Kobi, 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.
(Ref. Chart 1, p. xxii)
1.
Triage
2.
Emergency treatment
3.
History and examination
4.
Laboratory investigations, if required
5.
Main diagnosis and other diagnoses
6.
Treatment
7.
Supportive care
8.
Monitoring
9.
Plan discharge
10. Follow-up
Temperature: <35.0
0 C, pulse: 130/min,
RR: 50/min, Weight: 6 kg,
Length: 69cm
Emergency signs (Ref. p. 2, 6)
• Obstructed breathing
• Severe respiratory distress
• Central cyanosis
• Signs of shock
• Coma
• Convulsions
• Severe dehydration
Priority signs (Ref. p. 6)
• Tiny baby
• Temperature
• Trauma
• Pallor
• Poisoning
• Pain (severe)
• Respiratory distress
• Restless, irritable, lethargic
• Referral
• Malnutrition
• Oedema of both feet
• Burns
Emergency signs of shock
(Ref. p. 5)
• Lethargic or unconscious
How to treat for shock in a severely malnourished child (Ref. p. 5, 14)
• Cold hands/feet
AND
• Give oxygen
• Capillary refill longer than 3 s
• Give glucose
AND
• Give IV Fluids
• Weak and fast pulse
• Initiate feeding with F75 or Full
Strength Sunshine milk
AND
• Give antibiotics
Kobe does not have emergency signs of shock.
If a child is in shock refer to the pages of the book as listed above
Kobi was well until 5 months of age. At 5 months his mother became pregnant again. His mother had started to wean him from the breast at 3 months, as her milk supply was reduced. From 4 months he was fed formula milk from a bottle with a rubber teat. He was given solid food from four months of age, mostly potatos and some vegetables.
From 5 months he had six episodes of diarrhoea. Each lasted 5-6 days. During each episode of diarrhoea he was given reduced amounts of fluid and feeds because his mother thought this would reduce the severity of his diarrhoea. On this last occasion he was taken to the hospital, as he became irritable and was not drinking or eating well.
Kobi was wasted, having loose skin folds over his arms, buttocks and thighs and visible rib outlines.
Vital signs: temperature: <35.0
0 C, pulse: 130/min, RR: 50/min
Weight: 6 kg and Length: 69cm, MUAC 10.5cm
□ Use Table 35 p. 386 and assess Kobi’s weight-for-length
Chest: bilateral air entry was normal, no added sounds
Cardiovascular: both heart sounds were heard and there was no murmur
Abdomen: soft, bowel sound was audible; no organomegaly
Ears-Nose-Throat: dry mucus membranes
Eyes: sunken, no tears and dry conjunctiva
Skin: decreased skin turgor
Neurology: sick looking; no neck stiffness and no other focal signs
• Severe malnutrition (marasmus, kwashiorkor)
• Severe malnutrition due to other organic disease:
Tuberculosis
-HIV
-Malabsorption syndrome
-Micronutrient deficiency (Vitamin A, zinc)
(Ref. p. 198-199)
• Nutrition history from birth
• Duration and frequency of diarrhoea and vomiting
• Type of diarrhoea (watery / bloody/ mucous / pus)
• Family circumstances
• Chronic cough
• Contact with TB, measles
• Known or suspected HIV
Kobi had been on formula feed since 4 months of age.
The milk was diluted (one scoop of milk per whole bottle of water). His mother would wash his bottles and teats in tap water. He was given weaning food at six months of age, mainly contained potato and occasional vegetables. He would get meat occasionally, but not for the past 2 months. He usually received two meals and two bottles of milk each day. Kobi had to share his plate of food with his other siblings.
Kobi lives with his parents in a small house. He has three older sisters and two older brothers. They have a small plot of land on which they grow crops, but which is not sufficient to feed their family. Kobi ’ s father works as a farmer and his mother as a housemaid where they can earn some more money for food. Because they are busy, Kobi ’ s older siblings mostly take care of him.
