74 Malnutrition and CHAIN

Jay Barclay 07/11/18

Simple measures can help predict mortality. MUAC can work really well!

Children with malnutrtion in east africa have really raised inflammatory markers, this gut inflammation will then impair them absorbing food!

Current treatment strategies ignore this aspect of inflammation and chronic illness and social problems that contribute to malnutrition. They just feed the kid and don’t fix the underlying causes.

Current guidelines are based on emergency scenarios where you go from adequate food to no food very quickly. But the majority of malnutrition cases globally are coming from areas where there was chronic malnutrition.

Current guidelines split things into:

Normal
Wasting
Stunting

They’d split wasting as acute and stunting as chronic. But that’s probably not a good way to divide.

Usually malnutrition sees wasting on stunting

There’s another group: Kwashiorkor. This is tissue oedema, bleeding skin, hair changes. We don’t know what causes it, traditionally called protein intake, but that’s NOT necessarily the case. But it might be a specific amino acid deficiency plus genetic influences. We don’t really know though.

74.1 Aetiology

When you get infections you get malnourished, when you get malnourished you’re more at risk of infection.

Also the gut loses it’s barrier function and bugs start leaking through, your microbiome changes and you absorb less food. You may also get subclinical as well as overt infection.

Your social/environment/economc will also contribute to all these things

74.2 Diagnostics

Wasting: Weight for Height Z Score (it can be v hard to measure height in unhappy sick kids)

Kwashiorkor: Oedema

Stunting: Height For Age Z Score (it’s sometimes hard to know age)

MUAC: Captures wasting and stunting, and easier to measure

74.2.1 WHO Growth Reference Standards

ADD THE TABLE FOR DEFINITIONS OF STUNTING ETC

This compares the kids to the global advantage kids. When you maximally advantage kids in any ethnicity, you see the same growth curves! A local growth reference commits children to the existing disadvantage.

Your weight for height cutoffs were created to see adjusted odds mortality for different causes of death. It’s not just that you’re skinny, you’re at an increased risk of dying.

There are no studies that show stunting as a risk of mortality etc.

Clinician perception is only about 50% sensitive. It will miss half of all severely malnourished kids.

MUAC isn’t established for <6 months or > 5 years yet though.

74.3 Treatment Aims

We want to improve growth and body composition. (This includes organ growth, muscle growth, etc)

But really you want to reduce mortality, reduce susceptibility to infections, improve neuro, reduce risk of NCDS, reduce intergenerational effects

74.4 Childhood Acute Illness and Nutrition Network

The inpatient case fatality for severe pneumonia is <1% if well nourished, but if you’re malnourished the risk is ~14% with the same good care! The moderately malnourished group is ~3% death.

And if you survive to get discharged from hospital, the severely malnourished group still have a much increased risk of death (~16% die over a year) when well nourished have ~1% risk of death over year.

If you see someone at admn w/ pneumonia and severe malnutrition, they’ve got somewhere between 1/4 and 1/3 risk of death in a year!

Any hospital admission will mark you out at an increased risk of death after discharge, regardless of diagnosis or nutrition status.

Undernourished and admission to hospital really means bad things. There’s so little reserve, there’ll be decompensation.

74.4.1 What’s the problem causing chronic ill health in kids in LMIC?

74.4.1.1 Infection?

Well on autopsy its always infection

So do you think, are we missing the diagnosis? Are we giving right antimicrobials? Are there other conditions mimicking sepsis?

If you “fix” nutrition, do you reduce risk of future infections?

If you get sick post discharge? Is it a new seperate illness, or is it inadequate treatment for the first illness? Or is it that you caught some new illness in hospital?

What’s different about the kids that die after discharge. The early mortality rate is pretty steep, so people that died, died early.

These kids that died had higher levels of: CRP, Calprotectin (a neutrophil protein), Plastin 2 (found on T Cell receptors), LPS binding protein (what you make when you’re exposed to gram negative stuff), von-Willebrand

It looks like a “sepsis like profile” is associated with death after discharge.

74.4.1.2 Nutrition?

Is it related to nutritional status and recovery?

Kids who remain malnourished still have increased risk of becoming sick again. Kids who were malnourished and not now, are better, but not back to normal risk. So is that cos they’re back in social setting that put them malnourished in first place? Or their immune system isn’t back to normal?

Kids who are fatty acid deficient, become more deficient with standard plumpy nut, that was only fixed by supplementing with fish oil

74.4.1.3 Gastrointestinal Function?

Well is it bacterial overgrowth? and we know there’s enteropathy and malabsorption. And we think that the microbiome things change.

Is it due to problems with WASH

So there have been big WASH trials, but havenet seen any changes in stunting measures. You need to fix the whole environment rather than one aspect