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Presentation Outline

• Case Identification
• Subjective Findings
• Objective Findings
• Pharmacist assessment
• Physician’s Assessment
• Background
• Current medication
• Pharmaceutical Care Plan and Follow Up
• Patient Education
• References
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 Case Identification

Name: M.E

Sex: F

Age: 2 yr

Card No: 675507

Date of admission: 10/6/2012

Ward : Pediatrics

Address:
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 Subjective Finding

C/C : cough of 1 wks duration

HPI: This is a 2 years old female child patient presented with cough which is non barking,

non whooping type cough associated with this fast breathing, high grade intermittent fever

non projectile vomiting of ingested matter

 she has also decrease appetite and failure to gain weight for the last 6 month

 She was exclusively breast feed for six month

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 Objective Findings
GA : ASL

v/s : PR 136 RR = 36 Tem = 36.8

Anthropometrics :
• Wt =6.8

• Ht =80cm
• MUAC = 11 cm
• BMI = 10.62kg/ m2 (sever wasting )

• W/H =below -3 z score (severe wasting)

• W/A = below -3 z score (severe under weight)

• H/A= below -3 z score (severe stunting) 5

Cont..

HEENT : PC,NIS

Chest : coarse crptation over more posterior right lower 2/3 of chest feel

: minimal sub costal and inter costal retraction

CVS : S1 and S2 well heard

Abd: no tenderness and organ omegally

MSS: no deformity
CNS :Alert
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 Vital sign
date PR RR Tc Wt(kg)
10/06/2012 130 36 36.8 7.5
11/06/2012 134 54 36.3 7.6
12/06/2012 121 40 35.8 7.68
13/06/2012 130 36 36
14/06/2012 126 34 36.9 7.88
15/06/2012 128 38 36.2 7.99
16/06/2012 126 30 35.5 8.1

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 Lab Investigation cont …
10/06/20102EC
CBC
• WBC:11{3-15} 103 u/l
• RBC:4.8 {2.5-5.5} 106 u/l
• HGB:14.8 {8-17) g/dl
• HCT:40.8{26-50}%
• MCV: 88.7 {86-110}fl
• MCH:32.1 (26-38)pg
• MCHC:36.2 {31-37}g/dl
• PLT: 347 {150-451} 103 u/l

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Pharmacist assessment

Past medical History

• She has no hx of chronic illness like Asthma, DM, HTN, cardiac and renal

Past medication Hx :

 she has no past medication history

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 cont…

Family History :-
she has no history of DM ,HTN and other chronic illness

She had no history of TB and has no recent contact with persons with active
TB

Drug allergic : NKDA

Immunization : partially Immunized

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Physician Assessment

SAM+SCAP

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Background

SEVERE ACUTE MALNUTRTION (SAM)

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Malnutrition refers to all deviations from adequate
nutrition.
• It can exist in three forms;
 Over nutrition and
 Under nutrition of Macronutrients and/ or Micronutrients.
 Imbalance of diet

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 Conti…
• SAM is defined by the presence of bilateral pitting oedema or severe
wasting (MUAC < 11.5 cm or a WFH < -3 z-score [WHO standards])
in children 6-59 months old.
• A patient with SAM is highly vulnerable and has a high mortality risk.
• SAM can also be used as a population-based indicator defined by the
presence of bilateral pitting oedema or severe wasting (WFH < -3 z-
score [WHO standards]).

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 Epidimology
 Most malnourished persons live in developing countries,
 about 30% each in Africa and far east and
 15% each in Latin America and middle east.
 One of every three children under the age of 5 years in the
developing country – or 177 million children –are or had been
malnourished
 In industrialized countries, malnutrition is seen mainly among young
children of low socioeconomic groups, the elderly who live alone, adults
addicted to alcohol and drugs
 According to unicef the extent of malnutrition in Ethiopia is
-Underweight ( 0 -4 yrs) – 38%
- Wasting (12 -23 months) – 19%
- Stunting ( 24 -59 months) – 43%

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 Etiology
Primary – nutritional insufficiency
Inadequate protein, calorie and nutrient intake

 Secondary – malnutrition following infections, injury, chronic disease, excessive nutrient

loss as occurs in chronic diarrhea, HIV, malabsorption syndrome etc…
Social and economic – Poverty that results in low food
availability, overcrowding and unsanitary living condition
Biologic factors
 Maternal malnutrition prior or during pregnancy
Environmental factors
 Overcrowded or unsanitary living conditions
 Agricultural patterns, drought, floods, wars and forced migration
lead to cyclic, sudden or prolonged food scarcities
 pathophysiology
• When a child’s intake is insufficient to meet daily needs,
physiologic and metabolic changes take place in an orderly
progression to conserve energy and prolong life.
• Fat stores are mobilized to provide energy.
• Later protein in muscle, skin, and the gastrointestinal tract is
mobilized.

