persistent diarrhea with severe malnutrition type marasmus
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Case Report
Infection Unit
Severe Nutrition Type Marasmus And Persistent Diarrhea
Presentator: Prakash Kanayasan
Navin Kanvinder Singh
Day, Date : Wednesday, 19 October 2011
Supervisor : dr. Hj Tiangsa Br Sembiring, Sp.A (K)
Introduction
Malnutrition is a broad term which refers to both undernutrition (subnutrition) and
overnutrition. Individuals are malnourished, or suffer from undernutrition if their diet does not
provide them with adequate calories and protein for maintenance and growth, or they cannot
fully utilize the food they eat due to illness. People are also malnourished, or suffer from
overnutrition if they consume too many calories. Malnutrition can also be defined as the
insufficient, excessive or imbalanced consumption of nutrients. Several different nutrition
disorders may develop, depending on which nutrients are lacking or consumed in excess.
According to the World Health Organization (WHO), malnutrition is the gravest single threat to
global public health.1
The World Health Organization (WHO)2 defines malnutrition as "the cellular imbalance
between the supply of nutrients and energy and the body's demand for them to ensure growth,
maintenance, and specific functions." The term protein-energy malnutrition (PEM) applies to a
group of related disorders that include marasmus, kwashiorkor, and intermediate states of
marasmus-kwashiorkor. The term marasmus is derived from the Greek word marasmos, which
means withering or wasting. Marasmus involves inadequate intake of protein and calories and is
characterized by emaciation. The term kwashiorkor is taken from the ‘Ga’ language of Ghana
and means "the sickness of the weaning." Williams first used the term in 1933, and it refers to an
inadequate protein intake with reasonable caloric (energy) intake. Edema is characteristic of
kwashiorkor but is absent in marasmus.
Studies suggest that marasmus represents an adaptive response to starvation, whereas
kwashiorkor represents a maladaptive response to starvation. Children may present with a mixed
picture of marasmus and kwashiorkor, and children may present with milder forms of
malnutrition. For this reason, Jelliffe suggested the term protein-calorie (energy) malnutrition to
include both entities. Although protein-energy malnutrition affects virtually every organ system,
this article primarily focuses on its cutaneous manifestations.2
In general, marasmus is an insufficient energy intake to match the body's requirements.
As a result, the body draws on its own stores, resulting in emaciation. In kwashiorkor, adequate
carbohydrate consumption and decreased protein intake lead to decreased synthesis of visceral
proteins. The resulting hypoalbuminemia contributes to extravascular fluid accumulation.
Impaired synthesis of B-lipoprotein produces a fatty liver. 4
In 2000, the WHO4 estimated that malnourished children numbered 181.9 million
(32%) in developing countries. In addition, an estimated 149.6 million children younger than 5
years are malnourished when measured in terms of weight for age. In south central Asia and
eastern Africa, about half the children have growth retardation due to protein-energy
malnutrition. This figure is 5 times the prevalence in the western world.4
Approximately 50% of the 10 million deaths each year in developing countries
occur because of malnutrition in children younger than 5 years. In kwashiorkor, mortality tends
to decrease as the age of onset increases. Dermatologic findings appear more significant and
occur more frequently among darker-skinned peoples. This finding is likely explained by the
greater prevalence and the increased severity of protein-energy malnutrition in developing
countries and not to a difference in racial susceptibility4.
Marasmus most commonly occurs in children younger than 5 years. This period
is characterized by increased energy requirements and increased susceptibility to viral and
bacterial infections. Low intake of calories or an inability to absorb calories is the key factor in
the development of kwashiorkor. A variety of syndromes can be associated with kwashiorkor. 4
Patients with protein-energy malnutrition present with poor weight gain or
weight loss, slowing of linear growth; and behavioral changes, such as irritability, apathy,
decreased social responsiveness, anxiety, and attention deficit nonhealing wounds. Signs include
diarrhea and psychomotor changes. This may signify a catabolic process that requires nutritional
intervention. The overall metabolic adaptations that occur during marasmus are similar to those
in starvation, which have been more extensively investigated. The primary goal is to preserve
adequate energy to the brain and other vital organs in the face of a compromised supply. Early
on, a rise in gluconeogenesis leads to a perceived increased metabolic rate. As fasting progresses,
gluconeogenesis is suppressed to minimize muscle protein breakdown, and ketones derived from
fat become the main fuel for the brain. With chronic underfeeding, the basal metabolic rate
decreases. One of the main adaptations to long-standing energy deficiency is a decreased rate of
linear growth, yielding permanent stunting. The energy saving is partially attenuated by the
diversion of energy from muscle to the more metabolically active organs. With reduced energy
intake, a decrease in physical activity occurs followed by a progressively slower rate of growth.
Weight loss initially occurs due to a decrease in fat mass, and afterwards by a decrease in muscle
mass, as clinically measured by changes in arm circumference. Muscle mass loss results in a
decrease of energy expenditure. Reduced energy metabolism can impair the response of patients
with marasmus to changes in environmental temperature, resulting in an increased risk of
hypothermia. 4
Immune impairment and infections are usually associated with marasmus.
Thymus atrophy is a characteristic manifestation of marasmus, but all T lymphocyte–producing
tissues are affected. However, B-lymphocyte tissues, such as Peyer patches, the spleen, and the
tonsils, are relatively preserved. Cellular immunity is most affected, with a characteristic
tuberculin anergy. However, antibody production is maintained. In marasmus, a general acquired
immunodeficiency occurs, with a decrease in secretory immunoglobulin A (IgA) and an
impairment of the nonspecific local defense system, such as mucosal integrity and lymphokine
production. 4
Management of moderate marasmus can be performed on an outpatient basis, but severe
marasmus or marasmus complicated by a life-threatening condition generally requires inpatient
treatment. In these cases, management is divided into an initial intensive phase followed by a
consolidation phase (rehabilitation), preparing for outpatient follow-up management. The WHO
has developed guidelines to help improve the quality of hospital care for malnourished children
and has prioritized the widespread implementation of these guidelines.4
The guidelines highlight 10 steps for routine management of children with malnutrition, as
follows:4
Prevent and treat the following:
o Hypoglycemia
o Hypothermia
o Dehydration
o Electrolyte imbalance
o Infection
o Micronutrient deficiencies
Provide special feeds for the following:
o Initial stabilization
o Catch-up growth
o Provide loving care and stimulation
o Prepare for follow-up after discharge
Nutritional management of the acute phase of severe marasmus in week 1 coresponds to
maintenance of vital functions and tissue renewal . During this period, the electrolyte imbalance,
infections, hypoglycemia, and hypothermia are treated, and then feeding is started. Oral
renutrition of a child with marasmus should be started as early as possible, as soon as the child is
stable and the hydroelectrolyte imbalances are corrected. The term gut rest has no physiological
basis. Enteral feeds decrease diarrhea and prevent bacteremia from bacterial translocation.In
cases of shock, intravenous (IV) rehydration is recommended using a Ringer-lactate solution
with 5% dextrose or a mixture of 0.9% sodium chloride with 5% dextrose. Enteral hydration
using ReSoMal should be started as early as possible, preferably at the same time as the IV
solution.4
