Nutritional assessment in pediatrics in an overwhelming topic for doctors

How to assess malnutrition in pediatrics using different methods

1. Nutritional assessment and Anthropometric measurement, Severe Acute Malnutrition Dr Abebe Y. (MD, Assistant Professor of Pediatrics and Child Health) April,2024 1

2. OUTLINES Introduction Definition Epidemiology of SAM Physiology of a SAM patient Nutritional Assessment Anthropometric measurement Medical Complications and its management Nutritional management 2

3. INTRODUCTION Nutrition is the body’s process of taking food; using it for growth, reproduction, immunity, breathing, work, and health; and storing nutrients and energy in appropriate parts of the body. 3

4. Introduction… The nutrients that provide energy intake in the child's diet are : Fats -- (9 kcal/g) Carbohydrates-- (4 kcal/g) Proteins -- ( 4 kcal/g) 4

5. INTRODUCTION…. Malnutrition: condition caused by excess or deficient food energy or nutrient intake or by imbalance of nutrients It is classified into Under and Over nutrition Under Nutrition: Primary vs Secondary malnutrition Acute vs chronic malnutrition Deficiencies of essential vitamins, amino acids and minerals Causes of undernutrition Immediate, Underlying and Basic causes 5

6. Severe Acute Malnutrition Definition: Severe acute malnutrition is defined as severe wasting and/or bilateral pitting edema Epidemiology Ethiopia Based on the 2019 EDHS 7% of children under five are wasted and 1% of these severely wasted Children with SAM have a nine-fold risk of mortality compared to well-nourished children 6

7. Types of malnutrition Based on nutrition Over nutrition Under nutrition Macronutrients Micronutrients Based on Duration Acute malnutrition Chronic malnutrition ABENEZER FOR BLEN , FOREVER 7

8. Based on the Origin Primary malnutrition Cause :- Inadequate food intake Onset :- usually Gradual Clinical characteristics :- Protein &/or Energy deficit predominates Secondary malnutrition Cause Other diseases that lead to low food ingestion, Inadequate nutrient absorption or utilization, Increased nutritional requirements, and/or Increased nutrient losses . Onset :- relatively fast Clinical characteristics :- specific to vitamin, mineral, or disease ABENEZER FOR BLEN , FOREVER 8

9. Malnutrition …. Wasting ;- Acute WFH MUAC Stunting ;- Chronic Reversible Irreversible Under Wt ;- composite indicator , Not specific Acute malnutrition present as;- SEVERE MODERATE 9

10. Causes of Malnutrition Immediate Causes: Inadequate dietary intake and repeated infectious diseases Underlying Causes: Food insecurity; Defective maternal and child caring practices;and Unsafe water ,poor sanitation,and inadequate health services. Basic Causes: limited education,poverty,and marginalization(the act of treating someone as if not important).. (UNICEF Programme guidance document,2015) 10

11. Factors Causing Malnutrition Biologic Factors Maternal malnutrition Before, during pregnancy or After pregnancy Infectious diseases N.B:- as precipitating factors Eg :- Diarrheal disease, measles, IP ,.. etc Result in negative protein and energy balance Diets low concentrations of proteins and energy, over diluted milk formulas or bulky vegetable foods ( Excessive Juice food ) 11

12. B. Age of the Host All age groups More among infants & young children Dependent age groups for food Susceptible for infections Under 1yr  Marasmus After 18 months  Kwashiorkor Older children copes better  mild Malnutrition 12

13. C. Social and Economic Factors: - Poverty low food availability Ignorance , poor infant- and child-rearing practices, misconceptions of use of certain foods, Practice And Duration Of Breast-feeding , Longer period of breast feeding Inappropriate/ inadequate weaning Social problems such as child abuse, maternal deprivation, & alcoholism, and drug addiction Cultural and social practices that impose Food taboos , migration from traditional rural settings to urban slums . 13

