Marasmus - Case Report

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CHAPTER 1 INTRODUCTION

Malnutrition is the result of deficiency of protein, energy, minerals as well as vitamins leading to loss of body fats and muscle tissues. Malnutrition is a significant public health problem which is often neglected. (2). The World Health Organization estimates that by the year 2015, the prevalence of malnutrition will have decreased to 17.6% globally, with 113.4 million children younger than 5 years affected as measured by low weight for age. The overwhelming majority of these children, 112.8 million, will live in developing countries with 70% of these children in Asia, particularly the southcentral region, and 26% in Africa. An additional 165 million (29.0%) children will have stunted length/height secondary (3)

to poor nutrition. Malnutrition is directly responsible for 300,000 deaths per year in children younger than 5 years in developing countries and contributes indirectly to more than half of all deaths in children worldwide.

(6)

Protein-energy

Malnutrition (PEM) in children is still a problem of nutrition and public health in Indonesia. Based Health Research in 2010, as many as 13.0% less nutritional status, of which 4.9% severe malnutrition. The same data showed 13.3% of children underweight, of which 6.0% was emaciated children and 17.1% of children have a very short category. Riskesdas 2013 there is an increased  prevalence of malnutrition-less, namely 19.6%, of which 5.7% 5.7% severe malnutrition and 13.9% less nutritional status. Protein-energy undernutrition (PEU), previously called protein-energy malnutrition, is an energy deficit due to deficiency of all macronutrients. It commonly includes deficiencies of many micronutrients. In children, chronic  primary PEU has 2 common forms: marasmus and kwashiorkor. The form depends on the balance of nonprotein and protein sources of energy. (7)  Marasmus is one of the serious forms of PEM. Marasmus is almost never seen in the developed world.

 

  CHAPTER II LITERATURE REVIEW undernutrition ion  2.1 Marasmus Marasmus  www.unicef.org type of undernutrit

A rapid deterioration in nutritional status in a short time can lead to

marasmus, one form of acute malnutriti malnutrition. on. Marasmus is the most common form of acute malnutrition in nutritional emergencies and, in its severe form, can very quickly lead to death if untreated. It is characterised by severe wasting of fat and muscle which the body breaks down to make energy. Wasting can affect both children and adults. The body of a wasted child tries to conserve energy as much as possible by reducing physical activity and growth, reducing internal body processes and shutting down the body’s response to infection. This reduced activity results in limited function of the liver, kidney, heart and gut putting the child at risk for:   Low blood sugar (hypoglicemia) (hypoglicemia) 

  Low body temperature (hypotermia) (hypotermia)



  Fluid overload/heart failures



  Infection



2.2. Etiologi Marasmus

The immediate cause of PEM is a deficiency of calories and protein with various symptoms. While the cause is not immediately KEP very much, so the disease is often called a multifactorial causes. One reason is the relationship with time breastfeeding or  breast milk and and supplementary supplementary food after weaning weaning (Khurnaidi, (Khurnaidi, 1989). Jellife (1998) states that the nutritional state of a person is the interaction of all aspects of the environment including the physical environment, biological and cultural factors. Broadly speaking, the factors that determine the nutritional state of the public, especially the children is the parents' education level, economic conditions, the availability of sufficient food, as well as health aspects. PEM is basically determined by two factors. Factors that can directly affect the occurrence of PEM in children under five is the food and the presence or absence of infectious diseases. Both of these factors are influenced by the quality and quantity of food eaten on a child, among others, determined by some indirect factor, namely a) the nutrients contained in the food, b) the purchasing power of families, including income,

 

the price of materials food, and family expenditures for other needs besides food, c)  beliefs about food and health of the mother, d) the presence or absence of health care, including cleanliness (Levinson, 1979 in Lismartina, 2000).

