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Nutritional Disorders. Dr. Shreedhar Paudel 04/02/ 2009. Malnutrition. One of the major causes of death in children < 5 yrs of age Infants ( up to 1 yr of age) on an average require 103 kcal/kg/day
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Nutritional Disorders Dr. Shreedhar Paudel 04/02/ 2009
Malnutrition • One of the major causes of death in children < 5 yrs of age • Infants ( up to 1 yr of age) on an average require 103 kcal/kg/day • Even in children who die of pneumonia, diarrhoea, measles– malnutrition is a significant underlying factor
Protein-Energy malnutrition • One of the most serious health problem of children of developing countries • WHO definition– “PEM is a range of pathological condition arising out of coincident lack of protein and energy in varying proportions, most frequently seen in infants and young children and usually associated with infections”
Protein-Energy malnutrition…. • Risk factors:- • Age—6 mo to 18 mo; child is growing fast, food commonly given is not adequate • Sex—many cultures boys valued more than girls → girls neglected • Many children • Short interval between births
Protein-Energy malnutrition…. • Risk factors:- • Failure or stoppage of breast feeding • Delay in introducing additional food • Infectious diseases, especially—repeated diarrhoea, whooping cough or measles • Low birth weight • twins
Protein-Energy malnutrition…. • Diagnosing Tools? • WEIGHT for age • HEIGHT for age • ARM Circumference • CRANIAL Circumference
Marasmus contd…. • one component of protein-energy malnutrition (PEM) • severe form caused by inadequate intake of protein and calories, and it usually occurs in the first year of life, resulting in wasting and growth retardation, no edema
Marasmus contd…. • Results from a negative energy balance --decreased energy intake --increased energy expenditure, or --both, ( such as that observed in acute or chronic disease) • Occurs in infants exclusively on mother’s milk when the amount of breast milk is markedly reduced; inadequately prepared bottle milk
Marasmus contd…. • Children adapt to an energy deficit with --decrease in physical activity --lethargy --decrease in basal energy metabolism --slowing of growth --finally weight loss
Marasmus contd…. • Clinical features: • Skin is thin, flaccid, wrinkled, seeming larger than the body it covers • Bony prominences protrude due to loss of subcutaneous fat • Drastic loss of adipose tissue from normal areas of fat deposits like buttocks and thighs ( buccal pad of fat is preserved till the malnutrition becomes extreme)
Marasmus contd…. • Clinical features:- • Abdomen is distended due to wasting and hypotonia of abdominal wall muscle • irritable and may show voracious appetite • alternate bands of pigmented and depigmented hair (flag sign) • flaky paint appearance of skin due to peeling
HAFIZ USMAN WARRAICH ROLL #17-C Kwashiorker • Condition arises when a child recieves a diet very low in proteins but adequate calorie to satisfy the child’s need • Occurs weeks or months after weaning if weaning food is deficient in protein (human milk had sufficient protein till that time)
Kwashiorker…… • Clinical features:- • Markedly retarded growth • Psychomotor changes • Edema – of dependent parts • Mental changes • Lethargic, listless, apathetic • Little interest in environment—does not play • Rejects examination by physician • Appetite—impaired and difficult to feed him orally
Kwashiorker…… • Edema caused by— • Hypoalbuminemia • Increased capillary permeability as a result of infection • Free radical induced damage to cell membrane • Fat, chubby appearance with moon shaped and puffy face (contrary to marasmus)
Kwashiorker…… • Dermatosis --large areas of erythema simulating second degree burns -- progressively dry, hyperkeratotic and hyperpigmented • Hair—dry, thin, looses its normal color and lusture and easily pulled out
Kwashiorker…… • History of diarrhoea almost always present • Fatty changes in the liver ( hepatomegaly) • Atrophy of intestinal mucosa • Atrophy of acini in pancreas • HAFIZ USMAN WARRAICH ROLL #17-C
Management of PEM • Grade the nutritional status of the child • Find out the probable cause for malnutrition • Mild malnutrition:- nutritional advice for proper feeding and treatment of underlying conditions responsible for poor feeding (e’g: worm infestation, skin infections, nutritional anaemia)
Management of PEM…….. • Moderate malnutrition:- --will respond to nutrition education and demonstration in absence of any disease and adequate appetite --treatment of underlying condition --difficult cases with severe refusal of food—admission in hospital required
