Malnutrition And Fluids
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Malnutrition And Fluids

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  • 1. MALNUTRITION http://crisbertcualteros.page.tl
  • 2. COMPUTATIONS
    • Weight for Age (WFA) = actual wt x 100
    • wt at p50
    • Height for Age (HFA) = actual ht x 100
    • ht at p50
    • Weight for Height (WFH) = actual wt x 100
    • wt at p50 of ht at p50
  • 3. Interpretation
    • WFA (PEM)
    • A+C
    • >90 N
    • 75-90 Mild
    • 60-74 Mod
    • <60 Severe
    • WFH (wasting)
    • A
    • >95 N
    • 90-94 Mild
    • 85-90 Mod
    • <85 Severe
    HFA (stunting) C >95 N 90-94 Mild 85-90 Mod <85 Severe
  • 4. EXAMPLE
    • 15mos
    • boy
    • wt = 6.6kg
    • length = 70cm
  • 5. WATERLOW CLASSIFICATION
    • Weight for Age (WFA)
    • = actual wt x 100
    • wt at p50
    • e.g. 15 mos. Old baby boy
    • Ht = 70 cm, wt = 6.6 kg
    • WFA = 6.6 kg x 100 = 59 % severe PEM
    • 11.1 kg
  • 6.
    • Height for Age (HFA)
    • = actual ht x 100
    • ht at p50
    • e.g. HFA= 70 cm x 100 = 89% mod stunting
    • 79 cm
  • 7.
    • Weight for Height (WFH)
    • = actual wt x 100
    • wt at p50 of ht at p50
    • e.g. 6.6 kg x 100 = 79% mod wasting
    • 8.4 kg
  • 8.  
  • 9. COMPUTATION FOR TOTAL CALORIC REQUIREMENT (TCR)
    • Required Daily Allowance (RDA)
    • AGE WEIGHT CALORIES CHON
    • (kg) (kcal/kg) (g/kg)
    • 0 - 5 mo 3 - 6 115 3.5
    • 6 -11 mo 7 - 9 110 3.0
    • 1-2 y 10 - 12 110 2.5
    • 3-6 y 14 - 18 90 - 100 2.0
    • 7-9 y 22 - 24 80 - 90 1.5
    • 10-12 y 28 - 32 70 - 80 1.5
    • 13-15 y 36 - 44 55 - 65 1.5
    • 16-19 y 48 - 55 45 - 50 1.2
    EXAMPLE: 1 yr old baby weighing 10kg
  • 10. A. Solve for TOTAL CALORIC REQUIREMENT (TCR)
    • TCR = Actual body weight (kg) x Calories (kcal/kg)
    • e.g. 1 yr old baby weighing 10 kg
      • 10 kg x 110 kcal/kg = 1100 kcal
  • 11. B. Determine TCR CHON in grams, then convert to calories
    • TCR CHON = CHON (g/kg) x ABW (kg)
    • e.g. 2.5 g CHON/ kg x 10 kg = 25 g CHON
    • recall conversion factor to calories :
    • 1 g CHON = 4kcal/g
    • 1 g CHO = 4kcal/g
    • 1g fat = 9kcal/g
    • e.g. 25 g CHON x 4kcal/g CHON = 100 kcal CHON
  • 12. C. Subtract TCR CHON from TCR total then get fraction of CHO & fats (usual ratio 60:40)
    • e.g. 1100 kcal - 100 kcal CHON = 1000 kcal
    • 60% of 1000 = 600 kcal CHO
    • 40% of 1000 = 400 kcal fats
  • 13. D. Convert back to grams
    • e.g. 100 kcal CHON = 100 / 4 = 25 g
    • 600 kcal CHO = 600/ 4 = 150 g
    • 400 kcal fats = 400 / 9 = 45 g
  • 14. E. Write final prescription
    • e.g.
    • 1100kcal = 25g 150g 45g
    • TCR CHON CHO fats
  • 15. Catch-up Calories
    • Ex: 13yo, girl, ABW = 29kg
    • IBW (p50)= 48kg
    • Compute for TCR = IBW x Calories
        • 48kg x 80cal/kg = 3840cal/day
        • 60% of 3840cal/day = 2304cal/day
    • Protein requirement
    • = ABW kg x protein g/kcal x 4 kcal/g
    • = 29kg x 1.5g/kcal x 4cal/g = 232 kcal
    • CHO = (TCR - CHON) x .6 = 1243.2 kcal
    • Fat = (TCR - CHON) x .4 = 828.8 kcal
  • 16.  
