2. Function ( example )
Requirement
Vitamin
Visual integrity , cell differentiation,
mucosal integrity
1500 units/ day
Vit A
Control of calcium and phosphorus
metabolism
400 iu /day
Vit D
Antioxidant
5 micro g day
Vit E
Integrity of coagulation cascade
15
microgram/day
Vit K
Cofactor , synthesis of collagen ,
repair of tissues and wound healing
50 mg / day
Vit C
Coenzyme , ATP synthesis ,
cell membrane integrity
0.7 micro g/day
Vit B1
DNA synthesis
50 microgram
/day
Folic acid
3. # protein energy malnutrition
( PEM ) :
-The World Health Organization (WHO) defined
malnutrition as
“ the cellular imbalance between the
supply of nutrients and energy and
the body’s demand for them
to ensure growth , maintenance , and specific functions
” .
4.
5. #Pathophysiology :
- Severe malnutrition is disorder that results from
the interaction of three distinct but related
processes , each of which appears to be related
directly to the food consumed , but none of
which can be easily understood simply by a
consideration of food :
1- reductive adaptation
2- inflammatory and immune responses
3- specific nutrient deficiencies
6. 1- reductive adaptation :
- Is a general response to preserve essential
function that takes place when the demand of
the body for energy and nutrients are not
adequately met by the dietary intake .
7. # structure :
- when the food consumption is significantly reduced ,
metabolic processes continue to enable the body to
function , and the energy to support these
processes is derived from reserves within the body.
- As blood glucose level decrease , will lead to
decrease insulin and increase glucagon , that
stimulating the release of fuels into blood .
- The liver maintain blood glucose levels first by
glycogen breakdown ( glycogenolysis ) then by
gluconeogenesis .
8. - adipode tissue , TAG , glycerol and fatty acid .
- muscle :
- there is a rapid breakdown of muscle protein providing
amino acids that are used by the liver for gluconeogenesis .
- the body is in negative balance , and the tissue mass
cannot be maintained , leading to loss of weight . ( wasting )
- the losses are uneven between tissues ,
with major losses in subcutaneous fat and muscle ,
and relative preservation of the metabolically
more active visceral tissues .
9. # functional cost of reductive adaptation
:
- efficiencies are achieved by reducing the amount
of work carried out by the body .
- External work is reduced by decreasing physical
activity .
-
internal work use are reduced by
-
decreasing cellular metabolic activity , with
subsequent effects upon tissues function .
10. -
Protein synthesis is fundamentally but
-
energetically expensive ,
-
reduced synthesis of nutrient transport proteins may
-
save energy , but at cost of reduced delivery to peripheral
tissues and enhances the accumulation of lipids in liver (
fatty infiltration in liver ) .
- The cell membrane tends to become more ‘’ leaky ‘’ , as its
lipid composition changes and the Na , K ATPase is down
regulated as one way in which to reduce energy
expenditure . ( so all people with malnutrition will have
reduced intracellular potassium and increased
intracellular sodium )
11. # Effects of malnutrtion on systems :
A - Brain :
- Brain function is relatively well preserved .
- Nevertheless , there is blunting of higher functions with
decreased mentation , apathy , and depression , and
impaired control of hormone and integrative responses .
B - cardiovascular system :
-
A reduction in the functional reserve of the heart ,
-
slower pulse , and increase circulation time make heart
failure more likely if excess fluids is given intravenously .
- There is poor circulatory control , with a tendency to
reduced intravascular volume with an expanded
interstitial fluid space .
12. C – gastrointestinal system :
- Loss of mucosa and sub-mucosa tissues .
- Loss of gastric acidity .
- Reduced capacity for digestion and absorption
• This leads to
• impaired bioavailability of nutrients from food
• decreased transit time , and
• predisposition to small bacterial overgrowth .
13. D- Liver :
- There is down regulation of
- synthetic and excretory processes
( as transport proteins , clotting factors , bile and
bile salts ) .
- Decrease metabolism and clearance of drugs and
toxins .
14. E – Renal :
- There is decreased functional capacity of the
kidney , with an impaired ability to concentrate ,
dilute or acidify urine .
F – skin :
-
The skin wastes , loss its ability to retain heat and
readily
-
becomes breached and infected .
15. G – muscluskeletal :
-
Muscle mass is reduced , and
-
muscle function impaired by reduced potassium ,
which together lead to
-
reduced generation of the heat .
H – Immune system :
- There is increased exposure to pathogens and a
decreased capacity to respond (inflammation and
immune response ) .
16. # biochemical effects of malnutrtion :
A - Serum protein and albumin :
* serum albumin :
- reduction of 20% or more of serum albumin
indicates early malnutrition .
