Malnutrition Flashcards
When are people malnourished?
When they have decreased caloric intake(malnutrition) or if their diet does not provide enough calories(over-nutrition)
What is protein energy malnutrition?
Malnutrition caused by insufficient food and defined as dietary energy intake below the minimum level
What is reductive adaptation?
When the body adapts to under-nutrition by maintaining vital functions, slowing down cell growth, and differentiation and decreasing the metabolic rate
How many more times will SAM cause death in children?
10 times more likely
Why does gas to-intestinal infections cause malnutrition?
Because often the child vomits, has diarrhea, anorexia, and increased metabolic needs
What information does height/length for weight give us?
Stunting and points more to a chronic illness
At what age do we stop measuring head circumference?
5 years
Ands we have to at least get 2 measurements for head circumference
Why does the head seem bigger in malnourished children?
Because the head circumference is the last to stop growing in chronic malnutrition
What does weight for height/length indicate?
Recent loss of weight(wasting)
When do we start calculating the BMI?
After 2 years
It is calculated with weight/height (m) squared
What is the MUAC and in which age group do we use it in?
6-59 months and it is a screening tool for malnutrition
What do these readings mean? MUAC: <11,5cm 11,5cm-12,4cm 12,5-13,5 cm >13,5 cm
- Severe acute malnutrition
- Moderate malnutrition
- Mild malnutrition
- Normal child
What are the signs of shock in a child?
- Cold hands
- Lethargic or unconscious
- Weak fast pulse
What lab tests can we do in malnutrition?
- Serum pre-albumin and albumin
- Transferrin
- Electrolyte abnormalities like hypokalaemia, hypocalcaemia, and hypomagnesemia are usually found as well
- CD4, CD8 indices usually fall as well
How do we define SAM?
- Presence of bipedal oedema not caused with other reasons
2. Severe wasting- weight for heigh
Why should we restrict sodium in malnourished children?
Because one of the cellular changes that happen is the conservation of sodium and the leakage of potassium into the urine
What happens to the heart in children with SAM?
Decreased contractility and bradycardia because of hypokalaemia
-the cardiac output and stroke volume are also decreased in proportion to the weight loss
What happens in the liver?
There is decreased metabolism and toxins
What happens with the urogenital system in these patients?
They have frequent UTI’s
Because of the reduced glomerular filtratration rate
The ability of the kidneys to excrete sodium, excess acid and water is greatly reduced
What happens in the gastro-intestinal tract?
Atrophy of the bowel mucosa with billows atrophy
Pancreatic enzyme secretion is decreased due to atrophy of the pancreas
-there is decreased secretion of gastric acid, decreased intestinal motility and bacterial motility overgrowth
What happens in the endocrine system?
- Patients have glucose intolerance and develop hypoglycemia during periods of infection and refeeding
What happens with metabolism?
- Heat production and heat loss are impaired
The child becomes hypothermic in a cold environment and hyperthermia in hot environments
What is the effect on the immune system?
- Malnutrition causes atrophy of the lymph glands, tonsils, the thymus, affecting cellular immunity the most
This causes delayed hypersensitivity so even typical signs of infection like leucocytosis and fever are frequently absent
What is the haematological effect on malnutrition?
There is low red cell count which results in anaemia which can be normochromic normocytic, microcytic and macrocytic
Anaemia of malnutrition may be caused by iron deficiency anaemia
What is the effect on the neurological system?
Behavioral changes like irritability and apathy, decreased social responsiveness and attention deficits
-severe malnutrition can causes decreasesd neurons, synapses and myelinations which leads to decreased brain size
What are the features of malnutrition on the skin, muscle and glands?
- Loose skin folds because the subcutaneous fat is atrophied
- The skeletal muscle is lost as lactate, amino acids and pyruvate
What age group is affected by kwashiorkor most?
Between 9 months and 3 years
What kind of oedema do children with kwashiorkor develop?
- Mild oedema- feet and ankles
- Moderate- feet, lower legs, hands or lower arms
- Severe- generalised pitting oedema including peri-orbital
Why do children with kawashiorkor develop abdominal distension?
Poor abdominal musculature
Why do children with kwashiorkor develop hepatomegaly?
Secondary to fatty infiltration
What are the skin lesions that occur in kwashiorkor?
The skin becomes hyperpigmentated, dry and then splits into pale areas particularly over the limbs, the perineum and the buttocks
What happens to the hair of children with kwashiorkor?
It becomes depigmented like reddish yellow to white
Curly hair becomes straight
-the starlight sign starts to occur-where there are intermittent bands of dark and pale hair if there are periods of good nutrition and bad nutrition
What do the faces of children with kwashiorkor look like?
Moon face with rounded prominence of the cheeks
What is nutritionally acquired immune deficiency syndrome?
-the triad of malnutrition leads to impaired immunity which leads to more infection which precipitates the the infection further
What ages are affected by marasmus?
All ages but young infants are more at risk
-it is the childhood equivalent to starvation
What is the clinical presentation of children with marasmus?
