COMPREHENSIVE CLINICAL
CLASS
SEVERE ACUTE MALNUTRITION
Mentor: [Link] Gupta
HOD, Pediatrics
UCMS, Delhi.
Presenter: [Link] S Patel
1st year PG
BMCRI, Bengaluru.
GENERAL INFORMATION
• Name: XYZ
• Age: 18 months
• Sex: Male
• Second born to non-consanguineous parents.
• Address: KR Market, Bengaluru.
• Religion: Hindu
• Informant: Mother, reliable.
• Date of Admission: 12/08/20
• Date of Examination: 12/08/20
Chief Complaints:
• Unable to gain weight, apathy and decreased food intake for 6
months.
• 2 episodes of loose stools, 2 months back and presently for 4 days.
• Fever & vomiting for 2 days.
HISTORY OF PRESENTING ILLNESS:
• The child was apparently normal 6 months back after which the mother noticed
that the child was unable to gain weight and appeared weaker as compared to his
sibling. Mother also tells that the weight of the child at 9 months was 7kg and at
16 months was 7.5kg(at immunization).
• The mother has noticed decreased physical activity in the child, doesn’t show
interest in playing with toys, food intake is less as compared to sibling when he
was of same age.
• The mother complaints that he had sudden onset of loose stools since 2months
back, ORS was taken and resolved in 4 days; presently with loose stools since 4
days, 6-8 episodes per day, clear watery stools, large quantity, no blood & mucus
in stools, the child is irritable & cries frequently, drinks water eagerly, reduced
urine output to 4 times a day as compared to 8-10 times before & decreased
appetite.
• Associated with vomiting, 2-3 episodes per day since 2 days, containing food
particles, non-projectile, non-bilious, not blood stained.
• The mother complaints that he had sudden onset, intermittent, moderate
grade fever since 2 days, relieved on taking over the counter medication,
details of which are unknown, not associated with, rashes, cough & running
nose, cry during micturition.
• No complaints of unconsciousness, lethargy, seizures.
• The mother also complaints of recurrent oral ulcers.
• No history of any bony deformity, frequent falls during night, gum bleeding,
hemorrhagic manifestation, skin changes, seizures, progressive pallor.
• No history of increased water intake, polyuria, dribbling of urine.
• No history of suck rest suck cycle, cyanosis, feeding difficulties,
sweating over forehead.
• No history of large, bulky, foul smelling foods, loose stools after
starting complimentary feeds, repeated vomiting episodes.
• No history of any abnormal movements, posturing, delayed
developmental milestones.
Past history:
• No history of tuberculosis, measles.
• No history of any hospital admission.
Treatment History:
• The child was given over the counter medication for fever & ORS for
loose stools.
Antenatal History:
The child is of 2nd order born out of non-consanguineous marriage with a gap of
one year between the first and second child.
The mother is a registered case and history is as follows:
1st trimester:
• No h/o of fever, rash.
• Dating scan was done
• Folic acid was taken
• No other drug intake or radiation exposure.
• No alcohol/tobacco/substance abuse.
2nd Trimester:
• Quickening felt at 18 weeks.
• 2 doses of Tetanus toxoid taken 1 month apart.
• Iron, frolic acid & calcium taken.
• Anomaly scan done and no abnormality noted.
• No h/o Headache, swelling of feet, blurring of vision, pedal edema,
documented hypertension.
• No h/o of Polyuria, Polydipsia & OGTT was done and was normal.
3rd Trimester:
• Appreciated fetal movements well.
• No h/o maternal fever, diarrhoea, UTI.
• No bleeding per vaginum, leaking per vaginum, foul smelling liquor,
premature rupture of membranes.
Birth History:
• Place: Vani Villas Hospital
• Mode: Normal Vaginal Delivery
• Period of gestation: 39 weeks of gestation
• Baby cried immediately after birth.
Postnatal History:
• Birth weight: 2.9kg.
• Full term
• Cried immediately after birth
• Breastfeeding started 30 mins after delivery.
• Breast feeding was done adequately on demand at day and night, no
feeding problems was noticed.
• No respiratory difficulty, jaundice, cyanosis or seizures.
Developmental history:
Domain Milestone Age of Attainment Expected Age DQ
Gross Motor Walks without 17 months 15 months 88
support
Running, explores Not attained 18 months
drawers
Fine motor Spontaneous 16 months 15 months 93
scribbling
Horizontal line, Not attained 18 months
Tower of 3 blocks
Adaptive & Social Turns pages 2-3 at a 17 months 15 months 88
time
Copies parents in Not attained 18 m0nths
task
Language Speaks 2-3 words 16 months 15 months 93
with meaning
8-10 word Not attained 18 months
vocabulary
Immunization History:
• Immunised upto date according to National Immunization schedule.
Diet history:
The child was exclusively breastfed till 4 months of age, following which she started on cow’s milk in 1:2 dilution 400mL per day. She has been breastfeeding twice a day since then. Complimentary feeds was started at 9 months of age. The
child was fed mashed rice with dal twice a day.