The first step is often simply rehydration. Dehydration in children with marasmus is
difficult to evaluate, is overdiagnosed, or is misinterpreted as septic shock. Rehydration should
be enteral except in case of coma or shock, when intravenous therapy is required. Rehydration
solution should be adapted to marasmic children with a low sodium content and a high potassium
content. This can be prepared using standard WHO solution as a base or by directly
administering a modified oral rehydration (ReSoMal) solution if available. The overall goal of
nutrition rehabilitation is to overcome the anorexia often associated with marasmus, as well as to
avoid the causes that lead to anorexia.4
The next step is transitional state that is to avoid cardiac failure while providing enough
energy to avoid catabolism. The goal usually is to provide 80-100 kcal/kg/d in 12 meals per day
or continuously by NG tube to avoid hypoglycemia. This amount of calories should be reached
progressively in a few days to avoid life-threatening problems such as cardiac failure or
hypokalemia. The WHO had recommended the use of the liquid products, such as the F75
solution, which provides 75 kcal/100 mL, mainly as carbohydrates. This solution provides a
limited amount of fat, which is often malabsorbed because of the associated pancreatic
insufficiency, and a limited amount of proteins, which can precipitate renal failure during initial
refeeding of children with marasmus. F75 is available as a ready-to-use formula or can be
prepared using widely available foods listed in Table 3 below. Recipes and cooking guidelines,
including possible alternative foods, are available through the WHO. The ready-to-use formulas,
as well as the micronutrient mixtures, are commercially available. 4
The third step is rehabilitation. In the rehabilitation phase of treatment, nutritional intake
can reach 200 kcal/kg/d. The goal is to reach a continuous catch-up growth in weight and height
in order to restore a healthy body weight. Only children who have been weaned from their NG
tube can be considered as being in the rehabilitation phase. Therefore, specific goals of this
phase are to encourage the child to eat as much as possible, to restart breastfeeding as soon as
possible, to stimulate the emotional and physical development, to actively prepare the child and
mother to return to home and prevent recurrence of malnutrition.4
During the rehabilitation phase, the F100 formula, with a higher protein content With the
child's increased appetite during this phase, use of the F75 formula only leads to a fat increase,
without an appropriate gain in fat-free mass. The main risk of this phase of the rehabilitation is
that the nutrients provided are not sufficient to sustain the weight gain, which can reach as much
as 15 g/kg/d.Powdered skim milk is used to prepare the F75 or F100 formula. In that form, the
lactose concentration is low, about 10 times less than in breast milk, which is also well tolerated
by children with marasmus. Only in cases of persistent diarrhea or established lactose
intolerance, which is rare, should lactose be excluded. High-fat foods are well tolerated at this
point because they slow gastric emptying and may decrease lactose production. 4
Mortality of hospitalized children with marasmus is high, especially during the first few
days of rehabilitation. Death is usually caused by infections or other causes. If the child has no
clinical sign of infection, the WHO recommends 5 days of oral cotrimoxazole therapy. If the
child presents with clinical signs of infection, hypoglycemia, or hypothermia he or she must be
considered as seriously infected and treated with parenteral ampicillin and gentamicin. Practice
guidelines for acute diarrhea have been established. Persistent and profuse diarrhea has 2 main
causes. Infectious etiology (especially lambliasis): This can be promptly treated with
metronidazole if possible, after stool examination. In osmotic diarrheas sugar of the F75 solution
should be replaced by cereal flour for 1-2 weeks. 4
Case report:
ANS, a 9months and 20days baby boy came to RS HAM emergency department with the main
complain of diarrhea. Patient is origin from Desa Nagori Sinasih Kec Silau.
- Patient has been experiencing diarrhea since 1 month ago with the frequency of more than 3
times a day (watery diarrhea). Volume of diarrhea 100cc per time.
- Vomit is also experienced by patient with the frequency of more than two times a day contains
of what that is eaten with the volume of about 50cc per time.
- Fever(-) cough(-)
- Birth history : spontaneous with the help of midwife. Patient cried spontaneous with no
asphyxia .
- Birth weight: 3700grm. Birth length 33cm. Patient is the 3rd child.
- Patient was breast fed till the age of 4months, given formula milk from age 4month till 6
months old.
- Growth history : at this point, patient can only carry his head and turn around
- History of illness: patient is consulted from RS Perdagangan by a general practitioner with the
diagnosis of persistent diarrhea .
- History of medications : ivfd ringer lactate
- History of defecation : diarrhea
- History of mictuation : normal
- History of Immunization : BCG: 1x
` Hepatitis B 3x
Polio 4x
- History of Previous Drug : Not clear.
- History of Previous Disease : -
Physical examination
Presence Status:
Sensorium: Alert; temperature: 37 oC; BW: 5,1 kg; BL: 65 cm; BW/BL: 57%, BW/A : 56 %,
BL/A : 92 %., Anemic (-), Dyspnea (-), Icteric (-), Cyanosis (-), Oedem (-)
Localized Status:
Head : Old man face (+) Eye: Sunken eyes (+), light reflexes (+/+), isochoric pupil, pale
conjunctiva palpebra inferior (-/-)
Ear and Nose: within normal limit;
Neck : Lymph node enlargement (-), jugular vein pressure: R-2 cmH2O
Chest : Symetric fusiform, HR : 120 bpm, regular, murmur (-)
RR : 48 tpm, regular, rales (-/-)
Abdomen : Soepel, Ascites (-), undulation (-), shifting dullness (-), smilling umbillicus (-)
Hepar/Lien: non palpable, turgor (-), peristaltic ( +)
Extremities: Baggy pants (+), oedem (-), cyanosis, Pols: 120 bpm, regular, adequate
pressure/volume, CFT<3”, (-) BP : 110/90 mmHg
Genitalia : Male, within normal range
Working Diagnosis : Severe nutrition type marasmus with persistent diarrhea
Plan:
- Full blood count
- Feces routine
- Electrolite
- Consul to nutrition and dietary disease
Therapy:
- Cotrimoxazole syrp 2x ½ ctg
- Zinc tablet 1x20mg
- Vitamin A 1x100.000iu
- Multivitamin without ferum 1x cFs I
- Resomal 50cc/2hrs
- F 75 diet 55cc/2hrs/oral
laboratory Result 2st August 2011:
Complete Blood Count Results Normal Value
Hemoglobin (Hb) 7,70 g % 11,3 – 14,1g %
Erytrocyte (RBC) 2,67 x 106/mm3 4,40 – 4,48 x106/mm3
Leukocyte (WBC) 8,22 x 103/mm3 4,5 – 13,5 x103/mm3
Hematocrite 22,80 % 37 – 41 %
Trombocyte (PLT) 69 x 103/mm3 217 – 497 x103/mm3
MCV 80,70 fL 93 – 115 fL
MCH 23,90 pg 29 – 35 pg
MCHC 29.60 g % 28 – 34 g %
RDW 15,70 14,9 – 18,7 %
Neutrofil 26,92 % 37 – 80 %
Limfosit 64,80 % 20 – 40 %
Monosit 6,60 % 2 – 8 %
Eosinophil 1,80 % 1 – 6 %
Basophil 0,100 % 0 – 1 %
Neutrophil absolute 2,15x 103/µL 1,9 – 5,4 x103/µL
Limfosit absolute 5,20 x 103/µL 3,7 – 10,7 x103/µL
Monosit absolute 0,53 x 103/µL 0,3 – 0,8 x103/µL
Eosinophil absolute 0,13 x 103/µL 0,2 – 0,5 x103/µL
Basophil absolute 0,01 x 103/µL 0 – 0,1 x103/µL
GLUCOSE Ad Random
Blood glucose 139 mg/dl <200 mg/dl
Follow Up 15 – 16th September 2011
S : Watery diarrhea (2x), blood (-), mucous (-), vomit (-)
O :
Presence status :
Sensorium : Alert, Body temperature : 36,7 – 36,8 ºC, BW : 5,1 kg, BL : 65 cm,
BW/BL = 57%
Anemic (-), Dyspnea (-) , Icteric (-), Cyanosis (-), Oedema (-)
Localized status :
Head : Old man face (+) Eye : Sunken eyes (+), light reflexes (+/+),
isochoric pupil, pale conjunctiva palpebra inferior (-/-),palpebra
superior oedem (-/-), Mouth cyanosis (-), tears (+), wet lip mucous
Ear / Nose: within normal limit
Neck : Lymph node enlargement (-), jugular vein pressure : R-2 cmH2O.
Cannon wave (-)
Chest : Symmetric fusiform
HR : 112 - 120 bpm, regular, murmur (-)
RR : 30 - 36 tpm, regular, rales (-/-),skin turgor (N)
Abdomen : Soepel, peristaltik (+) N
Hepar/Lien: non palpable
Extremities : Baggy pants (+), muscle hypertrophy (+), pols: 112 - 120 bpm,
regular, adequate pressure/volume, CFT<3”, warm, pitting oedem
(-). BP : 100/70 mmHg
Anogenital : Male, within normal limit.
