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Paediatric Under Nutrition; Assessment & Treatment

Paediatric Under Nutrition; Assessment & Treatment. By Professor Dr. Nosheen Aziz. The orange ribbon ---- an awareness ribbon for malnutrition. Malnutrition. Malnutrition comprises both Under nutrition and Over nutrition. Under Nutrition Can take the form of

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Paediatric Under Nutrition; Assessment & Treatment

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  1. Paediatric Under Nutrition;Assessment & Treatment By Professor Dr. Nosheen Aziz The orange ribbon ---- an awareness ribbon for malnutrition.

  2. Malnutrition • Malnutrition comprises both Under nutrition and Over nutrition. Under Nutrition Can take the form of Underweight (being underweight for one’s age) Wasting(dangerously thin for one’s height) Stunting (too short for one’s age) Micronutrient deficiencies , Hidden Hunger (deficient in vitamins and minerals) For under developed countries terms, Malnutrition and under-nutrition are used synonymously.

  3. MALNUTRITION; WHO’s Prospective.Target Age Groups • Women Pregnancies and breast feeding enhance nutrient requirement. • Children Children are at risk of malnutrition even before birth. Lack of breast feeding and improper upbringing practices can adversely affect them. • Elderly Can not care for themselves have unique complications like changes in appetite and energy level.

  4. DISEASES Protein energy malnutrition Clinical conditions resulting from varying degree of protein lack &energy 1 Nutritional marasmus • Kwashiorkor • Marasmic kwashiorkor • Nutritional stunting

  5. Epidemiology of Malnutrition

  6. Worldwide Malnutrition by Percentage.

  7. Percentage of Children with Malnutrition

  8. Growth Faltering

  9. Significance of PEMUnder nutrition and child mortality 54% of child mortality is associated with underweight condition 9.5 million under five deaths in 2006 The single largest common denominator in global child deaths is malnutrition Severe wasting is an important cause of these deaths (it is difficult to estimate) Proportion associated with acute malnutrition often grows dramatically in emergency contexts Malnutrition54% Caulfied, LE, M de Onis, M Blossner, and R Black, 2004

  10. National Nutritional Survey 2011 • Underweight __________ 38% • Stunted ______________ 36.8% • Wasting ______________ 13.2% • SAM ______________ 03% • Anemia ______________ 50.9%

  11. NUTRITION 2008-2012 THE STATE OF THE WORLD’S CHILDREN 2014 IN NUMBERS BY UNICEF

  12. NUTRITION 2008-2012

  13. NUTRITION 2008-2012 BASIC INDICATORS 2012

  14. Malnutrition:WHO’s Prospective.

  15. Malnutrition;WHO’s Prospective. The WHO has reported; • Hunger and related malnutrition as the greatest single threat to the world’s public health.[6] • Improving Nutrition is regarded as the most effective form of aid .[6][7] • Nutritional interventions addressing causes of under nutrition are the best value for money of all development interventions.[8]

  16. MALNUTRITION;WHO’s Prospective.Emergency Measures Providing deficient micro-nutrient through; • Fortified sachet powders. • direct supplements . Providing energy rich food; • Ready to use therapeutic foods (Plumpy nuts) through community management of SAM. • For famine relief giving cash or cash vouchers to hungry to pay to local farmers. By WHO, UNICEF and UN World Food Program

  17. Long Term Measures Green Revolution • Nitrogen Fertilizer and pesticides. Investment in Agriculture • Fostering nutritionally dense agriculture by genetic engineering. Improvement in Irrigation Systems Health education to mothers • Breast Feeding. • Complementary Feeding. • Balanced Diet during pregnancy. • Supplementation. Restricting population size. Strong Primary Health Care System; • Distribution of supplementation foods and education on dietary needs

  18. RISK FACTORS SOCIAL RISK FACTORS • Maternal Ill, working, incompetent • Father Ill, unemployed • Parental loss • Death, divorce, separation • Drug addiction • More than 2 children under 5 years of age • Previous infant/ child death • Large family size • Poverty and in availability of food • Girl child

  19. RISK FACTORS MEDICAL, NUTRITIONAL FACTORS • Low birth weight • Twins • Lactation failure • Bottle feeding, over diluted milk • Delayed weaning • Food fads • Inappropriate eating habits • Lack of immunization • Recurrent infections • Measles • Chronic diseases

