Clinical Cases from Resource Limited Settings: Beatriz Thome & Suzinne Pak-Gorstein


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Participants will be able to: recognize importance and identify resources for learning about a country and local 'disease' profile; local/regional guidelines and algorithms appropriate for the specific clinical setting; how to address limitations in clinical resources for diagnosis and management of clinical cases; and understanding health care service structure and personnel/staffing structure.

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  • The lowest level of care is provided by Health Posts (total of 638, 27,674 people per Health Post). 30-50% of the population have access to basic preventive and curative health services, which means that they live within 10kms of a health facility High level of Communicable Diseases (13% of adults living with HIV/AIDS, 18,108 cases of Malaria per 100,000 [3]) Lack of staff (599 \"Superior Health Personnel\" [2] in the whole country, including 400 Mozambican doctors) General lack of resources from “paper and desks to medical equipment and medicines”
  • Health center:3 antibiotics if you are luckyLab services as listed here, but lab supplies often are intermittent (thick/thin smears, Hbg, stool O&P, urinalysis)300 vaccinations / day
  • Road to health card – photo hereAfter 1 year of age – primarily acute illness visits – no concept of check-ups for screening, counseling, etc.<number>
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  • The prevalence of severe malnutrition is estimated as around 2% in the least-developed countries and 1% in other developing countries [1], which translates to about 10 million severely malnourished children at one time.About 10 million children under five die each year. Some 4 million of these are neonatal deaths, which are not generally preventable by addressing severe malnutrition, but a significant proportion of the remaining 6 million may be preventable in this way. Malnutrition, severe or otherwise, is estimated to be a contributing factor in over 50% of child deaths [4], and it is estimated that the reduction in child mortality and morbidity (i.e., loss of disability-adjusted life-years [DALYs] averted) if malnutrition were eliminated would be at least one-third.possibly 1 million child deaths (out of 6 million) associated with SAM.Moderate malnutrition contributes more to the overall disease burden than severe malnutrition, since it affects many more children, even if the risk of death is lower<number>
  • Height-for-Age - StuntingWeight-for-Age – Underweight Weight-for-Height – WastingProtein-Energy Undernutrition: Classification Severe malnutrition, defined by severe wasting (weightfor-height < –3 z-scores or < 70% of the medianNational Center for Health Statistics/World HealthOrganization [NCHS/WHO] reference) and/or thepresence of nutritional edema, is a life-threateningcondition requiring urgent treatment<number>
  • 6-59 monthsRelaxed arm< 110 cm – increased mortalityMeasures muscle wastingoverestimates rates in the 6-12 month age groups- however, the risk of measurement error is very high, therefore MUAC is only used for quickscreening and rapid assessments of the nutritional situation of the population to determine theneed for a proper W/H random survey<number>
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  • Saves 1 million lives per yearDiarrhea deaths HALVED from 1990-2000Diarrhea causes loss of micronutrients such as zinc so those w/ borderline deficiencies may be particularly impacted after bout of ge. Zinc has direct effect on intestinal villus, brush border disaccharidase activity and intestinal transport of water and electrolytes. Zinc also affects T cell func and as such its supplementation may reduce severity of diarrhea. The case management of diarrhea by health care workers includes the recognition of dehydration, sufficient utilization of ORT, use of appropriate antibiotics for bloody diarrhea, and zinc supplementation. Health care providers should also recognize treatment failure and persistent diarrhea which should either be further managed or referred.
