MALNUTRITION http://crisbertcualteros.page.tl
COMPUTATIONS <ul><li>Weight for Age (WFA)  =  actual wt  x  100 </li></ul><ul><li>  wt at p50 </li></ul><ul><li>Height for...
Interpretation <ul><li>WFA (PEM) </li></ul><ul><li>A+C </li></ul><ul><li>>90  N </li></ul><ul><li>75-90 Mild </li></ul><ul...
EXAMPLE <ul><li>15mos </li></ul><ul><li>boy </li></ul><ul><li>wt = 6.6kg </li></ul><ul><li>length = 70cm </li></ul>
WATERLOW CLASSIFICATION <ul><li>Weight for Age (WFA)  </li></ul><ul><li>=  actual wt  x  100 </li></ul><ul><li>wt at p50 <...
<ul><li>Height for Age (HFA) </li></ul><ul><li>= actual ht x 100 </li></ul><ul><li>ht at p50 </li></ul><ul><li>e.g. HFA=  ...
<ul><li>Weight for Height (WFH) </li></ul><ul><li>= actual wt x 100 </li></ul><ul><li>wt at p50 of ht at p50 </li></ul><ul...
 
COMPUTATION FOR TOTAL CALORIC REQUIREMENT (TCR) <ul><li>Required Daily Allowance (RDA) </li></ul><ul><li>AGE WEIGHT  CALOR...
A. Solve for TOTAL CALORIC REQUIREMENT (TCR) <ul><li>TCR = Actual body weight (kg) x Calories  (kcal/kg) </li></ul><ul><li...
B. Determine TCR CHON  in grams,  then convert to calories <ul><li>TCR CHON  = CHON (g/kg) x ABW (kg)   </li></ul><ul><li>...
C. Subtract TCR CHON  from TCR total then get fraction of CHO & fats  (usual ratio 60:40) <ul><li>e.g. 1100 kcal - 100 kca...
D. Convert back to grams <ul><li>e.g.  100 kcal CHON = 100 / 4 =  25 g </li></ul><ul><li>600 kcal CHO = 600/ 4 =  150 g </...
E. Write final prescription <ul><li>e.g. </li></ul><ul><li>1100kcal = 25g 150g 45g </li></ul><ul><li>TCR   CHON CHO fats <...
Catch-up Calories <ul><li>Ex: 13yo, girl, ABW = 29kg </li></ul><ul><li>IBW (p50)= 48kg </li></ul><ul><li>Compute for TCR =...
 
COMPUTATION FOR TOTAL CALORIC REQUIREMENT (TCR) <ul><li>Required Daily Allowance (RDA) </li></ul><ul><li>AGE WEIGHT  CALOR...
FLUIDS
Fluid Composition
Generalities   <ul><li>Three types of fluid therapy: </li></ul><ul><li>Maintenance </li></ul><ul><li>Replacement </li></ul...
Maintenance fluid   <ul><li>Replaces the obligatory fluid losses both  measurable (urine and stool) and not measurable (in...
Components of Maintenance water 05%  Stool 35% Insensible (skin and lungs) 60% Urine
<ul><li>It provides approximately 20% of the normal caloric needs of the patient enough to prevent ketoacidosis from starv...
Body Weight Method for calculating Maintenance Fluid Volume <ul><li>Holliday-Segar Method </li></ul>The maximum total flui...
Maintenance fluid to gtts/min <ul><li>1600ml  x  1 day   x  1 hr   x  15gtts </li></ul><ul><li>day  24 hrs  60mins  ml </l...
Maintenance Fluids <ul><li>Ludan’s Method </li></ul>Eg. 25kg child: 25kg x 60ml/kg/d = 1500ml/day 75 100 75 60 50 0-3 3-10...
Maintenance Fluids <ul><li>Based on BSA </li></ul><ul><li>TFR = IWL + urine output </li></ul><ul><ul><li>where: </li></ul>...
Comparison <ul><li>8y.o. girl, 25kg, 125cm </li></ul><ul><li>Holliday Segar = 1,600ml/day </li></ul><ul><li>Ludan’s Method...
Maintenance Electrolytes   1-2 meq /kg / 24 hour  Potassium  2-3 meq /kg / 24 hour  Sodium
Composition of Intravenous solutions   28 3 4 109 130 Ringer lactate 38.5 38.5 ¼ Normal Saline (0.225% NaCl) 77 77 ½ Norma...
Adjustments in maintenance Water   Hypothyroidism  <ul><li>Surgical drain  </li></ul><ul><li>Third spacing  </li></ul>Misc...
Replacement Fluid   <ul><li>GI tract  is potentially a source of considerable water loss; </li></ul><ul><li>GI losses are ...
Replacement Fluid   <ul><li>Losses should then be replaced  as they occur using a solution with the same approximate elect...
Adjusting Fluid therapy in Diarrhea <ul><li>Average composition of Diarrheal fluid </li></ul><ul><li>Sodium:  55 meq / l <...
Adjusting Fluid Therapy for Emesis or Nasogastric losses <ul><li>Average composition of Gastric Fluid </li></ul><ul><li>So...
THANK YOU!
Fluid Management of Specific Fluid & Electrolytes Disturbance  <ul><li>Hyponatremia: </li></ul><ul><li>Initial goal is cor...
Management of Specific Fluid & Electrolytes Disturbance   <ul><li>Hypernatremia:  </li></ul><ul><li>Decrease in sodium con...
 
