1. Challenges in Recognizing and Caring for the Malnourished Child Family Medicine Specialist CME Pakse, Laos PDR, October 15-17, 2012

2. Objectives Using case studies, recognize the common clinical finding of malnutrition Discuss challenges in treating the malnourished child and child with nutritional deficiencies Understand strategies for preventing and monitoring malnutrition in the community

3. Case #1 A six week old infant is brought to the health centre by his grandmother. He is sleepy, very thin, and grandma is worried he is not gaining weight.

4. Discussion questions What do you want to ask about the feeding? What other questions do you want to ask the mother? What might be wrong with the child?

5. What questions would you ask on history? Nutrition –Breastfeeding history, age of weaning, bottle feeding, appetite, usual diet Past illnesses –Hospitalization, diarrhoea, dysentery, pneumonia, TB, measles Family circumstances –Adopted / abandoned child –Mother pregnant or unwell –TB, HIV Immunization

6. Facts Born at term, 3 rd baby of this mother. Bwt 2.8 kg No resuscitation required. Mom did not have fever. Baby seemed healthy the first week, but gradually got less active, and lethargic Mom feeds the baby for a few minutes, then goes to lie down. Grandma is feeding him rice water when he cries, but GM is often in the rice-fields working. No fever, no diarrhea, no vomiting, no respiratory distress 2 urinations a day. Slimy green stool, very small amounts Baby has had no immunizations

7. What is the Differential Diagnosis?

8. Differential Diagnosis Late onset sepsis Malabsorption Cardiac disease Poor intake-malnutrition Post partum depression in mother leading to feeding problems

9. What will you look for on Physical examination?

10. P. Ex. HR-130, RR-35,T-37C, Wt:3.2 kg, HC 37cm, Lth 50 cm MUAC 9.5cm Fontanelle sunken, eyes sunken, skin slack and hanging on legs HS normal, chest clear, abdomen scaphoid, no masses

11. How will you manage this baby? Assess dehydration(watery stools?) Assess for life threatening complications-eg. sepsis, heart failure, hypoglycemia, infections, infestations, severe anemia Nutritional treatment based on a maintenance diet -100cal/kg/da divided into frequent meals Transition phase-increase diet over 4-5 days Correct nutrient deficiencies over 2-3 weeks, high intake and stimulation

12. What could have been done in the community to prevent this? Post partum monitoring of mom Education of families around normal growth Volunteers monitoring new babies

13. Case study: Kanchha Kanchha, a 12- month-old boy brought to district hospital from rural area. 8 day history of loose watery stools. 2 days of increased irritability and poor oral intake.

14. What questions do you want to ask the mother?

15. What questions would you ask on history? Nutrition –Breastfeeding history, age of weaning, bottle feeding, appetite, usual diet Past illnesses –Hospitalization, diarrhea, dysentery, pneumonia, TB, measles Family circumstances –Adopted / abandoned child –Mother pregnant or unwell –TB, HIV Immunization

16. Stages in the management of a sick child (Ref. Chart 1, p.xx) Triage Emergency treatment History and examination Laboratory investigations, if required Diagnoses (main and secondary) Treatment Monitoring and supportive care Reassess Plan discharge

17. Triage Emergency signs (Ref: p2) Obstructed breathing Severe respiratory distress Signs of shock Coma Convulsing Severe dehydration Priority signs (Ref: p.2) Severe wasting Oedema of feet Palmar pallor Young infant Lethargy, drowsiness Irritable and restless Major burns Any respiratory distress Urgent referral note

18. What to look for on examination Temperature (35.3 degrees) Weight (5.1kg) Length (69cm) Localizing signs of infection? –Pneumonia, meningitis, skin (including scabies), perianal excoriation, rectal prolapse Signs of heart failure?

19. Palmar pallor Check also: Conjunctiva and mucous membranes

20. Emergency assessment and treatment Weigh, measure length & MUAC Measure blood glucose or treat for hypoglycaemia –“ If the child is alert, keep warm and give 10% glucose (10 ml/kg) by mouth or nasogastric tube, and proceed to further assessment and treatment. ” Assess for signs of dehydration or shock Avoid IV fluids because of the risk of heart failure. If children with malnutrition in shock then iv resuscitation as per (Ref. Chart 8)

21. What to look for on examination Micronutrient deficiency –Eye signs of vitamin A, dermatosis of zinc deficiency Signs of tuberculosis –Lymphadenopathy, ascites, hepatosplenomegaly Signs of HIV infection –Oral thrush, multiple infections, lymphadenopathy, hepatosplenomegaly * * note overlap between HIV and generalized TB Signs of kwashiorkor –Depigmentation, sparse discoloured hair

22. Diagnosis Eye signs of vitamin A deficiency: Dry conjunctiva or cornea Bitot ’ s spots Corneal ulceration Keratomalacia

23. Kwashiorkor and dermatosis of zinc deficiency

24. What investigations would you do?

25. Investigations Hypoglycaemia –Blood glucose 2.8 mmol/L (3-6.5mmol/L) Severe anaemia –Hb 5.6 g/dL (105-135) CXR normal Diarrhoea –Stool microscopy shows trophozoites of giardia

26. How would you manage this child?

27. Stabilization Hypoglycaemia 10% dextrose by NGT DehydrationReSolMal / ORS, avoid IV ElectrolytesZinc, Magnesium, Potassium HypothermiaKeep warm overnight, feeding Infection Broad spectrum antibiotics Diarrhoea Albendazole, metronidazole (Giardia) Micronutrients Vitamin A, zinc Anaemia When stable Fe, transfuse if heart failure