1. MALNUTRITION IN CHILDREN. PRINCIPLES OF DEHYDRATION CORRECTION.
Sakharova Inna Ye., MD, PhD

2. Malnutrition will be responsible for 3,000 deaths globally, mostly women, infants and children, during this lecture!
Malnutrition accounts of ≈ 30 million
deaths per year (about 1 death per second)

3. Some Major World Risk Factors Causing Deaths

4. A healthy diet provides a balanced nutrients that
satisfy the metabolic
needs of the body without
excess or shortage.
Dietary requirements of children vary according to age, sex & development.
Dora, 3, receives a dose of vitamin A
outside a mobile health clinic in
Namurava village in Mozambique.

5. “Hidden Hunger” – deficit of vitamins and microelements in diet.

6. Around the world, billions of people live with vitamin and mineral deficiencies. For instance, approximately one third of the developing world’s children under the age of five are vitamin A-deficient, and therefore ill-equipped for survival. Iron deficiency anaemia during pregnancy is associated with 115,000 deaths each year, accounting for one fifth of total maternal deaths.
WHO Report, 2009

7. Lab Assesment Full blood counts Blood glucose profile Septic screening
Stool & urine for parasites & germs
Electrolytes, Ca, Ph & ALP, serum proteins
CXR & Mantoux test
Exclude HIV & malabsorption

8. NON-ROUTINE TESTS Hair analysis Skin biopsy
Urinary creatinine over proline ratio
Measurement of trace elements levels, iron, zinc & iodine

9. OVERVIEW OF PEM (Protein Energy Malnutrition)
The majority of world’s children live in developing countries
Lack of food & clean water, poor sanitation, infection & social unrest lead to LBW & PEM
Malnutrition is implicated in >50% of deaths of <5 children (5 million/yr)

10. OVERVIEW OF PEM
In 2000 WHO estimated that 32% of <5 children in developing countries are underweight (182 million).
78% of these children live in South-east Asia & 15% in Sub-Saharan Africa.
The reciprocal interaction between PEM & infection is the major cause of death & morbidity in young children.

12. Definitions of Malnutrition
Kwashiorkor: protein deficiency
Marasmus: energy deficiency
Marasmic/ Kwashiorkor: combination of chronic energy deficiency and chronic or acute protein deficiency
Failure to thrive: marasmus in U. S. children under 3.

13. Definitions of Malnutrition
Primary: inadequate food intake
Secondary: result of disease
Mixed

14. Diagnosis Normal: ± 1 SD Mild: -1.1 to -2 SD Moderate -2.1 to -3 SD
Severe greater than -3
Less than 5th percentile
BMI in adolescents
Moderate <15 ages 11-13, <16.5 ages 14-17
Severe <13 ages 11-13, <14.5 ages 14-17

15. CLASSIFICATION OF MALNUTRITION IN CHILDREN
MILD MALNUTRITION
MODERATE MALNUTRITION
SEVERE
MALNUTRITION
Percent Ideal Body weight
80-90 %
70-70 %
LESS THAN 70 %
Percent Usual Body weight
90-95 %
80-85 %
LESS THAN 80 %
Albumin (g/dL)
LESS THAN 2.1
Transferrin (mg/dl)
LESS THAN 100
Total Lymphocyte Count (per µL)
LESS THAN 800

16. Gomez Classification: The child's weight is compared to that of a normal child (50th percentile) of the same age. It is useful for population screening and public health evaluations.
percent of reference weight for age = ((patient weight) / (weight of normal child of same age)) * 100
Interpretation:
% normal
% Grade I: mild malnutrition
% Grade II: moderate malnutrition
< 60% Grade III: severe malnutrition

17. Wellcome Classification: evaluates the child for edema and with the Gomez classification system.
Grades:
80-60 % without oedema is under weight
80-60% with oedema is Kwashiorkor
< 60 % with oedema is Marasmus-Kwash
< 60 % without oedema is Marasmus

18. KWASHIORKOR
Cecilly Williams, a British nurse, had introduced the word Kwashiorkor to the medical literature in The word is taken from the Ga language in Ghana & used to describe the sickness of weaning (“the sickness the older child gets when the next baby is born”).

19. ETIOLOGY
Kwashiorkor can occur in infancy but its maximal incidence is in the 2nd yr of life following abrupt weaning.
Kwashiorkor is not only dietary in origin. Infective, psycho-socical, and cultural factors are also operative.

20. ETIOLOGY
Kwashiorkor is an example of lack of physiological adaptation to unbalanced deficiency where the body utilized proteins and conserve S/C fat.
One theory says Kwash is a result of liver insult with hypoproteinemia and oedema. Food toxins like aflatoxins have been suggested as precipitating factors.

21. CONSTANT FEATURES OF KWASH
OEDEMA
PSYCHOMOTOR CHANGES
GROWTH RETARDATION
MUSCLE WASTING

22. USUALLY PRESENT SIGNS MOON FACE HAIR CHANGES SKIN DEPIGMENTATION
ANAEMIA

23. OCCASIONALLY PRESENT SIGNS
HEPATOMEGALY
FLAKY PAINT DERMATITIS
CARDIOMYOPATHY & FAILURE
DEHYDRATION (Diarrh. & Vomiting)
SIGNS OF VITAMIN DEFICIENCIES
SIGNS OF INFECTIONS

26. DD of Kwash Dermatitis Acrodermatitis Entropathica Scurvy Pellagra
Dermatitis Herpitiformis

27. MARASMUS
The term marasmus is derived from the Greek marasmos, which means wasting.
Marasmus involves inadequate intake of protein and calories and is characterized by emaciation.
Marasmus represents the end result of starvation where both proteins and calories are deficient.