- Wizened and cachetic look(due to loss of buccal fat pads)
- Redundant skin folds due to loss of fat, and muscle which affects the buttock, legs, arms and face more commonly
- The head looks disproportionately bigger than the body
- These children are bradycardia, have hypotension and are hypothermic
What lab tests would we do in children with malnutrition?
- Blood glucose
- Blood culture
- Blood smear
- Electrolytes (Potassium, calcium, magnesium)
- Urine culture to test for UTI
- HIV
What does IMCI stand for?
Integrated management of childhood illness
What are the 12 danger signs of the IMCI?
- Lethargy
- Hypoglycaemia
- Hypotension
- Convulsions
- Weeping skin lesions
- Dehydration
- Anorexia
- Jaundice
- Respiratory distress
- Bleeding
- Shock
- Vomiting all feeds
Why cant we give IV infusions to children with SAM?
They are at increased risk of heart failure because of strophic heart muscle, electrolyte imbalance and in trace lunar sodium
How often do we need to feed children with SAM in casualty?
2-3 hours per day and night
What are the 10 WHO steps
- Treat/prevent hypoglycaemia
- Treat/prevent hypothermia
- Treat/prevent dehydration
- Correct electrolyte imbalance
- Treat infection
- Correct micro-nutrient deficiency
- Feed cautiously initially
- Rebuilds wasted tissues
- Provide stimulation with stimulation, love and care
- Prepare fo follow up after discharge
What are the two phases of management for malnutrition?
- Stabilization phase
2. Rehabilitation phase
What does the stabilization phase entail?
It usually happens over 3-5 days
This is to return the body to homeostasis
The main objective is to stabilize the child and not necessarily aim for weight gain
We also treat the immediate life threatening situations: hypoglycemia, hypothermia, dehydration and anaemia
What is the transition phase?
It is between the stabilization and rehabilitation phase
-it is for 4-5 days
What is the rehabilitation phase?
This usually occurs for 4-6 weeks
The children are given more high protein and high energy food
How do we treat the hypoglycemia? <3mmol/l
- Start with feeds every 2-3 hours
- If asymptomatic: give 10% dextrose orally
- If symptomatic give 10% dextrose IV bolus(5ml/kg)
Why does hypoglycemia occur in these patients?
There is decreased gluconeogenis in the liver and decreased glycogen reserves in the liver and muscle
How do we treat the hypothermia?
Hypothermia is rectal or oral temperature of <35,5 degrees and if in the axilla it is 35 degrees
Why are malnourished children at an increased risk of hypothermia?
Decreased metabolic rate and so heat production is decreased
They also have less insulation because of the loss of fat
How do we treat the dehydration?
Oral rehydration solution
-we only would use IV ringers lactate with 5% dextrose at 15ml/kg if the patient is in shock
What is management for the electrolyte imbalances?
- Never give sodium because the child is already overloaded
2. Give F-75 and F-100 feeds to help give the micro-nutrients
How do we treat children with infections?
- Give broad spectrum AB-amoxicillin orally if not complicated
- If complicated give ampicillin and gentamycin IV(UTI’S, hypoglycemia, hypothermia)
What is the management for micro-nutrient deficiency?
- Give vitamin A, folic acid, zinc, copper, and multivitamin supplements
- They should also be given iron in the rehabilitation phase
What are the doses of vitamin a we can give to patients on admission day?
- <6 months we give 50 000 units
- 6-12 months we give 100 000 units
- > 12 months we give 200 000 units
When would we consider blood transfusion?
Hb of <4
Why should we not give iron in the stabilization but only in the rehabilitation phase?
Because children have less transferrin to allow binding of iron
This results in free iron which can cause growth of pathogens and oxidative damage of the cell membranes
How do start cautious feeding?
With F-75 which contains 75 calories and lower amounts of fats and protein
-this is to prevent refeeding syndrome
The actual mixture contains cows mil, sugar, vegetable oil and mineral and vitamin mixes(CMV)
How much F-75 do we usually give 2-3 hourly?
130ml/kg/day in divided 3 hourly feeds and then increased to 150/ml/day
What do we need do in rebuilding wasted tissue?
We start F-100 which has 100 calories
The signal to start the rehabilitation phase is shown with return of appetite of the child usually after a week
Why do we need to provide sensory stimulation and love and care?
Because children with malnutrition will always have developmental delay and and slow behavioral developmental so we need to provide love
How do we prepare the child to be discharged?
The child can be discharged once -there’s no oedema, good appetite, good weight, no infection and a playful and alert child
What are the 3 main nutrients involved in refeeding syndrome?
- Hypophosphotamia
- Hypo magnesemia
- Hypokalaemia
What is refeeding syndrome?
It is a syndrome that occurs after children are started on food again
-the phosphate, magnesium and potassium initially moves intracellularly making the serum(blood) have less of them
What is the presentation of refeeding syndrome?
- Arrhythmia
- Convulsions
- muscle weakness
- Cardiac failure