A: Severe nutrition type Marasmus with persistent diarrhea
P : - Cotrimoxazole syrp 2x ½ ctg
- Zinc tablet 1x20mg
- Multivitamin without ferum 1x cFs I
- Resomal 50cc/2hrs
- F 75 diet 55cc/2hrs/oral
Planning: Routine feces examination
Electrolite examination
Follow Up 17 – 18th September 2011
S : Watery diarrhea (2x), blood (-), mucous (-), vomit (-)
O :
Presence status :
Sensorium : Alert, Body temperature : 36,8 ºC, BW : 5,1 kg, BL : 65 cm, BW/BL
= 57%
Anemic (-), Dyspnea (-) , Icteric (-), Cyanosis (-), Oedema (-)
Localized status :
Head : Old man face (+) Eye : Sunken eyes (+), light reflexes (+/+),
isochoric pupil, pale conjunctiva palpebra inferior (-/-),palpebra
superior oedem (-/-), Mouth cyanosis (-), tears (+), wet lip mucous
Ear / Nose: within normal limit
Neck : Lymph node enlargement (-), jugular vein pressure : R-2 cmH2O.
Cannon wave (-)
Chest : Symmetric fusiform
HR : 128 bpm, regular, murmur (-)
RR : 28 tpm, regular, rales (-/-),skin turgor (N)
Abdomen : Soepel, peristaltik (+) N
Hepar/Lien: non palpable
Extremities : Baggy pants (+), muscle hypertrophy (+), pols: 120 bpm, regular,
adequate pressure/volume, CFT<3”, warm, oedem (+/+).
BP : 100/70
Anogenital : Male, within normal limit.
A: Severe nutrition type Marasmus with Persistent diarrhea
P : - Cotrimoxazole syrp 2x ½ ctg
- Zinc tablet 1x20mg
- Multivitamin without ferum 1x cth I
- F 75 diet 55cc/2hrs/oral
Planning : Feces culture examination
Laboratory Result 17th September 2011: Urine
Urine Results
Colour Yellow
Erytrocyte (RBC) 0-2
Leukocyte (WBC) 2-4
Epitel 0-1
Cristal -
Bacteria -
Glucose -
Bilirubin -
Keton -
pH 8,0
Protein -
Urobilinogen -
Nitrate -
Blood -
Laboratory Result 17th September 2011: Feces
Feces Results
Colour Yellow
Consistency Dilute
Blood -
Mucous -
Worm eggs -
Amoeba +
Erytrocyte 0 -1
Leucocyte 0 – 1
Follow Up 19 – 20th September 2011
S : Diarrhea (-), vomit (-), complete diet
O :
Presence status :
Sensorium : Alert, Body temperature : 36,7 ºC, BW : 5,5 kg, BBI : 8,1kg BW/BL
= 67%
Anemic (-), Dyspnea (-) , Icteric (-), Cyanosis (-), Oedema (-)
Localized status :
Head : Old man face (+), hair can’t be plucked out easily, Eye : Sunken
eyes (+), light reflexes (+/+), isochoric pupil, pale conjunctiva
palpebra inferior (-/-), palpebra superior oedem (-/-), Mouth cyanosis
(-), tears (+), wet lip mucous
Ear / Nose: within normal limit
Neck : Lymph node enlargement (-), jugular vein pressure : R-2 cmH2O.
Cannon wave (-)
Chest : Symmetric fusiform
HR : 92 bpm, regular, murmur (-)
RR : 28 tpm, regular, rales (-/-),skin turgor (N)
Abdomen : Soepel, peristaltik (+) N
Hepar/Lien: non palpable
Extremities : Baggy pants (+), muscle hyperthrophy (+), pols: 92 bpm, regular,
adequate pressure/volume, CFT<3”, warm, thin subcutan fat (+),
BP : 100/60
Anogenital : Male, within normal limit.
A: Severe nutrition type Marasmus
P : - Cotrimoxazole syrp 2x ½ cth
- Zinc tablet 1x20mg
- Multivitamin without ferum 1x cth I
- F 100 diet 55cc/2hrs/oral (120kkal/kgBW/day)
Follow Up 21 – 22nd September 2011
S : Diarrhea (-), vomit (-), complete diet
O :
Presence status :
Sensorium : Alert, Body temperature : 37 ºC, BW : 5,5 kg, BBI : 8,1kg BW/BL =
67%
Anemic (-), Dyspnea (-) , Icteric (-), Cyanosis (-), Oedema (-)
Localized status :
Head : Old man face (+), hair can’t be plucked out easily, Eye : Sunken
eyes (+), light reflexes (+/+), isochoric pupil, pale conjunctiva
palpebra inferior (-/-), palpebra superior oedem (-/-), Mouth cyanosis
(-), tears (+), wet lip mucous
Ear / Nose: within normal limit
Neck : Lymph node enlargement (-), jugular vein pressure : R-2 cmH2O.
Cannon wave (-)
Chest : Symmetric fusiform
HR : 106 bpm, regular, murmur (-)
RR : 32 tpm, regular, rales (-/-),skin turgor (N)
Abdomen : Soepel, peristaltik (+) N
Hepar/Lien: non palpable
Extremities : Baggy pants (+), muscle hyperthrophy(+), pols: 106 bpm, regular,
adequate pressure/volume, CFT<3”, warm, thin subcutan fat (+).
BP : 100/70
Anogenital : Male, within normal limit.
A: Severe malnutrition type Marasmus
P : - Cotrimoxazole syrp 2x ½ ctg
- Zinc tablet 1x20mg
- Multivitamin without ferum 1x cth I
- F 100 diet 60cc/2hrs/oral (140kkal/kgBW/day)
- Lacto B 2x1
Follow Up 23 – 24th September 2011
S : Diarrhea (-), vomit (-), complete diet
O :
Presence status :
Sensorium : Alert, Body temperature : 36,8 ºC, BW : 5,5 kg, BBI : 8,1kg,
Bl=65cm BW/BL = 67%
Anemic (-), Dyspnea (-) , Icteric (-), Cyanosis (-), Oedema (-)
Localized status :
Head : Old man face (+), hair can’t be plucked out easily Eye : Sunken
eyes (+), light reflexes (+/+), isochoric pupil, pale conjunctiva
palpebra inferior (-/-),palpebra superior oedem (-/-), Mouth cyanosis
(-), tears (+), wet lip mucous
Ear / Nose: within normal limit
Neck : Lymph node enlargement (-), jugular vein pressure : R-2 cmH2O.
Cannon wave (-)
Chest : Symmetric fusiform
HR : 106 bpm, regular, murmur (-)
RR : 32 tpm, regular, rales (-/-),skin turgor (N)
Abdomen : Soepel, peristaltik (+) N
Hepar/Lien: non palpable
Extremities : Baggy pants (+), muscle hyperthrophy (+), pols: 106 bpm, regular,
adequate pressure/volume, CFT<3”, warm, thin subcutan fat (+).
BP : 110/60
Anogenital : Male, within normal limit.
A: Severe malnutrition type Marasmus
P : - Cotrimoxazole syrp 2x ½ ctg
- Zinc tablet 1x20mg
- Multivitamin without ferum 1x cth I
- F 100 diet 70cc/2hrs/oral (140kkal/kgBW/day)
- Lacto B 2x1
Planning : Echocardiography
Consult to Haemato oncology
Lab : Hb : 7.00
Ht : 22,8
L : 8,02
T : 69.00
Follow Up 25 – 26th September 2011
S : Diarrhea (-), vomit (-), complete diet
O :
Presence status :
Sensorium : Alert, Body temperature : 36,9 ºC, BW : 5,5 kg, BBI : 8,1kg,
Bl=65cm BW/BL = 67%
Anemic (-), Dyspnea (-) , Icteric (-), Cyanosis (-), Oedema (-)
Localized status :
Head : Old man face (+), hair can’t be plucked out easily Eye : Sunken
eyes (+), light reflexes (+/+), isochoric pupil, pale conjunctiva
palpebra inferior (-/-),palpebra superior oedem (-/-), Mouth cyanosis
(-), tears (+), wet lip mucous
Ear / Nose: within normal limit
Neck : Lymph node enlargement (-), jugular vein pressure : R-2 cmH2O.
Cannon wave (-)
Chest : Symmetric fusiform
HR : 110 bpm, regular, murmur (-)
RR : 24 tpm, regular, rales (-/-),skin turgor (N)
Abdomen : Soepel, peristaltik (+) N
Hepar/Lien: non palpable
Extremities : Baggy pants (+), muscle hyperthrophy (+), pols: 110 bpm, regular,
adequate pressure/volume, CFT<3”, warm, thin subcutan fat (+).
