CASE PRESENTATION

A Malnourished Child

Presentated By Dr Vedant, Dr Madan

Under supervision of Dr S C Soni, Dr Suman
• NAME: Neelam
• AGE: 13 months
• SEX: FCH
• RELIGION: Hindu
• ADDRESS: Sointra Nagor
• DOA: 1.07.22
• DOE: 1.07.22
• CONSANGUINITY: 3rd issue of nonconsanguineous marriage
• INFORMANT: Mother
 CHIEF COMPLAIN
• Not gaining weight for 6 months
• Recurrent episodes of loose motions for 2 months
• Vomiting for 5 days
 HISTORY OF PRESENT ILLNESS
• As per mother child was apparently alright 6 months back then she noticed
that her baby was not gaining weight as compared to peers.
• Although the weight of the child has never been documented before but
mother gives a history of progressively decreasing weight, decreased physical
activity and not showing any interest in toys or food intake.
• Mother also gives a history of recurrent episodes of loose stools for last 2
months. 4-5 such episodes have occurred till now and each episode had lasted
for almost 5-6 days.
• During the last episode 6-8 episodes of clear watery, profuse and foul smelling
loose stools were occurring in a day not associated with blood or mucous.
• Patient has taken treatment for previous episodes on OPD basis and has taken
ORS at home but has never been hospitalised for such episodes.

• Now Patient also developed vomiting for 5 days, 2-3 episodes

occurring in a day, containing fluid only, not a/w blood, non bilious and
non projectile in nature.
• Mother also gives a history of child being irritable, drinking water
eagerly and urine output decreased to 4 times a day as compared to
usual 10 times in a day.
• No history of fever
• No history of any exanthematous illness in past
• No history of suck rest cycle/increased sweating during breastfeeding
• No history of recurrent respiratory tract illness
• No history of greasy/ clay coloured stool
• No history of gum bleeding/ oral ulcer/ petechiae/ nightblindness
• No history of TB contact
• No history of pica
 ANTENATAL HISTORY
• G3 P3 L3 AO
• Unplanned but booked pregnancy
• Mother took TT immunization.
• Has taken IFA supplementation in last month of pregnancy.
• USG done once in third trimester and was explained to be normal to them.
• As per mother blood test was done once and mother was explained to be
anaemic to them.No documents available.
• No history of fever with rash during pregnancy
• No history of blood transfusion during pregnancy.
 NATAL AND POSTNATAL HISTORY
• Single term NVD at home (attended by local Dai)
• Birth weight not remembered or documented but was described by
mother as being equal to her siblings.
• Baby cried immediately after birth.
• Prelacteal feed given(honey).
• 1st breast feed was given approximately 1 hour after birth,
• No issues regarding feeding were observed during rest of neonatal
period
• No h/o OPD visit or hospitalization during neonatal period.
 IMMUNISATION HISTORY
• Patient is incomplete immunised.
• Never visited immunisation centre.
• Vaccines received through outreach services only.
• Immunisation card not available.
• BCG scar absent.
 DIETARY HISTORY
• Child was exclusively breastfed till 4 month of age following which she was
started on cow’s milk 1:2 dilution.
• But then she started vomiting after feeding due to which top milk was withheld
and has not been introduced till date.
• Mother also continue to give water to baby from 4 months of age 3-4 times a
day.
• The child has also been introduced with khichadi, dalia and rabdi at around 5
months of age but as per mother the baby developed vomiting after feed for
which these were restricted and not introduced again till the day of
hospitalization.
• Presently the child is taking breast milk only .
 content consumed expected deficient
calorie 350 kcal 1060 kcal 66%
protein 5.8 gm 16.7 gm 59.2%
 FAMILY HISTORY
• She is 3rd issue of non consanguineous marriage
• Father is 25 years and mother is 22 years and both of them are
healthy.
• Has 2 siblings- 5 yr and 3 yr…both are males and healthy. No such
complains has been observed by mother in them.
• No history of chronic cough in any member of the family.
 SOCIO ECONOMIC HISTORY
• 12 membered family
• According to kuppuswamy classification belongs to lower class.
• Patient eligible for chirinjivi yojana
• health and hygeine awareness poor.
• hand washing awareness not adequate.
• have a toilet in house, does not follow open defecation practices
• family does not access local heath centre for needs like contraceptives,
immunization or dietary supplements.
 ANTHROPOMETRY
PARAMETER OBSERVED EXPECTED INFERENCE
WEIGHT FOR AGE 4.2 Kg 9.2 Kg less than -3 SD
(-3SD = 6.4 Kg)
LENGTH FOR AGE 62 cm 75.2 cm less than -3 SD
(-3 SD = 67.3 cm)
WEIGHT FOR 4.2 kg 6.4 Kg less than -3 SD
LENGTH (-3SD = 4.9 Kg)
MUAC 10.5 cm 16 cm Severe Acute
Malnutrition
HC 38 cm 38 to 43 cm normal for length
 INFERENCE OF ANTHROPOMETRY
• Weight for age is less than -3 SD : Severely underweight acc to WHO Classification
Grade 3 under weight acc to Gomez Classification
Grade 4 underweight acc to IAP Classification
Marasmus acc to Welcome Trust Classification
• Length for age less than -3 SD : Severe stunting acc to WHO Classification
• Weight for Length less than -3 SD : Severe Wasting (and also SAM) acc to WHO
Classification
• MUAC less than 11.5 cm : Severe Acute Malnutrition acc to WHO Classification
 Examination
• The child was seated on mothers lap during examination.
• Child is irritable, not interested in surroundings and gross wasting
present.
• Vitals:
Temp: 98.6 F in right axilla by digital thermometer.
PR: 120/m, regular, normovolumic , no radioradial or radio femoral
delay
RR: 22/m RIGHT LEFT

