Treatment management-of-severe-protein-energy-malnutrition-2
Severe Malnutrition
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Case ReportSEVERE MALNUTRITION
Presentator:Andika Pradana 070100071Ira Nola Lingga 070100109
Deprtment of Pediatrics FK USU, July 4th 2011
SUPERVISOR:Dr. SRI SOFYANI, Sp.A(K)
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SEVERE MALNUTRITION
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LEVEL OF COMPETENCE
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DEFINITION
World Health Organization:
Malnutrition is the cellular imbalance between the supply of nutrients and energy and the body's demand for them to ensure
growth, maintenance, and specific functions
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CLINICAL FINDINGS
Three types of clinical findings in severly malnourished children:
1.Marasmus2.Khwarsiorkor
3.Marasmus - Khwarsiorkor
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Clinical Features
Feature Kwarshiorkor Marasmus
Growth failure Present Present
Wasting Present Present, marked
Oedema Present Absent
Hair Changes Common Less common
Mental Changes Very common Uncommon
Dermatosis, flaky-paint Common Does not occur
Appetite Poor Good
Anemia Severe (sometimes) Present, less severe
Subcutaneous fat Reduced but present Absent
Face May be oedematous Draw in, monkey-like
Fatty infiltration of liver Present Absent
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CLINICAL FINDINGS: Marasmus
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CLINICAL FINDINGS: Marasmus
Marasmus:- Old man face- Extreme wasting- Prominent ribs- Baggy pants- Muscle hypotrophy- No edema
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CLINICAL FINDINGS: Khwarsiorkor
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CLINICAL FINDINGS: Khwarsiorkor
KHWARSIORKOR:- Moon face- Pale and sparse hair- Enlarged liver- Edema- Peeling skin (crazy
pavement dermatosis)
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CLINICAL FINDINGS: Marasmus Khwarsiorkor
MARASMUS KHWARSIORKOR:
The patient appears like a marasmus child, combined with signs of khwarsiorkor such edema and enlarged liver
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PATHOPHYSIOLOGY
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• Decrease Imune System
• Enlarged Liver and accumulation
of triglyserides• Tachypnea• Malabsorbtion• Anemia
• Developmental delay•etc
• Decrease Imune System
• Enlarged Liver and accumulation
of triglyserides• Tachypnea• Malabsorbtion• Anemia
• Developmental delay•etc
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DIAGNOSIS
WHO, 1999:Severe Malnutrition if:
BW / BL is below 70% BW / BL is between 70 – 79% but with
edema presents
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Based on Body weight according to Body
length
BW/BL
very low low normal high70 80 90 110 120 %-3SD -2SD +2SD +3SD
PEM severe mod mild overweight obese
-Kwashiorkor -Marasmus -M-K
DIAGNOSIS
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HISTORY TAKING
• Usual diet before current episode of illness• Food and fluids taken in past fiew days• Duration and frequency of vomiting or diarrhoea,
appearance of vomit or diarrhoea stool• Time when urine was last passed• Birth weight, birth length and growth chart• Breastfeeding history• Milestones reached• Immunization
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Tests that may be useful
Blood glucose Glucose concentration <54 mg/dl is indicative of hypoglycaemia
Examination of blood smear
by microscopy
Presence of malaria parasites is indicative of infections
Haemoglobin or packed-cell
volume
Haemoglobin <40 d/l or packed-cell volume <12% is indicative of very
severe anemia
Examination and culture of
urine specimen
Presence of bacteria on microscopy is indicative of infections
Examination of faeces by
microscopy
