1. By Dr Hayder Hadi Al-Musawi MD, FIBP, BACCH
NUTRITION
By Dr Hayder Hadi Al-Musawi MD, FIBP, BACCH

2. Malnutrition
Malnutrition:-this term is now in common use for all degrees and clinical types of the most widespread nutritional disorders of childhood.
Classifications of malnutrition:-
There are many modes of classifying malnutrition according to the
1- Cause– either primary or secondary.
2- Clinical types ---either excess( obesity)
Or –deficiency (under nutrition ).
3- Degree– either mild, moderate or sever.
4- Duration – either acute or chronic.
5- Out come – either reversible or irreversible.
6- Nutrient --- either vitamins, elements, protein or energy sources.
Under nutrition ( definition ) :-
-- Wasting :- is the acute loss of weight or failure to gain weight at the expected rate, produce a condition of reduce weight for height.

3. Under nutrition
Stunting :- is the reduction in the height for age ,as is seen in more chronic malnutrition.
Mild under nutrition, is characterized by decrease in weight with normal height and OFC.
While in sever chronic under nutrition, weight, height and eventually head circumference will slow relative to the standard for age.
Marasmus :- means significant calorie deprivation producing sever wasting.
Kwashiorkor :- indicate significant protein deprivation in the face of adequate energy intake .it is called edematous under nutrition.

4. Under nutrition Under nutrition measurements :-
A number of anthropometric indices have been used successfully to estimate the prevalence of under nutrition among preschool children. These include :
Height for Age :- an index of cumulative effects of under nutrition during the life of the children.
Weight for Age :- reflects the combined effects of both recent and long term levels of under nutrition.
Weight for Height :- reflects recent nutritional experiences. Value below % of expected are considered abnormally low.

5. Etiology of Under nutrition:-
1- inadequate dietary intake.
2- inappropriate formula mixing.
3- family believes that lead to hypo caloric or unbalanced dietary intake.
4- family dysfunction that lead to neglect or abuse.
5- infectious diseases.
6- low birth weight.
Consequences of Under nutrition :-
Acute under nutrition will increase mortality and morbidity.
Long term under nutrition will have an effect on cognitive and social development, physical work capacity and economic growth
Sever under weight children ( less than 60% of reference weight for age have more than 8 fold greater risk of mortality than normal children.
Moderate under weight children ( % ) will have 4-5 fold increase risk.
Mild under weight children ( % ) will have 2-3 fold increase risk.

6. Protein energy malnutrition ( PEM ) :-
Deficiency of a single nutrient is an example of under nutrition .usually there is a deficiency of several nutrients.
PEM is manifested primarily by inadequate
dietary intake of protein and energy. PEM is almost always accompanied by deficiencies of other nutrients.
It could be either primary malnutrition ( inadequate food intake ).or Secondary malnutrition ( increase nutrient needs, decrease nutrient absorption, and or increase nutrient loss.)
Protein energy malnutrition is a spectrum ranging from mild under nutrition resulting in some decrease in length and / or weight for age to sever form of under nutrition resulting in marked deficits in weight and length for age as well as wasting ( i.e. low weight for length).

7. Protein energy malnutrition
The most sever forms of PEM are :
1- Marasmus : result primarily from inadequate energy intake.
2- Kwashiorkor : result primarily from inadequate protein intake.
3- Marasmic-Kwashiorkor : has features of both disorders.
The three conditions have distinct clinical and metabolic features but they have also a number of overlapping features e.g. low plasma level of albumin is common in both Marasmus and kwashiorkor. Because of these overlapping the term currently preferred as edematous and non edematous PEM.

8. Non edematous PEM ( Marasmus ):-
Clinical Manifestations :-
Non edematous PEM ( Marasmus ):-
Initially there is failure to gain weight and irritability , followed by weight loss and listlessness until emaciation results.
The skin loses turgor and becomes wrinkled and loose as subcutaneous fat disappears.
Loss of fat from the sucking pads of the cheeks may occur late giving old man face appearance.
The abdomen may be distended or flat . There is muscle atrophy and resultant hypotonia.
The temperature is low and the pulse is slow. The infants are usually constipated but may develop a starvation diarrhea with frequent small stool containing mucus.
Clinically the infant looks WASTED .

9. Edematous PEM ( Kwashiorkor ) :-
Initially presents as vague manifestations such as lethargy, apathy or irritability. when well advanced, there is inadequate growth, loss of muscle tissue, increase susceptibility to infection, vomiting, diarrhea, anorexia, flabby subcutaneous tissues and edema.
The EDEMA usually develops early and may mask failure to gain weight, but the liver may be enlarged early or sometimes late. Edema is present in internal organs before it is recognized in the face and limbs.
Dermatitis is common with darkening of the skin in irritated areas but not in areas exposed to sunlight, in contrast to pellagra.

