Allison schmale 59054563

1. Allison schmale 59054563

2. Children and Malnutrition Allison Schmale, PCV

3. Introduction • Qualifications: Bachelor of Science in Nutrition and Dietetics from St. Louis University • Objectives • Identifying Malnutrition in Children • Meal Planning for Malnourished Children • Budgeting for Cost Effectiveness • Practicing Food Safety

4. Protein Energy Malnutrition Protein Energy Malnutrition/Undernutrition (PEM/U) results from lack of food or an infection, causing lack of appetite, often occurring in children between the ages of 6 months and 5 years in developing countries.

5. Marasmus • Marasmus is a type of PEM resulting from long term starvation or chronic infections causing small food intake. • A defining sign is a “skin pulled over bones” look to the child with little to no fat present along with severe wasting of shoulders, arms, buttocks and thighs, and visible rib outlines. • Wasting: Involuntary weight loss and loss of lean body mass and fat

6. Marasmus, Continued • Physical Signs of Marasmus: • Thin, “wizened” face • “Baggy Pants”-Loose skin of the buttocks hanging and flabby • Noted Alertness in Children • No Edema in the lower limbs • Edema: Fluid pooling under the skin because of poor nutrition, often in the stomach or extremities. Causes a pit or indent when pressure is applied. • Ribs are Very Prominent

7. Kwashiorkor • Kwashiorkor occurs when children get enough food, but not enough protein to support proper growth. This usually occurs in children from 1-4 years. • Edema is the main sign that indicates Kwashiorkor and helps you to distinguish it from Marasmus. • Edema may cause the child to look fat and well fed • Edema can be identified, when applying moderate pressure for 3 seconds and a definite pit results.

8. Kwashiorkor, continued • Physical Signs of Kwashiorkor: • Edema in stomach or extremities. • Hair changes: loss of pigmentation (dark hair gets a red or orange tint) and curly hair becomes straight and is easily plucked. • Skin changes: sores and patches of darker or lighter skin • Children can become apathetic, miserable, and irritable. They often show no signs of hunger and it can be difficult to get them to eat • Not all symptoms always occur, however edema usually is there while others are not.

9. Marasmic Kwashiorkor This is a mix of both types of PEM and the general signs are edema along with other signs of Kwashiorkor.

10. Initial Refeeding • First any underlying problems must be addressed • Special care must be taken when refeeding severely malnourished children in order to prevent refeeding syndrome. • Refeeding syndrome results from over-aggressive introduction of nutrients after chronic malnutrition, causing an imbalance of electrolytes in the body which can result in cardiac and pulmonary complications. • To avoid refeeding syndrome give moderate carbohydrates and adequate electrolytes (as in ORS)

11. As feeding continues… Initially the child should have less and less diarrhea until it completely goes away Edema should begin to go away Appetite should return Do not allow children to consume huge amounts, but rather give them small amounts of nutrient dense food frequently First introduce carbohydrates and work in other food groups like protein and fats and fruit and vegetables as the child continues to eat more. This is easier on their digestive systems and helps their gastrointestinal tract to get back in working order.

12. Meal Planning for Children If severe malnutrition is present, moderate amounts of food should be given, beginning with carbohydrates and slowly integrating small servings of protein, fats, and fruits and vegetables given in small, frequent meals. It is very important that the children get adequate protein. If malnutrition is present and severe, the child will not be able to make up for their lack of mental development, but adequate amounts of protein will help with further physical development.

13. Meal Planning for Children, continued • Once the child is getting adequate and consistent amounts of food, other deficiencies, like kwashiorkor or pellagra, should go away with the introduction of the necessary nutrients. • The most important part of a child’s diet is that they get enough protein everyday, without protein they cannot further development both mentally and physically.

14. Meal Planning for Children, continued

15. Meal Planning For Children, continued • Notes on Previous Slide • Carbohydrates do not dominate the plate, it is important they are in proportion with other nutrients on the plate, especially if the child is recovering from severe malnutrition.

