1. Chapter 7 Severe 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 4

5. What emergency and priority signs does Kobi have
Temperature: <35.00C, 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
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

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 □ 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

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 )

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. 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.

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
Bitot’s 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 ( )
Chest x-ray: normal, no features of TB
Stool microscopy shows trophozoites of giardia
After counseling of parents, HIV PCR test - negative

20. 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)

23. 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

24. 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

25. 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 or PNG malnutrition guidelines for details

26. 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 ( mmol/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

27. 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

28. 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

29. 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

31. 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

32. 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 ) 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:
>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

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 )
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

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