10. Protein energy malnutrition
Edematous PEM ( Kwashiorkor ) :-
Depigmentation of the skin may occur after desquamation in irritated areas or it may be generalized. The hair is sparse and thin. In dark haired children, may become streaky red or gray. The texture is coarse in chronic disease. Eventually there is stupor, coma and death.
Complications of Kwashiorkor :-
1- sever infections such as bronchopneumonia, measles,T.B,and gastroenteritis.
2- sever water and electrolytes disturbances as hypokalemia, metabolic acidosis, hypoglycemia and hypomagnesaemia
3-sever anemia.

11. Treatment of PEM :- three phases
1- Stabilization phase :- ( 1-7days )
During this phase Rehydration if dehydration is present. ORT is preferred because of the difficulty of estimating hydration state. If intravenous fluid is necessary, frequent assessment of hydration state is mandatory particularly during the first 24 hours of therapy. correction of dehydration usually by oral solution containing less sodium and more potassium than the standard ORS, this solution is called (ReSoMal) rehydration salts solution for malnourished children.
Antibiotics therapy is initiated during this phase to control infection.
Oral feedings are started with specialized high calorie formula (with F75 diet ) this contain 75 kcal/100ml.Feedings are initiated with higher frequency and smaller volume .the frequency is reduced from 12 to 8 to 6 feedings /24hours.
-- Introduction of diet providing maintenance requirement of energy and protein ( cal/ kg and 1 gm /kg/ day of protein. ) along with adequate electrolyte, vitamins and trace minerals. if the infant is unable to take the feeding from cup or bottle, administration of feeding by NGT rather by parenteral route is preferred.
During this phase hypothermia should be managed by warming the patient ,maintaining and monitoring body temperature..

12. Protein energy malnutrition
2- Rehabilitation phase :- (2- 6 weeks )
May include continued antibiotic therapy and introduction of the F100 diet ( 100kcal/100ml ) with a goal of at least 100kcal/kg /day. The patient should be switched gradually to recovery diet providing up to 150 kcal/kg/day and 4 gm /kg/day of protein.
Iron therapy should NOT be started until this phase of treatment to prevent binding of iron to already limited stores of transferrin which in turn may interfere with protein host defense mechanisms. Free iron during the early phase may exacerbate oxidants damage, precipitating clinical kwashiorkor or Marasmic- kwashiorkor in a child with clinical Marasmus.
By the end of the second phase, any edema should be disappeared, infections are under control, the child is becoming more interested in his surrounding and his appetite is returning.

13. Treatment of PEM 3- Follow up phase (7-26 weeks):-
This phase consists of feeding to cover catch-up growth as well as the provision of emotional stimulation.
In developing countries this final phase carried out at home. In all phases, parental education is important for continued effective treatment and prevention of additional episodes.
There are several problems during management of sever PEM these are Hypothermia, Hypoglycemia ,Dehydration, Infection ( septic shock ),and Correction of electrolytes.
Trace elements (copper, zinc ) should be given along with folate and multivitamins at this phase.

14. nutrition
Marasmus Kwashiorkor

15. Failure to Thrive
Failure to Thrive is a symptom which is specific to childhood indicating failure of physical growth at an expected rate, often associated with poor developmental and socioemotional functioning.
Failure to thrive usually refers to growth below the 3rd or the 5th percentile or a change in growth that has crossed two major percentiles in a short time.( i.e. from above 75th percentile to below 25th percentile)
Traditionally failure to thrive (FTT) is either :
1- Organic F.T.T is marked by an underlying medical condition.
2- Non organic or psychosocial F.T.T occurs in a child who is usually younger than 5 years and has no known medical condition that cause poor growth.

16. For some children the cause may be a complex mixture of both, it is estimated that up to 10% of children seen in pediatrics primary care have signs of growth failure.
Etiology of F.T.T :-
The cause of psychosocial F.T.T is often due to :
1- inadequate diet because of poverty ,food insufficiency or error in food preparation.
2- food refusal.
3- parental cognitive or mental health problems.
4- child abuse or neglect.
Major causes of Organic F.T.T are :
1- Gastrointestinal :- cleft lip and palate, pyloric stenosis, gastroesophageal reflux, celiac disease, lactose intolerance, milk protein intolerance, hirschsprungs disease, pancreatic insufficiency , biliary disease and cirrhosis.
2- Renal :- urinary tract infection, renal tubular acidosis, diabetes insipidus , and chronic renal failure.

17. Failure to Thrive
3- Cardiopulmonary :- cardiac diseases leading to congestive heart failure, asthma, cystic fibrosis, bronchopulmonary dysplasia, obstructive sleep apnea, anatomic abnormalities of upper airways.
4- Endocrine :- diabetes mellitus , hypothyroidism, adrenal insufficiency, growth hormone deficiency, parathyroid disorders, pituitary disorders.
5- Neurological :- mental retardation, cerebral palsy, degenerative disorders and cerebral tumors.