14. D. Environmental Factors Overcrowded and/or unsanitary living conditions Agricultural patterns, Droughts, & floods, Wars, & forced migrations 14

15. …. The most common mechanisms for illness-related causes of insufficient growth include failure to ingest sufficient calories, or starvation (e.g., cardiac failure, fluid restriction), (2) increased nutrient losses (e.g., protein-losing enteropathy chronic diarrhea), (3) increased metabolic demands, as seen in extensive burn injuries, and (4) altered nutrient absorption or utilization (e.g., cystic fibrosis, short bowel syndrome). More than one mechanism can exist simultaneously . 15

16. Physiology of a child with SAM Reductive Adaptation: When a child’s intake is insufficient to meet daily needs , physiologic and metabolic changes take place in an orderly progression to conserve energy and prolong life Reductive Adaptation It affects all body organs e.g. liver, kidney, heart, GIS, electrolyte, Immunity, micronutrients … etc Energy is conserved by reducing Physical activity and growth, Basal metabolism and the functional reserve of organs, and Inflammatory and immune responses 16

17. PATHOPHYSIOLOGY … Liver: reduced protein synthesis, reduced metabolism and excretion of toxins, lower energy production & reduced gluconeogenesis. Kidneys: Are less able to excrete excess fluid and sodium Heart: Cardiac output and stroke volume are reduced Blood pressure is low Renal perfusion and circulation time are reduced 17

18. PATHOPHYSIOLOGY … Skin, Muscles and Glands: The skin and subcutaneous fat are atrophied  loose folds of skin Glands are atrophied  reduced sweat production GIT: reduced gastric acid, atrophied pancreas and reduced enzyme production, atrophied mucosa of small intestine with reduced enzyme production, reduced intestinal motility , bacterial over growth, reduced nutrient absorption. Diarrhea is due to villous disuse atrophy and bacterial over growth, reduced nutrient absorption. 18

19. PATHOPHYSIOLOGY … Cellular function: Sodium pump activity is reduced and cell membranes are more permeable than normal  an increase in intracellular sodium and a decrease in intracellular potassium and magnesium • Protein synthesis is reduced Micronutrients: RBC mass is reduced, releasing iron , which requires glucose and amino acids to be converted to ferritin Incomplete conversion to ferritin  unbound/free iron promotes pathogen growth and formation of free radicals Free radicals  cell damage  Edema and hair/skin changes 19

20. PATHOPHYSIOLOGY … Immunity: All aspects of immunity are diminished esp . Cell-mediated (T-cell) immunity Lymph glands , tonsils and the thymus are atrophied IgA levels in secretions are reduced Complement components are low Phagocytosis is suppressed Endocrine: Insulin levels are reduced and the child has glucose intolerance Insulin growth factor 1 (IGF-1) levels are reduced, although growth hormone levels are increased Cortisol levels are usually increased 20

21. PATHOPHYSIOLOGY… CNS : No protein=no NTs No fat=no myelin sheath Small sulci and gyri = poor IQ Electrolytes: Sodium : leaky cell membranes and reduced activity of the sodium-potassium pump  excess body sodium, fluid retention, and edema Potassium : reduced due to Reduction in muscle protein and increased urinary and fecal losses 21

22. Nutritional Assessment Nutritional assessment is the quantitative evaluation of nutritional status A comprehensive nutritional assessment has five components : History (Dietary, medical, and medication) Physical examination Anthropometric and body composition measurements Laboratory tests Intervention and monitoring 22

23. A complete history should include a detailed nutritional, family, and prenatal history; the quantity, quality, and frequency of meals; and further information regarding the onset of the growth failure. 23

24. Anthropometric Assessment Common anthropometric measurements are weight, height, MUAC, head circumference, BMI - Indices : for interpretation of measurements. - Weight-for-age - Height/length-for-age - Weight-for-height/length - BMI-for-age - MUAC 24

