2. Objectives
o To recognize the changing nutritional needs
of children.
o To understand that nutritional
recommendations for children vary by age
and stage of development.
o To understand the global burden of child
malnutrition
3. Why nutrition?
o Energy of daily living
o Maintenance of all body functions
o Vital to growth and development
o Therapeutic benefits
Healing
Prevention
4. Determinants of Caloric Needs
o Basal metabolic rate (BMR)
o Activity level
o Growth (2x BMR during first year)
o Stress (infection, surgery, illness)
5. Nutritional recommendations
Infancy (Birth to 1 year)
o This is a critical period because the rate of
growth and development is more rapid than
any time in life.
o Milk is the sole source of nutrition up until 4
to 6 months of age.
o Milk could be in the form of breast milk,
infant formula, or a combination of both.
6. Cont…
o Breast feeding is superior to formula
feeding.
o WHO recommends exclusive breast feeding
the first 6 months of life, with continued
breast feeding along with appropriate
complementary foods through the first 2
years of life.
o Worldwide, it is estimated that only 34.8%
of infants are exclusively breastfed for the
first 6 months of life.
7. Cont…
Breast feeding advantages - Infant
o Immunologic benefits.
o Decreased incidence of ear infections, UTI,
gastroenteritis, respiratory illnesses, and
bacteremia.
o Convenient and ready to feed.
o Reduced chance of overfeeding?
o Fosters mother-infant bonding.
8. Cont…
BF advantages - Mother
o May delay return of ovulation.
o Loss of pregnancy-associated adipose
tissue and weight gain.
o Suppresses post-partum bleeding.
o Decreased breast cancer rate.
9. Cont…
o Solid foods (such as cereals, fruits and
vegetables) can be introduced when the
infant is developmentally and
physiologically ready by the age of 4 to 6
months.
o Gradual introduction of semisolid and solid
foods to the infant until s(h)e is accustomed
to the regular family diet.
o Complementary foods need to be
nutritionally adequate, safe, and
appropriately fed in order to meet the young
child’s energy and nutrient needs.
10. Cont…
Between Infancy and Childhood
o The period between age 1 and 2 is a
transition between infancy and childhood.
o There is dramatic decrease in growth rate
reflected in disinterest in food.
o Growth, BMR, and endless activity require
an energy supply of 1300 kcal/day for ages
1 to 3.
11. Cont…
Children 4 to 6 years old
o Children can have their independent eating
styles.
o Snacks form an integral part of the child’s
nutrient intake.
o Energy requirements increase to 1800 kcal/
day.
12. Cont…
Children 7 to 12 years old
o Actual growth may slow down at this stage
o The body is preparing for the puberty
growth spurt
o Puberty for girls may begin from around
age 9 and on and, for boys, puberty may be
reached in early teen years
o Energy requirements increase to 2000 to
2200 kcal/day
13. Growth monitoring
o Use growth charts
o Monitor trends in growth not one value
using wt, ht, HC (< 2 yrs), BMI.
o In general, normals fall within 5th-95th%ile.
o Evaluate changes in %iles.
o Malnutrition results in:
Decreased weight (acute), then height,
then head circumference (chronic).
14. Protein Energy Malnutrition
Malnutrition is defined 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.
Malnutrition :overnutrition (obesity) and
undernutrition
15. Cont…
It is accompanied by deficiency of several
micronutrients.
The origin of protein-energy malnutrition
(PEM) can be primary or secondary.
16. Cont…
Historical Background
1930s
Dr. Cicely Williams described kwashiorkor
1940s
researchers showed that most patients with
kwashiorkor had low concentrations of
serum proteins
17. Cont…
1950s
PEM gained worldwide recognition
1960s
Studies done since this period have
shown that marasmus and kwashiorkor
have distinct metabolic features.
18. Epidemiology
Child malnutrition remains a major public
health problem in almost all developing
countries.
In some of these countries, severe
malnutrition is the most common reason
for pediatric hospitalization.
19.
20. 500,000 Ethiopian children under-5 dying each year
ranking 6th in the world in number of deaths
72 % preventable
10/28/2023 20
Neonatal, 25%
Malaria, 20%
Pneumonia,
28%
Diarrhea, 20%
AIDS, 1%
Measles, 4%
Other, 2%
Malnutrition
57%
HIV
11%
21. Etiology
Protein-energy malnutrition results from
the interaction of several factors of which
inadequate diets and infectious diseases
are most important.
