Malnutrition in Children- what do I need to know ?

Unterernährung bei Kindern- was muss ich wissen ?

Judith Lindert, DTMH

University Lübeck

foring

29. April.2017

numbers

• 16.000 children < 5 die every day

• ≈ 45% percent related to malnutrition

• 1/7 children underweight

• In-patient treatment challenged by HIV, TB other medical complications still high case fatality

WHO Definition of SAM (severe acute Malnutrition in children

Mid upper arm circumferenceMUAC

Growth percentiles

• % of children identified by each indicator similar BUT not same children -> all tests should be used

• Only visual examination identifies half of the cases

© WHO

Impact of severe acute malnutrition

Weight-for-height <-3SD (WHO standards) isassociated with large increase in risk of dying in children 6-60 months

WHO child growth standards and the identification of severe malnutrition in infants and children. WHO/UNICEF 2009

Marasmus- on examination

© Lindert

• Inadequate energy intake• Often but not always

chronic process• Metabolic adaptions tend

to protect function of the brain and other organs and prolong survival

• Wasting• “too much skin”• Grannies face• Bones visible

© Kitz

Kwashiorkor- on examination

• Fatty infiltration liver hepatomegaly

• Discoloured, sparse hair

• Flaky skin desquamation

• Skin colour changes

• Anorexia

• Metabolic disturbance © Lindert

© Lindert

© Bartels

© Lindert

Kwashiorkor

• ????????????

• Previously: low protein diet with low serum albumin results in oedema and kwashiorkor

• Metabolic complex:• Increased oxidative stress

• Hepatic steatosis –mechanism ?

• Severe metabolic disturbance-hypoglycaemia

• ? Severe hepatic dysfunction?

• Exclusively breast fed children and children within the same family/community sharing the same diet some develop marasmus and some kwashiorkor

• oedema independent of albumin levels and improvement unrelated

Mixed type- marasmic kwashiorkor

© Lindert

Oedema DD non nutritional

• Cardiac failure

(rheumatic heart disease )

• Kidney disease; nephroticsyndrom

• Hepatic failure

(traditional medicine)

• Poor intestinal absorption/enteropathy

• Trauma e.g. burns; protein loss

SAM- initial assessment

Anthropometry (body measurements)• quantify by reference to

international standards

Clinical assessment• type of malnutrition

• Severity

• Identifying acute life-threatening complications• E.g. ETAT

History of illnessMain problem according to caretaker ?Since when weight loss/oedema?Last meal?Usual diet? Appetite?Number of children?Fever?Diarrhea? Frequency, type?Vomiting?Cough?TB contactGeneral condition

alertnessWant to play?Vital signs

Therapeutic concept/treatment options

Management of SAM in health facilities• WHO: only children with complicated SAM

should be admitted• General danger sings: high fever severe anemia

resp distress systemic infection

• Anorexia: failed appetite test

• Significant social issues: orphans single parent family

• Community management

© Lindert© Lindert

© Lindert

Community vs hospital

PROTOCOLS

• essential and significantly reduce the mortality associated with malnutrition

• Studies from several countries (India, Bangladesh, South Africa, Colombia) show a halving in the death rate when WHO guidelines are followed

PROTOCOLS

• essential and significantly reduce the mortality associated with malnutrition

• Studies from several countries (India, Bangladesh, South Africa, Colombia) show a halving in the death rate when WHO guidelines are followed

© Bartels

Therapeutic approach

• Identification of SAM using anthropometry and examination for oedema:

Therapeutic approach

• 1. treat/prevent hypoglycemia

• 2. treat/prevent hypothermia

• 3. treat/prevent dehydration

• 4. correct e´lyte imbalance

• 5. treat/prevent infection

• 6. correct/substitute micronutrient deficiencies

• 7. start cautious feeding

• 8. slowly increase calorie intake for catch up growth

• 9. provide sensory stimulation and emotional support

• 10. prepare for follow- up after discharge

1. treat/prevent hypoglycemia

• Malnourished children are very vulnerable to hypoglycemia

- glucose storage capacity decreases

- Cannot handle glucose imbalances

avoid prolonged periods without food

start early frequent small feeds

• A: conscious and blood sugar (BS) < 54mg/dl/ <3mmol/l:

➢Glucose orally/NG-tube: e.g. 50ml 10% glucose or 10% sucrose solution ( 1 teaspoon sugar in 3.5 teaspoon water)

➢Feed F-75 every 30 min for two h (1/4 of the feeding amount each time)

• B: unconscious, lethargic or convulsing:

➢Iv 10% glucose (5ml/kg) followed by 50ml 10% glucose or sucrose NG-tube

➢2h- feeding

• Consider infection: antibiotics?

