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MALNUTRITION IN CHILDREN . PRINCIPLES OF DEHYDRATION CORRECTION.

MALNUTRITION IN CHILDREN . PRINCIPLES OF DEHYDRATION CORRECTION. Sakharova Inna Ye., MD, PhD. Malnutrition will be responsible for 3,000 deaths globally, mostly women, infants and children, during this lecture! Malnutrition accounts of ≈ 30 million

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MALNUTRITION IN CHILDREN . PRINCIPLES OF DEHYDRATION CORRECTION.

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  1. MALNUTRITION IN CHILDREN.PRINCIPLES OF DEHYDRATION CORRECTION. Sakharova Inna Ye., MD, PhD

  2. Malnutrition will be responsible for 3,000 deaths globally, mostly women, infants and children, during this lecture! • Malnutrition accounts of ≈ 30 million deaths per year (about 1 death per second)

  3. Some Major World Risk Factors Causing Deaths

  4. A healthy diet provides a balanced nutrients that satisfy the metabolic needs of the body without excess or shortage. • Dietary requirements of children vary according to age, sex & development. Dora, 3, receives a dose of vitamin A outside a mobile health clinic in Namurava village in Mozambique.

  5. “Hidden Hunger” – deficit of vitamins and microelements in diet.

  6. Around the world, billions of people livewith vitamin and mineral deficiencies. Forinstance, approximately one third of thedeveloping world’s children under the ageof five are vitamin A-deficient, andtherefore ill-equipped for survival. Irondeficiency anaemia during pregnancy isassociated with 115,000 deaths eachyear, accounting for one fifth of totalmaternal deaths. WHO Report, 2009

  7. Lab Assesment • Full blood counts • Blood glucose profile • Septic screening • Stool & urine for parasites & germs • Electrolytes, Ca, Ph & ALP, serum proteins • CXR & Mantoux test • Exclude HIV & malabsorption

  8. NON-ROUTINE TESTS • Hair analysis • Skin biopsy • Urinary creatinine over proline ratio • Measurement of trace elements levels, iron, zinc & iodine

  9. OVERVIEW OF PEM (Protein Energy Malnutrition) • The majority of world’s children live in developing countries • Lack of food & clean water, poor sanitation, infection & social unrest lead to LBW & PEM • Malnutrition is implicated in >50% of deaths of <5 children (5 million/yr)

  10. OVERVIEW OF PEM • In 2000 WHO estimated that 32% of <5 children in developing countries are underweight (182 million). • 78% of these children live in South-east Asia & 15% in Sub-Saharan Africa. • The reciprocal interaction between PEM & infection is the major cause of death & morbidity in young children.

  11. Definitions of Malnutrition • Kwashiorkor: protein deficiency • Marasmus: energy deficiency • Marasmic/ Kwashiorkor: combination of chronic energy deficiency and chronic or acute protein deficiency • Failure to thrive: marasmus in U. S. children under 3.

  12. Definitions of Malnutrition • Primary: inadequate food intake • Secondary: result of disease • Mixed

  13. Diagnosis • Normal: ± 1 SD • Mild: -1.1 to -2 SD • Moderate -2.1 to -3 SD • Severe greater than -3 • Less than 5th percentile • BMI in adolescents • Moderate <15 ages 11-13, <16.5 ages 14-17 • Severe <13 ages 11-13, <14.5 ages 14-17

  14. CLASSIFICATION OF MALNUTRITION IN CHILDREN

  15. Gomez Classification: The child's weight is compared to that of a normal child (50th percentile) of the same age. It is useful for population screening and public health evaluations. • percent of reference weight for age = ((patient weight) / (weight of normal child of same age)) * 100 Interpretation: 90 - 110% normal 75 - 89% Grade I: mild malnutrition 60 - 74% Grade II: moderate malnutrition < 60% Grade III: severe malnutrition

  16. Wellcome Classification: evaluates the child for edema and with the Gomez classification system. • Grades: • 80-60 % without oedema is under weight • 80-60% with oedema is Kwashiorkor • < 60 % with oedema is Marasmus-Kwash • < 60 % without oedema is Marasmus

  17. KWASHIORKOR • Cecilly Williams, a British nurse, had introduced the word Kwashiorkor to the medical literature in 1933. The word is taken from the Ga language in Ghana & used to describe the sickness of weaning (“the sickness the older child gets when the next baby is born”).

  18. ETIOLOGY • Kwashiorkor can occur in infancy but its maximal incidence is in the 2nd yr of life following abrupt weaning. • Kwashiorkor is not only dietary in origin. Infective, psycho-socical, and cultural factors are also operative.

  19. ETIOLOGY • Kwashiorkor is an example of lack of physiological adaptation to unbalanced deficiency where the body utilized proteins and conserve S/C fat. • One theory says Kwash is a result of liver insult with hypoproteinemia and oedema. Food toxins like aflatoxins have been suggested as precipitating factors.

  20. CONSTANT FEATURES OF KWASH • OEDEMA • PSYCHOMOTOR CHANGES • GROWTH RETARDATION • MUSCLE WASTING

  21. USUALLY PRESENT SIGNS • MOON FACE • HAIR CHANGES • SKIN DEPIGMENTATION • ANAEMIA

  22. OCCASIONALLY PRESENT SIGNS • HEPATOMEGALY • FLAKY PAINT DERMATITIS • CARDIOMYOPATHY & FAILURE • DEHYDRATION (Diarrh. & Vomiting) • SIGNS OF VITAMIN DEFICIENCIES • SIGNS OF INFECTIONS

  23. DD of Kwash Dermatitis • Acrodermatitis Entropathica • Scurvy • Pellagra • Dermatitis Herpitiformis

  24. MARASMUS • The term marasmus is derived from the Greek marasmos, which means wasting. • Marasmus involves inadequate intake of protein and calories and is characterized by emaciation. • Marasmus represents the end result of starvation where both proteins and calories are deficient.