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  • Management of the child with severe malnutrition is divided into three phases.These are:• Initial treatment: life-threatening problems are identified and treated in a hospitalor a residential care facility, specific deficiencies are corrected, metabolic abnormalitiesare reversed and feeding is begun.• Rehabilitation: intensive feeding is given to recover most of the lost weight, emotionaland physical stimulation are increased, the mother or carer is trained to continuecare at home, and preparations are made for discharge of the child.• Follow-up: after discharge, the child and the child’s family are followed to preventrelapse and assure the continued physical, mental and emotional development of thechild.A typical time-frame for the management of a child with severe malnutrition isshown in Table 1.Residential care is essential for initial treatment and for the beginning of rehabilitationof a child with severe malnutrition. The child should be admitted to hospital, preferablyto a special nutrition unit, which is an area in a general hospital that is dedicated to theinitial management and rehabilitation of severe malnutrition. When the child has completedthe initial phase of treatment, has no complications, and is eating satisfactorilyand gaining weight (usually 2–3 weeks after admission), he or she can usually be managedat a non-residential nutrition rehabilitation centre. A nutrition rehabilitation centreis a day hospital, primary health centre or similar facility that provides daytime careby staff trained in the rehabilitation of malnourished children. The child sleeps at home,is brought to the centre each morning, and returns home each evening.IN ABSENCE OF SPECIFIC MEDICAL COMPLICATION, routine treatment in both ambulatory/hospital settings:INFECTION:* Measles vaccination on admission* Broad spectrum abx on D1 (amox po 70-1– mg/kg/day in 2 divided doses for 5 days)* In endemic malaria areas: rapid test on D1 w tx as needed. If testing not available, give tx.* Tx for intestinal worms on D1 (albendazole PO – 1-2 yo: 200 mg (1/2 tab) x1. - >2 yo: 400 mg x1) (or mebendazole >1 yo 500 mg x1)MICRONUTRIENT DEFICIENCIESTherapeutic foods corrects most deficiencies. Some supplements necessary.* Vitamin A - routinely on admission (retinol: 6m-1yo 100,000 IU x1; > 1yo 200,000 IU x1)* Folic Acid 5 mgMANAGEMENT OF COMMON COMPLICATIONS ----DIARRHEA and DEHYDRATIONDiarrhea often associated w malnutritionTherapeutic foods facilitate recovery of GI mucosa and restore production of gastric acid, digestive enzymes and bile. AMOX reduces bacterial load. Diarrhea generally resolves without any additional treatment. Watery diarrhea sometimes related to another pathology (otitis, pna, malaria) to be considered.Plain water, not ORS, given to children after each watery stool. ORS is only for cases of established dehydration.DEHYDRATION – more difficult to assess in malnourished children (e.g. delay in return of skin pinch and sunken eyes are present even without dehyration in children w marasmus)Dx based on history of watery diarrhea or recent onset w weight loss. Chronic and persistent diarrhea does not require rapid rehydration.<number>
  • REHYDRATION protocol differs from that in non-malnourished children.In absence of hypovolemic shock – use oral route with ReSoMal <Na, >K.Under strict medical supervision (clinical evaluation and weight every hour). 10 ml/kg/hour for first 2 hours, then 5 ml/kg/hour until weight loss (known or estimated) has been corrected.Determine target weight before starting rehydration (wt before onset of diarrhea). Can estimated wt loss at 2-5% of current wegith. Target wt should not exceed 5% of current wt (e.g. if weighs 5 kg before rehydration, target wt should not exceed 5.250 kg). Stop if fluid overload sxs.IV ROUTE carries significant risk of fluid overload and cardiac failure. Used only in cases of hypovolemic shock (weak/absent radial pulse, cold extremities, altered LOC, assicated w recent wt loss).* Darrows solultion (half-strength) or Ringer Lactate : 15 ml/kg over 1 hour. Every 15 min evaluate clinical response and check for sxs of over-hydration- if clinical condition improved after 1 hr (recovery consciousness, strong pulse), continue infusion at rate of 15 ml/kg for another hour, then switch to oral ReSoMal at 10 ml/kg/ hour for 2 hours.- if no improvement/worsens (overload) after first hour, KVO, and treat for septicemia.BACTERIAL INFECTIONS* LRI, AOM, UTI, Skin infxn – common. Difficult to identify (no fever, sxs) . Suspect infection in drowsy/apathetic child.