Child Nutrition for midwifery.pptx

Child Nutrition
By: Wubet T. (BSc, MSc in PCHN)
1
04/01/2024 Child Nutrition By: Wubet T.

Introduction
Nutrients are substances that are essential for the growth,
development, and maintenance of an organism.
Nutrients provide the necessary energy and raw materials
required for various metabolic processes in the body.
There are six main classes of nutrients. ?????????????????
Nutrition is the provision of adequate energy and nutrients to
the cells for them to perform their physiological function.
04/01/2024 Child Nutrition By: Wubet T. 2

Continue ….
A normal and balanced diet, consists of food that has
sufficient amounts of:
 Proteins − necessary for growth, development and
maintenance
 Carbohydrates and fats − necessary for energy
 Vitamins and Minerals − for protecting against disease
• The WHO defines malnutrition as the cellular imbalance
between supply of nutrients and energy and the body's
demand for them to ensure growth, maintenance, and
specific functions.
 That is, it occurs when there is a prolonged discrepancy
between food consumption and nutritional needs.

• Macronutrients (carbohydrates, lipids,
proteins & water) are needed for energy and cell
multiplication & repair.
• Micro-nutrients are trace elements & vitamins,
which are essential for metabolic processes.
4

Pediatric Nutritional Requirements
• Nutrients are required for growth, development, health and
strengthen immune system to fight infection.
• Water, proteins, carbohydrates, fats, vitamins and minerals are the
chief constituents of food.
• These six factors form the human body in the following way: water
63%, proteins 17%, fats 12%, carbohydrates 1% , vitamins and
minerals 7%.

Continue…
• The common feature of infancy, childhood and
adolescence is that all these age groups are undergoing
rapid growth and development.
• Therefore, they need a nutrient intake that is proportional
with their rate of growth.
 The infancy growth period is rapid, critical for
neurocognitive development, and has the highest energy
and nutrient requirements.
 It is followed by the childhood period of growth, during
which 60% of total growth occurs, and is finally followed
by the puberty phase.

The break-up of energy expenditure
7
Physical activity 25%
Basal metabolism 50%
Fecal loss 8%

• In order to meet the growth needs in first 3 years
and during adolescence, a higher energy dense
diet (less complex carbohydrates and larger
quantity of fat) is needed
8

Energy
• Calorie or energy requirement varies from age to age
• On an average, 50% of calories should come from
carbohydrates, 35% from fats and 15% from protein
• It is worth remembering that daily requirement is
100 to 120 kilocalories per kg for the first year of life
9

Daily calorie requirement of infants
10

• According to Holiday and Seger formula, calorie
requirement is as follow:
–up to 10 kg : 100 kcal/kg
–10 to 20 kg : 1000 + 50 kcal for each
–kg > 10 kg
– > 20 kg : 1500 + 20 kcal for each kg > 20 kg
11

Daily requirement for proteins

Daily requirement for vitamins

Daily requirement for minerals

Feeding of Newborns
• Breast milk is the ideal food for newborn and infants
 Exclusive breastfeeding reported to be 62.3% up to 6 month
• It contains carbohydrate, protein, fat, minerals and vitamins
also adequate amount of water
• Major Contents of breast milk
– Energy content of breast milk is 67Kcal/100ml
– Protein 1.1-1.3gm/dl
– Fat 3.8 - 4.5 g/dl
– CHO 6.8 g/dl
16

.
• Preterm's and low birth weight infants require
higher energy and protein than term babies
• Content of breast milk varies based on the
gestational age the mother gave birth
• Breast milk production is different in amount and
consistency becomes mature after 3-4weeks of
delivery
• Colostrum produced in the first 1wk after
delivery is smaller in quantity
• reassure mother that it is enough don’t
discard, it’s rich in immunoglobulin 17

Infant and Young Child Feeding
• Breastfeeding is an unequalled way of providing ideal food for the
healthy growth and development of infants.
• As a global public health recommendation, infants should be
exclusively breastfed (only breast milk and no other food or fluid
including water except medication) for the first six months of life to
achieve optimal growth, development and health.
• Thereafter, to meet their evolving nutritional requirements, infants
should receive nutritionally adequate and safe complementary foods
(addition to breast milk) while breastfeeding continues for up to two
years of age or beyond.

Feeding during the 1st 6 month of life
• Exclusive Breastfeeding:
Breast milk, the most ideal, safe and complete food
for the healthy growth and development of infants;
 It is remarkably adopted to the requirements of the
infant and provides the best start in life.
It is not only the best but the ‘‘must’’ for the baby

BENEFITS TO THE INFANT
• It provides all nutrients in the correct amount and proportion for normal
growth and development
• It is easily digested and absorbed.
• It is always fresh, pure and ready made, requiring no preparations. It is at
the right temperature.
• It is uncontaminated and aseptic.
• Promote bonding and improved behaviour and neurodevelopment
• Breastfeeding protects infant from a wide array of infectious and
noninfectious diseases
• Promotes long term health
• It avoids the danger of diluted or concentrated formula.
• promotes growth of Lactobacilli
AAP,2005

Continue..
• Immuno-protection--- Breast milk contains many anti-infective
factors, such as antibodies, living cells (lymphocytes and
macrophages) and complement.
– High conc. of secretary IgA
• It contains lactoferrin, a substance that inhibits growth of E. coli, a
common cause of infantile gastroenteritis.
• Also, it assists in gradually establishing the organism,
Lactobacillus bifidus, in the baby’s intestine. This organism is of
help in digestion of sugar.
• Furthermore, it contains agents against Staphylococcus group of
organisms which are responsible for septicemia of the newborn.