Anogenital : Male, within normal limit.
A: Severe malnutrition type marasmus
P : - Cotrimoxazole syrp 2x ½ ctg
- Zinc tablet 1x20mg
- Multivitamin without ferum 1x cth I
- F 100 diet 80cc/2hrs/oral (190kkal/kgBW/day)
Advice Haemato oncology :
Anemia ec DD/ 1. Non deficiency anemia
+ Severe malnutrition type marasmus
2. Chronic disease
Lab results : 26th September 2011
Hematology Result Referance
Reticulocyte 11.61% 0.2 – 2.5
Ret. He 29.4 pg 28.8 – 32.9
Hemostasis Result Referance
Ferritin 100.00 ng/mL Adult : 15 – 300
Child : 15 – 240
Ferum 67 mg/dL 61 – 157
TIBC 242 µg/dL 112 – 346
Imunoserology Result Referance
CD 4 % 47 31 – 60
CD 4 absolute 2577 Cell/uL 410 – 1590
Follow Up 27 - 28th September 2011
S : Diarrhea (-), vomit (-), complete diet
O :
Presence status :
Sensorium : Alert, Body temperature : 36,9 ºC, BW : 5,5 kg, BBI : 8,1kg,
Bl=65cm BW/BL = 68%
Anemic (-), Dyspnea (-) , Icteric (-), Cyanosis (-), Oedema (-)
Localized status :
Head : Old man face (+), hair can’t be plucked out easily Eye : Sunken
eyes (+), light reflexes (+/+), isochoric pupil, pale conjunctiva
palpebra inferior (-/-),palpebra superior oedem (-/-), Mouth cyanosis
(-), tears (+), wet lip mucous
Ear / Nose: within normal limit
Neck : Lymph node enlargement (-), jugular vein pressure : R-2 cmH2O.
Cannon wave (-)
Chest : Symmetric fusiform
HR : 98 bpm, regular, murmur (-)
RR : 38 tpm, regular, rales (-/-),skin turgor (N)
Abdomen : Soepel, peristaltik (+) N
Hepar/Lien: non palpable
Extremities : Baggy pants (+), muscle hyperthrophy (+), pols: 98 bpm, regular,
adequate pressure/volume, CFT<3”, warm, thin subcutan fat (+).
BP : 100/70
Anogenital : Male, within normal limit.
A: Severe nutrition type Marasmus
P : - Folic acid 1x 1 mg
- Basefort 1x 1 cth
- Cotrimoxazole syrp 1x ½ cth
- Semi solid diet 3 x 500 calories with11 gr protein plus F 100 120cc/6hrs/oral
Follow Up 29th - 30th September 2011
S : Diarrhea (-), vomit (-), complete diet
O :
Presence status :
Sensorium : Alert, Body temperature : 36,9 ºC, BW : 5,5 kg, BBI : 8,1kg,
Bl=65cm BW/BL = 68%
Anemic (-), Dyspnea (-) , Icteric (-), Cyanosis (-), Oedema (-)
Localized status :
Head : Old man face (+), hair can’t be plucked out easily Eye : Sunken
eyes (+), light reflexes (+/+), isochoric pupil, pale conjunctiva
palpebra inferior (-/-) ,palpebra superior oedem (-/-), Mouth cyanosis
(-), tears (+), wet lip mucous
Ear / Nose: within normal limit
Neck : Lymph node enlargement (-), jugular vein pressure : R-2 cmH2O.
Cannon wave (-)
Chest : Symmetric fusiform
HR : 108 bpm, regular, murmur (-)
RR : 30 tpm, regular, rales (-/-),skin turgor (N)
Abdomen : Soepel, peristaltik (+) N
Hepar/Lien: non palpable
Extremities : Baggy pants (+), muscle hyperthrophy (+), pols: 30 bpm, regular,
adequate pressure/volume, CFT<3”, warm, thin subcutan fat (+).
BP : 100/60 mmHg
Anogenital : Male, within normal limit.
A: Severe nutrition type Marasmus
P : - Folic acid 1x1 mg
- Multivitamin with Fe 1x1
- Semi solid diet 3 x 500 calories with 11 gr protein plus F100 120 cc/6hrs/oral
Planning : Mantoux test
Patient is allowed to go home with scheduled control to the pediatric
department
DISCUSSION AND SUMMARY
According to Medilexicon's medical dictionary: 1
Malnutrition is "Faulty nutrition resulting from malabsorption, poor diet, or overeating."
Undernutrition is "A form of malnutrition resulting from a reduced supply of food or from
inability to digest, assimilate, and use the necessary nutrients."
Malnutrition is caused mainly by not consuming what the National Health Service (NHS), UK,
calls "the right balance of nutrients from major food groups". These include: 1
Carbohydrates
Fruit and vegetables
Protein
Dairy - vegans are able to find abundant nutrients from non-animal sources
Fats
Subnutrition occurs when an individual does not consume enough food. It may exist if the
person has a poor diet that gives them the wrong balance of basic food groups. According to the
Food and Agriculture Organization (FAO), the number of people globally who were
malnourished stood at 923 million in 2007, an increase of over 80 million since the 1990-92 base
period.1
The World Health Organization (WHO) says that malnutrition is by far the largest contributor to
child mortality globally, currently present in half of all cases. Underweight births and inter-
uterine growth restrictions are responsible for about 2.2 million child deaths annually in the
world. Deficiencies in vitamin A or zinc cause 1 million deaths each year.
WHO adds that malnutrition during childhood usually results in worse health and lower
educational achievements during adulthood. Malnourished children tend to become adults who
have smaller babies. While malnutrition used to be seen as something which complicated such
diseases as measles, pneumonia and diarrhea, it often works the other way round - malnutrition
can cause diseases to occur. 1
In 2000, the WHO2 estimated that malnourished children numbered 181.9 million (32%) in
developing countries. In addition, an estimated 149.6 million children younger than 5 years are
malnourished when measured in terms of weight for age. In south central Asia and eastern
Africa, about half the children have growth retardation due to protein-energy malnutrition. This
figure is 5 times the prevalence in the western world. The World Health Organization (WHO)
estimates that every year ten million children under the age of five died and 50 percent of them
died with protein-energy malnutrition (PEM). Marasmus most commonly occurs in children
younger than 5 years. This period is characterized by increased energy requirements and
increased susceptibility to viral and bacterial infections.
In this case the patient is only 9 months old and his weight for age suggest malnutrition.
His BW/BL is 57%.
Globally, as well as in developed, industrialized countries, the following groups of people are
at highest risk of malnutrition (subnutrition):1
Elderly people, especially those who are hospitalized or in long-term institutional care
Individuals who are socially isolated
People on low incomes (poor people)
People with chronic eating disorders, such as bulimia or anorexia nervosa
People convalescing after a serious illness or condition
Signs and symptoms of malnutrition (subnutrition) include:
Loss of fat (adipose tissue)
Breathing difficulties, a higher risk of respiratory failure
Depression
Higher risk of complications after surgery
Higher risk of hypothermia - abnormally low body temperature
The total number of some types of white blood cells falls; consequently, the immune
system is weakened, increasing the risk of infections.
Higher susceptibility to feeling cold
Longer healing times for wounds
Longer recover times from infections
Longer recovery from illnesses
Lower sex drive
Problems with fertility
Reduced muscle mass
Reduced tissue mass
Tiredness , fatigue, or apathy
Irritability
In more severe cases of malnutrition:
Skin may become thin, dry, inelastic, pale, and cold
Eventually, as fat in the face is lost, the cheeks look hollow and the eyes sunken
Hair becomes dry and sparse, falling out easily
Sometimes, severe malnutrition may lead to unresponsiveness (stupor)
If calorie deficiency continues for long enough, there may be heart, liver and respiratory
failure
Total starvation is said to be fatal within 8 to 12 weeks (no calorie consumption at all)
In our case, our patient experienced loss of fat, the cheeks looked hollow and the eyes sunken.
Children who are severely malnourished typically experience slow behavioral development, even
mental retardation may occur. Even when treated, undernutrition may have long-term effects in
children, with impairments in mental function and digestive problems persisting; in some cases
for the rest of their lives.
