CASE REPORT MALNUTRITION TYPE MARASMUS AND DOWN SYNDROME

By : Nurtilawati siregar Rahmah Khairuna D Supervisor : (090100310) (090100330)

dr. Pertin Sianturi Sp.A(K)

BACKGROUND
Malnutrition is still the main problem in public health especially in developing countries, it contributes more than half death case of children under 5 years. It is one of the main problem of nutrition in Indonesia. Protein-energy malnutrition, for example, plays a major role in half of all under-five deaths each year in developing countries

BACKGROUND
Down syndrome occurs due to an excess number of chromosomes in chromosome number 21, which is supposed to be two to three. Chromosomal abnormalities was not heredity Until now, the cause of abnormalities of chromosome number that is not yet known

OBJECTIVE

The aim of this study is to explore more about the theoritical aspects on severe malnutrition and down syndrome, and to integrate the theory and application of severe malnutrition, in this case marasmus and down syndrome in daily practices.

MALNUTRITION
Malnutrition essentially means bad nourishment. Clinically, malnutrition is characterized by inadequate or excess intake of protein, energy, and micronutrients such as vitamins, and the frequent infections and disorders that result

EPIDEMIOLOGY

Prevalence is high especially in children < 5 years. Based on SUSENAS 2002, 26% of children < 5 years having malnutrition, and 8% among them are in severe malnutrition, but in Riskesdas 2007, there prevalence decreases to 13% for moderatemalnutrition and 5.4% for severe malnutrition

THEORETICAL FRAMEWORK OF NUTRITION PROBLEMS. Nutrition problems Food intake

Food availability in household

Infect Disease
Mother & child caring Health service

direct causes indirect causes

POOR FAMILY & EDUCATION, FOOD STUFF & JOB OPPORTUNITY

main problem

ECONOMIC & POLITIC CRISIS

core problem

Clinical Feature of Marasmus and Kwashiorkor

Feature Growth failure Wasting Oedema Hair changes Mental changes Dermatosis, flaky-paint Appetite Anaemia Subcutaneous fat Face Fatty infiltration of liver

Kwashiorkor Present Present Present (mild) Common Very common Common Poor Severe (sometimes) Reduced but present May be oedematous Present

Marasmus Present Present, marked Absent Less common Uncommon Does not occur Good Present, less severe Absent Drawn in, monkey-like Absent

<<< MARASMUS

KWASHIORKOR >>>

CLASSIFICATION OF MALNUTRITION
Clasiffication of malnutrition Mild-moderate Symmetrical oedema Weight for height -3 SD < 2 -3 SD < 2 < -3 SD (severe No Severe Yes

wasting)
Height for age < -3 SD (severe stunting)

DIAGNOSIS

History Taking - usual diet before current episode of illness - breastfeeding history - Food and fluids taken in past few days - Recent sinking of eyes - Duration and frequency of vomiting or diarrhoea - Appearance of vomit or diarrhoea stool - Time when urine last passed - Contact with people with measles or tuberculosis - Any deaths of siblings - Birth weight - Milestones reached (sitting up, standing, etc) - Immunizations

DIAGNOSIS

Physical Examination - Weight and length or height - Oedema - Enlargement or tenderness of liver, jaundice - Abdominal distension, bowel sound - Severe pallor - Signs of circulatory collapse: cold hands and feet, weak radial pulse, diminished consciousness - Temperature: Hypotermia or fever - Thirst - Eyes: corneal lessions indicative of vitamin A - Ears, mouth, throat : evidence of infection - Skin : evidence of infection or purpura - Respiratory rate and type of respiration: sign of pneumonia or heart failure - Appearance of faeces

DIAGNOSIS

Other investigation - Blood Glucose : < 54 mg/dl = hypoglicemia - Blood Smear : malaria - Hb or Ht : < 4 g/dl or < 12% = severe anemia - Urynalysis/culture : bacteria + or > 10 WBC/ big view = infection - Faeces : blood (+) = dysentri, Giardia (+)/ other parasites = infection - CXR : Pneumonia, heart failure, fracture - Tuberculin Skin Test : often negative

TREATMENT OF MALNUTRITION

1. 2. 3. 4. 5.

There are five key-points in management of severe malnutrition, they are : Ten main steps, Treatment of co-morbid, Failure to respond to treatment, Education before discharge, and Management of emergency condition (such as shock and severe anemia).

