Siti hawa tahir an infant with persistent diarrhea-a case study

2,874 views

Published on

Published in: Health & Medicine, Business
0 Comments
3 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
2,874
On SlideShare
0
From Embeds
0
Number of Embeds
235
Actions
Shares
0
Downloads
0
Comments
0
Likes
3
Embeds 0
No embeds

No notes for slide

Siti hawa tahir an infant with persistent diarrhea-a case study

  1. 1. MDA 2012 1
  2. 2. Baby PA• Personal History – Baby PA – DOB: 24/01/2012 – Chinese – Social history • Mom – schoolteacher • Father – businessman • Taken care by grandmother in Ipoh with her 3 year old sister MDA 2012 2
  3. 3. Medical HistoryPresented with watery diarrhea since day 1 of lifeMixed breastfeeding and cow’s milk based infant formula since birthuntil 3/52 of lifeAntenatal history • No consanguinity • No other family history of chronic diarrhoea or early neonatal deathAlready on Pregestimil® for a month before being referred topediatric gastroenterologist in Pantai Medical CenterShe was then referred to UMMC for further management of possiblecow’s milk protein allergy MDA 2012 3
  4. 4. Diarrhea• Diarrhea (WHO, 2005) – defined as the passage of unusually loose or watery stools, usually at least 3 times in a 24-hour period – It is the consistency of the stools that is most important, rather than the frequency• Persistent Diarrhea (Schidmt, 2004) – diarrhea that lasts 14 days or longer – May lead to malnutrition and serious infection with or without dehydration. MDA 2012 4
  5. 5. Cow’s Milk Protein Allergy• Cows milk protein allergy is defined as an immunologically mediated adverse reaction to cows milk protein• It affects about 2-6 % of infants under 1 year of age (Host, 2002)• Allergy is a hypersensitivity reaction initiated by specific immunological mechanisms) – Mechanisms may be IgE-mediated or non-IgE mediated. MDA 2012 5
  6. 6. Initial Presentation• Anthropometric measurements – Weight • Birth weight – 3.37 kg • Weight history - ↓ 2.9 kg at 1/12 • Current weight – 3.37 kg (<3rd centile) – Length – 51 cm (3rd centile) – Head circumference – 36.5 cm (3rd centile)• Biochemical data – Not available MDA 2012 6
  7. 7. Initial Presentation• Nutrition focused physical finding – Extremities – poor muscle bulk and fat stores – Skin – no obvious sign of dehydration – GI • Watery, greenish stools observed in her diaper • frequency 7-8 x/day, usually post feeding, greenish in colour • No perianal excoriation – Urine - yellowish MDA 2012 7
  8. 8. Initial Presentation Food/Nutrition-Related HistoryMixed of breastfeeding Lactose free and Soyand Cows Milk Infant based IF x 1/52Formula until 3/52 • No improvement• BO -.10 times/day, watery, no stool particles Pregestimil at 1/12 • BO frequency ↓ to 7-8 times/day • Some stool particles MDA 2012
  9. 9. Food/Nutrition-Related History• Weight gain – 470 g in 1/12 (15.7 g/day)• Current intake –105 ml every 2-3 hourly (6- 7x/day) – Volume – 630-735 mL (189-221mL/kg/day) – Energy – 422-492 kcal/day (127 - 148 kcal/day) – Protein – 11.6 -13.5 g/day (3.5-4 g/kg/day) Weight gain was poor Further investigation for neonatal diarrhea MDA 2012 9
  10. 10. MDA 2012 (Ravikumara,2008) 10
  11. 11. Nutrition DiagnosisInappropriate intake of proteinsrelated to possible cow’s milkprotein allergy as evidenced bypersistent diarrhea with waterystools up to 7-8 times/day MDA 2012 11
  12. 12. Nutrition Intervention• Goals Lactose –free – Optimize patient’s nutritional status formulas Extensively – Establish Soy based hydrolysed appropriate nutrition prescription • formula • Milk based Cow’s milk Amino acid based based formula Which formula formula to consider? MDA 2012 12
  13. 13. Available Formulas recommended Contraindicated or not Soy formulas Cows milk-basedSuitable Extensively (including anti- hydrolysed formulas regurgitation) (eHF) Lactose-free cows • Pregestimil® milk-based • Alimentum® • Mamex Gold Pepti Partially hydrolysed Amino acid formulas cows milk-based (AAF) (pHF) • Neocate® Goats milk-based • Comidagen™ formula MDA 2012 13