- Albumin /globulin ratio is low .
- During recovery , albumin level rises early before
changes in the clinical picture and can be used as
an indicator .
* ß- globulin level decrease more than gamma
globulin .
* Both transferrin and pre-albumin are reduced
early .
17. b - glucose :
May be decreased to less than 54 mg % in severe
cases .
18. c - water and electrolytes :
-
Total body water is increased in both kwashiorkor
and marasmus through there may be evidence of
dehydration .
-
Total body sodium is raised ,
-
total body potassium is low and this may lead to
rigidity and convulsion ( low k , ca and mg ) .
19. A - cellular immunity :
- There is Markedly defective cell mediated immunity .
-
thymus is atrophic with fibrous tissue replacing its normal
lymphoid tissue and hassle's corpuscles ,
-
also periphral lymph nodes and spleen may become atrophic
.
- Delayed cutaneous hypersensitivity .
- Decreased number and depressed responsiveness of thymus
dependent ( T ) lymphocytes .
- Chemotaxis , phagocytosis and degranulation of polymorphs
are normal but the killing function is defective .
2 - inflammatory and immune response:
20. B - humoral immunity :
- Is less effected than cellular immunity .
- B cells number is normal or elevated .
- IgA , IgG , IgM in the circulation are normal or elevated
.
-
Secretory IgA level is reduced leading to
-
increased susceptibility to gram negative bacterial
infections of the respiratory and gastrointestinal tract .
- IgE and IgD level are elevated .
- Complement proteins are all decreased except C4 .
22. Disadvantages
advantages
Depends on
Classification
1 cann’t apply when
the age of pt is not
known .
2. doesn't consider
the chronicity of the
disease .
3- Sever edematous
kwashiokor can be
above 80%
1- wt/age
2- presence or
abscent of edema
1- Wellcome
classification
1- It is very good
indicator ,
2- quick
3- more reliable
classification
- Mid way b/w the
acromion &
olecranon
- For up to 5 yearsold.
( Shakir’s tape )
2- Mid upper arm
circumference
( M.U.A.C )
1 – easy .
2- More reliable
classification
3 – the most useful .
wt for height
chart
3- WHO
Classification
23. Advantages
depends
Classification
Weight for height can
be
examined even if
ages are not known .
- Weight for height .
- Height for age
4- Waterlow
classification
1- simplicity .
2- reproducibility
3- comparability
( used for fieldwork
, research and
puplic health
evaluation ) .
weight for age
5- GOMES
Classification
24. :
1- Wellcome classification ( 1969 )
-Depend on Wt / Age plus presence or absence of edema
No Oedema
oedema
Wt
( % of Harvard
standard )
Under weight
kwashiorkor
80 – 60 %
Marasmus
Marasmic
kwashiorkor
< 60 %
25. percent weight
for age =
((weight of patient)
/ (weight of a
normal child of the
same age )) X 100
26. - The average weight at birth = 3-3.5 kg
- - After that calculated by the following
formula:
* 3 -12 months : wt in kg = [ ( age in month+9) / 2 ] .
* 1 – 6 years : wt in kg = [ (age in years x 2 ) + 8 ] .
* 7 - 12years : wt in kg = [ ((age in years x 7 ) - 5 ) / 2 ] .
# Expected weight for age :
27. 2- M.U.A.C classification :
- Mid way between the acromion & olecranon .
Classification
M.U.A.C
Normal
16 – 13.5 cm
Mild malnutrition
13.5-12.5 cm
Severe malnutrtion
< 12.5 cm
28. # shaker’s tape :
- Green colour =
normal
- colour =
re-asses
- Red colour =
need intervention
29. 3 - WHO classification :
- depends on standard score ( z score ) .
- Is a method of calculating how many standard
deviation in a data set is above or below the
mean .
30.
31. 4- waterlow classification :
- Chronic malnutrition results in stunting.
- malnutrition also affects the child's body proportions
eventually resulting in body wastage.
- percent weight for height =
((weight of patient) / (weight of a normal child of the
same height )) x 100
- percent height for age =
((height of patient) / (height of a normal child of the
same age)) x 100
32. # waterlow classification :
Height for Age
(stunting)
Weight for
Height (wasting)
> 95
> 90
Normal
90 - 95
80 - 90
Mild
85 - 90
70 - 80
Moderate
< 85
< 70
Severe
34. # cardinal features of malnutrition :
1- psychological changes .
2- growth retardation .
3- muscle wasting and loss of subcutaneous fat .
4- presence or absence of edema .
37. )
زالُهال
1- marasmus : (
- The term marasmus is derived
from the Greek marasmos ,
which means wasting .