24 hour recall method:
Time Food Items Amount Calorie(kcal) Protein(g)
8am Milk 100mL 36 1.6
Sugar 20g 20
10am Idly ½ 35 1.5
Milk Half cup – 100mL 36 1.6
Sugar 1tsp – 20g 20
1pm Rice ½ 55 1
Sambhar ½ 100 2.5
6pm Biscuit(Parle-G) 1 30 0.5
Milk Half cup - 100mL 36 1.6
Sugar 1tsp- 20g 20
9pm Rice ½ cup 55 1
Sambhar ½ cup 55 2.5
Total:
• Calorie: 498kcal/day
• Protein: 13.8g/day
Expected:
• Calorie: 1060kcal/day
• Protein: 16.7g/day
Gap:
• Calorie: 562kcal/day(53% deficit)
• Protein: 2.9g/day(17% deficit)
Family history:
• Type: Extended family
• Members: 6(Grand parents, Parents & 2 kids)
• Sibling: 3 years old boy child.
• No abortion or stillbirths.
• No history of tuberculosis contact, early death due to congenital or
chromosomal disorders.
Pedigree
Socioeconomic Status:
• House: 2 room Pucca house, with a kitchen, separate bathroom and
toilet, with adequate sanitary measures & clean water supply.
• Hand hygiene: poor
• Father occupation: labour(5000 per month) education till Middle
school.
• Mother occupation: Servant(5000 per month), no schooling.
• Kuppuswamy scale: Class 5
Summary:
• 18 month old child of birth order 2, born of non consanguineous
marriage, Full Term Normal Vaginal Delivery, belonging to Class 4
Kuppuswamy Scale, all developmental domains achieved & fully
immunized, was brought to the OPD with History of unable to gain
weight since 6 months, loose stools since 4 days, vomiting & fever
since 2 days, with dietary deficit of 498kcal/day & 2.9g/day of protein.
• With this would like to consider that the child is suffering from failure
to thrive, appears to be because of chronic nutritional insult. The child
also has acute infective gastroenteritis with some dehydration.
General Examination:
• The child was seated on mother’s lap during examination.
• Child is irritable, not interested in surroundings, gross wasting is present, with
prominent scapula & ribs, hollow cheek appearance, loose folds of skin.
Vitals:
• Temperature: 98.6 degree Fahrenheit
• PR: 150bpm
• RR: 26/min
• CFT<3 seconds
• Hydration: Irritable, dry oral mucosa & tongue, skin pinch test(the skin goes
back slowly), drinks water eagerly, reduced urine output.
Head to Toe Examination:
• Pallor: present
• Icterus: Not present
• Cyanosis: Not present
• Clubbing: Not present
• Lymphadenopathy: Not present
• Edema: pedal edema
• Head: normal in size and shape, sunken anterior fontanel.
• Hair: lustreless, thin, brittle.
• Face: hollow cheek appearance, no frontal bossing.
• Oral Cavity: oral mucosa dry, ulcers present, fissures present at the angle
of the mouth & lips, no cleft lip & palate, gum bleeds.
• Eyes: no bitot spots, ulcer, scar, corneal neovascularization, conjunctivitis,
conjunctival haemorrhages.
• Ears: no discharge.
• Nose & nasal cavity: normal.
• Neck: no rashes around neck.
• Chest: ribs are prominent, no Rachitic rosary, Harisson’s sulcus, pigeon chest.
• Umbilicus: normal position & inverted.
• Abdomen: protrudent belly
• Genitalia: normal
• Groin: visible wasting present, no peri-anal excoriation
• Back: prominent scapulae
• Extremity: knuckle hyperpigmentation, platynychia present
• Skin: shiny over edema toys regions, loose skin folds present over buttocks &
thighs, dry.
• Skeletal system: no valgus or Varum deformity, anterior tibial Boeing.
Anthropometric:
Parameter Observed Expected Inference
Weight for Age 7.5kg 10.9kg <-3SD
Length for age 75cm 82.3cm -2SD to -3SD
Weight for Length 7.5 9.5 -3SD
MUAC 10cm Severe malnutrition
HC 47.2cm 47.4cm Median
Inference:
Severely underweight
Moderate Stunting
Severe Wasting
Systemic Examination:
GASTROINTESTINAL System:
Inspection:
• Shape: protrudent abdomen
• Movement: All quadrants move equally with respiration
• Umbilicus: central & inverted
• No skin scars or incisions
• Superficial dilated veins not present
• No visible peristalsis
• No visible pulsation
• Groin: wasting present
• Scrotum: normal
Palpation:
• Liver: liver span was 9cm, no other abnormalities noted.
Percussion: no fluids was noticed
Auscultation: Normal bowel sounds heard.
Hepatomegaly noted.
CNS:
•Child was alert & irritable
•Higher mental function was normal
•GCS: 15
•Cranial nerves: normal
•Motor system:
Bulk: Reduced
Tone: Normal
Power: Grade 5
DTR: Normal
Gait: Normal
No abnormal movements
•Sensory system examination: normal
•Cerebellum signs: normal
•No signs of meningeal irritation
•Skull & Spine normal
• CVS: S1 S2 heard, no murmur, no added sounds.
• RS: Normal Vesicular Breath Sounds
Diagnosis:
• Edematous Severe Acute Malnutrition with nutritional anemia &
multiple micronutrient deficiency with acute infective gastroenteritis.
THANK YOU