16. Meal Planning for Children, continued • Protein takes up at least one third of the plate, it should always be present and should not be replaced or omitted, avoid dairy here in the initial phases of refeeding a severely malnourished child because the child has difficulty digesting diary initially and dairy should be slowly reintroduced into the diet to prevent further complications. • Vegetable servings can be made up of several vegetables, the more variety on the plate the more nutrients the child will get

17. Recipe Analysis for Children • Standard Menu for Lunch or Dinner: • 1 cup papa • ¼ cup meroho • ¼ cup eggs • While this menu does supply protein and vitamins and minerals it can be improved by enriching it and adjusting the proportions

18. Recipe Analysis for Children, continued • Improved Menu • 1 cup papa => ½ cup papa made with milk • ¼ cup meroho=> ¼ cup spinach, carrots, and onion ¼ cup pumpkin, all made with minimum salt/Aromat • ¼ cup eggs=> 1egg scrambled or hard boiled (approximately ½ cup) • This allows the child to get more nutrition out of their meal and supplies all nutrients in adequate amounts along with a variety of foods.

19. Enriching Foods The best way to enrich foods is to add milk or eggs because they are a very good source of protein and vitamins as well as inexpensive. Milk and eggs can be added to breads, papa, porridge, and samp. Foods, like porridge and bread, can also be enriched using pumpkin seeds or beans which add protein and calories to foods.

20. Enriching Foods, continued • This enrichment will help the food to be more filling and gets more protein into the child. • When cooking eggs you can also add vegetables to the eggs in order to get more vegetable servings in a meal. • If a child is not eating well and is lacking in appetite, add extra oil in the food to make up for calories lost because of small intake.

21. Food Comparisons-Which food is better? • Carbohydrates: • The less the grain has been processed the better it is for you. Ex: wheat/brown bread is better for you than white bread. • Rice, in full grain form is, better than papa (unenriched) because it too provides protein and has not been as processed as the papa. • Keep to the rule that the whole grains, or the closer to it, is better than those that have been processed or are white.

22. Food Comparisons-Which food is better? continued • Proteins: • Eggs are one of the best sources of protein because the protein in eggs is very biologically available (meaning our bodies can use it easily with little to no waste) • Dairy is also a good source of protein, but should not be given to children recovering from malnutrition initially because the digestive system is not ready to digest lactose (the sugar in dairy) yet. • Non-animal sources also supply good protein when paired with the right carbohydrate. • Example: beans and rice, peanut butter and bread

23. Food Comparisons-Which food is better? continued • Vegetables and Fruits: • Raw vegetables are best because all of the nutrients are still intact • Vegetables should only be cooked until they are just done to avoid overcooking, which destroys nutrients • A minimal amount of oil and salt should be used

24. Food Comparisons-Which food is better? continued • Colorful vegetables are more nutritious than others. For example: spinach has more nutrients than potatoes, pumpkin has more nutrients than corn/maize. • Eat a variety of colors means you are getting more variety in the meal because different colors represent different nutrients. • Fruits should be used instead of snack foods like simbas or desserts. Fruits also supply a good source of fiber and other nutrients

25. Food Costing With your budget, you have to find out how much you can spend on each child per day. Then from there you can develop a menu to fit your budget for each child. Careful planning needs to go into planning the menu and the budget needs to be followed exactly in order for it to be effective.

26. Food Costing, continued • Tips: • Buy in bulk • Use standardization of recipes and servings (use the same amount every time and give out the same amounts for the children) • Take advantage of complimentary proteins to save money by serving meat or eggs every few days and beans and papa on other days

27. Food Costing, continued • Grow your own food-have a garden, have layers for eggs, have a milking cow for milk, etc • Buy food locally, from other households and local shops because you will save on transport, support local businesses in your area, and the vegetables will be healthier because they are fresh

28. Basics to Food Safety • Food safety is very important and should be practiced every time you handle food. • There are four simple steps to food safety and sanitation: • Clean • Separate • Cook • Chill

29. Basics to Food Safety, continued Cross contamination is when the harmful bacteria on food, cutting boards, utensils, surfaces or hands contaminates (or gets onto) another food. This is prevented by separating food and by keeping your hands, utensils and food handling surfaces clean. Food preparation puts the food’s safety completely in your hands, making you responsible for preparing quality and safe food to eat. This starts with using clean preparation methods and cooking food to the right temperatures. This starts with proper hand washing.

30. Basic to Food Safety, continued • Unclean surfaces and utensils are often the cause of “cross-contamination.” • It is especially important to keep raw foods, like raw meat, poultry, fish and their juices away from other foods. • Wash cutting boards, surfaces, and countertops with hot, soapy water after you prepare each item and before moving on to the next. • This is extremely important when handling raw meat, poultry, fish, and seafood. • Cooking food to a safe temperature is the best way to make it safe, to make sure it is safe, there are temperatures that food should be cooked to, to destroy any harmful bacteria that may be in the food.