* Hypothermia/hypoglycemia is suspicious for severe infection. Broad spec ABX using 2 ANTIBIOTICS.HYPOTHERMIA/HYPOGLYCEMIA* Hypothermia (rectal temp <35.5C, axillary < 35C) frequent cause of death in first days of hosp.* Prevention: kangaroo method, blankets. - monitor temp, treat hypoglycemia/underlying infxn.* In suspected/confirmed hypoglycemia – give glucose PO if conscious (50 ml sugar water (50 ml water + tsp sugar or 50 ml milk); if unconscious 1 ml/kg 50% glucose IV. Tx underlying infxn.Because severely malnourished children are deficient in potassium and have abnormallyhigh levels of sodium, the oral rehydration salts (ORS) solution should contain lesssodium and more potassium than the standard WHO-recommended solution. Magnesium,zinc and copper should also be given to correct deficiencies of these minerals. Thecomposition of the recommended ORS solution for severely malnourished children(ReSoMal) is given in Table.ReSoMal is available commercially. However, ReSoMal can also be made by dilutingone packet of the standard WHO-recommended ORS in 2 litres of water, instead of 1litre, and adding 50 g of sucrose (25 g/l) and 40 ml (20 ml/l) of mineral mix solution1The reason for advocating a low sodium high potassium ORS in severe malnutrition is to prevent heart failure. The risk of sodium overload is particularly marked with kwashiorkor cases where research shows that heart failure can be induced with relatively low sodium intakes. Such levels may be easily reached by rehydrating a severely malnourished child with standard WHO ORS. Between 70 and 100 ml of ReSoMal per kg of body weight is usually enough to restorenormal hydration. Give this amount over 12 hours, starting with 5 ml/kg every 30 minutesfor the first 2 hours orally or by NG tube, and then 5–10 ml/kg per hour. This rate isslower than for children who are not severely malnourished. Reassess the child at leastevery hour. The exact amount to give should be determined by how much the child willdrink, the amount of ongoing losses in the stool, and whether the child is vomiting andhas any signs of overhydration, especially signs of heart failure. ReSoMal should bestopped if:— the respiratory and pulse rates increase;— the jugular veins become engorged; or— there is increasing oedema (e.g. puffy eyelids).Rehydration is completed when the child is no longer thirsty, urine is passed and anyother signs of dehydration have disappeared. Fluids given to maintain hydration shouldIt is difficult to estimate dehydration status in a severely malnourished child using clinical signsalone. So assume all children with watery diarrhoea may have dehydration and give:- ReSoMal 5ml/kg every 30min for 2h, orally or by nasogastric tube, then 5-10ml/kg/h for next 4-10h: the exact amount to give should be determined by how muchthe child wants, and /or stool loss and whether vomiting. Replace the ReSoMal doses at6h and 10h with an equal amount of F-75 if rehydration is continuing at these times initiate refeeding with starter F-75 (see step 7)During treament, rapid respirations and pulse rate should slow and the child begin to pass urine.Monitor:-assess progress of rehydration half-hourly for 2h, then hourly for the next 6-12h observing:- pulse rate respiratory rate urine frequency stool/vomit frequency(Return of tears, moist mouth, eyes and fontanelle less sunken, and improved skin turgor, are alsosigns that rehydration is proceeding, but note that many severely malnourished children will notshow these changes even when fully rehydrated).Continuing rapid respiratory and pulse rates during rehydration suggest coexisting infection oroverhydration. Signs of too much fluid (overhydration) are increasing respiratory and pulse rates,increasing oedema and puffy eyelids. If these signs occur, stop fluids immediately and reassessafter 1h.<number>
  • Therapeutic Milks (only for hospitalized pts)F-75 - LOW protein, sodium, calories. 75 kcal/100 ml ; 0.9 gm protein - INITIAL TREATMENT- cover basic needs while complications being treated. Given 8 daily mealsF-100 – HIGHER protein/calories. 100 kcal/100 ml. 2.9 gm protein. - AFTER SEVERAL DAYS once pt stabilised (return appetite, clinical improvement, disappearance/reduction edema. Objective: rapid weight gain. Can be given with or replaced by RUTFALSO give WATER if ambient temperature if high or child is febrileBREASTFEEDING should continue.
