MALNUTRITION IN CHILDREN and adults.pptx

Malnutrition in children

1. Malnutrition Dr. M. Senthil kumar MD( Paed )., Professor of Paediatric Dept, Govt Coimbatore Medical College Hospital, Coimbatore

2. MALNUTRITION WHO definition Cellular imbalance between the supply of nutrients and energy & the body’s demand for them to ensure growth, maintenance and specific functions.

3. Spectrum of Malnutrition Undernutrition Overnutrition Malnutrition

4. Overnutrition Overweight = >23rd of adult equivalent Obesity = >27th of adult equivalent

5. HISTORY History suggestive of macronutrient deficiency like failure to thrive,loss of weight,failure to gain weight,edema . History suggestive of micronutrient deficiencies such as VITAMIN A deficiency : night blindness VITAMIN B deficiency : chelitis , angular stomatitis, glossitis,aphthous ulcer. VITAMIN C deficiency : bleeding gums,bony deformities,delayed dentition. Iron deficiency : progressive pallor,pica Electrolyte disturbances like sodium – seizures,irritability,lethargy . Potassium – hypotonia,abdominal distension. Calcium – seizures,tetany,stridor Zinc – skin ,hair changes/alopecia

6. CHELITIS GLOSSITIS ZINC DEFICIENCY SKIN CHANGES PALLOR

7. History pertaining to etiology History suggestive of chronic systemic illness like recurrent diarrhoea,recurrent pneumonia,congenital heart disease . Congenital anomalies – cleft palate GERD Worm infestation – bleeding manifestations. PAST HISTORY : Previous history of measles /previous admissions. DEVELOPMENT HISTORY : H/O isolated gross motor delay DIET HISTORY : Duration of Breast feeding Duration of complementary feeding .

8. ENERGY REQUIREMENT/EXPENDITURE ICMR 2020 REQUIREMENT CALORIE PROTEIN gm/d 0—6 months 550 8.1 6—12 months 670 10.5 1—3 yrs 1010 11.3 4---6 yrs 1360 15.9 7---9 yrs 1700 23.3 10—12 yrs boys 2220 31.8 girls 2060 32.8 EXPENDITURE BMR 50 ACTIVITY 25 GROWTH 12 FECAL LOSS 08 SDA 05

9. Anthropometric Measures - Interpretation Z Score Percentile +3 99th +2 97th +1 85th 50th -1 15th -2 3rd -3 1st

10. Current Acceptable Terminologies - WHO CUTOFF BETWEEN -1 AND +1 BETWEEN -1SD to -2SD WT For AGE Normal Mild underweight Wt For HEIGHT Normal Mild wasting BETWEEN -2 AND -3SD Moderate underweight HT For AGE Normal Moderate Stunting Mild Stunting Moderate wasting BELOW -3 SD Severe underweight Severe Stunting Severe wasting

11. WHO CLASSIFICATION WFA HFA WFH INTERPRETATION NORMAL NORMAL NORMAL NORMAL DECREASED NORMAL DECREASED ACUTE MALNUTRITION DECREASED DECREASED NORMAL CHRONIC MALNUTRITION DECREASED DECREASED DECREASED ACUTE ON CHRONIC MALNUTRITION

12. Acute Malnutrition SAM 6 - 59months SAM 1 - 5 months MAM 6 - 59 months Wt for Ht < -3SD and/or MUAC <11.5cm and/or Bilateral Pitting oedema without other known cause Wt for Length < -3SD and/or Visible wasting in infant with length <45cm and/or Bilateral Pitting oedema without other known cause Wt for Ht -2SD to -3SD and/or MUAC 11.5 to 12.4cm and No oedema

13. Clinical syndromes of undernutrition Marasmus Kwashiorkar Marasmic Kwashiorkar SAM - program settings

14. Marasmus Severe form of wasting Server MARASMUS is typical form of severe acute malnutrition (SAM ) C/F : 1. T hin ( skin & bones ) and has no fat 2.Loss of buccal pad of fat so face appearance called monkey facies 3. L oss of fat at buttocks called baggy pants appearance 4. Child is alert 5. No edema

15. Monkey facies Baggy pants appearance

16. Wasting Grading Grade I Grade II Grade III Axilla and Groin Buttocks and Thighs Chest and Abdomen Grade IV Buccal pad of fat

17. Kwashiorkar Fat sugar baby appearance Pitting edema Muscle wasting ( + ) , hypotonic Skin – pigmentation , desquamation , dyspigmentation and patechiae May present over abdomen Mucous membrane lesion – smooth tongue, cheilosis , angular Stomatitis are common , herpes simplex Stomatitis may also present