18. Clinical Manifestations :-
6- Infectious :- parasitic and bacterial infections of GIT, T.B, H.I.V
7- Metabolic :- inborn errors of metabolism
8- Congenital :- chromosomal abnormalities, congenital syndromes and congenital infections.
9- Miscellaneous :- lead poisoning, malignancy, collagen vascular diseases, recurrently infected adenoids and tonsils.
Clinical Manifestations :-
The clinical presentation of FTT ranges from failure to meet expected age norms for height and weight, to alopecia, loss of subcutaneous fat , reduced muscle mass, dermatitis, recurrent infections, Marasmus and kwashiorkor.
In developing countries, recurrent infections, Marasmus and kwashiorkor are more common presentations. The infants with FTT may have thin extremities, a narrow face prominent ribs ,wasted buttocks. neglect of hygiene may be evidenced by diaper rash, unwashed clothing and dirty finger nails. there is delay in social and speech development.

19. Failure to thrive For weight mild FTT is 75-90% of standard
Clinical Manifestations :-
The degree of FTT is usually measured by calculating each growth parameter ( weight, height and weight/ height ratio ) as percentage of the median value for age based on appropriate growth charts. For premature infant correction should be made for the extent of prematurity . Corrected age rather than chronologic age should be used in calculations of their growth percentile until 1-2yr of corrected age .
For weight mild FTT is 75-90% of standard
For moderate FTT is % of standard
For sever FTT is less than 60% of standard weight.

20. Failure to thrive For height mild FTT is 90-95% of standard
For moderate FTT is 85-89% of standard
For sever FTT is less than 85% of standard height.
For the weight/ height ratio the values are
Mild 81-90%
Moderate %
Sever less than 70% of standard .
The weight for age percent of the standard value decreases early in the course of FTT followed by a decrement of height for age.

21. Diagnosis of FTT :-
The history, physical examination, and observation of parent – child interaction, and observation of infant feeding all are important in diagnosis of FTT.
The causes of insufficient growth include :-
1- failure of a parent to offer adequate calories due to lack of knowledge or parental depression, unusual dietary beliefs, or lack of food.
2- failure of the child to take sufficient calories.
3- failure of the child to retain sufficient calories.
With young infants , it is important to take a detailed dietary history, including what the diet consist of, how often the infant is fed, and how the parents respond when the child cries or sleep for prolonged period.
Vomiting, diarrhea and malabsorption are general causes of inadequate caloric absorption.

22. Failure to thrive Investigations :-
Full physical examination is important for diagnosis, as it may reveal dysmorphic features, or features of a specific organ dysfunction. Although in many cases examination reflects neglect of hygiene like diaper rash, unwashed skin, uncut and dirty finger nails or unwashed clothing.
Investigations :-
The laboratory evaluation of children with FTT is often not helpful and therefore should be used judiciously. these include complete blood count, lead level, urine examination, bone age, thyroid function tests, sweat test, tests for gastro esophageal reflux and malabsorption, organic and amino acids studies.

23. Failure to thrive Treatment :-
The treatment of FTT requires an understanding of all the elements that contribute to a child growth: like the child health and nutritional status, family issues, and the parent- child interaction. Regardless of cause ,an appropriate feeding atmosphere at home is important.
For children with organic FTT , the underlying medical condition should be treated. The type of caloric supplementation must be based on the severity of FTT and the underlying medical condition. proper formula preparation and proper feeding technique is important in treatment of infants with psychosocial FTT.

24. Failure to thrive Treatment :-
For older infants and young children with psychosocial FTT, mealtimes should be approximately min, solid foods should be offered before liquids, environmental distraction should be minimized, and children should eat with other people and not be forced fed. the intake of water, juice, and low calorie beverages should be limited. High calorie foods such as whole milk, cheese and dried fruits should be emphasized.
Weight gain in response to adequate caloric feeding establishes the diagnosis of psychosocial FTT.

25. Failure to thrive Indications for hospitalization :-
1- sever malnutrition.
2- further diagnostic and laboratory evaluation.
3- lack of catch up growth.
4- evaluation of parent- child feeding interaction.
For psychosocial FTT hospitalization often lasts 5-10 days.
The goals of hospitalization are to obtain sustained catch up growth and educate parent about appropriate food and feeding style.
For both types of FTT the approach to feeding in the hospital should mimic the anticipated treatment at home before discharge.

26. Failure to thrive Prognosis :-
Failure to thrive in the first year of life regardless of the cause, is particularly ominous.
Approximately one third of children with psychosocial FTT are developmentally delayed and have social and emotional problems.
The prognosis of organic FTT is more variable depending on the specific diagnosis and severity of FTT.
Ongoing assessment and monitoring of cognitive and emotional development is necessary for all children with FTT.