Malnutrition, the result of a lack of essential nutrients, resulting in poorer health, may be caused
by a number of conditions or circumstances. In many developing countries long-term (chronic)
malnutrition is widespread - simply because people do not have enough food to eat.
In more wealthy industrialized nations malnutrition is usually caused by1:
Poor diet - if a person does not eat enough food, or if what they eat does not provide
them with the nutrients they require for good health, they suffer from malnutrition. Poor
diet may be caused by one of several different factors. If the patient develops dysphagia
(swallowing difficulties) because of an illness, or when recovering from an illness, they
may not be able to consume enough of the right nutrients.
Mental health problems - some patients with mental health conditions, such as
depression, may develop eating habits which lead to malnutrition. Patients with anorexia
nervosa or bulimia may develop malnutrition because they are ingesting too little food.
Mobility problems - people with mobility problems may suffer from malnutrition,
simply because they either cannot get out enough to buy foods, or find preparing them
too arduous.
Digestive disorders and stomach conditions - some people may eat properly, but their
bodies cannot absorb the nutrients they need for good health. Examples include patients
with Crohn's disease or ulcerative colitis. Such patients may need to have part of the
small intestine removed (ileostomy). Individuals who suffer from Celiac disease have a
genetic disorder that makes them intolerant to gluten. Patients with Celiac disease have a
higher risk of damage to the lining of their intestines, resulting in poorer food absorption.
Patients who experience serious bouts of diarrhea and/or vomiting may lose vital
nutrients and are at higher risk of suffering from malnutrition.
Alcoholism - an alcoholic is a person who suffers from alcoholism - the body is
dependent on alcohol. Alcoholism is a chronic (long-term) disease. Individuals who
suffer from alcoholism can develop gastritis, or pancreas damage. These problems also
seriously undermine the body's ability to digest food, absorb certain vitamins, and
produce hormones which regulate metabolism. Alcohol contains calories, reducing the
patient's feeling of hunger, so he/she consequently may not eat enough proper food to
supply the body with essential nutrients.
In poorer, developing nations malnutrition is commonly caused by1:
Food shortages - in poorer developing nations food shortages are mainly caused by a
lack of technology needed for higher yields found in modern agriculture, such as nitrogen
fertilizers, pesticides and irrigation. Food shortages are a significant cause of malnutrition
in many parts of the world.
Food prices and food distribution - it is ironic that approximately 80% of malnourished
children live in developing nations that actually produce food surpluses (Food and
Agriculture Organization). Some leading economists say that famine is closely linked to
high food prices and problems with food distribution.
Lack of breastfeeding - experts say that lack of breastfeeding, especially in the
developing world, leads to malnutrition in infants and children. In some parts of the
world mothers still believe that bottle feeding is better for the child. Another reason for
lack of breastfeeding, mainly in the developing world, is that mothers abandon it because
they do not know how to get their baby to latch on properly, or suffer pain and
discomfort.
In this patients originates from a place called Desa Nagosih. It is considered to be a rural area
where food shortage normally occurs. Besides, from the clucking that we got from out patient’s
mother, we found that our patient has been breastfed in a minimal amount not reaching the
recommended six months. The mother could not produce enough milk due to lack of nutritional
food. Thus this contributes to the present malnourished condition of this patient
Echocardiography was performed on this patient. This is because, imaging and
radiographic scans may be ordered to help evaluate the health of internal organs and the normal
growth and development of muscles and bones.normally in long term malnutrition patients, a
disturbance or failure of organ growth is a complication.
The normal clinical sign of marasmus are firstly the patient looks very thin, until the
bones wrapped in skin, face like a parent, patient is normally whiny and fussy. The child
normally has wrinkled skin, subcutaneous fatty tissue is very little to none and on the buttock
area looks like wearing baggy pants. Anaemia is usually present. Some kids also present with
sunken abdomen. Mostly patients present with infections and diarrhea. Stools may be loose, but
this is not a constant feature of the disease. Diarrhoea of an infective nature, as mentioned above,
may commonly have been a precipitating factor. 1
Other clinical manifestation are wasting and stunting that are defined below.
I. wasting: acute current, short-duration malnutrition, where weight for age and weight for
height are low but height for age is normal;
II. stunting: past chronic malnutrition, where weight for age and height for age are low but
weight for height is normal;
III. wasting and stunting: acute and chronic or current long-duration malnutrition, where
weight for age, height for age and weight for height are all low.3
It is difficult to differentiate kwashiorkor and marasmus. Understanding the clinical signs can
help make a better diagnosis3.
Comparison of the features of kwashiorkor and marasmus
Feature Kwashiorkor Marasmus
Growth failure Present Present
Wasting Present Present, marked
Oedema Present (sometimes mild) Absent
Hair changes Common Less common
Mental changes Very common Uncommon
Dermatosis, flaky-paint Common Does not occur
Appetite Poor Good
Anaemia Severe (sometimes) Present, less severe
Subcutaneous fat Reduced but present Absent
Face May be oedematous Drawn in, monkey-like
Fatty infiltration of liver Present Absent
For instance, in this case it is clearly visible that he has baggy pants sign, wasting, no mental
changes, oedema is absent, dermatosis is not found anemia is suspected and old man face is
present. His chief complaint is persistent diarrhea. This patient has no signs of fussiness or
irritability. Based on his symptom it is more likely to diagnose him marasmic instead of
kwashiorkor.
In patients with marasmus metabolic changes occur to cope with the energy deficiency of
the body. The overall metabolic adaptations that occur during marasmus are similar to those in
starvation, which have been more extensively investigated. The primary goal is to preserve
adequate energy to the brain and other vital organs in the face of a compromised supply. Early
on, a rise in gluconeogenesis leads to a perceived increased metabolic rate. As fasting progresses,
gluconeogenesis is suppressed to minimize muscle protein breakdown, and ketones derived from
fat become the main fuel for the brain. With chronic underfeeding, the basal metabolic rate
decreases. One of the main adaptations to long-standing energy deficiency is a decreased rate of
linear growth, yielding permanent stunting. The energy saving is partially attenuated by the
diversion of energy from muscle to the more metabolically active organs. With reduced energy
intake, a decrease in physical activity occurs followed by a progressively slower rate of growth.
Weight loss initially occurs due to a decrease in fat mass, and afterwards by a decrease in muscle
mass, as clinically measured by changes in arm circumference. Muscle mass loss results in a
decrease of energy expenditure. Reduced energy metabolism can impair the response of patients
with marasmus to changes in environmental temperature, resulting in an increased risk of
hypothermia.4
In general patients with marasmus experience fat stores depletion. Fat storage can
decrease to as low as 5% of the total body weight and can be macroscopically undetectable. The
remaining fat is usually stored in the liver, giving a paradoxical appearance of a fatty liver.
Although this is often observed in kwashiorkor, it also occurs to a lesser extent in marasmus. A
study from Nigeria examined serum lipids in malnourished children. These authors found that
total cholesterol, low density lipoprotein cholesterol, and high density lipoprotein cholesterol
levels were significantly higher in children with kwashiorkor than in those with marasmus.4
There are several classification used around the world for classifying PEM . Wellcome classification of severe forms of protein-energy malnutrition4
Percentage of standard weight for age Oedema present Oedema absent
60-80 Kwashiorkor Undernourishment
<60 Marasmic kwashiorkor Nutritional marasmus
The Gomez classification of malnutrition based on weight-for-age standards4
Classification Percentage of standard weight for age
Normal >90
Grade I (mild malnutrition) 75-89.9
Grade II (moderate malnutrition) 60-74.9
Grade IIIa (severe malnutrition) <<60
Management of moderate marasmus can be performed on an outpatient basis, but severe
marasmus complicated by a life-threatening condition generally requires inpatient treatment. In
these cases, management is divided into an initial intensive phase followed by a consolidation
phase (rehabilitation), preparing for outpatient follow-up management. The WHO has developed
guidelines to help improve the quality of hospital care for malnourished children and has
prioritized the widespread implementation of these guidelines.4
Severe malnutrition is defined in these guidelines as the presence of severe wasting (<70% weight-for-height or <-3SD) and/or oedema.5
The guidelines are divided in five sections
A. General principles for routine care (the’10 steps’)
B. Emergency treatment of shock and severe anaemia
C. Treatment of associated conditions
D. Failure to respond to treatment
E. Discharge before recovery is complete
There are ten essential steps in treating malnutrition5:
1.Treat/prevent hypoglycaemia
2.Treat/prevent hypothermia
3.Treat/prevent dehydration
4.Correct electrolyte imbalance
5.Treat/prevent infection
6.Correct micronutrient deficiencies
7.Start cautious feeding
8.Achieve catch-up growth
9.Provide sensory stimulation and emotional support
10. Prepare for follow-up after recovery
These steps are accomplished in two phases that are an initial stabilisation phase where the acute
medical conditions are managed and a longer rehabilitation phase.5
Step 1
Hypoglycaemia and hypothermia usually occur together and are signs of infection. Check for
hypoglycaemia whenever hypothermia (axillary<35.0oC; rectal<35.5oC) is found. Frequent
feeding is important in
preventing both conditions.
