SEVERE ACUTE MALNUTRITION

Globally, child malnutrition is a public health problem with major

consequences for child survival, damaging the cognitive and physical

development of children and the economic productivity of individuals

and societies. Malnutrition contributes to 50% of all child deaths and

11% of the total global disability-adjusted-life-years worldwide. Acute

malnutrition is an indicator of an emergency that requires urgent

action. The UN estimates that acute malnutrition affects 8% of

children (52million) across the world (1 in 12 children in this age

group). Globally, acute malnutrition accounts for >50% of cases of

childhood mortality (about 3.5 million deaths) in children under 5

each year (NHSP, 2015).

Severe acute malnutrition (SAM) is a major cause of child mortality under

5 years of age. Severe acute malnourished children are nine times more likely

to die than healthy children. Globally, it is estimated that there are nearly 20

million severe acute malnourished children. The UN estimates that around one

million children under the age of 5 die every year from SAM. Similarly, the

prevalence of wasting among children younger than 5 years is 3.6%

(12.9million) in Asia and 3.3% (18.5million) in low and middle income countries

(Nilesh et al., 2017).

Tuberculosis (TB), human immunodeficiency virus (HIV) infection and

severe acute malnutrition (SAM) are individually responsible for high levels of

morbidity and mortality among children across sub-Saharan Africa. Over

650,000 cases of paediatric TB occur annually in the 22 highest-burden

countries, resulting in an estimated 140,000 annual deaths. Over 2.6 million

children across the world are living with HIV, with 90% of these living in sub-
Saharan Africa. HIV was responsible for 150,000 childhood deaths in 2014.

SAM including marasmus, kwashiorkor and marasmic kwashiorkor is

responsible for as much as 10% of all global mortality in children aged, 5 years,

with marasmus alone accounting for over 500,000 deaths annually in this age

group. In South Africa, over 36,000 cases of childhood TB occur annually, one

quarter of which are believed to be HIV co-infected. HIV is responsible for 17%

of all deaths in South African children aged , 5 years. One study found that 10%

of children initiating antiretroviral therapy (ART) in rural South Africa also had

SAM (Alder et al., 2017).

While SAM combined with HIV has already been recognised as a

challenging clinical entity associated with increased mortality, the contribution of

TB to this scenario is uncertain. Malnutrition is associated with increased

mortality in paediatric TB, particularly with HIV co-infection. TB causes cachexia

and wasting, and may itself be impacted by poor nutritional status. HIV is an

independent risk factor for both TB and malnutrition, worsening the outcomes of

either condition (Alder et al., 2017).

SAM was defined as weight-for-height Z-score below 􏰀3 standard

deviations from the World Health Organization (WHO) median or a mid-upper

arm circumference of 115 mm, with or without bilateral oedema, and was

managed according to the latest WHO guidelines.

Other studies in Africa have started with a diagnosis of TB and looked

backwards for associa- tions with malnutrition and/or HIV, usually finding strong

and independent associations with both of these risk factors and TB mortality.

The only other studies that we can find that began with malnourished children

and looked for associations with TB were carried out in South Asia, where

paediatric HIV prevalence is far lower, and differ in many important

methodological factors from our study. One such study examined 405 severely
malnourished Bangladeshi children with respiratory symptoms and radiographic

pulmonary infiltrates: 7% had confirmed TB and a further 16% were treated

based on clinical suspicion. HIV prevalence was not determined, but was known

to be rare in that setting. While this study is important in raising awareness

about TB mimicking acute pneumonia in children with SAM, the TB prevalence

in a select population with radiological changes will obviously be higher than the

TB prevalence in malnourished children in general (Alder et al., 2017).

In this patient the diagnosis of severe acute malnutrition is based on

clinical criteria, anthropometric status, and laboratory. From the clinical criteria,

it is found that chronic infection is HIV, physical examination shows that the

child looks thin (an impression of poor nutrition), hepatomegaly, and there is

muscle atrophy. From the McLaren score, a score of 3. From anthropometric

status, based on the upper arm circumference was <-3SD and the body weight

over body height was <-3SD. On laboratory examination anemia was obtained.

Severe acute malnutrition is primary due to inadequate or inappropriate food

intake. This often happens in the lower middle class with low socioeconomic

where the composition and amount of food does not meet the recommended

needs. In the end cause of nutritional disorders to severe deficiency. The

second cause is a secondary cause where nutritional disorders are caused by

other diseases that cause reduced nutritional intake or adequate nutrition, but

with the condition that children need more nutrition than usual because the

metabolic process is indeed increasing. One of the causes is chronic illness and

malignancy. Children with chronic diseases are often accompanied by

nutritional disorders because during the process of illness, children often have

complaints of decreased appetite, nausea, and vomiting while at the same time

children with chronic diseases have higher metabolic requirements compared to

normal children. In this case the cause of malnutrition is primary because

patients come from low socio-economic and secondary due to chronic infection

that is suffering from HIV and pulmonary tuberculosis, so the management must

also be overcome the contributing factors.

