Oedematous malnutrition
oedematous malnutrition Annalies Borrel 06.05.99
oedematous malnutrition Michael Golden 06.05.99
RE: : oedematous malnutrition Benjamin Torun 06.05.99
Re: : oedematous malnutrition Tony Nelson 07.05.99
Re: Oedematous malnutrition David Picou 11.05.99


Date: Thu, 06 May 1999 11:28:30 +0100

From: "Annalies Borrel" <annalies.borrelatconcern.ie>

Subject: oedematous malnutrition

 

To Mike,

Please find below two queries that I have received from our project nurse in Rwanda (Ruhengeri). I thought they would be good questions to share on the NGONUT as they may be of interest to others. I have given brief responses but additional information from the experts would be appreciated!! .

 

1. Bipedal oedema and facial oedema

"In the nutrition centre, I am having difficulty explaining that kwashiorkor is defined (for admission to TFC) as bilateral pedal oedema. There have been several admissions, particularly to the SFP, of children with oedema but not of the feet. Children are being admitted who they say have facial oedema, kwashiorkor type hair and skin changes but not pedal oedema. If there is a case as described above who has definite facial oedema without pedal oedema, should s/he be admitted to the TFC? Does this symptom indicate the onset of generalised oedema i.e. with facial oedema manifesting itself first?"

2. Use of Lasix for management of oedema

"Still on oedema, a visiting doctor has started to prescribe lasix for the odd case of persistent oedema in the centres. I am worried that these cases have not been given enough time to allow the oedema to resolve through dietary and electrolyte management. Is there any documentation available explaining and demonstrating the potentially dangerous use of lasix for the management of oedema".

Hope this is okay?!

Best wishes,

 

Annalies


Date: Thu, 06 May 1999 12:14:23 +0100

From: Michael Golden <m.goldenatabdn.ac.uk>

Subject: oedematous malnutrition

 

Dear Annalies,

1. Bipedal oedema and facial oedema

The real problem here is to differentiate "jowls" from actual oedema of the face. The face does become rounded, with non-pitting swelling around the cheeks and the skin becomes shiny - so that the face looks swollen and this is interpreted as oedema. A paper by Whitehead et al (Lancet 1973;i;63-66) described this as pre-kwashiorkor and demonstrated that the serum albumin was lower in these non-oedematous patients. However, the presence or absence of jowls did not make any difference to the prognosis in the Jamaican children I studied. Likewise the hair color changes do not affect the likelihood of death. So that neither jowls or hair changes should affect the admission criteria.

On the other hand - if the face has PITTING oedema on it then this is indeed, kwashiorkor and should be treated as such - nearly always the oedema of the shins (do not use the feet) is actually present but needs to be looked for carefully - in these cases, pressure should be applied for about 30 sec on the shins (medial aspect of the tibia and not for 3 seconds on the feet which seems to me to be the common practice.

The only thing that gives me pause is the statement that the children have typical skin lesions of Kwashiorkor - Could the nurse describe these more fully as there are several types of "typical" skin lesions. The "open", "atrophic" weeping type of lesion can occur in marasmus as well as oedematous kwashiorkor and in both are associated with an increased risk of death. They are responsive to zinc and it is important that children with such lesions get adequate zinc in their diets (Golden et al, Lancet 1980;i, 1256).

 

2. Use of Lasix for management of oedema

The kidneys of these children are rarely responsive to frusemide (Lasix) in giving a naturesis. Indeed, Lasix seems frequently to make the oedema worse in these patients! I presume that this is related to the accompanying loss of potassium and magnesium! Many years ago de Wardner (a doyenne of renal medicine) described a series of young women with resistant oedema that was induced by Lasix they were taking as part of their psychological problem, the oedema disappeared when they stopped taking Lasix! It is likely that the same mechanism is operating in some of the kwashiorkor children - but this has not been investigated to my knowledge. At any rate Lasix certainly can greatly exacerbate these children's electrolyte problems and should never be used to clear oedema per se - the consensus is that it is indeed dangerous and a frequent cause of death in this situation.

Hospitals which use Lasix for oedema usually have a mortality of about 40%. I would be very interested to know what has happened to the case fatality rate in your centre since the Doctor arrived and instituted this policy - if there has been an increase then this should definitely be written up.

On the other hand, Lasix is used when the child has heart failure (this usually occurs from day 3 to 14 when oedema fluid is being LOST from the tissues into the circulation - and sodium is being exported from the intracellular compartment faster than the kidney can respond - in these circumstances the clinician usually thinks that everything is going well, until the patient dies with a rapid respiratory rate, again often misdiagnosed as pneumonia). Lasix can also be given to "cover" a blood transfusion if this really has to be given at this critical time (3-14 days) of electrolyte mobilisation and dysequlibrium -as well as giving the blood as a "exchange transfusion" rather than as a straight transfusion.