  14. 14. Soy Formula• Soy formula is recommended as first choice for infants over 6 months of age with immediate food reactions, and for those with gastrointestinal symptoms or atopic dermatitis in the absence of failure to thrive. – MJA 2008; 188: 109–112• Soy formula provokes more frequent reactions in children with CMPA aged less than 6 months [Klemola, 2002] but not in older children MDA 2012 14
  15. 15. Extensively Hyrolyzed Formula• About 10% of children with CMPA react to eHF [Vandenplas, 2007]• Recommended as first line of therapy – cows milk allergy (non-anaphylactic), – food protein-induced enterocolitis syndrome – atopic eczema – gastrointestinal symptoms and – food protein-induced proctocolitis (MJA 2008; 188: 109–112) MDA 2012 15
  16. 16. Amino Acid Formula• Amino acid formula (AAF) is non allergenic [Hill, 2007]. – Recommended as first choice in anaphylaxis and eosinophilic oesophagitis. (MJA 2008; 188: 109–112) MDA 2012 16
  17. 17. (Kemp, 2008), MDA 2012 17
  18. 18. Hydrolysis Can Reduce Allergenicity of Cow Milk Proteins 12,000 10,000 10,000 8,000Daltons 6,000 4,000 2,000 1,100 450 0 Extensively Partially Hydrolyzed Whole Protein Hydrolyzed Casein Whey Casein/Whey
  19. 19. 2012 19
  20. 20. 22/3 Hospital Course 27/3 Change feed to Trial of Comidogen full Comidogen strength ¼strength, then Diarrhea worsen ½ strength - no diarrhea No Investigations so far: diarrhea with ORS Full strength - • Stool for fat: Positive (2x) diarrhea • Stool for reducing sugar: Negative • Stool rotavirus, shigella, salmonella, ova & cyst – all negative • Normal Immunoglobulins MDA 2012 20
  21. 21. 3-5/4 Hospital Course 10-16/4 PICC line inserted Tolerated up to ¾ On PN ST Mamex Gold Pepti Challenged with Mamex Gold Pepti FS before OGDS 12/4- diarrhea Plan for scope and intestinal biopsy • Back to previous Other investigations – ST Had 3/7 episodes of • Sweat test – negative • Stool electrolytes – normal infective diarrhea • Urine Osmolality - normal • Diarrhea with ORS • RVD – Not detected • OGDS – normal endoscopic • ↑ WBC findings, awaiting biopsy result 2012 MDA 21
  22. 22. Hospital Course Poor weight gain No diarrhea with ORSIssues Our Understanding • 16/4 – 3.33 - 3.66kg No diarrhea when No definite diagnosis NBM • Malabsorption syndrome Not an 2º enteropathy immunodeficiency Therapeutic nutrition • PN Stool fat – positive • No established feed yet • Negative sweat test Unable to progress beyond ¾ ST of eHF and AAF MDA 2012 22
  23. 23. Hospital Course Feeding ModePlan • Continuous feeding via NG with Comidagen • Started at ½ ST • Initial rate at 1 mL/kg/H • Increment at 2 mL daily • Full PN – 135 kcal/kg/day • 20 mL/H • 2.2 mL/H x 20H lipid infusion MDA 2012 23
  24. 24. Hospital Course Weight - ↓ 3.98523-27/4 30/4 Able to progress to FS up to 20 kg mL/H Aim to optimize Off PN 27/4 – feeding Biopsy Result Blocked line • Increment 2 mL/H BO 2x/day – soft– acute on chronic of • Stomach after 12H toleration inflammation stools • Duodenum – focal villous atrophy Weight and non specific inflammation – 4.0 kg (27/4) • Suggestive of CMPA MDA 2012 24
  25. 25. Hospital Course7-15/5 15/5 – 11/6 Slow progression 25/5 – barium meal of feed follow through- no • Tolerated up to 25 evidence of short mL/H bowel Plan for discharge Unable to tolerate • Establish oral feeding 20 mL oral feed and wean off pump • Up to 15 mL 4x/day • BO – 8x/day • To step up to 20 Weight on mL/feed discharge - 4.85 kg • Weight = 4.14 kg (14/5) MDA 2012 25
  26. 26. Discharge Plan• COORDINATION OF CARE – Home nutrition support with feeding pump• Optimize feeding rate up to 30 mL/H• Oral feed 15 mL 6 x/day• Delay complementary feeding after 6/12 of age MDA 2012 26
  27. 27. Learning Points• Learn from your patient• Dietitian plays an important role in clinical management of CMPA and persistent diarrhea MDA 2012 27

×