Contine…..
Some protective and bioactive factors in human milk
Secretory IgA Specific antigen-targeted antiinfective
action
Lactoferrin Immunomodulation, iron chelation,
antimicrobial action, antiadhesive,
trophic for intestinal growth
κ-Casein Antiadhesive, bacterial flora
Oligosaccharides Prevention of bacterial attachment
Cytokines Anti-inflammatory, epithelial barrier
Function.
Growth factors
Epidermal growth factor
Transforming growth
factor (TGF)
Nerve growth factor
Luminal surveillance, repair of intestine
Promotes epithelial cell growth (TGF-β)
Suppresses lymphocyte function (TGF-β)
Promotes neural growth

Conditions for Which Human Milk Has
Been Suggested to Have a Protective Effect
• Acute disorders
• Diarrhea
• Otitis media
• Urinary tract infection
• Necrotizing enterocolitis
• Septicemia
• Infant botulism
• Insulin-dependent diabetes
mellitus
• Celiac disease
• Crohn disease
• Childhood cancer
• Lymphoma
• Leukemia
• Recurrent otitis media
• Allergy
• Obesity and overweight
• Hospitalizations
• Infant mortality

Benefits to the mother
– Most economical
– Breast milk is instantly available at all times
– Gives her confidence and feeling of self
sufficient(emotional satisfaction)
– Helps to form a strong bond between mother and infant.
– Helps the mother to lose excessive weight gained during
pregnancy
– Protect post-partum haemorrhage
– Family planning (child spacing)
– Protection against breast and cervical cancers
– Breast feeding helps the involution of the uterus and
reduces the amount of bleeding during the puerperium
26

Why is breastfeeding so important?
WHO Breastfeeding Counselling:
A Training Course 1993
27

Feeding of term and late preterm infants
• Feed directly on the breast unless there are
contraindications
• Start feeding with in the first 1hr of birth
• Teach mom a proper positioning and attachment
• Feed day and night, or on demand ( 10-12times /
day)
• Complete one breast before switching to the other
• Exclusive BF for 6 months (no water or other fluid)
• Start complementary feeding at 6month
28

Key messages for optimal breastfeeding practices
• Initiating breastfeeding within one hour of birth.
The first milk (colostrum) is of particular
nutritional and health value to the infant because
of its high content of proteins and fat-soluble
vitamins and its anti-infective properties.
 helps to expel the placenta more rapidly and
reduces blood loss by the mother.
 also helps expel meconium, stimulates further
breast milk production and keeps the newborn
warm through skin-to-skin contact.

Proper positioning of babies
– Infants whole body supported
– Infants head, neck and body should be straight
– Mother’s back is supported whether sitting or
lying down,
– Infant facing mother
– Infants body close to mother
30

Cont...
 Signs that infant is properly attached include:
 The mother brings infant toward her breast, not the breast
toward her infant
 The infant’s mouth is open wide
 The infant’s lips are turned outwards (like a fish mouth)
 The infant’s chin touches the mother’s breast
 The mother’s entire nipple and a good portion of the areola
are in the infant’s mouth
 More areola is showing above rather than below the nipple.

Cont...
Key points of good attachment

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Cont...
• Frequent and on-demand breastfeeding, including
night feeds (as often as infant wants).
Feeding every 2 to 3 hours (8 to12 times per 24
hours) or more frequent suckling is important for
milk production.
• Offer second breast after infant empties the first.
The infant receives both ’fore‘ milk (which has a
high water content to quench the thirst) and ‘hind‘
milk (which is rich in fat and nutrients).
• Exclusive breast feeding for the first 6 months.
Do not give any fluids such as water, other liquids
and foods other than breast milk before 6 months
of age.

Cont...
• The mother continues breastfeeding when either she or
the infant is sick
 Breast milk still protects the infant against illness.
 It replaces water and nutrients lost through frequent
loose stools, and is the most easily digestible food for the
sick infant.
• The mother should eat more than usual
 breastfeeding increases the nutritional requirements of
the mother,
 she needs to have two additional meals (about 500 kcal)
every day.
 Her diet should also be varied (for example by adding
vegetables and fruits).

Signs for adequate breast feeding
–At least 3-5 strong suckling before pausing
for breath or rest
–Dimpling of cheeks may be seen while
suckling
–Hearing of swallowing gurgle
–Milk may be seen around the mouth leaking
out when it is excess
44

Well breast fed infant
–Go a sleep for 2- 4 hours between each
feedings
–Will have frequent wet diapers (at least 6
times)
–Increase weight daily after 7 postnatal days
(20 – 30 gm/kg/day)
45

Formula Feeding
• Formula is a breast milk substitute made from a
special dried-milk powder
• Most infant formula is made from cow’s milk,
vitamins and minerals
• Formula is mixed with cooled boiled water and fed
to babies in a bottle or cup
• The nutrients in formula support a baby’s growth
during their first 6 months
• Once they reach 6 months, they can start eating Smi
solid and solids as well, but a baby should not drink
regular cow’s milk until they are at least 12 months
old 46

.
• Formula is a nutritionally complete food for
babies
• Many formula products contain extra ingredients
so that they more closely match breast milk
• One of the main differences between formula and
breast milk is that breast milk contains
antibodies, which help protect the baby against a
range of illnesses
• Breast milk also has less protein than formula
• Choosing a formula with less protein will reduce
your baby’s risk of becoming overweight or
obese as they get older
47

.
In addition infant formula is used as a
supplement to support inadequate weight gain
in breast fed infants.
Reason of offering formula feeding:-
• Not all women can breastfeed: some may be
unable to produce enough milk for their baby’s
needs
• If the mothers have a health condition or
take medication that prevents them from
breastfeeding
48

Infant formula
• 3 Forms:
1. Ready to feed - most expensive, does not
require water.
2. Concentrate - requires mixing with water in
equal parts.
3. Powder - requires mixing with water.
4. Specialty Formula: Designed to meet specific
dietary needs or address certain conditions.
E.g: Formulas designed for premature infants,
infants with lactose intolerance or cow's milk
allergy, and formulas with added rice starch for
infants with reflux. 49

Feeding during the 2nd 6 month of life-
CF
• After 6 months of age, it becomes increasingly
difficult for breastfed infants to meet their
nutrient needs from human milk alone.
51