2.3 Pathophysiology

Protein-energy malnutrition will occur when the body's need for calories,  protein, or both are not fulfilled by diet. (Arisman, 2004: 92). In a state stat e of lack of food, the body is always trying to preserve life by meeting basic needs or energy. The ability of the body to use carbohydrates, proteins and fats is very essential to maintain life, carbohydrates (glucose) can be used by all body tissues as fuel, unfortunately the body's ability to store carbohydrates very little, so that after 25 hours was possible shortage. As a result, protein catabolism occurs after a few hours to produce amino acids are immediately converted into carbohydrates in the liver and kidneys. Diving fasting fat tissue are broken down into fatty acids, glycerol and ketone bodies. Muscles can use fatty acids and ketone bodies as an energy source that is running a chronic food shortage. The body will defend itself not to break down proteins again after losing roughly half of the body.  2.4 Clinical Signs of Marasmus Marasmus www.fao.org.human nutrition in a developing world

Poor growth. growth. In all cases the child fails to grow properly. If the age is known, the weight will be found to be extremely low by normal standards (below 60 percent or -3 SD of the standard). In severe cases the loss of flesh is obvious: the ribs are prominent; the belly, in contrast to the rest of the body, may be protuberant; the face has a characteristic characteristic simian (monkey-like) appearance; and the limbs are very emaciated. The child appears to be skin and bones. An advanced case of the disease is unmistakable, and once seen is never forgotten.

Wasting.. The muscles are always extremely wasted. There is little if any subcutaneous fat Wasting left. The skin hangs in wrinkles, especially especially around the buttocks and thighs. When the skin is taken between forefinger and thumb, the usual layer of adipose tissue is found to be absent.

 

 Alertne  Ale rtness ss.. Children with marasmus are quite often not disinterested like those with kwashiorkor. Instead the deep sunken eyes have a rather wide-awake appearance. Similarly, the child may be less miserable and less irritable.

 Appe  App etite. The child often has a good appetite. In fact, like any starving being, the child may be ravenous. Children with marasmus often violently suck their hands or clothing or anything else available. Sometimes they make sucking noises.

 Anorexi  Anore xia a. Some children are anorexic. Diarrhoea.. Stools may be loose, but this is not a constant feature of the disease. Diarrhoea Diarrhoea of an infective nature, as mentioned above, may commonly have been a  precipitating factor. factor.

.  Anaem  Anae mi a Anaemia is usually present.  Ski n so sorr es. There may be pressure sores, but these are usually over bony prominences, not in areas of friction. In contrast to kwashiorkor, there is no oedema and no flaky-paint dermatosis in marasmus.

H ai r change changess. Changes similar to those in kwashiorkor can occur. There is more frequently a change of texture than of colour.

Dehydration.. Although not a feature of the disease itself, dehydration is a frequent Dehydration accompaniment accompa niment of the disease; it results from severe diarrhoea (and sometimes vomiting)

F. Diagnosis

In malnourished patients, the most common complain is no increase of body weight, poor feeding, frequently ill, or bilateral ankle edema, and the whole body. In patients with kwashiorkor, children look letargis, apatis, and or irritable. The apparently manifestation of kwashiorkor are swelling of the abdominal wall, making the body weight undecreased in thr first time of kwashiorkor.

 

Diagnosis of malnutrition is made based on nutritional status of the patient.  Nutritional status is defined by physical examination and anthropometric (BW/BL, AC). Clinical manifestations of children with kwashiorkor are: alterations of consciousness to apatis, anemia, alterations or colour and texture of hairs, easy to peel of, disturbaances of gastrointestinal system, hepatomegaly, dermatosis, athrophy of muscles, bilateral ankle pitting edema to the whole body. Based on physical examination and anthropometric (BW/BL), nutritional status is categorized to be severe malnutrition, mild-moderate malnutrition, health, and obesity.

Clinical Presentation

Anthropometry (BW/BL)

**)  Looked very thin and or bilateral < -3 SD **)  ankle edema and the whole

Severe malnutrition

 body. Mild-moderate malnutrition

Looked thin

- 3 SD < - 2 SD  SD  

Health

Looked health

- 2 SD 2 SD SD  

Obesity

Looked fat

> 2 SD  SD 

**) BW/BL can be > -3 SD if there is severe edema (the whole body).  body).   Malnutrition is categorized to severe malnutrition with complications, severe malnutrition without complications and mild-moderate malnutrition.  malnutrition.   Physical Examination, BW/BL, AC  Severe malnutrition

Severe malnutrition without

Mild-moderate

with complications 

complications 

malnutrition 

 