28. MARASMUS Marasmus represents an
adaptive response to starvation, whereas kwashiorkor represents a maladaptive response to starvation
In Marasmus the body utilizes all fat stores before using muscles.

29. EPIDEMIOLOGY & ETIOLOGY
Seen most commonly in the first year of life due to lack of breast feeding and the use of dilute animal milk.
Poverty or famine and diarrhoea are the usual precipitating factors
Ignorance & poor maternal nutrition are also contributory

30. Clinical Features of Marasmus
Severe wasting of muscle & s/c fats
Severe growth retardation
Child looks older than his age
No edema or hair changes
Alert but miserable
Hungry
Diarrhoea & Dehydration

33. Complications of P.E.M Hypoglycemia Hypothermia Hypokalemia
Hyponatremia
Heart failure
Dehydration & shock
Infections (bacterial, viral & thrush)

34. TREATMENT Correction of water & electrolyte imbalance
Treat infection & worm infestations
Dietary support: 3-4 g protein & 200 Cal /kg body wt/day + vitamins & minerals
Prevention of hypothermia
Counsel parents & plan future care including immunization & diet supplements

35. KEY POINT FEEDING Continue breast feeding Add frequent small feeds
Use liquid diet
Give vitamin A & folic acid on admission
With diarrhea use lactose-free or soya bean formula

36. PROGNOSIS
Kwash & Marasmus-Kwash have greater risk of morbidity & mortality compared to Marasmus and under weight
Early detection & adequate treatment are associated with good outcome
Late ill-effects on IQ, behavior & cognitive functions are doubtful and not proven

39. Pediatric Fluid Therapy Principles
Assess water deficit by:
1. weight:
weight loss (Kg) = water loss (L) OR
2. Estimation of water deficit by physical exam:
Mild moderate severe
Infants < 5 % % >10 %
Older children < 3 % % > 6 %

44. MANAGEMENT OF DEHYDRATION -Replace Phase 1: Acute Resuscitation :
Give Lactated Ringer OR Normal Saline at ml/kg IV OR 5 % albumin over minutes.
May repeat bolus until circulation stable
-Calculate 24 hour maintenance requirements
Formula:
First 10 kg: (100 cc/kg/24 hours)
Second 10 kg: (50 cc/kg/24 hours)
Remainder: (20 cc/kg/24 hours)
Example: 35 Kilogram Child
Daily: 1000 cc cc cc = 1800 cc/day
-Calculate Deficit:
Mild Dehydration: (40 ml/kg)
Moderate Dehydration: (80 ml/kg)
Severe Dehydration: (120 ml/kg)

45. MANAGEMENT Continue
-Calculate remaining deficit:
Substract fluid resuscitation given in Phase 1
-Calculate Replacement over 24 hours:
First 8 hours: 50% Deficit + Maintenance
Next 16 hours: 50% Deficit + Maintenance
Determine Serum Sodium Concentration
Hypertonic Dehydration (Serum Sodium > 150)
Isotonic Dehydration
Hypotonic Dehydration (Serum Sodium < 130)
Add Potassium to Intravenous Fluids after patient voids urine
Potassium source
Potassium Chloride
Potassium Acetate for Metabolic Acidosis
Potassium dosing
Weight <10 kilograms: 10 meq KCl /liter glucose
Weight >10 Kilograms: 20 meq KCl /liter glucose

46. Hypertonic dehydration
Serum Na+ > 150 meq/L (up to 213)
Deficit replacement over 48 hours 0.18% – 0.3% saline
Regular daily maintenance
Fluid evenly distributed over time
Dialysis option in severe hypernatremia

47. Hypotonic (hyponatriemic) dehydration
Total Na+ Deficit =
(Desired Na+) – (Actual Na+) × Body Wt Kg × 0.6 +
Calculate Fluid Deficit similar to Isonatremic Dehydration

48. Convulsions Rapid Intravenous administration of Na+
3% saline infusion (1-12ml/kg body weight)

49. Potassium Daily requirement: 1-2 meq / kg body weight.
Usually add meq KCl / L of IV fluid.
Added only once the urine output is established.
In Hypokalemia, add: meq / L of IV fluid
40 meq / L of IV fluid
50 meq / L of IV fluid
60 meq / L of IV fluid
70 meq / L of IV fluid
ECG monitoring
Frequent testing

50. Hypokalemia Management
Maximum IV infusion rate:
1 mEq/kg/hr
Marked hypokalemia:
Monitor serum K closely
0.5-1 mEq/kg/dose given as an infusion of 0.5 mEq/kg/hr for 1-2 hour

51. In severe acidosis: Alkali therapy (NaHCO3) IV Calculation:
(Desired HCO3- - Actual HCO3-) × body wt Kg × 0.45

54. THANKS FOR ATTENTION