Cont...
• Furthermore most infants are developmentally ready for other
foods at about 6 months.
• Infants capacity to:
– Digest and absorb a variety of dietary components
– Metabolize, utilize and excrete the absorbed products of
digestion is near adult capacity
– Teeth are beginning to erupt
– Begin to explore his surrounding
• Therefore , addition of other foods is recommended ( weaning)
52

Complementary Feeding/Weaning
• Complementary feeding is giving suitable foods to
babies in addition to breast milk.
• Solid foods are introduced alongside breast milk or
formula to provide a varied and balanced diet to infants.
• These foods should complement, not replace, breast
milk.
• Replacement foods – foods other than formula given to
formula fed infants .
• Weaning is a broader term that encompasses the entire
process of transitioning an infant from a milk-based diet
(breast milk or formula) to a diet that includes a variety
of solid foods.
53

Continue……………
• The term weaning means “to be taken off the breasts” or
“introduction of top feed”
• At the time of introducing complementary/weaning Ensuring
that their nutritional needs are met thus requires that
complementary foods be:
 Timely – meaning that they are introduced when the need for
energy and nutrients exceeds what can be provided through
exclusive and frequent breastfeeding;
 Adequate- meaning that they provide sufficient energy, protein
and micronutrients to meet a growing child’s nutritional needs;

Cont...
 Safe– meaning that they are hygienically stored and prepared,
and fed with clean hands using clean utensils and not bottles
and teats;
 properly fed – meaning that they are given consistent with a
child’s signals of appetite and satiety, and that meal frequency
and feeding method – actively encouraging the child, even
during illness, to consume sufficient food using fingers, spoon
or self-feeding – are suitable for age.
These energy-dense foods should be ;
cost-effective,
affordable,
easily available and
well tolerated
55

.
Addition of other foods is recommended ( weaning)
• The median age of introduction of complementary
feeding is at 6 months
Delayed introduction of complementary foods is
known to cause;
• malnutrition and growth retardation,
Whereas premature introduction of such foods
exposes;
• to the risk of infections and
• the resultant morbidity and mortality
56

.
Important Principles of Weaning
• Weaning should be stepwise to both breast fed and formula fed
infants
• Begin at 6 mo of age. At the proper age, encourage a cup rather
than a bottle
– Cereals, a good source of iron, usually should be the first food
– Vegetable & fruits are introduced next
– Meats follows shortly
– finally eggs
– One new food should be introduced at a time
– Energy density should exceed that of breast milk
– Additional new foods should be spaced by 3-4 days
• Adverse reactions (families with food or other allergies)
57

.
• Either home prepared or manufactured
complementary foods can be used
• The latter are more convenient and likely to contain
less salt – have supplemental nutrients ( eg Iron)
• Egg containing products should be delayed
• Food should be served 3 -5 time per day including
night
• With this most infants receive adequate nutrients
58

Stages of weaning
Stage – 1
– Fluid & semi - solid foods like porridge, cow milk &
atmite once a day.
Stage – 2
–Mashed food can be started,
E.g. mashed fruits, like banana
Stage – 3
-Similar to adult.
59

Feeding problems during the 1st year of life
• Underfeeding
– Suggested by restlessness and crying
– Failure to gain weight
– Possible causes
• Check frequency of feeding, mechanics of
feeding
• Abnormal mother-infant bonding
• Possible systemic disease
– Rx – Instructing mother about the art of BF and
psychological support
_ specific management of systemic illnesses 60

.
• Overfeeding
– Regurgitation and vomiting
Reg.- is return of small amount of swallowed food
Vomiting – more complete emptying of stomach
– Too high in fat – delay in gastric emptying, cause
abd. distention and Discomfort,
– Too high in CHT- distention and flatulance
• Loose stools
– Milk stool – loose, greenish yellow containing
mucus with freq. of 6-8 times/24hrs
– All diarrhea - infectious
61

Feeding during the 2nd year of life
• By the end of 1st year- 3 meals a day plus 1-2 snacks
• Changes in eating behavior
– Reduced food intake –rate of growth declines
– Lack of interest in food – temporary
– Never force feed
– Self selection of diets – should be respected
– Self feeding by infant
• Basic daily diets
– Grains, fruits, vegetables, meats and dairy
products-balanced diet with
– Snacks between meals- orange or other fruit juice
with biscuit
62

Thank You!!.

Malnutrition
64

Malnutrition
Definition
• The WHO defines malnutrition as the cellular imbalance between
the supply of nutrients and energy and the body’s demand to
ensure growth, maintenance, and specific functions.
Generally malnutrition can be classified into two:
• A. Over-nutrition (Obesity): is due to excess intake of nutrients
• B. Under-nutrition: is due to inadequate nutrient in terms of
quality and quantity.
 It takes two forms:
 1. Protein energy malnutrition (PEM): due to inadequate
energy and protein supply to cells.
2. Micronutrient deficiencies: like vitamins and minerals

Malnutrition refers to deficiencies, excesses, or imbalances in a
person’s intake of energy and/or nutrients.
1. Under nutrition, which includes
 wasting (low weight-for-height)
 stunting (low height-for-age) and
 underweight (low weight-for-age);
• micronutrient-related malnutrition, which includes
micronutrient deficiencies (a lack of important vitamins and
mineral
2. Over Nutrition (overweight)- obesity and diet-related non
communicable diseases (such as heart disease, stroke, diabetes
and some cancers) 66

• What are the consequences of malnutrition?
• What is being done to address malnutrition?
• What wasting ?
• What Stunting ?
• What underweight ?
67

• 149 million children under 5 were estimated to
be stunted (too short for age),
• 45 million were estimated to be wasted (too
thin for height), and
• 38.9 million were overweight or obese
69
Globally in 2020,

