THIRD YEAR CASE WRITE UP ON UNDERNUTRITION KABALE

1. KABONEROGRACE
16/A/MBChB/0744/F
KABALE UNIVERSITY
SCHOOL OF MEDICINE
DEPARTMENT OF PAEDIATRICS
MASAI DANIEL WALTER
16/A/MBChB/O744/F
A CASE WRITE-UP ON SEVERE CHRONIC UNDERNUTRITION WITH
EDEMA
DR. MARCEL NIYOMUGABA

2. KABONEROGRACE
16/A/MBChB/0744/F
Summary of the case;
Avituswasa 1-year-oldmale whocame toward with one-monthhistoryof refusaltofeed; one-week
historyof diarrheaand vomitingandbodyswellingfor6 days.
Examinationrevealedachild withsome dehydration,,thatwasseverelystunted,severelywasted.
He wasdiagnosedwithSevere chronicundernutritionwithedemaand wasput on nutritional
rehabilitation;andIV antibioticsandwasdischargedbetteronthe 5th
day.
Problem list;
 Refusal tofeedforone month
 Vomitingand diarrheaforone week
 Bodyswellingfor6days
Diagnosis;
Severe chronicUndernutritionwithedema
Differential diagnosis;
 Renal failure
 Rightheart failure
 Depression
 ActinicPrurigo
 AtopicDermatitis
 InflammatoryBowel Disease
Actual management of the patient;
 Formulafeeds(F-75) 90 mls3 hourly
 Formulafeeds(F-100) 300 mls3 hourly
 Ampicillin300mg6 hourlyfor5 days
 Gentamicin5mgonce dailyfor5 days
 Readyto use Therapeuticfeeds3sachets/dayfor2 weeks
 Nutritional advice tomother.
Key information in history that aided diagnosis;
 Refusal tofeedforone month
 Vomitingand diarrheaforone week
 Bodyswellingfor6days

3. KABONEROGRACE
16/A/MBChB/0744/F
Key information in physical examination that aided diagnosis;
Examinationrevealedachildwithsome dehydration,apathetic,thatwasseverelystunted,severely
wasted.Asall anthropometricmeasurementsforage were below -3standarddeviationinthe WHO z-
scores
Relevant pathophysiology to this condition;
Undernutrition iscausedprimarilybyaninadequate intake of dietaryenergy,regardlessof whetherany
otherspecificnutrientisalimitingfactor.
Marasmus occurs whenthere isan insufficientenergyintake tomatchthe body'srequirements.Asa
result,the bodydrawson itsownstores,resultingin emancipation.Inkwashiorkor,adequate
carbohydrate consumptionanddecreasedproteinintake leadtodecreasedsynthesisof visceral
proteins.The resultinghypoalbuminemiacontributesto edema.Impairedsynthesisof B-lipoprotein
producesa fattyliver.
Protein-energymalnutritionalsoinvolvesaninadequate intake of manyessential nutrients.Low serum
levelsof zinchave beenimplicatedasthe cause of skinulcerationinmanypatients.Serumzinclevels
correlatedcloselywiththe presence of edema,stuntedgrowth,andsevere wasting.The classic"mosaic
skin"and"flakypaint"dermatosisof kwashiorkorbearsconsiderable resemblancetothe skinchangesof
acrodermatitisenteropathica,the dermatosisof zincdeficiency.
For complex reasons,sickle cell anemiacanpredispose suffererstoproteinmalnutrition.
Worldwide,the mostcommoncause of malnutritionisinadequate foodintake.Preschool-agedchildren
indevelopingcountriesare oftenatriskformalnutritionbecauseof theirdependence onothersfor
food,increasedproteinandenergyrequirements,immature immune systemscausingagreater
susceptibilitytoinfection,andexposure tononhygienicconditions.
Anothersignificantfactorisineffective weaningsecondarytoignorance,poorhygiene,economic
factors,and cultural factors.The prognosisisworse whenprotein-energymalnutritionoccurswith
humanimmunodeficiencyvirus(HIV) infection.Gastrointestinalinfectionscanandoftendoprecipitate
clinical protein-energymalnutritionbecause of associateddiarrhea,anorexia,vomiting,increased
metabolicneeds,anddecreasedintestinal absorption.Inaddition,parasiticinfectionsplayamajorrole
inmany parts of the world.
In developednations,inadequate foodintakeisalesscommoncause of malnutritionthanthatcaused
by decreasedabsorptionorabnormal metabolism.Thus,diseases,suchascysticfibrosis,chronicrenal
failure,childhoodmalignancies,congenital heartdisease,andneuromusculardiseasescontribute to
malnutritionindevelopedcountries.Faddiets,inappropriatemanagementof foodallergies,and
psychiatricdiseases(e.g.,anorexianervosa) canalsoleadtosevere protein-energymalnutrition.

