2009 外文讲义2

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  • 2009 外文讲义2

    1. 1. Protein-Calorie Malnutrition (PCM)
    2. 2.   adequate and balanced intake of foods obtain the nutrients (protein, fat, water, vitamins, minerals) growth development normal metabolic functions
    3. 3. a substance obtained from food and used in the body to promote growth, maintenance, and repair of body tissues “ a substance that provides nourishment” Nutrient
    4. 4. energy-producing nutrition carbohydrates, fat and protein Micronutrients vitamins and minerals two groups
    5. 5. Overnutrition <ul><li>Consumption of too many calories </li></ul><ul><ul><li>Obesity </li></ul></ul>
    6. 6. undernutrition <ul><ul><li>Protein Energy Malnutrition </li></ul></ul><ul><ul><ul><li>Most important </li></ul></ul></ul><ul><ul><li>Micronutrient Malnutrition </li></ul></ul>
    7. 9. The single largest common denominator in global child deaths is malnutrition 9.7 million under five deaths in 2006
    8. 10. PCM affects 1/4 child “ The silent emergency ” is an accomplice in at least 5.2million child death each year
    9. 11. <ul><li>Malnutrition is a chronic nutritional deficiency resulting from relative and/or absolute deficiencies of protein and calories. </li></ul><ul><li>Clinical manifestations </li></ul><ul><li>progressive leanness </li></ul><ul><li>decreased subcutaneous fat </li></ul><ul><li>edema </li></ul><ul><li>dysfunction of different organs </li></ul>Definition
    10. 12. Role of calories <ul><li>Involuntary use: breathing, blood circulation digestion, maintaining muscle tone and body temperature </li></ul><ul><li>Physical activity </li></ul><ul><li>Mental activity </li></ul><ul><li>Fighting disease </li></ul><ul><li>Growth </li></ul>
    11. 13. Role of protein <ul><li>For building cells that make up muscles, </li></ul><ul><li>membranes, cartilage and hair </li></ul><ul><li>Carrying oxygen </li></ul><ul><li>Nutrient transport </li></ul><ul><li>Antibodies </li></ul><ul><li>Enzymes needed for most chemical </li></ul><ul><li>reactions in the body </li></ul>
    12. 14.   dietary deficiency influence of diseases Physiological dysfunction Etiology
    13. 15. poverty cultural practices using foods of low-nutrient density child abuse anorexia of psychic or physical origin absence or prolonging of breast-feeding without the addition of supplementary diets poor dietary habits Dietary deficiency
    14. 16. <ul><li>Economists </li></ul><ul><li>Slow GDP growth </li></ul><ul><li>Low incomes </li></ul><ul><li>Nutritionists </li></ul><ul><li>Not enough calories or protein </li></ul><ul><li>Poor nutrition knowledge </li></ul><ul><li>Micronutrient deficiencies </li></ul><ul><li>Infections </li></ul>economic factor is largely attributed to PCM poor socio-economic groups <ul><ul><li>Not enough food </li></ul></ul><ul><ul><li>Poor quality food </li></ul></ul>
    15. 17. social and cultural factors also contribute significantly to the overall picture of Malnutrition ignorance superstitions wrong food beliefs
    16. 18. Sex Incidence : - <ul><li>Sex No. Percentage </li></ul><ul><li>Male 220 44 </li></ul><ul><li>Female 280 56 </li></ul><ul><li>  </li></ul>
    17. 19.   Gastrointestinal infection Congenital defects of anatomy or metabolism Infectious diseases Influence of diseases
    18. 20. harelip Cleft palate
    19. 21. Children with Intestinal Parasites
    20. 22. <ul><li>insufficient stores and increased metabolic </li></ul><ul><li>premature infant </li></ul><ul><li>twins </li></ul><ul><li>small for gestational age infant </li></ul><ul><li>because they are growing, children </li></ul><ul><li>must consume enough nitrogenous </li></ul><ul><li>food to maintain a positive nitrogen </li></ul><ul><li>balance </li></ul>Physiological dysfunction
    21. 23. <ul><li>Children in the lower quartile of weight-for-age were 2.5 times as likely to die </li></ul>
    22. 27. Nutrition in the Life Cycle
    23. 28. In mild and moderate PCM decrease in subcutaneous fat mild muscular atrophy In severe PCM thin intestinal mucosa disappearance of mucosal plicae cloudy swelling of myocardial fibers fatty infiltration of liver atrophy of lymphoid tissue and thymus Pathogenesis and pathophysiology
    24. 29.   Carbohydrate metabolism Hypoglycemia commonest feature anorexia, insufficient food intake insufficient or over utilization of glycogen Protein metabolism Insufficient ingestion of protein serum total protein and albumin total protein is <40g/l and/or albumin is <20g/l hypoprotein edema. Metabolic disturbances
    25. 30.   Fat metabolism Large amount of fat utilized cholesterol liver Fatty infiltration and degenerative   Fluids and electrolyte disturbances The total water content is relatively increased hypotonic extracellular fluid Hypotonic dehydration acidosis hypopotasaemia hypocalcemia hypomagnesemia Metabolic disturbances
    26. 31.     Gastrointestinal hypofunction digestive juice enzyme volume enzyme activity peristaltic function digestive function diarrhea occurs Circulatory hypofunction cardiac contractility cardiac output blood pressure Pulse is week. Hypofunction of tissues and organs
