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Malnutrition
Malnutrition
Children with severe malnutrition are at risk of several life-threatening problems like hypoglycaemia, hypothermia, serious infection, and severe electrolyte disturbances. Because of this vulnerability, they need careful assessment, special treatment and management, with regular feeding and monitoring. Their treatment in hospital should be well organized and given by specially trained staff.
Malnutrition
Burden of disease WHO has estimated that 54% of child deaths are associated with malnutrition.
Definition Severe malnutrition is defined as the presence of: Severe wasting (<70% of the median weight-for-height or <3SD), and/or Oedema of both feet.
Malnutrition
Severe malnutrition includes: 1- marasmus, 2- marasmic-kwashiorkor and 3- kwashiorkor. - Children with marasmus have severe wasting without oedema; -Those with marasmic-kwashiorkor have severe wasting + oedema; -Those with kwashiorkor have oedema, Low weight-forage is not a criterion for hospital treatment by itself; it could lead to stunted children being hospitalized, which would be inappropriate, as the short stature is not going to be improved in the short term.
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Child with marasmus
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is a less
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Clinical presentation - Severe malnutrition may occur at any age but is most common between 6 and 30 months, except during famine. -It often follows a severe illness such as measles or persistent diarrhoea, or repeated infections - Severe wasting is due to loss of fat and skeletal muscle and is most visible on the buttocks, thighs and upper arms, where the skin hangs loose in folds. The ribs and shoulder blades are clearly visible.
Malnutrition
Clinical presentation
-The eyes may appear sunken due to wasting of the tissues behind the eye. The face gives an old person appearance. Weakened abdominal muscles and intestinal gas from bacterial overgrowth in the small bowel can lead to a distended belly. - Wasted children are often anxious and irritable, and cry easily. Tears, however, may be absent due to atrophy of the lacrymal glands.
Malnutrition
Clinical presentation In oedematous malnutrition, the oedema usually appears first in the feet, and then the lower legs. Gross oedema includes the arms and face and can develop quickly. Skin changes include abnormally dark, crackled, peeling patches (called flaky paint dermatosis) with pale skin underneath that is easily damaged and infected.
Hair becomes brittle, is easily pulled out, becomes discoloured, and loses its color in ethnic group. The liver may be enlarged with fat. Children with oedema are miserable, dislike being touched, and may have a complaining cry.
Malnutrition
Clinical presentation In oedematous malnutrition Children with oedematous malnutrition may appear chubby, but wasting becomes evident when oedema fluid is lost during the first few days of treatment. In the presence of oedema, muscle wasting can be best seen over the upper arms and shoulders.
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Aetiology
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Pathophysiology - When food intake is severely reduced, physiological and metabolic changes begin to take place in an orderly progression to conserve energy and support life for as long as possible. This process is called reductive adaptation. Fat stores are mobilized to provide energy and eventually muscle and skin proteins are also used. Energy is conserved by: reducing physical activity and growth; reducing basal metabolism by: slowing the rate of protein turnover, reducing the functional reserve of organs, slowing the Na+/K+ pumps in cell membranes, and reducing inflammatory and immune responses
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Pathophysiology - Consequently: less heat is produced; loss of muscle leads to associated loss of potassium, magnesium, zinc and copper; red cell mass is reduced, liberating iron; the heart is smaller and weaker than usual, and has a reduced output; it cannot cope with excess fluid in the circulation, which increases the risk of heart failure
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Pathophysiology the kidneys cannot extract excess sodium or excess fluid from the blood; excess fluid easily builds up in the circulation; sodium builds up inside cells due to slower and fewer Na+/K+ pumps, leading to excess retention of sodium and water; potassium leaks out of cells and is lost in the urine, which contributes to electrolyte imbalance, anorexia, fluid retention and heart failure;
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Pathophysiology The liver produces less albumin, transferrin and other transport proteins; gluconeogenesis is reduced; a dysfunctioning liver is less able to excrete toxins, such as aflatoxin, and cannot cope with excess dietary protein; the gut produces less gastric acid and enzymes; motility is reduced; bacteria often colonize the stomach and small bowel, damaging the mucosa and deconjugating bile salts; damaged, flattened villi cause impaired digestion and absorption of nutrients; and immune function is impaired, particularly cell-mediated immunity; there may be no fever, no redness or swelling, or raised white cell count during an infection. .
