Case Report

SEVERE MALNUTRITION
Presentator:
Andika
Pradana
070100071
Ira
Nola
Lingga
SUPERVISOR:
070100109
Dr. SRI SOFYANI, Sp.A(K)
Deprtment of Pediatrics FK USU, July

SEVERE MALNUTRITION

LEVEL OF COMPETENCE

DEFINITION
World Health Organization:
Malnutrition is the cellular imbalance
between the supply of nutrients and
energy and the body's demand for
them to ensure growth, maintenance,
and specific functions

CLINICAL FINDINGS
Three types of clinical findings
in severly malnourished
children:
1.Marasmus
2.Khwarsiorkor
3.Marasmus - Khwarsiorkor

Clinical Features
Feature

Kwarshiorkor

Marasmus

Growth failure

Present

Present

Wasting

Present

Present, marked

Oedema

Present

Absent

Hair Changes

Common

Less common

Mental Changes

Very common

Uncommon

Dermatosis,

flaky- Common

Does not occur

paint
Appetite

Poor

Good

Anemia

Severe (sometimes)

Present, less severe

Subcutaneous fat

Reduced but present Absent

Face

May be oedematous

Fatty
liver

infiltration

of Present

Draw in, monkey-like

Absent

CLINICAL FINDINGS:

Marasmus

CLINICAL FINDINGS:

Marasmus

Marasmus:
-

Old man face

Extreme wasting
Prominent ribs
Baggy pants
Muscle
hypotrophy
- No edema

CLINICAL FINDINGS:

Khwarsiorkor

CLINICAL FINDINGS:

Khwarsiorkor

KHWARSIORKOR:
- Moon face
- Pale and sparse
hair
- Enlarged liver
- Edema
- Peeling skin (crazy
pavement
dermatosis)

CLINICAL FINDINGS:

Marasmus Khwarsiorkor
MARASMUS
KHWARSIORK
OR:
The patient appears
like a marasmus
child,
combined
with
signs
of
khwarsiorkor such
edema
and
enlarged liver

PATHOPHYSIOLOGY

 Decrease
Imune System
Enlarged
Liver and
accumulation
of triglyserides
Tachypnea

Malabsorbtion
Anemia

Developmental
delay
etc

DIAGNOSIS
WHO, 1999:
Severe Malnutrition if:
BW / BL is below 70%
BW / BL is between 70 79%
but with edema presents

DIAGNOSIS
Based on Body weight according to Body length
BW/BL
very low

low

70
-3SD

PEM severe mod

obese
-Kwashiorkor
-Marasmus
-M-K

80

90
-2SD

normal

mild

high

110
+2SD

120 %
+3SD

overweight

HISTORY TAKING
Usual diet before current episode of illness
Food and fluids taken in past fiew days
Duration and frequency of vomiting or
diarrhoea, appearance of vomit or diarrhoea
stool
Time when urine was last passed
Birth weight, birth length and growth chart
Breastfeeding history
Milestones reached
Immunization

LABORATORY
FINDINGS

Tests that may be useful

Blood glucose
Examination

Glucose
of

concentration

<54

mg/dl

is

indicative

of

hypoglycaemia
blood Presence of malaria parasites is indicative of infections

smear by microscopy
Haemoglobin or packed- Haemoglobin <40 d/l or packed-cell volume <12% is
cell volume

indicative of very severe anemia

Examination and culture Presence of bacteria on microscopy is indicative of

of urine specimen
Examination

of

infections
faeces Presence of blood is indicative of dysentry

by microscopy
Chest X-Ray

Pneumonia causes less shadowing of the lungs in

malnourished children that in well-nourished children
Bones may show rickets or fractures of the ribs

Skin test for tuberculosis Often negative in children with tuberculosis or those
previously vaccinated with BCG vaccine