- Marasmus represents the end
result of starvation where
both proteins and calories are
deficient.
- Marasmus represents an
adaptive response to
starvation , whereas
kwashiorkor represents a
maladaptive response to
starvation .
- In Marasmus the body utilizes
all fat stores before using
muscles.
38. - Seen most commonly
in the first year of life
40. # Clinical Features of Marasmus :
1- psychological changes .
2- growth retardation .
3- muscle wasting and loss of subcutaneous fat .
4- no edema .
+ chronic diarrhea .
+ recurrent infection .
+ associated deficiency .
41. in marasmus :
No
- Edema
- Dermatosis
- Hair changes .
- Fatty infiltration of liver
42. # Clinical Features of Marasmus :
1- psychological changes :
- Irritable
- Anxious
- Cry excessively
- Sleep little
- Good appetite ( hungry child ) , anorxia is less
common in marasmus unless the cause is
secondary .
- However the pt is less miserable than kwash .
43. 2- growth retardation :
-Weight is less than 60% of expected wt for age and
sex .
- Length and head circumference are also affected but
need longer duration of malnutrition than wt
44. 3- muscle wasting and loss of
subcutaneous fat :
:
# loss of subcutaneous fat
- It is lost in the following order ( 4 degree ) :
A- from abdominal wall : Lead to loss of skin elasticity .
B- from limbs ( thigh and buttocks ) :
The skin become wrinkled and hanging into longitudinal
folds .
C- from internal fat
D- buccinator ( buccal ) pad of fat :
- which is the last to disappear ( probably due to different
chemical position of its fat )
-
Lead to :
-
hollowing of the checks and senile ( old man ) face .
46. # sites to examine wasting :
1- arm bit :
- at back of arm ( triceps , biceps and deltoid ) .
2- buttock :
( flat with corrugation of the skin with boggy trousers
called boggy pant ) .
3- inner part of the thigh .
4- below the scapula .
5- lateral aspect of pectoralis major .
6- shoulders .
7- abdominal muscles .
8- intercostal muscles ( clear ribs ) in late wasting .
50. (
المخلوع الطفل
(
2 - kwashiorkor :
- The word is taken from
the Ga language in Ghana
& used to describe the
sickness of weaning.
- Means the deposed child
that is no longer suckled
.
- It is a severe form of PEM
occurring principally in
the weaning and post
weaning period , when
the diet is persistently
deficient in essential
51. - Kwashiorkor can occur in infancy
but its maximal incidence is in
the 2nd yr of life following
abrupt weaning.
- Kwashiorkor is not only dietary
in origin. Infective , psycho-
socical, and cultural factors are
also operative.
- Kwashiorkor is an example of lack
of physiological adaptation to
unbalanced deficiency where
the body utilized proteins and
conserve S/C fat.
52. Heart faliure in Kwash due to
•
Toxic cardiomyopathy
•
Anemia
•
High protein ttt not gradually
•
Cardiac degeneration
56. :
1- psychological changes
- Is apathetic , weak , inactive and miserable .
- They lack interest in the surroundings , don’t
move .
- Look sad , weak cry and never smile .
- Appetite is bad .
2- growth retardation :
- weight is 60-80% of the expected wt for age .
- The length , head circumference and
bone age are also retarded .
- Is not observed by mother ( as marasmus ) that because is
masked by excess subcutaneous fat and edema .
57. 3- disturbed muscle / fat ratio :
# muscle wasting :
-
There is a generalized muscle wasting –
-
The children are often weak , hypotonic and
unable to stand and walk .
58. 4- edema :
- Is the most constant clinical sign of
kwashiorkor , it is pitting and
dependent .
- Is due to decrease of plasma
protien esp albumin .
- Starts :
a - dorsum of feet and lower parts of
limbs .
b - become generalized that affect
more the dependent parts as
sacrum .
c - check become pulky , pale and
waxy in appearance ( doll like
checks )
d - ascites and effusion is very rare
59.
60.
61. B – non essential manifestation :
1- hair changes
2- skin changes
3- Hepatomegaly
62. 1- hair changes
- Hair changes is progressive :
a - dyspigmentation :
- Hair loss its black colour and
become grayish or reddish .
- Is due to either defect in
melanin formation or
deficiency in sulfer
containing amino acids as (
cystine and methionine ) .
b - hair also become atrophic .
c- loss its curl.
63. d - easily puluckable , Hair is
spares ( esp over the
tamples and occipital area )
, also alopecia may found .
e - flag sign , is important
sign of recovery .
66. 2 - skin changes
A- dermatosis :
-
The characteristic rash , is usually
-
seen on anus , perianal , perineum , buttocks ,
inguinal region and back of the thighs and
axillae or others .
