Kwashiorkor

1. Presenters: Kasturi Mahalinggam ( 060100293) Siti Raihana (060100246) Supervisor: dr. Oke Rina Ramayani Sp.A KWASHIORKOR

2. Definition of Kwashiorkor "Kwashiorkor" is the name given to the protein-calorie malnutrition. It is a Ga word which describes the malnourished child, the result of the ill-health which develops when an infant is weaned from breast-feeding (which may be at about 2 years of age). When a sibling is born and monopolizes breast feeding, the "weaning" or deposed child may develop kwashiorkor, an all-embracing word for the clinical syndrome of malnourishment in which reddening of the child's hair is but a part.

3. EPIDEMIOLOGY … Close to 50 million children younger than 5 years have PEM Approximately 80% of these malnourished children live in Asia , 15% in Africa, and 5% in Latin America. MORTALITY/MORBIDITY … Five million children younger than 5 years die every year of malnutrition. 70 million present with wasting , and 230 million present with some stunting

4. Causes Social and Economic Poverty Ignorance Inadequate weaning practices Child abuse Cultural and social practices Vegan Low fat diets

5. Sign & Symptom

6. Pathophysiology Peripheral oedema Recent studies show that children in kwashiorkor have abnormal renal architecture that can be explained by loss of glycoseaminoglycans and they lose glycosaminoglycans from the intestine (particularly heparan sulphate proteoglycan ); the loss of the ability of glycosaminoglycans to retain water in the form of a gel, may cause the appearance of pitting oedema .

7. Fatty Liver It was further suggested that the impaired synthesis of VLDL- apo B-100 was due to a shortage of amino acids because of the chronically inadequate dietary protein intake of children with severe malnutrition. therefore unused lipids which would normally participate in lipoprotein synthesis begin to accumulate.

8. Distended abdomen Fat inside the liver can damage the liver cells, leading to what is known as fatty liver disease. When the liver cells are damaged, the immune system of the body respond to this damage and causes inflammation inside the liver which will cause the liver to enlarge in size. This is then known as Steatohepatitis . Damage to the liver cells or the liver cells dying off can decrease the functions the liver is able to do to keep the body well. One of these functions is to produce proteins. Therefore, it also leads to a decrease in albumin levels, which leads to this build up of abdominal fluid.

9. TREATMENT… 10 steps for routine management of children with malnutrition Prevent and treat the following: Hypoglycemia Hypothermia Dehydration Electrolyte imbalance Infection Micronutrient deficiencies Provide special feeds for the following: Initial stabilization Catch-up growth Provide loving care and stimulation Prepare for follow-up after discharge

10. Case Report MF, was admitted to RSUP HAM on April 13 th 2010 at 1500. 1 year old BW : 9.8 kg height : 70 cm Complaint : Oedem at the body with dermatosis mostly at lower extremities and some part of his body experience for the last 2 weeks. At first, oedem start at his face  genital  all of his body. Fever in last 2 days. Cough (-), flu (-). H istory of oedem (-) Defecation and urination : Normal. History of delivery ; spontaneous, aided by midwife, BW : 2800 gram, BL : unknown , crying, cyanosis (-). History of immunization : complete, BCG scar (+). History of feeding ; 0- week 1 : breast milk, week 1 – 2 month : SGM 30 cc, 6-7 times/day. 2 month-7 month : SGM + Promina. 7 month- 13 month : porridge 3 times/day volume half bowl. 13 month till now : rice. History of disease : (-)  

11. Physical Examination : Head Eye : Light reflexes (+/+), isochoric pupil, pale inferior conjunctive palpebra (-/-). Oedem palpebra (+). Face : Oedem Ear/Nose/Mouth : Normal Neck : Lymph node enlargement (-), deformation (+). Chest SF, retraction (-) Abdominal Soepel , peristaltic (+) N, Liver : palpable 2cm under the right arcus costa , sharp edge and smooth surface. Extremities Pulse : 120 bpm , regular, normal tone and volume Pitting oedem (+) at 4 extremities Genital Boy, Oedem scrotum (+), crazy pavement (+) Working Diagnosis Severe malnutrition kwashiorkor type.

12. Treatment Diet F75 125 cc/3 hours/oral. Zinc 1x20mg. Folic acid 1x1 mg Multivitamin without Ferum 1x1 Vitamin A 200000 IU

13. Follow : April 14-18 th 2010 Complaint Oedem all over the body. Fever (-), cough (-), vomit (-). Head Eye : Light reflexes (+/+), isochoric pupil, pale inferior conjunctive palpebra (-/-). Face : Oedem Nose : Nasogastric tube (NGT) Neck : Lymph node enlargement (-), dermatosis (+) Chest SF, retraction (-) Abdominal Soepel , peristaltic (+) N, Liver : palpable 2cm under the right arcus costa , sharp edge and smooth surface. Extremities Pulse : 104 bpm , regular, normal tone and volume. Working Diagnosis Severe malnutrition kwashiorkor type. Treatment - Cotrimoxazol 2x120g - Inj. Gentamicin 30 mg/24hours/IV - Zinc 1x20mg. - Folic acid 1x1 mg - Vitamin A 1x200000 IV - Diet F75 125cc/3hours/NGT

14. Laboratory Result : (April 15 th 2010) Liver : Total Bilirubin : 0.41 mg/ dL (<1) Direct Bilirubin : 1.32 mg/ dL (0-0.2) Alkaline Phosphatase : 133 U/L (<449) SGOT/AST : 68 U/L (<38) SGPT/ALT :34 U/L (<41) Albumin : 1.4 g/dl (3.8-5.4)   Kidney : Ureum : 12 mg/ dL (<50) Creatine : 0.24 mg/ dL (0.17-0.42) Uric acid : 1.4 mg/ dL (<7.0)  