• Around 45% of deaths among children under 5 years of age
are linked to under-nutrition
 At the same time, in these same countries, rates of
childhood overweight and obesity are rising
 According to EDHS 2016, the extent of under nutrition in
Ethiopia is:
 -Underweight ( 0 -4 yrs) – 24 %
 - Wasting (12 -23 months) – 10%
 - Stunting ( 24 -59 months) – 38%
70

Epidemiology

There are two types
Primary – nutritional insufficiency
 Inadequate protein, calorie and nutrient
intake
Secondary – malnutrition following infections,
injury, chronic disease, excessive nutrient loss as
occurs in chronic diarrhea, HIV, malabsorption
syndrome etc…
Social, economic, biologic, and environmental
factors underlying severe malnutrition
72
Cause

• Direct
–Clinical
–Anthropometric
–Dietary
–Laboratory
• Indirect
–Health statistics
–Ecological variables
74
Assessment of Nutritional status

Clinical Assessment
• Useful in severe forms of PEM
• Based on thorough physical examination for
features of PEM & vitamin deficiencies.
• Focuses on skin, eye, hair, mouth & bones
• Deficiency signs such as hair changes, anemia,
xerosis, cheilosis, angular stomatitis, rachitic
rosary, bleeding spongy gums, dental caries, etc.
should be actively looked for
75

• ADVANTAGES of Clinical Assessment
–Fast & Easy to perform
–Inexpensive
–Non-invasive
• LIMITATIONS of Clinical Assessment
–Did not detect early cases
–Trained staff needed
76

• Anthropometry is a very valuable index for
evaluation of nutritional status
• Objective with high specificity & sensitivity
• Measuring Ht.,Wt., MUAC., HC., skin fold
thickness & BMI.
• Reading are numerical & gradable on standard
growth charts.
• Non-expensive & need minimal training.
77
Anthropometry

• LIMITATIONS
–Inter-observers’ errors in measurement.
–Limited nutritional diagnosis.
–Problems with reference standards.
–Arbitrary statistical cut-off levels for
abnormality.
78

79

LAB ASSESSMENT
• Biochemical
–Serum proteins, creatinine/hydroxyproline
• Hematological
–CBC, iron, vitamin levels
• Microbiology
–Parasites/infection
80

• Breast & complementary feeding details
• 24 hr dietary recall
• Home visits
• Calculation of protein & Calorie content of
children foods.
81
DIETARY ASSESSMENT

Protein-Energy Malnutrition (PEM).
• Protein-energy malnutrition (PEM), also called protein-
energy undernutrition.
• Protein Energy Malnutrition (PEM) is a malnutrition
resulting from the deficiency of protein and/or energy in
diet due to insufficient intake or absorption of protein,
energy, and micronutrients to meet metabolic demand.

83
CLASSIFICATION OF PEM
1. Syndromal Classification
• Kwashiorkor
• Nutritional marasmus
• Marasmic kwashiorkor
• Nutritional dwarfing (Stunting)

Which one is Kwashiorkor and Marasmus?
84

• The term marasmus refers to wasting
• Marasmus involves inadequate intake of protein
and calories and is characterized by emaciation,
predominantly calorie
• Marasmus occurs before 1 year of age
• Marasmus represents the end result of starvation
where both proteins and calories are deficient
85
MARASMUS

Marasmus
• Generalized muscular wasting, absence of subcutaneous
fat
• 60% or less of wt for age
• Marked retardation in longitudinal growth
• The hair is sparse, thin, dry, and easily pluckable
• The skin is dry, thin, and wrinkles – ‘baggy pant
• Irritable, ravenously hungry but vomit easily
• Loss of bi-chat fat pad, last fat tissue to disappear
(monkey’s or old man’s face)
• Marked weakness
• Abdominal distention

Features of Marasmus
87

88

Muscle wasting in a child with marasmus
89
• Severe degree
of atrophy of
muscle and
subcutaneous
fat in a
malnourished
infant with
marasmus

It resulted from deficiency of proteins, though energy
deficiency is also present.
Kwashiorkor occurs due to protein deficiency with
adequate calorie intake
Kwashiorkor – after 18 months of age.
Constant signs
• Growth failure, W/A 60-80% of standard
• Edema of extremities (some times of the face)
• Muscle wasting with retention of subcutaneous fat
• Psychomotor changes mainly anorexia, misery and
apathy
• Kwashiorkor is due to more marked protein deficiency.
90
KWASHIORKOR

• Soft, pitting, painless edema, usually in the feet and leg.
• Skin lesions –flaky paint dermatosis
• Subcutaneous fat is preserved
• Weight deficit is not as severe as marasmus.
• Height may be normal or retarded
• Rounded prominence of the cheeks ("moon-face")
91
Clinical Features of Kwashiorkor

• The hair is dry, brittle, easily pulled out without
pain, pigment changed to brown, red, or even
yellow white
• ‘Flag sign’ – due to alternating period of poor
and good protein intake
• Apathetic and irritable, cry easily, and have an
expression of misery and sadness
• Anorexic and diarrhea is common
• Hepatomegaly
• Protuberant abdomen and peristalsis is slow
• Muscle tone and strength is reduced
92

Dermatosis of Kwashiorkor
93

94

Skin and Hair changes in Kwashakor
95

Flag sign
96

• Combines clinical feature of both kwashiorkor and
marasmus
• Edema
• Muscle wasting and decreased subcutaneous fat
• When edema subsides, the patient appearance resembles
that of marasmus
• Wt less that 60% and edema.
97
Marasmic-kwashiorkor

Peripheral signs of malnutrition
Clinical presentation Edematous /Kwashiorkor Non edematous /Marasmus
Peak age 12 – 36 months 6 – 12months
Growth retardation Absent Present
Mental changes Apathy Irritable
Appetite Poor Good
Kwash – dermatosis Present Absent
Hair color and skin change Common Infrequent
Moon face Present Absent
Hepatomegaly Present Absent
Long and curled eye lash Present Present
Anemia Present Present
Pot belly abdomen Present Present
Diarrhea Present Present
98