67. # stages of dermatosis :
1- just change in colour (
hyperpigment ) .
2- if get scaled .
3- fissure .
4- if it is infected .
68. # This dermatosis may be due to :
- Zinc deficiency
- Vit A deficiency
- Niacine deficiency
69.
70. :
3 - Hepatomegaly
- Which is caused by fatty infiltration of the liver which
is a constant pathological finding in kwashiorkor .
- Fatty liver may associated or not with hepatomegaly
.
# causes of fatty infiltration of the liver :
A- decrease synthesis of apolipoproteins that lead to
decrease release of fat from the liver .
B – increased mobilization of free fatty acids from
adipose tissue to the liver .
C- decreased oxidation of fatty acids in the liver .
73. # Risk factors of malnutrition :
A- nutritional risk factors :
1- poor ( or lack of ) breast feeding ,
late complementary feeding or poor quality or quantity or
both.
2- sudden weaning .
3- mother ignorance , lack of basic health education and
nutritional knowledge ( food taboos and believes ) .
4 - congenital anomalies ass with intake problem
( as cerebral palsy , cleft palate , CHD , … ) =
( secondary malnutrition .congenital Heart ds. Chronic Renal
ds
74. B – Illness :
1- recurrent gastroenteritis
2- infectious illness , ( non or partially vaccinated ) ,
especially :
- Measles
- Whooping cough .
- Tuberculosis
3- metabolic diseases.
C - social risk factors :
1- mother ignorance , lack of basic health education and
nutritional knowledge .
2- poverty or wars ( in adequacy or poor supplementation
of food ).
3- short spacing and large family ( overcrowding) .
4- bad housing sanitation , environmental condition and
over crowding .
77. 1- history taking :
A- main complain :
The mother may complain of any of the following :
Dairrhea more than 2 wks)
)
- Vomiting or diarrhea
-difficuty ------- Refusal of feeding
- Body swelling .
-
Loss of body wt
-
Respiratory distress
-
Symptoms suggest infection(fever,cough,crying during micturation
)
-
Vision problem
- Feature of complications .
B - HPI :
- Details about each complain .
78. C- systemic review :
* CPS : ( cough.. pneumonia.. whooping ..TB ..Measles , SOB, cyanosis, sweating TB
..HF..Rickets ) .
•
GIT : ( diarrhoea , vomiting ,loss of appetite , wt . Loss )
•
(CNS: convulsions= hypoglycemia ,)
GU :( urine amount and colour , crying during micturation
Musculoskeletal –skin changes
D – past medical history :
-
PMH of similar condition .
-
Recurrent gastroenteritis ( and the mother attitude toward it )-
Infectious disease esp ( measles , whooping cough and TB
E – developmental history :
- Prematurity is a risk factor .
- Regression of milestones after the child pass through normal
milestones . ( commonly gross m.s ) .
79. F – nutrtional history :
* Exclusive breast feeding :
- How many times ( day , night ) .
- Duration of each meal .
- Use both breast or not .
- Was the infant calm and satisfied after feeding or cry .
- Does he sleep well after feeding .
- Urine and stool amount .
* If no breast feeding , what is the cause ?
80. * Complimentary and supplementary feeding :
- Quantity : how much , frequency , any snack in
between , type and amount .
- Quality : type of food .
- Active feeding or not , the mother prepare the food
especially for the child , sit and feed him alone .
•
Weaning : sudden or gradually ,
•
sudden weaning lead to psychological trauma which
lead to refusal of feeding .
G – vaccination history :
-
Ask about the cause if the child not or partially
vaccinated ( believes or unavailability ) ,
-
esp : measles , whooping cough and TB .
81. H – family history :
- Number of children ( compare with income )
- Age of children ( to compare with spacing ) .
- Family history of Similar condition .
I – social history :
- Social status and Poverty .
- Mother ignorance and irresponsibility .
-
Occupation of the mother
-
( if it affect the number of meals and child care ) .
-
House condition , source of water supply
-
( poor sanitation = gastroenteritis ) .
J – drug history :
- Long term medication = chronic illness = malnutrition.
83. 2- physical examination :
A- general look :
- Ill or not
- Look malnourished .
- Irritable , crying , wasted , not interested in surrounding ,
old man face ( marasmus )
-
Apathetic , miserable , swelled , moon face
-
( kwashiorkor ) .
- Able to drink or breast feed ( NG tube if inserted ) .
Skin changes –canulated ---
# then , examine the child from top to button .
84. B – anthropemetric measurement :
* Weight :
If wt = 60 – 80 % of expected wt , with no edema is under
wt , if with edema is kwashiorkor .
If wt less than 60 % of expected wt , with no edema is
marasmus , with edema is marasmic kwashinkor .
