UpDate in Mx of Severe Malnutrition

Dr. Emmanuel Ameyaw KATH

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 problems besides the malnutrition.

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.

DEFINITION AND ADMISSION CRITERIA

Severe malnutrition is defined as severe wasting or oedema of both feet. Admission criteria is either weight for height <-3SD (<70% of expected weight) Or oedema of both feet.

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 of skins on buttocks and thighs (wearing baggy pants)

Recognizable signs of severe malnutrition

2. 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 + hand or lower arms +++ severe: generalised (moderate + face)

Recognizable signs of severe malnutrition

3. 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

Recognizable signs of severe malnutrition

Any 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 and fissures

Recognizable signs of severe malnutrition

4. Eye Signs: Vit. A deficiency
Night blindness Conjunctivitis xerosis Bitot spot Corneal xerosis Cornea ulceration Cornea scar

Infection
Pus

REDUCTIVE ADAPTATION
With severe malnutrition, the systems shut down or slow down and do less to allow survival on limited calories. With treatment, the systems gradually learn to function again. Rapid changes (feeding, fluid) would OVERWHELM the systems so feeding must be slowly and cautiously increased. This slowing down of the systems is called REDUCTIVE ADAPTATION.

Abnormal physiology in selected systems

System/Organ CVS Genitourinary Effect - C.O SV - plasma vol N - red cell vol - GF - acid & water load excrete - Na+ excretion - UTI common Mx/Caution - restrict Tx to 10ml/kg & give diuretics - No more protein than required for maintenance - Rx infection to prevent tissue break down

Abnormal physiology in selected systems

System/ Effect Organ - synthesis of protein Liver
- metabolic and excretory capacity - gluconeogenesis
GIT - gastric acid - GI mortility - atrophied mucusa & glands

Mx/Caution
- give just adequate protein - dose of drugs - feed CHO rich - no iron initially - give small feeds at a time

Abnormal physiology in selected systems

System/Organ Immune system Effect - all aspect - CMI, IgA Complement - atrophied lymph glands, thymus & tonsils - inflammatory response Mx/Caution Hypoglycemia & hypothermia are both signs of severe infection associated with septic shock.

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 formulas
F-75 & F -100, Suji, RUTF & resomal

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 growth Utilises energy and amino acids ferritin.

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 urine and stool as Na + is retained. This affects proper distribution of fluid oedema. Provide mg2+ as well (retains K+ in cells) . Resomal, F-75 & F-100 has require amount of electrolyte (mineral mix)

Common complications and their management

These account for most deaths in the first 48hrs of adm. Improper management of these complications similarly 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.

Common complications and their management

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 serious systematic infections.

Common complications and their management

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 being examined or weighed.

Common complications and their management

Promptly change wet clothes or beddings. Dry the child thoroughly after bathing. Let the child sleep snuggled up to the mother 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 (kangaroo technique). Use lamp or bulbs (not too close).

Common complications and their management

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 criteria below is fulfilled: i. Lethargic or unconscious ii. Cold hands and feet Plus either iii. Capi refil < 3sec Or iv. Weak/fast pulse

Common complications and their management

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.

Common complications and their management

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 with resomal 5 - 10ml/kg/hr to alternate with F-75 for up to 10hrs.

Common complications and their management

If shock does not resolve, add IVF and give whole blood 10ml/kg over 3hrs with lasix. Once transfusion is set up stop all other fluid.

4) Very severe anaemia Hb <4g/dl or PCV < 12%

Carries high risk of heart failure If not in failure, give whole blood 10ml/kg. If in failure, (RR, PR, engorged jugular vein, cyanosis, cold hand and feet) give packed red cells 5 7ml/kg. Also consider tx if Hb is 4 - 6g/dl plus resp. distress.

Common complications and their management

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. 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.

Rx

Common complications and their management

Signs of overhydration:
PR & RR engorged jugular vein oedema (eg. Puffi eyelid)

Signs of improving hydration

Less pronouced signs of dehydration, slowing PR & RR, passing urine and not thirsty. If signs of improvement (3 of the above), give plan A resomal: <2yrs 50 - 100ml/watery stool >2yrs 100- 200ml/water stool

 Assume infection and treat with ab straightaway. Selection of ab depends on presence or absence of complication

Common complications and their management 6) Infection

Common complications and their management

Note: The ab regimen can be modified a/c drug availability or local 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

Common complications and their management 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

Mx
Zinc 2mg/kg/dy Copper (0.3mg/kg/dy) Once gaining weight (during rehabilitation phase), Ferrous salt 3mg/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

Common complications and their management

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

Common complications and their management 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 system or 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 rehabilitation phase to rebuild waste tissue.

Common complications and their management

F-75 low in Na & protein & high in CHO 0.9g protein/100ml, provides 100kcalkg/dy F-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 for transition (usually 2 - 7dys): return of appetite, oedema, child smiles and is active.

Common complications and their management

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 - w1 kg x 1000 w1 wt gain = >10g/kg/dy = good wt gain = 5 - 10g/kg/dy = moderate wt gain = <5g/kg/dy = poor

11) Sensory stimulation & emotional support

Delayed mental & behavioral development occur in sev mal permanent disability. Provide stimulation and support thro

Common complications and their management

TLC, cheerful stimulating envt, structured play 15 - 30 dly, physical activity if child become strong, maternal involvement in feeding, bathing, play and consoling to build confidence and continuing 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 prevent relapse. Employ community nurse for home follow-up Regular hospital review: 1wk, 2wk, 1mth, 3mth, 6mth. Prepare parents for home feeding using simple modification of home food aimed at providing high energy and protein + mineral, vit, & E.

Common complications and their management

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 care pathway, daily care, 24hr food intake chart). Review childs record daily to assess progress and problems.