Spo2: UL 98 99

LL 97 98
• Hydration: Irritable, dry oral mucosa and tongue, skin pinch- skin goes
back slowely, drinks water eagerly, reduced urine output.
INFERENCE: Some Dehydration
BP: 78/54 mm hg in left arm by digital instrument.
• Pallor present
• clubbing, cyanosis, icterus and lymphadenopathy absent
INFERENCE:
 HEAD TO TOE EXAMINATION
• Head: Normal is shape and size( HC is less for age but normal for
length). AF open(1 by 1 cm) and sunken
• Hair: lustureless, thin, brittle and sparse hairs present.
easily pluckable and hypopigmented.
• Face: Skin dry, scaling present over forehead
No frontal bossing, buccal pad of fat preserved
• Oral Cavity: Oral mucosa dry, oral thrush present
lips dry, cracking present at angles of mouth
• Tongue: dry, pale, denuded (papillae atrophied)
• Eyes: conjunctival pallor present
bitots spot absent, no ulcer/scar seen
• Ears: No discharge seen in EAC
• Nose and nasal cavity: normal, no discharge
• Neck: scaling present over neck
peeling of skin present over neck, denuded raw skin seen in
creases.
• Chest: Ribs prominent, pigeon shaped chest
no rachitic rosary seen
• Umbilicus: normal in position and inverted
• Abdomen: protuberant
• Genetalia: Normal
• Back: scapula prominant
• Extremities: knuckle hyperpigmentation present
platynychia and pallor present
pallor seen in palm but creases are black
• Skin : dry, loose skin fold present over thighs and buttocks.
Scaling present
Phrynoderma present over elbows
hyperpigmentation present
SYSTEMIC EXAMINATION: GIT
• Abdomen slightly distended
• all quadrant move equally with respiration
• no scarmark, no dilated veins
• umbilicus central and inverted
• skin pinch : goes back slowly
• baby cries on palpation of periumbilical region
• liver palpable 2 cm below costal margin
• spleen : not palpable
• bowel sounds present
SYSTEMIC EXAMINATION : CNS
• Child is conscious, not intrested in surrounding, apathetic,
• looks towards the sound , drinks water eagerly
• muscle bulk decreased
• hypotonia present
SYSTEMIC EXAMINATION : CVS
• Apex beat in left 4th ICS 1 cm lat to mid clavicular line
• S1 S2 heard normal
• no murmer heard
SYSTEMIC EXAMINATION : RESPIRATORY
SYSTEM
• Pigeon shaped chest present
• ribs prominention both the sides
• normal bronchial breath sounds heard
• no adventitious sounds
 SUMMARY
Neelam , 13 mnths, Fch, 3rd isuue of non consanguineous marriage
belonging to low socio economic class and unimmunized is presently
being evaluated for not gaining weight for 6 months, recurrent episodes
of diarrhoea for 2 months and vomiting for 5 days with a dietary deficit
of 66% in calories and 59% in proteins intake per day.
On examination child is severely underweight with severe wasting and
stunting present, has some dehydration, features suggestive of short
bowel diarrhoea and signs of multiple vitamin deficiencies.
 PHYSICAL DIAGNOSIS
Severe Acute Malnutrition with multiple micronutrients deficiency with
acute gastroenteritis, some dehydration.
 Management of
• HospitalisationRxSAM
of complications
• Sugar deficiency (Hypoglycemia) (BG < 54 mg/dI): 10 % Dextrose
• Hypothermia (Rectal temp <35.5C): Warm up
• Infections: Antibiotics
• Electrolyte imbalance (Hypokalemia/ Hypophosphatemia):
Supplement K, Phosphate
• Dehydration: WHO ORS (in double dilution) / Resomal- Rehydration
solution for malnourished child (|Na, ^K)
• Deficiency of Micronutrients—Supplementation
• Iron should be started 1 - 2 weeks later
• Nutritional Rehabilitation- should be gradual- nrs /rfs
• Start with low calories & protein, gradually build up
• Initially F75 then F100 later RUTF =543kcal/ 100gm
• Fluid of choice DNS with added k+ = 420ml / 24 hours
• RUTF Ingredients
• • Milk powder+ Peanut Paste+ Oil (palm oil with added Vit A)+ Sugar
• • Vitamin Mineral Mix
• Easy to feed a child- Few spoons at a time, multiple times a day Continue
to breastfeed (or give clean water)
• No cooking required, No special storage, doesn't spoil easily
 PUBLIC HEALTH IMPORTANCE
More than 9.2 lakh children in India are ‘severely acute malnourished’,
with the most in Uttar Pradesh followed by Bihar, according to
government data.

