Severe acute malnutrition lecture presentation by habtamu

Severe Acute Malnutrition

By Habtamu A

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Definition Epidemiology Causes Pathogenesis/ Pathophysiology Clinical manifestations Diagnosis/Laboratory tests Complications Principles of management Prognosis and mortality

OUTLINES

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Hunger – physiological state when food is not able to meet energy needs Malnutrition – impaired development linked to both deficient and excessive

nutrient intake & could be overnutrition(obesity) or Undernutrition Undernutrition – most common form of malnutrition in developing countries;

energy, protein and micronutrients overnutrition(obesity) common on developed countries Severe acute malnutrition (macro- &micronutrient

deficiency) Bilateral pitting edema or WFH < 70 % or MUAC < 11 cm or Based on the Welcome classification, if the child has

Kwashiorkor, Marasmus, or Marasmic-Kwash

Definitions

Protein-energy malnutrition Obesity Micronutrient deficiency problems

◦ Iron deficiency anemia◦ Vitamin A deficiency◦ Iodine deficiency disorders◦ Zinc deficiency◦ Folate deficiency

HSERV 544 - Nutrition in Children 4

Major Nutritional Problems in the World

Frequently observed in children 6 months-to- 5 years.

Marasmus peaks in the first year Kwashiorkor peaks b/n 1-3 years of age. PEM is more common during weaning period and

rainy season. Malnutrition is much more serious than the other

conditions that are getting big attention.

Epidemiology

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500,000 Ethiopian children under-5 dying each yearRanking 6th in the world in number of deaths 72 % preventable

Neonatal, 25%

Malaria, 20%Pneumonia,

28%

Diarrhea, 20%

AIDS, 1%Measles, 4%

Other, 2%

Malnutrition57%

HIV11%

Basic Causes:- Inequality, drought, War

Underlying - poverty & Social disadvantage

Immediate - Lack of Food, Infections

Manifestation- Malnutrition

Causes

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Pathophysiology1.Marasmus

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Different proposed mechanisms : 1. Protein-energy deficiency2. Adaptation3. Free radical theory ( imbalance between

oxidants and antioxidants)No adequate explanation so far why some

children develop edematous malnutrition

Pathogenesis : kwashiorkor

It is a multi deficiency state, There are different theories proposed:

A) Theory of Low Protein & Calorie intake(Protein & Calorie Deficiency)

B) Theory of Dys-adaptation(Effect of Hormonal Difference)-

I.e Marasmus is well adapted to the deficiency state due to the high cortisol levels

Kwashiorkor is a poorly adopted form of PEM.

Pathogenesis…

C) Theory of Free-Radical Damage: 1)Increased production of free radicals(oxidants)-

Peroxides,Epoxides, due to Infections, Bowel bacteria, contaminated food, aflatoxine AND

2) Decreased scavenger mechanism that removes free radicals from the body because of deficiency of micronutrients (Vitamines-A,C,E & Minerals- zinc, selenium, etc.) and Glutathione( a very important antioxidant in the body)

Accumulation of free radicalsDamage of the cell

membranes & Blood vessels

Kwashiorkor-fatty liver,Dermatosis,edema etc.

Cont…

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Role of albumin

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Infection-Malnutrition Synergism

Weight lossGrowth faltering

Immunity lowered

Appetite lossNutrient loss

MalabsorptionAltered Metabolism

Inadequate dietary intake

Disease IncidenceSeverityDuration

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infections and kwashiorkor

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Oxidative stress

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Lack of Fatty acids

Body Composition: Diagnostic &

Theraputic Implications

- TBW and ECF increased Assessement of dehydration is difficult

- Increased ICF Na+- Decreased body K+ and Mg+ They need large doses of K+

& Mg+- Marked loss of fat and muscle Liver:-Fatty Liver Hepathomegaly -Reduction in synthesis of proteins Ability to take

up,metabolise & excrete toxins is limited. -Impaired gluconeogenesis Hypoglycemia

Pathophysiological changes:

GIT - Villi atrophy and reduced dissachardase malabsorption- small intestinal bacterial overgrwth AGE- Decreased biliary secretion reduced in digestion &

absorption of fatty meals Steatorrhea-Pancreatic acinar cells atrophyDecreased digestive

pancreatic enzymes Maldigestion- chronic pancreatic inssuficiency-

Pathophysiology,…

Defense against infection(Immunity)- All aspects of immunity are impaired but CMI profoundly

affected:- Reduced secretory IGA- Impaired phagocytic function- Impaired acute phase response - WBC do not migrate to area of infection- Non-specific defense is weakened

CVS and renal - Atrophied myocardium - Reduced cardiac output and stroke volume.- Blood pressure is low - Easily develop heart failure-Restrict IV fluid, rehydrate slowly.-Decreased renal blood flow -Poor concentrating and filtration capacity

Pathophysiology,…

Temprature: Heat generation is impared as a result of: -Decreased subcutanous fatty tissue

Hypothermia -Decreased muscle bulk-decreased

shivering Sweating is also impaired So prone both to hypothermia &

hyperthermia

Cont…

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Clinical manifestation

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Marasmus…-Marked loss of weight, almost no subcutaneous tissue and

atrophic muscles.-Old man face, sunken eye balls, distended abdomen, & usualy

have good appetite.-Mood changes (always irritable) & mild skin and hair changes.

