1. Nutritional Disorders Dr. Shreedhar Paudel 04/02/ 2009

2. 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

3. 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”

4. 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

5. 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

6. Protein-Energy malnutrition…. Diagnosing Tools? – WEIGHT for age – HEIGHT for age – ARM Circumference – CRANIAL Circumference

7. Weight-for-age (Gomez) classification ClassificationWeight as % of the standard Normal> 90 Grade 1 (mild undernutrition) 75-89 Grade 2 (moderate undernutrition) 60-74 Grade 3 ( severe undernutrition) < 60

8. Modified Gomez classification Nutritional statusWt. as % age of the standard wt. NormalMore than 80% Grade 171-80% Grade 261-70% Grade 351-60% Grade 4≤ 50%

9. Welcome Trust classification Range of weightEdema ±Nutritional Status > 80%AbsentNormal 60-80%AbsentUndernutrition 60-80%PresentKwashiorkor < 60%AbsentMarasmus < 60%PresentMarasmic Kwashiorkor

10. Waterlow’s classification Weight for heightHeight for ageNutritional status ≥ 80%≥ 90%Normal < 80%≥ 90%Wasted ≥ 80%< 90 %Stunted < 80%< 90%Wasted and stunted

11. Mid upper arm circumference Nutritional statusMUACColor on strip Normal> 13.5 cmGreen Moderately malnourished 12.5- 13.4 cmYellow Severely malnourished < 12.5 cmRed

12. Marasmus

13. 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

14. 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

15. 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

16. 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)

17. 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

18. 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)

19. 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

20. 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)

21. 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

22. 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

23. 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)

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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 1 st 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

30. 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

31. 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)

32. 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)

33. 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)

34. 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

35. 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

36. 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 1 st day followed by 1mg/day

37. 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

38. 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

39. 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

40. 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

41. 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