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• Malnutrition is globally the most important risk factor for
illness and death, contributing to more than half of deaths in children worldwide. • The World Health Organization defines malnutrition as "the cellular imbalance between supply of nutrients and energy and the body's demand for them to ensure growth, maintenance, and specific functions."
4 . Deficiency in micronutrients such as Vitamin A reduces the capacity of the body to resist diseases . Micronutrient deficiencies lead to a variety of diseases and impair normal functioning of the body. • micronutrient malnutrition: refers to inadequate availability of some essential nutrients such as vitamins and trace elements that are required by the body in small quantities .Classification & Forms of Malnutrition Common forms of malnutrition include: • protein-energy malnutrition (PEM(: refers to inadequate availability or absorption of energy and proteins in the body .
6 .Protein Energy Malnutrition • Protein Energy Malnutrition is a major condition of nutritional disorders and defines as :- A range of pathological conditions arising from coincident lack of proteins and calories in varying proportions. occurring most frequently in infants and young children and commonly associated with infections.
WHO classification. Welcome classification . Gomez classification. 3. 4. 2.Classification PEM is classified by many theories:- 1. 7 Water law classification. .
This classification took into account the effect of past as well as present malnutrition. seen in retarded height for age. 8 . • It is wasting code for present malnutrition and measured by loss of weight related to height. and past malnutrition (stunting).Water law Classification • This classification was based on weight for height and height for age.
But it is not applied in sever malnutrition. 75 – 90 % 1st degree Mild 60 – 74 % 2nd degree Moderate < 60 % 3rd degree sever 9 . population screening and public health evaluations.Gomez Classification Wt to age % It is used for field work. researches.
Weight loss. depending on two main criteria : PEM Form Body weight % of standard 60 – 80% Oedema underweight -ve 1.Welcome classification It is a simple and universally accepted one. kwashiorkor 60 – 80 % +ve Marasmus < 60 % -ve Marasmic kuwashiorkor < 60 % +ve 10 . 2.Oedema.
2 -( 85 – 90 %) 11 .WHO Classification It classifies malnutrition into moderate & sever depending on measuring:• Wt for Ht .3 ( < 85%) ( sever stunting) Weight for height -3 < SD score < .3 ( < 70% ) ( sever wasting) SD score < . and • Ht for age Moderate malnutrition Sever malnutrition Symmetrical Oedema No Yes ( oedematous malnutrition) SD score < .2 -(70 – 80 %) Height for age -3 < SD score < .
• It causes multisystem effect. • Its is a controllable and preventable disease. • Morbidity ( predisposing to infections). • Treatment is possible.Why Malnutrition is so Important?! • Incidence is app. 50% of population. 12 . • Mortality rate is about 12 – 20% of childhood death.
breastfeeding. pregnancy. 14 .. during infancy. adolescence. and old age).e.Risk Factors & Causes • Malnutrition is associated with many disorders and circumstances. early childhood. including poverty and social deprivation. • Risk is also greater at certain times (i.
3. 2. 5. low birth weight and twins. 15 . Sudden weaning and starvation therapy for diarrhoea. Preterm. 4.In infancy and childhood: Nutritional factors:1. Short spacing and large families. 6. 8. food taboos and believes). 7. late supplementation and poor quality or quantity or both. Non or partially vaccinated. Poor breast feeding. Poverty ( inadequate or poor supplementations of food). Bad housing ( sanitation and environmental conditions). Mother ignorance ( poor practicing.
16 .Kidney : obstructive uropathy. Malignancy : neuroblastoma. . Bronchiectasis. 4. 2. Psychological disturbances : maternal deprivation syndrome. Endocrinal : hyperthyroidism. DM.CVS: cyanotic congenital heart diseases. 3. 3. malaria . UTI. 2. Metabolic diseases: galactosemia. 1.In infancy and childhood: • Precipitating Factors:1. . Malabsorption syndromes.GIT: pyloric stenosis. Congenital malformations: .HIV. Recurrent GE or sever infections: TB.
electrolytes. Retarded linear growth ( in long standing cases). 3. 2. 18 .Pathophysiology • 1. 2. vitamins & minerals: 1. Water : total body is increased ( ECF). Bone age may be retarded. Sodium : total body sodium is higher than normal but serum sodium may be low due to excessive amount of water in ECF ( dilutional hyponatreamia) . 4. impairment of physical growth and of cognitive and other physiologic functions are as follows:Growth failure: Weight is markedly diminished. Head circumference may be also affected. Water.
