MALNUTRITION IN MALNUTRITION IN CHILDRENCHILDREN..

PRINCIPLES OF PRINCIPLES OF DEHYDRATION DEHYDRATION CORRECTION.CORRECTION.

Sakharova Inna Ye., MD, Sakharova Inna Ye., MD, PhDPhD

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MalnutritionMalnutrition will be responsible for 3,000 will be responsible for 3,000 deaths globally, mostly women, infants deaths globally, mostly women, infants and children, and children, during this lecture!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 Some Major World Risk Factors Causing DeathsDeaths

Some WHO Major Risk Factors Causing World Deaths in 2000

0 5 000 10 000 15 000 20 000 25 000 30 000 35 000

Malnutrition

Tobacco

Unsafe sex

Alcohol

Unsafe water,sanitation, hygiene

Occupational safety

Ris

k F

ac

tor

Number of Deaths (X1000)(World Health Report, 2002)

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A healthy diet provides a A healthy diet provides a

balanced nutrients that balanced nutrients that

satisfy the metabolic satisfy the metabolic

needs of the body without needs of the body without

excess or shortage.excess or shortage.

Dietary requirements of Dietary requirements of children vary according to age, children vary according to age, sex & development.sex & development.

Dora, 3, receives a dose of vitamin Aoutside a mobile health clinic inNamurava village in Mozambique.

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““Hidden Hunger”Hidden Hunger” – deficit of – deficit of vitamins and microelements vitamins and microelements in diet.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 AssesmentLab Assesment Full blood countsFull blood counts Blood glucose profileBlood glucose profile Septic screeningSeptic screening Stool & urine for Stool & urine for

parasites & germsparasites & germs Electrolytes, Ca, Ph & Electrolytes, Ca, Ph &

ALP, serum proteinsALP, serum proteins CXR & Mantoux testCXR & Mantoux test Exclude HIV & Exclude HIV &

malabsorptionmalabsorption

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NON-ROUTINE TESTSNON-ROUTINE TESTS

Hair analysisHair analysis Skin biopsySkin biopsy Urinary creatinine over proline Urinary creatinine over proline

ratioratio Measurement of trace elements Measurement of trace elements

levels, iron, zinc & iodinelevels, iron, zinc & iodine

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OVERVIEW OF PEM OVERVIEW OF PEM (Protein Energy (Protein Energy

Malnutrition)Malnutrition) The majority of world’s children The majority of world’s children

live in developing countrieslive in developing countries Lack of food & clean water, poor Lack of food & clean water, poor

sanitation, infection & social sanitation, infection & social unrest lead to LBW & PEMunrest lead to LBW & PEM

Malnutrition is implicated in Malnutrition is implicated in >50% of deaths of <5 children (5 >50% of deaths of <5 children (5 million/yr)million/yr)

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OVERVIEW OF PEM OVERVIEW OF PEM

In 2000 WHO estimated that 32% of In 2000 WHO estimated that 32% of <5 children in developing countries <5 children in developing countries are underweight (182 million).are underweight (182 million).

78% of these children live in South-78% of these children live in South-east Asia & 15% in Sub-Saharan east Asia & 15% in Sub-Saharan Africa.Africa.

The reciprocal interaction between The reciprocal interaction between PEM & infection is the major cause of PEM & infection is the major cause of death & morbidity in young children.death & morbidity in young children.

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Definitions of MalnutritionDefinitions of Malnutrition

KwashiorkorKwashiorkor: protein deficiency: protein deficiency MarasmusMarasmus: energy deficiency: energy deficiency Marasmic/ KwashiorkorMarasmic/ Kwashiorkor: :

combination of chronic energy combination of chronic energy deficiency and chronic or acute deficiency and chronic or acute protein deficiencyprotein deficiency

Failure to thriveFailure to thrive: marasmus in U. : marasmus in U. S. children under 3.S. children under 3.