Presence of blood is indicative of dysentry
Chest X-Ray Pneumonia causes less shadowing of the lungs in malnourished
children that in well-nourished children
Bones may show rickets or fractures of the ribs
Skin test for tuberculosis Often negative in children with tuberculosis or those previously
vaccinated with BCG vaccine
LABORATORY FINDINGS
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LABORATORY FINDINGS
Tests that are of little or no value
Serum proteins Not useful in management, but may guide prognosis
Test for human
immunodeficiency virus (HIV)
Should not be done routinely; if done, should be accompanied by
counselling of the child’s parents and result should be confidential
Electrolytes Rarely helpful and may lead to inappropriate therapy
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TREATMENT
Five General Principles:
1.Ten Principal Steps2.Treatment of Comorbidities3.Failure of Treatments4.Patient discharges before end of treatment5.Emergency Case
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TreatmentStabilization Transition Rehabilitation Follow Up
Day1-2
Day3-7
Week 2Week
3-6Week7-26
1 Hypoglycemia2 Hypothermia3 Dehydration4 Electrolyte Correction5 Treatment of Infection6 Micronutrition
Defficiency CorrectionWithout Iron
SupplementationWith Iron
Supplementation7 Initial Refeeding Formula 75 Formula 75
to Formula 100
8 Correctional Refeeding (Catch Up Growth)
9 Stimulation10 Prepare for Discharge
________________________ The Ten Principal Steps
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Ten Principal Steps:1. Hypoglycemia
Hypoglycemia if blood glucose level below 3 mmol/l or 54 mg/dl
- Loss of consciousness- Lethargic- Weak arterial pulse- Sweating
If it is difficult to test blood glucose level, consider all severely malnourished children are
hypoglycemic
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Ten Principal Steps:1. Hypoglycemia
Signs and Symptomps Treatment
Alert (not lethargic) Give 50 ml of Dextrose 10% per oral or via NGT
Loss of consciousness
(lethargic)
Give Dextrose 10% intravenous as much as 5 ml per each
kilogram body weight, followed by 50 ml of Dextrose
10% orlaly
Shock
Give Dextrose 10% intravenous as much as 5 ml per each
kilogram body weight, followed by Ringer Lactat +
Dextrose 10% (1:1) for 15 ml each kilogram body weight,
sould be given in 1 hour
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Ten Principal Steps:2. Hypothermia
Hypothermia if rectal temprature is below 36oCelcius
Treatment:- Kangoroo technique skin to skin contact- Radiant warmer- Follow the fluctuation of body temp every
30-60 minutes
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Ten Principal Steps:3. Dehydration
Evaluate the general condition, sunken eye, thirsty and skin pinch
Treatment: Give ReSoMal• 5 ml/kg bodyweight every 30 minutes for the
first 2 hours• Followed by another Resomal for as much as 5-
10 ml/kg body weight/hour, given alternately with Formula 75 as the early diet
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Ten Principal Steps:4. Electrolyte Correction
Hyponatremia and Hypokalemia are frequently found particularly if
diarrhea and vomitting are present
Treatment: Give ReSoMal
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ReSoMal (Rehidration Solution for
Malnutrition)
ReSoMal Modification
WHO-Oral rehydration solution : 1 sachet
Sugar : 50 gr
Potassium powder : 4 gr (40 ml)
Water added until : 2 liter
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Ten Principal Steps:5. Treatment of Infection
No clear evidence of infection:Cotrimoxazole (TMP 5 mg/kgBW + SMZ 25 mg/kgBW
orally twice daily for 5 days.
Infection• Ampicillin, 50 mg/kgBW IM or IV for the first 2
days, followed by Amoxicillin 15 mg/kgBW orally every 8 hours for the next 5 days), along with
• Gentamycin 7,5 mg/kgBW IM or IV once daily for 7 days.
