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Presentation Transcript

Malnutrition : 

Malnutrition Dr.Anita Lamichhane MD resident (Pediatrics) Shaikh Zayed hospital , Lahore

Slide 2: 

> 3.5 million/year , mothers & children die due to the underlying cause of under nutrition > 55 million (10%) of children are wasted < 19 million are severely wasted.

South Asia and sub-Saharan Africa Have the Highest Shares of Young Children who Are Underweight. : 

South Asia and sub-Saharan Africa Have the Highest Shares of Young Children who Are Underweight. Source: Carl Haub, 2007 World Population Data Sheet. Prevalence of Underweight Children Under Age 5, by Country

Vitamin A and Iron Deficiencies Are Also Prevalent Among Children < 5 years . : 

Vitamin A and Iron Deficiencies Are Also Prevalent Among Children < 5 years . Percent of Children Under Age 5 with Vitamin A and Iron Deficiencies, Selected Regions

Data from Pakistan : 

Data from Pakistan 36 % of children -- underweight before the current floods. Researchers claim that up to 44 % of children of rural area stunted. A survey by the World Health Organization -the number of underweight pre-school children (0-5 years of age) is 40 %

Malnutrition : 

Malnutrition Derived from malus (bad) and nutrire (to nourish) Includes both Under nutrition (deficiency of one or more essential nutrients) Over nutrition (an excess of a nutrient or nutrients)

Slide 8: 

Macronutrients (carbohydrates, lipids, proteins & water) - needed for energy, cell multiplication & repair Micronutrients are trace elements, vitamins & nutrients - essential for metabolic processes

Adaptation to Starvation energy source : 

Adaptation to Starvation energy source Depletion of glycogen stores gluconeogenesis ( glucose / insulin) (Glycerol, amino acids, lactate/ pyruvate) Fatty acid oxidation and ketone bodies Utilization Reduced protein catabolism & gluconeogenesis

Adaptation to StarvationFluid & Electrolyte : 

Adaptation to StarvationFluid & Electrolyte Inhibition of sodium pump intracellular Na total body water urinary loss of K, calcium, phosphate, magnesium & zinc total body K+ : hypotonia, apathy, impaired cardiac function

Refeeding syndrome : 

Refeeding syndrome Metabolic disturbances occur at this point Starvation- loss of lean muscle mass, water and minerals phosphorus Carbohydrate refeeding, insulin release glucose uptake Hyphosphatemia- red cell ATP K,Mg, glucose,thiamine



WHO classification : 

WHO classification Defined as the presence of edema of both feet or severe wasting {70% weight for height/length or (<-3SD)} or clinical signs of severe malnutrition

Gomez classification : 

Gomez classification If the wt is > 90 % of the expected weight –no malnutrition 1st degree- wt is 75-90% of the expected weight 2nd degree- wt is 60-75% of the expected weight 3rd degree- wt is < 60 % of the expected weight

Modified Gomez classification : 

Modified Gomez classification If the wt is > 80 % of the expected wt –no malnutrition 1st degree- wt is 70-80% of the expected wt 2nd degree- weight is 60-70% of the expected wt 3rd degree- wt is < 60 % of the expected wt

Water low classification : 

Water low classification

Welcome classification : 

Welcome classification

Harvard classification : 

Harvard classification If the wt falls 50th percentile- healthy child Grade I- if wt is 71-80% of 50th percentile Grade II- if wt is 61-70% of 50th percentile Grade III- if wt is 51-60% of 50th percentile Grade IV- if wt is 50% of 50th percentile

General classification : 

General classification Mid arm circumference – measured with a measuring tape At 12 months- 16.5 cm Between 12-48 months= 12.5-16.5 cm Cut off point- 75 % of the expected mid arm circumference If less than the cut off point (<14 cm)= malnourished

Slide 20: 

Skin fold thickness Herpeden caliper Triceps/back of shoulder Normal= 9-11 mm If < 9 mm- malnourished

Slide 21: 

Quac strip Special tape having colors on it

Slide 22: 

Body mass index (BMI) weight in kg height in m² <16 Malnourished >25 Obese 16-25 Normal

Etiology : 


Initial assessment of the severely malnourished child : 

Initial assessment of the severely malnourished child

History : 

History Recent intake of fluids & foods Usual diet (before the current illness) Breast feeding When was weaning started Duration & frequency of diarrhea & vomiting Type of diarrhea (bloody/watery) Loss of appetite

Slide 30: 

Time when urine was last passed Family circumstances-literacy level, socioeconomic status, housing, family members, vaccination Chronic cough Contact with tuberculosis Recent contact with measles Milestones reached

Examination : 

Examination Proper exposure of the child General look /appearance: Stunted,wasted,edematous, alert, apathetic, emaciated Anthropoetic measurements: weight, height, head circumference, mid arm circumference- plot in the centile chart