Factors causing the emergence of severe malnutritional conditions in

children with HIV are:

• Decreased food intake. Inadequate nutrient consumption is one of the factors

that can cause severe malnutritional conditions. Several factors can cause

food intake to be abnormal. For example, inflammation and ulcers in the

upper gastrointestinal tract can cause anorexia due to pain when swallowing.

• Gastrointestinal malabsorption. Malabsorption can cause changes in

nutritional status in people with HIV. So, even though the food eaten is

sufficient, but not all nutrients can be absorbed by the body effectively. This

can be caused by gastrointestinal mucosal abnormalities which can be

caused by HIV infection itself or secondary to intestinal infections of other

agents. If malabsorption is accompanied by chronic diarrhea, it will predispose

to the occurrence of severe malnutrition if not treated immediately. This

diarrhea may be a side effect of drugs, such as some antiretroviral drugs and

antibiotics.

• Increased amount of food intake or tissue catabolism needs. Increased

nutritional requirements and the rate of tissue catabolism are also

experienced by some HIV sufferers. The causes include; high levels of the

HIV virus in the blood, secondary infections, and constitutional symptoms

such as fever and night sweats. Chronic virus infections can affect energy use

and can predispose to secondary infections, thereby changing energy use

patterns. Therefore, in HIV sufferers the increase in energy use is mainly due

to the amount of HIV virus in the blood and the presence of co-infection and

comorbidity.
• Psychosocial factors; such as poverty, limited access to health services, or

drug abuse.

The clinical manifestations displayed by malnourished children with HIV

are often part of their own viral infections, opportunistic infections as well as

complications and interactions of treatment. This is what often affects the length

of stay and prognosis of patients. Management of malnutrition in children with

HIV / AIDS is no different from standard management. In children with

malnutrition whatever the reason, the thing that must be considered is the

presence or absence of gravity in these children, namely dehydration,

hypoglycemia, hypothermia, impaired electrolyte balance. These must be

addressed immediately during the stabilization phase, which is 1-2 days to 1

week. In this patient there is no emergence of severe malnutrition.

In this phase the F75 diet is determined with the calorie needs of 80-100

kcal / kg / day, fluid requirements of 100-130 cc / kg / day, and protein needs 1-

1.5 g / kg / day. The amount of fluid given is 130 ml / kgBB / day (in children

without edema) and 100 mL / kgBB / day in anasarka edema conditions.

Perform monitoring of hydration status and blood sugar levels regularly.

Patients are also placed in a bed that is not too close to the door or window,

thereby reducing exposure to wind flow from outside the ward. Then also added

micronutrient intake in the form of vitamin A 1 x 100,000 iu on the first day,

vitamin C 1 x 50 mg, vitamin E 1 x 50 iu, folic acid initial dose of 1 x 1 mg

followed by 1 x 1 mg and ZnSO4 1 x 20 mg. In the transition phase the

nutritional needs are adjusted by giving F100 and starting to be given solid food

with caloric needs of 100-150 kcal / kg / day, liquid needs 150 ml / kg / day and

protein needs 2-3 g / kg / day. Every day children with malnutrition are weighed

and assessed. Sign of the success of the management of malnutrition is the

 increase in body weight 10-15 g / kgBB / day. The results of weight evaluation

in this patient, up to the 3rd day of treatment of the patient's body weight gained

an increase in body weight, where when he first entered the hospital which was

4.5 kg, on the last day of observation the weight gain was 4.6 kg. In this patient,

weight gain was ≥5g / kg / day in 3 days of observation.

REFERENSI

Ader H, Archary M, Mahabeer P, LaRussa P, Bobat R.a. Tuberculosis in HIV-

infected South African children with complicated severe acute malnutrition.

2017. Int J Tuberc Lung Dis 21(4);438-45

Ministry of Health and Population. Nepal Health Sector Program- Implementation

Plan II(NHSP-IP 2) 2010-2015: Ministry of Health and Population.

Government of Nepal, 2010 312010.

Nilesh Kumar Pravana, Suneel Piryani, Surendra Prasad Chaurasiya, Rasmila

Kawan, Ram Krishna Thapa, Sumina Shrestha. 2017. Determinants of

severe acute malnutrition among children under 5 years of age in Nepal: a

community-based case-control study. BMJ open 2017;7