Challenges in Recognizing and Caring for the Malnourished C - PowerPoint Presentation

Slide1

Challenges in Recognizing and Caring for the Malnourished Child

Family Medicine Specialist CME

Pakse

, Laos PDR,

October 15-17, 2012Slide2

Objectives

Using case studies, recognize the common clinical finding of malnutrition

Discuss challenges in treating the malnourished child and child with nutritional deficiencies

Understand strategies for preventing and monitoring malnutrition in the communitySlide3

Case #1

A six week old infant is brought to the health

centre

by his grandmother. He is sleepy, very thin, and grandma is worried he is not gaining weight. Slide4

Discussion questions

What do you want to ask about the feeding?

What other questions do you want to ask the mother?

What might be wrong with the child?Slide5

What questions would you ask on history?

Nutrition

Breastfeeding history, age of weaning, bottle feeding, appetite, usual diet

Past illnesses

Hospitalization,

diarrhoea

, dysentery, pneumonia, TB, measles

Family circumstances

Adopted / abandoned child

Mother pregnant or unwell

TB, HIV

ImmunizationSlide6

Facts

Born at term, 3

rd

baby of this mother.

Bwt

2.8 kg

No resuscitation required.

Mom did not have fever. Baby seemed healthy the first week, but gradually got less active, and lethargic

Mom feeds the baby for a few minutes , then goes to lie down.

Grandma is feeding him rice water when he cries, but GM is often in the rice-fields working.No fever, no diarrhea, no vomiting, no respiratory distress2 urinations a day. Slimy green stool, very small amountsBaby has had no immunizations Slide7

What is the Differential Diagnosis?Slide8

Differential Diagnosis

Late onset sepsis

Malabsorption

Cardiac disease

Poor intake-malnutrition

Post partum depression in mother leading to feeding problemsSlide9

What will you look for on Physical examination?Slide10

P. Ex.

HR-130, RR-35,T-37C,

Wt:3.2 kg, HC 37cm,

Lth

50 cm

MUAC 9.5cm

Fontanelle

sunken, eyes sunken, skin slack and hanging on legs

HS normal, chest clear, abdomen scaphoid, no massesSlide11

How will you manage this baby?

Assess dehydration(watery stools?)

Assess for life threatening complications-

eg

. sepsis, heart failure, hypoglycemia, infections, infestations, severe anemia

Nutritional treatment based on a maintenance diet -100cal/kg/da divided into frequent meals

Transition phase-increase diet over 4-5 days

Correct nutrient deficiencies over 2-3 weeks, high intake and stimulationSlide12

What could have been done in the community to prevent this?

Post partum monitoring of mom

Education of families around normal growth

Volunteers monitoring new babiesSlide13

Case study:

Kanchha

Kanchha

, a 12-month-old boy brought to district hospital from rural area. 8 day history of loose watery stools. 2 days of increased irritability and poor oral intake.Slide14

What questions do you want to ask the mother?Slide15

What questions would you ask on history?

Nutrition

Breastfeeding history, age of weaning, bottle feeding, appetite, usual diet

Past illnesses

Hospitalization,

diarrhea

, dysentery, pneumonia, TB, measles

Family circumstances

Adopted / abandoned child

Mother pregnant or unwell

TB, HIV

ImmunizationSlide16

Stages in the management of a sick child

(Ref. Chart 1,

p.xx

)

Triage

Emergency treatment

History and examination

Laboratory investigations, if required

Diagnoses (main and secondary)

Treatment

Monitoring and supportive care

ReassessPlan dischargeSlide17

Triage

Emergency signs (Ref: p2)

Obstructed breathing

Severe respiratory distress

Signs of shock

Coma

Convulsing

Severe dehydration

Priority signs (Ref: p.2)

Severe wasting

Oedema of feet

Palmar pallor

Young infantLethargy, drowsiness

Irritable and restless

Major burns

Any respiratory distress

Urgent referral noteSlide18

What to look for on examination

Temperature (35.3 degrees)

Weight (5.1kg)

Length (69cm)

Localizing signs of infection?

Pneumonia, meningitis, skin (including scabies), perianal excoriation, rectal prolapse

Signs of heart failure?Slide19

Palmar pallor

Check also:

Conjunctiva and mucous membranesSlide20

Emergency assessment and treatment

Weigh, measure length & MUAC

Measure blood glucose or treat for hypoglycaemia

“

If the child is

alert

, keep warm and give 10% glucose (10 ml/kg) by mouth or nasogastric tube, and proceed to further assessment and treatment.

”

Assess for signs of dehydration or shock

Avoid IV fluids because of the risk of heart failure. If children with malnutrition in shock then iv resuscitation as per

(Ref. Chart 8)Slide21

What to look for on examination

Micronutrient deficiency

Eye signs of vitamin A,

dermatosis

of zinc deficiency

Signs of tuberculosis

Lymphadenopathy, ascites,

hepatosplenomegaly

Signs of HIV infection

Oral thrush, multiple infections, lymphadenopathy,

hepatosplenomegaly

** note overlap between HIV and generalized TBSigns of kwashiorkorDepigmentation, sparse discoloured hairSlide22

Diagnosis

Eye signs of vitamin A deficiency:

Dry conjunctiva or cornea

Bitot

’

s spots

Corneal ulceration

KeratomalaciaSlide23

Kwashiorkor and

dermatosis

of zinc deficiencySlide24

What investigations would you do?Slide25

Investigations

Hypoglycaemia

Blood glucose 2.8

mmol

/L (3-6.5mmol/L)

Severe

anaemia

Hb

5.6 g/

dL

(105-135)

CXR normalDiarrhoeaStool microscopy shows trophozoites of giardiaSlide26

How would you manage this child?Slide27

Stabilization

Hypoglycaemia

10

% dextrose by NGT

Dehydration

ReSolMal

/ ORS, avoid IV

Electrolytes Zinc, Magnesium, Potassium

Hypothermia Keep warm overnight, feeding

Infection

Broad spectrum antibioticsDiarrhoea Albendazole, metronidazole (Giardia)Micronutrients Vitamin

A, zincAnaemia When stable Fe, transfuse if heart failure