Malnutrition in Children-what do I need to know ... · numbers •16.000 children < 5 die every day...
Transcript of Malnutrition in Children-what do I need to know ... · numbers •16.000 children < 5 die every day...
Malnutrition in Children- what do I need to know ?
Unterernährung bei Kindern- was muss ich wissen ?
Judith Lindert, DTMH
University Lübeck
foring
29. April.2017
numbers
• 16.000 children < 5 die every day
• ≈ 45% percent related to malnutrition
• 1/7 children underweight
• In-patient treatment challenged by HIV, TB other medical complications still high case fatality
WHO Definition of SAM (severe acute Malnutrition in children
Mid upper arm circumferenceMUAC
Growth percentiles
• % of children identified by each indicator similar BUT not same children -> all tests should be used
• Only visual examination identifies half of the cases
© WHO
Impact of severe acute malnutrition
Weight-for-height <-3SD (WHO standards) isassociated with large increase in risk of dying in children 6-60 months
WHO child growth standards and the identification of severe malnutrition in infants and children. WHO/UNICEF 2009
Marasmus- on examination
© Lindert
• Inadequate energy intake• Often but not always
chronic process• Metabolic adaptions tend
to protect function of the brain and other organs and prolong survival
• Wasting• “too much skin”• Grannies face• Bones visible
© Kitz
Kwashiorkor- on examination
• Fatty infiltration liver hepatomegaly
• Discoloured, sparse hair
• Flaky skin desquamation
• Skin colour changes
• Anorexia
• Metabolic disturbance © Lindert
© Lindert
© Bartels
© Lindert
Kwashiorkor
• ????????????
• Previously: low protein diet with low serum albumin results in oedema and kwashiorkor
• Metabolic complex:• Increased oxidative stress
• Hepatic steatosis –mechanism ?
• Severe metabolic disturbance-hypoglycaemia
• ? Severe hepatic dysfunction?
• Exclusively breast fed children and children within the same family/community sharing the same diet some develop marasmus and some kwashiorkor
• oedema independent of albumin levels and improvement unrelated
Mixed type- marasmic kwashiorkor
© Lindert
Oedema DD non nutritional
• Cardiac failure
(rheumatic heart disease )
• Kidney disease; nephroticsyndrom
• Hepatic failure
(traditional medicine)
• Poor intestinal absorption/enteropathy
• Trauma e.g. burns; protein loss
SAM- initial assessment
Anthropometry (body measurements)• quantify by reference to
international standards
Clinical assessment• type of malnutrition
• Severity
• Identifying acute life-threatening complications• E.g. ETAT
History of illnessMain problem according to caretaker ?Since when weight loss/oedema?Last meal?Usual diet? Appetite?Number of children?Fever?Diarrhea? Frequency, type?Vomiting?Cough?TB contactGeneral condition
alertnessWant to play?Vital signs
Therapeutic concept/treatment options
Management of SAM in health facilities• WHO: only children with complicated SAM
should be admitted• General danger sings: high fever severe anemia
resp distress systemic infection
• Anorexia: failed appetite test
• Significant social issues: orphans single parent family
• Community management
© Lindert© Lindert
© Lindert
Community vs hospital
PROTOCOLS
• essential and significantly reduce the mortality associated with malnutrition
• Studies from several countries (India, Bangladesh, South Africa, Colombia) show a halving in the death rate when WHO guidelines are followed
PROTOCOLS
• essential and significantly reduce the mortality associated with malnutrition
• Studies from several countries (India, Bangladesh, South Africa, Colombia) show a halving in the death rate when WHO guidelines are followed
© Bartels
Therapeutic approach
• Identification of SAM using anthropometry and examination for oedema:
Therapeutic approach
• 1. treat/prevent hypoglycemia
• 2. treat/prevent hypothermia
• 3. treat/prevent dehydration
• 4. correct e´lyte imbalance
• 5. treat/prevent infection
• 6. correct/substitute micronutrient deficiencies
• 7. start cautious feeding
• 8. slowly increase calorie intake for catch up growth
• 9. provide sensory stimulation and emotional support
• 10. prepare for follow- up after discharge
1. treat/prevent hypoglycemia
• Malnourished children are very vulnerable to hypoglycemia
- glucose storage capacity decreases
- Cannot handle glucose imbalances
avoid prolonged periods without food
start early frequent small feeds
• A: conscious and blood sugar (BS) < 54mg/dl/ <3mmol/l:
➢Glucose orally/NG-tube: e.g. 50ml 10% glucose or 10% sucrose solution ( 1 teaspoon sugar in 3.5 teaspoon water)
➢Feed F-75 every 30 min for two h (1/4 of the feeding amount each time)
• B: unconscious, lethargic or convulsing:
➢Iv 10% glucose (5ml/kg) followed by 50ml 10% glucose or sucrose NG-tube
➢2h- feeding
• Consider infection: antibiotics?