  25. MARASMUS • Marasmus represents an adaptive response to starvation, whereas kwashiorkor represents a maladaptive response to starvation • In Marasmus the body utilizes all fat stores before using muscles.

  26. EPIDEMIOLOGY & ETIOLOGY • Seen most commonly in the first year of life due to lack of breast feeding and the use of dilute animal milk. • Poverty or famine and diarrhoea are the usual precipitating factors • Ignorance & poor maternal nutrition are also contributory

  27. Clinical Features of Marasmus • Severe wasting of muscle & s/c fats • Severe growth retardation • Child looks older than his age • No edema or hair changes • Alert but miserable • Hungry • Diarrhoea & Dehydration

  28. Complications of P.E.M • Hypoglycemia • Hypothermia • Hypokalemia • Hyponatremia • Heart failure • Dehydration & shock • Infections (bacterial, viral & thrush)

  29. TREATMENT • Correction of water & electrolyte imbalance • Treat infection & worm infestations • Dietary support: 3-4 g protein & 200 Cal /kg body wt/day + vitamins & minerals • Prevention of hypothermia • Counsel parents & plan future care including immunization & diet supplements

  30. KEY POINT FEEDING • Continue breast feeding • Add frequent small feeds • Use liquid diet • Give vitamin A & folic acid on admission • With diarrhea use lactose-free or soya bean formula

  31. PROGNOSIS • Kwash & Marasmus-Kwash have greater risk of morbidity & mortality compared to Marasmus and under weight • Early detection & adequate treatment are associated with good outcome • Late ill-effects on IQ, behavior & cognitive functions are doubtful and not proven

  32. Pediatric Fluid TherapyPrinciples Assess water deficit by: 1. weight: weight loss (Kg) = water loss (L) OR 2. Estimation of water deficit by physical exam: Mild moderate severe Infants < 5 % 5 - 10 % >10 % Older children < 3 % 3 - 6 % > 6 %

  33. MANAGEMENT OF DEHYDRATION -Replace Phase 1: Acute Resuscitation : • Give Lactated Ringer OR Normal Saline at 10-20 ml/kg IV OR 5 % albumin over 30-60 minutes. • May repeat bolus until circulation stable -Calculate 24 hour maintenance requirements • Formula: • First 10 kg: (100 cc/kg/24 hours) • Second 10 kg: (50 cc/kg/24 hours) • Remainder: (20 cc/kg/24 hours) Example: 35 Kilogram Child • Daily: 1000 cc + 500 cc + 300 cc = 1800 cc/day -Calculate Deficit: • Mild Dehydration: (40 ml/kg) • Moderate Dehydration: (80 ml/kg) • Severe Dehydration: (120 ml/kg)

  34. MANAGEMENT Continue -Calculate remaining deficit: • Substract fluid resuscitation given in Phase 1 -Calculate Replacement over 24 hours: • First 8 hours: 50% Deficit + Maintenance • Next 16 hours: 50% Deficit + Maintenance • Determine Serum Sodium Concentration • Hypertonic Dehydration (Serum Sodium > 150) • Isotonic Dehydration • Hypotonic Dehydration (Serum Sodium < 130) • Add Potassium to Intravenous Fluids after patient voids urine • Potassium source • Potassium Chloride • Potassium Acetate for Metabolic Acidosis • Potassium dosing • Weight <10 kilograms: 10 meq KCl /liter glucose • Weight >10 Kilograms: 20 meq KCl /liter glucose

  35. Hypertonic dehydration • Serum Na+ > 150 meq/L (up to 213) • Deficit replacement over 48 hours 0.18% – 0.3%saline • Regular daily maintenance • Fluid evenly distributed over time • Dialysis option in severe hypernatremia

  36. Hypotonic (hyponatriemic) dehydration • Total Na+ Deficit = (Desired Na+) – (Actual Na+) × Body Wt Kg × 0.6 + • Calculate Fluid Deficit similar to Isonatremic Dehydration

  37. Convulsions Rapid Intravenous administration of Na+ 3% salineinfusion (1-12ml/kg body weight)

  38. Potassium • Daily requirement: 1-2 meq / kg body weight. • Usually add 10-20 meq KCl / L of IV fluid. • Added only once the urine output is established. • In Hypokalemia, add: 30 meq / L of IV fluid • 40 meq / L of IV fluid • 50 meq / L of IV fluid • 60 meq / L of IV fluid • 70 meq / L of IV fluid ECG monitoring Frequent testing

  39. Hypokalemia Management • Maximum IV infusion rate: 1 mEq/kg/hr • Marked hypokalemia: Monitor serum K closely 0.5-1 mEq/kg/dose given as an infusion of 0.5 mEq/kg/hr for 1-2 hour

  40. In severe acidosis: • Alkali therapy (NaHCO3) IV • Calculation: • (Desired HCO3-- Actual HCO3-) × body wt Kg × 0.45

  41. THANKS FOR ATTENTION

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