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Ten Principal Steps:6. Micronutrient
Stabilization and Transitional Phase:Multivitamin supplementation - Folic Acid 1 mg/day ( 5mg on day 1 ) - Zn 2 mg/kgBW/day - Cu 0,2 mg/kgBW/day
- Vitamin A on the 1st day
Rehabilitation Phase• Iron added. Sulfas Ferrosus 10 mg/kgBW/day
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Ten Principal Steps:7. Initial Refeeding
WHO Formula 75
- Give a small portion but frequent feeding- Hypoosmolar and low in lactose- Energy: 80-100 kal/kgBW/day- Protein: 1-1,5 gr/kgBW/day- Fluid: 130 ml/kgBW/day, or 100 ml/kgBW/day if
edema presents
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Nutrients
Treatment Phase
Stabilization Transitional Rehabilitation
Energy 100 kcal/kg/day 150 kcal/kg/day 150-200
kcal/kg/day
Protein 1 – 1,5 g/kg/day 2-3 g/kg/day 4-6 g/kg/day
Fluid intake 130 ml/kg/day or
100 ml/kg/day if
edema presents
150 ml/kg/day 150 – 200
ml/kg/day
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Ten Principal Steps:8. Correctional Refeeding
WHO Formula 75 – 100 – 135
Transitional Phase:Correctional refeeding should be given alternatingly from F
75 to F 100 in the transitional phase
Rehabilitation Phase- Energy: 150-220 kkal/kgBW/day- Protein: 4-6 g/kgBW/day- Family food
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Ten Principal Steps:9. Stimulation
- Interaction to other children- Structured game designed for suitable age- Love and care from parents- Motor and language skills
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Ten Principal Steps:10. Discharge
Treatment Evaluation:
• If weight gain is less than 5 gr/kgBW/day, the child should be reassesed
• If weight gain is between 5 to 10 gr/kgBW/day, an undetected infection should be suspected
• If weight gain is more than 10 gr/kgBW/day, then the therapeutic program has reached its target.
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Ten Principal Steps:10. Discharge
Discharge Criteria:
1.BW/BL has no longer been below 70%2.Edema, vomitting and diarrhea are no longer
present3.Normal body temprature4.Adequate weight gain5.Patient can eat the whole diet prepared6.General condition improvement, skill and
motoric development are suitable to age
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SEVERE MALNUTRITION
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CM, Female, 14 year old, with the body weight and body height of 25 Kg and 144 cm respectively, was admitted to the non infectious unit of Haji Adam Malik General Hospital on June, 4th 2011 with the main complaint bulging of the lower abdomen for the last 3 months before admission. The bulging was previously 7 x 8 cm in size, and getting bigger day by day until now it has already been approximately 15 x 16 cm in size, immobile, soft in consistency and smooth surface, and well marginated with pain on palpation.
Interrupted flow of micturition (+) for the last 3 months, with micturition frequency was more than 6 times a day, volume less then 50 – 60 cc each time. Previously, the urine was transparent yellowish in colour, but for the last 2 weeks, she complained that the urine colour had been yellowish to brown. History of flank pain while urinating (-), no stones. Defecation (+) normal.
`
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Pallor (+) during the last 3 months, without any previous history of reccurent pale. History of bleeding (-).
Weight loss for as much as 6 kg in the past 3 months. This problem has actually been occuring since 2 years ago, and was getting worse for the last 3 months. Loss of appetite (+) for as long as 3 months, but previously eating poorly was found since the patient was 6 years old, and she had never eaten more than half of the food served for her. Fever (-), cough (-), night sweating (-), history of contact to tuberculosis patient (-).
Leg swelling (+) for the last 2 weeks, both in the right and the left one. Previous history of swollen leg was denied. Pain on palpation (-).
Menstruation delay (+) for the last 3 months. This patient got menarche on 13 years old and got menstruation regularly before. The duration of menstruation was 7 days per month.
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• She was born spontaneously, aided by midwife, with birth body weight was 3500 grams and body length was 50 cm, crying spontaneously, with APGAR score was not recorded. There was no pregnancy complication for both mother, nor child. History of immunization was incomplete. • Feeding history: within the normal limit, • History of growth and development: within the
normal limit • History of previous illness and medications :
unclear
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PHYSICAL EXAMINATIONGeneralized status
BW: 25 kg, BL: 144 cm, Upper arm circumference: 16 cm, Head circumference: 57 cmBW/BL : 78,13% (moderate malnutrition)BW/age : 49,02% (severe malnutrition)BL/age : 88,9% (normoheight)
Presens status
CM, Body temperature: 37,2oC. Anemic (+). Icteric (-). Cyanosis (-). Edema (+). Dyspnea (-). Thristy and drink eagerly was not found.
