Malnutrition in pediatrics

This presentation is about Malnutrition in Pediatrics; Epidemiology, Risk factors, etiology, Clinical Evaluation, plotting on Growth charts and Management are Covered.

1. MALNUTRITION Adrien MUGIMBAHO

2. Definition Malnutrition Deficiencies , excesses or imbalances in intake of energy/ nutrients. The term malnutrition covers 2 broad groups of conditions. Undernutrition stunting (low height for age), wasting (low weight for height), underweight (low weight for age) and micronutrient deficiencies or insufficiencies (a lack of important vitamins and minerals). Overnutrition

3. Epidemiology Rwanda: 38 % or 661,200 children under 5 years suffer from chronic malnutrition (stunting or low height-for-age) 37 % or 643,800 suffer from anemia Worldwide 52 million children under 5 years of age are wasted, 17 million are severely wasted and 155 million are stunted Around 45% of deaths among children under 5 years of age are linked to undernutrition

4. CHRONIC MALNUTRITION Diminished height (stunting ) P oor weight gain and D eficits in both lean body mass and adipose tissue. Other features include : reduced physical activity, mental apathy, and retarded psychomotor and mental development

5. ACUTE MALNUTRITION Marasmus Low weight-for-height and reduced MUAC Other physical examination findings may include : Head that appears large relative to the body, with staring eyes Emaciated and weak appearance. Bradycardia , hypotension, and hypothermia Thin , dry skin Shrunken arms, thighs, and buttocks with redundant skin folds caused by loss of subcutaneous fat Thin, sparse hair that is easily plucked

6. Kwashiorkor (edematous malnutrition) S ymmetric  peripheral pitting edema Apathetic , listless affect Rounded prominence of the cheeks ("moon-face ") Pursed appearance of the mouth Thin , dry, peeling skin hyperpigmentation and skin lesion( dermatitis)

7. Kwashiorkor con’t Dry, dull, hypopigmented hair that falls ( silky hair) Hepatomegaly (from fatty liver infiltrates ) Distended abdomen with dilated intestinal loops Bradycardia, hypotension, and hypothermia Despite generalized edema, most children have loose inner inguinal skin folds

8. SPECIFIC NUTRIENT DEFICIENCIES Vitamin A  deficiency corneal cloudiness, ulceration and xerosis Bitot spots Vitamin D deficiency Skeletal changes with beading of the ribs widening of the wrists bowed legs

9. Nutritional deficiency con’t Thiamine deficiency aphonia , peripheral neuropathy, nystagmus, ophthalmoplegia , cerebellar ataxia, confusion, or coma (dry beriberi), cardiomegaly and congestive heart failure (wet beriberi) Zinc deficiency  bullous dermatitis diarrhea

10. CLINICAL ASSESSMENT: Z-scores

11. CLINICAL ASSESSMENT: Z-scores

12. CLINICAL ASSESSMENT: Z-scores

13. CLINICAL ASSESSMENT: Z-scores

14. CLINICAL ASSESSMENT: Z-scores boys 0 to 2 years old Linear Growth Z-score >-2: No stunting Z-score >-3 and ≤-2: Moderate stunting Z-score ≤-3: Severe stunting Z-score >-2: No wasting Z-score >-3 and ≤-2 : Moderate wasting Z-score ≤-3: Severe wasting Weight for Length girls 0 to 2 years old Stunting Wasting Z-score >-2: No stunting Z-score >-3 and ≤-2: Moderate stunting Z-score ≤-3: Severe stunting Z-score >-2: No wasting Z-score >-3 and ≤-2: Moderate wasting Z-score ≤-3: Severe wasting

15. Mid-upper arm circumference ●Age 6 to 24 months – Severe wasting <120 mm; moderate wasting <125 mm ●Age 25 to 36 months – Severe wasting <125 mm; moderate wasting <135 mm ●Age 37 to 60 months – Severe wasting <135 mm; moderate wasting <140 mm

16. Diagnostic criteria Children 6 through 59 months Severe acute malnutrition : MUAC <115 mm,  or Weight-for-length Z-score <-3,  or Bilateral pitting edema Moderate acute malnutrition : MUAC 115 to 124 mm,  or Weight-for-length Z-score -2 to -3 Stunting  (indicates chronic malnutrition): Moderate stunting – Height or length Z-score -2 to -3 Severe stunting – Height or length Z-score <-3

17. Diagnostic criteria Cont’d Infants <6 months : same weight and height criteria for older infants and children the presence of bilateral pitting edema ) Children 5 years and older :  body mass index (BMI)-for-age Z-scores or MUAC-for-age Z-score -2 for moderate malnutrition and - 3 for severe malnutrition

18. Management uncomplicated severe acute malnutrition T reated as outpatients, provided that the child has a good appetite and no obvious acute infection or other medical complication Ready-to-use therapeutic food (RUTF), Regular follow-up at home or in decentralized health center RUTF at a dose of approximately 175 kcal (733 J)/ kg/day Should be fed in frequent, small feedings throughout the day, as driven by the child's appetite Should be considered a medication for this specific medical condition ( ie , SAM) and is not to be shared with others. RUTF should be the  only  food offered to the child; breast milk and water are the only other items the child should ingest during treatment. Antibiotics amoxicillin 40 to 45 mg/kg twice daily, or  cefdinir  7 mg/kg twice daily

19. Management Cont’d Discharge from treatment  — Children 6 to 59 months of age may be discharged from treatment when they meet  either  of the following anthropometric criteria : Weight-for-height Z-score ≥-2 and no edema for at least one to two weeks, or MUAC ≥12.5 cm and no edema for at least one to two weeks

