml/l)0.45% ( normal) saline with 5% dextrose (add

KCL 20mmol/l)

Monitor PR & RR while on IVF every 10min

After 2hrs of IVF, switch to N/G rehydration withresomal 5 - 10ml/kg/hr to alternate with F-75 forup to 10hrs.


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If shock does not resolve, add IVF and give whole blood10ml/kg over 3hrs with lasix.

Once transfusion is set up stop all other fluid.

4) Very severe anaemia Hb


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5) Watery diarrhoea and/or vomiting: small mucoid stools are common in sev. mal but do

cause dehydration. Signs of dehydration misleading Assume dehydration if watery diarrhoea and vomiting

present.Rx

do not give std ORS Give resomal 5ml/kg q 30min for 2hrs then 5 -

10ml/kg/hr to alternate with F-75 for 10hrs. Monitor RR & PR closely as HF may occur. Monitor urine freq. Stool, vomiting plus signs of

dehydration for any improvement.


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Signs of overhydration:

PR & RR engorged jugular vein oedema(eg. Puffi eyelid)

Signs of improving hydration

Less pronouced signs of dehydration, slowingPR & RR, passing urine and not thirsty.

If signs of improvement (3 of the above), giveplan A resomal: 2yrs 100- 200ml/water stool


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Common complications and

their management

6) Infection Assume infection and treat with ab

straightaway.

Selection of ab depends on presence orabsence of complication


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Note: The ab regimen can be modified a/c drug availability orlocal pattern of resistance

Parasitic worms

If evidence of worm infections or high prevalence give

mebendazole 100mg bd x 3 dys.7) Electrolyte imbalance & micronutrient

deficiency

All sev mal chn have K+& mg2+deficiencies a/c partly for

their oedema. Excess body Na+though plasma Na+.

Giving high Na+ load could kill the child


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Treatment Give extra K+3 - 4mmol/kg/dy

Give extra mg2+0.4 - 0.6mmol/kg/dy

Prepare food without adding salt

The extra K+& mg2+provided in mineral mix or CMV(included in F-75 & F-100) as well as resomal. Vit &mineral deficiency exist as well in the sev mal

Mx:

A multivitamin supplement (free of iron)

Daily Folic acid


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Mx

Zinc 2mg/kg/dy

Copper (0.3mg/kg/dy)

Once gaining weight (during rehabilitation phase), Ferrous salt3mg/kg/dy.

Give vit A po on day 1

Zn, Cu, K+and Mg2+all available in mineral mix or CMV

8) Eye problem & eye care Signs of vit A deficiency exist

Signs of eye infection (pus or redness)

Hx of measles in its past 3 months


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Dose: < 6mth = 50,000u po

6 - 12mth = 100,000 po

>12mth = 200,000 po

If in septic shock or has severe oedema/ severe anorexia,

Im vit A 1000,00u preferred as stat dose. Give the ff additional eye care if infection or corneal

involvement exist

Gutt chloramphenicol or tetra

*Gutt Atropine 8hrly *Cover eye with saline soaked pad

*Bandage eye

* - In corneal involvement

C li ti d th i t


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9) Severe Dermatosis (flaking, ulceration,fissures & raw areas)

Rx Bath in 1% potassium permagnate for 10min or dab with GV paint

Apply Zinc oxide ointment to raw area (barrier cream)

10) Feeding

Critical in mx of the sev mal Should begin immediately after adm or soon after stabilization .

Should however be started cautiously in small frequent amount

Aggressive handling or high protein/Na+diet could overwhelm systemor kill child.

Special Formulas; F-75 (75 kcal/100ml) as starter feed for stabilisation (usually 1st 2 - 7

dys)

F-100 (100 kcal/100ml) as catch up formula during rehabilitationphase to rebuild waste tissue.


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F-75 low in Na & protein & high in CHO

0.9g protein/100ml, provides 100kcalkg/dyF-100 more cal & protein

2.9g protein/100ml

Recipe for F-75 & F-100 in appendix 3

F-75 is started slowly on 2hrly 3hrly 4hrly basis as chd consumes

80% of the food offered.Amount offered is based or weight (see 24hr food intake chart)

Breastfeed in between feed

Assess need for transition into F-100 after 2-7 dy

Transition into F-100 should be gradual & carefully monitored as

HF may occur Amount of F-100 is same as last feed of F-75 and shd be

maintained for 1st 2dys, before . Signs of readiness fortransition (usually 2 - 7dys):return of appetite, oedema, childsmiles and is active.


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After 3rd F-100 by 10ml per feed till some is left over after most

feed & chd feeds freely on F-100 While on F-100, do dly wt gain in gm/kg/dy using

formula w2- w1kg x 1000w1

wt gain = >10g/kg/dy = good

wt gain = 5 - 10g/kg/dy = moderatewt gain =


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TLC, cheerful stimulating envt, structured play 15 - 30 dly,physical activity if child become strong, maternal involvementin feeding, bathing, play and consoling to build confidence andcontinuing treatment at home. Also toys for the children.

12) Preparation for discharge and follow-up Discharged if wt for ht is >-1SD (90% of expected wt for ht)

Identified home factor contributing to mal and tackle to preventrelapse.

Employ community nurse for home follow-up

Regular hospital review: 1wk, 2wk, 1mth, 3mth, 6mth.

Prepare parents for home feeding using simple modification ofhome food aimed at providing high energy and protein +mineral, vit, & E.


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Give appropriate meal at least 5x daily + high energy snack (banana,

bread, biscuit)

Give food separate to child (childs own plate)

Immunization: If not immunized then do so before discharge.

Monitoring and records: Detailed management should be

recorded on monitoring chart (monitoring record, critical carepathway, daily care, 24hr food intake chart). Review childs

record daily to assess progress and problems.

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Severe Malnutrition MED