Chapter 7 Severe Malnutrition

1
Chapter 7Severe Malnutrition
2
Case study Kobi
Kobi, a 12-month-old boy brought to district
hospital from rural area. 8 day history of loose
watery stools. 2 days of increased irritability
and poor oral intake.
3

• What are the stages in the management of any sick
  child?

4
Stages in the management of a sick child (Ref.
Chart 1, p. xxii)

• Triage
• Emergency treatment
• History and examination
• Laboratory investigations, if required
• Main diagnosis and other diagnoses
• Treatment
• Supportive care
• Monitoring
• Plan discharge
• Follow-up

5

• What emergency and priority signs does Kobi have

Temperature lt35.00C, pulse 130/min, RR
50/min, Weight 6 kg, Length 69cm
6
Triage

• Emergency signs (Ref. p. 2, 6)
• Obstructed breathing
• Severe respiratory distress
• Central cyanosis
• Signs of shock
• Coma
• Convulsions
• Severe dehydration

• Priority signs (Ref. p. 6)
• Tiny baby
• Temperature
• Trauma
• Pallor
• Poisoning
• Pain (severe)
• Respiratory distress
• Restless, irritable,
• lethargic
• Referral
• Malnutrition
• Oedema of both feet
• Burns

7
Does Kobe have signs of shock?

• Emergency signs of shock (Ref. p. 5)
• Cold hands/feet
• AND
• Capillary refill longer than 3 s
• AND
• Weak and fast pulse
• AND
• Lethargic or unconscious

• How to treat for shock in a severely malnourished
  child (Ref. p. 5, 14)
• Give oxygen
• Give glucose
• Give IV Fluids
• Initiate feeding with F75 or Full Strength
  Sunshine milk
• Give antibiotics

Kobe does not have emergency signs of shock. If a
child is in shock refer to the pages of the book
as listed above
8
History
Kobi was well until 5 months of age. At 5 months
his mother became pregnant again. His mother had
started to wean him from the breast at 3 months,
as her milk supply was reduced. From 4 months he
was fed formula milk from a bottle with a rubber
teat. He was given solid food from four months of
age, mostly potatos and some vegetables. From 5
months he had six episodes of diarrhoea. Each
lasted 5-6 days. During each episode of
diarrhoea he was given reduced amounts of fluid
and feeds because his mother thought this would
reduce the severity of his diarrhoea. On this
last occasion he was taken to the hospital, as he
became irritable and was not drinking or eating
well.
9
Examination

• Kobi was wasted, having loose skin folds over his
  arms, buttocks and thighs and visible rib
  outlines.
• Vital signs temperature lt35.00C, pulse
  130/min, RR 50/min Weight 6 kg and Length
  69cm, MUAC 10.5cm
• ? Use Table 35 p. 386 and assess Kobis
  weight-for-length
• Chest bilateral air entry was normal, no added
  sounds
• Cardiovascular both heart sounds were heard and
  there was no murmur
• Abdomen soft, bowel sound was audible no
  organomegaly
• Ears-Nose-Throat dry mucus membranes
• Eyes sunken, no tears and dry conjunctiva
• Skin decreased skin turgor
• Neurology sick looking no neck stiffness
• and no other focal signs

10
Differential diagnoses

• Severe malnutrition (marasmus, kwashiorkor)
• Severe malnutrition due to other organic disease
• -Tuberculosis
• -HIV
• -Malabsorption syndrome
• -Micronutrient deficiency (Vitamin A, zinc)
• (Ref. p. 198-199)

11
Additional questions on history

• Nutrition history from birth
• Duration and frequency of diarrhoea and vomiting
• Type of diarrhoea (watery / bloody/ mucous / pus)
• Family circumstances
• Chronic cough
• Contact with TB, measles
• Known or suspected HIV

12

• Nutrition history
• Kobi had been on formula feed since 4 months of
  age. The milk was diluted (one scoop of milk per
  whole bottle of water). His mother would wash his
  bottles and teats in tap water. He was given
  weaning food at six months of age, mainly
  contained potato and occasional vegetables. He
  would get meat occasionally, but not for the past
  2 months. He usually received two meals and two
  bottles of milk each day. Kobi had to share his
  plate of food with his other siblings.