Slide 32: 

Signs of dehydration & shock – cold hands, absent tears, slow capillary refill, weak & rapid pulse Hypo/hyper thermia Head- depressed and open fontanelle,fine sparse hair, hypo/ hyper pigmented, easily pluckable Hands –severe palmar pallor, clubbing, pulse, widening of wrist

Slide 33: 

Eyes- signs of vitamin A deficiency Ear – discharge from the ear, (serosanguneous or purulent) Neck-Goitre, lymph nodes Mouth- angular stomatits,Oral hygiene, gum (bleeding/hyperplasia),dentition, tongue( flat , loss of papilla, red and beefy), ulcer, oral thrush

Slide 34: 

Skin – colour, whether dry and lusterless, any exudative changes (resembling severe burn) often exist with secondary infecttion (including Candida),petechiae and bruises Chest- shape, prominent costochondral junction, ricket rosary, crowding of ribs, Harrison's sulcus CVS- signs of heart failure

Slide 35: 

Edema , jaundice Skin changes of Kwashiorkor Abdomen - distended, protuberant, tone of the muscles, bowel sounds, tender hepatomegaly

Investigations : 

Investigations Full blood counts, peripheral smear for MP Blood glucose level Septic screening Stool for cysts, ova, and C/S, fat globules (Malabsorption)

Slide 38: 

Urine microscopy and C/S Electrolytes, Ca, Ph & ALP, Serum albumin & total proteins CXR & Mantoux test Exclude HIV

Complications : 

Complications Hypoglycemia Hypothermia Hypokalemia Hyponatremia Heart failure Dehydration & shock Infections (bacterial, viral & thrush)

Management : 


Slide 41: 

Stabilization Rehabilitation 1 week 2-6 weeks Hypoglycemia Hypothermia Dehydration Electrolytes Infections micronutrients No iron Add iron Initiate feeding Catch up growth Sensory stimulation Follow up

Initial treatment ( First phase)(usually 2-7 days) : 

Initial treatment ( First phase)(usually 2-7 days)

Fluids and electrolyte balance : 

Fluids and electrolyte balance Iv infusion - indicated in a severely malnourished child with circulatory collapse (otherwise N/G feeding) ½ strength Darrow’s solution with 5% dextrose Half normal saline(0.45%) with 5% dextrose Give i/v fluid 15 ml/kg over 1 hour

Slide 44: 

Measure the vital signs( pulse rate, respiratory rate) at the start & every 5-10 minutes If signs of improvement, then repeat i/v 15 ml /kg over 1 hour, then switch to oral /NG rehydration with ReSoMal 10 ml/kg/hour up to 10 hour Initiate refeeding with starter F-75 ( 75 calories/100 ml) If the child fails to improve, assume the child has septic shock

Slide 45: 

Give maintenance i/v fluid (4ml/kg/hr) while waiting for blood Transfuse fresh whole blood 10 ml/kg slowly over 3 hours (packed cells used if in failure) Start antibiotics If the child comes out of shock, then start 70 ml/kg of RL(if not available, NS) over 5 hours in infants (<12 months) and over 2/12 hours in children (aged 12 months to 5 years)

Slide 46: 

Reassess the child every 1-2 hours As soon as the child can drink, give ORS solution Reassess after 6 hours(in infants) and 3 hours(in children) Classify dehydration and then choose the appropriate plan (A,B,or C) to continue treatment

Slide 47: 

If available, add selenium & iodine Solution stored in sterilized bottles in fridge Discards if it turns cloudy Add 20 ml of the concentrated electrolyte/mineral solution to each 1000 ml of milk feed

How to make ReSoMal??? : 

How to make ReSoMal??? ORS 1 packet Water 2 litres Sugar 40 gram Mineral mix 33 ml ( Zn given as syrup zincate, Mg given as I/V, K= 100 gm of KCl in 1 litre of water (take 40 ml of KCl)


CORRECTION OF HYPOGLYCEMIA PREVENTION: By feeding every 2 -3 hours/day TREATMENT: Conscious child- 50ml of 10% glucose/sucrose PO Unconscious child- 5ml/kg of 10% glucose I/V followed by 50ml of 10% glucose/sucrose by N/G Tube


HYPOTHERMIA Marasmic infants and children are more at risk of hypothermia if underarm temperature < 350C (950F) The child is rewarmed by: Kangaroo Method Warm Blanket & Lamp method


CONTROL OF INFECTION MILD INFECTIONS: Cotrimoxazole BD x 5 days SEVERE INFECTIONS WITH COMPLICATIONS: Ampicillin:50mg/kg I/M, I/V 6hr x 2days Amoxicillin:15mg/kg oral 8hr x 5 days Gentamicin:7.5mg/kg I/M,I/V O.D x 7days