* Length and head circumference :
affected just in long standing cases .
* MUAC :
- in malnutrition is less than 12.5 cm
- Caused mainly by wasting of muscle .
85.
86. C – anthropemetric measurement :
* Pulse :
- Tachycardia : ( anemia or infection ) .
- Thready pulse : ( shock ) .
* B.P :
- Hypotension in severe diarrhea .
* Temperature :
- Febrile : infection
- Hypothermia ( important complication ) .
* Respiratory rate :
- Rapid shallow breathing ( think in pneumonia )
- Rapid deep breathing ( acidosis with complicating diarrhea )
.
87. D - head and neck :
* Hair :
-
Hair changes in kwashiorkor , hair colour , spares or not
(tamples and occipital area ) , dry or easily puluckable .
االم مع وتقارنها ورقة في تختها
Flag sign
scar = infection = bad hyegine
89. - Nose and ears :
-
look for runny nose any ear discharge
-
- Cheecks :
- Old man face ( in severe marasmus ) .
- Full , doll like face ( in kwashiorkor )
- Mouth :,
-
angular stomatitis ( iron def-----poor feeding---cancrum oris)
dental caries---oral hygiene---Smooth tongue( iron @ riboflavin def)
pallor
Oral thrush. and
herpitic lesions.
- Delayed teething
* Neck :
goitre
---
- Examine LN , ( T.B ) .
90. E - skin :
- Loss of skin elasticity ( anterior abdominal wall ) .
- Skin changes ( in hyper pigmentation..keratosis ,
desquamation , erosion or ulcer )
- Excoriation of skin around the anus .
F – site of wasting :
1- arm bit .
Anus for Excoriation = Acidic diarrhea
--
2- buttock ( boggy pant
)
شيليها ألمو تقول
)
.
3- inner part of the thigh .
4- below the scapula .
5- lateral aspect of pectoralis major .
6- shoulders .
7- abdominal muscles .
8- intercostal muscles ( clear ribs ) in late wasting .
91. # dermatosis :
* Stages :
1- change in colour .
2- scaled .
3- fissure .
4- if get infected .
* Could be :
1- mild ( + ) : patch of skin .
2- moderate ( ++ ) : multiple patches .
3- severe ( +++ ) : scaling , ulceration , fissuring .
92. I – pericordium :
MURMER
=
- Exclude of possibility of congenital heart disease .
J – chest :
-
Exclude chest infection ( bronchopneumonia ) .
-
Respiratory rate @
-
Auscultate ( creps –air entery --bronchial breathing)
k – abdomen :
- Scaphoid abdomen or distended abdomen .
- Hepatomegaly ( fatty infiltration of liver in kwashiorkor ) .
- Hepatosplenomegaly ( miliary TB , metabolic disorders ) .
-
Ascitis is rare in kwashiorkor , except if the pt present with
liver failure .
-
Genitalia = Zinc def = Acrodermatitis enteropathica
93. G – CNS :
-
Mood changes if cardinal feature of
malnuturition.
Convulsions= hypo
94. # Edema :
1- Mild ( + ) :
- Which felt only on dorsum of foot .
2- modarate ( ++ ) :
- Which felt on feet and legs .
3- severe ( +++ ) :
- Which felt on foot , hand , and face ( become generalized )
.
95. •
This is a case of malnutrition
•
Must properly could be Kwashorkor OR
•
marasmus Kwashirkor
•
والعمر الوزن اعرف داير
•
الوزن
=
ضرب بالسنين العمر
2
+
8
96. Signs of bad prognosis
•
Bleeding ( DIC)
•
Jaundice
•
Sever Hypo
98. 3 – investigations :
A- CBC :
-
Anemia ( Hb % ,PCV,wbc total @ differentials
-
Lymph = TB ..viral
-
Neotro = bacteria
-
Eosino = parasitic..Allergy..schistosomiasis ,)
-
MCV ( microcytic iron def) ( normocytic =chronic ds )
-
MCH( hypochromic)
-
Platelet (DIC)
- Leukocytosis .
- ESR .
B – Random Blood Glucose .
C- BFFM .
UTI)
)
D - Urine general
(
E - stool general (Giardiasis @ ceiliac ds
-
Ph ( acidic ) = fermentation of reducing substance .subtotal villus atrophy
-
2types of diarrhea = osmotic @ acidic
-
Reducing substance = lactose.. excoriation around the anus
-
Dysentry ( RBCs @ Pus)
99. Urine culture.
serum protien and albumin.