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In addition, deficiencies of vitamin A, zinc, selenium and other antioxidant nutrients limit the ability to mop up free radicals that damage cell membranes.
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Management Many children hospitalized with a common illness as the primary diagnosis (e.g. diarrhoea or pneumonia) are severely malnourished. A common and often fatal mistake is to try to treat the illness first and the malnutrition afterwards. This ignores the profound metabolic and physiological changes that exist in severe malnutrition and greatly increases the risk of death. The correct approach is to regard such children as having severe malnutrition with a coexisting infection and to treat both conditions simultaneously.
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Management Severe malnutrition is managed in two phases: a stabilization phase, during which homoeostasis is restored and acute life threatening conditions are prevented or treated, and a longer rehabilitation phase of rapid catch-up growth. Treatment procedures are based on a 10-step approach and are similar for both wasted and oedematous children.
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Malnutrition
Severely malnourished children die in hospital from four main causes: hypoglycaemia, hypothermia, heart failure, and infection.
Centres with a record of low mortality take immediate steps to prevent death from these causes.
Centers where the mortality is high have practices that contribute to these causes of death.
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Severely malnourished children die in hospital from 1-Hypoglycemia: Severely malnourished children are at increased risk of hypoglycaemia due to increased demands for, and a limited supply of, glucose. This is because: their liver makes glucose less easily; they have less glycogen in reserve because their muscles have wasted; -They usually have multiple infections and the immune response requires relatively large amounts of glucose; - Treat: They need a specially prepared diet, such as F75, which contains sugar or another readily available source of glucose. If this is not immediately available, give a solution of 10% glucose or sucrose.
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Severely malnourished children die in hospital from 2. Hypothermia. Severely malnourished children have an increased risk of developing hypothermia due to: reduced heat production from lowered basal metabolism and diminished physical activity; increased heat loss from their relatively larger surface area/kg and loss of the insulation normally provided by subcutaneous fat; and infections, which increase the demand for glucose via the immune system
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Severely malnourished children die in hospital from 3. Dehydration. Severely malnourished children often have diarrhoea.
It is difficult to diagnose dehydration in a severely malnourished child because the common signs (slow skin pinch, sunken eyes, dry mouth, absent tears) are similar to the signs of malnutrition itself. All severely malnourished children with watery diarrhoea should be assumed to have some dehydration .
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Severely malnourished children die in hospital from 3. Dehydration. Severely malnourished children die from fluid overload during rehydration. There are three main reasons: The degree of dehydration is overestimated, because of confusion between signs of malnutrition and signs of dehydration; fluids are given intravenously, which increases the risk of overload; and children are not monitored carefully during rehydration, so fluid overload is not diagnosed until it is too late.
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Severely malnourished children die in hospital from 3. Dehydration. Severely malnourished children with diarrhoea should not be given IV fluids, except when there is shock. Instead they should be rehydrated orally with a special rehydration solution for malnutrition (ReSoMal) This is low in sodium (45 mmol/l) and has added potassium, magnesium, and sugar. Rehydration (5 ml/ kg every 30 min for 2 h and then 510 ml/kg/h for up to 10 h) is slower than for well-nourished children. Pulse and respiration rates should be monitored every 30 min for the first 2 h and then hourly for signs of Overhydration.
