Chapter 7 Severe Malnutrition

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.

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

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 4

What emergency and priority signs does Kobi have Temperature: <35.00C, pulse: 130/min, RR: 50/min, Weight: 6 kg, Length: 69cm

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

Does Kobe have signs of shock? Emergency signs of shock (Ref. p. 5) Cold hands/feet AND Capillary refill longer than 3 s Weak and fast pulse 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

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.

Examination □ Use Table 35 p. 386 and assess Kobi’s weight-for-length Kobi was wasted, having loose skin folds over his arms, buttocks and thighs and visible rib outlines. Vital signs: temperature: <35.00C, pulse: 130/min, RR: 50/min Weight: 6 kg and Length: 69cm, MUAC 10.5cm □ Use Table 35 p. 386 and assess Kobi’s 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

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)

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

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.

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. Kobi’s father works as a farmer and his mother as a housemaid where they can earn some more money for food. Because they are busy, Kobi’s older siblings mostly take care of him.

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)

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

Further examination based on differential diagnoses Look for signs of vitamin A deficiency: Dry conjunctiva or cornea Bitot’s spots Corneal ulceration Keratomalacia (Ref. p. 199)

Look for signs of Kwashiorkor and skin features of zinc deficiency

What investigations would you like to do to make a diagnosis?

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

Diagnosis  Severe Malnutrition  Anaemia (not severe) Giardia infection causing diarrhoea Hypoglycaemia

How would you treat Kobi?

Treatment includes 10 steps in 2 phases: initial stabilization and rehabilitation (Ref. p. 201)

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

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

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

Treatment: Step 4 □ Electrolytes (Ref. p. 206): If electrolytes are not added to the food, give:  zinc (10 mg/day if <10 kg ; 20mg/day >10kg)  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

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

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

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

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

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

What monitoring is required?

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)

Monitoring Weigh every 2nd day Record the adequacy of weight gain: >10g/kg/day – good 5-10g/kg/day – moderate <5g/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

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

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 >70g/kg/week and Z-score > -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

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.

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.

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