2. treat/prevent hypothermia
subcutaneous fat reductionIncrease body surface relative to weight- difficut to maintain body
temperature High risk for hypothermia
Avoid, detect (body temperature) and treat hypothermiaProtect against cold start feeding immediately
❖Warm environment❖Kangaroo care❖Avoid exposure:
UnwarppingWet clothes
!! Hypothermia and hypoglycemiaoften go together and are asociated with sepsis !! ? antibiotics!?
© Lindert
2. treat/prevent dehydration/diarrhea
© Bartels
© Bartels
2. treat/prevent dehydration/diarrhea
Causes of diarrhoea in malnutrition ward
© Bartels
3. treat/prevent dehydration
5. treat/prevent infection
SYSTEMATIC TREATMENT• Malnutrition often after infections such as measles or dysentery
• Impairement immunity adaptive (lymphocytes) & Innated(macrophages & granulocytes)
• Atrophy lympatic tissueTonsils thymusLymph glands
Nutritionally acquired Immunodeficiency syndrom (“NAIDS”)
5. treat/prevent infection
• Broad spectrum AB• Oral nystatin (if
thrush)• Anti-helmintics• Up-date vaccintions:
measles
measlesmeasles
© Lindert
© Lindert © Lindert
Symptomatic malnutrition?
Think of HIV• high prevalence setting (>1% in pregnant
women): do HIV test after informed consent• Low prevalence setting (<1% in pregnant
women): no systematic HIV test (except mum +ve)if no response to treatment after 2 weeks
Think of TB• TB contact• History of cough, how long• Lymphadenopathy• No weight gain with appropriate treament
Deaths regarding HIV status
stabilisation of medical
complications, restore metabolic
functions
F-75
100kcl/kg/d
8 meals
Phase 1 Transition Phase
Rehabilitation
Catch up
F-100
200 kcl/kg/d
6 meals
Phase 2
Recovery/discharge
RUTF
Ambulatory
Not yet ready for Phase 2
F-100135kcl/kg/d8 mealsIf possible introduce RUTF
What to feed the child ?
© Lindert© Lindert © Lindert © Lindert
Different standard milk (per 100ml)
measles
When to go back to phase 1?
measlesSevere ´clinical detoriation: any WHO danger signs
• Respiratory distress• Shock• Severe anaemia (Hb <5g/dl)• Convulsion/impaired
consciousness (BCS <4, AVPU V)
• Profuse diarrhea/severe dehydration
• Hypothermia (<36°C)• Hypoglycaemia (>54mg/dl)
© Bartels
If it is not going well
measles• Cardiac failure
Output stroke volume
• Liver failure
Proteins excretion
Energy production
• Kidney failure
GFR
• Intestinal failure
Gastric acid motility
Digestive enzymes
• Energy stores © Lindert
e.g. intestinal dysfunction
• Small intestine bacterial overgrowth measles
• Lipid maldigestion
• Exocrine pancreatic dysfunction
• Villus atrophy
• Intestinal infections
Enteropathy of the malnourished
© Bartels
Transfer to outpatient/ambulatory treatment
measles
Guided rather by clinical condition and social circumstanced than anthropometric targets
outcome
measles
© Kitz
measles
Not just Malnutrition
PreventionEarly detection and holistic treatment
Vielen Dank© Lindert
acknowledgments
• Rosalie Bartels, Blantyre Malawi/Global Child Health Group Amsterdam
• MSF, Nutritional and Medical Protocol for Treatment, Children from 6 to 59 months, MSF OCA
• WHO
• Penny, Mary
• MSF Mweso Team, DRC Congo
• MSF Quetta Team, Pakistan
• Christa Kitz, Severe Acute Malnutrition in Children