13

• Family circumstances
• Kobi lives with his parents in a small house. He
  has three older sisters and two older brothers.
  They have a small plot of land on which they grow
  crops, but which is not sufficient to feed their
  family. Kobis father works as a farmer and his
  mother as a housemaid where they can earn some
  more money for food. Because they are busy,
  Kobis older siblings mostly take care of him.

14
Further examination based on differential
diagnoses

• On examination, look for
• Severe palmer pallor
• Eye signs of vitamin A deficiency
• Skin changes of kwashiorkor
• Localizing signs of infection
• Signs of HIV
• Fever or hypothermia
• Mouth ulcers
• Signs of dehydration
• (Ref. p. 199)

15
Further examination based on differential
diagnoses

• Palmer Pallor indicates anaemia (Ref. p. 166).
  In any child with palmer pallor, check the
  haemoglobin or haematocrit level
• Check conjunctiva and mucous membranes

16
Further examination based on differential
diagnoses

• Look for signs of vitamin A deficiency
• Dry conjunctiva or cornea
• Bitots spots
• Corneal ulceration
• Keratomalacia
• (Ref. p. 199)

17
Look for signs of Kwashiorkor and skin features
of zinc deficiency
18
What investigations would you like to do to make
a diagnosis?
19
Investigations

• Blood glucose 2.4 mmol/L (3-6.5mmol/L)
• Haemoglobin 70 g/l (105-135)
• Chest x-ray normal, no features of TB
• Stool microscopy shows trophozoites of giardia
• After counseling of parents, HIV PCR test -
  negative

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Diagnosis

• ? Severe Malnutrition
• ? Anaemia (not severe)
• Giardia infection causing diarrhoea
• Hypoglycaemia

21
How would you treat Kobi?
22
Treatment includes 10 steps in 2 phases initial
stabilization and rehabilitation
(Ref. p. 201)
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Treatment Step 1

• ? Hypoglycaemia (Ref. p. 201)
• ? give the first feed of F-75 or Full Strength
  Sunshine Milk (FSS). If it is not quickly
  available give 50ml of 10 glucose solution
  orally or by nasogastric tube
• ? give 3 hourly feeds
• At least 6 feeds per day
• Day and night for the first day
• After day 1, give 6 feeds during day (e.g. 0600,
  0900, 1200, 1500, 1800, 2100) and overnight if
  possible

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Treatment Step 2

• ? Hypothermia (Ref. p. 202-203)
• ? immediate and 3 hour feeding reduces risk of
  hypothermia and hypoglycaemia
• ? make sure the child is clothed (including the
  head), use warmed blanket or put the child on the
  mother's bare chest or abdomen

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Treatment Step 3

• ? If there is Dehydration (Ref. p. 203-204)
• ? give rehydration solution orally or by
  nasogastric tube, much more slowly than you would
  when rehydrating a well-nourished child
• ? if rehydration is still occurring at 6 hours
  give the same volume of starter F-75 instead of
  ORS at these times
• ? Refer to Ref. p. 203-204 or PNG malnutrition
  guidelines for details

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Treatment Step 4

• ? Electrolytes (Ref. p. 206)
• If electrolytes are not added to the food, give
• ? zinc (10 mg/day if lt10 kg 20mg/day gt10kg)
• ? potassium (3-4mmol/kg/day)
• ? magnesium (0.4-0.6mmol/kg/day)
• ? prepare food without salt
• Giving high sodium loads can be very dangerous in
  severe malnutrition
• If F-75 is provided there is no need to add
  electrolytes to food

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Treatment Step 5

• ? Infection (Ref. p. 207-208)
• ? give all severely malnourished children
  broad-spectrum antibiotic (penicillin
  gentamicin)
• ? in this case treat also for giardia
  (metronidazole 5mg/kg, 3 times a day, for 5 days
  (Ref. p. 137)) or Tinidazole for 3 days
• ? give measles vaccine if the child is not
  immunized