-Severe wasting

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Baggy pants

Kwashakor…

-long eyelashes-brown hair, flag

sign ,easily & painlessly

plukable-flaky paint dermatosis

-signs of measels like

maculopapular rash, red eye…

Mucocutaneous and hair changes

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Neurobehavioral

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Cloudy cornea Bitot’s spot

Eyes

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Signs of rickets-rachitic rosary

-Harrison's sulcus

-wrist widening

Hct Blood glucose level Urine analysis Blood & urine culture Blood film if febrile Serum albumin etc

Investigations:

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Infection : lung , blood, UT, GIT, skin

Metabolic hypoglycemia hypocalcemiahypomagnesemiaHypothermia

Common complications

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With the current in-patient protocol mortality can be as low as 3-5%( Jimma experience )

LOW mortality is achieved by: Restricting the use of fluids, specially IV Treating in phases Preventing hypoglycemia and hypothermia “Early” diagnosis and treatment

Management principles

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Two level Community Done by community volunteers

Health facility OTP sites In-patients

Screening

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Anthropometry ( wt, ht/lth , MUAC) Check for edema Check for medical complication Appetite test Fast Tracking : leave test if patient is

critically ill

Procedure

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6 months to 18 years W/H or W/L < 70% or MUAC < 110 mm with a Length > 65 cm or Presence of bilateral pitting edemaAdults MUAC < 170 mm or MUAC < 180 mm with recent weight loss or

underlying chronic illness or BMI5 < 16 with or Presence of bilateral pitting edema (unless

there is another clear cut cause)

Admission criteria

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Bilateral pitting edema Grade 3 (+++) Marasmus-Kwashiorkor (W/H<70% with

edema or MUAC<11cm with edema) Number of breaths per minute:o 60 for under 2 monthso 50 from 2 to 12 monthso >40 from 1 to 5 yearso 30 for over 5 year-olds Or o Any chest in-drawing

Medical complications (1)

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Extensive skin lesions/ infection Very weak, lethargic, unconscious Fitting/convulsions Severe dehydration based on history &

clinical signs Any condition that requires an infusion or NG

tube feeding. Severe vomiting/ intractable vomiting

Complications (2)

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Very pale (severe anemia) Jaundice Bleeding tendencies Hypothermia: axillary’s temperature < 35°C

or rectal < 35.5°C Fever > 39°C Other general signs the clinician thinks

warrants transfer to the in-patent facility

Complications (3)

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anthropometric Vs metabolic malnutrition metabolic malnutrition causes death. Poor appetite ~severe metabolic

malnutrition

poor appetite indicates :serious infection, major organ dysfunction( e.g. liver), electrolyte imbalance, cell membrane damage or damaged biochemical pathways

Appetite test

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1. Quiet separate area2. Explain the purpose of the test to the

carer 3. The carer, where possible, should wash

his hands.4. The carer should sit comfortably and offer

the RUTF from the packet or put a small amount on finger

5. Gently encourage the child (don’t force )6. Offer plenty of water to drink with the

RUTF child may be frightened, distressed or

fearful of the environment or staff

Steps to test appetite

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Test result

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Routine Drugs Antibiotics Vitamins ( A and Folic acid) Deworming ( mebendazole / albendazole) Therapeutic diet( F-75 , F-100,RUTF) VaccinationMonitoring

Interventions

Admit all pts SAM (Wt/Ht< 70% or MUAC < 11cm or having bilateral pitting edema).

The treatment includes 3 phases of treatment: -Phase 1 -Transition phase & - Phase 2

1) PHASE -I-includes Feeding, Routine medication, Prevent & treat complications and monotoring

A)Feeding- Feed F-75 which has 75 kcal/100 ml. - It has less protein, energy & sodium - Amount- Give 100 kcal (130 ml)/kg/day or use

the look up table -Feed 8 times daily using a cup

Treatment of PEM

NG tube is indicated in: -Pneumonia with fast breathing -Painful oral lesions -Disturbances of consciousness -taking < 75% of the daily milk B) Routine Medications- -Vit.A – Give on days 1, 2 and 14 100,000 IU for children of age < 1 yr & 200,000IU for those > 1 yr of age -Folic asid- give 5 mg po single dose -Antibiotics- During Phase-1 + 4 days (in transition phase) -First line - Amoxicilline if there is no apparent

infn. -Second line- Chloramphenicol or Gentamycin -If there are signs of infection or complication, give Ampicilline & Gentamycin or Penicillin & Gentamycin