LABORATORY
FINDINGS
Tests that are of little or no value
Serum proteins
Not useful in management, but may guide prognosis
Test

for

human Should not be done routinely; if done, should be

immunodeficiency virus accompanied by counselling of the childs parents and

(HIV)
Electrolytes

result should be confidential

Rarely helpful and may lead to inappropriate therapy

TREATMENT
Five General Principles:
1.Ten Principal Steps
2.Treatment of Comorbidities
3.Failure of Treatments
4.Patient discharges before end of
treatment
5.Emergency Case

____________ The Ten Principal

Steps

Treatment
1
2
3
4
5
6

7
8

Hypoglycemia
Hypothermia
Dehydration
Electrolyte
Correction
Treatment
of
Infection
Micronutrition
Defficiency
Correction

Stabilizatio
n
Day
Day
1-2
3-7

Transitio Rehabilita Follow

tion
Up
n
Week
Week
Week 2
3-6
7-26

Without Iron
Supplementation

Initial Refeeding Formula 75

Correctional
Refeeding (Catch

Formula
75 to

With Iron
Supplementat
ion

Ten Principal Steps:

1. Hypoglycemia

Hypoglycemia if blood glucose

level below 3 mmol/l or 54 mg/dl
-

Loss of consciousness
Lethargic
Weak arterial pulse
Sweating
If it is difficult to test blood glucose
level, consider all severely
malnourished children are
hypoglycemic

Ten Principal Steps:

1. Hypoglycemia

Signs and

Treatment

Symptomps
Alert (not

Give 50 ml of Dextrose 10% per oral or via

lethargic)
Loss of

NGT
Give Dextrose 10% intravenous as much

consciousness

as 5 ml per each kilogram body weight,

(lethargic)

followed by 50 ml of Dextrose 10% orlaly

Give Dextrose 10% intravenous as much
as 5 ml per each kilogram body weight,

Shock

followed by Ringer Lactat + Dextrose 10%

(1:1)

for

15

ml

each

kilogram

weight, sould be given in 1 hour

body

Ten Principal Steps:

2. Hypothermia

Hypothermia if rectal temprature

is below 36oCelcius
Treatment:
- Kangoroo technique skin to skin
contact
- Radiant warmer
- Follow the fluctuation of body temp
every 30-60 minutes

Ten Principal Steps:

3. Dehydration

Evaluate the general condition,

sunken eye, thirsty and skin pinch
Treatment: Give ReSoMal
5 ml/kg bodyweight every 30 minutes for
the first 2 hours
Followed by another Resomal for as much
as 5-10 ml/kg body weight/hour, given
alternately with Formula 75 as the early
diet

Ten Principal Steps:

4. Electrolyte Correction
Hyponatremia and
Hypokalemia are frequently
found particularly if
diarrhea and vomitting are
present
Treatment: Give ReSoMal

ReSoMal
(Rehidration Solution for
Malnutrition)
ReSoMal Modification
WHO-Oral rehydration solution

: 1 sachet

Sugar

: 50 gr

Potassium powder
ml)

: 4 gr (40

Water added until

: 2 liter
26

Ten Principal Steps:

5. Treatment of Infection
No clear evidence of infection:
Cotrimoxazole (TMP 5 mg/kgBW + SMZ 25
mg/kgBW orally twice daily for 5 days.

Infection
Ampicillin, 50 mg/kgBW IM or IV for the
first 2 days, followed by Amoxicillin 15
mg/kgBW orally every 8 hours for the
next 5 days), along with
Gentamycin 7,5 mg/kgBW IM or IV once
daily for 7 days.

Ten Principal Steps:

6. Micronutrient

Stabilization and Transitional Phase:

Multivitamin supplementation
- Folic Acid 1 mg/day ( 5mg on day 1 )
- Zn 2 mg/kgBW/day
- Cu 0,2 mg/kgBW/day
- Vitamin A on the 1st day

Rehabilitation Phase
Iron added. Sulfas Ferrosus 10
mg/kgBW/day

Ten Principal Steps:

7. Initial Refeeding
WHO Formula 75
- Give a small portion but frequent
feeding
- Hypoosmolar and low in lactose
- Energy: 80-100 kal/kgBW/day
- Protein: 1-1,5 gr/kgBW/day
- Fluid: 130 ml/kgBW/day, or 100
ml/kgBW/day if edema presents