25. Parameters WEIGHT A good index of acute & chronic nutritional status. An accurate age, sex & reference standard is necessary for evaluation. Three ways: W/A, W/H, BMI W/A compares the individual to reference data for weight attained at any given age. W/H looks at the appropriateness of the individual’s weight compared to his or her own height. W/H assesses body build & distinguishes wasting (acute malnutrition) from stunting (chronic malnutrition). Useful when the exact age are difficult to determine . 25

26. 2) LENGTH Length is a simple & reproducible growth parameter that provides, in conjunction with weight, significant information. Length assesses growth failure & chronic under nutrition. Measurement of length is frequently errorneous because of improper technique or equipment. L/A= stunting (chronic malnutrition) Short suture can be Familial Chromosomal abnormalities like turner syndrome 26

27. 3) ARM CIRCUMFERENCE/MUAC Used to determine cross-sectional mid-arm muscle & fat areas. Colour-coded in red/yellow/green, non-tear, stretch-resistant plasticized paper. MUAC < 11.5cm= severely Malnutrition MUAC = 11.5-12.5cm : moderate Maln. MUAC >12.5cm =mild/N Age = 6mo-5yr & / or L=>65cm 27

28. 4) Head circumference /HC HC can be influenced by nutritional status until the age of 36 months (3yrs) Deficiencies are manifest in weight & height before being seen in brain growth. 28

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32. …………………………………… Severe PEM or severe acute malnutrition (SAM) can become manifested as: Marasmus Kwashiorkor Marasmic – kwashiorkor 32

33. Other Clinical features Edematous SAM (Kwashiorkor) Age: commonly 2-3yrs Apathy “ Radar Gaze ” " Moon Face ”– sagging cheeks Edema Liver enlargement Dermatosis Nonedematous SAM ( Marasmic ) Age:- < 5yrs, but any age Irritable / apathic Sever growth retardation No edema Wrinkled skin & Bony prominence 33

34. Inpatient (TFU) Admission Criteria to SC in 6-59 mo Grade III bilateral pitting edema (+++), OR Any grade of bilateral edema combined with severe wasting (MUAC < 11.5 cm or WFL < -3 z score), OR Severe wasting (MUAC < 11.5 cm, or WFH < -3 z score, or Bilateral pitting edema of ( + or ++) WITH *** medical complications, OR Referred from outpatient care according to the action protocol 34

35. Medical Complications Poor appetite Intractable vomiting Convulsions Very Weak, Lethargy, or Unconsciousness High fever (axillary temperature > 39°C), Hypothermia (axillary temperature < 35°C or rectal 35.5°C ) Lower respiratory tract infection Dehydration, or Shock Dysentery, or Persistent diarrhea 10. Severe anemia 11. Hypoglycemia 12. Severe skin lesions 13. Eye signs of vitamin A deficiency 14. Unable to breast feed, drink or feed 15. Jaundice 16. Bleeding Tendencies 35

36. PRICIPLES OF CARE 36

37. Management of Medical Complications I. Hypoglycemia: RBS < 54mg/dl Concomitant hypothermia is common Other signs of hypoglycemia (Lethargy, limpness, loss of consciousness, eye lid retraction) Rx: If alert PO/NGT … 50 ml bolus of 10% dextrose/sucrose Lethargic/unconscious/convulsing .... 5ml/kg of 10% glucose IV push, then 50 ml of 10% glucose /sucrose by NGT Once RBS corrected - start ¼ of F75 calculated for his/her Wt Q2hrly dose; given Q30 min for the 1 st 2 hrs via PO/NGT Feed F75 Q2hrs, day and night 37

38. Management of Medical Complications… II. Hypothermia Rectal temp. < 35.5, or axillary temp. <35.0 Cause – infection, Low body calorie ( dec. basal metabolic rate) Rx: Cover the child, including his head both at day & night time Move the child away from windows Maintain room temperature of 28 – 32c Warm your hands before touching the child Avoid leaving the child uncovered while being examined, weighed Frequent changing of wet clothes or bedding Dry the child thoroughly after bathing Use KMC 38

