MALNUTRITION CASE
Q&A COUNT: 35*
Algorithm to approach a case of Malnutrition
HISTORY:
Q&A COUNT: 35*
Algorithm to approach a case of Malnutrition
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HISTORY:
Causes of Yellow colour urine:
- Dehydration (most common)
- Fever
- Liver/ GI pathology
Nutritional and non nutritional causes of PEM
Nutritional Causes:
1. Prolonged breastfeeding after 6 months, without complementary feeds
2. Low calorie/protein intake than required
3. Use of overdiluted food formulas, restriction of food intake during illness time like diarrhoea
4. Social, culturals factors (Males given more food than females) and Food fads
Non Nutritional Causes:
1. Chronic illness and infections (due to increased demand but poor appetite)
2. Malabsorption
3. Excessive GI loss (Gastro enteritis)
4. Cleft lip and Cleft Palate
5. IUGR
6. INH (Pyridoxine deficiency), Phenytoin )Folic acid deficiency)
7. Inborn errors of metabolism
Important causes of PEM
1. History of recurrent RTI
2. History of recurrent Diarrhoea
3. Measles (causes recurrent infections)
4. Tuberculosis
5. Pertussis (loss of appetite due to vomiting)
6. Jaundice
1. Prolonged breastfeeding after 6 months, without complementary feeds
2. Low calorie/protein intake than required
3. Use of overdiluted food formulas, restriction of food intake during illness time like diarrhoea
4. Social, culturals factors (Males given more food than females) and Food fads
Non Nutritional Causes:
1. Chronic illness and infections (due to increased demand but poor appetite)
2. Malabsorption
3. Excessive GI loss (Gastro enteritis)
4. Cleft lip and Cleft Palate
5. IUGR
6. INH (Pyridoxine deficiency), Phenytoin )Folic acid deficiency)
7. Inborn errors of metabolism
Important causes of PEM
1. History of recurrent RTI
2. History of recurrent Diarrhoea
3. Measles (causes recurrent infections)
4. Tuberculosis
5. Pertussis (loss of appetite due to vomiting)
6. Jaundice
How measles cause recurrent infections?
1. Measles cause hypoproteinemia - low Ig - recurrent infections
2. Measles cause low Vit A binding protein - vitamin A deficiency - causes recurrent infections
3. Measles cause epithelial denudation in RS and GI Tract - IgA becomes low - causing post measles broncho pneumonia and diarrhoea
2. Measles cause low Vit A binding protein - vitamin A deficiency - causes recurrent infections
3. Measles cause epithelial denudation in RS and GI Tract - IgA becomes low - causing post measles broncho pneumonia and diarrhoea
What is recurrent Respiratory Tract infection? (or) Tell criteria to say it is recurrent RTI
6-8 episodes of Respiratory Infection in every year
Major symptomatology of PEM
- Poor weight gain
- Stunted growth
- Behavioral changes - Irritability, apathy, decreased responsiveness, anxiety, and attention deficits
SAM criteria:
1. Weight for height less than -3 SD (or)
2. MAC less than 11.5 cm in a child aged >6 months (or)
3. Presence of bilateral pedal edema
Name given for the Diarrhoea in SAM child for more than 14 days
PROTRACTED DIARRHOEA*
2. MAC less than 11.5 cm in a child aged >6 months (or)
3. Presence of bilateral pedal edema
Name given for the Diarrhoea in SAM child for more than 14 days
PROTRACTED DIARRHOEA*
EXAMINATION:
Head to Toe examination - What to look for in a Malnutrition case?
Describe Oldman facies
1. Pinched facies (loss of subcutaneous fat)
2. Sunken eyes
3. Hollow cheeks and temples
4. Alert child who is interested in surroundings
Seen in Marasmus
Head to Toe examination - What to look for in a Malnutrition case?
