Session 5

Malnutrition and Anemia

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Learning Objectives
By the end of this session, the students will be able to: (1) define malnutrition and anemia; (2) differentiate the forms of malnutrition and anemia; (3) demonstrate proper weighing and use of growth chart; (4) recognize the signs of malnutrition and anemia (5) assess and classify; and (6) demonstrate how to counsel mothers on proper nutrition

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Malnutrition
a

pathological state secondary to relative or absolute deficiency or excess of one or more essential nutrients  it can also develop in children with diet lacking in the recommended amounts of essential vitamins and minerals( iron)

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Major Causes of Malnutrition

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Forms of Malnutrition
(1) Protein Energy Malnutrition is a deficiency of calories and or protein in a child’s diet Forms of PEM
(1) marasmus (2) kwashiorkor
PEM
– – –

is present if:

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The child is severely wasted The child develop edema The child do not grow well and become stunted

Forms of Malnutrition
(2) Nutrient Deficiencies - anemia (lack of iron) - Vitamin A deficiency

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Kwashiorkor and Marasmus

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Marasmus
 occur

at all ages, more common at 0-2 years old  child is not getting enough energy from his regular diet  balanced starvation  result of unsuccessful breast feeding or insufficient breast supply  severely wasted
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Marasmus
 gross

loss of subcutaneous fat; “ all skin and bone; “ loose skin folds in buttocks  potbelly and winged scapulae  poor appetite  apathetic

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Marasmus

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Kwashiorkor
* usually 1 -3 years old * results from a low protein diet * presence of bipedal is a cardinal sign Common signs : - Hair changes – sparse - straight

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- dyspigmented (light brown, reddish brown blonde - flag sign (light and dark bands in hair) - Diffuse depigmentation – flaky paint or enamel dermatoses - Puffy and moon faced - Anemia

Kwashiorkor

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Malnutrition and Anemia
For ALL sick children ask the mother about the child’s difficult breathing, diarrhoea, fever, ear problem and then CHECK FOR MALNUTRITION AND ANAEMIA.

THEN CHECK FOR MALNUTRITION AND ANAEMIA
LOOK AND FEEL: Look for visible severe wasting. Look for palmar pallor. Is it: Severe palmar pallor? Some palmar pallor? Look for oedema of both feet. Determine weight for age.
Classify NUTRITIONAL STATUS

CLASSIFY the child’s illness using the colour-coded-classification table for malnutrition and anemia Then CHECK immunization status and for other problems.

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Malnutrition and Anemia
CHECK FOR MALNUTRITION AND ANEMIA LOOK AND FEEL: Look for visible severe wasting Look for palmar pallor. Is it: - severe palmar pallor? - some palmar pallor? Look for edema of both feet Determine weight for age CLASSIFY NUTRITIONAL STATUS

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How to check for malnutrition and anemia
 Look

for visible signs of wasting  Look for palmar pallor  Look and feel for edema of both feet  Determine weight for age

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How to determine weight for age

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How to classify nutritional status
 Severe

Malnutrition OR Severe Anemia  Anemia OR Very Low Weight  No Anemia AND Not Very Low Weight

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CLASSIFICATION TABLE FOR MALNUTRITION AND ANEMIA
SIGNS
Visible

CLASSIFY AS SEVERE MALNUTRITION OR SEVERE ANAEMIA

IDENTIFY TREATMENT (Urgent pre-referral treatments are in bold print.)
Give

severe wasting

or Severe palmar pallor or Oedema of both feet.
Some

Vitamin A. Refer URGENTLY to hospital.

palmar pallor or Very low weight for age. ANAEMIA OR VERY LOW WEIGHT

Assess

the feeding according to the FOOD box on the COUNSEL THE MOTHER chart. — If feeding problem, follow-up in 5 days. If pallor: — Give iron. — Give oral antimalarial if high malaria risk. — Give mebendazole if child is 2 years or older and has not had a dose in the previous 6 months. Advise mother when to return immediately. If pallor, follow-up in 14 days. If very low weight for age, follow-up in 30 days.
If

Not

very low weight for age and no other signs or malnutrition.

NO ANAEMIA AND NOT VERY LOW WEIGHT

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child is less than 2 years old, assess the feeding and counsel the mother on feeding according to the FOOD box on the COUNSEL THE MOTHER chart. — If feeding problem, follow-up in 5 days.
Advise

mother when to return immediately.