18. Hair – dyspigmentation , Curls , flag sign +
Mental change – unhappy , apathy , irritability, intermittent cry GI : anorexia, abdominal distension, stool low pH and contain unabsorbed sugars N utritional anemia CVS : circulatory insufficiency , prolonged circulatory time , bradycardia , diminished cardiac output, hypotension Renal : GFR and renal plasma flow rate diminished , Marasmic KWASHIORKOR – mixed form , edema occur , may or may not other signs of KWASHIORKOR signs present

19. Flag sign hair KWASHIORKOR CHILD

20. Oedema Grading Grade I Grade II Grade III Pedal oedema Facial oedema (+I) Paraspinal & Chest (+II) Grade IV Ascites(+III)

21. Management Assesment Categorize - SAM *with complication *without complication - MAM Decide - Home care --> SAM without complication/ MAM - Hospital care --> SAM with complication Act

22. SAM with complication Severe oedema Failed appetite test Presence of any general danger signs as per IMNCI Medical illness (severe Anaemia/Pneumonia/ Diarrhoea/ Failure)

23. Appetite Test An appetite test is done to children ages 6months to 5 years who have no medical complications in order to determine whether the child can eat the RUTF ( Plumpy Nut ) If a child fails the appetite test, it reflects a severe disturbance of the metabolism and this child needs to be treated as an in-patient. A poor appetite shows that the child has significant infection or a major metabolic abnormality such as Liver dysfunction, electrolyte imbalance,etc . such children with SAM are at immediate risk of death. If a child passes the appetite test, he/she should be treated as out-patient if OTP service is available

24. Criteria for Passing Appetite Test

25. WHO GUIDELINES FOR IN-PATIENT TREATMENT OF SEVERELY MALNOURISHED CHILDREN (SAM)

26. GENERAL PRINCIPLES FOR ROUTINE CARE These steps are accomplished in two phases: - an initial stabilization phase where the acute medical conditions are managed; and - a longer rehabilitation phase . Note the treatment procedures are similar for marasmus and kwashiorkar.

27. THE 10 STEPS

28. STEP 1. TREAT/PREVENT HYPOGLYCEMIA Blood sugar level <54mg/dl or 3mmol Assume hypoglycemia when levels cannot be determined conscious child- 50ml bolus of 10% glucose by nasogastric tube. unconscious child-lethargic or convulsing- IV sterile 10% glucose 5ml/kg , followed by 50ml of 10% glucose or sucrose by NG tube. Start two- hourly feeds day and night.

29. STEP 2. TREAT/PREVENT HYPOTHERMIA If axillary temperature < 35degree celcius , take rectal temperature. if the rectal temperature is < 35.5degree celcius(<95.9F) : - Rewarm the child: 2 layer clothes, cover with warmed blanket & place a heater or lamp nearby or put the child on the mother’s bare chest ( skin to skin ) and cover them- Kangaroo mother care - Feed straightaway

30. STEP 3. TREAT/PREVENT DEHYDRATION Difficult to estimate dehydration using clinical signs alone Assume all children with watery diarrhea may have dehydration Do not use the IV route for rehydration except in cases of shock continue feeding

31. ASSESMENT OF DEHYDRATION IN SAM Some signs --- unreliable Mental state Mouth, tongue and tears Skin turgor Urine output Edema and hypovolemia can coexist

32. DIAGNOSIS OF DEHYDRATION IN SAM CHILD History of diarrhea ( with large volume of stools) Increased thirst Recent sunken eyes Prolonged CFT, weak/absent radial pulse, decreased or absent urine flow Difficult using clinical signs alone Best to assume that all with watery diarrhea have some dehydration Treat with ORS unless shock is present

33. REHYDRATION SOLUTION FOR MALNUTRITION (ReSoMal) Standard WHO ORS WHO Reduced osmolarity ORS ReSoMal Sodium 90 75 45 Potassium 20 20 40 Glucose 111 75 125

34. COMPOSITION OF RESOMAL Ingredient Mass (g) mmol per 20 ml Potassium chloride (KCl) 224 24 Tripotassium citrate 81 2 Magnesium chloride (MgCl2.6H2O) 76 3 Zinc acetate (Zn acetate.2H2O) 8.2 0.3 Copper sulphate (CuSo4.5H2O) 1.4 0.045 to be added to diet or oral rehydration salts solution add 20 ml of the solution to a litre of diet or oral rehydration salts However appropriate vitamin mineral mix is not available in india. In this scenario, one may use combinations of various commercial preparations available

35. WHICH ORS SHOULD BE USED IN SEVERE MALNUTRITION? Options: Low osmolarity ORS with potassium supplements ReSoMal ( not available in india) IAP endorses the use of LOW OSMOLARITY WHO ORS for all types of diarrhea and nutritional status for logistics and programmatic advantages.