  • 17. COMPUTATION FOR TOTAL CALORIC REQUIREMENT (TCR)
    • Required Daily Allowance (RDA)
    • AGE WEIGHT CALORIES CHON
    • (kg) (kcal/kg) (g/kg)
    • 0 - 5 mo 3 - 6 115 3.5
    • 6 -11 mo 7 - 9 110 3.0
    • 1-2 y 10 - 12 110 2.5
    • 3-6 y 14 - 18 90 - 100 2.0
    • 7-9 y 22 - 24 80 - 90 1.5
    • 10-12 y 28 - 32 70 - 80 1.5
    • 13-15 y 36 - 44 55 - 65 1.5
    • 16-19 y 48 - 55 45 - 50 1.2
    EXAMPLE: 13yo, girl, BW=29kg
  • 18. FLUIDS
  • 19. Fluid Composition
  • 20. Generalities
    • Three types of fluid therapy:
    • Maintenance
    • Replacement
    • Deficit
  • 21. Maintenance fluid
    • Replaces the obligatory fluid losses both measurable (urine and stool) and not measurable (insensible losses from the skin and lungs)
    • Goals:
      • Prevent dehydration
      • Prevent electrolyte disorders
      • Prevent ketoacidosis
      • Prevent protein degradation
    • It is composed in general of a solution consisting of water, glucose, sodium and potassium;
  • 22. Components of Maintenance water 05% Stool 35% Insensible (skin and lungs) 60% Urine
  • 23.
    • It provides approximately 20% of the normal caloric needs of the patient enough to prevent ketoacidosis from starvation and protein degradation
    • It does not provide adequate calories, protein, fat, minerals ( calcium, phosphorus, magnesium or bicarbonate) and vitamins.
    • Calculation of maintenance fluid
    Maintenance fluid
  • 24. Body Weight Method for calculating Maintenance Fluid Volume
    • Holliday-Segar Method
    The maximum total fluid per day is normally 2,400 ml Eg. 25kg child (1000+500+100) = 1600ml/day 100ml/kg/day, plus 50ml/kg/day, plus 20ml/kg/day 1st 10kg BW 2nd 10kg BW BW > 20kg Total Fluid Requirement BW (kg)
  • 25. Maintenance fluid to gtts/min
    • 1600ml x 1 day x 1 hr x 15gtts
    • day 24 hrs 60mins ml
    • = 16gtts/min
  • 26. Maintenance Fluids
    • Ludan’s Method
    Eg. 25kg child: 25kg x 60ml/kg/d = 1500ml/day 75 100 75 60 50 0-3 3-10 10-20 20-30 >30 Volume of Fluid in 24h (ml/kg/d) Weight (kg)
  • 27. Maintenance Fluids
    • Based on BSA
    • TFR = IWL + urine output
      • where:
        • IWL: 400-600ml/m2/day x BSA
        • Urine: 600-1000ml/m2/day x BSA
      • BSA = (ht in cm) x (wt in kg)
        • 3600
    Eg. 8y.o. girl, 25kg, 125cm BSA = 0.931 TFR = 1488ml/day
  • 28. Comparison
    • 8y.o. girl, 25kg, 125cm
    • Holliday Segar = 1,600ml/day
    • Ludan’s Method = 1,500ml/day
    • Based on BSA = 1,488ml/day
  • 29. Maintenance Electrolytes 1-2 meq /kg / 24 hour Potassium 2-3 meq /kg / 24 hour Sodium
  • 30. Composition of Intravenous solutions 28 3 4 109 130 Ringer lactate 38.5 38.5 ¼ Normal Saline (0.225% NaCl) 77 77 ½ Normail Saline (0.45% NaCl) 154 154 Normal saline (0.9%NaCl) Lactate- Ca++ K+ Cl+ Na+ Fluid
  • 31. Adjustments in maintenance Water Hypothyroidism
    • Surgical drain
    • Third spacing
    Miscellaneous Oliguria / anuria Polyuria Renal
    • Diarrhea
    • Emesis
    • Nasogastric suction
    Gastrointestinal Tract Humidified ventilator Tachypnea Lungs mist tent
    • radiant warmer
    • Fever
    • Sweat
    • Burns
    Skin Causes of Decreased water needs Causes of Increased Water needs Source
  • 32. Replacement Fluid
    • GI tract is potentially a source of considerable water loss;
    • GI losses are often associated with loss of potassium, leading to hypokalemi a and bicarbonate, causing metabolic acidosis which maybe aggravated when there is hypoperfusion causing a concurrent lactic acidosis;
    • emesis or losses from NG tube cause a metabolic alkalosis .
