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What is nutrition?
The world health organisation (WHO) defines nutrition as A process where living organisms utilise food nutrients for the maintenance of life, maturation, and normal functioning of organs and tissues and the production of energy.
MALNUTRITION Is defined as a pathological state resulting from relative or absolute deficiency of one or more essential nutrients.
Primary: When there is deficiency of food availability. Secondary: When food is available but body cant assimilate it for one or another reason.
ETIOLOGY
Primary Malnutrition: 1. Failure of lactation. 2. Ignorance of weaning. 3. Poverty. 4. Cultural patterns and food fads. 5. Lack of immunization and primary care. 6. Lack of family planning.
Secondary Malnutrition
1. Infections. 2. Congenital disease. 3. Malabsorption. 4. Metabolic disorder. 5. Psychosocial deprivation.
CLASSIFICATIONS
KWASHIORKOR
Kwashiorkor is characterized by oedema, oedema, apathy and low body weight. In addition, there may be dermatosis, dermatosis, hair changes, hepatomegaly, hepatomegaly, diarrhoea and mental changes.
MARASMUS
Marasmus is characterized by very low body weight, loss of subcutaneous fat, muscle wasting and absence of oedema. oedema.
MARASMIC KWASHIORKOR
Combined forms with clinical signs of both marasmus and kwashiorkor are included here. They show gross wasting as well as oedema.
WELLCOME CLASSIFICATION
Malnutrition Underweight Marasmus Kwashiorkor Body weight
(% of standard)
Oedema _ _
6060- 80 <60 60 80
Marasmic Kwashiorkor
<60
GOMEZ CLASSIFICATION
Malnutrition Body weight of standard) First degree 75 - 90 Second degree 60 - 75 Third degree <60
WATERLOW CLASSIFICATION
Height for age <90 Weight for age expressed as % <80 80 120 >120
Chronic Malnutrition Stunted but no Malnutrition Stunted & Obese
>90
Acute Malnutrition
Normal
Obese
GENERAL CLASSIFICATION
MID ARM CIRCUMFERANCE
Mid arm circumferance 16.5 14 14 cm 12 cm Degree of Malnutrition No malnutrition 1st & 2nd degree malnutrition 3rd degree malnutrition
<12 cm
Skin fold
Skin fold thickness is assessed by the Herpenden Caliper in the region of triceps or back of shoulders; Normal: 9 -11 mm.
SKIN
Anemia Dry skin
Vitamin K deficiency
Zinc Deficiency
PELLAGRA (NIACIN)
SEBORRHOEIC DERMATITIS
UPPER LIMPS
Pulse Blood pressure clubbing Nails
Palms
Wrist
Forearm
EYES
Sunken (dehydration)
Conjunctiva Pallor (anaemia). Xerosis (Vitamin A). Conjunctivitis (Vitamin B2, C).
Cornea: Xerosis (Vitamin A). Cloudy (Vitamin A). Keratomalacia (Vitamin A). Opacification (Vitamin A, Zinc). Vascularisation (Vitamin B2).
Facial nerve:
MOUTH
Angular cheilosis and stomatitis. (iron, vitamin B2, niacin).
TEETH Caries (fluoride). Loose (vitamin C). Enamel defects (vitamin D).
TONGUE Glossitis, reddening and ulceration (vitamin B group). Moisture (hydration). Cyanosis (CHD).
BUCCAL MUCOSA Reddened & ulcerated (vitamin B group). Petechiae (vitamin C). GUMS Swollen,bleeding (vitamin C).
NECK
Goitre (iodine).
LOWER LIMPS
Palpate: Muscle bulk (PCM). Ankle oedema (PCM, CLD). Long bone tenderness (vitamin C). Calf tenderness (vitamin B1, selenium). Power: decreased (PCM, vitamin C, sodium, potassium, phosphate). Tone: decreased (PCM).
Reflexes: Decreased (vitamins B1, B6, B12, E). Increased (vitamin B12). Slow return (iodine).
Sensation: Peripheral neuropathy (vitamins B1, B6, B12, E). Posterior column dysfunction (vitamins B12, E).
INVESTIGATIONS
INVESTIGATIONS
CBC, ESR RBS. Urine D/R and Culture Stool D/R and Culture Chest X-ray. XMT. Serum proteins. Electrolytes. Urea/Creatinin Urea/Creatinin LFT MP
COMPLICATIONS
Hypothermia. Hypoglycemia. Electrolyte Imbalance Cardiac failure. Infections. Vitamin A deficiency. Severe anemia.
TREATMENT
DEFINITION
Presence of severe wasting ( <70% weight for height or 3SD) and/or edema.