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| The above pictures are from Aruchamy Textbook of Paediatrics |
Describe Oldman facies
1. Pinched facies (loss of subcutaneous fat)
2. Sunken eyes
3. Hollow cheeks and temples
4. Alert child who is interested in surroundings
Seen in Marasmus
Why no microcephaly in SAM?
Due to Head sparing effect
(Note that your case can have HC >CC or HC = CC due to this head sparing effect)
Due to Head sparing effect
(Note that your case can have HC >CC or HC = CC due to this head sparing effect)
Why flag sign is occuring in Kwashiorkar? (Denotes Alternative periods of malnutrition and normal nutrition)
What is KANAWATI INDEX?
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| The above picture is taken from Aruchamy Textbook of Paediatrics |
MANAGEMENT:
Why normal ORS cannot be given in SAM baby? (or) Why WHO reduced osmolality of ORS solution?
If there is ADD with malnutrition, there will be Villi mucosa atrophy due to adaptation. Now, by giving osmolar solution like normal ORS can cause osmotic diarrhoea - aggravating existing diarrhoea resulting in dehydration and death.
If there is ADD with malnutrition, there will be Villi mucosa atrophy due to adaptation. Now, by giving osmolar solution like normal ORS can cause osmotic diarrhoea - aggravating existing diarrhoea resulting in dehydration and death.
Why you cannot push fluids fast in a SAM child with diarrhoea?
Risk of water and sodium retention
Oral Fluids for SAM + Diarrhoea:
- Low osmolar ORS (less NaCl and less sugar)
- RESOMAL
What is the Ideal ORAL fluid for Malnutrition?
RESOMAL
What is ReSoMal? Its contents?
RE - Rehydration
SO - Solution for
MAL - Malnutrition
SAM baby has Potassium deficiency but high level of sodium. SAM baby also has magnesium, zinc and copper deficiency. So this special ORS solution contains 40 mEq/L of potassium with 45 mEq/L of sodium with Magnesium, zinc and copper.
Recommended by WHO for SAM babies
SO - Solution for
MAL - Malnutrition
SAM baby has Potassium deficiency but high level of sodium. SAM baby also has magnesium, zinc and copper deficiency. So this special ORS solution contains 40 mEq/L of potassium with 45 mEq/L of sodium with Magnesium, zinc and copper.
Recommended by WHO for SAM babies
10 steps of SAM management
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| The above picture is taken from OP Ghai Textbook of Paediatrics |
Phases in SAM management
There are 2 phases - Stabilization phase (involves steps 1-7) and Rehabilitation phase (involves steps 8,9,10 with electrolytes and micronutrients continued)
Duration:
Stabilization by 2-7 days
Rehabilitation by 2-6 weeks
Some books say, there are 3 phases:
1. Stabilization-Resuscitation phase (involves steps 1-6)
2. Restorative phase (step 7)
3. Rehabilitation phase (step 8,9,10)
Prefer telling 3 phases in exams*
There are 2 phases - Stabilization phase (involves steps 1-7) and Rehabilitation phase (involves steps 8,9,10 with electrolytes and micronutrients continued)
Duration:
Stabilization by 2-7 days
Rehabilitation by 2-6 weeks
Some books say, there are 3 phases:
1. Stabilization-Resuscitation phase (involves steps 1-6)
2. Restorative phase (step 7)
3. Rehabilitation phase (step 8,9,10)
Prefer telling 3 phases in exams*
F75 and F100
Both are milk based diet for "complicated" SAM without good appetite.
F75 - starter diet (initial part of restorative phase)
F100 - catch up diet (later part of restorative phase and rehabilitation phase)
First, F75 is started and slowly replaced by F100.
The number denotes amount of kcals per hundred ml. Ex: F75 contains 75kcal/100 ml
What is RUTF?
Ready to Use Therapeutic Foods
Used to treat SAM child with good appetite (uncomplicated SAM)
Note that:
F75, F100 - used for complicated SAM
RUTF - used for uncomplicated SAM
Comparisons between F75, F100, RUTF
Both are milk based diet for "complicated" SAM without good appetite.