31. Basics to Food Safety, continued • When serving food: • Keep hot food hot and cold food cold so the food doesn’t reach a temperature where bacteria can grow • Keep everything clean by washing your hands, wash utensils and dishes, keep food separate using plastic wrap and sealed containers, bring water and soap with you if there is no running water to wash things up • Wash dishes is warm soapy water and allow to sit in a solution of 1 tbsp bleach to 2 liters of water for a few minutes to ensure all the bacteria have been killed and the dishes are safe to use

32. Recipe Suggestions • Omelet (for four people) • 8 eggs (two per person served) • Tomato, chopped • Onion, chopped • Green pepper, chopped • Spinach, chopped • Salt and pepper • 2 tbsp Cooking oil or margarine, or more if needed • Beat eggs and add salt and pepper • Heat margarine or oil in pan, when hot pour in the eggs and stir. • When the mixture set, tilt the pan back so the uncooked portion will flow under the cooked portion. Continue this way until all is set and has light brown color underneath. • Add tomato, green pepper, spinach, and onion to one half and fold over. • Serve immediately.

33. Recipe Suggestions, continued • Spinach Fat Cakes • 4 cups spinach • 2 ½ cup flour • 1 tsp Salt • 2tsp Barbecue Spice • 2 egg • Cooking oil • Chop spinach • Stir together flour, salt, barbecue spice then add eggs and then add spinach. • Heat oil in a pan and drop about a handful size of spinach mixture into pan and fry until golden brown on both sides.

34. Recipes Suggestions, continued • Bean Soup • 2 cups beans • 1 cup potatoes • 1cup carrots • 1 green pepper • 2 tomatoes • 1 onion • 2 tbsp cooking oil • 2 tsp barbecue spice • 2 tsp white pepper • 2 tsp salt • Water • Cook beans until they are soft • Chop carrots, potatoes, tomatoes and green pepper • Fry onion • Mix together, and simmer until soft, stirring constantly • Allow to simmer until vegetables are soft

35. Recipe Suggestions, continued • Vegetable soup • 1 cup potatoes • 1 cup spinach • 1 cup carrots • 2 tomatoes • 1 tbsp cooking oil • ½ tsp salt • Wash, peel and cut up vegetables into small pieces • Cook carrots until soft, then add to vegetable mixture • Simmer until soft • Serve while warm

36. Recipe Suggestions, continued • Pumpkin Soup • 2 medium onions • 1 tbsp flour • 1 cup milk • 2 tbsp margarine • 2 cups chicken broth • 3 cups pumpkin puree • Salt and Pepper to taste • Sautee onions in margarine • Sprinkle flour over onions, stir and cook for 5 minutes • Gradually add chicken broth and milk stirring constantly • Add pumpkin puree and cook on low heat for 15 minutes • Add salt and pepper to taste

37. Recipe Suggestions, continued • Sechu (Mixed Vegetables) • 1 cup spinach • 1 cup carrots • 1 cup potato, cooked • 1 onion, chopped • 2 tomatoes • 1 green pepper • 2 teaspoons barbecue spice • 2 teaspoons white pepper • Salt to taste • Cooking oil • Cook potato by boiling in water until soft. • Chop all vegetables into small pieces • Sautee onion and green pepper in oil, then add carrots and cook until soft. Then add all the rest of the vegetables and seasonings, toss together in pan. • Take off heat and serve immediately.

38. Recipe Suggestions, continued • Improved Porridge with Egg • 1 cup sorghum meal • 1 cup milk • 1 egg • 2 cups water • 2 tsp sugar • Boil water • Mix flour with milk and sugar • Gradually add the milk and egg to mixture, while stirring • Simmer for 15 minutes

39. Recipe Suggestions, continued • Porridge with Milk • 1 cup maize meal • 3 cups milk • Add half cup milk to pan, then add second half once brought to boil • Mix and let simmer • Cook 20 minutes

40. Recipe Suggestions, continued • Bean Porridge • 2 tbsp maize meal, sorghum meal or wheat meal • 1 cup cooked beans or peas • Water • Mast the beans or peas, then sieve them • Cook the soft porridge • Add sieved beans to soft porridge, then let simmer • Remove from heat, cool

41. Sources “Protein Energy Malnutrition.” www.emro.who.int/nutrition/pdf/protein_malnutrition.pdf. May 18, 2009. Mahan, L. Kathleen and Stump, Sylvia Escott-Stump. Krause’s Food and Nutrition Therapy. 12 ed. Saunders Elsevier, St. Louis. 2008.