TIME FRAME FOR THE MANAGEMENT OF THE

CHILD WITH SEVERE MALNUTRITION

DOWN SYNDROME
Down syndrome is a genetic disorder known as Trisomy, because individuals who get a Down syndrome have excess chromosome. They have three chromosome 21 where the normal only has two. This will change the excess chromosome genetic balance of the body and result in changes in the characteristics physical and intellectual abilities, as well as disturbances in physiological function body

EPIDEMIOLOGY

Abnormality is found throughout the world, in all ethnic groups. Estimated incidence of 1.5: 1000 births, and there were 10% among patients with mental retardation. Found statistically more born to mothers over the age of 30 years, although not infrequently also found that babies born to young mothers

ETIOLOGY

Factors that play a role in the occurrence of chromosomal abnormalities are: - Maternal age : usually the mother over the age of 30 years, probably due to a hormonal imbalance. - Disorders of pregnancy. - Endocrine disorders in women : old age can occur relative infertility, thyroid disorders or ovarian.

CLINICAL MANIFESTATION

Children with this syndrome are very similar to each other Thinking skills can be classified as an idiot and will not be able to exceed a 7-year-old child Usually very interested in music Child's face is very typical (like the mongols) The growth of the teeth are very disturbed Smooth and loose skin In the folds of the neck are excessive Hypotonic muscles and joints from excessive movement Congenital heart defects such as ventricular septal defect is often found The growth is slow

DIAGNOSIS

Diagnosis based on: 1. Clinical symptoms 2. Additional examination - Dermatoglifik - Chromosome examination 3. Anatomic pathology Brains of children with disorder are usually smaller than normal and bigger children, the growth of the brain growing up.

TREATMENT

No special treatment

Name Age Sex Date of Admission

: REA : 1year 3 months : Boy : August, 17 th 2013

Main Complaint : Vomiting History : It is experienced by patients is approximately 2 days, the frequency of vomiting was not counted. Content of what they eat and drink - Diarrhoea (+) 2 days, 2x/day frequency, consistensi water than frothy pulp (+), lenders (+), blood (-) - When the patient's fever, a history of recurrent fever (+), fever is up and down, down with fever-reducing medicine. - Patient weight decreased since the age of 6 months - Both (+) = 0.7 cc / kg / hour

History of feeding: years old: ASI 0-6 months: exclusive breastfeeding 6-9 months: cereal + milk 9-12 months: breast + formula (SGM) + cereal . History of birth Pediatric patients to the second of the two brothers, was born normal, helped midwife, BBL = 2600gr PBL = 48cm, immediately cried

History of growth and development Now this patientcan only prone itself, babbling, imitating the words,smilling, and looking at his hands. BW/Age: <-3SD BH/Age: < -3SD BW/BH: < -3SD Presens status Sens: GCS12 (E4V2M6) Body temperature: 37,0oC, Pulse: 140 bpm, Respiratory Rate: 40 bpm.

Localized status Head : old man face (+),dismortik Face (+) Eye concave,light reflexes (+/+),isochore pupil, pale conjunctiva palpebra inferior (-/-),icteric sclera (-/-) , Ear : Normal ,Mouth : Normal , Nose: nasal canul O2 attached Neck : Lymph node enlargement (-) Thorax : Symmetrical fusiform, easily seen ribs(+) retraction (-) HR: 140x/i, reguler, sigh (-). RR: 40 x/i, regular, crackles (-/-) Abdomen : Soepel. Peristaltic (+) normal. Liver/Spleen/Renal : undeterminate Extremities : pulse : 140 x/i, regular, adequate pressure and volume, warm acral, CRT <3, baggy pants (+), muscle hypertrophy (+), TD=90/60mmhg.

Working Diagnosis Marasmus type Malnutrition (II condition) + susp.Down syndrome P: Management - O2 2L / i nasal canul - Inj. ceftriaxone 150 mg / 2 hours / IV -Resomal 50cc alternatif with diet F75 40cc /2hours with mineral mix 0,8cc - When diarrhea (+): Resomal / x diarrhea - Multivitamins without Fe 1 x 1 cth - Folic acid 1x1mg - Vitamin A 1x200.000 IV Planning Complet Blood Count Blood Glucose LFT,RFT Elektrolite

August, 17-18th 2013 (first -second day)

S: Vomiting (+), Diarrhea (-), shortness of breath(+) O: Sens: GCS 12 (E4V2M6) , T: 37 oC, Body weight: 3,4 kg PB = 65cm Head: Old man face (+), dismortic face (+) eye : concave, light reflexes (+/+), icteric Sclera (-/-), isochoric pupil, pale conjunctiva palpebra inferior (-/-), Ear : Normal, Nose: nasal canul O2 attached (+),NGT(+), Mouth: normal Neck :Lymph node enlargement (-) Thorax :Symmetrical fusiform, easily seen ribs(+),retraction (-) HR: 140x/i, reguler, sigh (-). RR: 40 x/i, regular, crackles (-/-) Abdomen :Soepel, Peristaltic (+) normal. Liver/spleen/renal :undeterminate