Severely malnourished child

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Severely malnourished children

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Anemia
A reduced number of red blood cells or A reduced amount of hemoglobin in each red blood cell

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Conditions Predisposing to Anemia
 infections  hookworm

and whipworm infections
 malaria

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How to check for Anemia
(1) Look for palmar pallor (2) Hold the child’s palm open by grasping it gently form the side.
DO NOT STRETCH THE FINGERS BACKWARDS

This may cause pallor by blocking the blood supply.
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How to check for anemia
(3) Compare the color of the child’s palm with your own palm and with the palm of other children. Severe palmar pallor - very pale or white Some palmar pallor - pale
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How to classify Anemia
Severe anemia severe palmar pallor Some anemia some palmar pallor No Anemia
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Children with Anemia and Malnutrition

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How to identify the treatment
Severe Anemia - severe palmar pallor At risk of death from: 1. Pneumonia 2. Diarrhea 3. Measles 4. Other severe diseases Needs: 1. Urgent referral to a hospital 2. Special feeding 3. Antibiotics 4. Blood transfusion Before discharge, give the child a dose of Vitamin A

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How to identify the treatment
Some Anemia – some palmar pallor Needs: 1. Iron 2. Anti-malarial if infected 3. Mebendazole if infected Give Mebendazole if the child is 2 years of age or older and has not had a dose of Mebendazole in the last 6 months

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How to identify the treatment
No Anemia If the child is less than 2 years of age,
(5)

assess the child’s feeding problems and malnutrition counsel the mother about feeding her child according to the recommendation in the Food Box on the Counsel the Mother

(7)

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Iron
 Under

12 months of age – Iron syrup 3 mg/kg - maintenance 5 mg/kg – treatment

 12

months or older – Iron tablets for 14 days

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Iron and Anti malarial Drugs
 Iron/folate

tablets may interfere with the action of sulfadoxine-pyrimethanine that contains antifolate drugs a child on anti-malarial drugs, iron/folate during the follow-up or after treatment of two weeks

 Give

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Mebendazole
 Treats

anemia by killing whipworms and hookworms that cause anemia through intestinal bleeding 500 mg/tab or five 100 mg/tab as

 Mebendazole

single dose

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Follow-up Care
(a) advise the mother to bring back her child after 14 days of iron treatment (b) continue to give the mother iron tablets when she returns every 14 days for up to 2 months (c) if after 2 months the child still has palmar pallor, refer the child.
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Case Study 1

 

Erika is 18 months old and weighs 7 kg. She was brought by her mother today because the child has had fever for 5 days and has a generalized rash. She does not have cough, runny nose or difficult breathing. She does not have diarrhea. She is able to drink, has not vomited, has not had convulsions, and is neither lethargic nor unconscious. Erika lives where there is a high risk of malaria. The health worker checked for danger signs. The health worker saw that Erika looks like skin and bones. Her temperature is 38.5 C. Her rash is generalized She has red eyes but does not have mouth ulcers, pus draining from the eyes nor clouding of the cornea. The rest of the physical examination is normal. The health worker next checked for malnutrition or anemia. Erika has visible severe wasting. There is no palmar pallor. She does not have edema of both feet. The health worker determined her weight for age.

Questions:  Classify and assess the child’s condition.  How are you going to manage the patient?

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Case Study 2

Michael is 11 months old and weighs 8 kg. His mother says that he has had cough for at least 3 weeks Michael does not have diarrhea. He has not had a fever during this illness. He does not have an ear problem. He does not have any general danger signs. His temperature is 37 C. He counted 41 breaths per minute. The health worker does not see chest indrawing. There is no stridor when the child is calm. The health worker checked him for malnutrition and anemia. He does not have visible severe wasting. His palms are very pale and appear almost white. There is no edema of both feet. The health worker determined Michael’s weight for age. Determine his weight for age.

Questions:  Determine his weight for age.  Assess and classify the patient’s condition.  What are you going to advise the mother?

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Case Study 3
Alulu is 9 months old and weighs 5 kg. He is at the clinic today because his mother and father are concerned about his diarrhea. He does not have cough nor difficult breathing. He has diarrhea for 5 days. They have not seen blood in the stool. He does not have fever nor an ear problem.  He does not have any general danger signs. He is not restless or irritable. He is not lethargic or unconscious. His temperature is 38 C. His eyes are not sunken. He is thirsty and eager to take the drink of water offered to him. His skin pinch goes back slowly.  The health worker checked for malnutrition and anemia. The child does not have visible severe washing. There is palmar pallor. He does not have edema of both feet. Questions:  Determine weight for age.  Assess and classify the child’s condition  Does the patient need urgent referral?

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Case Study 4

 

Melvin is 37 months old and weighs 9.5 kg. His mother says that he feels hot and has been crying and rubbing his ears. The mother noted ear discharge 5 days prior to consult and Melvin complained of ear pain. He has fever for 3 days accompanied by runny nose. He does not have cough, rashes nor diarrhea. He is able to drink and does not vomit everything he drinks. He has not had any convulsions. The risk for malaria is high in their area. He is neither lethargic nor unconscious. His temperature is 37.5 C. The health worker sees pus draining from his ear and does not feel any tender swelling behind either ear. He then checks the child for malnutrition and anemia. Melvin looks thin but does not have visible severe wasting. He has some palmar pallor. He does not have edema of both feet. The worker determined his weight for age.

Questions:  Determine weight for age.  Assess and classify the child’s condition  What will you advise the mother?

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