Assessment, Detection and Management of Malnutrition in Children

1. Assessment, Detection and Management of Malnutrition in Children BY Sampson Antwi (Dr) FWACP, FGCP Senior Lecturer: SMS-KNUST/KATH

2. Outline • Learning Expectations • Magnitude of malnutrition • Methods of nutritional assessment • Management of acute complications • Feeding, discharge & follow-up • Recipe for ReSoMal, F-75 & F-100

3. Learning Expectations By the end of presentation, participants should • appreciate the magnitude of malnutrition and its contribution to childhood morbidity and mortality • be familiar with the various methods of assessing the nutritional status of a child. • be able to recognise a child with malnutrition • be able to identify and manage common complications associated with the acute presentation of a child with malnutrition • be familiar with appropriate diet formulation for a child with malnutrition

4. Preamble • Malnutrition could be nutritional excess or nutritional deficiency • In this presentation, malnutrition only refers to nutritional deficiencies.

5. Magnitude of malnutrition • Globally, 9% of pre-school children are wasted[1] • In developing countries, however, under-5 malnutrition prevalence is estimated at 27%[2] • Worrying is the fact that as the global trend is decreasing, trend in Africa is increasing. (WHO Dept of nutrition 2010)

6. Malnutrition contributes to 54% of under-5 mortality[3] • A malnourished child suffers from multitude of problems including mental deficiency • S/he also has close to 50% chance of dying if not correctly identified and properly treated[4] • It is important therefore that children are properly assessed for evidence of malnutrition

7. Significance in clinical practice • Children constitute >50% of most out-patients clinical consultations in most hospitals in Africa • These children are seen mostly by General and Family Practitioners and even Specialist non-Paediatricians (locum Drs) • Paediatric practice should therefore be of interest to most Medical Practitioners in Africa

8. Under-diagnosis of malnutrition • Despite its high prevalence in developing countries, malnutrition is often under-diagnosed • Antwi S found only 5.9% of wasted children to be so identified by the attending Physicians in a tertiary hospital in Ghana.[5] • It is important therefore that all Practitioners attending to children properly assess for malnutrition and familiarise themselves with its treatment.

9. Methods of Nutritional assessment in children • Four (4) basic methods: • Nutritional and other relevant history • Clinical examination • Anthropometric measurements • Laboratory tests

10. 1. History • Dietary history may reveal deficiency in the quantity and quality of food intake. • A child at risk of malnutrition may have a history of one or more of the following: • Premature birth or LBW • Lack of breastfeeding in poor social circumstance • Twin birth • Prolonged or recurrent diarrhoea, TB or other infectious dx • Affectation or infection by HIV • Cancer or chronic dx

11. History cont. • Lost a parent by death or desertation • Large family size with poor social circumstances • Lives in a home without pipe-borne water or other source of clean water

12. 2. Clinical signs of malnutrition • Hair changes: • silkiness, • curliness or straightness, • lightly coloured to shades of brown/red • sparsely distributed • thin and easily pluckable

13. Dermatosis: commoner in oedematous type. Manifest as: • hypo-/hyper-pigmentation, • rough patches, • shedding in scales, • cracks and fissures. • Extensive desquamation that may resemble burns.

14. Visible signs of wasting: most visible in • chest as prominent ribs, • arms and thighs as loose skin and flabby muscle, • back as prominent scapula and spine, • buttocks as loss of fat and muscles with overlying skin hanging loose in a typical “baggy pants” fashion.

15. Peripheral oedema: • Suspect malnutrition in any child with bi-pedal oedema, particularly in presence of other physical signs of malnutrition • May mimic nephrotic syndrome and may sometimes be difficult to differentiate especially in presence of abnormal urinalysis from UTI • Note: presence of significant ascites discriminates against oedematous malnutrition

16. Other signs of malnutrition: • Pallor • moon face with drooping cheeks • angular stomatitis and • glossitis with loss of papilla • distended abdomen • irritability and apathy

17. Clinical signs of malnutrition:Dermatosis, hair changes, generalised oedema, baggy pants, and visible wasting

18. 3. Anthropometric measurements • May not accurately diagnose oedematous malnutrition due to added weight of oedema fluid. • Anthropometric measurements include: • Wt-for-age • ht-for-age • wt-for-ht • MUAC • head circumference • skinfold thickness.