39. Management of medical complications… III. Dehydration Difficult to Diagnose DHN in SAM pt by usual signs ( lethargy , sunken eyes , skin pinch, dry mouth ) But, Dx of DHN in SAM is mainly based on Hx: Hx of Watery diarrhea / vomiting Recent changes in appearance Recent sunkening of the eye balls 39

40. III. Dehydration Rx: Use ReSoMal for a total of 12hrs 5ml/kg … Q 30 min for the 1 st 2 hrs , then 5 – 10 ml/kg … Q 1 hr for the next 10 hrs , by alternating with F75 If child is already treated for shock with IV fluid, skip the 1 st 2 hrs and start 2 nd 10 hr mgt Monitoring: Observe the patient every 30 minutes for 2 hours, then hourly for the next 6 –12 hours, by recording the following: PR RR UOP,Stool /Vomiting frequency 40

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42. Management of medical complications… Signs of Improving Hydration Status: Fewer or less pronounced signs of dehydration(less thirsty, less lethargic ) Slowing of rapid respiratory and pulse rates Passing urine Gaining weight with clinical improvement If a child has 3 or more of the above signs of improving hydration status Stop giving ReSoMal Q1hr, instead offer per loss only 42

43. Management of medical complications… Signs of Overhydration : Increased RR by 5 breaths and PR by 25 beats per minute Engorged Jugular veins Sudden increase in liver size and tenderness Increasing edema (e.g. puffy eyelids) Increasing weight with clinical deterioration Stop ReSoMal if any of the above signs appear 43

44. Management of Medical Complications… Prevention of DHN: Replace ongoing loss by ReSoMal with 30 ml per watery stool … edematous child 50 – 100 ml per loss …. non edematous … < 2 yrs 100 – 200 ml per loss …. non edematous … > 2 yrs Keep feeding with F75 Encourage the care giver to continue breast feeding 44

45. Management of Medical Complications … IV. Shock Shock from dehydration and sepsis are likely to coexist in children with SAM Dx: Lethargic or unconscious, AND Has cold extremities, PLUS either : Slow capillary refill ( longer than 3 seconds ), or Weak , fast or absent radial or femoral pulses, and Absence of signs of heart failure in an edematous child 45

46. Management of Medical Complications… Shock Rx: Principles of shock treatment Keep the child warm Give O2, IV glucose, IV fluids IV glucose : 5ml/kg IV 10% glucose Infuse IV fluid : 15ml/kg over 1 hour Ringer’s lactate solution with 5% glucose, or 0.45 % half normal Saline with 5% glucose Measure and record PR & RR Q10 min Start antibiotics Note: Add KCl (20 mmol/L) to either of the above fluid items 46

47. Management of Medical Complications… Shock Follow up: If RR and PR are slower after 1 hour The child is improving Repeat the same amount of IV fluids for another 1 hour After 2 hours of IV fluids , Switch to Oral or NGT rehydration with ReSoMal Give 5-10 ml/kg ReSoMal Q 1 hr for 10hrs Give ReSoMal in alternate hrs with F75 Continue breast feeding If the RR and PR increase and child is gaining weight Treat as septic shock 47

48. Management of medical complications… Septic shock If the child fails to improve after the first hour of IV fluids for management of shock in dehydration, then assume that the child has septic shock Diagnosis of Septic Shock: 1. A fast weak pulse, with 2. Cold peripheries 3. Disturbed consciousness 4. Absence of signs of heart failure, AND 5. Failure to improve after the first hour of IV fluids for management of shock in dehydration 48