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 Clinical presentation
• PEM can affect all ages but common among infants and
young children
• Marasmus – before 1 year of age
• Kwashiorkor – after 18 months of age
• Diagnosis is principally based on dietary history and
clinical features

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 conti….
1. Marasmus
• Generalized muscular wasting, absence of subcutanous fat
• 60% or less of wt for age
• Marked retardation in longitudinal growth
• The hair is sparse, thin, dry, and easily pluckable
• The skin is dry, thin, and wrinkles – ‘baggy’ pant

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 Cont….
2. Kwashiorkor
•soft, pitting, painless edema, usually in the feet and leg
• Skin lesions – flaky paint dermatosis
• Subcutaneous fat is preserved
• Weight deficit is not as severe as marasmus
• Height may be normal or retarded
• The hair is dry, brittle, easily pulled out without pain,
pigment changed to brown, red, or even yellow white

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 Diagnosis
History – Nutritional history
Physical findings
Supportive lab studies
Anthropometric measurements

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Admission criteria
1. Any serious clinical condition, danger signs or medical
complication.
2. Recent weight loss or failure to gain weight;
3. Ineffective feeding (attachment, positioning and suckling)
directly observed for 15–20 min, ideally in a supervised
separated area;
4. Any pitting oedema;
5. Any medical or social issue needing more detailed
assessment or intensive support (e.g. disability, depression of
the caregiver, or other adverse social circumstances).
6. Infants who have been identified to have poor weight gain
and who have not responded to nutrition counseling and
support. 22
Management

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Admission Procedures and Triage

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 Phase I/Stabilization Center

Major activities performed includes;

1. Nutritional Rx - Feed the patient F-75
2. Give routine medications
3. Monitor the patient
4. Prevent, diagnose, and treat complications

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 1. Nutritional Therapy
 Diet – F-75
 (one sachet mixed with 2 liters of water)

 Provides -75 kcal and 0.9 gm protein per 100 ml =>

100Kcal=130ml F-75

 8 feeds per day –larger volume feeding can result in osmotic

diarrhea

 Breast fed children should always be given BM before the diet.

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 Phase -I
2. Routine medications
 Vitamin A
 On day 1 & 2 of admission when there is:
– Wasting with out edema
– For every patient on the day of discharge
Dosage:
- < 6 months=50 000 Iu
– 6 to 12 months = 100,000 IU
– >12 month = 200,000 IU
– Vitamin A not given in children taking with in the last
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 Phase -I
… Routine medications
 Folic acid - 5mg po single dose
Antibiotics
1st line – Amoxicillin
2nd line – Chloramphenicol or Gentamycin
Measles vaccine - if not vaccinated and
->6 to 9 months

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 Monitoring
 Twice per day- Body temperature
 Each Day;
o Weight
o Degree of edema
o Stool,
o Vomiting,
o Dehydration,
o Cough & RR
o Liver size & tenderness
 Each week– MUAC
 After 21 days- Height
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 Transition phase
• Criteria to progress from phase I to transition phase
– Beginning of loss of edema
– Return of good appetite
– No NG tube, IV line, and
– No Severe medical complications

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 cont…
• Feed the patient in exactly the same way as in phase 1 except
that
• F-100 (100kcal/100ml) is given instead of F-75
• The same volume is given so that energy intake is increased by
30% & the child starts to gain tissue
• Expected weight gain is 6gm/kg/day

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 cont…
• Criteria to move back to phase 1 from transition phase
– Rate of wt gain >10gm/kg/day
– Increasing edema or development of refeeding edema
– Increase in liver size & tenderness
– Signs of fluid overload, CHF, or respiratory distress
– Development of tense abdominal distension
– If there is sufficient diarrhea to give weight loss
– If complication develops that require IV infusion of drugs

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 Phase- II
• Criteria to progress from transition phase to phase II
– Good appetite

– Complete loss of edema

– No medical complications/ problems

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 Phase -II
• Give routine medicines
– Iron sulfate is added to the diet /200mg i.e 1 tablet in 2 liters of
F100/
– De-worming:- Mebendazole 100mg po BID for 03 days or
Albendazole 400mg po stat
– Vitamin A
– Measles vaccine – on discharge

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CRITERIA TO MOVE BACK FROM PHASE 2 TO PHASE 1
 Failure of the appetite
 Increase/development of oedema
 Development of refeeding diarrhoea sufficient to lead to weight loss.
 Fulfilling any of the criteria of “failure to respond to treatment”
 Weight loss for 2 consecutive weighing
 Weight loss of more than 5% of body weight at any visit.
 Static weight for 3 consecutive weighing
 Major illness

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 Criteria for discharge
• Wt for ht > 85%
• No edema for 10 days
• Education has been complete
• Immunization is up to date
• Adequate arrangement have been made for follow up

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 Current medication
10/06/2012
Ampcillin 50mg/kg/dose(375mg QID)
F-75
Gentamycin 5mg/kg/day(37.5mg/day)
11/06/2012-15/06/2012
Amoxacillin 250mg/5ml 7.5ml po tid
Gentamycin 5mg/kg/day(37.5mg/day)
16/06/2012
Amoxacillin 500mg PO tid
F-100
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 DTP Identified
 Needs additional drug therapy
- Deworming

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 Pharmacetical care plan & follow up..
Medical DTP Goals of Intervention Parameters to Status of
therapy be monitored intervention
condition Identified

worming Need To prevent Albendazol Sign and On progress

additional drug parasitic 400mg po stat symptom of
therapy infection Or infection
mebendazole
100 mg po bid
for 3 days
 Patient care giver education points

• About Personal and environmental hygiene

• About an appropriate diet and
• sanitary feeding technique

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 Patient prognosis
• Edema is subside
• No fever and cough
• Has good appetite
• Weight gain

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 References
1.Nelson TEXTBOOK Of PEDIATRICS, 21 EDITION
2. Guidelines for the management of acute malnutrition,March 2016

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