  • 33. Replacement Fluid
    • Losses should then be replaced as they occur using a solution with the same approximate electrolyte concentration as the GI fluid;
    • the losses are replaced every 1-6 hour depending on the rate of loss
  • 34. Adjusting Fluid therapy in Diarrhea
    • Average composition of Diarrheal fluid
    • Sodium: 55 meq / l
    • Potassium: 25 meq / l
    • Bicarbonate: 15 meq / l
    • Approach to Replacement of Ongoing Losses
    • Solution: D5 ¼ NS + 15 meq / L bicarbonate + 25 meq / L KCl
    • Replace stool ml/ml every 1-6 hour
  • 35. Adjusting Fluid Therapy for Emesis or Nasogastric losses
    • Average composition of Gastric Fluid
    • Sodium: 60 meq / L
    • Potassium: 10 meq / L
    • Chloride: 90 meq / L
    • Approach to Replacement of ongoing Losses:
    • Solution: D5 ½ NS + 10 meq /L KCL
    • Replace output ml / ml every 1-6 hour
  • 36. THANK YOU!
  • 37. Fluid Management of Specific Fluid & Electrolytes Disturbance
    • Hyponatremia:
    • Initial goal is correction of intravascular volume depletion with isotonic fluid (NS or Ringer lactate)
    • Formula for computing sodium deficit:
      • Sodium deficit = 0.6 x wt x ( {Na+} d – Na+} i )
      • * Na + d= sodium desired (135 meq / l)
      • * Na + i= initial sodium concentration
    • It is not necessary to increase sodium level beyond 135 meq / L; overcorrection and rapid correction (12 meq / L) are associated with an increased risk of central pontine myelinosis (CPM).
    • D5 ½ NS + 20 meq / L KCl is effective; half of the fluid can be administered over the first 8 hours.
  • 38. Management of Specific Fluid & Electrolytes Disturbance
    • Hypernatremia:
    • Decrease in sodium concentration should not be more than 12 meq / L; severe hypernatremia should be corrected over 2-4 days
    • Guide in the fluid treatment:
      • Restore intravascular volume:
        • Normal saline: 20 ml /kg over 20 minutes
        • Repeat until intravascular volume is restored
      • Determine the time for correction based on the initial sodium concentration
        • Na+: 145-157 meq / L = 24 hours
        • Na+: 158-170 meq / L = 48 hours
        • Na+: 171-183 meq / L = 72 hours
        • Na+: 184-196 meq / L = 84 hours
  • 39.  
  • 40. Assessment of State of Hydration
    • Clinical Manifestations:
      • Look:
        • Look at the child’s general condition :
          • Is the child lethargic or unconscious? Restless and irritable?
        • Look for sunken eyes and tears
        • Look for dry buccal mucosa
        • Offer the child with fluid
          • Does the child:
            • Not able to drink or drinking poorly?
            • Drink eagerly, thirsty?
  • 41.
    • Clinical Manifestations:
      • Feel
        • Pinch the skin on the abdomen
          • Does it go back:
            • Very fast ( < 2 seconds) or
            • Very slowly (longer than 2 seconds)?
      • Ask:
        • For frequency of urination
        • For the color of the urine
    Assessment of State of Hydration
  • 42. Classify Dehydration
    • Not enough signs to classify as some or severe dehydration:
    • NO DEHYDRATION Treatment Plan A
    • (Group A)
    • Volume loss: <3-6%
  • 43. Additional Clinical Parameters of Dehydration
    • Some signs of Dehydration: (Group B)
    • Mild dehydration (3-6%):
      • Volume loss: 30-60 ml / kg
        • Average: 50 ml / kg
        • Clinical Manifestations:
          • Normal pulse
          • decreased urine output
          • thirsty
          • normal physical examination
  • 44. Additional Clinical Parameters of Dehydration
    • Some signs of Dehydration : (Group B)
    • Moderate dehydration (7-10%):
      • Volume Loss: 70-100 ml / kg
        • Average: 80 ml / kg
      • Clinical Manifestations:
        • Tachycardia - dry mucous membranes
        • irritable / lethargic - little or no urine output
        • sunken eyes and fontanel - mild tenting of the skin
        • decreased tears - delayed capillary refill
        • Mottled skin
  • 45. Additional Clinical Parameters of Dehydration
    • Severe Dehydration ( > 11-15%): Shock (Group C)
      • Volume Loss: >110 ml – 150 ml / kg
      • Clinical manifestations:
        • rapid and weak pulse
        • decreased blood pressure
        • no urine output
        • very sunken eyes and fontanels
        • no tears
        • parched mucous membranes
        • tenting of the skin
        • very delayed capillary refill (>2 seconds)
        • cold and mottled skin
  • 46. Classify Dehydration
    • Two of the following signs:
    • Restless, irritable
    • Sunken eyes
    • Drinks eagerly, thirsty
    • Skin pinch goes back slowly
      • goes back immediately: Normal
      • < 2 seconds: Some signs of dehydration
      • > 2 seconds: Severe Dehydration
    • SOME DEHYDRATION Treatment Plan B
    • (Group B)
  • 47. Classify Dehydration
    • Two of the following signs:
    • Lethargic or unconscious
    • Sunken eyes
    • Not able to drink or drinking poorly
    • Skin pinch goes back very slowly (>2 seconds
    • SEVERE DEHYDRATION Treatment Plan C
    • (Group C)
  • 48.  