4.Pathophysiology 1. Magnesium : total amount may be decreased but in serum is normal due to shift from tissue to vascular compartment. niacin. 2. 19 Iron : low serum iron leading to microcytic hypochromic anaemia. 6. Vit A deficiency : leads to night blindness. 8. copper and zinc : will results in dermatosis. . 5. Manganese deficiency : results in mental status changes ( irritability and apathy). Riboflavin. Vit C and K : results in bleeding. Potassium : is low due to cellular destruction and losses in diarrhoea. Follic acids & vit B12 : low leads to megaloplastic anaemia. 7. 3.
Pancreatic and duodenal enzymes are diminished.reduced serum amino acid ( essential amino acids).Pathophysiology Metabolic changes : 1. . 20 . . esterase . alkaline phosphatase are low but hepatic enzymes are released like transaminase and isocitric dehydrogenase tend to increase with hepatic injury.Enzymes: amylase. .reduced serum albumin ( < 2g/dl)). Protein : .reduced total plasma protein (< 4g/dl).
Blood Urea and urine is markedly reduced because of deficient intake of endogenous proteins.( hypoproteineamia will results in decreased colloid oncotic pressure affecting the circulating blood volume leading stimulation of osmoreceptors ( ADH) and activation of renin angiotensin system leading to Na and water retention resulting in soft pitting oedema in dependant parts) 21 . .Pathophysiology .
deficiency of the enzymes involved in gluconeogenesis. Carbohydrates: hypoglycaemia due to 3.reduced level of serum triglycerides.reduced serum cholesterol level. 22 .reduced serum lipo protein. . Lipids : . .2.
Pathophysiology GIT : 1. 3. fat. 23 . Reduction of intestinal and pancreatic enzymes will lead to inadequate digestion of food and passage of loose stool. 2. Malabsorption of nitrogen. CHO and mineral due to atrophy of villi. Disaccharadiase deficiency leads to fermentative diarrhoea accompanied by abnormal distension and flatulence.
3. Increased mobilization of free fatty acids from adipose tissue to the liver. Decreased oxidation of fatty acid in the liver. leading to decrease release of fat from the liver. Increase fatty acid synthesis from glucose. Liver : is enlarged due to fatty infiltration resulting from :1. 24 . 4. Decrease synthesis of apolipoprotein. 2.
2. 4. decreased number of neurons. thinner cerebral cortex. CNS: 1. slowed rate of growth of the brain. More recently. neuroimaging studies have found severe alterations in the dendritic spine apparatus of cortical neurons in infants with severe protein-calorie malnutrition. insufficient myelinization. 3. and changes in the dendritic spines. lower brain weight. 25 .
decreased secretory immunoglobulin A (IgA).Pathophysiology Immune system: 1. 5. Loss of delayed hypersensitivity. impaired lymphocyte response. infectious diarrhoea 26 . 4. 3. impaired phagocytosis secondary to decreased complement and certain cytokines. fewer T lymphocytes. most commonly. 2. These immune changes predispose children to severe and chronic infections.
Apathy and irritability are common. 28 . Diarrhea is common and can be aggravated by deficiency of intestinal disaccharidases.Symptoms:Symptoms of moderate PEM: 1. especially lactase. 2. 5. 3. 4. Cognition and sometimes consciousness are impaired. The patient is weak. and activities decreases. Temporary lactose deficiency .
pale.Symptoms of sever PEM: 1. Muscles shrink and bones protrude. inelastic. 2. GE. 29 . chest infection. 3.e. 4. and cold. UTI. 5. Hypothermia. Wasting (called cachexia in adults) is most obvious in areas where prominent fat depots normally exist. Symptoms of associated disease due to low cellular immunity ( i. The skin becomes thin. Edema. dry. Signs of anemia. becoming sparse. The hair is dry and falls out easily. Wound healing is impaired. sepsis).
( flag sign: it’s a sign of improvement: means part of hair is dyspigmented and parts has normal black colour) 30 . tachycardia. • Hair : sparse over temples and occipital regions. dry and easily pickable. hypotensive. and may be unconscious. dyspigmentation. tachypnic. • vital signs: febrile. pale. may be oedematous.severly wasted. irritable or apathetic. • Anthropometric : retarded growth.Signs of malnutrition On examination : • Generally: pt looks ill.