Slide 52: 

Measles vaccination if the child is 6 months old & not immunized or if the child is > 9 months old & has been vaccinated before Mebendazole 100 mg PO OD x 5 days

ORS solution for severely malnourished children : 

ORS solution for severely malnourished children Malnourished children- deficient in K+ & abnormally high Na+ ORS soln should contain high K and low Na than the standard WHO- recommended solution Mg, Zn & Cu should also be given

Composition of ReSoMal : 

Composition of ReSoMal

Slide 55: 

ReSoMal available commercially Can also be made by diluting one packet of the standard WHO-recommended ORS in 2 litres of water; 50 g of sucrose (25g/l) and 40 ml (20 ml/l) of mineral mix Mineral mix supplies K+ - affects cardiac function & gastric emptying Mg2+ - essential for K+ to enter the cells and be retained does not contain iron Mineral mix is stored at room temp and added to ReSoMal or liquid feed at a conc. Of 20 ml/l

Mineral mix solution : 

Mineral mix solution

Types of formula feed : 

Types of formula feed F-75 (75 Kcal/ 3215kJ/100 ml)-used during the initial phase F-100 (100 Kcal/420kJ/100 ml)-used during the rehabilitation phase

Slide 60: 

How to prepare?? : 

How to prepare?? F-75/F-100 Add the dried skimmed milk,, sugar, cereal flour and oil to some water and mix Boil for 5-7 mins Allow to cool Add the mineral mix and vitamin mix and mix it again Make up the volume to 1000ml with water If dried skimmed milk not available, then 300 ml of fresh cow’s milk can also be used

Slide 62: 

F-75 diet should be given to all children during the initial phase of treatment At least 80 kcal/kg should be given but not > 100 kcal/kg If < 80 kcal/kg given- the tissues continue to break down & the condition will deteorate If >100 kcal/kg be given- serious metabolic imbalance will develop

Feeding after the appetite improves : 

Feeding after the appetite improves The initial phase of Tx ends when the child becomes hungry Now transfer to F-100 diet with an equal amount of F-100 for 2 days before increasing volume offered at each meal

Recording the food intake : 

Recording the food intake Type of feed given Amounts offered and taken must be recorded accurately after each feed and deducted from the total intake Once a day the energy intake for the last 24 hours should be determined & compared with the child’s weight


DIETARY MANAGEMENT 2-3 weeks Calorie : 120 -140 cal/kg/day Protein :3- 5 gm/kg/day Elemental iron: 3-6 mg/kg/day (ferrous sulphate) Vitamin A: 300,000I.U then 1500I.U/day

Slide 66: 

Vitamin D: 4000 I.U/day Vitamin k: 5mg I/M, I/V once only Folic acid: 5 mg on day 1, then 1 mg/day Copper: 0.3 mg/kg/day

Basic principle of dietary management : 

Basic principle of dietary management Improve the nutritional level of the child as quickly as possible by providing a diet with sufficient energy producing foods & high quality proteins

Initial refeeding : 

Initial refeeding Frequent small feeds of low osmolarity & low lactose Oral/NG feeds (never parenteral preparation) 100 cal/kg/day Continue breast feeding if the child is breast fed

Slide 69: 

Increase each successive feed by 10 ml until some feed remains uneaten Assess progress: weigh the child every morning before being fed, plot the weight Calculate weight gain every 3rd day If the weight gain is poor (<5 g/kg/day), check whether the intake targets are being met good wt gain = (>10g/kg/day)

Sensory stimulation : 

Sensory stimulation Provide Tender loving care A cheerful stimulating environment A structural play therapy for 15-30 mins / day Physical activity as soon as the child is well enough Maternal involvement as much as possible

Criteria for transfer to nutritional rehabilitation : 

Criteria for transfer to nutritional rehabilitation Eating well Improvement of mental state Sits, crawls stands or walks Normal temperature No vomiting/diarhea/edema Gaining wt > 5 gm/kg body wt/day x 3 consecutive days


NUTRTIONAL REHABILITatION Infants <24 months fed exclusively on liquid/ semi solid food Older children given solid food

Feeding < 2 years : 

Feeding < 2 years F-100 diet be given every 4 hours, night & day Increase the amount of diet at each feed by 10 ml When feed is not finished, the same amount should be offered at the next feed process is continued until some feed is left after most feed Any feed not taken should be discarded, should never be reused

Slide 74: 

If the intake is <130 Kcal, the child is failing to respond F-100 should be continued until the child achieves -1SD (90%) of the media WHO reference values for weight for height

Feeding children >2 years : 