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Definitions of MalnutritionDefinitions of Malnutrition

PrimaryPrimary: inadequate food : inadequate food intakeintake

SecondarySecondary: result of disease: result of disease MixedMixed

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DiagnosisDiagnosis Normal: ± 1 SDNormal: ± 1 SD Mild: -1.1 to -2 SD Mild: -1.1 to -2 SD Moderate -2.1 to -3 SDModerate -2.1 to -3 SD Severe greater than -3Severe greater than -3 Less than 5Less than 5thth

percentilepercentile BMI in adolescents BMI in adolescents

Moderate <15 ages Moderate <15 ages 11-13, <16.5 ages 14-11-13, <16.5 ages 14-1717

Severe <13 ages 11-Severe <13 ages 11-13, <14.5 ages 14-1713, <14.5 ages 14-17

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CLASSIFICATION OF CLASSIFICATION OF

MALNUTRITION IN CHILDRENMALNUTRITION IN CHILDREN MILD MILD MALNUTRITIONMALNUTRITION

MODERATE MODERATE MALNUTRITIONMALNUTRITION

SEVERESEVERE

MALNUTRITIONMALNUTRITION

Percent Ideal Percent Ideal Body weightBody weight

80-90 %80-90 % 70-70 %70-70 % LESS THAN 70 LESS THAN 70 %%

Percent Usual Percent Usual Body weightBody weight

90-95 %90-95 % 80-85 %80-85 % LESS THAN 80 LESS THAN 80 %%

Albumin (g/dL)Albumin (g/dL) 2.8-3.42.8-3.4 2.1-2.72.1-2.7 LESS THAN 2.1LESS THAN 2.1

Transferrin Transferrin (mg/dl)(mg/dl)

150-200150-200 100-149100-149 LESS THAN 100LESS THAN 100

Total Total Lymphocyte Lymphocyte

Count (per µL)Count (per µL)

1200-20001200-2000 800-1199800-1199 LESS THAN 800LESS THAN 800

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Gomez ClassificationGomez Classification: : The child's weight is The child's weight is compared to that of a normal child (50th percentile) compared to that of a normal child (50th percentile) of the same age. It is useful for population screening of the same age. It is useful for population screening and public health evaluations.and public health evaluations.

percent of reference weight for age = percent of reference weight for age = ((patient weight) / (weight of normal ((patient weight) / (weight of normal child of same age)) * 100child of same age)) * 100

Interpretation:Interpretation:90 - 110% normal90 - 110% normal75 - 89% Grade I: mild malnutrition75 - 89% Grade I: mild malnutrition60 - 74% Grade II: moderate malnutrition60 - 74% Grade II: moderate malnutrition< 60% Grade III: severe malnutrition< 60% Grade III: severe malnutrition

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Wellcome Classification:Wellcome Classification: evaluates evaluates the child for edema and with the the child for edema and with the Gomez classification system.Gomez classification system.

Grades:Grades: 80-60 % without oedema is under 80-60 % without oedema is under

weigweightht 80-60% with oedema is Kwashiorkor80-60% with oedema is Kwashiorkor < 60 % with oedema is Marasmus-< 60 % with oedema is Marasmus-

KwashKwash < 60 % without oedema is Marasmus< 60 % without oedema is Marasmus

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KWASHIORKORKWASHIORKOR Cecilly Williams, a British nurse, Cecilly Williams, a British nurse, had had

introduced the word introduced the word KwashiorkorKwashiorkor to to

the medical literaturethe medical literature in 1933 in 1933. The . The

word word is taken from the Ga language is taken from the Ga language

in Ghana & used to describe the in Ghana & used to describe the

sickness of weaning (“the sickness sickness of weaning (“the sickness

the older child gets when the next the older child gets when the next

baby is born”)baby is born”). .

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ETIOLOGYETIOLOGY Kwashiorkor can occur in Kwashiorkor can occur in

infancy but its maximal infancy but its maximal

incidence is in the 2nd yr incidence is in the 2nd yr

of life following abrupt of life following abrupt

weaning. weaning.

Kwashiorkor is not only Kwashiorkor is not only

dietary in origin. dietary in origin.

Infective, psycho-socical, Infective, psycho-socical,

and cultural factors are and cultural factors are

also operative.also operative.