 

Prof. Michael H.N.Golden


From: "Dr. Benjamin Torun" <btorunatincap.org.gt>

Subject: RE: : oedematous malnutrition

Date: Thu, 6 May 1999 13:59:04 -0600

 

Annalies,

I agree with Mike's answers to your queries and would only add the following:

 

1. The edema of kwashiorkor usually manifests itself in the lower limbs (dorsum of the feet, ankles, shins) due to a postural effect associated to resistance to venous return. However, facial edema may ocasionally be noted more easily than in the lower limbs, specially in children who are so ill that they can hardly stand and remain lying down most of the time. In any event, the absence of edema of the lower limbs should not preclude admission of children with other clear clinical signs of severe malnutrition and a clinical/dietary history of poor protein intake.

 

2. Edema is a SYMPTOM of kwashiorkor. It will disappear with adequate treatment of the CAUSE of the disease; that is, with adequate nutritional support. To reinforce Mike's comments about the CONTRAINDICATION of the use of diuretics to reduce edema in kwashiorkor, it is important that doctors, nurses and other health workers realize that these patients usually are hypokalotic (low body potassium), they are in a very labile equilibrium in terms of serum electrolytes, and they have low cardiovascular reserve.

These conditions, and specially their combination, are clear indications of the DANGER of giving diuretics to severely malnourished children. The only exceptions are when they are used as part of the overall treatment of children with kwashiorkor and heart failure, and to counteract an overload with intravascular fluids when blood transfusions are given (please note that blood transfusions should NOT be a regular practice; rather, they should be used only to treat or prevent imminent heart failure due to extremely severe anemia, or congestive heart failure secondary to septic shock). But even in these cases, the use of diuretics must be monitored very closely.

Ben

 

Benjamin Torun, M.D., Ph.D.

Jefe, Unidad de Nutricion Humana, Head, Human Nutrition Unit, Instituto de Nutricion de Centro Institute of Nutrition of Central America y Panama (INCAP). America and Panama (INCAP)

INCAP -- Calzada Roosevelt, Zona 11, Apartado Postal 1188

Guatemala, Guatemala

Tel: [+ 502] 471-9913, 471-5655, 472-3762 Fax: [+ 502] 473-6529

e-mail: btorunatincap.org.gt, WWW: http://www.incap.org.gt


Date: Fri, 07 May 1999 11:19:08 +0100

From: Tony Nelson <tony-nelsonatcuhk.edu.hk>

Subject: Re: : oedematous malnutrition

 

I note Mike's comments but would make one additional suggestion. Some of the "odd" cases of persistent oedema may be due to nephrotic syndrome. Such cases sometimes get mis-diagnosed as malnutrition. The diagnosis is based on demonstrating heavy proteinuria (by urine dipstick if these are available). It is also important that lasix is not given to these children as it may cause life-threatening hypovolaemia. If the diagnosis is nephrotic syndrome then oral steroid therapy may be beneficial in a proportion of cases.

 

Tony Nelson

 

Note added by Mike Golden:

Frequently there are no dipstick in the circumstances in which many work.

The answer is simple and sustainable, but needs some acumen and experience (disappearing in lab-based western practice) - take the urine in a tube or bottle and shake it - if it readily "froths" and the "froth" persists then there is significant proteinuria. Protein is the only substance that is commonly excreted that reduces the surface tension of urine and I have found that, with practice, this clinical assessment can be quite accurate in terms of how hard the tube needs to be shaken and how persistent the frothing is - I suggest that when you have dipsticks you practice this and get used to the frothing properties of proteinuric urine so that when the dipsticks run out you are not left without a solution to this problem.

Incidentely, I use exactly the same procedure to "judge" whether there is a raised protein in CSF (as well as looking to see if it is "gin clear" for cells) when there is no lab and I need to decide about meningitis.

However, the message is clear - in NEITHER kwashiorkor OR in nephrotic syndrome should diuretics be used.

Thanks for the message Tony.


Date: Tue, 11 May 1999 12:03:46 +0100

From: "David Picou" <ccmrc.ttattrinidad.net>

Subject: Re: Oedematous malnutrition

 

I entirely agree with Benny Torun about oedema in kwashiorkor and his caution about using diuretics. In over twenty years of treating severely malnourished children, including kwashiorkor, I do not recall using a diuretic as part of the treatment.

 

David Picou