On examination, look for:
• Severe palmer pallor
• Eye signs of vitamin A deficiency
• Skin changes of kwashiorkor
• Localizing signs of infection
• Signs of HIV
• Fever or hypothermia
• Mouth ulcers
• Signs of dehydration
(Ref. p. 199)
• Palmer Pallor – indicates anaemia (Ref. p. 166). In any child with palmer pallor, check the haemoglobin or haematocrit level
• Check conjunctiva and mucous membranes
Look for signs of vitamin A deficiency:
• Dry conjunctiva or cornea
• Bitot ’ s spots
• Corneal ulceration
• Keratomalacia
(Ref. p. 199)
• Blood glucose: 2.4 mmol/L (3-6.5mmol/L)
• Haemoglobin: 70 g/l (105-135)
• Chest x-ray: normal, no features of TB
• Stool microscopy shows trophozoites of giardia
• After counseling of parents, HIV PCR test negative
Severe Malnutrition
Anaemia (not severe)
Giardia infection causing diarrhoea
Hypoglycaemia
includes 10 steps in 2 phases: initial stabilization and rehabilitation
(Ref. p. 201)
□
(Ref. p. 201)
give the first feed of F-75 or Full Strength
Sunshine Milk (FSS). If it is not quickly available give 50ml of 10% glucose solution orally or by nasogastric tube
give 3 hourly feeds
At least 6 feeds per day
Day and night for the first day
After day 1, give 6 feeds during day (e.g. 0600, 0900,
1200, 1500, 1800, 2100) and overnight if possible
□
(Ref. p. 202-203)
immediate and 3 hour feeding reduces risk of hypothermia and hypoglycaemia
make sure the child is clothed (including the head), use warmed blanket or put the child on the mother's bare chest or abdomen
□
(Ref. p. 203-204)
give rehydration solution orally or by nasogastric tube, much more slowly than you would when rehydrating a well-nourished child
if rehydration is still occurring at 6 hours give the same volume of starter F-75 instead of ORS at these times
Refer to Ref. p. 203-204 or PNG malnutrition guidelines for details
□ Electrolytes (Ref. p. 206) :
If electrolytes are not added to the food, give:
zinc (10 mg/day if <10 kg ; 20mg/day >10kg)
potassium (3-4mmol/kg/day)
magnesium (0.4-0.6mmol/kg/day)
prepare food without salt
• Giving high sodium loads can be very dangerous in severe malnutrition
• If F-75 is provided there is no need to add electrolytes to food
□
(Ref. p. 207-208)
give all severely malnourished children broad-spectrum antibiotic (penicillin & gentamicin)
in this case treat also for giardia
(metronidazole: 5mg/kg, 3 times a day, for 5 days (Ref. p. 137) ) or Tinidazole for 3 days
give measles vaccine if the child is not immunized
□
(Ref. p. 208-209)
give daily multivitamins
give vitamin A orally on day 1
-
Do not need to repeat doses
once gaining weight, give ferrous sulfate
give iron only after the child gains weight, because iron can make infections worse
□
(Ref. p. 209-210)
give F-75 or Full Strength Sunshine milk
100kcal/kg/day (liquid: 130ml/kg/day ; protein: 1-1.5g/kg/day)
3 hourly feeds
At least 6 feeds per day
Day and night for the first day
After day 1, give 6 feeds during day (e.g. 0600, 0900,
1200, 1500, 1800, 2100) and overnight if possible
continue breastfeeding if possible in addition
□
(Ref. p. 210-215)
replace the starter F-75 with F-100 or Milk
Oil Formula. Use RUTF also if the child is older than 6 months
use the same amount of F-100 as F-75 for
2 days
then increase each feed until some food remains uneaten (up to 220 ml/kg/day)
continue breastfeeding if possible in addition
□ Sensory stimulation (Ref. p. 215) :
provide loving care, a cheerful stimulating environment and involvement of the mother
provide toys for the child to play with or books to look at
physical activity as soon as the child is well enough
• Monitor for early signs of heart failure (Ref. p. 214) : fast or slow heart rate, tachypnoea, oxygen saturation, oedema, chest crackles, large liver
• Monitor urinary frequency and frequency of stools and vomit
• Note number and amounts of feed offered and left over
•Standardize the weighing on the ward (Ref. p. 222-
223) Weigh the child the same time of the day, after removing clothes
• Calculate weight change and plot weight on chart
(Ref. p. 215)
• Weigh every 2 nd day
• Record the adequacy of weight gain:
– >10g/kg/day – good
– 5-10g/kg/day – moderate
– <5g/kg/day – poor
• E.g, a 6kg child should gain more than 6 x 10 x 7 g = more than 420 g per week
• An 8.5kg child should gain more than 8.5 x 10 x 7 g
= 595 g per week
• If weight gain is poor check the following points:
– Inadequate feeding – give more, observe the child feeding, consider need for a nasogastric tube
– Untreated infection?
– Another illness, such as HIV/AIDS?
– Emotional or psychological problems
(Ref. 219-222)
Before discharge the child should have:
• Completed antibiotic treatment
• Regained a good appetite, taking all feeds regularly
• Show good weight gain (weight gain >70g/kg/week and Z-score
> -2 SD)
The mother or carer should:
• Be available for child care
• Have received training on appropriate feeding
• Have enough resources at home to feed the child
• Make a plan for the follow-up of the child until complete recovery
• The child should be weighed weekly after discharge.
• If the child does not gain weight over 2-week period or it even lost weight, he should be referred back to hospital.
• Kobi was discharged after gaining weight and regaining appetite
• His parents were told to feed him at least 5 times per day. They had to give him high-energy snacks between meals (e.g. milk, banana, bread, biscuits).
• His parents were told to encourage him to complete each meal, to add micronutrient supplements to each feed and to monitor his appetite and intake.
• His mother was encouraged to breastfeed him as often as Kobi wants.
• Follow-up was arranged.
• Kobi still needs continuing care as an outpatient to complete rehabilitation and prevent relapse.
• 12-month-old boy, youngest of family of 6. Early weaning, diluted dirty formula, poorly nutritious food, repeated infections, diarrhoea and anaemia
• Severe malnutrition with hypothermia, hypoglycemia, anaemia, giardiasis
• HIV negative, no signs of TB
• Malnourished children have multiple medical, social and psychological problems, and each need to be identified and addressed