    27. 32. Renal hypofunction kidney function the ability to concentrate the urine gravity of urine   Central nervous system excitability decreased depression restlessness Hypofunction of tissues and organs
    28. 33.   Immune function Both nonspecific and specific immune functions are low poor defensive function of skin and mucous membranes phagocytic function of the polymorphonuclear leucocytes and complement function are reduced. humoral and cellular immunity are reduced Sensitization response to antigen and cutaneous hypersensitivity is delayed. Mantoux test is negative even when the child has tuberculosis . Hypofunction of tissues and organs
    29. 34. Less or no gain in body weight Height sometimes is lower than normal. Subcutaneous fat decreases or disappears. The order of disappearance of subcutaneous fat is: abdomen -> trunk -> buttocks -> extremities -> face . Clinical manifestation
    30. 35. measure the subcutaneous fat of the abdominal region On nipple line beside the umbilicus 3cm perpendicularly
    31. 36. anorexia, lethargy, apathy, or irritability inadequate growth, lack of stamina loss of muscular tissue the muscles are week, thin, and atrophic the hair sparse , thin, loses its elasticity hair texture becomes coarse in chronic disease. nutritional edema infections and parasitic infestations are common mental changes, stupor, coma, and death Clinical manifestation
    32. 37. Marasmic type : due to lack of total calories, protein and vitamins. Edematous type : it is caused by severe protein deficiency despite fair-to-normal calories. Also known as nutrition edema. Kwashiorkor syndrome is one type of nutrition edema. PCM is divided into 2 types
    33. 38. Severe growth failure and emaciation are the most striking characteristics of the marasmic infant. MARASMUS
    34. 39. 1st degree 2nd degree 3rd degree (mild) (moderate) (severe) loss of body 15%-25% 25%-40% >40% subcutaneous 0.8-0.4cm <0.4cm disappear height normal <normal below p 3 marasmus no obvious obvious “skin and bone” skin near normal slight pallor, severe pallor,shrivel, loose elasticity decreased muscular tone normal muscular flabby muscles thin and atrophy muscular tone decreased motional inactive listlessness apathy, irritability, reaction depressed slow reaction MARASMUS
    35. 40. <ul><li>essential clinical features </li></ul><ul><li>retarded growth </li></ul><ul><li>psychomotor changes </li></ul><ul><li>edema </li></ul>Kwashiorkor
    36. 41. <ul><li>Mental changes </li></ul><ul><li>lethargic listless apathetic </li></ul><ul><li>little interest in the environment </li></ul><ul><li>resents examination </li></ul><ul><li>Appetite is impaired </li></ul>Kwashiorkor
    37. 42. <ul><li>edema </li></ul><ul><li>hypoalbuminemia </li></ul><ul><li>retention of fluid and water </li></ul><ul><li>increased capillary permeability </li></ul><ul><li>free radical induced damage to cell </li></ul><ul><li>membranes </li></ul>Kwashiorkor
    38. 43. <ul><li>Other usual clinical features </li></ul><ul><li>Hepatomegaly </li></ul><ul><li>The liver is enlarged with rounded lower margin and soft consistency . Histological examination shows fatty infiltration. </li></ul><ul><li>Hair changes </li></ul><ul><li>The hair is thin, dry, brittle, sparse devoid of their </li></ul><ul><li>normal sheen, straight hypopigmented, reddish </li></ul><ul><li>brown. </li></ul>Kwashiorkor
    39. 45. <ul><li>Other usual clinical features </li></ul><ul><li>Skin changes </li></ul><ul><li>Large areas of skin show erythema, followed by hyperpigmentation. Hyperpigmented patches may desquamate to expose raw hypopigmented skin. </li></ul>Kwashiorkor
    40. 46. <ul><li>Other usual clinical features </li></ul><ul><li>Infections </li></ul><ul><li>These children often suffer from recurrent episodes of diarrhea, respiratory and skin infections. </li></ul>Kwashiorkor
    41. 47. <ul><li>Protein deficiency often associated with weaning onto thin cereal gruels. </li></ul><ul><ul><li>Cassava </li></ul></ul><ul><ul><li>Plantains </li></ul></ul><ul><li>Bloating of the stomach due to edema </li></ul><ul><ul><li>Fluid leaking into body </li></ul></ul><ul><ul><li>Wasted muscles </li></ul></ul><ul><li>Antibodies degraded to provide protein to body </li></ul><ul><ul><li>Infection </li></ul></ul><ul><ul><li>Dysentery </li></ul></ul><ul><ul><li>Death </li></ul></ul>
    42. 50. Marasmus differs from kwashiorkor in several important aspects : Marasmus Kwashiorkor 1.     The onset is earlier, usually in the first year of life Onset is later, after the breast-feeding is stopped. 2.      Growth failure is more pronounced. Not very Pronounced . 3.       There is no edema Edema is present. 4.      Blood protein concentration is reduced less markedly. Blood protein concentration is reduced very much. 5.      Skin changes are seen less frequently. Red boils and patches are classic symptoms . 6.       Liver is not infiltrated with fat Fatty liver is seen. 7.       Recovery is much longer. Recovery period is short .
