Model Answer
0 min readIntroduction
Malnutrition in children remains a significant global health concern, particularly in developing countries. It manifests not only as inadequate weight but also as deficiencies in micronutrients and loss of lean body mass. A 16-month-old child presenting with loss of subcutaneous fat and a low weight of 5.5 kg, coupled with a history of recurrent diarrhoea and respiratory infections, raises concerns about severe acute malnutrition (SAM) and the possibility of underlying conditions contributing to this state. This necessitates a thorough evaluation to determine the etiology and implement appropriate management.
Differential Diagnosis
The clinical presentation suggests several possible diagnoses, which need to be considered systematically:
- Severe Acute Malnutrition (SAM): This is the most likely diagnosis given the weight for age and loss of subcutaneous fat. SAM is categorized into Marasmus, Kwashiorkor, and Marasmic-Kwashiorkor.
- Cystic Fibrosis (CF): Recurrent respiratory infections and failure to thrive are hallmark features of CF. Malabsorption due to pancreatic insufficiency can lead to weight loss and fat malabsorption.
- Celiac Disease: This autoimmune disorder triggered by gluten can cause malabsorption, leading to weight loss, diarrhoea, and failure to thrive.
- Congenital Heart Disease (CHD): Certain CHDs can cause increased metabolic demands and failure to thrive.
- Chronic Infections: Prolonged infections like tuberculosis or HIV can contribute to malnutrition.
- Parasitic Infections: Heavy parasitic infestations can lead to nutrient loss and impaired growth.
- Endocrine Disorders: Though less common, conditions like hypothyroidism can contribute to growth failure.
History Taking
A detailed history is crucial. Key areas to cover include:
- Birth History: Birth weight, gestational age, any complications during pregnancy or delivery.
- Feeding History: Breastfeeding duration, type of formula used (if any), introduction of complementary foods, dietary intake, and any feeding difficulties.
- Developmental History: Assessment of developmental milestones to identify any delays.
- Infection History: Frequency, severity, and treatment of diarrhoea and respiratory infections.
- Family History: History of similar conditions in the family, particularly CF, celiac disease, or CHD.
- Socioeconomic Status: Assessment of food security and access to healthcare.
Physical Examination
A thorough physical examination should focus on:
- Anthropometry: Accurate measurement of weight, length/height, and head circumference. Calculation of weight-for-age, height-for-age, and weight-for-height Z-scores.
- General Appearance: Assessment of alertness, activity level, and overall well-being.
- Skin: Look for signs of edema (Kwashiorkor), skin lesions, or pigmentation changes.
- Hair: Assess hair texture and color (depigmentation can occur in Kwashiorkor).
- Cardiovascular System: Auscultation for heart murmurs suggestive of CHD.
- Respiratory System: Auscultation for wheezing or crackles suggestive of respiratory infection or CF.
- Abdomen: Palpation for hepatosplenomegaly or abdominal distension.
- Neurological Examination: Assessment of neurological function to rule out any underlying neurological disorders.
Investigations
The following investigations are recommended:
- Complete Blood Count (CBC): To assess for anemia and infection.
- Stool Examination: For ova, parasites, and occult blood.
- Electrolytes, Blood Urea Nitrogen (BUN), Creatinine: To assess renal function and electrolyte imbalances.
- Liver Function Tests (LFTs): To assess liver function.
- Serum Albumin and Total Protein: To assess nutritional status.
- Celiac Serology: Tissue transglutaminase (tTG) IgA antibody and endomysial antibody (EMA) to screen for celiac disease.
- Sweat Chloride Test: To diagnose cystic fibrosis.
- Chest X-ray: To evaluate for pneumonia or other respiratory abnormalities.
- Echocardiogram: If CHD is suspected.
- HIV testing: If risk factors are present.
Management
Initial management focuses on stabilization:
- Hypoglycemia: Correct with intravenous glucose.
- Hypothermia: Provide warmth.
- Dehydration: Rehydrate cautiously.
- Infection: Treat with appropriate antibiotics.
- Nutritional Rehabilitation: Initiate a carefully planned refeeding program, starting with F-75 (therapeutic milk) and progressing to F-100 (recovery milk).
Conclusion
The 16-month-old child’s presentation strongly suggests severe acute malnutrition, but a thorough evaluation is crucial to rule out underlying conditions like cystic fibrosis, celiac disease, or congenital heart disease. A detailed history, physical examination, and appropriate investigations are essential for accurate diagnosis and effective management. Early intervention with nutritional rehabilitation and treatment of any underlying causes is vital to improve the child’s prognosis and prevent long-term complications.
Answer Length
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