Extremities :Pulse 140 x/i, regular, adequate pressure and volume, warm acral, CRT < 3, baggy pants (+), muscle hypertrophy (+), TD=90/60 mmgh A: Marasmus type Malnutrition (II condition) + susp.Down syndrome P: Management - O2 2L / 1 nasal canul - Inj. ceftriaxone 150 mg / 2 hours/IV - Resomal 50cc alternating with diet F75 40cc /2hrs with mineral mix 0,8cc - Multivitamins without Fe 1 x 1 cth - Folic acid 1x1mg - Vitamin A 1x200.000 IV Plan : Complete Blood Count Blood Glucose LFT,RFT

Complete Blood Count Hemoglobin (HGB) Eritrosit (RBC) Leukosit (WBC) Hematokrit Trombosit (PLT) MCV MCH MCHC RDW MPV PCT PDW Diftel Neutrofil Limfosit Monosit Eosinofil Basofil Neutrofil Absolut Limfosit Absolut % % % % % 103/L 103/L 83.20 7.40 9.10 0.10 0.200 37.41 3.33 37 80 20 40 28 16 01 1.9 - 5.4 3.7 - 10.7 g% 106/ mm3 103/ mm3 % 103/ mm3 fL Pg g% % fL % fL 13.20 4.87 45.00 37.70 736 77.40 27.10 35.00 15.10 9.90 0.73 10.7 11.3 14.1 4.40 4.48 6.0- 17.5 37 41 217 497 81 95 25 29 29 31 11.6 14.8 7.2 - 10.0

Monosit Absolut
Eosinofil Absolut Basofil Absolut

103/L
103/L 103/L

4.11
0.04 0.11

0.3 - 0.8
0.20 - 0.50 0 - 0.1

Clinical Chemistry Blood gas analysis

SATUAN

HASIL

RUJUKAN

Ph pCO2 mmHg

7.490 42.8

7.35-7.45 38-42

Bicarbonate (HC08)
Total CO2 Base excess (BE) O2 saturation CARBOHYDRATE METABOLISM Blood glucose (As) ELEKTROLIT Natrium (Na) Kalium (K) Klorida (Cl)

mmHg
mmol/L mmol/L %

153.8
31.9 33.2 7.8

85-100
22-26 19-25 (-2)-(+2)

mg/dL

331.00/

<200

mEq/L mEq/L mEq/L

123 3.3 87

135-155 3.6-5.5 96-106

Laboratory Result:

1.

August, 19th 2013

Clinical Chemistry

SATUAN

HASIL

RUJUKAN

CARBOHYDRATE METABOLISM

Blood glucose (As)

Mg/dL

129.00

<200

IMUNOSEROLOGI

TIROID

T3 Total

g/mL

0.67

0.8-2

T4 Total

g/dL

7.09

5-14

TSH

U/mL

1.460

0.27-4.2

August,19-20th 2013 (third fourth day)

S: Vomiting (-), Diarrhea (+), shortness of breath() O: Sens: GCS 12 (E4V2M6) , T: 37 oC, Body weight: 3,4 kg PB = 65cm Head: Old man face (+), dismortic face (+) eye : concave, light reflexes (+/+), icteric Sclera (-/-), isochoric pupil, pale conjunctiva palpebra inferior (-/-), Ear : Normal, Nose: nasal canul O2 attached (+),NGT(+), Mouth: normal Neck :Lymph node enlargement (-) Thorax :Symmetrical fusiform, easily seen ribs(+),retraction (-) HR: 120x/i, reguler, sigh (-). RR: 32 x/i, regular, crackles (-/-) Abdomen :Soepel, Peristaltic (+) normal. Liver/spleen/renal :undeterminate

Extremities :Pulse 120 x/i, regular, adequate pressure and volume, warm acral, CRT < 3, baggy pants (+), muscle hypertrophy (+), TD=90/60 mmgh A: Marasmus type Malnutrition (II condition) + susp.Down syndrome P: Management Resomal 50 cc / x diarrhea Folat acid 1 x 1 mg Multivitamin without Fe 1 x 1cth Diet F75 40cc / 2 hrs with mineral mix 0.8 cc Plan : -Blood Glucose -Tiroid

August,21th 2013 (fifth day)