19. Ht-for-age < 90% centile (-2SD)→stunted and implies chronic malnutrition. (severe if <85% or -3SD) • Wt-for-age < 80% (-2SD)→malnourished (If <60% →marasmus [Wellcome criteria]) • difficult to accurately diagnose acute malnutrition • wt-for-ht (age independent) • Accurately assesses for acute wasting • <80% (<-2SD)=moderate • <70% (<-3SD)=severe • MUAC • Has been used as proxy for wt-for-ht for children <5yrs • If <12.5cm, then severe wasting

20. Anthropometry cont. • Head circumference • Malnutrition in the first 2 yrs of life may result in faltering HC • Rarely useful after 2 years • Skinfold thickness • Assesses for the thickness of skin and subcutaneous fat and thus the nutritional store • Nutritional deficiency →loose and overhanging skin fold

21. 4. Laboratory evaluation • Not routinely employed in nutritional assessment • Can sometimes be valuable. • May also be useful in monitoring Rx response • Lab abnormalities include: • ↓serum pre-albumin & albumin, • ↓urea, • ↓cholesterol, • profoundly low K+, • low Hb & MCV • Low transferin

23. Management -1:Acute complicationsActively looked for the following and treat: Hypoglycaemia Hypothermia D and/or V (dehydration) Shock very severe anaemia 6. heart failure 7. severe dermatosis 8. Xerophthalmia 9. focus of specific infection

24. 1.Hypoglycaemia: (RBS < 3mmol/l) • 50mls of 10% dextrose or sucrose per osor NG tube . • Alternatively, 5ml/kg of 10% dextrose IV (if unconscious) • Then start feed with F-75 q30 min for next 2 hours plus monitor RBS 2. Hypothermia: (T<35⁰C axillary) • Active warming – • kangaroo technique, • provide bulbs • Passive warming- • keep room temp at 250C, • don’t leave child uncovered or close to open window, • promptly change wet nappies, • warm hands during physical exams, • wrap baby in clothes and cover head too

25. 3. Diarrhoea/vomiting: • ReSoMal 5mls/kg q30 min for 2 hrs then: • alternate ReSoMal with F-75 qhourly 4. Shock: • IVF (1/2 Darrows in 5%DW or R/lactate with added KCl [20mmol/l] in 5% Dextrose) • 15ml/kg for 1 hour. • Repeat x 1 if improving. • O2, IV antibiotics 5. V. Severe anaemia: (Hb <4g/dl or PCV < 12%) • Transfuse PRBCs 5-7ml/kg or 10ml/kg over 3 hours with IV lasix 6. Xerophthalmia: • Vitamin A on days 1, 2, 15 plus: • treat eye infection if present. • Bandage eye after atropine and antibiotic eye drops if corneal ulceration

26. 7. Severe dermatosis: Dilute potassium permanganate dabbing or GV painting 8. Heart failure: Iv lasix, restrict all fluids including feeds till out of failure 9. Specific focus of infection: Appropriate IV antibiotics. If no focus of infection and child has no acute complication, then oral antibiotics (co-trimoxazole or amox)

27. Management -2:Feeding + mineral supplement • If no complications on presentation; • out-patient mx in a feeding center with RUTF may be instituted • For all SAM with complications, in-patient mx should be instituted • Here, 2 types of milk feeds are prescribed: • F-75 during the acute stabilisation phase • F-100 in the subsequent rehabilitation phase

28. The feeds are prepared with added mineral-mix or CMV • In addition, all SAM should receive • Folic acid (5mg stat then 1mg daily) • Vit A on day 1 • Where no mineral-mix, • Give analytical grade KCl or slow K (1/2tab/kg/day) • Iron should only be given in rehabilitation phase • Stimulative play activity should be introduced

29. Important things not to do Do not use diuretics to treat oedema Do not use IV fluids for rehydration if not in shock Do not give iron during initial stabilisation Do not give high sodium diet • Do not give high protein diet > 1.5g/kg/day or high calories >100kcal/kg/day during the initial stabilisation phase • Be careful with transfusion for anaemia that occurred after admission

30. Discharge & Follow-up • Discharge preferably if wt-for-ht is > -2SD or • by linking up to out-patient feeding center after all acute complications have been treated • Follow-up should be arranged • Home visit may be arranged before and during discharge

31. Recipe for ReSoMal (45mmol Na/L)

32. Recipe for F-75

33. Recipe for F-75 & F-100 cont.

34. References • World Health Organization (1999). Management of severe malnutrition: manual for physicians and other senior health care workers. Geneva: WHO. • United Nations Children’s Fund (2006). Malnutrition –the challenge. Available on line at: URL:http://www.childonfo.org/areas/malnutrition/index/php 3. World Health Organisation (2005). Handbook: IMCI Integrated Management of Childhood Illness. Geneva. WHO. 4. World Health Organization (2000). Management of the child with a serious infection or severe malnutrition: guidelines for care at the first-referral level in developing countries. Geneva: WHO. 5. Antwi S.Malnutrition: missed opportunities for diagnosis.Ghana Med J. 2008 Sep;42(3):101-4.