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ETIOLOGYETIOLOGY Kwashiorkor is an example of Kwashiorkor is an example of

lack of physiological lack of physiological adaptation to unbalanced adaptation to unbalanced deficiency where the body deficiency where the body utilized proteins and utilized proteins and conserve S/C fat. conserve S/C fat.

One theory says Kwash is a One theory says Kwash is a result of liver insult with result of liver insult with hypoproteinemia and hypoproteinemia and oedema. Food toxins like oedema. Food toxins like aflatoxins have been aflatoxins have been suggested as precipitating suggested as precipitating factors.factors.

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CONSTANT FEATURES OF KWASHCONSTANT FEATURES OF KWASH

OEDEMAOEDEMA

PSYCHOMOTOR PSYCHOMOTOR

CHANGESCHANGES

GROWTH GROWTH

RETARDATIONRETARDATION

MUSCLE WASTINGMUSCLE WASTING

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USUALLY PRESENT SIGNSUSUALLY PRESENT SIGNS

MOON FACEMOON FACE

HAIR CHANGESHAIR CHANGES

SKIN SKIN

DEPIGMENTATIONDEPIGMENTATION

ANAEMIAANAEMIA

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OCCASIONALLY PRESENT SOCCASIONALLY PRESENT SIGNSIGNS

HEPATOMEGALYHEPATOMEGALY

FLAKY PAINT DERMATFLAKY PAINT DERMATITIITISS

CARDIOMYOPATHY & CARDIOMYOPATHY & FAILUREFAILURE

DDEHYDRATION (Diarrh.EHYDRATION (Diarrh. & & Vomiting)Vomiting)

SIGNS SIGNS OF OF VITAMIN VITAMIN DEFICIENCIESDEFICIENCIES

SIGNS OF INFECTIONSSIGNS OF INFECTIONS

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DD of Kwash DermatitisDD of Kwash Dermatitis

AcrodermatitiAcrodermatitis s EntropathicaEntropathica

ScurvyScurvy PellagraPellagra Dermatitis Dermatitis

HerpitiformisHerpitiformis

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MARASMUSMARASMUS

The term marasmus is The term marasmus is derived from the Greek derived from the Greek marasmos,marasmos, which means which means wasting. wasting.

Marasmus involves Marasmus involves inadequate intake of protein inadequate intake of protein and calories and is and calories and is characterized by emaciation.characterized by emaciation.

Marasmus represents the Marasmus represents the end result of starvation end result of starvation where both proteins and where both proteins and calories are deficient.calories are deficient.

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MARASMUSMARASMUS

Marasmus represents Marasmus represents an an

adaptive response to adaptive response to starvation, whereas starvation, whereas kwashiorkor kwashiorkor represents a represents a maladaptive response maladaptive response to starvation to starvation

IIn Marasmus n Marasmus tthe body he body utilizes all fat stores utilizes all fat stores before using muscles.before using muscles.

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EPIDEMIOLOGY & ETIOLOGYEPIDEMIOLOGY & ETIOLOGY

Seen most commonly in the first Seen most commonly in the first year of life due to lack of breast year of life due to lack of breast feeding and the use of dilute feeding and the use of dilute animal milkanimal milk..

Poverty or famine and diarrhoea Poverty or famine and diarrhoea are the usual precipitating factorsare the usual precipitating factors

Ignorance & poor maternal Ignorance & poor maternal nutrition are also contributory nutrition are also contributory

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Clinical Features of Clinical Features of MarasmusMarasmus

Severe wasting of Severe wasting of muscle & s/c fatsmuscle & s/c fats

Severe growth Severe growth retardationretardation

Child looks older Child looks older than his agethan his age

No edema or hNo edema or hair air changeschanges

Alert but Alert but miserablemiserable

HungryHungry Diarrhoea & Diarrhoea &

DehydrationDehydration

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Complications of P.E.MComplications of P.E.M

HypoglycemiaHypoglycemia HypothermiaHypothermia HypokalemiaHypokalemia HyponatremiaHyponatremia Heart failureHeart failure Dehydration & shockDehydration & shock Infections (bacterial, viral & thrush)Infections (bacterial, viral & thrush)

