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MALNUTRITION IN CHILDREN. PRINCIPLES OF DEHYDRATION CORRECTION.
Sakharova Inna Ye., MD, PhD
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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)
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Some Major World Risk Factors Causing Deaths
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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.
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“Hidden Hunger” – deficit of vitamins and microelements in diet.
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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
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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
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NON-ROUTINE TESTS Hair analysis Skin biopsy
Urinary creatinine over proline ratio Measurement of trace elements levels, iron, zinc & iodine
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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)
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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.
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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.
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Definitions of Malnutrition
Primary: inadequate food intake Secondary: result of disease Mixed
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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
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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
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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
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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
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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”).
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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.
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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.
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CONSTANT FEATURES OF KWASH
OEDEMA PSYCHOMOTOR CHANGES GROWTH RETARDATION MUSCLE WASTING
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USUALLY PRESENT SIGNS MOON FACE HAIR CHANGES SKIN DEPIGMENTATION
ANAEMIA
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OCCASIONALLY PRESENT SIGNS
HEPATOMEGALY FLAKY PAINT DERMATITIS CARDIOMYOPATHY & FAILURE DEHYDRATION (Diarrh. & Vomiting) SIGNS OF VITAMIN DEFICIENCIES SIGNS OF INFECTIONS
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DD of Kwash Dermatitis Acrodermatitis Entropathica Scurvy Pellagra
Dermatitis Herpitiformis
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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.
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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.
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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
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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
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Complications of P.E.M Hypoglycemia Hypothermia Hypokalemia
Hyponatremia Heart failure Dehydration & shock Infections (bacterial, viral & thrush)
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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
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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
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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
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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 %
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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)
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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
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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
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Hypotonic (hyponatriemic) dehydration
Total Na+ Deficit = (Desired Na+) – (Actual Na+) × Body Wt Kg × 0.6 + Calculate Fluid Deficit similar to Isonatremic Dehydration
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Convulsions Rapid Intravenous administration of Na+
3% saline infusion (1-12ml/kg body weight)
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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
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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
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In severe acidosis: Alkali therapy (NaHCO3) IV Calculation:
(Desired HCO3- - Actual HCO3-) × body wt Kg × 0.45
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THANKS FOR ATTENTION
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