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Severely malnourished children die in hospital from 4. Electrolytes. All severely malnourished children have excess body sodium (even though plasma sodium may be low) and deficiencies of potassium and magnesium. Oedema is partly due to these imbalances. All malnourished children should be given extra potassium (4 mmol/kg/d as potassium chloride) and extra magnesium (0.6 mmol/kg/d as magnesium chloride) for at least 2 weeks. A combined solution (e.g. a vitaminmineral mix) can be added to feeds and to ReSoMal. Sodium should be restricted. Diuretics make potassium deficiency worse and should never be given to treat oedema.
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Severely malnourished children die in hospital from 5. Infection. Infections are easily missed in severely malnourished children as the normal signs are often absent. All children should, therefore, be presumed to be infected, even if there are no clinical signs. A broadspectrum oral antibiotic such as cotrimoxazole should be given straightaway on the first day of admission. Children who are hypoglycaemic, hypothermic or who appear seriously ill should be given IM or IV ampicillin and gentamicin. Malnourished children are very vulnerable to nosocomial infection. Good ward hygiene and handwashing by doctors, nurses and other carers are therefore important.
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Severely malnourished children die in hospital from 5. Infection. Overcrowding and sharing of cots should be avoided. Measles vaccination should be given to nonimmunized children aged 9 months
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Severely malnourished children suffer in hospital from 6. Micronutrients deficiencies. All severely malnourished children have vitamin and mineral deficiencies which must be corrected. A large dose of vitamin A should be given on Day 1 to boost immune function and prevent blindness. If there is any sign of xerophthalmia, the dose should be repeated on Day 2 and Day 14. Other deficiencies are treated by giving multivitamins, folic acid, zinc and copper. Provision of iron should be delayed until the child is gaining weight in the rehabilitation phase.
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Severely malnourished children need in hospital from 7. Initial feeding. During the stabilization phase, the aim is to provide just enough energy and protein to meet basic needs (100 kcal/kg/d and ~1g protein/kg/d) and 130 ml fluid/kg/d (or 100 ml/kg/d if the child has gross Oedema). Giving too much food initially stresses the liver, kidneys, heart and gut. Initial feeding should consist of small, frequent feeds of a low osmolar and low lactose diet that contains 75 kcal and 0.9 g protein per 100 ml. Milkbased feeds (such as starter formula F-75) are best for most children and should be started immediately after admission. Breastfeeding should be continued.
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Severely malnourished children need in hospital 8. Catch-up growth. Readiness to enter the rehabilitation phase and start catch-up growth is signalled by a return of appetite, usually about one week after admission. Feeding should then be increased. A controlled transition over 3 days is recommended to prevent a child suddenly consuming huge amounts, which can lead to heart failure. Thereafter, unlimited amounts should be given. The aim of the rehabilitation phase is to achieve intakes of 150220 kcal/kg/d and 46 g protein/kg/d.
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Severely malnourished children need in hospital 8. Catch-up growth. The recommended catch-up formula (F-100) contains 100 kcal and 2.9 g protein/100ml. Modified porridges or modified family foods can be used, provided they have comparable energy and protein concentrations. Mothers should be encouraged to continue breastfeeding. Rates of weight gain are considered poor if <5 g/kg/d, moderate if 510 g/kg/d, and good if >10 g/kg/d.
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iSeverely malnourished children need in hospital 9. Prepare for follow-up. Continuing care after discharge and back referral letters should be organized before children leave hospital. The parent or caregiver needs to be given knowledge and skills to feed the child at home in ways that will promote good health and continued catch-up growth. Parents should be advised to take their child for regular follow-up checks and ensure that booster immunizations are given, and also 6-monthly vitamin A doses in areas where vitamin A deficiency and xerophthalmia are common.
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Weight-for-Height (WFH) reflects recent weight loss or WASTING gain ACUTE MALNUTRIITON
Height-for-Age (HFA) reflects skeletal growth STUNTING
CHRONIC MALNUTRITION
Weight-for-Age (WFA) is a composite index UNDERWEIGHT
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