15. Hematology Hemoglobin : 9.36 g% (10.7-17.1) Erythrocyte : 3.55 10 6 /mm 3 (3.75-4.95) Leukocyte : 26.80 10 3 /mm 3 (6.0-17.5) Hematocryte : 28.40 % (38-52) Thrombocyte : 129 10 3 /mm 3 (217-497) Neutrophil : 28.50 % (37-80) Lymphocyte : 63.50 % (20-40) Monocyte : 6.41 % (2-8) Eosinophil : 0.19 (1-6) Basophil : 1.41 % (0-1) Neutrophil Absolute : 7.36 10 3 /µL (1.9-5.4) Lymphocyte Absolute : 17 10 3 /µL (3.7-10.7) Monocyte Absolute : 1.72 10 3 /µL (0.3-0.8) Eosinophil Absolute : 0.050 10 3 /µL (0.2-0.5) Basophil Absolute : 0.377 10 3 /µL (0-0.1)

16. Follow : April 19 & 21-23 th 2010 Complaint Oedem all over the body. Fever (+) 38⁰C , cough (-), vomit (-). Head Eye : Light reflexes (+/+), isochoric pupil, pale inferior conjunctive palpebra (-/-). Face : Oedem Nose : Nasogastric tube (NGT) Neck : Lymph node enlargement (-), dermatosis (+) Chest SF, retraction (-) Abdominal Soepel , peristaltic (+) N, Liver : palpable 2cm under the right arcus costa , sharp edge and smooth surface. Extremities Pulse : 125 bpm , regular, normal tone and volume. Working Diagnosis Severe malnutrition kwashiorkor type.

17. Treatment Inj. Amoxicillin 3x150mg Inj. Gentamycin 80 mg/24hours/IV Zinc 1x20mg. Folic acid 1x1 mg - Diet F75 125cc/3hours/NGT Multivitamin without Ferum 1 tsp/day. Paracetamol syr 3 tsp CTM 1x1mg Miconazole cream - Compress NaCl 0.9 % (10-15 min, 3x/day)

18. Follow : April 20 th 2010 Complaint Oedem all over the body. Fever (+) 38⁰C , cough (-), vomit (+), diarrhea (+) Head Eye : Light reflexes (+/+), isochoric pupil, pale inferior conjunctive palpebra (-/-). Face : Oedem Nose : Nasogastric tube (NGT) Neck : Lymph node enlargement (-), dermatosis (+) Chest SF, retraction (-) Abdominal Soepel , peristaltic (+) N, Liver : palpable 2cm under the right arcus costa , sharp edge and smooth surface. Extremities Pulse : 130 bpm , regular, normal tone and volume. Working Diagnosis Severe malnutrition kwashiorkor type.

19. Treatment Inj. Amoxicillin 3x150mg Inj. Gentamycin 80 mg/24hours/IV Zinc 1x20mg. Folic acid 1x1 mg - Diet F75 125cc/3hours/NGT Multivitamin without Ferum 1 tsp/day. Paracetamol syr 3 tsp Resomal 50cc (when diarrhea)

20. Follow : April 24 th - Mei 2 nd 2010 Complaint Oedem all over the body. Fever (-), cough (-), vomit (-). Head Eye : Light reflexes (+/+), isochoric pupil, pale inferior conjunctive palpebra (-/-). Face : Oedem Nose : Nasogastric tube (NGT) Neck : Lymph node enlargement (-), dermatosis (+) Chest SF, retraction (-) Abdominal Soepel , peristaltic (+) N, Liver : palpable 2cm under the right arcus costa , sharp edge and smooth surface. Extremities Pulse : 104 bpm , regular, normal tone and volume. Working Diagnosis Severe malnutrition kwashiorkor type. Treatment - Zinc 1x20mg. - Folic acid 1x1 mg - Diet F135 200cc/4hours/NGT Multivitamin without Ferum 1 tsp/day. Miconazole cream

21. Follow : Mei 3 – 5 th 2010 Complaint Oedem all over the body. Fever (-), cough (-), vomit (-). Head Eye : Light reflexes (+/+), isochoric pupil, pale inferior conjunctive palpebra (-/-). Face : Oedem Nose : Nasogastric tube (NGT) Neck : Lymph node enlargement (-), dermatosis (+) Chest SF, retraction (-) Abdominal Soepel , peristaltic (+) N, Liver : palpable 2cm under the right arcus costa , sharp edge and smooth surface. Extremities Pulse : 104 bpm , regular, normal tone and volume. Working Diagnosis Severe malnutrition kwashiorkor type. Treatment - Diet F135 200cc/4hours/NGT - Multivitamin without Ferum 1 tsp/day. - Miconazole cream

22. DISCUSSION

23. Theory Case Protein energy malnutrition Protein malnutrition characterized by low level of Albumin : 1.4 g/dl (3.8-5.4) Characterized by edema , irritability, anorexia , ulcerating dermatosis , and an enlarged liver with fatty infiltrates also thinning hair Edema, dermatosis , enlarged liver, thinning hair In at-risk populations, kwashiorkor may develop after a mother weans her child from breast milk and replaces the diet with foods high in starches and carbohydrates and deficient in protein. 0- week 1 : breast milk

24. SUMMARY It has been reported that an 1 year old baby boy with his chief complaint of oedem all over his body. He has been diagnosed with severe malnutrition kwashiorkor type based on the history taking, physical examinations and laboratory results.

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