Assessment of State of Hydration   <ul><li>Clinical Manifestations: </li></ul><ul><ul><li>Look:  </li></ul></ul><ul><ul><u...
<ul><li>Clinical Manifestations: </li></ul><ul><ul><li>Feel </li></ul></ul><ul><ul><ul><li>Pinch  the skin on the abdomen ...
Classify Dehydration <ul><li>Not enough signs to classify as some or severe dehydration: </li></ul><ul><li>NO DEHYDRATION ...
Additional Clinical Parameters of Dehydration  <ul><li>Some signs of Dehydration: (Group B) </li></ul><ul><li>Mild dehydra...
Additional Clinical Parameters of Dehydration  <ul><li>Some signs of Dehydration : (Group B) </li></ul><ul><li>Moderate de...
Additional Clinical Parameters of Dehydration <ul><li>Severe Dehydration ( > 11-15%): Shock (Group C) </li></ul><ul><ul><l...
Classify Dehydration <ul><li>Two of the following signs: </li></ul><ul><li>Restless, irritable </li></ul><ul><li>Sunken ey...
Classify Dehydration <ul><li>Two of the following signs: </li></ul><ul><li>Lethargic or unconscious </li></ul><ul><li>Sunk...
 
Deficit Therapy <ul><li>ORT </li></ul><ul><li>Treatment Plan A: Treat Diarrhea at Home: </li></ul><ul><ul><li>Three rules ...
Treatment Plan A: Treat Diarrhea at Home   <ul><li>Continue feeding </li></ul><ul><li>Follow-up </li></ul>
Treatment Plan B: Treat Some Dehydration   with ORS   <ul><li>Give in clinic recommended amount of ORS over 4-hour period ...
Treatment Plan B: Treat Some Dehydration with ORS   <ul><ul><li>If the child wants more ORS than shown, give more </li></u...
Treatment Plan B: Treat Some Dehydration   with ORS <ul><li>After 4 hours: </li></ul><ul><ul><li>Reassess the child and cl...
Treatment Plan C: Treat severe Dehydration Quickly   <ul><li>Start IVF immediately. If the child can drink, give ORS by mo...
Treatment Plan C: Treat severe Dehydration Quickly   <ul><li>Reassess the child every 1-2 hours. If hydration is not impro...
 
FOOD GUIDES <ul><li>  Primary Role of Food Guides  </li></ul><ul><li>To communicate an  optimal diet  for </li></ul><ul><l...
 
 
 
<ul><li>Thank you… </li></ul>
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Malnutrition And Fluids

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Malnutrition And Fluids

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