• Several methods have been suggested for the
classification of PEM
–Wellcome classification
–Gomez classification
–Water low classification
99
Classification

Wellcome classification based on the
Harvard standard
malnutrition Body weight for age
based on Harvard curve
Edema
Underweight 60 – 80 _
Marasmus <60 _
Kwashiorkor 60 – 80 +
Marasmic
kwashiorkor
<60 +
It is used for clinical purpose
100

• It does not indicate the duration of
malnutrition
• Moreover, difficulties may be encountered in
some communities where the precise ages of
the children are not known
101
Drawback of well come classification

Gomez classification based on the
Harvard standard
Malnutrition Body weight for age based
on the Harvard standards.
First degree (mild) 75 – 90
Second degree
(moderate)
60 – 75
Third degree (severe) <60
It is used for community purpose
102

• It does not indicate the duration and type of
malnutrition
• Moreover, difficulties may be encountered in
some communities where the precise ages of
the children are not known
103
Drawbacks of Gomez classificatio

Water- low classification
Malnutrition Weight for
length/Height.
Length/Height
for age.
Mild 80 – 90% 90 – 95%
Moderate 70 – 80% 85 – 90%
Severe <70% <85%
It is well accepted one
104

Classification of malnutrition according to the
World Health Organization (WHO)
105
Classification
Moderate
malnutrition
Severe malnutrition
(type)*
Symmetrical
edema
No
Yes (edematous
malnutrition) •
Weight-for-
height
-3 ≤ SD-score <-2 Δ
SD-score <-3 Δ (ie,
more than 3 SD below
the median)
(severe wasting) ◊
Height-for-age -3 ≤ SD-score <-2 Δ SD-score <-3
(severe stunting)

106
• The child's weight for his or her height and the height
for his or her age are expressed as Z-scores (also
known as the standard deviation [SD] score
• Charts — The degree of malnutrition can be
determined by plotting the height and weight on Z-
score charts.
– Charts based on recumbent length are used for
children up to two years of age and
– charts based on standing height are used for those
between two and five years

107
Wasting and stunting are defined by the following
1. Wasting (indicates acute malnutrition):
– Moderate wasting — weight/height z-score <
-2 to -3
– Severe wasting — weight/height z-score <-3
2. Stunting (indicates chronic malnutrition):
– Moderate stunting — height or length z-score
<-2 to -3
– Severe stunting — height or length z-score <-3

Length-for-age boys: birth to 2 years (z-scores)
108

Classification based on mid upper arm
circumference
Malnutrition MUAC
No Malnutrition >12.5cm
Moderate 11.5 – 12.5 cm
Severe < 11.5cm
It is well accepted one
109

Consequences of Under nutrition
• When a child’s intake is insufficient to meet daily
needs, the systems of the body begin to slow down and
do less to conserve energy and prolong life.
• Energy is conserved by:-
− reducing physical activity and growth,
− reducing basal metabolism and the functional reserve
of organs and
− reducing inflammatory and immune responses.
• This process is called reductive adaptation.

Complications
• Hypoglycemia
• Hypothermia
• Dehydration
• Infection especially pneumonia, sepsis, UTI, gastroenteritis
• Fluid and electrolyte imbalance
• Anemia
• Hemorrhagic tendency, purpura
• Heart failure due to anemia and infection.
• Developmental delay

• History – nutritional history
• Physical findings
• Anthropometric measurements
 wt for ht –index of current nutritional status
 ht for age –index of past nutritional history
 -Harvard status – for under 5th
112
Diagnosis

Investigation
• Hct and Hgb
• WBC count and differential
• RBS
• Urinalysis and urine culture
• Chest X-ray
• Blood culture
• Total serum protein
• Reduced urinary creatinine clearance 113

Management of PEM
Adequate balanced feeding
Treatment of the cause
Emergency treatment for complications
Antibiotics
Vitamins and minerals supplementation
114

Quiz 1
1. When Breast Feeding is replaced by less nutritive
food low in proteins and calories, the infant below the
age of 1yr are more likely to suffer from
A. Marasmus C. kwashiorkor
B. Rickets D. pellagra
2. Emaciation of the body, thinning of limbs, skin
becomes dry, thin and wrinkled. This is associated with:-
A. Kwashiorkor C. Marasmus
B. Indigestion D. A and C
115

3. PEM is mostly seen and has the most destructing
consequences in
(a) adulthood and adolescence
(b) adolescence and early childhood
(c) infancy and early childhood
(d) only infancy
4. Disorders related to nutrition is known as
(a) balancing of nutrition
(b) insolubility of nutrition
(c) solubility of nutrition
(d) malnutrition
5. Edema occurs due to lack of albumin in
A. Marasmus C. both
B. Kwashiorkor D. None
116

 SAM is defined as the presence of oedema of both feet or severe
wasting (weight-for-height/length <-3SD or mid-upper arm
circumference < 115 mm).
 Children with severe acute malnutrition have had a diet
insufficient in energy and nutrients relative to their needs.
 Occurs more frequently when infections impose additional
demands, induce greater loss of nutrients.
118
Severe Acute Malnutrition (SAM)

Continue……..
• Moderate Acute Malnutrition (MAM), is defined by
 MUAC ≥ 11.5 cm and < 12.5 cm or
 WFH ≥ -3 z-score and < -2 z-score (WHO standards) in children
6-59 months old.