Treatment:
If the child is conscious and dextrostix shows <3mmol/l or 54mg/dl give:
• 50 ml bolus of 10% glucose or 10% sucrose solution (1 rounded
teaspoon of sugar in 3.5 tablespoons water), orally or by nasogastric (NG) tube. Then feed starter
F-75 every 30 min. for two hours (giving one quarter of the two-hourly feed each time)
• antibiotics
• two-hourly feeds, day and night
If the child is unconscious, lethargic or convulsing give:
• IV sterile 10% glucose (5ml/kg), followed by 50ml of 10% glucose or sucrose by Ng tube.
Then give starter F-75 as above
• antibiotics
• two-hourly feeds, day and night
Monitor:
• blood glucose: if this was low, repeat dextrostix taking blood from finger or heel, after two
hours. Once treated, most children stabilize within 30 min. If blood glucose falls to <3 mmol/l
give a further 50ml
bolus of 10% glucose or sucrose solution, and continue feeding every 30 minutes until stable
• rectal temperature: if this falls to <35.5oC, repeat dextrostix
• level of consciousness: if this deteriorates, repeat dextrostix
Prevention:
• feed two-hourly, start straightaway (see step 7) or if necessary,rehydrate first5
Step 2.
Treatment:
If the axillary temperature is <35.0oC, take the rectal temperature using a low reading
thermometer.
If the rectal temperature is <35.5oC (<95.9oF):
• feed straightaway (or start rehydration if needed)
• rewarm the child: either clothe the child (including head), cover with a warmed blanket and
place a heater or lamp nearby (do not use a hot water bottle), or put the child on the mother’s
bare chest (skin to skin) and cover them
• give antibiotics
Monitor:
• body temperature: during rewarming take rectal temperature two hourly until it rises to
>36.5oC (take half-hourly if heater is used)
• ensure the child is covered at all times, especially at night
• feel for warmth
• blood glucose level: check for hypoglycaemia whenever hypothermia is found
Prevention:
• feed two-hourly, start straightaway (see step 7)
• always give feeds throughout the day and night
• keep covered and away from draughts
• keep the child dry, change wet nappies, clothes and bedding
• avoid exposure (e.g. bathing, prolonged medical examinations)
• let child sleep with mother/carer at night for warmth5
Step 3. Treat/prevent dehydration
Note: Low blood volume can coexist with oedema. Do not use the IV route for rehydration
except in cases of shock and then do so with care, infusing slowly to avoid flooding the
circulation and overloading the heart.
Treatment:
The standard oral rehydration salts solution (90 mmol sodium/l) contains too much sodium and
too little potassium for severely malnourished children. Instead give special Rehydration
Solution for Malnutrition (ReSoMal).
It is difficult to estimate dehydration status in a severely malnourished child using clinical signs
alone. So assume all children with watery diarrhea may have dehydration and give:
• ReSoMal 5 ml/kg every 30 min. for two hours, orally or by nasogastric tube, then
• 5-10 ml/kg/h for next 4-10 hours: the exact amount to be given should be determined by how
much the child wants, and stool loss and vomiting. Replace the ReSoMal doses at 4, 6, 8 and 10
hours with F-75 if rehydration is continuing at these times, then
• continue feeding starter F-75 (see step 7)
During treatment, rapid respiration and pulse rates should slow down and the child should begin
to pass urine.
Monitor progress of rehydration:
Observe half-hourly for two hours, then hourly for the next 6-12 hours, recording:
• pulse rate
• respiratory rate
• urine frequency
• stool/vomit frequency
Return of tears, moist mouth, eyes and fontanelle appearing less sunken, and improved skin
turgor, are also signs that rehydration is proceeding. Itshould be noted that many severely
malnourished children will not show these changes even when fully rehydrated. Continuing rapid
breathing and pulse during rehydration suggest coexisting infection or overhydration. Signs of
excess fluid (overhydration) are increasing respiratory rate and pulse rate, increasing oedema and
puffy eyelids. If these signs occur, stop fluids immediately and reassess after one hour.
To prevent dehydration when a child has continuing watery diarrhoea:
• keep feeding with starter F-75 (see step 7)
• replace approximate volume of stool losses with ReSoMal. As a guide give 50-100 ml after
each watery stool. (Note: it is common for malnourished children to pass many small unformed
stools: these should not be confused with profuse watery stools and do not require fluid
replacement)
• if the child is breastfed, encourage to continue5
Step 4. Correct electrolyte imbalance
All severely malnourished children have excess body sodium even though plasma sodium may
be low (giving high sodium loads will kill). Deficiencies of potassium and magnesium are also
present and may take at least two weeks to correct. Oedema is partly due to these imbalances.
Give:
• extra potassium 3-4 mmol/kg/d
• extra magnesium 0.4-0.6 mmol/kg/d
• when rehydrating, give low sodium rehydration fluid (e.g. ReSoMal)
• prepare food without salt
The extra potassium and magnesium can be prepared in a liquid form and added directly to feeds
during preparation. Appendix 3 provides a recipe for a combined electrolyte/mineral solution.
Adding 20 ml of this solution to 1 litre of feed will supply the extra potassium and magnesium
required. The solution can also be added to ReSoMal.5
Step 5: Treat/prevent infection
In severe malnutrition the usual signs of infection, such as fever, are often absent, and infections
are often hidden.
Therefore give routinely on admission:
• broad-spectrum antibiotic(s) and
• measles vaccine if child is > 6m and not immunized (delay if the child is in shock)5
Step 6. Correct micronutrient deficiencies
All severely malnourished children have vitamin and mineral deficiencies. Although anaemia is
common, do not give iron initially but wait until the child has a good appetite and starts gaining
weight (usually by the second week), as giving iron can make infections worse.
Give:
• Vitamin A orally on Day 1 (for age >12 months, give 200,000 IU; for age 6-12 months, give
100,000 IU; for age 0-5 months, give 50,000 IU) unless there is definite evidence that a dose has
been given in the last month
Give daily for at least 2 weeks:
• Multivitamin supplement
• Folic acid 1 mg/d (give 5 mg on Day 1)
• Zinc 2 mg/kg/d
• Copper 0.3 mg/kg/d
• Iron 3 mg/kg/d but only when gaining weight
Appendix 3 provides a recipe for a combined electrolyte/mineral solution. Adding 20 ml of this
solution to 1 litre of feed will supply the zinc and copper needed, as well as potassium and
magnesium. This solution can also be added to ReSoMal.5
Step 7. Start cautious feeding
In the stabilisation phase a cautious approach is required because of the child’s fragile
physiological state and reduced homeostatic capacity. Feeding should be started as soon as
possible after admission and should be designed to provide just sufficient energy and protein to
maintain basic physiological processes. The essential features of feeding in the stabilisation
phase are:
• small, frequent feeds of low osmolarity and low lactose
• oral or nasogastric (NG) feeds (never parenteral preparations)
• 100 kcal/kg/d
• 1-1.5 g protein/kg/d
• 130 ml/kg/d of fluid (100 ml/kg/d if the child has severe oedema)
• if the child is breastfed, encourage to continue breastfeeding but give the prescribed amounts of
starter formula to make sure the child’s needs are met. The suggested starter formula and feeding
schedules (see below) are designed to meet these targets. Milk-based formulas such as starter F-
75 containing 75 kcal/100 ml and 0.9 g protein/100 ml will be satisfactory for most children (see
Appendix 5 for recipes). Give from a cup. Very weak children may be fed by spoon, dropper
or syringe. A recommended schedule in which volume is gradually increased, and feeding
frequency gradually decreased is:
Days Frequency Vol/kg/feed Vol/kg/d
1-2 2-hourly 11 ml 130 ml
3-5 3-hourly 16 ml 130 ml
6-7+ 4-hourly 22 ml 130 ml
For children with a good appetite and no oedema, this schedule can be completed in 2-3 days
(e.g. 24 hours at each level). Appendix 6 shows the volume/feed already calculated according to
body weight. Appendix 7 gives the feed volumes for children with severe oedema. Use the Day 1
weight to calculate how much to give, even if the child loses or gains weight in this phase.5
If, after allowing for any vomiting, intake does not reach 80 kcal/kg/d (105 ml starter
formula/kg) despite frequent feeds, coaxing and re-offering, give the remaining feed by NG tube
Do not exceed 100 kcal/kg/d in this phase.