Lack of tears. Pus and inflammation ( eye infection). jaundice 4. Sunken eyes ( dehydration and wasting). 31 . vascularization of cornea with photophobia + tears ( riboflavin deficiency). Pallor. 2. 3. • Eyes: 1. Keratitis.Signs of malnutrition • Fontanelles: is depressed due to dehydration. 5.
xeropthalmia fundus. which are: .conjunctival xerosis. .keratomalacia.blindness. . .Signs of malnutrition 6.corneal xerosis. 32 .bitot spots. .corneal scar. . . Signs of vit A deficiency. .night blindness.corneal ulceration. .
33 .• Nose & Ears: discharges denote rhinitis or otitis media. • Cheeks: • loss of buccal bad of fat ( old man face). doll like cheeks. • In kuwash they appear full.
( anaemia) Angular stomatitis. Delayed teething. Dry tongue.• • • • • • • • 34 Mouth: look for: pallor. Glazed tongue : iron deficiency anaemia Magenta – coloured tongue( riboflavin def ). Oral thrush. .
Back and extremities: • Oedema • Muscle wasting + loss of subcutaneous fat = sticky like limbs. • Goiter. • Cold cyanotic extremities : shock complicating diarrhoea.• Neck : • Lymph nodes enlargement ( TB. Lymphoma). 35 . arthritis if present. • Skin rash.
Is character of kwash. hands and lower arms. lower legs.Forms of oedema:classification Mild Moderate description Both feet Both legs.the whole body is oedematus but term of kwash will not be 36 used Sever .
• • • • • Skin : Inelastic skin ( slow skin pinch). • petechiae. hyper/hypopigmeneted areas Shedding and ulceration of skin of perineum. Dermatosis. limbs and axilla. inguinal. Loss of subcutaneous fat. 37 .
fissures. raw skin. Multiple patches on arms and/or leg. Flaking skin.Forms of Dermatosis:classification Mild Moderate sever description Discoloration or few rough patches. 38 .
or signs of pleural effusion. Hepatosplenomegally. 39 . CNS: psychic changes. Abdominal distension.• Chest: for crepitations. wheezes. • Abdomen: for :- • • • • • Hepatomegally. Masses ( neuroblastoma) Ascitis. exclude meningitis. • Heart : to exclude possibility of congenital heart disease. For chest infection.
• Full investigations should includes:1. CBC ( low heamatocrite and leucocytosis). Blood culture ( septicaemia). 2.Mantoux Test & sputum stain and culture. 12. Urine analysis & culture ( UTI). 7. 11.• The most helpful laboratory studies in assessing the nutritional status of a child are Haematological studies and lab. CXR for hidden T or pneumonia. Plasma proteins (hypoproteineamia) 6. 5. 4. Blood glucose ( hypoglycaemia). 8. studies evaluating protein status.Liver function test. 41 . 10. 3. BFFM.Ultrasonography for obstructive uropathy and pyloric stenosis.. Stool analysis & culture ( diarrhoeal diseases) 9. Blood urea & electrolytes ( hypocaleamia).
Jaundice. Serious health problems includes: 1. 5. 7. Septicaemia.. TB. Blindness. Sever infection ( Pneumonia. 4.Severely malnourished child is likely to have many serious health problem in addition to malnutrition. Electrolytes and acid – base disturbances.). Heart failure. malaria. Dehydration. 9. 6. etc. 3. 8. . Hypoglycaemia. 2. 43 Hypothermia.
45 . Wt/ ht less than 3 SD ( < 70 % of the stanard wt and/or oedema of the both feet) or MUAC <110mm.Criteria for admission 1. Septicaemia. Dehydration and shocked child. Malnourished children presented with complications eg: Diarrhoea Respiratory infection. 2.
9. Achieve catch up growth. Start cautious feeding. 3. 10.Guidelines and principles of management flowing the 10 --steps:1. 2. 4. 6. Provide sensory stimulation and emotional support. 7. 5. Correct micronutrient deficiencies. Treat/ prevent dehydration. Treat/ prevent hypothermia. Treat/ prevent infections. 8. Prepare for follow up after recovery. 46 . Correct electrolyte imbalance. Treat / prevent hypoglycaemia.
1. Hypoglycaemia • Hypoglycaemia hypothermia usually occur together and they may be signs of infection • Hypoglycaemia is considered when blood glucose is less than 3 mmol/dl 47 .
Then star F-75 every 30 minutes for 2 hours Feeds two hourly day and night Give antibiotics If the child unconscious lethargic or convulsing Give IV sterile glucose 10 % Fallowed by 50ml of 10% glucose or sucrose by NG tube . – Then star feeding F-75 – Two hourly feeds day and nigh – Give antibiotic 48 .Hypoglycaemia • Treatment: If the child is conscious Give 50ml of 10 % glucose or 10 % sucrose solution Orally or by NG tube.