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TREATMENTTREATMENT

Correction of water & electrolyte Correction of water & electrolyte imbalanceimbalance

Treat infection & worm infestationsTreat infection & worm infestations Dietary support: 3-4 g protein & 200 Dietary support: 3-4 g protein & 200

Cal /kg body wt/day + vitamins & Cal /kg body wt/day + vitamins & mineralsminerals

Prevention of hypothermiaPrevention of hypothermia Counsel parents & plan future care Counsel parents & plan future care

including immunization & diet including immunization & diet supplementssupplements

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KEY POINT FEEDINGKEY POINT FEEDING

Continue breast feeding Continue breast feeding Add frequent small feedsAdd frequent small feeds Use liquid dietUse liquid diet Give vitamin A & folic acid on Give vitamin A & folic acid on

admissionadmission With diarrhea use lactose-free or With diarrhea use lactose-free or

soya bean formulasoya bean formula

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PROGNOSISPROGNOSIS

Kwash & Marasmus-Kwash have Kwash & Marasmus-Kwash have greater risk of morbidity & mortality greater risk of morbidity & mortality compared to Marasmus and under compared to Marasmus and under weightweight

Early detection & adequate treatment Early detection & adequate treatment are associated with good outcomeare associated with good outcome

Late ill-effects on IQ, behavior & Late ill-effects on IQ, behavior & cognitive functions are doubtful and cognitive functions are doubtful and not provennot proven

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Pediatric Fluid TherapyPediatric Fluid TherapyPrinciplesPrinciples

Assess water deficit by:Assess water deficit by:1. weight:1. weight:

weight loss (Kg) = water loss (L)weight loss (Kg) = water loss (L) OROR2. Estimation of water deficit by 2. Estimation of water deficit by

physical exam:physical exam:Mild Mild moderate moderate

severesevereInfantsInfants << 5 % 5 % 5 - 10 %5 - 10 % >>10 %10 %Older childrenOlder children << 3 % 3 % 3 - 6 %3 - 6 % >> 6 % 6 %

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Signs & sympt. MILD Moderate Severe

General Thirsty, allert, restless

Thirsty, irritable, or drowsy

Drowsy – limp, skin cold / sweaty

Radial pulse Normal rate Rapid, weak Rapid, feeble

Respiration Normal Deep Deep & rapid Anterior font. Normal Sunken Very sunken Skin turgor Pinch retracts

immediately Retracts slowly Poor

Eyes Normal Sunken Grossly sunken

Tears Present Absent Absent Mucous memb. Moist Dry Very dry Urine flow Normal Dark &

decreased Oliguria / anuria

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MANAGEMENT OF DEHYDRATIONMANAGEMENT OF DEHYDRATION--Replace Phase 1: Acute Resuscitation :Replace Phase 1: Acute Resuscitation :

Give Lactated Ringer OR Normal Saline at 10-20 Give Lactated Ringer OR Normal Saline at 10-20 ml/kg IV OR 5 % albumin over ml/kg IV OR 5 % albumin over 30-60 minutes.30-60 minutes.

May repeat bolus until circulation stable May repeat bolus until circulation stable -Calculate 24 hour maintenance requirements -Calculate 24 hour maintenance requirements

Formula: Formula: First 10 kg: (100 cc/kg/24 hours) First 10 kg: (100 cc/kg/24 hours) Second 10 kg: (50 cc/kg/24 hours) Second 10 kg: (50 cc/kg/24 hours) Remainder: (20 cc/kg/24 hours) Remainder: (20 cc/kg/24 hours)

Example: 35 Kilogram Child Example: 35 Kilogram Child Daily: 1000 cc + 500 cc + 300 cc = 1800 cc/day Daily: 1000 cc + 500 cc + 300 cc = 1800 cc/day

-Calculate Deficit:-Calculate Deficit: Mild Dehydration: (40 ml/kg) Mild Dehydration: (40 ml/kg) Moderate Dehydration: (80 ml/kg) Moderate Dehydration: (80 ml/kg) Severe Dehydration: (120 ml/kg) Severe Dehydration: (120 ml/kg)