TREAT HYPOGLYCEMIA
Hypoglycemia is present when blood glucose is <54mg/dl (<3mmol/l ) Treatment:
If child is conscious, give: 50ml bolus of 10% glucose (1 round tsf of sugar in 3.5 tbsp of water) orally or by N/G tube. Then feed starter F-75 every 30 minutes for 2 hours. (give 1 quarter of the 2 hourly feed each time) Keep warm Antibiotics
If child is unconscious or convulsing, give: IV 10% Glucose (5ml/kg) or, if unavailable, 50ml 10% Glucose by N/G tube. Starter F-75 every thirty minutes for 2 hours (give 1 quarter of the 2 hourly feed each time) Keep warm Antibiotics Monitoring: Repeat RBS 2 hour. Rectal temperature; if this falls to <30.5 *C, repeat RBS Level of consciousness
TREAT HYPOTHERMIA
If axillary temperature is <35.0*C, or Rectal <35.5*C Treatment:
Re-warm the child either, clothe the child (including head), cover with a warm blanket and place a heater or lamp nearby. Or Put child on mother s bare chest, skin to skin, and cover them. Give antibiotic Feed straight away (or start rehydration if needed)
MONITORING:
Rectal temperature 2 hourly, until it
rises to >36.5*C Feel for warmth Check for hypoglycemia whenever hypothermia is found.
TREAT DEHYDRATION
Do not use the IV route for rehydration, except in shock, Infusing slowly to avoid flooding the circulation and overloading the heart. Standard WHO ORS contains too much Sodium and too little potassium for severely malnourished children. Instead give special Rehydration Solution for Malnutrition (ReSoMal).
TREATMENT
ReSoMal 5ml/kg every 30 minutes for 2 hours, orally for by N/G tube. Then; 5-10 ml/kg per hour for next 4-10 hours. Replace the ReSoMal doses at 6 hours and 10 hours with an equal amount of F-75. If rehydration is continuing at these times. Begin feeding with starter F-75 During treatment, rapid respiration and pulse rate should slow and child will begin to pass urine.
half hourly for 2 hours. Then hourly for next 4-10 hours regarding.
1)Pulse rate 2)Respiratory rate 3)Urine frequency 4)Stool/Vomit frequency Continuing rapid respiratory and pulse rates during rehydration suggest coexisting infection or overhydration
TREAT INFECTION
Assume all malnourished children have an infection and give routinely on admission: Broad spectrum antibiotics AND Measles vaccine if child is >6 months and not immunized. In addition, some experts recommend Metronidazole (7.5mg/kg 8 hourly for 7 days) to hasten repair of the intestinal mucosa and reduce the risk of oxidative damage and systemic infection arising from the overgrowth of anaerobic bacteria in gut.
Choice of broad spectrum anti-biotic a) If the child is with no complications give Co-trimoxazole 5ml orally twice daily for 5 days (2.5ml if weight <4kg). b) If the child is severely ill or has complications give, Ampicillin 50mg/kg IM/IV 6 hourly for 2 days, then oral amoxycillin 15mg/kg 8 hourly for 5 days, and gentacin 7.5mg/kg IM/IV once daily for 7 days.
If the child fails to improve clinically within 48 hours, ADD: Chloramphenicol 25mg/kg IM/IV 8 hourly for 5 days. Where specific infection are identified, ADD: Specific antibiotics if appropriate Antimalarial treatment if the child has a positive blood film for malaria parasite.
ZINC DEFICIENCY
WITHOUT EDEMA
F-75: 130 ml/kg/day 2 hourly
WITH EDEMA
F-75: 100 ml/kg/day 2 hourly
A recommended schedule in which volume is gradually increased, and feeding frequency gradually decreases is as follows. Days Frequency 1 -- 2 2-hourly 3 --5 3-hourly 6 --7 + 4-hourly Monitor and note: Amount offered and leftover Vomiting Stool frequency and consistency Daily weight gain Vol/Kg/fee d 11ml 16ml 22ml Vol/Kg/Day 130ml 130ml 130ml
After the Transition, give Frequent feed (at least 4 hourly) of unlimited amount of catch-up formula 150-220KCal/kg per day 4-6gm Protein/kg per day If Child is breastfed, encourage to continue, also give F-100 as indicated
2. Dermatosis Signs:hypo- or hyper-pigmentation desquamation ulceration (spreading over limbs, thighs, genitalia, groin, and behind the ears) exudative lesions (resembling severe burns) often with secondary infection, including Candida Zinc deficiency is usual in affected children and the skin quickly improves with zinc supplementation
IN ADDITION:Dab affected areas with gauze soaked in 0.01% potassium permanganate solution Apply barrier cream (zinc and castor oil ointment, or petroleum jelly or tulle gras) to raw areas Omit nappies so that the perineum can dry
3. Parasitic worms
give Mebendazole 100mg orally, twice daily for 3 days
Lactose Intolerance.