العين فحص
– chest x-ray ( pul T.B , pneumonia )
-
Normal x-ray does not exclude
-
blood culture if septicemia suspected
-
Monteux test if false negative then do
-
accelerated or diagnostic BCG in Lt Arm =
skin test ( in normal ..result takes 6 to 8 Wks but in Tb
pt it
takes 6 to 8 days)
104. A- initial phase :
•
Include :
* It begin with admission until the condition is stable and
the appetite has returned
- Treatment of life threatening conditions .
- Specific deficiencies are corrected .
- Feeding is begun .
* It takes about 2-7 days , if more than 10 days indicate
failure to response .
.
105. # management of complications:
1- management of hypoglycemia .
2- management of hypothermia .
3- treat and prevent dehydration and electrolytes
disturbance .
4- management of shock .
5- management of severe anaemia .
6- management of vit A deficency.
8- management of dermatosis.
106. 1- management of hypoglycemia :
-
Hypoglycemia and hypothermia usually occur together
and are signs of infection.
check for hypoglycemia whenever hypothermia is found.
- It is considered if blood glucose is <3mmol/l ( < 54 mg/dl )
.
- is due to :
a - Decrease intake .
b - Malabsorption .
c - Low glycogen stores in liver .
d - No enough counter regulatory hormones .
e - Excessive consumption of glucose .
107. - Classical presentation is unusual and the Child often
present just with drowsiness and is usually is
hypothermic .
- Pt may present with classical presentation as
sweating , lethargy , convulsion or loss of
consciousness .
# prevention :
-
start F-75 ( formula of milk ) as soon as
possible every 2 hours for every pt admitted with
malnutrition .
- continue feeding during night.
108. # treatment :
-
If the pt is conscious :
-
Bolus of 50 ml of 10% glucose orally or by NG tube.
-
If the pt is Lethargic [comatose] or convulsing
-
5ml/Kg of 10% glucose iv followed by
-
50 ml of 10% glucose by NG tube .
Then Give F-75 half an hour later every ½ hr during the 1st
2hrs .
-
2 hourly feeding
-
Iv antibiotics
-
Take another blood sample ( RBG ) after 2hrs.
-
If normal Continue in feeding every 2 hours by F-75 ,
if abnormal ( still hypoglycemic = repeat management ) .
- Treat any Hypoglycemia for infection and hypothermia.
109. .
If you are unable to test blood glucose level ,
assume all severely malnourished children
are hypoglycemic and treat accordingly.
110. 2 - management of hypothermia :
- When temperature less than 35.5 c rectally or 35 axillary .
- Is common with hypoglycemia .
- Is due to :
a- hypoglycemia or low caloric supply .
b- loss of subcutaneous fat that increase heat loss .
c- muscle wasting
111. # prevention :
1- feeding (2 hourly) during day and night .
2- Cover the child particularly at night ( including the
head ) and keep away from draughts.
4- Move the child away from the windows .
5- Maintain room temp of 25-30 C .
6- Consider warm environment .
7- Cover the mother & child with Blanket
8 . Keep the child dry , change wet nappies clothes and
bedding.
112. .
If hypothermic :
feeding + warming + antibiotics
Check for hypoglycemia whenever
hypothermia is found.
# Re warming Techniques:
1- Kangaroo technique ( put the child in mother bare
chest .. Skin to skin and cover them) or cover the child
including head with a warm blanket .
2- Heater with frequent monitoring (every 30 min) if
available.
3- Do not use hot water bottle
113. 3- dehydration :
Depends on history of losses
diarrhoea, vomiting, oliguria.
# Reliable signs of dehydration in malnurished
pt are :
1- dry mouth and tongue .
2- thirsty .
3- tearless cry .
4. Sunken eyes
5. Not pass urine
114. Treatment
- dehydration in malnourished pt need special ttt , it should be
corrected within 12 hours ( avoid rapid introduction of
electrolytes which lead to flooding the circulation and
overloading the heart ) .
- Whenever possible , rehydration should be orally , IV
infusion should be used only when there are signs of
shock .
- Severe malnourished children have low potassium
and high sodium , so ORS should contain less sodium
and more k , mg , zinc and copper .
- So , resomal ( Rehydration Solution Of Malnourished
child ) can be used .
115. - Resomal should be given to all pts with severe Malnutrition with
diarrhoea &/or vomiting because classification of dehydration is
difficult.
1 - Start Resomal 5 ml/Kg every 30min/1st 2 hrs .
2- then 5-10 ml/Kg in alternate hrs with F-75 for up to 10 hrs .
Moniter progress of rehyration half hourly during the first 2 hours then
hourly by :
Pulse rate
Respiratory rate
Urine frequency
stool/ vomit frequency
# signs of improving hydration status : .
- Slowing of rapid respiratory or pulse rate .
-
Pt begin to pass urine .