    43. 51. Infection: diarrhea pneumonia tympanitis otitis media Iron deficiency anemia Vitamin deficiency Hypoglycemia shock Complication
    44. 52. malnutrition reduces T lymphocytes, impairs antibody formation, decreases complement formation, and causes atrophy of lymphoid tissues—all necessary in combating infection malnutrition isn’t just a risk factor for increased mortality and morbidity, but also a barrier for effective treatment of infectious diseases
    45. 54. concentration of serum albumin Ketonuria is the early stage of inanition but frequently disappears in the later stages Blood glucose values are low Laboratory data
    46. 55. Plasma values of essential amino acids may be decreased relative to nonessential ones, and there may be increased aminoaciduria . Potassium and magnesium deficiencies are frequent. Bone growth is usually delayed. Anemia may be normocytic, microcytic, macrocytic. vitamin and mineral deficiencies Laboratory data
    47. 56. history of feeding loss body weight decrease in subcutaneous fat function disturbance of different organs Diagnosis
    48. 57. <ul><li>WHO Assess methods </li></ul><ul><li>wasting low weight-for-height </li></ul><ul><li>stunting low height-for-age </li></ul><ul><li>underweight low weight-for-age </li></ul>low means- 2standard deviations (SDs) Indices of Children’s Nutritional Status
    49. 58. Protein-energy malnutrition (PEM) <ul><li>Wasting </li></ul><ul><ul><li>insufficient weight gain relative to height/losing weight </li></ul></ul><ul><ul><li>implies recent/acute malnutrition </li></ul></ul><ul><li>Stunting </li></ul><ul><ul><li>insufficient height gain relative to age; </li></ul></ul><ul><ul><li>implies long-term malnutrition and poor health </li></ul></ul><ul><ul><li>Underweight </li></ul></ul><ul><ul><li>insufficient weight gain relative to age or losing weight </li></ul></ul><ul><ul><li>implies various combinations of stunting and wasting </li></ul></ul>
    50. 59. Malnutrition Among Children Percent Children under age 3 Underweight stunting wasting
    51. 60. Strengthen child health care have good nursing care proper feeding since newborn propagate the knowledge of infant feeding to mothers. Prevention
    52. 61. Breast feeding must be encouraged in infants especially in prematurity. artificial feeding instructions should be given to mothers for adequate volume and dilution of milk powder or cow’s milk , supplementary food including vitamins and minerals. Food begin from fluid to solid after weaning. Prevention
    53. 62. Children 1-7 months who were breastfeeding poorly were 5.5 times more likely to die than those feeding normally
    54. 63. Rational living schedules Enough sleeping time good hygienic habits outdoor activities and exercises Prevention
    55. 64. Correct of congenital defects Harelip cleft palate hypertrophic pyloric stenosis Prevention
    56. 65. <ul><li>Regular prophylaxis immunization </li></ul><ul><li>Vaccine : </li></ul><ul><li>poliomyelitis vaccine mumps vaccine </li></ul><ul><li>measles vaccine tuberculosis vaccine </li></ul><ul><li>diphtheria and tetanus toxoids and pertussis </li></ul><ul><li>hepatitis vaccine </li></ul><ul><li>epidemic meningitis vaccine </li></ul>Prevention
    57. 66. Treatment of primary disease Nutritional therapy Treatment of complications Intensive nursing Treatment
    58. 67. Nutritional Therapy Improvement of feeding regulation of diet Enough energy and protein Principle: individual supply gradual increase in diet maintain on positive nitrogen balance Treatment
    59. 68. Choice of food Breast feeding is the best Food are easily digested and high nutrition, high protein, high calorie , high vitamins Adding supplement should gradually Treatment