Treatment Phase
Nutrients
Energy

Stabilization
100 kcal/kg/day

Transitional
150 kcal/kg/day

Rehabilitation
150-200
kcal/kg/day

Protein

1 1,5 g/kg/day

2-3 g/kg/day

4-6 g/kg/day

Fluid intake

130 ml/kg/day or

150 ml/kg/day

150

100 ml/kg/day if
edema presents

ml/kg/day

200

Ten Principal Steps:

8. Correctional Refeeding
WHO Formula 75 100 135
Transitional Phase:
Correctional refeeding should be given
alternatingly from F 75 to F 100 in the
transitional phase

Rehabilitation Phase
- Energy: 150-220 kkal/kgBW/day
- Protein: 4-6 g/kgBW/day
- Family food

32

Ten Principal Steps:

9. Stimulation

- Interaction to other children

- Structured game designed for suitable
age
- Love and care from parents
- Motor and language skills

Ten Principal Steps:

10. Discharge

Treatment Evaluation:
If weight gain is less than 5 gr/kgBW/day,
the child should be reassesed
If weight gain is between 5 to 10
gr/kgBW/day, an undetected infection
should be suspected
If weight gain is more than 10
gr/kgBW/day, then the therapeutic
program has reached its target.

Ten Principal Steps:

10. Discharge

Discharge Criteria:
1.BW/BL has no longer been below 70%
2.Edema, vomitting and diarrhea are no
longer present
3.Normal body temprature
4.Adequate weight gain
5.Patient can eat the whole diet prepared
6.General condition improvement, skill and
motoric development are suitable to age

SEVERE MALNUTRITION

CM, Female, 14 year old, with the body weight and

body height of 25 Kg and 144 cm respectively, was admitted
to the non infectious unit of Haji Adam Malik General Hospital
on June, 4th 2011 with the main complaint bulging of the
lower abdomen for the last 3 months before admission. The
bulging was previously 7 x 8 cm in size, and getting bigger
day by day until now it has already been approximately 15 x
16 cm in size, immobile, soft in consistency and smooth
surface, and well marginated with pain on palpation.
Interrupted flow of micturition (+) for the last 3
months, with micturition frequency was more than 6 times a
day, volume less then 50 60 cc each time. Previously, the
urine was transparent yellowish in colour, but for the last 2
weeks, she complained that the urine colour had been
yellowish to brown. History of flank pain while urinating (-),
no stones. Defecation (+) normal.

Pallor (+) during the last 3 months, without any

previous history of reccurent pale. History of bleeding (-).
Weight loss for as much as 6 kg in the past 3
months. This problem has actually been occuring since 2
years ago, and was getting worse for the last 3 months.
Loss of appetite (+) for as long as 3 months, but
previously eating poorly was found since the patient was
6 years old, and she had never eaten more than half of
the food served for her. Fever (-), cough (-), night
sweating (-), history of contact to tuberculosis patient (-).
Leg swelling (+) for the last 2 weeks, both in the
right and the left one. Previous history of swollen leg was
denied. Pain on palpation (-).
Menstruation delay (+) for the last 3 months. This
patient got menarche on 13 years old and got
menstruation regularly before. The duration of
menstruation was 7 days per month.

 She was born spontaneously, aided by

midwife, with birth body weight was
3500 grams and body length was 50 cm,
crying spontaneously, with APGAR score
was not recorded. There was no
pregnancy complication for both mother,
nor child. History of immunization was
incomplete.
Feeding history: within the normal limit,
History of growth and development:
within the normal limit
History of previous illness and
medications
: unclear

PHYSICAL
EXAMINATION

Generalized status
BW: 25 kg, BL: 144 cm, Upper arm
circumference: 16 cm, Head circumference: 57
cm
BW/BL : 78,13% (moderate malnutrition)
BW/age: 49,02% (severe malnutrition)
BL/age : 88,9% (normoheight)

Presens status
CM, Body temperature: 37,2oC. Anemic (+).
Icteric (-). Cyanosis (-). Edema (+). Dyspnea
(-). Thristy and drink eagerly was not found.