116. -
Continuing rapid RR and PR during rehydration
-
suggest coexisting infection or overhydration.
# Stop resomal and reasses after one hour if:
1- both respiratory and pulse rate increase .
2- jugular vein engorgement .
3- increasing edema and puffy eyelids.
118. # Contents of prepare Resomal:
- Water ( 2 liters ) .
- WHO ORS ( 1 liter – packet )
- Sugar ( 50 mg ) .
- Mineral ( mix 40 mmol )
119. 4- management of shock :
# It is considered by:
1- Lethargy or unconsciousness .
2- Cold hands .
3- either slow capillary refill (longer than 3 seconds) or
Weak or fast pulse .
# Fast Pulse:-
- Child 2 months – 1 year : 160 beats/m
- Child 1 – 5 years : 140 beats/m
120. # treatment :
1- oxygen
2- ( 5 ml/kg ) of 10 % glucose
3- IV fluids ( 15ml/Kg for 1hr ).
Check RR & pulse every 10min.
* IV Fluids:
1- Check the starting RR & pulse & record the time
(
2- Give IV fluids ( 15ml/Kg for 1hr
- Ringer lactate with 5% glucose
- Or strength Darrow with 5% glucose
- Or 0.45% saline with 5% glucose
*if these are unavailable ringer lactate
121. -
Check RR & pulse every 10min -
-
if both are increasing , stop the IV fluids (
septic shock ) .
-
- if both are slower & the child is improving repeat
the same for another 1hr.
-
After 2hrs switch to Resomal = 5 -10ml/Kg in
alternate hrs with F-75/10 hrs ( orally or by NG tube).
# septic shock :
- If the pt not improve after given the first dose / hour ,
stop iv fluids and prepare blood ( transfuse blood 10
ml/ kg slowly over 3 hours).
- Before coming of blood , give fluids ( 4 ml/kg to keep the
line opened ) till blood come and give antibiotics.
122. 5- management of severe anaemia
- If Hb less than 4 mg/dl or
- pcv < 12 % or
- HB ( 4 -6 ) and there is respiratory distress
-
this severe anaemia can cause heart failure .
- Give whole blood 10ml/kg ( slowly over 3 hours ) if
not in heart failure.
-
If there are signs of Heart failure , give
-
packed cells 5-7 ml/kg rather than whole blood.
- Causes of heart failure :
1- very severe anaemia
2- complication of over hydration .
3- high sodium diet .
123. .
In mild or moderate anaemia , oral iron should
be given for 2 monthes to replenish iron stores
but this should not be started untill the child
has begun to gain weight ( 2 weeks ).
124. 6- emergency care for corneal ulceration :
- Give Vit. A orally
IM if there is:
A- oedema
B- severe anorexia
C- Septic shock
125. # Vit A deficiency :
- Diagnosis :
1- clinically .
2- therapeutic response to vit A .
3- low blood level
( serum retinal concentration < 20 mg/dl ) .
# symptoms :
1- visual problem ( night blindness )
2- increase risk of infection ( respiratory , UTI , GIT ) .
3- decrease growth rate .
4- decrease bone development .
126. # Signs of vitA deficiency in eye :
Stage
feature
XN
Night blindness
X1A
Conjuctival xerosis
X1B
Bittot spot
X2
corneal xerosis
X3A
Corneal dryness and ulceration
( keratomalasia )
< 1/3 of corneal surface
X3B
> 1/3 of corneal surface
XS
Corneal scar
xF
Xerophthalma fundus
127.
128.
129.
130.
131.
132.
133. # Treatment of vit A deficiency :
0-5 months = 50 000 iu
6-12 months = 100 000 iu
> 12 months = 200 000 iu
# dose : ( 0 / 1 /7 days) or ( 1 /2/8 days ) .
if there is corneal clouding or ulceration give
additional eye care to prevent extrusion of the lens :
instill chloramphenicol or tetracycline eyedrops ( 1%)
2-3 hourly as required for 7 -10 days.
instill atropine eye drops (1%) 1 dropp three times daily for
3 -5 days.
cover with eye pads soaked in saline solution and bandage.
134. .
# prophylaxis :
- from birth to 5 years .
- Oral dose every 6 months according to the age
with food rich vitA as ( carotenes , liver , eggs
, … ) .
135. 7- treatment of infection
In malnutrition, the usual signs of infections such as fever are
often absent and infections are often hidden , therefore give
routinely on admission :
Broad spectrum antibiotics .
-
if child appears to have no complications give
-
co-trimoxazole 5 ml paediatric suspention orally twice
daily for 5 days ( 2.5 ml if wt less than 6).