36. TREATMENT OF DEHYDRATION ONLY Rehydrate until the weight deficit (measurd or estimated) is corrected and then STOP- DO not give extra fluid to “prevent recurrence” C onscious Unconscious ReSoMal IV Fluid 5ml/kg/30min for first 2 hours Ringer lactate & 5% Dextrose at 15ml/kg for first hr & Reasses - if improving 15ml/kg 2nd hr - if conscious, NGT: ReSoMal - if not improving = Septic shock

37. Measure Weight Take Pre-management Weight Child with SAM and Diarrhea Gain M-ORS 5ml/kg every 30mins for 2 hours Loss Stable Improvement Signs of Overhydration Increase M-ORS by 5ml/kg/hr Re-assess after one hour Increase M-ORS by 10ml/kg/hr i.e. (20ml/kg/hr) Re-assess after one hour Continue M-ORS 5-10ml/kg every alternate hour with starter feed for upto 10 hours Stop all rehydration fluid Give starter diet Re-assess and revise diagnosis Shift to M-ORS 5-10ml/kg every alternate hour with starter feed for up to 10 hours Rehydration algorithm for SAM with diarrhea

38. STEP 4. CORRECT ELECTROLYTE IMBALANCE Plasma sodium may be low though body sodium is usually high sodium supplementation may increase mortality. Potassium and magnesium are usually deficient and needs supplementation; may take atleast two weeks to correct. Edema if present is partly due to these imbalances. Do NOT treat edema with a diuretic.

39. POTASSIUM In SAM children, there is too little potassium inside cells. All SAM children should be given potssium supplements (3-4 mmol/kg/day) for 2 weeks. Potassium chloride syrup is the most available medicine of which every 15ml contains 20mmol potassium. Give extra potassium daily for 2weeks Do not treat edema with diuretic since most diuretics increase loss of potassium and make electrolyte imbalance worse

40. MAGNESIUM in SAM children, there is too little magnesium inside cells. on 1st day 0.3ml/kg of 50% magnesium sulphate ( upto a maximum of 2ml) should be given IM once. After this from 2nd day onwards magnesium should be given orally ( 0.1ml/kg/day/0.4-0.6mmol/kg/day) X 2weeks. Give extra magnesium daily

41. STEP 5. TREAT/PREVENT INFECTION Usual signs of infection , such as fever are often absent. Give broad spectrum antibiotics to all. Hypoglycemia/ Hypothermia usually coexistent with infection. Hence if either is present assume infection is present as well No complications - Co-trimoxazole/Amoxicillin Severely ill - Ampicillin+ Gentamicin if the child fails to improve clinically within 48 hours, add; Cefotaxime/ceftriaxone as per Facility based - FIMNCI

42. STATUS ANTIBIOTICS infected child or complications* present IV Ampicillin 50mg/kg/dose q 6hourly and IV Gentamicin 2.5mg/kg/dose q 8hourly/once daily add IV Cloxacillin 100mg/kg/day q 6hourly if staphylococcal infection is suspected. for septic shock or No improvement or worsening in initial 48 hours Add third generation cephalosporins i.e.IV Cefotaxime 100mg/kg/day q 8hourly Meningitis IV Cefotaxime 200mg/kg/day IV q 6hourly with IV Amikacin 15mg/kg/day q 8hourly Dysentery Ciprofloxacin 30mg/kg/day in 2 divided doses. IV Ceftrioxone 50mg/kg/day in od or q 12 hourly if child is sick or has already received nalidixic acid

43. STEP 6. CORRECT MICRONUTRIENT DEFICIENCIES All severely malnourished children have Vitamin and Mineral deficiencies. Vitamin A orally on Day 1 Give daily - Multivitamin supplement - Folic acid 1mg/day (give 5mg on Day 1) - Zinc 2mg/kg/day - Iron 3mg/kg/day after first week

44. HOW TO CORRECT VITAMIN A DEFICIENCY? Vitamin A orally immediately on Day 1 unless there is definite evidence that a dose has been given in the last month or if bilateral edema < 6months-- 50,000 IU or 0.5 ml 6-12months-- 1,00,000 IU or 1ml >12months-- 2,00,000 IU or 2 ml (but <8kg then 1L IU) In edematous patient, give one dose edema has subsided Repeat dose on Day2 and Day14 if there is any sign of Xerophthalmia, as children can go blind very quickly - WITHIN HOURS!