Treatments of SAM
1. Out-patient Treatment program (OPT)
uncomplicated SAM- no medical complications, Passes
appetite test
2. In- patient care (SC)- all children with:
- Medical complications or failed appetite test or
- +++ edema or wt-for ht <-3 Z-score and with edema;
- Children with SAM and referred from OPT for in-
patient care OR
- when OPT is not available
 Classified as complicated SAM
120

Admission
procedure
121

OTP Admission Criteria
• Bilateral pitting oedema + or ++
• OR
• MUAC <11.5 cm.
• OR
• WFH <-3 z-score
• AND
• Appetite test passed.
• No medical complications
• Clinically well and alert.
• OR Referred from SC after stabilisation

SC Admission Criteria for children from 6-59
months
• Bilateral pitting oedema +++
OR
• Any grade of bilateral pitting oedema combined with
severe wasting (MUAC <11.5 cm or WFH < -3 z-score)
OR
• Bilateral pitting Oedema +, ++
OR
• Severe wasting (MUAC <11.5 cm or WFH < -3 z score)
• WITH any of the following medical complications
• OR Referred from outpatient care according to the action
protocol

Medical complications of SAM
• Shock
• Dehydration
• Hypoglycemia
• Infection-
Pneumonia/severe
pneumonia
• Severe anemia: Hgb <
4gm/dl.
• Hypothermia :axillary
temp<35°c or rectal
<35.5°c.
• Fever >39°c.
• Vomiting everything
• Very Weak, Lethargic or
unconscious
• Convulsion
• Dysentery
• Jaundice
• Bleeding Tendencies
• Extensive skin lesion
/infection
(+++dermatosis). 124

Appetite Test
• The test is done at admission and at all OTP follow-up visits
to ensure that the child 6–59 months or older can eat Ready-
to-Use Therapeutic Food (RUTF).
• If the patient has no appetite, she/he must be referred to the
Stabilisation Centre (SC).
• This is done to determine whether the child can eat the RUTF
(e.g. Plumpy Nut) and can be treated at home
• The test shows whether the child has appetite, accepts the
RUTF’s taste, consistency and can swallow
• If a child fails, the appetite test, it reflects a severe disturbance
of the metabolism and this child needs to be treated in the
stabilization center.
125

126

The 10 steps of treatment for complicated SAM and
their approximate time frames.

Hypoglycemia
• Life threatening complications
• At risk because of alteration in glucose metabolism
• Signs –low body temperature, lethargy, eye lid retraction,
twitching or convulsion.
• RBS <54 mg/dl.
• If conscious: Immediately give 50 ml bolus of 10%
glucose Po. or NGT.
• If the child is lethargic, unconscious, or convulsing,
give 5 ml/kg 10% glucose by IV, followed by 50 ml of
10% glucose or sucrose Po or by NG tube.
• Feed every 2 hr. for at least first day. Initially give 1/ 4 of
feed every 30 min.
• Keep warm, Start broad-spectrum antibiotics

Hypothermia
• Body temperature <35.5 degree
• Due to impaired thermoregulatory mechanism, reduced fuel
substrate or severe infection
• Actively rewarm
• Breast Feed and provide therapeutic feeds.
• Skin-to-skin contact with carer (“kangaroo technique”) or
dress in warmed clothes, cover head, wrap in warmed
blanket and the room should be kept warm (b/n 28 -32
degree).
• Monitor temperature hourly (or every 30 min if using
heater)
• Stop rewarming when rectal temperature is 36.5°C (97.7°F)

Dehydration
• Useful signs –thirst, dry tongue and mouth, low urinary
output, weak and rapid pulse, low blood pressure, cool
and moist extremities, and declining state of
consciousness.
• Unreliable signs – sunken eyeball, decreased skin turgor,
irritability and apathy.
• Rehydration should be preferably orally or through NG
tube.
• Solution should contain less Na and more K – ORS ( not
ideal) Resomal (best).
• Indication for iv fluid – shock and coma.

Anemia
• Usually due to Fe and/or folic acid deficiency
• Clinically pale , low HGB/ HCT
• Indication for transfusion –HGB <4gm/dl , HCT
<12% or heart failure.
• Transfuse whole fresh blood at 10ml/kg over 3 hours.

Infection
• Clinical manifestations may be mild
• Classical signs ( fever, tachycardia and leukocytosis) may
be absent.
• Assume that children with severe malnutrition have a
bacterial infection.
• Gram positive and gram negative
• Safer to treat all with broad spectrum antibiotics
1. If no complications: Amoxicillin PO 25 mg/kg BID for 5
days
2. If complications Occurs:
• Gentamicin (7.5 mg/kg IV or IM) once daily for 7 days and
• Ampicillin (50 mg/kg IV or IM) every 6 hr for 2 days, then
oral amoxicillin (25-40 mg/kg) every 8 hr. for 5 days

Continued…
• Duration of antibiotic –
– Every day during phase I and 4 more days –in patient
– 7 days total in out patient care
• Malaria
• Measles vaccine on the 4th week of treatment
• Deworming – at the start of phase II.
– worm medicine is only given children who can walk
– Albendazole 400mg. PO STAT.
– Mebendazole 100mg. TWICE DAILY FOR 3 DAYS

Correct micronutrient deficiencies
1. Give vitamin A on day 1 (under 6 mo. 50,000 units;
6-12 mo. 100,000 units; >12 mo. 200,000 units) if
child has any eye signs of vitamin A deficiency or
has had recent measles. Repeat this dose on days 2
and 14
2. Folic acid 1 mg (5 mg on day 1)
3. Zinc (2 mg/kg/day) and copper (0.3 mg/kg/day).
4. Multivitamin syrup or CMV

Feeding Children 6-59 Months
Phase I (stabilization phase) (2-7 days)
• Prevent and treat Complications( 1-2 days)
• Give small, frequent feeds of F-75 every 2 hours, orally or by NGT.
• F-75 contains 75 kcal and 0.9 g of protein per 100 ml
• Use the day 1 weight to determine how much to give, even if the patient loses or
gains weight in this phase.
• Give routine medications
– Antibiotics
• 1st line is Amoxicillin PO (or Ampicillin PO)
• 2nd line is add Gentamycin or CAF on the 1st line or give Augmentine
• 3rd line is based on the clinician decision
– Vit. A for non edematous
– Folic acid
– Measles vaccine for age ≥9 months, if not vaccinated before
• Monitor the patient.
136