If the child severly ill ( apathetic, lethargic) or has complications (
hypoglycemia , hypothermia , …..) give
- Gentamycin 7.5 mg/Kg iv/im once daily for 7 days +
ampicillin 50mg/Kg iv/im 6 hrly/2 days followed by
amoxycillin 15 mg/Kg 8 hourly for 5 days
136. .
-
add chlorampheniol 25 mg/kg im/iv 8 hourly
for 5 days if fails to improve clinically within 48 hrs
-
- Specific Antibiotics for specific infection.
-
Antimalarial treatment if the child has a positive
blood film for malaria.
-
If anorexia persists after 5 days of antibiotic
treatment complete a full 10 day course.
If still persist reassess the child fully for
-
sites of infection and resistant organisms.
137. 8- dermatosis
- Daily bathe unless they are very sick
-
If there is severe dermatosis
-
bathe in 1% potassium permanganate or
-
gentian violet.
-
To relieve pain & prevent infection apply
-
zinc & castor oil ointment in the raw areas .
omit nappies so that the perineum can dry.
138. .
•
correction of micronutrient defieciency
all severly malnourished children have vitamins
and mineral deficiencies.
give daily :
Folic acid .
Zinc.
multivitamins.
139. feeding :
# Feeding Formulas :
(
( F-75 & F-100
.Start by F-75 as soon as possible –
Contents :
* F75 : ( 75 kcal and 0.9g protein / 100ml )
* F100 : ( 100 kcal and 2.99 g protein /100 ml ) .
140. # Recipes for F-75 :
(cereal flour + cooking facilities )
Amount
Substance
300ml
Fresh cow’s milk
70 mg
Sugar
35g
Cereal flour
20g
Vegetable oil
20ml
Mineral mix
1000ml
Water to make
141. # Recipes for F-100 :
Amount
Substance
880ml
Fresh cow’s milk
100 g
Sugar
20 g
Vegetable oil
20 ml
Mineral mix
1000 ml
Water to make
142. # Feeding :
A- stabilization phase :
- Start with F75 initially , amount ( 130 ml /kg /day = 100
kcal/day) + 1- 15 gm proteins/kg/day .
* Children with severe edema , ( 100ml/kg/day )
-
Start every 2 hours even during the night during the first
2 days..
-
During ( 3rd – 5th) days incrase the volume and decrease the
frequency to 3 hourly ,,
-
during the (6th and 7th ) days to 4 hourly.
- Don’t exceed 100kcal/day in this phase.
143. -
Increase the volume &
-
decrease the frequency to 3 hrly , Then 4 hrly if :
1- Little or No vomiting
2- diarrhoea to < 5 times
3- Finishing most feeds.
Moniter and note :
.1
amounts offered and left over.
.2
vomitting.
.3
frequency of diarrhoea.
4
daily weight.
- - This phase takes 2-7 days usually
144. B - rehabilitation Phase :
# Signs of readiness to enter rehabilitation phase :-
1- Return of appetite about one week after the admission.
2- Reduced oedema
3- +ve mood changes.
a gradual transition is recommened to avoid the risk of
heart failure which occur if the children suddenly
consume huge amounts.
* Give : F-100
- Duration: 3 days
- 1st 2 days give F-100 every 4 hrs in the same
previous amount .
145. - Day 3 increase each feed by 10ml as the child finishing
feeds
e.g. 100, 110, 120 etc. until some food is left after most
feeds.
- Monitor carefully during transition for RR and pulse 4
hourly .
After the transition give :
frequent feeds ( at least 4 hourly ) of
unlimited amounts of F 100.
150-220 kcal/kg/day.
4-6 gm/kg/day.
If the child is breastfed , encourage to continue.
146. .
Moniter progress after the transition by assessing
the rate of weight gain :
weigh child each morning before feeding.
each week calculate and record weigh gain as
gm/kg/day.
# Monitoring wt gain : ( For a child on F-100 ) :
- Good wt gain is 10g/kg/day.
- moderate wt gain is 5-10g/kg/day.
- Poor wt gain < 5/kg/day .
147. .
provide sensory stimulation and
emotional support ( tendor loving care ,
cheerful stimulating environment ) because in
severe malnutrition there is delayed mental
and behavioural development.
148. # Causes of failure to respond:
I- For individual child:
- Insufficient food given
- Losses
- Congenital anomalies
- Untreated infections.
- specific nutrients deficiency.
- HIV/AIDS.
-Psychlogical problems.
152. C - Follow-up
- Is to prevent relapse .
- Planned follow up at regular intervals is essential .
-
At each visit the mother should be asked about the
-
child recent health , feeding , and play activity .
-
The child should be examined ( esp wt ) , and needed
vaccine should be given .