1. 2. 3. 4. 5. Check blood glucose after 2 hours. If it is < 3 mmol/L, give further 50 ml bolous of 10% glucose or dextrose. Continue feeding every two hours till blood glucose become 3 mmol/L. If rectal temp is < 35.5 c, repeat the bolous. If level of consciousness is deteriorated, repeat the bolous.
– Feed every two hours – Always give feeds through the day and night
• If the axillary temperature is < 35 c or rectal temp is < 35.5 c: 1. Feed straight away ( or start rehydration). 2. Rewarm the child ( clothes, blankets, heater, or lamp nearby, bottles are dangerous). 3. Kangaroo technique: placing the child on the mother’s bare chest & abdomen an covering both of them. 4. Give antibiotics
• 1. 2. 3. • 1. 2. 3. 4.
Monitor : Body temp, rectally every 2 hrs till rises above 36.5 c. Child must be covered all time esp. at night. Blood glucose level whenever there is hypothermia. Prevention : Feed 2 hrly through out day and night. Keep the child dry. Avoid exposure ( bathing or prolonged medical examination). Let child sleep beside his mother esp. at night.
as blood flow to the vital organs decreases. Dehydration • Dehydration progresses from “some” to “sever”.3. with care and slowly to avoid fluid overload. where as septic shock progresses from “incipient” to “developed”. reflecting 5 – 10% and > 10% wt loss. 52 . • Don’t use iv line for rehydration except in shock. respectively.
Classification of Dehydration Clinical signs Watery diarrhoea Some dehydration Sever dehydration yes yes Thirst Hypothermia Sunken eyes Weak radial pulse Cold hands & feet Urine flow Mental state Drinks eagerly NO yes no no yes Restless. comatose . irritable 53 Drinks poorly NO yes yes yes No Lethargic.
• Treatment : 1. Zinc Start feeding F. 2.045 54 ORS 111 90 20 80 10 - .3 0. composition Use Resomal ( Glucose rehydration solution for Sodium malnutrition). Citrate Then 5 – 10ml/kg hrly in Magnesium the next 4 – 10 hrs.75. Potassium Give 5ml/kg every 30 min for first 2 hrs orally Chloride or by NG tube. copper Resomal 125 45 40 70 7 3 0. 3. 4.
Replace the volume of stool losses with Resomal (50 – 100ml after each watery stool). Keep feeding with F – 75.• Monitor : 1. 55 . 2. urine frequency and stool vomiting. every ½ hrly for 2 hrs then hrly for 6 – 12 hrs. Observe the vital signs. 2. 3. • Prevention : 1. Stop to give fluid if continuous rapid breathing and pulse ( infection or over hydration) or oedema and puffyness of eyes. Encourage breast feeding.
Extra potassium ( 3 – 4 mmol/kg/day). 2.6 mmol/L/kg/day). * 20 ml of combined electrolyte/ mineral solution or Resomal to 1 litre of feed will supply the requirement of K and Mg. 56 .4. Electrolyte imbalance • Oedema is a result of electrolyte imbalance. 3.4 – 0. Give low sodium rehydration (Resomal). that’s why we don’t treat it with diuretics. 4. Prepare food without salt. Extra magnesium ( 0. • Give:1.
infection • Give: 1. Measles vaccine if the child above 6 month of age and not immunized (delayed in shocked pt). 57 . Reduce systemic infection arising of anaerobic bacterial infection in small intestine.5 mg/kg/8hrly for 7 days) routinely in addition to antibiotics for: Hasten repair of intestinal mucosa. 2. Broad spectrum antibiotics. Reduce risk of oxidative damage. 3.5. May give metronidazole ( 7.
> 6 month : 5 ml / BD / for 5 days.etc): ampicillin (50 mg/kg IM or IV / 6 hrly for 2 days) then orally amoxycillin (15 mg /kg/ 8hrly for next 5 days). UTI. And : Gentamycine (7. 58 . hypothermia.• Drugs of choice:1.5 mg/kg IM or IV once daily for 7 days) 3. 2. If the child is severely ill and has complications (hypoglycaemia.. After 48 hrs if child fail to improve : add chloramphinicol 25 mg/kg IM or IV 8 hrly for 5 days. If no complications : cotrimoxazole (5ml = 40 mg TMP + 200 mg SMX) < 6month: 2.5 ml / BD / for 5 days.