LABORATORY RESULT
Parameters

Value

Normal Value

Hemoglobin

4,76 gr%

12,0 14,4 gr%

Hematocrite

14,9 %

38 44%

Erithrocyte

1,82 x 106 /mm3

4,2 4,87 x 106 /mm3

Leucocyte

3530 /mm3

4500 11000 /mm3

226.000 /mm3

150000 450000 /mm3

MCV

82 fl

85 95 fl

MCH

26,2 pg

28 32 pg

MCHC

32 gr%

33 35 gr%

RDW

16,6 %

11,6 14,8 %

Diftel

0 / 0 / 78 / 9 / 13

Platelet

WORKING DIAGNOSIS
Suspect Tumor
Abdomen e.c
dd/
- Wilms Tumor
Neuroblastom
a

Severe
Malnutrition
Marasmic Khwarsiorkor
Type

TREATMENT
Bedrest, threeway and urinary catheter inserted
IVFD D5% NaCl 0,45% 20 gtt/i micro
Diet Formula 75 280 cc / 2 hours (stabilization
phase)
Multivitamin without Fe 1 x cth II
Folic acid tab 1 x 5 mg
Cotrimoxazole tab 2 x 480 mg
Vitamin A 1 x 200.000 IU
Packed red cell transfusion 75 cc / 12 hours
Needed: 4 x ( 11-4,76 ) x 25 kg = 624 cc
Transfusion ability: 3cc x 25 kg = 75 cc

DIAGNOSTIC PLANNING
Complete blood count post transfusion
Liver Function Test and Renal Function
Test
Serum Electrolytes, Serum Albumin
Blood Glucose ad random
Abdominal CT Scan
Urinalysis
Fluid Balance per 6 hours

SEVERE MALNUTRITION

June 5th-7th, 2011

S

Bulging of the lower abdomen (+), Pallor (+), Abdominal pain (-)

Sens: CM, Temp: 36,7 36,9oC. Anemic (+), Edema (+).

BW: 25 kg, BL: 144 cm. UOP: 3,4 6,1 cc/kg/hour, Urine colour : yelowish
to brown
In the abdomen: Bulging (+) in regio hypogastrium, 8 x 9 cm in size, immobile,
soft and well marginated. Pain on palpation (-)
Laboratory Findings:
SGOT: 11 U/L
Na: 131 mEq/L
Ureum: 64,50 mg/dl
SGPT: 3 U/L
K: 3,9 mEq/L
Kreatinin: 2,32 mg/dl
Albumin: 2,7 gr/dl
Cl : 113 mEq/L

Dipstick urine:
Leu / Nit / Uro / Protein / pH / Blood / SG / Ket / Bil / Glu
+2 / + / /
+ / 6,5 / +3 / 1,01/ - / - / -

A
P

Suspect Tumor Abdomen e.c dd/ - Wilms Tumor

Marasmic- Neuroblastoma
Management:
Bedrest, threeway and urinary catheter inserted
IVFD D5% NaCl 0,45% 20 gtt/i micro
Diet Formula 75 270 cc / 2 hours (stabilization phase)
Multivitamin without Fe 1 x cth II
Cotrimoxazole tab 2 x 480 mg
Transfusion PRC 75 cc / 12 hours
Folic acid 1 mg/day (the following day)

+ Severe Malnutrition
Kwarshiorkor Type
Diagnostic Planning:
Complete blood count
post transfusion
Abdominal CT Scan
Urinalysis

June 8th-11th, 2011

S

Bulging of the lower abdomen (-). Pallor (-). Abdominal pain (-).
The patient ate the whole diet provided.

Sens: CM, Temp: 37,0 37,6oC. Anemic (-), Edema (-).