S: Vomiting (-), Diarrhea (+), shortness of adequate pressure and volume, breath(+) warm acral, CRT < 3, baggy o O: Sens: GCS 12 (E4V2M6) , T: 37 C, pants (+), muscle hypertrophy (+), Body weight: 3,4 kg PB = 65cm A: Marasmus type Malnutrition (II Head: Old man face (+), dismortic face condition) + susp.Down syndrome (+) eye : concave, light reflexes (+/+), icteric P: Management Sclera (-/-), isochoric pupil, pale Resomal 50 cc / x diarrhea conjunctiva palpebra inferior Multivitamin without Fe 1 x cth 1 (-/-), Ear : Normal, Nose: nasal canul O2 Folat acid 1 x 1 mg attached (+),NGT(+), Mouth: normal Contrimoxazole syr 1x 1cth Neck :Lymph node enlargement (-) Thorax :Symmetrical fusiform, easily Diet F75 40cc / 2 hrs/NGT with seen ribs(+),retraction (-) HR: 112x/i, mineral mix 0,8 cc reguler, sigh (-). RR: 38 x/i, regular, Plan :crackles (-/-) Abdomen :Soepel, Peristaltic (+) normal. Liver/spleen/renal :undeterminate

Extremities :Pulse 112 x/i, regular,

Extremities :Pulse 102 x/i, regular, adequate pressure and volume, warm acral, CRT < 3, baggy S: Vomiting (-), Diarrhea (-), shortness of breath(-) pants (+), muscle hypertrophy (+), O: Sens: compos mentis , T: 37 oC, Body A: Marasmus type Malnutrition + weight: 5,2kg PB = 65cm susp.Down syndrome Head: Old man face (+), dismortic face P: Management (+) eye : concave, light reflexes (+/+), icteric Folat acid 1 x 1 mg Sclera (-/-), isochoric pupil, pale Cotrimoxazole syr 1x1 cth conjunctiva palpebra inferior Multivitamin without Fe 1 x1 cth (-/-), Ear : Normal, Nose: nasal canul O2 Diet F100 65cc / 2 hrs with attached (+),NGT(+), Mouth: normal mineral mix 1,3 cc Neck :Lymph node enlargement (-) Resomal 50cc/x diarrhea Thorax :Symmetrical fusiform, easily seen ribs(+),retraction (-) HR: 102x/i, Plan :

August,22-25th 2013 (sixth-seventh day)

reguler, sigh (-). RR: 32 x/i, regular, crackles (-/-) Abdomen :Soepel, Peristaltic (+) normal. Liver/spleen/renal :undeterminate

Extremities :Pulse 102 x/i, regular, adequate pressure and volume, warm acral, CRT < 3, baggy S: Vomiting (-), Diarrhea (-), shortness of pants (+), muscle hypertrophy (+), breath(-) A: Marasmus type Malnutrition + O: Sens: compos mentis , T: 37 oC, Body susp.Down syndrome weight: 5,3kg PB = 65cm Head: Old man face (+), dismortic face P: Management (+) eye : concave, light reflexes (+/+), icteric Multivitamin without Fe 1x1 cth Sclera (-/-), isochoric pupil, pale Folat acid 1x1mg conjunctiva palpebra inferior Diet F100 100cc /3hrs/ NGT with (-/-), Ear : Normal, Nose: nasal canul O2 mineral mix 2 cc

August,26th-30th 2013 (tenth fourteenth day)

attached (+),NGT(+), Mouth: normal Neck :Lymph node enlargement (-) Thorax :Symmetrical fusiform, easily seen ribs(+),retraction (-) HR: 102x/i, reguler, sigh (-). RR: 24 x/i, regular, crackles (-/-) Abdomen :Soepel, Peristaltic (+) normal. Liver/spleen/renal :undeterminate

DISCUSSION

REA, male, 1 year 3 month was admitted to RS Haji Adam Malik with the main complaint of vomiting, diarrhea, and fever. On physical examination the patient looks old man face in appereance, dismorfik face, easily seen ribs (+) , hypotropy muscle (+), subcutan lipid decreasing (+) and baggy pants (+), flat nose, smooth and loose skin, thick lips, on the pinkie finger looks short and bent inward, and the growth of the teeth are very disturbed. Now this patient can only prone itself, babbling, imitating the words, smiling, and looking at his hands

SUMMARY

REA is diagnosed with marasmus type malnutrition plus suspect down syndrome, and is managed with As. Folat 1x1, Multivitamin without Fe 1x 1 cth, Diet F100 100 cc/3hrs with mineral mix 2 cc, Cotrimoxazole syrup 1x1 cth, Resomal 50 cc/x diarrhea.

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