Malnutrition occurs as result of a multitude factors such as poverty, old-age, chronic disease etc.
About 10% of patients aged over 65 years are considered to be malnourished.
- BMI of <18.5.
- Unintentional weight loss of more than 10% within 3-6 months.
- BMI <20 + unintentional weight loss more than 5% within 3-6 months.
👀 Screening
We can screen for malnutrition using the Malnutrition Universal Screen Tool (MUST). It needs to be done on admission to care homes and hospitals. It categorises patients into low, medium, high risk.
There are 5 steps involved:
- Measure height and weight and calculate BMI.
- Note percentage of unplanned weight loss and score it using the tables provided:
- <5% = 0
- 5-10% = 1
- >10% = 2
- Calculate acute disease effect score:
- If the patient is acutely ill and there has been/will have no nutritional intake for >5 days then they score 2.
- Add scores together:
- 0 - Low risk
- 1 - Medium risk
- 2> - High risk
- Management:
- Low risk - repeat screening weekly in hospital, monthly in care home, or annually in community.
- Medium risk - document dietary intake for 3 days. If intake is adequate then repeat screening. If it is inadequate then follow local policy.
- High risk - refer to dietican and improve overall nutritional intake, continue to monitor weekly in hospital or monthly in care homes/community.
🧰 Management
If the patient is high risk then dietician support is needed.
We should have a food-first approach, encouraging the patient to improve their dietary intake with solid foods.
Oral nutritional supplements (ONS) can be prescribed and taken in between meals along with improving their dietary intake.
Pathophysiology
It was believed that it occurs when we have a sufficient calorie intake but a severely deficient protein intake. However, dietary supplementation of protein has not reduced the risk of kwashiorkor, and associated oedema resolves even when on a restricted-protein diet. It mostly associated with corn or cassava based diets.
What occurs is that cell membranes are damaged throughout the body and potassium and water is released from cells → oedema and hypokalaemia (<35mmol/kg).
We also observe hypophosphataemia in severe cases. Cardiac output reduces by 30% also.
It often is referred to as “the sickness the baby gets when the new baby comes” as older children in impoverished environments tend to get it when weaned off of breast milk and switch to a carbohydrate rich diet.
🏘 Epidemiology
It affects children, mostly in sub-Saharan Africa.
It is associated with HIV and TB and dietary insufficiency.
😷 Presentation
- Bilateral pitting oedema
- Distended abdomen
- Hepatomegaly with fatty infiltration
- Muscle wasting
- Thin hair and skin
- Irritability
🔍 Investigations
🏆It is primary a clinical diagnosis with history of chronic poverty/food insecurity, pitting oedema, distended abdomen.
- ⭐️ Hypokalaemia
- ⭐️ Hypophosphotaemia
- ⭐️ Hyponatraemia
- Hypoalbuminaemia
- Hypoproteinaemia usually
- Anaemia
Anthropometry can also done. This is the study of proportions of the human body. We do this by calculating expected body weight for age, weight-for-height score, and mean upper arm circumference (MUAC).
🧰Management
🏆 Optimise nutrition using RUTF (ready-to-use therapeutic food). This continues until oedema resolves for at least 1 week and anthropometry measurements are trending well.
Marasmus differs from kwashiorkor as we have inadequate calorie intake.
😷 Presentation
- ⭐️ Emaciated appearance with a disproportionately large head.
- ⭐️ Severe muscle wasting
- ⭐️ Weakness and lethargy - children have a reduced physical activity output as a result.
- Irritability
- Growth retardation
🧰 Management
- Prophylactic antibiotics may be given due to malnutrition-induced immunodeficiency.
- Correcting glycemic, electrolyte and hydration abnormalities.
- Gradual protein refeeding.
Refeeding syndrome refers to metabolic abnormalities that may occur upon refeeding an individual following a period of starvation, this includes anorexics, alcoholics, fasting individuals. It occurs when we have an extended period of catabolism ending abruptly and switching to carbohydrate metabolism.
It can be potentially fatal as it may produce arrhythmias, cardiac failure, seizures.
- Hypophostaemia
- Hypokalaemia
- Hypomagnesaemia - can predispose an individual to Torsades de Pointes (remember that IV magnesium sulphate is the first-line treatment for TdP).
- Hyperglycaemia
- Abnormal fluid balance
❌ Prevention
We can prevent it if we identify patients at high-risk of 1 or more of the following:
- BMI <16
- Unintentional weight loss >15% within 3-6 months
- Decreased/little nutritional intake >10 days
- Hypokalaemia, hypomagnesaemia, hypophosphataemia prior to feeding.
They may be considered high-risk if 2 or more of the following:
- BMI <18.5
- Unintentional weight loss >10% within 3-6 months
- Decreased/little nutritional intake >5 days
- Hx of alcohol abuse, insulin, chemotherapy, diuretics and antacids
🏆 If a patient hasn’t eaten for >5 days, we should re-feed them at <50% of their requirements within the first 2 days. Thiamine replacement can also be given to all at-risk patients.
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