Children with one

Children with

Children with

AC>11.5cm<12.5cm

or more signs:

one or more

one or more

(children 6-59

-Looked very thin

signs:

signs:

months) (BW/BL<-2

-Edema the whole

-Looked very

body 

thin

very thin -

- BW/BL<-3SD 

-Minimal

BW/BL<-3SD 

And 

-AC<11,5cm

edema, bilateral

-

Goodly feeding 

(children 6-59

palm/ankle

AC<11,5cm

No clinical

months) and one or

edema

(children 6-59

abnormality 

more medical

- BW/BL<-3SD 

months) 

complications

-AC<11,5cm

signs: 

(children 6-59

-goodly feeding 

-Anorexia 

months) 

-without any

-Severe pneumonia 

and 

-Severe anemia 

-goodly feeding 

-Severe

-without any

dehydration 

medical

-High grade fever 

complications 

-Looked

to -3 SD)  No edema 

And 

medical complications 

-↓level of consciousness 

Some laboratories examination we should do for patients with kwashiorkor are blood glucose, peripheral blood smear, urinalysis, stool examination, electrolyte, protein, and ferittin. Maantoux test, chest chest x-ray, and ECG to exclude exclude differential diagnosis should be consider. G. Management 

Children with malnutrition should be treated with four phases, they are: stabilization,

transition,

rehabilitation,

and

further

management

 

Medical Steps 

Stabilization

Transition  Rehabilita- Further tion 

o H 1-2 

H 3-7 

nd

 

management   th

th

S

th

2 -6  

7 -66  

weeks 

weeks 

ome importa

Preventing and

nt

treating hypoglycemia

things we must

---

Preventing and

attend

treating

are:

hyp hypoth otherm ermia

-----

D

Preventing and

on't

treating

give Fe

dehy ehydra dration tion

-----

 before 2nd

Treating electrolyte imbalance

----

Treating

week (Fe is given in

in infe fect ctio ion n

--------------------------------

stabiliza

Stabilized

tion

micronutrient

Without Fe

deficiencies

-------------------------

With Fe

 phase). Don't

-----Feeding for

give intraven ous fluid

stabilization and transition

drip

Feeding for

unless

growth

the

Stimulating for development Preparation for 0

further management at home

 patient is

in shock or severe

 

dehydration. Don't give high protein diet in stabilization phase. Don't give diuretics to patients with kwashiorkor.

Preventing and treating hypoglycemia hypoglycemia 

Hypoglycemia is defined with blood glucose < 40mg% in children and blood glucose <50mg% in infant. Treat hypoglycemia with rapid injection of 50cc glucose 10% or sucrose 10% per oral/NGT.

Preventing and treating hypothermia

Hypothermia is defined with axilla temperature < 36.5 o C. Treat hypothermia with kangaroo method, hold the child in the chest, a blanket to the head.

Preventing and treating dehydration

Classification of dehydration (min 2 signs + 1 *) Without dehydration Mild-moderate

Severe dehydration

dehydration Presentation*

Alert

Irritable

Letargis

Tears

+

-

-

Eyes

N

Sunken

Very sunken

Lips mucosa

N

Dry

Very dry

Thirsty*

Want to drink

Thirsty

Cannot drink

Turgor *

Good

<

Poor

To treat dehydration, give Resomal (Rehydration Solution for Malnutrition) 5cc/kgBW/30' for 2 hours orally/NGT.

Antibiotic for Infection

 No complications

Cotrimoxazole (25mg sulfametoksasol+5mg trimethoprim/kg)/12 hours for 5 days

 

Complications (shock,

Gentamicin iv or im (7.5mg/kg)/day for 7 day,

hypoglycemia, hypothermia,

 plus

dermatosis, URI,UTI, or

Ampicillin iv or im

Followed by

letargis, ill looking)

(50mg/kg)/6 hours for

amoxicillin orally

2 days

(15mg/kg)/8 hours for

 No improvement of any

5 days Chloramphenicol iv or im (25mg/kg)/8 hours

symptoms within 48 hours, add:

for 5 days (every 6 hours if suspected for meningitis)