49. Management of medical complications… Septic Shock Treatment of septic shock Stop the IV rehydration, AND Give maintenance IV fluids 4ml/kg/ hr while waiting for blood Transfuse fresh whole blood at 10 ml/kg slowly over 3 hrs Then, begin with F75 Broad-spectrum antibiotics 49

50. Management of medical complications… V. Severe Anemia Severe anemia is a Hgb < 4 g/dl (or Hct <12%) Dilutional anemia, pseudo-anemia - Symptoms of moderate and severe anemia may appear between day 2 and 14 days of treatment of malnutrition Pseudo-anemia normally resolves spontaneously after 2 or 3 day s 50

51. Severe Anemia: Blood transfusion : Give blood transfusion in the first 48 hours if: Hgb is < 4 g/dl, ( Hct is < 12 %), or Hgb 4 to 6 gm/dl ( Hct 12 to 18%) with respiratory distress Transfusion is not recommended between 48 hours and day 14 unless there is Heart failure, and Cause is other than dilutional anemia If no signs of CHF .. ( whole fresh blood at 10 ml/kg slowly over 3 hours) If there are signs of CHF … packed RBC with 5-7 ml/kg over 3 hrs 51

52. Management of medical complications… VI. Electrolyte Imbalance: Na, K and Mg Therapeutic foods (F-75, F-100, and RUTF) and ReSoMal contain extra potassium and magnesium VII. Eye Signs: Vitamin A supplementation indication: eye signs of vitamin A deficiency, active measles infection or in the past 3 months 52

53. Management of medical complications… Measles vaccine: at admission and discharge if unvaccinated . Deworming on phase 2 53

54. Management of medical complications… iX . Infections 54

55. X. Bathing and Skin care Dermatitis: More common in children who have edema than in wasted children Use either potassium permanganate solution, gentian violet or Zinc oxide 55

56. FEEDING Inpatient (TFU) Three important phases Phase I Transition Phase Phase II 56

57. Appetite Test Done to: Children who are 6mo – 5yrs Who have no medical complications Takes 30’ – 1hr RUTF Appetite Test Results 57

58. FEEDING Phase I (Stabilization Phase) AIM : To repair cellular function , correct fluid and electrolyte imbalance , restore homeostasis , and prevent death from the interlinked triad of hypoglycemia , hypothermia , and infection Feeding with F-75 milk Low caloric, protein, fat and sodium, but Rich in Carbohydrate Contains 75kcal & 0.9 gm protein per 100ml If breastfed child, encourage the child to continue breastfeeding Given for 2-7 days until child is stabilized Don’t start ART, AntiTB , Iron 58

59. Phase I (Stabilization Phase) NG Tube Feeding Unable to take enough F75 by mouth(< 80% intake) Unconscious Very weak child Has painful mouse lesions/ulcers, cleft palate Pneumonia with rapid respiration and difficulty of swallowing NGT not allowed to stay > 3 days and it is only used in phase I NG Tube Removal Child taking > 80 % of the daily’s amount orally Two consecutive feeds fully by mouth (but if it is at night wait until morning) 59

60. Monitoring during Stabilization Phase Monitor body temperature, pulse, and respiration … Q4 hours Daily Measure: Measure and record - weight on the Multi-chart and plot it on the chart - degree of oedema (0, +, ++, +++) - symptoms like diarrhea, vomiting, signs like dehydration, feeding frequency , route of feeding - Input/Output Weekly Measure: Measure MUAC on admission , and then once per week 60

61. Transition Phase RUTF or F-100 is gradually introduced with phase I amount Prepares the patient for rehabilitation phase If the patient took >75% of RUTF, link to OTP Indications Appetite recovered No medical complications Edema started to subside (++ or less) No IV line, No NGT 61

62. Transition Phase Feeding with F100 ( catch up growth & rebuild wasted tissue), or RUTF Routine drugs are continued Amount of F100 given is the same as F75 in phase I (max. 100 -135 kcal/kg/day) For 2-3 days Breast Feeding is continued Monitoring during Transition Phase Temp., RR & PR … Q 6 hrs The rest are the same as Phase I Observe mood and smile of the kid 62