Monitor and note:
• amounts offered and left over
• vomiting
• frequency of watery stool
• daily body weight
During the stabilisation phase, diarrhoea should gradually diminish and oedematous children
should lose weight. If diarrhoea continues unchecked despite cautious refeeding, or worsens
substantially, see section C4 (continuing diarrhoea).5
Step 8. Achieve catch-up growth
In the rehabilitation phase a vigorous approach to feeding is required to achieve very high
intakes and rapid weight gain of >10 g gain/kg/d. The recommended milk-based F-100 contains
100 kcal and 2.9 g protein/100 ml. Modified porridges or modified family foods can be used
provided they have comparable energy and protein concentrations. Readiness to enter the
rehabilitation phase is signalled by a return of appetite, usually about one week after admission.
A gradual transition is recommended to avoid the risk of heart failure which can occur if children
suddenly consume huge amounts. To change from starter to catch-up formula replace starter F-
75 with the same amount of catch-up formula F-100 for 48 hours then, increase each successive
feed by 10 ml until some feed remains uneaten. The point when some remains unconsumed is
likely to occur when intakes reach about 30 ml/kg/feed (200 ml/kg/d).5
Monitor during the transition for signs of heart failure:
• respiratory rate
• pulse rate
If respirations increase by 5 or more breaths/min and pulse by 25 or more beats/min for two
successive 4-hourly readings, reduce the volume per feed (give 4-hourly F-100 at 16 ml/kg/feed
for 24 hours, then 19 ml/kg/feed for 24 hours, then 22 ml/kg/feed for 48 hours, then increase
each feed by 10 ml as above).
After the transition give frequent feeds (at least 4-hourly) of unlimited amounts of a catch up
formula
• 150-220 kcal/kg/d
• 4-6 g protein/kg/d
if the child is breastfed, encourage to continue. Breast milk does not have sufficient energy and
protein to support rapid catch-up growth.
Monitor progress after the transition by assessing the rate of weight gain:
• weigh child each morning before feeding.
• each week calculate and record weight gain as g/kg/d3
If weight gain is:
• poor (<5 g/kg/d), child requires full reassessment
• moderate (5-10 g/kg/d), check whether intake targets are being met, or if infection has been
overlooked.
• good (>10 g/kg/d), continue to praise staff and mothers5
Step 9. Provide sensory stimulation and emotional support
In severe malnutrition there is delayed mental and behavioural development.
Provide:
• tender loving care
• a cheerful, stimulating environment
• structured play therapy 15-30 min/d (Appendix 10 provides examples)
• physical activity as soon as the child is well enough
• maternal involvement when possible (e.g. comforting, feeding, bathing, play)5
Step 10. Prepare for follow-up after recovery
A child who is 90% weight-for-length (equivalent to -1SD) can be considered to have recovered.
The child is still likely to have a low weight-for-age because of stunting. Good feeding practices
and sensory stimulation should be continued at home. Show parent or carer how to:
• feed frequently with energy- and nutrient-dense foods
• give structured play therapy5
Advise parent or carer to:
• bring child back for regular follow-up checks
• ensure booster immunizations are given
• ensure vitamin A is given every six months5
Diarrhoea is a common feature of malnutrition but it should subside during the first week of
treatment with cautious feeding. In the rehabilitation phase, loose, poorly formed stools are no
cause for concern provided weight gain is satisfactory.Mucosal damage and giardiasis are
common causes of continuing diarrhoea. Where possible examine the stools by microscopy.
Give:
• metronidazole (7.5 mg/kg 8-hourly for 7 days) if not already given .Lactose intoleranceis only
rarely is diarrhoea due to lactose intolerance. Treat only if continuing diarrhoea is preventing
general improvement. Starter F-75 is a low-lactose feed. In exceptional cases substitute milk
feeds with yoghurt or a lactose-free infant formula and reintroduce milk feeds gradually in the
rehabilitation phase. Osmotic diarrhoea may be suspected if diarrhoea worsens substantially with
hyperosmolar starter F-75 and ceases when the sugar content is reduced and osmolarity is <300
mOsmol/l. In these cases use isotonic F-75 or low osmolar cereal-based F-75 and introduce F-
100 gradually.5
If TB is strongly suspected (contacts with adult TB patient, poor growth despite good
intake, chronic cough, chest infection not responding to antibiotics) perform Mantoux test (false
negatives are frequent) chest X-ray if possible. If test is positive or there is a strong suspicion of
TB, treat according to national TB guidelines.5
FAILURE TO RESPOND TO TREATMENT
Failure to respond is indicated by:5
• within 24 hours: consider untreated or delayed treatment of hypoglycaemia, hypothermia,
septicaemia, severe anaemia or incorrect rehydration fluid or volume.
• within 72 hours: check whether the volume of feed is too high or the wrong formulation is used
• at night: consider hypothermia from insufficient covers, no night feeds
• when changing to catch-up F-100: consider too rapid a transition
2. Low weight gain during the rehabilitation phase
Poor: <5g/kg/d
Moderate: 5-10g/kg/d
Good: >10 g/kg/d
If weight gain is <5 g/kg/d determine:
• whether this is for all cases (need major management overhaul)
• Whether this is for specific cases (reassess child as for a new admission)
Possible causes of poor weight gain are:
a) Inadequate feeding
Check:
• That night feeds are given
• That target energy and protein intakes are achieved: is actual intake (offered minus leftovers)
correctly recorded? Is the quantity of feed recalculated as the child gains weight? Is the child
vomiting or ruminating?
Feeding technique: is the child fed frequently and offered unlimited amounts?
• Quality of care: are staff motivated/gentle/loving/patient?
• All aspects of feed preparation: scales, measurement of ingredients, mixing, taste, hygienic
storage, adequate stirring if the ingredients separate out
• That if giving family foods, they are suitably modified to provide >100 kcal/100g (if not, re-
modify). If resources for modification are limited, or children are not inpatients, compensate by
replacing F-100 with catchup F-135 containing 135 kcal/100ml.
b) Specific nutrient deficiencies
Check:
• adequacy of multivitamin composition and shelf-life
• preparation of electrolyte/mineral solution and whether this is correctly prescribed and
administered. If in goitrous region, check potassium iodide (KI) is added to the
electrolyte/mineral solution (12 mg/2500 ml) or give all children Lugol’s iodine (5-10 drops/day)
• that, if modified family foods are substantially replacing F-100, electrolyte/ mineral solution is
added to the family food (20 ml/day)
c) Untreated infection
If feeding is adequate and there is no malabsorption, some hidden infection can be suspected.
Urinary tract infections, otitis media, TB and giardiasis are easily overlooked, hence re-examine
carefully, repeat urinalysis for white blood cells, examine stools and if possible, take chest X-
ray. Later alter the antibiotic schedule only if a specific infection is identified.
d) HIV/AIDS
In children with HIV/AIDS, good recovery from malnutrition is possible though it may take
longer and treatment failures may be common. Lactose intolerance occurs in severe HIV-related
chronic diarrhoea. Treatment should be the same as for HIV negative children.5
Our patient is administered F75 diet 55cc orally every two hours and was later increased
to F100 diet 55cc orally every two hours. For the first few days the patient was give resomal
until the diarrhea stops. Cotrimoxazole syrup was given as a prophylaxis antibiotics. Later on as
patient showed less improvement in weight gain, the F100 diet was increased .