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MANAGEMENT Continue MANAGEMENT Continue -Calculate remaining deficit:-Calculate remaining deficit:

Substract fluid resuscitation given in Phase 1 Substract fluid resuscitation given in Phase 1 -Calculate Replacement over 24 hours: -Calculate Replacement over 24 hours:

First 8 hours: 50% Deficit + Maintenance First 8 hours: 50% Deficit + Maintenance Next 16 hours: 50% Deficit + Maintenance Next 16 hours: 50% Deficit + Maintenance

Determine Serum Sodium Concentration Determine Serum Sodium Concentration Hypertonic DehydrationHypertonic Dehydration ( (Serum SodiumSerum Sodium > 150) > 150) Isotonic DehydrationIsotonic Dehydration Hypotonic Dehydration Hypotonic Dehydration ( (Serum SodiumSerum Sodium < 130) < 130)

Add Potassium to Intravenous Fluids after patient Add Potassium to Intravenous Fluids after patient voids urine voids urine Potassium source Potassium source

Potassium Chloride Potassium Chloride Potassium Acetate for Potassium Acetate for Metabolic AcidosisMetabolic Acidosis

Potassium dosing Potassium dosing Weight <10 kilograms: 10 meq KCl /liter Weight <10 kilograms: 10 meq KCl /liter

glucose glucose Weight >10 Kilograms: 20 meq KCl /liter Weight >10 Kilograms: 20 meq KCl /liter

glucoseglucose

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Hypertonic dehydrationHypertonic dehydration

Serum Na+ > 150 meq/L (up to 213)Serum Na+ > 150 meq/L (up to 213) Deficit replacement over 48 hours Deficit replacement over 48 hours

0.18% – 0.3%0.18% – 0.3% saline saline Regular daily maintenanceRegular daily maintenance Fluid evenly distributed over timeFluid evenly distributed over time Dialysis option in severe Dialysis option in severe

hypernatremiahypernatremia

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Hypotonic (hyponatriemic) Hypotonic (hyponatriemic) dehydrationdehydration

Total NaTotal Na++ Deficit = Deficit =

(Desired Na(Desired Na++) – (Actual Na) – (Actual Na++) ) ×× Body Wt Body Wt Kg Kg ×× 0.6 0.6

++

Calculate Fluid Deficit similar to Calculate Fluid Deficit similar to Isonatremic DehydrationIsonatremic Dehydration

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ConvulsionsConvulsionsRapid Intravenous administration Rapid Intravenous administration

of Naof Na++

3% saline3% saline infusion (1-12ml/kg infusion (1-12ml/kg body weight)body weight)

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PotassiumPotassium Daily requirement: 1-2 meq / kg body weight.Daily requirement: 1-2 meq / kg body weight. Usually add 10-20 meq KCl / L of IV fluid.Usually add 10-20 meq KCl / L of IV fluid. Added only once the urine output is Added only once the urine output is

established.established. In Hypokalemia, add: 30 meq / L of IV fluidIn Hypokalemia, add: 30 meq / L of IV fluid 40 meq / L of IV fluid40 meq / L of IV fluid 50 meq50 meq / L of IV fluid / L of IV fluid 60 meq60 meq / L of IV fluid / L of IV fluid 70 meq70 meq / L of IV fluid / L of IV fluid ECG monitoringECG monitoring Frequent testingFrequent testing

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Hypokalemia Hypokalemia ManagementManagement

Maximum IV infusion rate:Maximum IV infusion rate:

1 mEq/kg/hr1 mEq/kg/hr Marked hypokalemia:Marked hypokalemia:

Monitor serum K closelyMonitor serum K closely

0.5-1 mEq/kg/dose given as an 0.5-1 mEq/kg/dose given as an infusion of 0.5 mEq/kg/hr for 1-2 infusion of 0.5 mEq/kg/hr for 1-2 hourhour

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In severe acidosis:In severe acidosis: Alkali therapy (NaHCOAlkali therapy (NaHCO33) IV) IV Calculation: Calculation:

(Desired HCO(Desired HCO33-- -- Actual HCO Actual HCO33

--) ) ××

body wt Kg body wt Kg ×× 0.45 0.45

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