2. treat/prevent hypothermia

subcutaneous fat reductionIncrease body surface relative to weight- difficut to maintain body

temperature High risk for hypothermia

Avoid, detect (body temperature) and treat hypothermiaProtect against cold start feeding immediately

❖Warm environment❖Kangaroo care❖Avoid exposure:

UnwarppingWet clothes

!! Hypothermia and hypoglycemiaoften go together and are asociated with sepsis !! ? antibiotics!?

© Lindert

2. treat/prevent dehydration/diarrhea

© Bartels

© Bartels

2. treat/prevent dehydration/diarrhea

Causes of diarrhoea in malnutrition ward

© Bartels

3. treat/prevent dehydration

5. treat/prevent infection

SYSTEMATIC TREATMENT• Malnutrition often after infections such as measles or dysentery

• Impairement immunity adaptive (lymphocytes) & Innated(macrophages & granulocytes)

• Atrophy lympatic tissueTonsils thymusLymph glands

Nutritionally acquired Immunodeficiency syndrom (“NAIDS”)

5. treat/prevent infection

• Broad spectrum AB• Oral nystatin (if

thrush)• Anti-helmintics• Up-date vaccintions:

measles

measlesmeasles

© Lindert

© Lindert © Lindert

Symptomatic malnutrition?

Think of HIV• high prevalence setting (>1% in pregnant

women): do HIV test after informed consent• Low prevalence setting (<1% in pregnant

women): no systematic HIV test (except mum +ve)if no response to treatment after 2 weeks

Think of TB• TB contact• History of cough, how long• Lymphadenopathy• No weight gain with appropriate treament

Deaths regarding HIV status

stabilisation of medical

complications, restore metabolic

functions

F-75

100kcl/kg/d

8 meals

Phase 1 Transition Phase

Rehabilitation

Catch up

F-100

200 kcl/kg/d

6 meals

Phase 2

Recovery/discharge

RUTF

Ambulatory

Not yet ready for Phase 2

F-100135kcl/kg/d8 mealsIf possible introduce RUTF

What to feed the child ?

© Lindert© Lindert © Lindert © Lindert

Different standard milk (per 100ml)

measles

When to go back to phase 1?

measlesSevere ´clinical detoriation: any WHO danger signs

• Respiratory distress• Shock• Severe anaemia (Hb <5g/dl)• Convulsion/impaired

consciousness (BCS <4, AVPU V)

• Profuse diarrhea/severe dehydration

• Hypothermia (<36°C)• Hypoglycaemia (>54mg/dl)

© Bartels

If it is not going well

measles• Cardiac failure

Output stroke volume

• Liver failure

Proteins excretion

Energy production

• Kidney failure

GFR

• Intestinal failure

Gastric acid motility

Digestive enzymes

• Energy stores © Lindert

e.g. intestinal dysfunction

• Small intestine bacterial overgrowth measles

• Lipid maldigestion

• Exocrine pancreatic dysfunction

• Villus atrophy

• Intestinal infections

Enteropathy of the malnourished

© Bartels

Transfer to outpatient/ambulatory treatment

measles

Guided rather by clinical condition and social circumstanced than anthropometric targets

outcome

measles

© Kitz

measles

Not just Malnutrition

PreventionEarly detection and holistic treatment

Vielen Dank© Lindert

acknowledgments

• Rosalie Bartels, Blantyre Malawi/Global Child Health Group Amsterdam

• MSF, Nutritional and Medical Protocol for Treatment, Children from 6 to 59 months, MSF OCA

• WHO

• Penny, Mary

• MSF Mweso Team, DRC Congo

• MSF Quetta Team, Pakistan

• Christa Kitz, Severe Acute Malnutrition in Children