Mortality of hospitalized children with marasmus is high, especially during the first few
days of rehabilitation. Death is usually caused by infections or other causes. If the child has no
clinical sign of infection, the WHO recommends 5 days of oral cotrimoxazole therapy. If the
child presents with clinical signs of infection, hypoglycemia, or hypothermia he or she must be
considered as seriously infected and treated with parenteral ampicillin and gentamicin. Practice
guidelines for acute diarrhea have been established. Persistent and profuse diarrhea has 2 main
causes. Infectious etiology (especially lambliasis). This can be promptly treated with
metronidazole if possible, after stool examination. In osmotic diarrheas sugar of the F75 solution
should be replaced by cereal flour for 1-2 weeks. 2
Malnutrition places stressed patients at a greatly increased risk for morbidity and
mortality. Numerous reports have documented the association between malnutrition and clinical
outcome in a variety of clinical settings.
Some complications are considerably more common in malnourished patients and those with
inadequate nutrient intake than in well-nourished individuals.
These complications include: 3
A longer recovery period.
Impaired host defenses and sepsis.
Impaired wound healing.
Anemia.
Impaired GI tract function.
Muscle atrophy.
Impaired cardiac function.
Impaired respiratory function.
Reduced renal function.
Brain dysfunction.
Delayed bone callus formation.
Atrophic skin.
Malnutrition is a common factor seen in HIV/AIDS patients especially kids.
There is usually a combination of reasons why people with AIDS become malnourished.
First of all, there is the impact of HIV itself. The virus can cause changes in the body's
metabolism. Metabolic disturbances may cause the metabolic rate to go up. This results
in the body burning calories more quickly than is normal and thus requiring more calories
than is normal. If the HIV+ patient is not taking in enough calories to make up for this
increased metabolic rate, he/she can quickly become malnourished. Another metabolic
deregulation that we sometimes find with HIV is cachexia. Normally, when someone is
malnourished, their body burns fat and preserves the lean tissue mass. With cachexia,
there is accelerated tissue loss, with an almost immediate depletion of lean tissue mass.
This speeds up the wasting and brings on immediate threats. Diarrhea is a common
symptom of HIV disease and can contribute to malnutrition. Some of the causes of
diarrhea are amoebas, cryptosporidium and microsporidium. With these conditions, the
body is not able to absorb the calories that it is taking in. Besides the absorption
problems, diarrhea can also cause someone to cut down or stop eating. For these reasons,
chronic diarrhea can bring on severe wasting. Many people with AIDS suffer from
nausea. Chemotherapy for lymphoma can bring this on, as well as many of the drugs used
to fight opportunistic infections. When people are nauseous, they simply do not want to
eat. This is very dangerous for PWAs, and can start the weight loss that can become life
threatening. A host of oral problems can also stop someone from eating. Gum disease,
herpes in the mouth, lesions in the mouth or esophagus, oral candida, and oral ulcers are
all problems that people with HIV may face. All of these conditions make it painful to eat
or swallow; without realizing it, someone with any one of these conditions can begin to
avoid eating and become malnourished. 2
Our patient was done CD4+ count to eradicate the possibility of HIV causing the
malnutrition and the result suggest no HIV present. The patient has diarrhea that may have been
the cause of his poor hygiene practice by family in food presentation or way of living.
The next discussion is about diarrhea that is present in the patient. Diarrhea occurs
commonly in both children and adults. Diarrhea lasting less than seven days is considered acute.
The majority of diarrheal episodes fall into this category. Diarrhea lasting more than 7 days is
defined as persistent, while diarrhea for more than 30 days is chronic. Malabsorption is the
body's inability to use the food that it takes in, often causing diarrhea.5
Diarrhea lasting more than seven days can be caused by a number of different problems,
including6
Chronic gastroenteritis can be caused by infections, including those caused by viruses,
bacteria and parasites. Most children with chronic diarrhea will have a stool test for polys
and blood, a routine bacterial culture, an ova and parasite test, a test for the Giardia
antigen and C. difficile toxin, especially if he has recently been on antibiotics.10
Postinfectious diarrhea sometimes occurs in children with gastroenteritis and may be
from an intolerance to lactose or proteins in cow's milk. Soy milk or formula (for younger
children) may be helpful for children with this condition.8
Toddler's Diarrhea or chronic nonspecific diarrhea usually occurs in children between the
ages of 6 months and 3 years, and causes loose, watery stools in children without other
symptoms. Although they have chronic diarrhea, children with toddler's diarrhea should
have a normal appetite and will be growing and developing normally, and usually drink
too much juice. If your doctor suspects that you child's diarrhea is from this condition,
then it may help to decrease the amount of fluids your child drinks, and especially avoid
juices with a high sorbital or fructose content, like apple and pear juice. Instead, give him
orange and grape juice. It may also help to increase the amount of fat and fiber in his
diet.6
Malabsorption can be caused by many different medical conditions, including cystic
fibrosis, short bowel syndrome, celiac disease or gluten sensitive enteropathy and
infections, especially Giardiasis. Children with malabsorption typically have very large
and foul smelling stools, which may appear greasy, weight loss or poor weight gain and
abdominal distention. An examination for stool fat content or a 72 hour stool collection
for fat analysis, a test for carbohydrate by checking for reducing substances, and testing
the stool pH may be helpful to see if a child has malabsorption. Children with
malabsorption may also have a low serum albumin concentration. Other testing may
include a small bowel biopsy.6
Inflammatory bowel disease , including Ulcerative Colitis and Crohn's disease, with the
most common symptoms being diarrhea, usually with bleeding, cramping abdominal
pain, obstruction (a blockage of the intestine), malabsorption (failure of the intestines to
absorb minerals and nutrients), and weight loss or poor weight gain. Other symptoms can
include fever, anorexia (poor appetite), anemia (low blood counts), skin rashes, especially
erythema nodosum (tender red bumps or nodules on the front of the lower legs) and
pyoderma gangrenosum (painful skin ulcers), oral aphthous ulcers, and hepatitis
(inflammation of the liver). Children with Crohn disease can also have perirectal disease,
with fistulas, abscesses, or fissures around the rectum.6
lactose intolerance causes diarrhea, abdominal pain, bloating, gas and weight loss can
occur in children who don't have enough of the enzyme lactase to digest lactose in the
foods they eat. While some children do have to avoid all products with lactose, others are
able to handle some foods, such as yogurt, and other foods after taking a lactase enzyme
supplement.6
Other causes of chronic diarrhea can include food intolerances, immune disorders,
metabolic abnormalities, hormone secreting tumors, and other conditions that affect the
pancreas, liver or small intestine.6
In our case, our patient comes with the complaint of constant diarrhea more than one
month. The content of the feces is water more than waste. Besides that, our patient also vomits
out whatever which is being eaten up.
Referance
1. American Association for Clinical Chemistry 2011. Accesed on 2011-10-03.
2. World Health Organization. WHO Global Database on Child Growth and Malnutrition.
Geneva: WHO. 1997.
3. Rich Klasco, M.D., FACEP. Kwashiorkor symptoms and diagnosis.
http://www.bettermedicine.com/article/kwashiorkor
4. Noah S Scheinfeld, MD, JD, FAAD; Chief Editor: William D James, MD.
http://emedicine.medscape.com/article/1104623-overview
5. Crosworth Ann, Guidelines for the inpatient treatment of the severely malnourished
patient. WHO Publication 2003.
6. DuPont HL, Practice Parameters Committee of the American College of
Gastroenterology. Guidelines on acute infectious diarrhea in adults. The American
Journal of Gastroenterology. 1997;92(11):1962–1975.
7. Ramaswamy K, Jacobson K. Infectious diarrhea in children. Gastroenterology Clinics of
North America. 2001;30(3):611–624
8. National Digestive Diseases Information Clearinghouse (NDDIC)
http//:www.digestive.niddk.nih.gov/
9. Persistent Diarrhoea : Clinical Update: A supplement to Issue no. 48 - March 1992
http://rehydrate.org/dd/su48.htm
10. Gastroenterology and hepatology nutrition
http://www.nationwidechildrens.org/persistent-diarrhea-and-malabsorption
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