Severe Malnutrition

Chapter 7

Case study: Kanchha

Kanchha, 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

1. Triage

(Ref. Chart 1, p. xxii)

Emergency treatment, if required

2.
3. 4. 5. 6. 7.

History and examination

Laboratory investigations, if required

Differential diagnoses
Main diagnosis

Treatment Supportive care Monitoring Plan discharge

Follow-up, if required

What emergency and priority signs have you noticed from the history and from the picture?
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

History
Kanchha Lama 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 rice with dahl (lentil soup). From 5 months he had six episodes of diarrhoea. Each episode lasted for 5-6 days, which was treated locally from a medical shop. 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.

Nutrition history
Kanchha was started on formula feed at 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, and rarely would boil the bottles. He was given weaning food at six months of age, mainly contained rice with dal and only 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. Kanchha always had to share his plate of food with his other siblings.

Family circumstances
Kanchha lives with his parents in a small cottage. 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. Kanchhas father works as a farmer and his mother as a housemaid where they can earn some more money for food and beverages. Because they are so busy, Kanchhas older siblings mostly take care of him.

Examination
Kanchha was visibly wasted, having 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 Kanchas 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: irritable, sick looking; no neck stiffness and no other focal signs

Differential diagnoses
List possible causes of the illness Main diagnosis Secondary diagnoses Use references to confirm (Ref. p. 198-199)

Differential diagnoses (continued)

Primary severe malnutrition (marasmus, kwashiorkor) Secondary severe malnutrition in the course of:

-Tuberculosis
-HIV -Pneumonia -Measles -Malabsorption syndrome -Micronutrient deficiency (Vitamin A, zinc)

Additional questions on history

Concerning:

Recent intake of food and fluids

Usual diet (before the illness) Breastfeeding

Duration and frequency of diarrhoea and vomiting

Type of diarrhoea (watery/bloody) Loss of appetite

Family circumstances (social background)

Chronic cough Contact with TB, measles

Known or suspected HIV

Further examination based on differential diagnoses

On examination, look for:
Severe palmar 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 Shock (Ref. p. 199)

Further examination based on differential diagnoses

Palmar Pallor indicating

severe anaemia (Ref. p. 167). In any child with palmar pallor, determine the haemoglobin or haematocrit level Check also conjunctiva and mucous membranes

Further examination based on

differential diagnoses
Look for signs of vitamin A deficiency:
Dry conjunctiva or cornea Bitots spots

Corneal ulceration
Keratomalacia (Ref. p. 199)

Kwashiorkor and dermatosis of zinc deficiency

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

Investigations
Blood glucose Haemoglobin Chest x-ray Stool microscopy

Investigations (continued)
Blood glucose: 2.4 mmol/L (3-6.5mmol/L)

Haemoglobin: 70 g/l (105-135)

Chest x-ray: normal Stool microscopy shows trophozoites of giardia

Diagnosis
Summary of findings:
Examination: pale, irritable, and ill-looking. He was visibly wasted, having skin folds over his arms, buttocks and thighs. He had visible rib outlines, hypothermia, sunken eyes with no tears and dry conjunctiva and decreased skin turgor. History: several risk factors for malnutrition such as poor socioeconomic status, a large family, non-nutritious family food, early weaning from breast milk, diluted, dirty formula feeding Weight-for length: <70% or -3SD Low haemoglobin No contact with TB No signs of HIV Stool microscopy shows trophozoites of Giardia lamblia

Diagnosis (continued)
Severe Malnutrition Anaemia (not severe) Giardiasis

How would you treat Kanchha?

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 if it is not quickly available give 50ml of 10% glucose solution orally or by nasogastric tube give 2-3 hourly feeds, day and night, at least for the first day

Treatment: Step 2
Hypothermia (Ref. p. 202-203):
feed the child immediately 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
Dehydration (Ref. p. 203-204):
give ReSoMal rehydration fluid orally or by nasogastric tube, much more slowly than you would when rehydrating a well-nourished child if rehydration is still occurring at 6 and 10 hours give the same volume of starter F-75 instead of ReSoMal at these times

Treatment: Step 4
Electrolytes (Ref. p. 206): If electrolytes are not added to the food:
give extra potassium (3-4mmol/kg) give extra magnesium (0.4-0.6mmol/kg) prepare food without salt

Giving high sodium loads could kill the child

Consider 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 a broad-spectrum antibiotic in this case give also treatment for giardiasis (metronidazole: 5mg/kg, 3 times a day, for 5 days (Ref. p. 137)) 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 a multivitamin supplement, folic acid, zinc, copper give vitamin A orally on day 1 once gaining weight, give ferrous sulfate give iron only after the child gains weight, because iron can make infections worse

Consider if F-75 is provided there is no need to add electrolytes to food

Treatment: Step 7
Initiate feeding (Ref. p. 209-210):
give F-75 100kcal/kg/day (protein: 1-1.5g/kg/day; liquid: 130ml/kg/day) continue breastfeeding if possible, but make sure the prescribed amounts of starter formula are given

Treatment: Step 8
Catch-up growth (Ref. p. 210-215):
replace the starter F-75 with F-100 for 2 days or use RUTF, if the child is elder than 6 months then increase each feed by 10ml until some feed remains uneaten continue breastfeeding if possible and give F-100 as indicated

Treatment: Step 9
Sensory stimulation (Ref. p. 215): provide tender loving care, a cheerful stimulating environment and maternal involvement as much as possible provide structured play therapy for 15-30 minutes a day physical activity as soon as the child is well enough

Treatment Step 10: Prepare for discharge

and follow-up

What monitoring is required?

Monitoring
Monitor for early signs of heart failure (Ref. p. 214): Pulse

RR Monitor urinary frequency and frequency of stools and vomit Note amounts of feed offered and left over and daily body weight Standardize the weighing on the ward (Ref. p. 222223) Weigh the child the same time of the day, after removing clothes Calculate weight gain (Ref. p. 215)

Monitoring (continued)
Note the weight gain: poor: <5g/kg/day moderate: 5-10g/kg/day good:>10g/kg/day If weight gain is poor check the following points: Inadequate feeding Untreated infection HIV/AIDS Psychological problems

Discharge home
(Ref. 219-221)

If you discharge the child home before the full recovery: The child :
Should Should Should Should have completed antibiotic treatment have a good appetite show good weight gain at least be losing oedema

The mother or carer:

Should be available for child care Should have received specific training on appropriate feeding Should have resources to feed the child

Mothers should understand that it is essential to give frequent meals with a high energy and protein content

Follow-up
Make a plan for the follow-up of the child until recovery Contact the outpatient department (or nutrition rehabilitation centre, local health clinic, health worker) who will take responsibility for continuing supervision of the child. The child should be weighed weekly after discharge. If the child does not gain weight over 2-week period or it even losts weight, it should be referred back to hospital.

Progress
Kanchha was discharged before full recovery. 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 assist and to encourage him to complete each meal, to add electrolytes and micronutrient supplements to each feed and to monitor his intake as well. His mother was encouraged to breastfeed him as often as Kanchha wants. Follow-up was arranged. Kanchha still needs continuing care as an outpatient to complete rehabilitation and prevent relapse.

Kanchha

Summary
12-month-old boy, youngest of family of 6. Several episodes of gastroenteritis since he was five months of age. For the last 8 days he had been having frequent loose watery stools. Early weaning, diluted dirty formula, nutritious food, repeated infections Alert but severely wasted, with palmar pallor Severe malnutrition with hypoglycemia, anaemia, giardiasis hypothermia, poorly