PRESENTERS: KASTURI MAHALINGGAM ( 060100293)SITI RAIHANA (060100246)

SUPERVISOR: DR. OKE RINA RAMAYANI SP.A

KWASHIORKOR

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.

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

Causes

Social and EconomicPovertyIgnoranceInadequate weaning practicesChild abuseCultural and social practices

○ Vegan○ Low fat diets

Sign & Symptom

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.

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.

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.

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

Case Report MF, was admitted to RSUP HAM on April 13th 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 (-). History 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 : (-) 

Physical Examination :Head Eye : Light reflexes (+/+), isochoric pupil, pale inferior

conjunctive palpebra (-/-). Oedem palpebra (+).Face : OedemEar/Nose/Mouth : NormalNeck : 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 volumePitting oedem (+) at 4 extremities

Genital Boy, Oedem scrotum (+), crazy pavement (+)

Working Diagnosis

Severe malnutrition kwashiorkor type.

Treatment

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

Follow : April 14-18th 2010Complaint Oedem all over the body. Fever (-), cough (-), vomit (-).

Head Eye : Light reflexes (+/+), isochoric pupil, pale inferior conjunctive palpebra (-/-).Face : OedemNose : 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

Laboratory Result : (April 15th 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)

 

Hematology

Hemoglobin : 9.36 g% (10.7-17.1) Erythrocyte : 3.55 106/mm3 (3.75-4.95) Leukocyte : 26.80 103/mm3 (6.0-17.5) Hematocryte : 28.40 % (38-52) Thrombocyte : 129 103/mm3 (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 : 7.36 103/µL (1.9-5.4) Lymphocyte Absolute : 17 103/µL (3.7-10.7) Monocyte Absolute : 1.72 103/µL (0.3-0.8) Eosinophil Absolute : 0.050 103/µL (0.2-0.5) Basophil Absolute : 0.377 103/µL (0-0.1)

Follow : April 19 & 21-23th 2010Complaint Oedem all over the body. Fever (+) 38 C⁰ , cough (-),

vomit (-).

Head Eye : Light reflexes (+/+), isochoric pupil, pale inferior conjunctive palpebra (-/-).Face : OedemNose : 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.

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)

Follow : April 20th 2010

Complaint Oedem all over the body. Fever (+) 38 C⁰ , cough (-), vomit (+), diarrhea (+)

Head Eye : Light reflexes (+/+), isochoric pupil, pale inferior conjunctive palpebra (-/-).Face : OedemNose : 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.

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)

Follow : April 24th - Mei 2nd 2010Complaint Oedem all over the body. Fever (-), cough (-), vomit (-).

Head Eye : Light reflexes (+/+), isochoric pupil, pale inferior conjunctive palpebra (-/-).Face : OedemNose : 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

Follow : Mei 3 – 5th 2010Complaint Oedem all over the body. Fever (-), cough (-), vomit (-).

Head Eye : Light reflexes (+/+), isochoric pupil, pale inferior conjunctive palpebra (-/-).Face : OedemNose : 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

DISCUSSION

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

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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