Continue….
• Feed by cup and saucer. Only feed with an NGT when the patient is
unable to take enough F-75 by mouth.
• Enough is defined as intake of 80% of the milk.
 An NGT should be used if the child:
 Takes less than 80% of the prescribed diet on two consecutive feeds
during stabilisation
 Has pneumonia (rapid respiration rate) and difficulty swallowing
 Has painful lesions/ulcers of the mouth
 Has a cleft palate or other physical deformity
 Is very weak and shows difficulty remaining conscious.
 The NGT should only be used in the stabilisation phase

Transition Phase
Use the following criteria to assess a patient’s readiness to
transition from the stabilisation phase:
• Appetite has returned (i.e., easily finishes all F-75 milk).
• Subsiding bilateral pitting oedema (e.g., severe oedema [+++]
has been reduced to at least moderate oedema [++]).
• No serious medical problems
• Transition Using RUTF
 During this period, introduce RUTF gradually alongside F-75.
Some children may initially refuse the RUTF
 The recommended energy intake during transition is 100-135
kcal/kg bodyweight/day.

Transition phase
– Continue any medication not completed in phase 1
– Transition can take around 2 to 3 days, during which RUTF
is introduced and if needed F-75 should be given
accordingly
– Start giving RUTF as prescribed for the transition phase
– Encourage the patient to have small, frequent RUTF feeds
every 4 hours (six times per day)
– Increase the amount of RUTF over 2–3 days until the child
takes the full requirement of RUTF
– If the child does not take the prescribed amount of RUTF,
then top up the feed with F-75 (if not taking sufficient
RUTF)
139

– Every 4 hours, provide a top up amount of F-75 therapeutic
milk as in the stabilization phase.
– When the patient finishes 50 percent of the RUTF, reduce the
volume of F-75 provided by 50 percent
– Stop providing F-75 when the patient can finish 75–100 percent
of the daily RUTF ration.
– If the RUTF is not available or if the child does not accept
it, give F-100
– F – 100, 130ml/kg/24hrs divided in to 8 doses
– RUTF can be given in a place of F – 100
When the patient is taking more than 75% of the daily
prescribed amount of RUTF, he/she should be referred to OTP
and continue treatment at home
140

Criteria to moved back from transition to the
stabilization phase
• Weight gain of more than 10 g/kg/day in association
with an increase in respiratory rate
• Increasing or developing oedema
• A rapid increase in the size of the liver
• Any sign of fluid overload
• Tense abdominal distension
• A complication that necessitates an IV infusion
• Need for feeding by NGT
• Significant refeeding diarrhoea leading to weight loss

142

Criteria to change transition phase to Rehabilitation
(phase 2)
Good appetite: takes more than 75 percent of the daily
RUTF ration or all of the F-100 in SC.
Oedema reduced to moderate (++) or mild (+).
If wasting with bilateral pitting oedema, oedema should
completely disappear.
Medical complications are resolving.
Clinically well and alert.

Rehabilitation Phase (phase 2 )
– In this phase, Vigorous approach to feeding is
required to achieve very high energy intakes and rapid
weight gain of > 10 g/kg/day
– Give F – 100, every four hours.
– RUTF can be given in a place of F – 100
– Albendazole or mebendazole
– Iron supplementation
– Advice and health education
144

Criteria to return from TP or phase 2 to
phase 1
• Diarrhea or vomiting
• Any medical complication
• Edema (new or exacerbation),
• Hepatomegaly
• abdominal distention or Sign of heart failure
• Loss of appetite
145

Preparation of F-75 and F-100
1 Red scoop( spoon): 25 ml for F75
1 Rscoop ( spoon): 25 ml for F100
146

147

OTP Discharge Criteria
 If admitted with bilateral pitting oedema, discharge cured when:
• No bilateral pitting oedema for 2 consecutive visits
• AND MUAC ≥ 12.5 cm or WFH/WFL ≥ -2 z-score
• AND Clinically well and alert
 If admitted based on MUAC, discharge cured when:
• MUAC ≥ 12.5 cm
• AND No bilateral pitting oedema
• AND Clinically well and alert
 If admitted based on WFH/WFL, discharge cured when:
• WFH/WFL ≥ -2 z-score
• AND No bilateral pitting oedema
• AND Clinically well and alert.

Discharge Criteria for Children 6-59 Months
In general Children receiving SAM or MAM treatment
should be discharged when they reach a
• MUAC ≥ 12.5 cm or WFH ≥ -2 z-scores and have no
bilateral pitting oedema for two consecutive visits
• No medical complication
• Good appetite

Treatment and Care of Infants 0-6 Months of Age
• SC Admission Criteria for Infants 0-6 Months
• Any grade of bilateral pitting oedema (+, ++ or +++)
OR
• WFL < -3 z score
OR
• Recent weight loss or failure to gain weight.
OR
• Ineffective feeding (attachment, positioning and suckling).
OR
• Presence of any of medical complications
• Any medical or social issue needing more detailed assessment or
intensive support.

Management of the Breastfeed Infant 0-6 Months
• Promote and support the mother or caregiver to breastfeed.
Routine Medicines and Supplements
• The choice of broad-spectrum antibiotics for infants 0-6 months is
the same as that of children 6-59 months.
• Ferrous Sulphate
• Provide daily doses of iron syrup orally
Dietary Treatment
 The infant should be breastfed as frequently as possible.
 Breastfeed every 3 hours for at least 20 minutes.
 Between 1 hour and 30 minutes after a normal breastfeeding
session, give therapeutic milk

Continue……………………….
• Give F-100-Diluted to breastfed infants without bilateral Oedema.
• F-100-Diluted is prepared by adding 30% water to dilute full
strength F-100
• Diluted F – 100, if no edema (with supplementary suckling
technique if the infant is on breast feeding)
• Start with F – 75 if there is bilateral pitting edema (with
supplementary suckling technique
• If edema resolved, and the infant is on breast feeding, change to
diluted F – 100.
• Mother should be supplemented with vitamins and mineral
• Other routine managements are the same.
• Never give full strength F-100 to infants 0-6 months old.
152

Continue………………………….
 Give F-100-Diluted or F-75 every 3 hours (8 feeds per day).
 Use the supplementary suckling technique to re-establish or
commence breastfeeding.