63. Criteria to Move Back to Phase I If … Rapid Weight gain > 10g/kg/d with increase in RR (this indicates excess fluid retention) Increasing/newly developing edema Rapid increase in the size of the liver Any other signs of fluid overload Tense abdominal distension Significant refeeding diarrhea leading to weight loss Medical complications w/c needs IV infusion NGT needed for feeding Taking < 75% of the feeds in Transition Phase 63

64. Transition Phase … To move from Transition Phase to Rehabilitation Phase (Phase II) Good appetite: Oedema reduced to moderate (++) or mild (+). Medical complications are resolving Clinically well and alert 64

65. Phase II (Rehabilitation Phase) AIM: is to restore wasted tissues ( i.e Catch-up Growth) Routine drugs, deworming tablets and iron Feeding with RUTF or F100 is increased in amount based on daily Wt measurement Rapid Wt gaining > 10 gm/kg/day is expected Can be carried out at Inpatient , or OTP level 65

66. Monitoring during Phase II Daily Measure: Wt Degree of edema (+,++,+++) Clinical signs ( stool, vomiting, dehydration, cough, and respiration ) Absence, refusal of feed Findings of full medical examinations Weekly: MUAC 66

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68. Criteria for Discharge The same anthropometric indicator that is used to identify and confirm SAM on admission should be used to determine recovery and discharge from treatment 68

69. Any grade of bilateral pitting oedema (+, ++ or +++), OR WFL < -3 z score, OR Recent weight loss or failure to gain weight, OR Ineffective feeding (attachment, positioning and suckling) directly observed for 15-20, minutes, ideally in supervised separate area, OR Presence of any of the medical complications , OR Any medical or social issue needing more detailed assessment or intensive support (e.g., disability, depression of caregiver, or other adverse social circumstances) Admission criteria for age < 6month 69

70. Feeding Infants < 6 mo Always treated as inpatient No RUTF is used b/c reflex of swallowing is not well developed No need of doing appetite test A. Infants with female caretaker/Mother/willing breastfeed No Separate Phase I – Transition – phase II Use diluted F-100 Use Supplementary Suckling System (SSS) Diluted F100 is given at 130 ml/kg/day , distributed in 12 meals 70

71. Feeding Infants < 6 mo Edematous vs Non edematous: No edema: There are not separate phases in the treatment of infants with the SSS technique ( no need to start with F75) Edema: Start treatment with F75 After resolution of edema , change to diluted F100 71

72. Feeding Infants < 6 mo …. B. Infants who have no caretaker : No use of SSS Have separate phase I, Transition phase and phase II 1. Phase I: No edema – diluted F100 Edematous – F75 (as edema subsided, change to diluted F100) 2. Transition phase diluted F100 - increased by 1/3 from phase I 3. Phase II: diluted F100 - double the amount from phase I 72

73. Feeding Infants < 6 mo … Follow up (Daily Measure): If Wt gain is : ≥ 20 gm/kg/day … reduce F100 by half then more breast feed Maintained 10gm/kg/day … stop supplement and continue BF … if maintained by BF only despite W/L measurement … discharge Absent … continue SSS & add 5ml F100 diluted to each feed 73

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75. Mgt of SAM in Co-infections HIV Infected Children Treatment of SAM is Same as HIV negatives Delay antiTB & ART initiation for 1-2 wks High tendency of Rx failure Malaria in SAM Don’t give Quinine IV otherwise treat as non SAM pt 75

76. References Ethiopian National SAM guideline, 2019, 3 rd ed EDHS 2019 WHO SAM guideline, 2013 Nelson Textbook of pediatrics, 21 st ed. Modern Nutrition in health and disease 10 th edition UpToDate 2023 76

77. THANK YOU!!! 77