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Treatment Step 6

• ? Micronutrients (Ref. p. 208-209)
• If micronutrients are not added to the food
• ? give daily multivitamins
• ? give vitamin A orally on day 1
• - Do not need to repeat doses
• ? once gaining weight, give ferrous sulfate
• ? give iron only after the child gains weight,
  because iron can make infections worse

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Treatment Step 7

• ? Initiating feeding (Ref. p. 209-210)
• ? give F-75 or Full Strength Sunshine milk
• ? 100kcal/kg/day (liquid 130ml/kg/day protein
  1-1.5g/kg/day)
• ? 3 hourly feeds
• At least 6 feeds per day
• Day and night for the first day
• After day 1, give 6 feeds during day (e.g. 0600,
  0900, 1200, 1500, 1800, 2100) and overnight if
  possible
• ? continue breastfeeding if possible in addition

30
Treatment Step 8

• ? Catch-up growth (Ref. p. 210-215)
• ? replace the starter F-75 with F-100 or Milk
  Oil Formula. Use RUTF also if the child is older
  than 6 months
• ? use the same amount of F-100 as F-75 for 2
  days
• ? then increase each feed until some food
  remains uneaten (up to 220 ml/kg/day)
• ? continue breastfeeding if possible in addition

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Treatment Step 9

• ? Sensory stimulation (Ref. p. 215)
• ? provide loving care, a cheerful stimulating
  environment and involvement of the mother
• ? provide toys for the child to play with or
  books to look at
• ? physical activity as soon as the child is well
  enough

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What monitoring is required?
33
Monitoring

• Monitor for early signs of heart failure (Ref.
  p. 214) fast or slow heart rate, tachypnoea,
  oxygen saturation, oedema, chest crackles, large
  liver
• Monitor urinary frequency and frequency of
  stools and vomit
• Note number and amounts of feed offered and left
  over
• Standardize the weighing on the ward (Ref. p.
  222-223) Weigh the child the same time of the
  day, after removing clothes
• Calculate weight change and plot weight on chart
  (Ref. p. 215)

34
Monitoring

• Weigh every 2nd day
• Record the adequacy of weight gain
• gt10g/kg/day good
• 5-10g/kg/day moderate
• lt5g/kg/day poor
• E.g, a 6kg child should gain more than 6 x 10 x 7
  g more than 420 g per week
• An 8.5kg child should gain more than 8.5 x 10 x 7
  g 595 g per week

35
Monitoring

• If weight gain is poor check the following
  points
• Inadequate feeding give more, observe the child
  feeding, consider need for a nasogastric tube
• Untreated infection?
• Another illness, such as HIV/AIDS?
• Emotional or psychological problems

36
Discharge and follow-up
(Ref. 219-222)

• Before discharge the child should have
• Completed antibiotic treatment
• Regained a good appetite, taking all feeds
  regularly
• Show good weight gain (weight gain gt70g/kg/week
  and Z-score gt -2 SD)
• The mother or carer should
• Be available for child care
• Have received training on appropriate feeding
• Have enough resources at home to feed the child

37
Follow-up

• Make a plan for the follow-up of the child until
  complete recovery
• The child should be weighed weekly after
  discharge.
• If the child does not gain weight over 2-week
  period or it even lost weight, he should be
  referred back to hospital.

38
Progress

• Kobi was discharged after gaining weight and
  regaining appetite
• His parents were told to feed him at least 5
  times per day. They had to give him high-energy
  snacks between meals (e.g. milk, banana, bread,
  biscuits).
• His parents were told to encourage him to
  complete each meal, to add micronutrient
  supplements to each feed and to monitor his
  appetite and intake.
• His mother was encouraged to breastfeed him as
  often as Kobi wants.
• Follow-up was arranged.
• Kobi still needs continuing care as an outpatient
  to complete rehabilitation and prevent relapse.

39
Summary

• 12-month-old boy, youngest of family of 6. Early
  weaning, diluted dirty formula, poorly nutritious
  food, repeated infections, diarrhoea and anaemia
• Severe malnutrition with hypothermia,
  hypoglycemia, anaemia, giardiasis
• HIV negative, no signs of TB
• Malnourished children have multiple medical,
  social and psychological problems, and each need
  to be identified and addressed