Module 6.2- Screening and management of Acute Malnutrition in Children under 5 years of age

three faces of malnutrition

three faces of malnutrition

Canada doesn’t provide info to this

Today we are talking about wasting

People like to focus on stunting because it’s a bigger problem- but those wasting will die

Under-nutrition

malnutrition caused by an inadequate food supply or an inability to use the nutrients in food.

Edema or Oedema

the abnormal fluid accumulation in the interstitial spaces of tissues such as the pericardial sac, intra-pleural sac, peritoneal cavity, or joint capsules.

Food security

refers to physical and economic access to food of sufficient quality and quantity

Nutrition security

refers to secure access to food coupled with a sanitary environment, adequate health services, and knowledgeable care to ensure a healthy life.

Z score

a normalized value created from a member of a set of data by expressing it in terms of standard deviations from the median.

Causes of malnutrition- 4

•Food: Inadequate household food security(limited access or  availability of food)

•Nutrition: Inadequate access to food coupled with unsanitary  environment, inadequate health services, and lack of  knowledgeable care to ensure healthy life.

•Health: Limited access to adequate health services and/or  inadequate environmental health conditions.

•Care: Inadequate social and care environment in the household  and local community, especially in regard to women and children.

Conceptual framework of malnutrition  

Pathophysiology of Undernutrition

Reductive adaptation

•Reductive adaptation - defined as the physiological response of  the body to undernutrition i.e. Systems slow down and do less in severe acute under nutrition to allow survival onlimited nutrient  resources especially calories.

•reduced cellular metabolism

•reduction of protein/enzymes synthesis

•reduced cardiac output

•reduced kidney function -Limited capacity of excretion,

•Electrolyte imbalance -Concentration K+ ↓; Na+↑

•Iron -anaemia

•low transferrin

•Immune system-Inflammatory responses absent or severely weakened

•Thermoregulation altered; poikilothermia: hypothermia/pyrexia- body works in reverse- too hot they becme cold and vice versa this will kill children so it must be considered

Always treat with antibiotics because you cant know if they are affected

PHYSIOLOGICAL BASIS FOR TREATMENT- Cardiovascular and circulatory  system

•Cardiac output and stroke volume are reduced

•Infusion of saline may cause an increase in venous pressure

•Any increase in blood volume can easily produce acute heart failure;

•Any decrease will further compromise tissue perfusion

•Blood pressure is low

•Plasma is normal with reduced red cell volume

•Basic metabolic rate is reduced by about 30%.

Energy expenditure due to activity is very low

PHYSIOLOGICAL BASIS FOR TREATMENT- Liver

•Synthesis of all proteins is reduced

•Abnormal metabolites of amino acids are produced

•The capacity of the liver to take up, metabolize and excrete toxins is severely reduced

•Energy production from substrates such as galactose and fructose is much slower than normal

•Gluconeogenesis is reduced, which increases the risk of hypoglycemia during infection

•Bile secretion is reduced

•Gluconeogenesis is reduced, which increases the risk of hypoglycemia during infection

Bile secretion is reduced

PHYSIOLOGICAL BASIS FOR TREATMENT- Genitourinary system

•Glomerular filtration is reduced

•Capacity of kidney to excrete  excess acid or water load is  greatly reduced

•Urinary phosphate output is low

•Sodium excretion is reduced

•Urinary tract infection is  common

Body wont produce increased leukocytes so hard to know of they have infection

PHYSIOLOGICAL BASIS FOR TREATMENT- Gastrointestinal system

•Production of gastric acid is reduced

•Intestinal motility is reduced

•Pancreas is atrophied and production  of digestive enzymes is reduced

•Small intestinal mucosa is atrophied;  secretion of digestive enzymes is  reduced

•Absorption of nutrients is reduced

PHYSIOLOGICAL BASIS FOR TREATMENT- Immune system

•All aspects of immunity are  diminished

•Lymph glands, tonsils and the  thymus are atrophied

•Cell-mediated (T-cell) immunity is severely depressed

•IgA levels in secretions are reduced

•Complement components are low

•Phagocytes do not kill ingested bacteria efficiently

PHYSIOLOGICAL BASIS FOR TREATMENT- Immune system

•Tissue damage does not result in  inflammation or migration ofwhite cells to  the affected area

•Acute phase immune response is  diminished

•Typical signs of infection, such as an  increased white cellcount and fever, are  frequently absent

•Hypoglycemia and hypothermia are both  signs of severeinfection and are usually  associated with septic shock

PHYSIOLOGICAL BASIS FOR TREATMENT- Endocrine system

•Insulin levels are reduced, and  the child has glucose  intolerance

•Insulin growth factor 1 (IGF-1)  levels are reduced

•Growth hormone levels are  increased

•Cortisol levels are usually  increased

PHYSIOLOGICAL BASIS FOR TREATMENT- Cellular function

•Sodium pump activity is reduced,  and cell membranes are more  permeable than normal,

•which leads to an increase in  intracellular sodium anda decrease  in intracellular potassium and  magnesium

Protein synthesis is reduced

BASIS FOR DIAGNOSIS

•The skin and subcutaneous fat are and glands atrophied, which  leads to loose folds

•Signs of dehydration are unreliable; eyes maybe sunken because  of loss of subcutaneous fat in the orbit

•Many glands, including the sweat, tear and salivary glands, are  atrophied; the child has dryness of the mouth and eyes, and sweat production is reduced

•Respiratory muscles are easily fatigued; the child is lacking in  energy

The child is a pathetic and annoyed

Last two are big

Categories of Under nutrition

•Acute and Chronic under nutrition.

•Children can have a combination of both  acute and chronic under nutrition.

••Acute under nutrition is categorized into  Moderate and Severe acute under nutrition, determined by the client's  degree of wasting (is an indicator of acute  undernutrition, the result of more recent  food deprivation or illness).

•All cases of bi-lateral oedema are  categorized as severe acute under nutrition.- both sides- indicates lympatic system is non fuctional- need hospital

Normal is meeting the WHO growth standards

How we treat?

Preferred approach: community treatment- new concept before that always hospital- they often died there anyway

•Child-centred approach and of  caring for mothers and their infants  as an interdependent pair;- works better to treat whole family

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•Breastfeeding and access to  nutrient-dense home diets are a  critical component of both prevention  and management; and

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•Community health workers can  play an important role in providing  evidence-based care for children with  acute malnutrition.

Day 1-7 in hospital

Don’t give iron initially - the infection will utilize the iron so have to treat first