20. Management Cont’d 2. Complicated severe acute malnutrition Initial stabilization Rehabilitation Follow-up

21. Steps 1 and 2 Prevent/treat HYPOGLYCEMIA Prevent/treat HYPOTHERMIA KEY is frequent feeding – every two hrs night/day Skin to skin contact with parent, warm lamp, warm blanket, avoid exposure

22. STEP 3 Give ReSoMaL or comparable oral solution. 5 ml/kg every 30 min for two hours 5-10 ml/kg/h for next 4-10 hours Do not use the IV route except in shock, Feed through diarrhea ( 50-100 ml after each watery stool) continue breast feeding Treat/prevent dehydration

23. STEP 4 child with severe acute malnutrition has: Excessive sodium Low potassium Low magnesium So they need low sodium diet and fluid Remember : Two weeks minimum to correct Do NOT use a diuretic to treat edema CORRECT ELECTROLYTE IMBALANCES

24. STEP 5 U sual signs of infection usually hidden Give to ALL severely malnourished children broad-spectrum antibiotic measles vaccine to all children > 6 months. Vitamin A ( if eye symptoms present) Mebendazole 100 mg BID x 3 days(after 7 day) TREAT INFECTION

25. STEP 6 All severely malnourished children have vitamin and mineral deficiencies. Recommended: Zinc, copper and MV daily Vitamin A and folic acid on Day 1 Do NOT give iron until the child has a good appetite and starts gaining weight (usually during the second week of treatment). CORRECT MICRONUTRIENT DEFICIENCIES

26. STEP 7 Cautious Feeding small , frequent feeds of low osmolality and low lactose May include electrolyte/mineral solution Day 1 – 7 Low in protein and iron, high in energy

27. Feeding protocols During stabilization phase : Start F75 100ml/kg/day divided in every 2 to 3 hours Or 130 ml/Kg/day if no edema divided in every 2 to 3 hours Monitor if vomiting and diarrhea Weigh the child every day ( the child would loose weight when edema are resolving.

28. Feeding protocol con’t If edema are resolved and the child has appetite. Start F100, at the last volume of F75 divided in every 3 to 4 hours Check recurrence of edema and rapid weight gain If the child is not tolerating F100 or edema reoccur you may go back to F75 Once the child tolerate F100, the solid food /RUTF may be introduced

29. C atch-up growth Second week change from starter to catch-up formula Advance to 200 ml/kg/day div q 3 to 4 hours Advance to local foods – peanut butter, beans, margarine – energy dense local foods Monitor progress after the transition by assessing the rate of weight gain Step 8

30. STEP 9 In severe malnutrition there is delayed mental and behavioural development . Provide : • tender loving care • a cheerful, stimulating environment • structured play therapy 15-30 min/d • physical activity as soon as the child is well enough • maternal involvement when possible (e.g. comforting, feeding, bathing, play) 90% expected weight for height ready for discharge Stimulation, Play and Loving Care

31. Step 10 Preparation for Discharge Nutritional education Show parent or carer how to: • feed frequently with energy- and nutrient-dense foods • give structured play therapy Advise parent or carer to: • bring child back for regular follow-up checks • ensure booster immunizations are given • ensure vitamin A is given every six months

32. References Phillips SM, Jensen C, Editor S, Motil KJ, Editor D, Hoppin AG. Micronutrient deficiencies associated with malnutrition in children Micronutrient deficiencies associated with malnutrition in children. 2013;1(table 1):1–15. Praveen S Goday M. Malnutrition in children in resource-limited countries: Clinical assessment - UpToDate . UpToDate [Internet]. 2019;5. Available from: https://www.uptodate.com/contents/malnutrition-in-children-in-resource-limited-countries-clinical-assessment%0Ahttps://www.uptodate.com/contents/malnutrition-in-children-in-resource-limited-countries-clinical-assessment/print WHO. Girls z-scores. 2006;15. Available from: http://www.who.int/childgrowth/standards/LFA_girls_0_13_percentiles.pdf%5Cnpapers2://publication/uuid/8A8286DD-5E8A-4952-AAFF-8A0275597782 WHO. WHO | Chart catalogue. Who. 2010. Ashworth A, Schofield C. Book Review: Guidelines for the Inpatient Treatment of Severely Malnourished Children. Food Nutr Bull. 2005;26(2):245–245. Goday P. Malnutrition in children in resource-limited countries: Clinical assessment - UpToDate [Internet]. UpToDate . 2019. Available from: https://ezproxy.ufm.edu:2053/contents/malnutrition-in-children-in-resource-limited-countries-clinical-assessment?search=malnutrition in children&source = search_result&selectedTitle =1~150&usage_type= default&display_rank =1

33. References USAID. Rwanda : Nutrition Profile. American [Internet]. 2014;(June):7–10. Available from: https://www.usaid.gov/sites/default/files/documents/1864/Rwanda-Nutrition-Profile-Mar2018-508.pdf Trehan I, Manary M. Management of complicated severe acute malnutrition in children in resource-limited countries. UpToDate.com [Internet]. 2017;1–22. Available from: https://0-www.uptodate.com.innopac.wits.ac.za/contents/management-of-complicated-severe-acute-malnutrition-in-children-in-resource-limited-countries?source=search_result&search=severe malnutrition&selectedTitle =1~150 Trehan I, Manary M. Management of complicated severe acute malnutrition in children in resource-limited countries [Internet]. UpToDate.com. 2017. p. 1–22. Available from: https://0-www.uptodate.com.innopac.wits.ac.za/contents/management-of-complicated-severe-acute-malnutrition-in-children-in-resource-limited-countries?source=search_result&search=severe malnutrition&selectedTitle =1~150 Airlines S. 済無No Title No Title. J Chem Inf Model. 2013;53(9):1689–99.