59 . Site of infection. If its resistant organism. 3. Ensure vitamin and minerals supplements. • If anorexia still persist :Reassess the child fully : 1. • If anorexia persist after 5 days of antibiotics: treat a full complete 10 days course. 2.• If specific infections are identified add the specific antibiotics.
000 IU 6 – 12 month = 100.6.000 IU Give daily for at least 2 weeks:Multivitamin supplement or combined mineral vitamins (CMV). 2 & 7. Copper 0. Follic acid 1 mg/ kg/ day. Iron 3 mg /kg/day (but only after gaining wait) 2.Correct micronutrient deficiency • 1. 0 – 5 month = 50. Give : Vit A orally: day 1 .3/kg/day.000 IU above 12 month= 200. 60 .
Amount in F100 80 g 50 g 60 g 20 mL 140 mg 1000 mL .7. • On first day give child: Small amount of F-75 every 2 hrs. if pt hypoglycaemic give ¼ of 2 hrly amount ever ½ hr an hr till blood glucose become at least 3 mmol/L. Cautious feeding • Ingredient Dry skimmed milk Sugar Cereal flour Vegetable oil Mineral mix Vitamin mix Water to mix Amount in F75 25 g 70 g 35 g 27 g 20 mL 140 mg 1000 mL 61 Formula used are: F-75 and F-100.
The essential features are: Small frequent feeds of low osmolarity and low lactose. Total amount of F-75 which is given per day( 130 ml/kg which is appropriate until the child is stabilized equal to : 100 kcl/kg/day 1 – 1. Orally or nasogastric tube is used for feeding never parentral. 3. 2.• • • 1.5 g/kg/day of protein. 62 . • • On 2nd day : increase the volume per fed gradually and decrease the frequency (every 3 – 4 hrs) Child feeding plan should be recorded in the 24 hrs food intake chart.
estimate the amount of vomits and offer the amount of feed again or give half the amount every hr till vomit stop. 63 . give Resomal: < 2 yrs = 50 – 100 ml > 2 yrs = 100 – 200 ml (after every loose stool) • If the child vomits.• If the child continue watery diarrhoea.
Recommended volume which gradually increased:Days 1–2 3–5 6 – 7+ Frequency 2 hrly 3 hrly 4 hrly Vol/kg/feed 11 ml 16 ml 22 ml 64 vol/kg/day 130 ml 130 ml 130 ml .
• 1. 2. 65 . 4. Monitor and note : Amount offered and left over. 3. 2. Diarrhoea should gradually diminish. Vomiting Frequency of watery stool Daily body wt • During stabilization phase: 1. Oedematous children should lose wt.
3.9 kl/100 ml. 100 kcl and 2. contains: 1. • We change to F-100 when the child return his appetite and reduce oedema. Achieve catch up growth • Catch up formula F-100 used to rebuild wasted tissues. 2. 66 . More calories and protein. Gradual transition is recommended to avoid heart failure.8. Start when the child is stabilized ( after 2 – 7 days).
• Transitional phase: 1. 2. Pulse rate. In the next 24 hours: increase each successive feed by 10 ml until some feeds remains uneaten ( usually when intakes reach 30ml/kg/feed – 200 ml/kg/day) • Monitor for: 1. In first 48 hours: replace F-75 with same amount of catch up formula F-100 every 4 hrs. 67 . 2. Respiratory rate.
Increased by > 5 breath/min or pulse by 25 or more / min for two successive 4 hourly: reduce the volume per feed : 1st 24 hrs: 4 hourly F-100 at 16 ml/kg/feed. Then increase each feed by 10 ml as above.• If RR. 2nd 24 hrs: 19 ml/kg/feed . 68 . next 48 hrs: 22 ml/kg/feeds.
Moderate ( 5-10g/kg/day) check for intake or infection). 69 . Good ( > 10g/kg/day).• Rehabilitation phase: The daily need is calculated by :wt x 150 (minimum) – 220 (max) 6 (feeds per day) • If wt gain is: 1. 2. 3. Poor ( < 5 g/kg/day) require full reassessment.
play) 70 . Maternal involvement when possible (feeding. 2. 4. stimulating environment. Provide: Tender loving care. Structural play therapy 15 – 30 minutes /day. 5. Provide sensory stimulation & emotional support:• 1. 3. Physical activity as soon as the child well enough.9. bathing. A cheerful.