  • Bitot’s spots or conjunctival xerosis Corneal clouding< 6 months old VA 50,000 IU PO on days 1, 2 and 14 Plus topical antibiotics, atropine drops, saline gauzes, and bandage eyes6-12 months 100,000 IU> 12 months 200,000 IUMDG1 – measuring hunger, as measured by the proportionof children under five who are underweight. But that captures only one dimension of nutrition. A child may die from a weakened immune system when vitamin A is lacking for example, without being apparently hungry or underweight.Myxedematous endemic cretinism in the DR Congo. Four inhabitants aged 15-20 years : a normal male and 3 females with severe longstanding hypothyroidism with dwarfism, retarded sexual development, puffy features, dry skin and hair and severe mental retardation. (From Delange’s book)Community supplementation reduces all cause infectious etiologies of death but no specific impact on ARLI and diarrhea. High dose supplementation reduces measles mort by 50% and also impacts HIV survival. No effect on non measles ARLI. <number><number>
  • Because RUTF do not contain water, children should also be offered safe drinking water to drink at will.RUTF – ready for consumption (e.g. peanut paste enriched w milk solids such as Plumpy’nut), used for children in both hospital or ambulatory settings. Nutritional composition similar to F-100; but higher iron content.For rapid weight gain. 500 kcal/100g
  • Components of CTC Outpatient Therapeutic Program (OTP) - severe malnutrition, good appetite, and without medical complications Inpatient Stabilisation Centre (SC)Triaging and Assessing MalnutritionAlthough anthropometric data are essential for establishing entry and discharge criteria, it has become clear that the appetite and clinical status of the child are the most sensitive indicators of risk and of the necessity for hospitalization. Children who do not eat what they are fed at a nutritional rehabilitation center usually have serious infectious or metabolic disorders that necessitate hospitalization. <number>
  • Beatriz here<number>
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  • Medicine is but one component to a larger effort to save lives – appreciate prevention and community-based effortsBeatriz – story about visitor coming in with ‘advisory’ mentalityInternational guidelinesLocal contextTraditional practicesHistorical and socioeconomic contextDon’t jump to judgments or conclusionsPatience and flexibility<number>
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  • Clinical Cases from Resource Limited Settings: Beatriz Thome & Suzinne Pak-Gorstein

    1. 1. Beatriz Thome MD / Suzinne Pak-Gorstein MD PhD MPH 5 April 2009
    2. 2. <ul><li>A 3-year old girl named Marta is brought to you at to rural clinic from a village in Mozambique that is a 2 day walk away. She appears to be weak and frail. She has also been having loose stools for the last 2 weeks. She also has a bad eye 'infection'.  </li></ul><ul><li>What resources can you expect to be able to utilize? </li></ul>
    3. 3. <ul><li>Population : 21,669,278 </li></ul><ul><li>Per capita income : $US 397 </li></ul><ul><li>IMR : 105.8 deaths/100,000 live births </li></ul><ul><li>U5MR : 138/1000 live births </li></ul><ul><li>3 physicians per 100,000 people </li></ul><ul><li>Average distance to a rural health facility : 19 km (11 miles) </li></ul>
    4. 4. <ul><li>Health Center </li></ul><ul><li>Limited medical supplies </li></ul><ul><li>Limited lab services </li></ul><ul><li>40-50 daily acute care visits / provider </li></ul><ul><li>District/Provincial Hospital </li></ul><ul><li>50-200 beds (few ‘pediatric’ beds; <5 years of age) </li></ul><ul><li>Intermittent clean water supply and electricity </li></ul><ul><li>Limited basic supplies </li></ul><ul><li>Nonexistent or limited radiographic facilities </li></ul><ul><li>1-5 doctors (very few pediatricians), 10-50 nurses often working overtime </li></ul>
    5. 5. <ul><ul><li>Growth monitoring </li></ul></ul><ul><ul><li>Vaccination </li></ul></ul><ul><ul><li>Child at Risk Consultation </li></ul></ul><ul><ul><li>IMCI guided acute care triage </li></ul></ul>
    6. 6. <ul><li>WHO integrated approach to child health </li></ul><ul><li>Aims: reduce death, illness and disability, promote improved growth and development for children <5y </li></ul><ul><li>preventive and curative elements </li></ul><ul><li>implemented by families, communities and health facilities </li></ul>Integrated Management of Childhood Illnesses (IMCI)
    7. 7. IMCI example chart
    8. 8. <ul><li>Loose stools for the last 2 weeks; “Eye infection’” </li></ul><ul><li>Her older sister has been caring for her while her mother has been harvesting corn. </li></ul><ul><li>  </li></ul><ul><li>10.1 Kg, HT 92 cm, T 37, HR 90, RR 30, </li></ul><ul><li>Emaciated, weak appearing </li></ul><ul><li>Sunken eyes, Right cloudy cornea </li></ul><ul><li>Dry oral mucosa </li></ul><ul><li>Lungs clear </li></ul><ul><li>Cap refill: 3-5 seconds, Skin pinch returns slowly </li></ul><ul><li>Thin, dry skin, No edema; Hair sparse </li></ul>
    9. 9. <ul><li>How many children under five years of age suffer from severe acute malnutrition? </li></ul><ul><li>~20 million children under five suffer from severe acute malnutrition </li></ul><ul><li>Severe acute malnutrition contributes to 1 million child deaths every year </li></ul><ul><li>What percentage of all child mortality and morbidity would be reduced if malnutrition was eliminated? </li></ul><ul><li>Malnutrition contributes to over 50% of child deaths , and </li></ul><ul><li>an estimated one third of all child mortality and morbidity would be reduced if malnutrition was eliminated </li></ul>Undernutrition underlying cause 53% deaths
    10. 10. <ul><li>Marasmus –  muscle mass, subcutaneous fat </li></ul><ul><li>Kwashiorkor – bipedal edema/edema of face; skin: shiny/cracked; hair: brittle/discolored </li></ul><ul><li>Mixed </li></ul>WHO: Management of Severe Malnutrition, 1999. // MSF: Nutrition Guidebook, 1999.