Discharge Criteria for the Breastfed Infants 0-6 Months
• Successful re-lactation and effective
breastfeeding has been achieved.
• Gaining weight on exclusive breastfeeding
• No bilateral pitting oedema.
• Infant has been checked for immunization and
other routine interventions.
• Mothers or caregivers have been linked with
community-based follow-up and support.

Management of the Non-Breastfed Infant 0-6 Months
• Treatment of non-breastfed infants 0-6 months is divided into
stabilisation phase, transition, and rehabilitation phase.
STABILISATION PHASE
• The choice of broad-spectrum antibiotics is the same as that of
children 6-59 months
• . Provide daily doses of iron syrup orally
• The dietary treatment for non-breastfed infants is the same as that
of breastfed infants

Criteria to Progress from the Stabilisation Phase to the
Transition Phase
• Return of appetite.
• Lessening of oedema
Transition phase
• Routine antibiotic therapy should be continued
• Use only F-100-Diluted.
• Increase its volume by 30% as compared to stabilization phase

Criteria to Progress from the Transition Phase to the
Rehabilitation Phase
• Good appetite, (at least 90%) of the F-100-Diluted ‹
‹
• Complete loss of bilateral pitting oedema.
• Completed a minimum 2-day stay in the transition phase.
• No medical complications.
Rehabilitation phase
• Use F-100-Diluted.
• Infants should receive twice the volume of F-100-Diluted per
feed, as compare to the amount given during the stabilisation
phase.

Discharge Criteria for the Non-Breastfed Infants 0-6
Months
• Infant is feeding well with the replacement feed.
• Has adequate weight gain and has a WFL ≥ -2 z-score.
• No bilateral pitting oedema.
• Infant has been checked for immunization and other routine
interventions.
• Mothers or caregivers have been linked with community-based
follow-up and support

Thank you !!!.

Micronutrient Deficiency
160

Common micronutrient deficiency
Vitamin A deficiency-xeropthalmia ,
Iron deficiency-anemia ,NTD[Neural tube
defect]
Iodine deficiency- goiter
Zink deficiency-Multiple disorder,
Vitamin D deficiency(Rickets) ,
 and Vitamin C deficiency(scurvy)
161

Vitamin A
• Use In vision ,in reproduction, growth, embryonic and fetal
development, and bone development, hematopoietic, and
immune functions
Sign and symptom of Vitamin A
• Night blindness is one of the first signs of vitamin A
deficiency .Diarrhea, Coreal Xerosis(Dryness)
• Corneal Ulceration/ Keratomalacia
• Bitot’s spots(cornea keratinizes and develops plaques)
• Conjunctiva Xerosis, lack of secretion Dry, rough skin
• poor growth and serious health problems in children
Treatements:Doses of oral vitamin A
- Intake of diet rich in vitamin A.(liver, green and yellow
vegetables, dairy product, eggs yolk) 162

Folate (iron deficiency)
• Iron: Chief functions in the body- Part of coenzymes
used in DNA synthesis and used to prevent Neural
tube defect.
• Source are grains ,legumes ,liver ,green vegetables
• Most common problem
• Sign and symptom -Irritability,Neural tube defects if
deficient during pregnancy,
• Weakness, Lack of energy, Sleeping difficulties
Paleness , Sore red tongue, diarrhea,
• Mild mental symptoms, such as forgetfulness and
confusion
• Treatment- oral folic acid 163

Zink deficiency
Function: reducing the duration of acute diarrhea
• Metabolism (functions in over 200 enzymatic reactions)
• Immunity ,Wound healing, Fetal Growth and
Development
• Production of brain neurotransmitters
Sign and symptom-Weight loss ,Growth retardation
,Dwarfism ,Poor Immune system , Rough skin ,Poor
appetite , Mental lethargy ,Delayed wound healing
,Diarrhea ,Pneumonia
Treatement- Zink supplementation
164

Iodine deficiency
• For the normal development of the brain of fetus
• Necessary for reproduction and growth
• Fetus
• Congenital anomalies, Increased infant mortality
• Neurologic cretinism (including mental deficiency) ,
Psychomotor defects
• Neonatal goiter, Neonatal hypothyroidism
• Child and adolescent- Goiter
• Impaired mental function
• Retarded physical development
Treatement: iodized oil capsule and increase diet( fish, milk,
eggs, bread, iodized salt)
• Increase access and consumption by all families of iodized
165

Vitamin ‘D’ Deficiency (Rickets)
• It is characterized by weakness and deformity of bones.
• Deficiency states occur due to lack of calcium ion in the
body. Risk for those non –exposure to sunshine
Sign and symptom : malformation of joints or bones,lack
of tooth development
• weak muscle, bowed legs, knocked knees and delayed
fontanel closure
• Osteomalesia (adult rickets) ,muscles weakness and
spasm and easily broken bone, Myopathies
• DX- serum calcium, phosphate, vit D, bone x-ray
Treatments: Vit D, Exposure to sun light(daily for 10
minute), Exclusive breast feeding
166

Vitamin C deficiency
 Involved in collagen synthesis, metabolism of cholesterol and
neurotransmitters(conversion).
• Helps support and protect blood vessels, bones, joints, organs
and muscles
• Protective barrier against infection and disease
• Promotes healing of wounds, fractures and bruises.
Sign and symptom: Small blood vessels fragile,Gums reddened
and bleed easily,Teeth loose, Joint pains, Dry scaly skin ,lower
wound-healing, increased susceptibility to infections, and defects
in bone development in children
Treatement: Daily intake of of orange or tomato juice ,Vitamin C
supplements of 100–200 mg orally or parenteral
167

THANK YOU!!!
168

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