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LABORATORY RESULT
Parameters Value Normal Value
Hemoglobin 4,76 gr% 12,0 – 14,4 gr%
Hematocrite 14,9 % 38 – 44%
Erithrocyte 1,82 x 106 /mm3 4,2 – 4,87 x 106 /mm3
Leucocyte 3530 /mm3 4500 – 11000 /mm3
Platelet 226.000 /mm3 150000 – 450000 /mm3
MCV 82 fl 85 – 95 fl
MCH 26,2 pg 28 – 32 pg
MCHC 32 gr% 33 – 35 gr%
RDW 16,6 % 11,6 – 14,8 %
Diftel 0 / 0 / 78 / 9 / 13
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WORKING DIAGNOSIS
Suspect Tumor Abdomen e.c dd/ - Wilms Tumor- Neuroblastoma
Severe Malnutrition Marasmic - Khwarsiorkor Type
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TREATMENT• Bedrest, threeway and urinary catheter inserted• IVFD D5% NaCl 0,45% 20 gtt/i micro• Diet Formula 75 280 cc / 2 hours (stabilization phase)• Multivitamin without Fe 1 x cth II• Folic acid tab 1 x 5 mg• Cotrimoxazole tab 2 x 480 mg• Vitamin A 1 x 200.000 IU• Packed red cell transfusion 75 cc / 12 hours
Needed: 4 x ( 11-4,76 ) x 25 kg = 624 ccTransfusion ability: 3cc x 25 kg = 75 cc
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DIAGNOSTIC PLANNING
• Complete blood count post transfusion • Liver Function Test and Renal Function Test• Serum Electrolytes, Serum Albumin• Blood Glucose ad random• Abdominal CT Scan• Urinalysis• Fluid Balance per 6 hours
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SEVERE MALNUTRITION
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June 5th-7th, 2011
S Bulging of the lower abdomen (+), Pallor (+), Abdominal pain (-)
O Sens: CM, Temp: 36,7 – 36,9oC. Anemic (+), Edema (+). BW: 25 kg, BL: 144 cm. UOP: 3,4 – 6,1 cc/kg/hour, Urine colour : yelowish to brownIn the abdomen: Bulging (+) in regio hypogastrium, 8 x 9 cm in size, immobile, soft and well marginated. Pain on palpation (-)
Laboratory Findings: SGOT: 11 U/L Na: 131 mEq/L Ureum: 64,50 mg/dlSGPT: 3 U/L K: 3,9 mEq/L Kreatinin: 2,32 mg/dlAlbumin: 2,7 gr/dl Cl : 113 mEq/L Dipstick urine:Leu / Nit / Uro / Protein / pH / Blood / SG / Ket / Bil / Glu+2 / + / - / + / 6,5 / +3 / 1,01/ - / - / -
A Suspect Tumor Abdomen e.c dd/ - Wilms Tumor + Severe Malnutrition Marasmic- - Neuroblastoma Kwarshiorkor Type
P Management:Bedrest, threeway and urinary catheter insertedIVFD D5% NaCl 0,45% 20 gtt/i microDiet Formula 75 270 cc / 2 hours (stabilization phase)Multivitamin without Fe 1 x cth IICotrimoxazole tab 2 x 480 mgTransfusion PRC 75 cc / 12 hoursFolic acid 1 mg/day (the following day) Vitamin A was no longer given (no deficiency sign found)
Diagnostic Planning:Complete blood count post transfusion Abdominal CT ScanUrinalysis
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June 8th-11th, 2011
S Bulging of the lower abdomen (-). Pallor (-). Abdominal pain (-).The patient ate the whole diet provided.
O Sens: CM, Temp: 37,0 – 37,6oC. Anemic (-), Edema (-). BW: 25 kg, BL: 144 cm. UOP: 3,4 – 5,5 cc/kg/hour, Urine colour : yelowish to brownIn the abdomen: Bulging was not found after urinary catheter insertion.
