Severe Acute Malnutrition
-[Link] RAO
NAME :
SEX : Male
3 years old Male child, born 2nd of non-
consanguineous marriage brought my his
mother whose reliability is good came with
the chief complaint of
Not gaining weight for past 2 years
Improper intake of food for past 2 years
History of Presenting Illness
The child was apparently normal 2 years
back, after which mother noticed child was
not gaining weight
H/o improper intake of food for past 2 years
H/o delayed milestone
Bitot spot present
No h/o cough
No h/o breathlessness
No h/o abdominal distension or head lag
No h/o convulsions
No h/o pain during micturition
No h/o jaundice , swelling of legs , facial
puffiness
No h/o ear discharge
No h/o skin lesions
No h/o mouth ulcers
No h/o bone defects
No h/o pica
No h/o swallowing problems
No h/o bleeding gums , joint pain
Past History
H/o loose stools present and got admitted
twice in hospital in past 2 years
H/o measles infection one year back
No h/o TB , Chronic heart disease
No h/o previous surgeries
No h/o blood transfusion
Antenatal History
FIRST TRIMESTER:
Pregnancy confirmed at 6 weeks by UPT ,
registered in local PHC , mother attended
regular antenatal checkups
Obstretic score : P2 L2 A0
No h/o hyperemesis gravidarum
No h/o fever with rash/ lymphadenopathy
No h/o radiation exposure / drug intake
Dating scan done at 10 weeks
Folic acid tablets taken
SECOND TRIMESTER:
Quickening felt at 20 weeks
Iron and folic acid tablets taken
Anomaly scan done at 20 weeks
Two doses of Td taken at 4th and 5 th months
No h/o PIH/GDM
THIRD TRIMESTER:
No h/o UTI, pre-eclampsia,headache,blurring
of vision
No h/o bleeding/draining PV
No h/o PIH/GDM
Growth scan taken at 33 weeks
Treated with Iron Injection
Total weight gain 7 Kgs
during Pregnancy
Natal History
Full term vaginal delivery
Birth weight: 2Kg
Baby cried immediately after birth
Post-natal History
Baby was breastfed 1 hour after delivery
Baby cried immediately after birth
No pre-lacteral feeds were given
h/o meconium and urine passage on first day
No h/o post partum hemorrhage
No h/o NICU admission
Developmental History
The age appropriate milestones were not
attained
The child started walking at 2 years of age
Immunization History
Completely Immunized appropriate for age
CONTACT HISTORY:
No h/o contact with TB
Diet History
Exclusively breastfed for first 3 months only
H/o bottle feeding with milk powder was
present
Complementary feeding was introduced at 10
months
Now he is given regular family food
Family History
Non consanguineous marriage
No h/o convulsions in other family members
PEDIGREE CHART:
Environmental History
Nuclear family
No of family member : 4
Living room: 1
Adequate ventilation is not present
Over crowding present
Summary
3 year old male child of second birth
order , born of non-consanguineous marriage
by vaginal delivery , completely immunized
for age was brought with chief complaint of
poor weight gain and improper intake of food
for past 2 years having delayed milestone
belonging to nuclear family living in a single
room with inadequate ventilation and
overcrowding. Exclusive breastfed was
stopped early, which was replaced by
bottlefeed milk powder and start on
complementary feed was delayed.
GENERAL EXAMINATION
The child was lethargic
Pallor present
No icterus , cyanosis , clubbing,edema, lymphadenopathy
Visible wasting of lower limb and gluteal muscles are present
Bitot spot present
Sparse hair present
VITALS
Temperature: 98^F measured in left axilla
Respirstory rate: 26/min
Heart rate: 98/min
Blood pressure: 90/60mm Hg measured in left upper arm
in sitting position
Anthropometry
PARAMETER OBSERVE EXPECTE INFERENC BASED
D D E ON
WEIGHT 8 Kg 14 Kg <-3 SD /3rd WHO
percentile CHART
HEIGHT 87 cm 95 cm <-3 SD/3rd WHO
percentile CHART
HEAD 39 cm 49 cm <-3 SD/3rd WHO
CIRCUMFEREN percentile CHART
CE
MID 11 cm 13.5 cm Lies in RED SHAKIE’S
UPPERARM zone TAPE
CIRCUMFEREN
CE
Weight for Height < -3 SD/3rd percentile according to
WHO CHARTS
Head to Foot Examination
HEAD- Microcephaly
HAIR- Sparse,brittle,lustreless
FACE- no frontal bossing, buccal pad of fat preserved
EYES- Bitot spot present, sign of vitamin A deficiency
seen
EARS- no discharge
ORALCAVITY- no sign of vitamin B
deficiency(angular stomatitis, cheilitis).
NECK- no lymphadenopathy
CHEST- movement of chest is seen, ribs are promient,
no harrisons sulcus, no rachitic rosary
UMBILICUS- normal
ABDOMEN- not distended
GENITALIA- normal
BACK- promient scapula
EXTREMITY- bulk of muscle decreased
uniformly
around gluteal region and
lower limbs
SKIN- no hypo or hyperpigmentation.
FEET- no edema, normal
SYSTEMIC EXAMINATION
ABDOMINAL EXAMINATION:
INSPECTION
Abdomen not distended :flanks free
Movements: All quadrants moves equally with
respiration
Umbilicus normal in shape and position.
No skin scars, dilated veins and sinuses.
No visible peristalsis
PALPATION
No organomegaly
No free fliud
CVS EXAMINATION:
S1,S2 heard, no murmur
RS EXAMINATION:
Normal vesicular breath sounds, no added
sounds
CNS EXAMINATION:
No focal neuralogical deficit
Diagnosis
From the above finding I come to the
probable diagnosis of SEVERE ACUTE
MALNUTRITION with micronutrient
deficiency(vitamin A).
Investigations
Complete blood count
Peripheral smear
Serum electrolyte
X-ray chest
Mantoux test
USG abdomen
RFT, Urea, serum creatinine
Blood sugar
Urine – sugar, albumin deposits
LFT: A:G ratio, total protein
Stools :microscopy –ova/cysts, culture