Only rarely is diarrhea due to lactose intolerance. Treat only if continuing diarrhea is preventing general improvement. Starter F-75 is a low-lactose feed.
In exceptional cases:substitute milk feeds with yoghurt or a lactose-free infant formula reintroduce milk feeds gradually in the rehabilitation phase
TUBERCULOSIS
If TB is strongly suspected (contacts, poor growth despite good intake, chronic cough, chest infection not responding to antibiotics):Perform Monteux test (NB false negatives are frequent) Chest x-ray If positive test or strong suspicion of TB, treat according to national TB guidelines.
Recipe for ReSoMal oral rehydration solution (using the new ORS formulation)
Ingredient Amount
Water (boiled & cooled) WHO-ORS Sugar Electrolyte/mineral solution ReSoMal contains approximately 45mmol/l Na 40mmol/l K 3mmol/l Mg.
The HDD-I diet provides approximately 45 calories/ oz or 1.5 calories/ ml. (HDD-I has been developed by the Nutrition Support Programme- a Government Assisted programme.).
F-75 feed volumes by feeding frequency, and body weight and for nasogastric feeding
Childs Weight Kg 2-hourly (ml/feed) 3-hourly (ml/feed) 4-hourly (ml/feed) Switch to NG Feeding if intakes (ml) fall below:-
2.0 2.2 2.4 2.6 2.8 3.0 3.2 3.4 3.6 3.8 4.0
20 25 25 30 30 35 35 35 40 40 45
30 35 40 45 45 50 55 55 60 60 65
45 50 55 55 60 65 70 75 80 85 90
210 230 250 270 290 320 340 360 380 400 420
4.2 4.4 4.6 4.8 5.0 5.2 5.4 5.6 5.8 6.0 6.2 6.4 6.6 6.8 7.0 7.2 7.4 7.6 7.8 8.0
45 50 50 55 55 55 60 60 65 65 70 70 75 75 75 80 80 85 85 90
70 70 75 80 80 85 90 90 95 100 100 105 110 110 115 120 120 125 130 130
90 95 100 105 110 115 120 125 130 130 135 140 145 150 155 160 160 165 170 175
440 460 490 510 530 550 570 590 610 640 660 680 700 720 740 760 780 810 830 850
8.2 8.4 8.6 8.8 9.0 9.2 9.4 9.6 9.8 10.0
135 140 140 145 145 150 155 155 160 160
180 185 190 195 200 200 205 210 215 220
870 890 910 930 950 980 1000 1030 1040 1060
2-hourly
3-hourly
4-hourly
5.2 5.4 5.6 5.8 6.0 6.2 6.4 6.6 6.8 7.0 7.2 7.4 7.6 7.8 8.0 8.2 8.4
45 45 45 50 50 50 55 55 55 60 60 60 65 65 65 70 70
85 90 95 95 100 105 105 110 115 115 120 125 125 130 135 135 140
8.6 8.8 9.0 9.2 9.4 9.6 9.8 10.0 10.2 10.4 10.6 10.8 11.0 11.2 11.4 11.6 11.8 12.0
70 75 75 75 80 80 80 85 85 85 90 90 90 95 95 95 100 100
110 110 115 115 120 120 125 125 130 130 135 135 140 140 145 145 150 150
145 145 150 155 155 160 165 165 170 175 175 180 185 185 190 195 195 200
RECOVERY
Recovery takes place in two stages: Initial recovery occurs in 2-3 weeks when 2edema disappears and other signs improve. Consolidation phase: In next 2-3 months 2child regains normal weight & is considered clinically recovered.
CHILD
Weight gain is adequate. Eating an adequate amount of nutritious diet that the mother can prepare at home. All vitamin & mineral deficiencies have been treatd. All infections have been treated. Full immunization programme started.
MOTHER
Able and willing to look after the child. Knows how to prepare appropriate food & to feed the child. Knows how to make appropriate toys & to play with the child. Knows how to give home treatment for diarrhoea, fever & ARI .
HEALTH WORKER
Able to ensure follow up of the child & support for the mother.
FOLLOW UP
After discharge the child & the child family are followed to prevent relapse & assume the continued physical, mental & emotional development of the child. Planned follow up of the child at regular intervals after discharge is essential. As the risk of relapse is greatest soon after discharge, the child should be seen after 1 week, 2 weeks, 1 month, 3 months & 6 months. If a problem is found visits should be more frequent until it is resolved. After 6 months, visits should be twice yearly until the child is atleast 3 years.
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