23. Pathophysiology
Physical parameters Pathophysiological Profile
Body composition • Changes in protein/fat metabolism
• Imbalance in body water distribution
• Reduced sodium, potassium, and magnesium
GI tract • Hypochlorhydria
• Mucosal atrophy
• Changes in transit time
• Impaired pancreatic function
• Altered gut microbial flora
Cardiac system • Decreased cardiac output
• Increased plasma volume
Liver • Ultrastructural alterations
• Decreased protein synthesis
Kidney • Reduced glomerular filtration
• Impaired tubular function
Nervous system • decreased brain growth and myelination
• decreased neurotransmitter production and conduction
Thymolymphatic & Immune system • Thymus atrophy
• Loss of germinal centers in the lymph nodes
• Decreased tonsil and spleen size
• Decrease in thymus dependent lymphocytes
• Depressed complement system
25. Pathogenesis: Kwashiorkor
Different proposed mechanisms :
a. Protein-energy deficiency
b. Adaptation
c. Free radical theory ( imbalance
between
oxidants and antioxidants)
No adequate explanation so far why some
children develop edematous malnutrition
27. Classification
Depends on the purpose for which it is
used: Clinical studies or community
surveys
WHO has broadly classified PEM into
underweight, wasting and stunting.
Clinically, PEM is a disease spectrum
that can present as underweight,
marasmus, marasmic-kwashiorkor or
kwashiorkor.
28. Gomez classification of malnutrition
Malnutrition Body weight (% of standard)
First degree 75-90
Second degree 60-75
Third degree <60
29. Wellcome classification of malnutrition
Malnutrition Body weight (% of
standard)
Oedema
Underweight 60-80 -
Marasmus <60 -
Kwashiorkor 60-80 +
Marasmic
kwashiorkor
<60 +
30. Clinical Manifestations
Marasmus
o Generalized muscular wasting & absence
of
subcutaneous fat
o W/A <60%
o Sparse, thin, and dry hair which is easily
pulled out
o Dry & thin skin with little elasticity
o Old man face
o Baggy pant
32. Cont…
Kwashiorkor
o Pitting edema, usually in the feet and legs
o Skin lesions, in the areas of edema
o Epidermis peels off in large scales
o Sparse, thin, and dry hair which is easily
pulled out
o Apathetic and irritable, cry easily
o Hepatomegaly with a soft, round edge
46. Admission Criteria
Age Admission criteria
6 month -18yrs
Adults
• W/H or W/L<70% or
• MUAC <110mm with
length>65cm or
• Presence of bilateral pitting
edema
• MUAC<170mm
• MUAC < 180 mm with
recent weight loss or
underlying chronic illness or
• BMI < 16 with or
• Presence of bilateral pitting edema
(unless there is another clear cut
cause)
47. Screening Procedure
o Anthropometry ( wt, ht/ lth , MUAC)
o Check for edema
o Check for medical complication
o Appetite test
Fast Tracking : leave test if patient
is critically ill
48. Common Complications
Infections: lung , blood, UT, GIT, skin
Metabolic: Hypoglycemia, hypocalcaemia,
hypomagnesaemia
Hypothermia
Dehydration and electrolyte disturbances
Heart failure
Severe anemia
Stupor, coma, or other alterations in
awareness
49. Appetite test
o Anthropometric Vs metabolic malnutrition
o Metabolic malnutrition causes death.
o Poor appetite ~severe metabolic malnutrition
WHY?
o Poor appetite indicates :serious infection,
major organ dysfunction( e.g. liver), electrolyte
imbalance, cell membrane damage or damaged
biochemical pathways.
50. Steps to test appetite
o Quiet separate area.
o Explain the purpose of the test to the carer.
o The carer, where possible, should wash his
hands.
o The carer should sit comfortably and offer the
RUTF from the packet or put a small amount
on finger.
o Gently encourage the child (don’t force ).
o Offer plenty of water to drink with the RUTF.
child may be frightened, distressed or fearful of
the environment or staff.