45. HOW TO CORRECT ANAEMIA? Giving iron too early is dangerous because the blood may have too little protein to bind the iron and keep it safe. unbound iron can stimulate the growth of bacteria and make infections worse. start iron supplements in the catch- up/ Rehabilitation phase when there has been time for iron to be bound and antibiotics to reverse the infection.

46. HOW TO CORRECT ANAEMIA ? Cont.. Fe 3mg/kg body weight per day . If the anaemia is very severe ( i.e.Severe pallor of the palms of the hands) and there is a risk of heart failure, then treat with a very carefully administered small blood transfusion.

47. HOW TO CORRECT OTHER MICRONUTRIENT DEFICIENCY? To correct deficiecies of riboflavin, ascorbic acid, pyridoxine, thiamine and fat soluble vitamins- ADEK- give Multivitamin supplement ( without iron) Folic acid orally: on Day1 5mg and from 2nd day onwards 1mg/day daily in >6months old. Zinc: 2mg/kg/day Copper: 0.2-0.3mg/kg/day. continue giving nutritious mixed diet. **All these micronutrients may be available together in a premixed packet, ready to add to formula.

48. STEP 8. ACHIEVE CATCH-UP GROWTH Readiness to enter the rehabilitation phase is signaled by a RETURN OF APPETITE, usually about one week after admission. Do appetite test & plan phase II Recommended milk-based F-100 contains 100kcal & 2.9-3gm protein/100ml in rehabilitation phase vigourous approach to feeding is required to achieve very high intakes & rapid weight gain of >10gm gain/kg/day

49. TO CHANGE FROM STARTER TO CATCH-UP FORMULA Replace starter F-75 with the same amount of catch-up formula F-100 for 48hours then, Increase each successive feed by 10ml until some feed remains uneaten. The point when some remains unconsumed is likely to occur when intakes reach about 30ml/kg/feed (200ml/kg/day & 6gm/kg protein/day) Daily record weight & plot ( Tick sign may be seen in edematous SAM due to initial weight loss)

50. LOCALLY PREPARED PREPARATIONS F75 F100 Full cream milk-30ml/ Full cream milk-90ml/ 5g powder 15g powder 10gm sugar 5gm sugar 1/2 tsp MCT oil 1/2 tsp MCT oil water upto 100ml water upto 100ml 75-80 kcal and 1gm protein 100kcal and 3gm protein RUTF, 20gm=100ml of F100 F100 with skimmed milk 100gm=500cal and 15gm protein 10gmSM powder 10gm sugar + 1/2 tsp oil

51. STEP 9. PROVIDE SENSORY STIMULATION AND EMOTIONAL SUPPORT Delayed mental and behavioural development is present Provide: - Tender loving care - Cheerful, stimulating environment - Structured paly therapy 15-30min/day - Physical activity as soon as the child is well enough - Maternal involvement when possible (e.g comforting, feeding, bathing, play, skin to skin, eye to eye contact)

52. STEP 10. PREPARE FOR FOLLOW-UP AFTER RECOVERY Target weight for discharge: >15% of baseline weight A child who is 90% weight-for-length (equivalent to -1SD) can be considered to have recoverd Show parent or caretaker how to: - Feed frequently with energy- and nutrient-dense foods - Give structured play therapy Advice parent or caretaker to: - Bring child back for regular follow-up checks - Ensure booster immunization are given - Ensure Vitamin A is given every six months

53. Discharge criteria Weight gain > 15% from baseline weight Weight gain >5gm/kg/day for 3 consecutive days Edema has resolved Free from infections Eating 120-130cal/kg/day

54. Treatment failure Primary failure to respond: Failure to regain appetite by day 4 Failure to start losing edema by day 4 Presence of edema on day 10 Failure to gain weight at least 5gm/kg/day by day 10 Secondary failure to respond: Failure to gain weight at least 5gm/kg/day for 3 consecutive days during rehabilitation.

55. MAM 150kcal/kg/day Calories 3gm/kg/day Protein Frequent feeds- 7feeds/day Energy dense feeds like egg, oil, sugar… Amox 5days Minerals/ Vitamin supplementation Deworming.