BW: 25 kg, BL: 144 cm. UOP: 3,4 5,5 cc/kg/hour, Urine colour : yelowish to
brown
In the abdomen: Bulging was not found after urinary catheter insertion.
Laboratory Findings:
Hb: 13,5 gr%
Ht: 39,5 %
RBC: 5,16 x 106 / mm3

WBC: 10470/ mm 3
PLT: 263000/ mm 3
RDW: 19,6%
LED : 14 mm/hours

MCV : 76,6 fl
MCH : 26,2 pg
MCHC : 34,2 gr%

Dipstick urine:
Leu / Nit / Uro / Protein / pH / Blood / SG / Ket / Bil / Glu
+ / - / 0,2 /
/ 5 / +3 / 1,01/ - / - / A
P

Hydronephrosis bilateral e.c (?) + severe malnutrition marasmic khwarsiorkor

type + suspect urinary tract infection
Management:
Diagnostic Planning:
Bedrest, threeway and urinary catheter inserted
Abdominal CT Scan
IVFD D5% NaCl 0,45% 20 gtt/i micro
Urinalysis and urine
Diet Formula 75 270 cc / 2 hours (stabilization phase) culture + sensitivity
Multivitamin without Fe 1 x cth II
test
Folic acid 1x1 mg
Injection Ceftriaxone 1 gr / 12 hours
Cotrimoxazole tab 2 x 480 mg

June 12th-18th, 2011

S

Fever (+). Bulging of the lower abdomen (-). Pallor (-). Abdominal pain (-).

Sens: CM, Temp: 37,3 38,1oC. Anemic (-), Edema (-).

BW: 25 kg, BL: 144 cm. (BW/A: 50,9) UOP: 2-3,1cc/kg/hour, Urine colour :
transparent yellowish
In the abdomen: Bulging was not found after urinary catheter insertion.
CT Scan Reports:
No mass in the abdomen could be identified
There is a hyperthrophy of the urinary bladder wall
Muscle hypertrophy due to urinary retention should be suspected.
Suggestion: Cystoscopy
Urine Culture:
Pseudomonas aeruginosa was found, with concentration more than 105 CFU/ml
Sensitive to Meropenem
Dipstick urine:
Leu / Nit / Uro / Protein / pH / Blood / SG / Ket / Bil / Glu
+ /- / - /
+
/ 5 / +3 / 1,01/ - / - / -

A
P

Hydronephrosis bilateral e.c. Retensio Urine + Severe Malnutrition Marasmic

Khwarsiorkor type + Urinary Tract Infection
Management:
Planning:
Bedrest, threeway and urinary catheter inserted
Urinalysis
IVFD D5% NaCl 0,45% 20 gtt/i micro
Diet Formula 100 470 cc / 3 hours (transition phase)
Injection Meropenam 250 mg / 8 jam
Multivitamin without Fe 1 x cth II

SEVERE MALNUTRITION

Loss of appetite since 3 months,pallor,

weight loss, old man face, thinning of
subcutaneous fat, muscle hypotrophy,
prominent ribs, edema dorsum pedis,
Antropomethric measurement:
BW/BL below 70% with edeme presents
Dx: SEVERE MALNUTRITION MarasmusKhwarsiorkor

IVFD D5% NaCl 0,45%, Diet Formula 75,

Multivitamin, Antibiotic, Transfussion PRC

AMENORRHEA and
MALNUTRITION

STABILIZATION PHASE

STABILIZATION PHASE

STABILIZATION PHASE

TRANSITIONAL PHASE
Formula
75
Formula
100
Formula
135
Family
Food

Low calorie
Low lactose
Frequent Frequency
Higher Calorie
Evaluate tolerance
Evaluate appetite
Given in the rehabilitation
phase only after weight gain is
adequate

TREATMENT EVALUATION
INADEQUATE WEIGHT
GAIN
(below 5 gr/kg/day)

WHY?
?
Reanamnesis: Pain while
urinating
Laboratory findings: Leukosituria, Nitrate
in urine (+)
Urine Culture: Pseudomonas aeruginosa

Urinary tract infection as a

COMORBID
Treat based on sensitivity

Xie xie

Arigato Gozaimasu

Syukran

Terim
a
Kasih
Kapkun Kha

Gracia

Mercie