52. Principle of Management
Three stages:
a. Resolving life-threatening conditions
<> prevent & treat complications
b. Restoring nutritional status
<> Treat in phases(PI,TF & PII)
c. Ensuring nutritional rehabilitation
<> usually 2 to 3 weeks after
admission
53. Cont…
Routine drugs
o Antibiotics
o Vitamins ( A and Folic acid)
o Anthelmintics( mebendazole /
albendazole)
o Therapeutic diet( F-75 , F-100,RUTF)
o Vaccination
o Ferrous
54. Cont…
Treating Complications
Hypothermia (axillary<35.0oC; rectal<35.5oC)
o “kangaroo technique”
o Put a hat on the child and wrap mother and
child together
o Give hot drinks to the mother so her skin
gets warmer & keep the room warm.
o Treat for hypoglycemia and give second-
line antibiotic treatment.
55. Cont…
Hypoglycemia
A. Conscious child with RBS of <54mg/dl :
o Give 50 ml bolus of 10% glucose or 10%
sucrose solution and then feed F-75 every
30 min. for two hours
o Antibiotics- second-line
o Two-hourly feeds, day and night
56. Cont…
B. If the child is unconscious, lethargic or
convulsing
o IV sterile 10% glucose (5ml/kg), followed by
50ml of 10% glucose or sucrose by Ng tube.
Then give F-75
o Antibiotics- second line
o Two-hourly feeds, day and night
Monitor
o Blood glucose
o Rectal temperature
o Level of consciousness
57.
58.
59.
60. Cont…
Infection
o In SAM the usual signs of infection, such
as fever, are often absent, and infections
are often hidden.
Therefore give routinely on admission:
• broad-spectrum antibiotic(s) AND
• measles vaccine if child is > 6m and
not
immunised (delay if the child is in
shock)
61. Cont…
The antibiotic regimen
o 1st line: oral Amoxicillin or ampicillin
o 2nd line: add Gentamycin or
Chloramphenicol
on 1st line treatment or change
to
amoxycillin/clavulinic acid
o 3rd line: individual medical decision
o systemic anti-fungal (fluconazole) for
severe sepsis or systemic candidiasis.
62. Cont…
Restoring nutritional status
Phase I
o Diet: F75
o Contains 75 kcal and 0.9g protein/100 ml.
o one large packet of F75 to 2 litres of water.
o Feeding frequency: 5-8 times/24 hr.
o Vitamin A if indicated.
o When? The first few days of admission(2-
5days)
o Folic acid 5mg if signs of anemia.
63.
64. Cont…
Transition phase
o Diet: F100 or RUTF
o Contains 100 kcal and 2.9 g protein/100 ml
o Feed 5-8 times/24hr and the same volume
as Phase-I
o Continue oral antibiotics
o It last b/n 1 and 5 days – usually 2 or 3 days
o This phase prepares the patient for Phase 2
treatment.
65. Cont…
Phase II
o Diet : F100 or RUTF
o Contains 100 kcal and 2.9 g protein/100 ml
o Feed 5 times /24hr
o Introduce iron
o De-worming
o 3rd dose of Vitamin A
o Consider Discharge if the criteria fulfilled
66. Drug Metabolism - PEM
Drug metabolism may be altered
Detoxification mechanisms may be
compromised
Why?
o Delayed absorption
o Abnormal intestinal permeability
o Reduced protein binding
o Changes in the volume of distribution
o Decreased conjugation or oxidation in the
liver
o Decreased renal clearance
67. Physical
Parameter
Pathophysiological
Profile
Pharmacokineti
c Parameters
Body
composition
• Changes in protein/fat
metabolism
• Imbalance in body water
distribution
• Reduced sodium,
potassium, and
magnesium
• Protein binding
• Tissue uptake
and
distribution
• Retention and
elimination
GI tract • Hypochlorhydria
• Mucosal atrophy
• Changes in transit time
• Impaired pancreatic
function
• Altered gut microbial flora
• Absorption
• Enterohepatic
circulation
• Gut wall and
gut bacterial
metabolism
Cardiac
system
• Decreased cardiac output
• Increased plasma volume
• Organ blood
flow
• Tissue
perfusion
69. Discharge criteria
Greater than 6 months
o WFH > 85 % and
o MUAC > 12 cm and
o No edema for at least ten days and
o No medical illness mandating in-patient
treatment
Less than 6 months( with lactating mother)
o Baby thriving on breast milk