Any specific infection

Specific antibiotics

Stabilization Phase

Fluid and feeding allowance in stabilization phase to a malnourished patient without any warning signs (shock, unconscious, and vomiting/diarrhea/dehydration). Give 50ml of glucose 10% orally rapidly, monitor heart rate, respiratory and alertness every 30 minutes in the first 2 hours, and every 1 hour in the next 10 hours. In the first 2 hour, give F-75 every 30 minutes, ¼ doses for 2 hours based on body weight (with or without edema). Monitor heart rate, respiratory, alertness and provision of F75 every 30 minutes. In the next 10 hours, continue the provision of F75 in children every 2 hours. Monitor heart rate, respiratory and provision of F75. If the child is still breastfeeding, give ASI between the provisions of F75. If the child can consume almost of F75, change the time of provision to be every 3 hours or every 4 hours if the child can consume the whole of F75. You'd better give F75 orally as much as you can. Consider NGT if the child cannot consume the whole F75. Reduce to give F75 based on minimal calories requirements in stabilization phase (with or without edema) if you find any warning signs; heart rate and respiratory rate increased,  jugular vein blocked, or edema increased (e.g.: markedly periorbital edema).

Transition and Rehabilitation Phase

(4)

 

If every doses of F75 given per 4 hours could be finished by children, change F75 to  be F100 as much as the volume of F75 for 2 day. Monitor heart rate, respiratory and  provision of F100 every 4 hours. If the child is stable, continue F100 based on body weight in

 

the third day. Increase 10 ml every 4 hours until unti l the child couldn’t finish the formula, but not to exceed the maximal doses of F100. In the fourth day of transition phase, give F100 every 4 hours based on body weight  between minimal and maximal doses. Continue F100 for next 14 days (last (las t day of transition tr ansition  phase). In rehabilitation phase, give F100 and solid food based on body weight. If the BW < 7kgs, give F100 plus soft food and fruits extract. If the BW>7kgs, give F100 plus soft food and fruits. Continue giving the food until BW/BL>-2 SD standard WHO 2005. Reduce to give F100 if you find any warning signs; heart rate and respiratory rate increased, jugular vein blocked, or edema increased (e.g.: markedly periorbital edema). Evaluate for 1 hour.

Giving sensory and emotional stimulation

A child with malnutrition is usually accompanied by delayed of mental and behavior, so the parents should give love, happy environmental, structured playing treatment for 15-30 minutes/day, daily activities as soon as the child recover with mother's involvement.

Preparation for further management at home  

Children with malnutrition is said to be recovered if BW/BL > -2SD. Instruct the  parents how to make a meal based on the child’s BW. Control the growth and development of children once per week in the first month, once every 2 weeks in the second month, and once every month in the next 4 months. Remember to give immunizations and booster, and highdose vitamin A every 6 months (based on age).

H. Prognosis

(12)

 

Getting treatment early generally leads to good results. Treating kwashiorkor in its late stages will improve the child's general health. However, the child may be left with  permanent physical and mental problems. If treatment is not given or comes too late, this condition is life-threat 

CHAPTER III CASE REPORT 3.1 Objective

 

The objective of this paper is to report a case of 2 years and 3 months old girl with a diagnosis of Bronchopneumonia. 3.2 Case K, a 2 years and 3 months girl, with 7 kg of BW and 79 cm of BH, is a new patient of infection unit in Pediatric Department in Central Public Hospital Haji Adam Malik Medan on September nd 2  2015 at 14.55. Her chief complaint was dyspnea. History of disease: K ,a girl, 2 years and 3 months old, came to Haji Adam Malik Hospital at September 2 nd 2015 with dyspnea as the chief complaint. The patient have been experienced this since morning. Patient looks weak since a day before. Dyspnea (+) since 2 days ago. Dyspnea doesn’t caused by activity or weather. Cough (+) been experienced for 2 weeks. At first was dry, but then became  productive. History of recur cough since this past 2 months. Her grandmother also had productive cough for a month. History History of fever was 2 months ago, ago, lasted for this two weeks, up and down. Diarrhea was experienced for a day, without losing losin g weight. Vomitting was denied. No history of family having the same condition. History of previous illness: The patient is a new patient History of medication:History of family: No family history of DM and other diseases History of parent’s medication medication: unclear History of pregnancy: Patient’s mother was 27 years old during pregnancy. The gestation age was 36 weeks. No history of complication neonate and maternal problem. History of birth: Birth assisted by GP. The baby was born paravaginal and she cried spontaneously. Bluish was not found. Body weight 2700 gram, body length 46 cm, and head circumference was not measured. History of feeding: 6 months of exclusive breast feeding, additional food since 7 months old and family food was given from 19 th week onward. History of immunization: BCG, Polio 4 times, Hepatitis B 3 times, DPT 3 times, and Measles. History of growth and development: Face down: 4 months old, Sit down: 6 months old, Crawl: 8 months old, Stand up: 10 months old, Walk: 13 months old, Talk: 12 months old. Physical Examination: Present status: Level of consciousness: Conscious, Body temperature: 38°C, HR: 100 bpm, RR: 48 bpm, BW: 7 kg, BH: 79 cm, BW/A: -3 < SD BL/A: -3 < SD < -2, BW/BL: -3 < SD , anemic (-), icteric (-), dyspnea (+), cyanosis (-), edema (-). Localized status:

Face edema (-), Eyes: superior and inferior palpebral edema (-), Light reflex +/+, isochoric pupil,  pale wasn’t found in inferior conjunctiva palpebral. Ears: within normal range  Nose: within normal range Mouth: within normal range -) Symmetrical fusiform, suprasternal, intercostal and substrenal retraction (+), Cor S1,S2 (+), HR: 100 bpm, regular, murmur (-), ( -), RR: 48 bpm, regular, rhonchi (+/+) wheezing (-/-), rales (-/-) Symmetric, supple, normal peristaltic, liver and spleen: unpalpable. 00 bpm regular, p/v adequate, warm acral, CRT < 3”, clubbing finger(-), finger(-),  pretibial oedema (-).

 

Laboratory finding

Complete blood analysis (September 2nd , 2015) Test Hemoglobin Erythrocyte Leucocyte

Result 10.40 3.77 18.13

Unit g% 106/mm3 103/mm3

Referral 12.0-14.4 4.40-4.48 4.5-13.5

Thrombocyte Hematocrite Eosinophil Basophil  Neutrophil Lymphocyte Monocyte  Neutrophil absolute Lymphocyte absolute Monocyte absolute Eosinophyl absolute Basophyl absolute MCV MCH MCHC RDW

332 32.30 1.00 0.900 62.90 27.50 7.70 11.41 4.99 1.39 0.18 0.16 85.70 27.60 32.20 12.60

103/mm3 % % % % % % 103/μL 103/μL 103/μL 103/μL 103/μL fL Pg g% %

150-450 37-41 1-6 0-1 37-80 20-40 2-8 2.4-7.3 1.7-5.1 0.2-0.6 0.10-0.30 0-0.1 81-95 25-29 29-31 11.6-14.8

Morphology: Erythrocyte: normochromic normosite Leukocyte: leukocytosis Thrombocyte: thrombocytosis Clinical Chemistry Test Result Unit Carbohydrate Metabolism Blood Glucose 151.00 mg/dL Electrolite  Natrium 138 mEq/L Kalium 4.3 mEq/L Chloride 104 mEq/L Blood Arterial Gas Analyse  pH  pCO2  pO2 Bicarbonate (HCO3) Total CO2 Base Excess(BE) O2 Saturation

7.320 21.0 183.0 10.8 11.4 -14.0 100.0

mmHg mmHg mmol/L mmol/L mmol/L mmol/L

Referral

< 200 135-155 3.6-5.5 96-106

7.35-7.45 38-42 85-100 22-26 19-25 (-2)  –  –  (+4)  (+4) 95-100

Working diagnosis : Bronchopneumonia + Mild Malnutrition Therapy : 1. O2 nasal canule 1 liter/i

2. Inj Meropenem Meropenem 140 mg/8 hour /iv 3. Salbutamol 3x0,5 mg 4. Ambroxol 3x5 mg

 

5. As. Folat 1x1 mg 6. Vit. C 1x100 mg 7. Vit. B Complex 1x1 8. Diet F 75 100cc/3hour+ mineral mix 2cc Planning Assement

1. Blood gas saturation, electrolytes, /3 hour 2. Balance fluid / 6 hour 3. Observe vital sign/ 30 minutes

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