F75 - starter diet (initial part of restorative phase)
F100 - catch up diet (later part of restorative phase and rehabilitation phase)
First, F75 is started and slowly replaced by F100.
The number denotes amount of kcals per hundred ml. Ex: F75 contains 75kcal/100 ml
What is RUTF?
Ready to Use Therapeutic Foods
Used to treat SAM child with good appetite (uncomplicated SAM)
Note that:
F75, F100 - used for complicated SAM
RUTF - used for uncomplicated SAM
Comparisons between F75, F100, RUTF
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| The above picture is taken from Aruchamy Textbook of Paediatrics |
How to say SAM baby responds well to therapy?
At the end of 1st week.. the baby must attain normal calorie intake.
Monitor daily weight for baby.
There must be adequate weight gain.
But - If daily weight gain crosses 2 percentile per day - IT IS NOT NORMAL.
SAM discharge criteria
1. Reduced edema
2. Settled medical complications
3. Good appetite - consuming adequate RUTF
4. Clinically well and alert
5. 15-20% of weight gain
Complications of SAM Treatment
1. Nutritional recovery syndrome
2. Encephalitis like syndrome
3. Protein overload syndrome
4. Pseudotumor cerebri (increased ICT, self limiting)
2. Settled medical complications
3. Good appetite - consuming adequate RUTF
4. Clinically well and alert
5. 15-20% of weight gain
Complications of SAM Treatment
1. Nutritional recovery syndrome
2. Encephalitis like syndrome
3. Protein overload syndrome
4. Pseudotumor cerebri (increased ICT, self limiting)
Nutritional recovery syndrome?
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| The above picture is taken from Aruchamy Textbook of Paediatrics |
What is Protein overload syndrome?
Occurs when protein intake is more than 6g/kg/day or calorie intake >250 kcal/kg/day
Complication of SAM treatment
Features: Cushing facies, edema, increased HR and RR
Reason: Due to functional hyperthyroid or hyperadrenocortical state
Treatment: Symptomatic, low protein intake <4g/kg/day
How will you prevent Malnutrition?
Occurs when protein intake is more than 6g/kg/day or calorie intake >250 kcal/kg/day
Complication of SAM treatment
Features: Cushing facies, edema, increased HR and RR
Reason: Due to functional hyperthyroid or hyperadrenocortical state
Treatment: Symptomatic, low protein intake <4g/kg/day
How will you prevent Malnutrition?
To prevent PEM, UNICEF formulated strategies like GOBI FFF, NIMFES and SHAPOBI
Indian program - ICDS also intended to prevent PEM
What is GOBI FFF, NIMFES and SHAPOBI?
Indian program - ICDS also intended to prevent PEM
What is GOBI FFF, NIMFES and SHAPOBI?
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| The above picture is taken from Aruchamy Textbook of Paediatrics |
What is POSHAN abhiyaan?
POSHAN - PM's Overarching Scheme for Holistic Nutrition
Focus on first 1000 days of life
Launched on Feb 2018
It involves IT driven tracking of beneficiaries apart from growth monitoring*
Goals:
1. Reduce stunting by 2% per annum
2. Reduce under nutrition by 2% per annum
3. Reduce LBW by 2% per annum
4. Reduce anemia among young children by 3% per annum
5. Reduce anemia among adolescent girls and woman by 3% per annum
DISCUSSION:
How Malnutrition child undergo ADAPTATION?
- Cell replication limited (mucosal atrophy)
- BMR gets low
- Breakdown of body proteins and its use dor gluconeogenesis
What is Gopalan's theory?
GOPALAN's theory of adaptation states that lack of this adaptation to Malnutrition causes Kwashiorkar and good adaptation to Malnutrition causes Marasmus
What is Holliday Segar Formula?
What is Holliday Segar Formula?
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| The above picture is taken from Google search |