    11. 11. <ul><li>So, how severe acute malnutrition be screened for in the field without a scale, height board, growth chart, or trained health professional? </li></ul>
    12. 12. Observed relationship between MUAC and child mortality in five studies Briend , BMJ 1986 Mid-Upper Arm Circumference
    13. 13. Identifying Children with Acute Malnutrition If the color is red (MUAC below 11 cm), then the child is severely malnourished and need to immediately be taken to the nearest qualified health worker, health facility or hospital for assessment, treatment and follow up. If the color is yellow (MUAC below 12.5 cm), then the child is moderately malnourished and needs assessment and supplementary foods (additional enriched food). Green color (MUAC above 12.5 cm) means that the child is healthy and not malnourished. This child should continue to eat the nutritious foods Check for Edema
    14. 14. <ul><li>ORT preferred </li></ul><ul><ul><li>Recognition of dehydration </li></ul></ul><ul><ul><li>IV hydration only if shock or impending shock </li></ul></ul><ul><li>Continued feeding/Breastfeeding </li></ul><ul><li>Zinc supplementation </li></ul><ul><ul><li>Given during acute diarrhea episode reduces duration and severity of episode </li></ul></ul><ul><ul><li>Given for 10-14 days reduces incidence of diarrhea in following 2-3 months </li></ul></ul>
    15. 15.
    16. 16. WHO. Management of severe malnutrition.
    17. 17. Normal SAM ORS R-ORS Na 75, glu 75 Re-So-Mal Rehydration 60 – 80 ml/kg over 4h 5 ml/kg every 30 minutes over 2h then 5 ml/kg/h over next 4-10 hours
    18. 19. <ul><li>Vitamin A </li></ul><ul><li>Iodine </li></ul><ul><li>Zinc </li></ul><ul><li>Iron, Folate </li></ul>Vit A Deficiency -> Associated with a 20-24% INCREASE in Risk of death from Diarrhea, Measles, Malaria AL Rice et al In: Comparative quantification of health risks, 2004
    19. 20. <ul><li>Energy-dense pastes or biscuits </li></ul><ul><li>Children 6 months and older </li></ul><ul><li>Guided by appetite of the child </li></ul><ul><li>Eaten directly from the container </li></ul><ul><li>Contains micronutrients </li></ul><ul><li>Does not contain water </li></ul><ul><ul><li>Bacteria less likely to grow </li></ul></ul><ul><ul><li>No refrigeration required </li></ul></ul><ul><ul><li>Child should be offered safe water to drink at will </li></ul></ul>
    20. 22. <ul><li>No Plumpy Nut or Zinc in the smaller Health Centers </li></ul><ul><li>Minimal follow-up </li></ul><ul><li>Little time for dietary counseling </li></ul>
    21. 24. <ul><li>GREATEST IMPACT IS IN THE COMMUNITY  HEALTH PROMOTION </li></ul><ul><li>KNOW YOUR RESOURCES </li></ul><ul><li>WEAR OTHER’S SHOES </li></ul><ul><li>DO NO HARM </li></ul>
    22. 27. Global Burden of Malnutrition Undernutrition underlying cause 53% deaths