  • 49. Deficit Therapy
    • ORT
    • Treatment Plan A: Treat Diarrhea at Home:
      • Three rules of home treatment:
        • Give extra fluids (as much as the child will take)
          • Tell the mother :
            • Breastfeed frequently and for longer at each feed
            • If the child is exclusively breastfed, give ORS or clean water in addition to BM
            • If the child is not exclusively breastfed, give one or more of the following: ORS solution, food-based fluids (such as soup, rice water, and yoghurt drinks or clean water
          • Teach the mother how to mix and give ORS, give the mother 2 packets of ORS to use at home.
          • Show the mother how much fluid to give in addition to the usual fluid intake:
            • up to 2 years: 50-100 ml after each loose stool
            • 2 years of more: 100-200 ml after each loose stool
  • 50. Treatment Plan A: Treat Diarrhea at Home
    • Continue feeding
    • Follow-up
  • 51. Treatment Plan B: Treat Some Dehydration with ORS
    • Give in clinic recommended amount of ORS over 4-hour period
    • Determine amount of ORS to give during the first 4 hours:
    900-1400 700-900 400-700 200-400 In ml 2 yrs-5 yrs 10-<12 kg 6-<10 kg < 5kg Weight 2 yrs-5 yrs 12 mos – 2 yrs 4 mos – 12 mos Up to 4 mos Age
  • 52. Treatment Plan B: Treat Some Dehydration with ORS
      • If the child wants more ORS than shown, give more
      • For infants < 6 months who are not breastfed, also give 100-200 ml clean water during this period
    • Show the mother how to give ORS solution
      • Give frequent small sips from a cup
      • If the child vomits, wait 10 minutes, then continue, but more slowly
      • Continue BF whenever the child wants
  • 53. Treatment Plan B: Treat Some Dehydration with ORS
    • After 4 hours:
      • Reassess the child and classify the child for dehydration
      • Select the appropriate plan to continue treatment
      • Begin feeding the child in clinic
    • If the mother must leave before completing treatment:
      • Show her how to prepare ORS solution at home
      • Show her how much ORS to give to finish the 4-hour treatment at home
      • Give her enough ORS packets to complete rehydration. Also give her 2 packets as recommended in Plan A
  • 54. Treatment Plan C: Treat severe Dehydration Quickly
    • Start IVF immediately. If the child can drink, give ORS by mouth while the drip is set up. Give 100 ml / kg Ringer’s Lactate Solution (or if not available NSS), divided as follows:
    * Repeat once if radial is still very weak or not detectable 2 ½ hours 30 minutes* Children (12 mos-5 yrs) 5 hours 1 hour* Infants (under 12 mos) Then give 70 ml / kg in: First give 30 ml / kg in: Age
  • 55. Treatment Plan C: Treat severe Dehydration Quickly
    • Reassess the child every 1-2 hours. If hydration is not improving, give the IV drip more rapidly.
    • Also give ORS (about 5 ml /kg / hour) as soon as the child can drink: usually after 3-4 hours (infants) or 1-2 hours (children).
    • Reassess an infant after 6 hours and a child after 3 hours. Classify hydration. Then choose the appropriate plan (A, B, C) to continue treatment.
  • 56.  
  • 57. FOOD GUIDES
    • Primary Role of Food Guides
    • To communicate an optimal diet for
    • overall health of the population, whether
    • a pyramid, star, pagoda, rainbow, circle is
    • used, to improve quality of life and
    • nutritional well being in a simple and
    • understandable way.
  • 58.  
  • 59.  
  • 60.  
  • 61.
    • Thank you…