Model Answer
0 min readIntroduction
Protein-energy malnutrition (PEM) remains a significant public health problem globally, particularly in developing countries. It manifests with a spectrum of clinical features depending on the severity and type of deficiency. Kwashiorkor, a severe form of PEM, is characterized by adequate energy intake but insufficient protein consumption, leading to edema, growth retardation, and characteristic skin lesions. The clinical presentation of this 11-month-old infant strongly suggests a diagnosis within the spectrum of PEM, with features leaning towards Kwashiorkor. Early diagnosis and prompt intervention are crucial to prevent irreversible consequences and improve the child’s prognosis.
(i) Most Likely Diagnosis
The most likely diagnosis is Kwashiorkor. The clinical features – delayed weaning, recurrent diarrheal episodes, apathia, significant weight deficit (5.5 kg at 11 months is significantly below the expected weight range), depigmented hair (flag sign – a classic sign of Kwashiorkor), and edema over the limbs – are highly suggestive of this condition. The history of recurrent diarrhea likely exacerbates the malnutrition by causing nutrient malabsorption and further protein loss.
(ii) Clinical Assessment and Investigations
Clinical Assessment
- Anthropometric Measurements: Accurate measurement of weight, length/height, and mid-upper arm circumference (MUAC) to assess the degree of wasting and stunting. Plotting these on growth charts is essential.
- Physical Examination: Detailed assessment for edema (pitting vs. non-pitting), skin lesions (dermatosis, desquamation), hair changes (depigmentation, thinness), and signs of infections.
- Neurological Assessment: Evaluation of alertness, responsiveness, and presence of any neurological deficits.
- Dietary History: Thorough assessment of the infant’s feeding practices, including breastfeeding duration, timing of weaning, types of complementary foods offered, and frequency of meals.
- Developmental Assessment: Assessment of developmental milestones to identify any delays.
Investigations
- Complete Blood Count (CBC): To assess for anemia and infection.
- Serum Albumin: Low serum albumin levels are characteristic of Kwashiorkor due to decreased protein synthesis.
- Serum Electrolytes: To identify and correct electrolyte imbalances (hypokalemia, hyponatremia).
- Blood Glucose: To rule out hypoglycemia.
- Stool Examination: To identify any parasitic or bacterial infections contributing to diarrhea.
- Urine Analysis: To assess renal function and rule out urinary tract infections.
- C-Reactive Protein (CRP): To assess for inflammation and infection.
- Zinc Levels: Zinc deficiency is common in PEM and contributes to impaired immune function.
(iii) Ten Essential Steps and Two Phases of Treatment
Phase I: Stabilization (First 24-48 hours)
This phase focuses on correcting life-threatening complications.
- Correct Hypoglycemia: Administer 10% dextrose intravenously if blood glucose is <50 mg/dL.
- Correct Electrolyte Imbalance: Carefully correct hypokalemia, hyponatremia, and other electrolyte disturbances.
- Control Infection: Initiate appropriate antibiotic therapy based on clinical assessment and investigations.
- Treat Diarrhea: Provide oral rehydration solution (ORS) to correct dehydration.
- Start with F-75 Formula: Begin feeding with a low-protein, high-carbohydrate formula (F-75) in small, frequent amounts to avoid refeeding syndrome.
Phase II: Rehabilitation (After Stabilization)
This phase focuses on achieving catch-up growth.
- Increase Protein Intake: Gradually transition to a higher-protein formula (F-100) as tolerated.
- Provide Micronutrients: Supplement with vitamin A, iron, zinc, and other essential micronutrients.
- Monitor Weight Gain: Regularly monitor weight gain and adjust feeding accordingly.
- Provide Psychosocial Support: Address the psychosocial needs of the child and family.
- Prepare for Follow-up: Educate the parents on appropriate feeding practices and the importance of regular follow-up visits.
Conclusion
Kwashiorkor, as presented in this case, requires a meticulous and phased approach to treatment. The initial stabilization phase is critical for addressing immediate life-threatening complications, followed by a rehabilitation phase focused on achieving sustained nutritional recovery. A comprehensive assessment, appropriate investigations, and diligent monitoring are essential for successful management. Preventive measures, including promoting breastfeeding and providing adequate complementary feeding, are crucial to reduce the incidence of PEM in the community.
Answer Length
This is a comprehensive model answer for learning purposes and may exceed the word limit. In the exam, always adhere to the prescribed word count.