Feeding children >2 years Introduce solid food, local foods should be fortified to increase their content of energy, mineral and vitamins Oil added to increase the energy content The mineral & vitamin mixes used in F-100 should be added after cooking Other ingredients-dried skimmed milk may also be added to increase the protein content Supplementation of food with folic acid and iron

Slide 76: 

Daily weight and plotted on a graph Mark the point that is equivalent too -1SD (90%) of the median/WHO reference values for wt. for ht. on the graph which is the target weight for children Usual weight gain is 10-15/kg/day

How to calculate the calories : 

How to calculate the calories Required calories = currently required for age + 25% calories for catch up growth for e.g. calculation of calories for one year old child with weight 6.5 kg expected wt at one year = 10 kg So the required calorie should be = 1000 ( 100 cal/kg/day)+ 250 (25% of 1000 calories) Start with 625 cal/day or whatever the child is taking and if it is > 625 calories/day

Slide 78: 

Then increase by 10% per day liquid solid months Calories required 1/3 0 18 12 6 24 2/3 1/2 1/2 2/3 1/2

Source of calorie supply : 

Source of calorie supply Carbohydrate : 50-55% Fat: 30-35% Protein: 10-15%

Slide 80: 

Daily increment < 6 months= 50 calories/day 6-9 months= 75 calories/day > 1 year=100 calories/day

Micronutrient deficiencies : 

Iron & folic acid for anemia Iron dose : 3mg/kg/day in 2 divided doses Folic acid :5mg on day one then 1mg/day Zinc : 2-3 mg/kg/day Copper : 0.3 mg/kg/day Ferrous sulphate (3-6 mg/kg/day) Micronutrient deficiencies

Treatment of the associated conditions : 

Treatment of the associated conditions Eye problem Vit A supplement Chloramphenicol/tetracycline drops- 4 drops daily x 7-10 days Atropine drops 1 drop tds x 3-5 day Cover with saline soaked eye pad Bandage the eyes

Slide 83: 

Severe anemia: blood transfusion Skin lesions in kwashiorkor: zinc supplementation, barrier cream ( Zn and castor oil ointment), nystatin cream to skin sores,oral nystatin(1000 IU QID) Bathe or soak the affected area for 10 mins/day in 0.01% KMnO4 solution

Slide 84: 

Giardiasis: metronidazole Lactose intolerance: substitute with yogurt or lactose free formula, reintroduce milk feeds in the rehabilitation phase Treatment of tuberculosis

Congestive cardiac failure : 

Congestive cardiac failure usually a complication of overhydrationn,very severe anemia, blood or plasma transfusion or giving a diet with high Na content When due to fluid overload: stop all oral intake and IV fluids Diuretic IV ( furosemide 1 mg/kg) Do not give digitalis unless the diagnosis of heart failure is unequivocal & the plasma K level is normal

Drugs for the treatment of malaria in severely malnourished child : 

Drugs for the treatment of malaria in severely malnourished child


NUTRTIONAL REHABILITION Child should be weight daily Usual weight gain is 10 to 15Gm/kg/day Treatment failure: when the child doesn't gain wt at least 5Gm/kg/day for 3 consecutive days target wt for discharge achieved after 2 to 4 wks


RECOVERY Takes place in 2 phases INITIAL RECOVERY PHASE It takes 2 -3 wks: edema & other signs improve CONSOLIDATION PHASE In next 2 to 3 months child regains normal weight and is clinically recovered


CRITERIA for DISCHARGE from HOSPITAL CHILD Weight gain is adequate Eating an adequate amount of diet Vitamins & mineral deficiencies treated All infections & other conditions treated Full immunization programme started

Slide 90: 

2. MOTHER Able & willing to look after the child Knows how to prepare & feed balance diet Knows how to play with child Knows how to give home treatment for diarrhea, fever and ARI. Warn for danger signs

Slide 91: 

FOLLOW UP Follow up at regular intervals after discharge Child should be seen after every 2 days for 1 wk once weekly for 2nd wk at 15 days interval for 1 - 3 months monthly for 3- 6 months More frequent visits if there is problem After 6 months, visits twice a year until the child is at least 3 years old

Prognostic factors in PEM : 

Prognostic factors in PEM Grade of PEM & the type Grade III-IV marasmus & severe of Kwashiorkor are associated with increased mortality Girls diagnosed as marasmus have been found to have a higher death rate than boys Age: case fatality rate decrease with increase in age

Slide 93: 

low weight for age is a sensitive indicator of mortality Presence of serious complications like septicemia, pneumonia & severe diarrheal diseases with dehydration severe hypokalaemia & hyponatremia- poor prognosis hypoproteinemia & hypoalbuminemia- poor prognosis

Prevention : 

Prevention Education of mother Counseling regarding family planning and spacing between children Promotion of breast feeding Education of the parents regarding immunization of the children



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