  20. CAUSAL FRAMEWORK OF UNDERNUTRITION Child Malnutrition, death and disability OUTCOME Immediate Causes Inadequate dietary intake Disease Inadequate maternal and childcare practices Underlying causes at household/ Family Level Insufficient access to food Poor sanitation/water and inadequate health services Quantity and quality of actual resources—human, economic and organizational—and the way they are controlled Basic causes at Social Level Inadequate and/or inappropriate knowledge and discriminatory attitudes, limited household access to resources Political, cultural, religious, economic and social systems, including women’s status, limit the utilization of potential sources Potential resources: environment, Technology, people

  21. ASSESSMENT METHODS • History & clinical examination • Anthropometry • Bio-Chemical • Proxy indicators(Vital Health Statistics) • Assessment of dietary intake • Ecological Studies These methods are complimentary & not mutually exclusive.

  22. Nutritional Anthropometry

  23. Classification of malnutrition Moderate malnutrition Severe malnutrition Symmetrical edema No Yes .edematous mal Weight-for-height ˂-2≥-3 SD-Score, -3˂SD-score, (<70%) (70-79%)e (severe wasting) Height-for-age -2 < SD-score < -3 SD-score <-3 (<85%) (85-89%) (severe stunting)

  24. Severe Malnutrition : Criteria • Middle Upper Arm Circumference (MUAC) < 11.5mm in children between 6 – 59 months of age • Presence of Oedema on both feet • Weight-for-height <70% or < -3SD of the median

  25. Moderate Malnutrition : Criteria • Middle Upper Arm Circumference (MUAC) < 12.5mm in children between 6 – 59 months of age • Oedema not present • Weight-for-height <80% or < -2SD of the median

  26. CLASSIFICATION BASED ON Ht for ageStunting • Normal 95-100% of expected • First degree of stunting 90-95% of expected • Second degree 85-90% of expected • Third degree < 85% of expected

  27. WELLCOME OR INTERNATIONAL CLASSIFICATION • Weight between 60 to 80% of expected for age with edema kwashiorkor without edema under nutrition • Weight below 60% of expected for age with edema marasmic kwashiorkor without edema nutritional marasmus

  28. Process for successful management of the severely malnourished child This includes….. 1&2.Treat/prevent hypothermia and hypoglycemia (which are often related)by feeding, keeping warm, and treating infection . 3- Treat/prevent dehydration using Rehydration solution for malnutrition(ReSoMal) 4- Correct electrolyte imbalance (by giving feed(F75 & F100) minerals mix or CMV.

  29. Process for successful management of the severely malnourished child 5-Presume and treat infection with antibiotics 6-Correct micronutrient deficiencies (by giving feeds prepared with minerals mix or CMV and by giving extra vitamins and folic acid as needed. 7-Start cautious feeding with F-75 to stabilize the child (usually 2 – 7 days) 8-Rebuild wasted tissue through higher protein/ calorie feeds (F-100) 9-Provide stimulation, play and loving care 10-Prepare parents to continue proper feeding and stimulation after discharge.

  30. Feeding Formulas

  31. Important things NOT to do and why?

  32. Important things NOT to do and why 1.Donot give diuretics to treat oedema of malnutrition. Giving a diuretic will worsen the child’s electrolyte imbalance and may cause death. 2.Donot give iron during the initial feeding phase. Add iron only after the child has been on F-100 for 2 days (usually during week 2). 3.Donot give high protein formula (over 1.5g protein per kg body weight daily )too much protein is dangerous because the severely malnourished child is unable to deal with the extra metabolic stress involved. Too much protein could overload the liver, heart and kidneys and may cause death. 4.Do not give IV fluids routinely. IV fluids can easily cause fluids overload and heart failure in a severely malnourished child. Only give IV fluids to children with signs of shock .

  33. Discharge policies for a severe malnutrition ward W.H.O recommends that children be kept in the severe malnutrition ward or area until they reach – 2 SD weight for height. If early discharge is necessary, many preparations must be made to ensure that the parents can continue care at home. Follow up visits are essential

  34. Ready-to-Use Therapeutic Food (RUTF) • Energy and nutrient dense: 500 kcal/92g • No microbial growth even when opened • Safe and easy for home use • Is ingested after breast milk • Safe drinking water should be provided • Well liked by children • Can be produced locally • Is not given to infants under 6 months

  35. Prevention of Malnutrition;Efforts in Pakistan • Proper antenatal care. • Breast feeding education and promotion. • Health education about complementary feeds. • Immunization. • Food fortification. • Health home and primary health at grass root level

  36. THANK YOU THANK YOU

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