4. KABONEROGRACE
16/A/MBChB/0744/F
Epidemiology
Protein-energymalnutritionisthe mostcommonformof nutritional deficiencyamongpatientswhoare
hospitalizedinthe UnitedStates.Upto half of all patientsadmitted tothe hospital have malnutritionto
some degree.Ina surveyof a large children'shospital,the prevalenceof acute andchronic protein-
energymalnutritionwasmore than50%.
Protein-energymalnutrition isverymucha disease thatoccursin 21st century, eveninthe UnitedStates
and otherdevelopednations.
In 2000, the WorldHealthOrganization(WHO) estimatedthatmalnourishedchildrennumbered181.9
million(32%) indevelopingcountries. Inaddition,approximately149.6 millionchildrenyoungerthan 5
yearswere malnourishedwhenmeasuredintermsof weightforage.Insouthcentral Asiaand eastern
Africa,abouthalf the childrenhadgrowthretardationdue toprotein-energymalnutrition.Thisfigure
was five timesthe prevalence inthe westernworld.
Important risk factors predisposing to disease;
Undernutritionisassociatedwithmanydisordersandcircumstances,includingpovertyandsocial
deprivation.
Riskisalso greaterat certaintimes(i.e.duringinfancy,earlychildhood,adolescence,pregnancy,
breastfeeding,andoldage).
The commonestriskfactorsinclude;pretermbirth,age atbreastfeedingcessation,age at
complementaryfeedsintroduction,type of complementaryfeedsintroduced,chronicillnesseslike –
pulmonarytuberculosis.
Infantsand childrenare particularlysusceptibletoundernutritionbecause of theirhighdemandfor
energyandessential nutrients.Because vitaminKdoesnotreadilycrossthe placenta,neonatesmaybe
deficient,sotheyare givenasingle injectionof vitaminKwithin1hof birthto prevent hemorrhagic
disease of the newborn,alife-threateningdisorder.
Inadequatelyfedinfantsandchildrenare atriskof protein-energyundernutrition (PEU—previously
calledprotein-energymalnutrition)anddeficienciesof iron,folate (folicacid),vitaminsA andC, copper,
and zinc.
Duringadolescence,nutritional requirementsincreasebecause the growthrate accelerates. Anorexia
nervosamayaffectadolescentgirlsinparticular.
Relevant pharmacology and pharmacy;
 Ampicillinisa broadspectrumpenicillintattinterfereswithbacterial cellwall formationduring
active replication, andthushasbactericidal activityagainstsusceptible organisms.Itisan
alternative toamoxicillinwhenpatientisunable totake drugsorally.Itis able tocross blood
brainbarrierin inflamedmeninges,butthisishighlydose dependent.
It isadministereddosedependentonweight;6hourlyfor5 days.
 Gentamicinisan aminoglycoside antibioticforgramnegative cover;includingpseudomonas
species.

5. KABONEROGRACE
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It issynergisticwithbetalactamase againstenterococci
Mode of actionis interference with bacterial proteinsynthesis bybindingto30s and 50s
ribosomes.
GentamicindiffusionintoCSFisminimal evenininflamedmeninges(about10-30%)
It isalso administereddose dependentonweight;once dailyfor5-10 days.
Relevant hematological investigations;
Complete bloodcount;A CBCcount withRBC indicesandaperipheral smear.Thiscouldalsohelp
exclude anemiasfromnutritional deficienciessuchasiron,folate,andvitaminB-12deficiencies.
Measuresof proteinnutritional statusinclude serumalbumin,retinol-bindingprotein,prealbumin,
transferrin,creatinine,andBUN levels.Retinol-bindingprotein,prealbumin,andtransferrin
determinationsare muchbettershort-termindicatorsof proteinstatusthanalbumin.However,inthe
field,abettermeasure of long-termmalnutritionisserumalbuminbecause of itslongerhalf-life.
Serumelectrolytes;thisisbecause there’samajorderangementinthese whenachildin
undernourished.The problemsare usuallyinpotassiumlevels.
Relevant non-hematological investigations;
Urinalysis;thisisaspart of a whole workupto rule out infection.In particular, urinarytractinfection,as
these childrenare particularlyimmunocompromised
Stool specimensshouldbe obtainedif the childhasahistoryof abnormal stoolsorstoolingpatternsor
if the familyusesanunreliableorquestionable source of water.
Additional studiesmayfocusonthyroidfunctionsorsweatchloride tests,particularlyif heightvelocityis
abnormal.Furtherdiagnosticstudiesshouldbe determinedasdictatedbythe historyandphysical
examination.Forexample,labtestsevaluatingrenal function,suchasphosphorusandcalcium, should
be obtainedinthe presence of renal symptoms.Childrenwithsuspectedliverdiseaseshouldhave
triglyceride andvitaminlevelsobtained,whilezinclevelsshouldbe obtainedinpatientswithchronic
diarrhea.
Evidence Based management plan;
The Uganda clinical guidelines2016 recommendsthe following;
Preventhypoglycaemiabygiving small sipsof sugarwater,keepthe childwarm, firstdose of antibiotics
(ampicillin+gentamicin).
Treat shock,hypoglycemia,and corneal ulceration,immediately.
General treatmentinvolves10stepsin two phases:initialstabilisationfor1weekandrehabilitation(for
weeks2-6) as inthe table below;

6. KABONEROGRACE
16/A/MBChB/0744/F
Personal learningpoints;
I learntthat refeedingsyndromeisa syndrome consistingof metabolicdisturbancesthatoccur as a
resultof reinstitutionof nutritiontopatientswhoare starved,severely malnourished ormetabolically
stresseddue tosevere illness.Whentoomuchfoodand/orliquidnutritionsupplementisconsumed
duringthe initial fourtosevendaysof refeeding,this triggerssynthesisof glycogen,fatandproteinin
cells,tothe detrimentof serum(blood)concentrationsof potassium,magnesium, andphosphorus.
Cardiac,pulmonaryandneurological symptomscanbe signsof refeedingsyndrome.
REFERENCES;
 Protein-energymalnutrition
https://emedicine.medscape.com/article
 Uganda clinical guidelines2016
Managementof severe undernutrition
 WorldHealth Organization/ Undernutrition
https://www.who.int/nutrition/publications/undernutrition