To review the prevalence and consequences of childhood undernutrition

To discuss methods of nutritional surveillance and management of child

malnutrition in emergencies.

To consider the complex interplay of "development" and malnutrition

- politics, climate and agriculture, shifting food preferences
• Determinants of malnutrition: The 6 "P's". ACC to UNICEF 2015
• Production - About half of people in developing countries do not have an
adequate food supply - issues of food production and local availability of food
• Preservation - 25% of grains are lost to bad post harvest handling, spoilage
and pest infestation; up to 50% of easily perishable fruits and vegetables are
not consumed
• Population - density, distribution, urban migration
• Pathology - nutrition-infection synergism
• Poverty - root cause of malnutrition income inequality, household food
distribution
• Politics - government policies can foster malnutrition directly by how food is
subsidized and distributed; indirectly civil unrest and natural disasters affect
market availability and costs of foods
Major risks for infants and young children in complex
humanitarian crisis

• Separation from family

. Hypo or hyperthermia
• Dehydration
• Starvation
• PTSD/depression
• Abrupt weaning
• Illness - gastroenteritis, respiratory infection, skin infections,
measles and malaria
 Nutrition doesn't improve in a vacuum..
• Water and sanitation
• Maternal mental health, child development, family structure
• Access to health care, family planning
• Education, pro-family social services
• Civil society, food security, famine
• NUTRITION TRANSITION
• Nutrition transition -"Progress" in biology and technology..

• Shift to less physical economic work, urban migration trends globally and
increased taste preferences for sweet and fatty foods
• Edible oil revolution (easier to extract oil)
• Corn/fructose and soy excess dumping by developed countries into
processed foods
• Unlike undernutrition, overnutrition will not be solved by economic growth
and development
• Need innovative approaches - integrated interventions to different "types" of
malnutrition, linkages between climate/agriculture and food/development
 Thank You

• Question & Comments

 References:-
https://www.thehindu.com/news/national/927-lakh-severely-acute-mal
nourished-children-identified-till-november-last-year-rti/article347436
42.ece
Save the Children. Emergency Health and Nutrition Toolkit (2014)
Nutrition in the first 1000 days - State of the World's Mothers. 2012. N
ewYork
World Food Programme. State of Food Insecurity in the World. 2013.
Rome
.
World Health Organization. Rapid Health Assessment Protocols for E
mergencies and WHO Management of Nutrition (1999) in Emergencie
s (2003)