Management of PEM…….. • Criteria for admission:- • Weight less than 60 % with • Edema • Severe dehydration • Diarrhoea • Hypothermia • Shock • Systemic infection; jaundice; bleeding • Age less than 1 year • Persistent loss of appetite
Management of PEM…….. Follow up Discharge Prevent Catch up Relapse growth & Restore Wt for Ht Rehabilitaion Initiation Begin feeding , Energy defense of feeding feeding , Stimulation, Transfer to home Treatment of Sugar deficiency, Hypothermia, Infection, Complications Electrolyte imbalance, Dehydration, Deficiency of micronutrients
Management of PEM…….. • Treatment of complications:- (Day 1-2) • S- sugar deficiency i.e., hypoglycemia • H- Hypothermia • I- Infection and septic shock • EL- Electrolyte imbalance • DE- Dehydration • D- deficiencies of iron vitamins & other micronutrients • HAFIZ USMAN WARRAICH ROLL #17-C
Management of PEM…….. • Hypoglycemia:- --May present with seizures or loss of consciousness --Treated with IV infusion of glucose solution • Hypothermia:- --children < 1 yr of age, with marasmus, extensive skin loss or serious infections --cover with blanket & monitor patient
Management of PEM…….. • Infections:- --treat accordingly • Septic shock:- --it’s very difficult to differentiate severe dehydration and septic shock --all such children are treated with IV fluids for 1st two hours as for severe dehydration --in case child doesn’t improve after 2 hrs of intensive fluid replacement—Septic shock strongly considered --Broad spectrum antibiotics started ASAP
Management of PEM…….. • Dehydration:- --evaluation of dehydration is difficult --loss of elasticity of skin can be due to loss of subcutaneous fat or dehydration --dehydration– oral mucosa feels dry, no tear secretion when child cries, decreased formation of urine
Management of PEM…….. • Dehydration mgt:- --IV therapy for severe dehydration and shock ↓ RL or N/2 saline in 5 % dextrose (30ml/kg in 2 hours) ↓ N/6 saline in 5% dextrose (100ml/kg at the rate of 10ml/kg/hr in next 10 hrs) ↓ same solution at half the rate( 5ml/kg/hr) (next 12hrs)
Management of PEM…….. • Dehydration mgt:- once dehydration is corrected ↓ maintenance fluid (N/6 in 5 % dextrose at the rate of 75- 100ml/kg/day till feeding is established)
Management of PEM…….. • ReSoMal (rehydration solution for severely malnourished child → supplements more of potassium -- undernourished and dehydrated children are deficient in potassium and have relatively higher sodium levels --can be prepared by mixing 1 pkt of ORS in 2 lts of water + 50 gm of sucrose + 40 ml of mineral mix solution( with high potassium)
Management of PEM…….. • Electrolyte imbalance:- --sodium intake restricted to prevent sodium overload and water retention --severely malnourished children with superimposed diarrhoea or infection may develop severe hypokalemia → so requires extra supplement of potassium
Management of PEM…….. • Congestive heart failure:- --may occur secondary to -overhydration -severe anaemia -high sodium intake --diuretics should never be given to reduce edema in malnourished patients --digoxin is used only when there is ↑JVP and potassium level is normal
Management of PEM…….. • Associated nutritional deficiency:- --severe anaemia– requires treatment --vitamin A deficiency– needs supplement --Vitamin k—single dose 2.5 mg im --magnesium sulfate– 2 ml of 50% soln on day 1 of therapy --folic acid—5mg on 1st day followed by 1mg/day
Management of PEM…….. • Dietary Therapy:- (Day 3-7) • B- Beginning of feeding • E- Energy dense feeding • S- Stimulation of emotional and sensorial development • T- Transfer to home –based diets before discharge or transfer to nutritional rehabilitation centers
Dietary therapy.. • Start with lower volume of feed and increase gradually • Milk based diets are the most suitable initially • Start with energy of 80KCal/kg/d and protein 0.7g/kg/d • Gradually increase to energy of 150 Kcal/kg/d and protein 2-3 g/kg/d in a week • Fluid should be limited to 100-125 ml/kg/d • After 1 wk you can start energy dense feeding
Management of PEM…….. • Recovery and Discharge:- --Early signs of recovery -return of appetite -gain in body weight with loss of edema -disappearance of hepatomegaly - rising serum albumin
Management of PEM…….. • Criteria for Discharge:- --appetite returned, adequate oral intake --constantly gaining weight at normal rate --all infections, vitamin and mineral deficiencies been treated --immunization initiated --mother educated about home care
Management of PEM…….. • Follow Up:- --To prevent relapse --To assure continued physical, mental and emotional development --Reviewed periodically; after -1 week -2 weeks -1 month -3 months -6 months after discharge