Cont…

-Measles vaccination- for older than 6 months & not vaccinated -Treat malaria –According to national guidelineC) Prevent & Treat Complications: 1) Hypoglycemia- -Prevent it by frequent feeding & keeping the temprature to

normal. -If conscious – give 50 ml 10% sugar water( 5gm or 1 tsp of sugar

in 100 ml of water) or F-75 by mouth. -If unconscious or convulsing, 5 ml/kg of 10% glucose IV or give sugar water by NG tube -Start second line antibiotics 2) Hypothermia (T< 35.5) -Environmental temprature must be monitored & kept b/n 28-32 degree celcius -Don’t wash a severely malnourished child

Cont…

Treatment of hypothermia: -Warm with kangaroo mathod for young infants -Put a hat on the child & wrap the mother and the child

together -Feed frequently - Treat for hypoglycemia & start second line antibiotics -Monitor temprature every 30 minutes -Give hot drinks to the mother to warm her skin3) Dehydration- - The treatment is different from normal children - Rehydrate as much as possible orally -IV infusions are almost never used unless clearly indicated (i,e severe dehydration or septic shock) -ReSoMal, rather than standard ORS, is prefered b/c it has low sodium & osmolality and high potassium. -Rehydration should be slowly over 12 hours.

Cont…

-Before treatment take Wt, PR, RR, Liver size. -Feed during rehydration -Monitor closely (every 1 hour)for both under & over

hydration. -If the child has recent sunkening of the eyes or eager to

drink and conscious, give ReSoMal 5 ml/kg every 30 minutes for the first 2 hours PO or through NG tube and then 5-10 ml/kg/hr for 10 hrs.

-If the child is unconscious, start IV infusion to give RL or halve NS with 5% DW, add 20 mmol Kcl/L

- Rate of infusion- 15 ml/kg over 1 hr and reassess. If improving give 15 ml/kg the next 1 hr

-If the child regains his conscioussness or PR drops, continue the rest of the rehydration with 10 ml/kg/hr of ReSoMal.

-Monitor Wt, PR, RR, Liver size & heart sound(gallop rhythm).

Cont…

4) CHF -Treatment-Stop all Po intakes and IV fluids -Give small amount of sugar water -Furosemide 1-2 mg/kg stat -Give a very small dose of digoxine (5 mic. Gm /kg ) -Do not transfuse even though anemic5) Anemia -If Hgb < 4 gm% or Hct < 12% and with in 48 hrs of

admission, transfuse with 10 ml/kg of packed cell vollume or whole

blood over 3 hrs and give furosemide 1 mg/kg stat. -If Hgb is > or= 4 gm% or Hct > or= 12% or any level of

Hct 2-14 days after admission, give iron during phase II

Cont…

D) Monitoring: - Temprature twice daily -Wt, Edema, diarrhea, vomiting, signs of

dehydration, PR, RR & liver size daily

Phase I cont…

Progress to transition phase: -If the edema starts to decrease -The appetite returns & -No NGT, infusion & severe medical problems - For Marasmic children, if the pt tolerates the diet for 2 days,

the appetite returns & no NGT, infusion and severe medical

problems Mgt in transition phase- - Is the same as Phase I (the Feeding, routine medications & Monitoring) except F-100 is given instead of F-75. - The same volume is given as F-75 so that the energy intake

increased by 30% and the child starts to gain tissue without causing

fluid- overload or CHF.

2)TRANSITION PHASE

Indication to return to phase I: -Increasing edema -Rate of Wt gain > 10 gm/kg/day which is a sign of fluid

retention -Any sign of fluid overload, heart failure, or resp. distress -Tense abdominal distention -Development of complications that require IV drugs or

rehydration therapy or poor appetite - Refeeding diarrhea that result in Wt. loss

Cont…

Also called phase of recovery Criteria to enter this phase(all should be fulfilled): -Good appetite -At least 2 days for wasted(marasmic) pts -When the edema disappears (for edematous pts) -No other medical problems Protocol – Feed, Routine medication & MonitorA) Feed -It is the period of catch up growth so they need high protein &

calorie diet -Feed F-100 five times a day based on the Wt, refer chart for the amount -Additionally, give porridge if the child's wt is > 8 kg

3)PHASE II

B) Routine Medications: -Start ferrous sulphate -Deworming-with mebendazole or albendazole -Give the 3rd dose of vit. A at day 14.C) Monitor: -Weight 3 time/week -Temprature daily - Diarrhea, vomiting, dehydration, cough, PR, RR daily -Degree of edema every 2 weeks Good response – Wt. gain > 10 gm/kg/day Return to Phase I if there is any sign of morbidity

Phase II, cont…

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Greater than 6 months WFH > 85 % and MUAC > 12 cm and No edema for at least ten days and No medical illness mandating in-patient

treatmentLess than 6 months( with lactating mother) Baby thriving on breast milk

Discharge criteria