Laboratory Findings:Hb: 13,5 gr% WBC: 10470/ mm3 MCV : 76,6 flHt: 39,5 % PLT: 263000/ mm3 MCH : 26,2 pgRBC: 5,16 x 106 / mm3 RDW: 19,6% MCHC : 34,2 gr% LED : 14 mm/hours Dipstick urine:Leu / Nit / Uro / Protein / pH / Blood / SG / Ket / Bil / Glu+ / - / 0,2 / ± / 5 / +3 / 1,01/ - / - / -
A Hydronephrosis bilateral e.c (?) + severe malnutrition marasmic khwarsiorkor type + suspect urinary tract infection
P Management: Bedrest, threeway and urinary catheter insertedIVFD D5% NaCl 0,45% 20 gtt/i microDiet Formula 75 270 cc / 2 hours (stabilization phase)Multivitamin without Fe 1 x cth IIFolic acid 1x1 mgInjection Ceftriaxone 1 gr / 12 hoursCotrimoxazole tab 2 x 480 mg
Diagnostic Planning:Abdominal CT ScanUrinalysis and urine culture + sensitivity test
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June 12th-18th, 2011
S Fever (+). Bulging of the lower abdomen (-). Pallor (-). Abdominal pain (-).
O Sens: CM, Temp: 37,3 – 38,1oC. Anemic (-), Edema (-). BW: 25 kg, BL: 144 cm. (BW/A: 50,9) UOP: 2-3,1cc/kg/hour, Urine colour : transparent yellowishIn the abdomen: Bulging was not found after urinary catheter insertion.
CT Scan Reports:No mass in the abdomen could be identifiedThere is a hyperthrophy of the urinary bladder wallMuscle hypertrophy due to urinary retention should be suspected. Suggestion: Cystoscopy
Urine Culture:Pseudomonas aeruginosa was found, with concentration more than 105 CFU/mlSensitive to Meropenem
Dipstick urine:Leu / Nit / Uro / Protein / pH / Blood / SG / Ket / Bil / Glu+ / - / - / + / 5 / +3 / 1,01/ - / - / -
A Hydronephrosis bilateral e.c. Retensio Urine + Severe Malnutrition Marasmic – Khwarsiorkor type + Urinary Tract Infection
P Management:Bedrest, threeway and urinary catheter insertedIVFD D5% NaCl 0,45% 20 gtt/i microDiet Formula 100 470 cc / 3 hours (transition phase)Injection Meropenam 250 mg / 8 jamMultivitamin without Fe 1 x cth IIFolic acid 1x1 mg/day
Planning:Urinalysis
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SEVERE MALNUTRITION
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Loss of appetite since 3 months,pallor, weight loss, old man face, thinning of subcutaneous fat, muscle
hypotrophy, prominent ribs, edema dorsum pedis,
Antropomethric measurement: BW/BL below 70% with edeme presents
Dx: SEVERE MALNUTRITION Marasmus-Khwarsiorkor
IVFD D5% NaCl 0,45%, Diet Formula 75, Multivitamin, Antibiotic, Transfussion PRC
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AMENORRHEA and MALNUTRITION
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STABILIZATION PHASE
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STABILIZATION PHASE
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STABILIZATION PHASE
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TRANSITIONAL PHASE
Formula 75
Formula 100
Formula 135
Low calorieLow lactose
Frequent Frequency
Higher CalorieEvaluate toleranceEvaluate appetite
Family Food
Given in the rehabilitation phase only after weight gain is adequate
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TREATMENT EVALUATION
INADEQUATE WEIGHT GAIN(below 5 gr/kg/day)
WHY??
Reanamnesis: Pain while urinatingLaboratory findings: Leukosituria, Nitrate in urine (+)Urine Culture: Pseudomonas aeruginosa
Urinary tract infection as a COMORBID Treat based on sensitivity MEROPENEM
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Terima
KasihKapkun Kha Gracia
Xie xie SyukranArigato Gozaimasu
Mercie