    60. 69. Breast-milk Feeding Advantages <ul><ul><li>Easily digestible </li></ul></ul><ul><ul><li>Nutritious and complete </li></ul></ul><ul><ul><li>Always available </li></ul></ul><ul><ul><li>No special preparation needed </li></ul></ul><ul><ul><li>Protects from diarrhoea, pneumonia, </li></ul></ul><ul><ul><li>and other infections/diseases </li></ul></ul><ul><ul><li>Promotes bonding </li></ul></ul>
    61. 70. The energy content of human milk = 640 kcal/L A 780 daily intake would provide 500 kcal The protein content of human milk varies from 9.4 –12.9 g/L A 780 ml daily intake would provide 6.7-10.0 gr
    62. 71. Dietary Protein <ul><li>Good quality protein refers to an appropriate balance of essential or indispensable amino acids </li></ul><ul><li>which cannot be synthetized by the human body. </li></ul><ul><li>The supplement of protein should be </li></ul><ul><li>2-3g/kg/d </li></ul>
    63. 72. Food Pyramid <ul><li>Established based on 3 principles </li></ul><ul><li>Variety </li></ul><ul><li>Moderation </li></ul><ul><li>proportionality </li></ul>
    64. 73. WHO Feeding Recommendations <ul><li>Breastfeed children for at least 2 years </li></ul><ul><li>No bottle feeding </li></ul><ul><li>Start breastfeeding immediately after birth </li></ul><ul><li>Exclusive breastfeeding for first 6 months </li></ul><ul><li>Introduce solid/mushy foods at 6 months </li></ul><ul><li>together with breastfeeding </li></ul>
    65. 74. Percent of Breastfed Children Given Solid/Mushy Food Percent Months Should begin solid/mushy food at4-6 mos.
    66. 75. Methods mild or moderate malnutrition may be oral severe may be nasal feeding, elementary diet, or total parenteral nutrition. Treatment
    67. 76. 1st degree 2nd degree 3rd degree calorie 120->140->120 60 ->120->140 35 ->60->120 (kcal/kg.d) ->174->120 ->140->174->120 protein 3->3.5 2 ->3->3.5 1.3 ->2->3->3.5 (g/kg.d) ->4.5->3.5 ->4.5->3.5 fat 1.8->2.8->3.5 1.0 ->1.8->2.8 0.4 ->1->1.8 (g/kg.d) ->7->3.5 ->2.8->7->3.5 carbohydrate 11 ->23->25 6.5 ->11->23 (g/kg.d) 23->25->14 ->24->14 ->25->24->14
    68. 77. Dietary Increase number and variety of food offered Increase energy density of usual foods (add cheese, margarine and cream) Behaviour Have meals at regular times, eaten with other family members Praise when food is eaten Gently encourage child to eat ,but avoid conflict Never force-feed Strategies for increasing energy intake
    69. 78. Encourage digestion and improve metabolic function Drug therapy a. Digestive enzymes i.e. peptin ,trypsin b. Vitamins, especially A,D,E,K, c.   Micro-elements d.  Insulin 2-3u e.  Traditional medicine Nutritional Therapy Treatment
    70. 79. <ul><li>s evere diarrhea s evere anemia s hock </li></ul><ul><li>h ypoglycemia h ypothermia </li></ul><ul><li>r enal failure </li></ul><ul><li>moderate or severe d ehydration </li></ul><ul><li>acidosis </li></ul><ul><li>manifest or suspected i nfection </li></ul>Immediate management of any acute problems Treatment of complications Treatment
    71. 80. Supporting therapy   Treatment of complications Small and repeated doses of blood and plasma infusions TPN Treatment
    72. 81. c lean and comfortable environment f resh air and enough sunlight a dequate room temperature p rotective isolation Intensive nursing Treatment
    73. 82. PROGNOSIS <ul><li>Kwashiorkor have greater risk of morbidity </li></ul><ul><li>& mortality compared to Marasmus </li></ul><ul><li>Early detection & adequate treatment are associated with good outcome </li></ul><ul><li>Late ill-effects on IQ, behavior & cognitive functions are doubtful and not proven </li></ul>
    74. 83. <ul><li>Thank you </li></ul>

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