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  1. 1. MalnutritionDr.Anita LamichhaneMD resident (Pediatrics)Shaikh Zayed hospital , Lahore
  2. 2. • > 3.5 million/year , mothers & children die due to the underlying cause of under nutrition• > 55 million (10%) of children are wasted• < 19 million are severely wasted.
  3. 3. South ASiA And Sub-SAhArAn AfricA hAvethe higheSt ShAreS of Young children who Are underweight. Prevalence of Underweight Children Under Age 5, by Country Source: Carl Haub, 2007 World Population Data Sheet.
  4. 4. vitAmin A And iron deficiencieS Are AlSo PrevAlent Among children < 5 YeArS . Percent of Children Under Age 5 with Vitamin A and Iron Deficiencies, Selected Regions
  5. 5. dAtA from PAkiStAn• 36 % of children -- underweight before the current floods.• Researchers claim that up to 44 % of children of rural area stunted.• A survey by the World Health Organization -the number of underweight pre-school children (0-5 years of age) is 40 %
  6. 6. mAlnutrition• Derived from malus (bad) and nutrire (to nourish)• Includes both  Under nutrition (deficiency of one or more essential nutrients)  Over nutrition (an excess of a nutrient or nutrients)
  7. 7. • Macronutrients (carbohydrates, lipids, proteins & water) - needed for energy, cell multiplication & repair• Micronutrients are trace elements, vitamins & nutrients - essential for metabolic processes
  8. 8. AdAPtAtion to StArvAtion energY Source• Depletion of glycogen stores gluconeogenesis ( glucose / insulin) (Glycerol, amino acids, lactate/ pyruvate)• Fatty acid oxidation and ketone bodies Utilization• Reduced protein catabolism & gluconeogenesis
  9. 9. AdAPtAtion to StArvAtion fluid & electrolYte• Inhibition of sodium pump intracellular Na total body water• urinary loss of K, calcium, phosphate, magnesium & zinc• total body K+ : hypotonia, apathy, impaired cardiac function
  10. 10. refeeding SYndrome• Metabolic disturbances occur at this point• Starvation- loss of lean muscle mass, water and minerals phosphorus• Carbohydrate refeeding, insulin release• glucose uptake• Hyphosphatemia- red cell ATP• K,Mg, glucose,thiamine
  11. 11. clASSificAtion
  12. 12. who clASSificAtion• Defined as the presence of edema of both feet or severe wasting {70% weight for height/length or (<-3SD)} or clinical signs of severe malnutrition
  13. 13. gomez clASSificAtion• If the wt is > 90 % of the expected weight –no malnutrition• 1st degree- wt is 75-90% of the expected weight• 2nd degree- wt is 60-75% of the expected weight• 3rd degree- wt is < 60 % of the expected weight
  14. 14. modified gomez clASSificAtion• If the wt is > 80 % of the expected wt –no malnutrition• 1st degree- wt is 70-80% of the expected wt• 2nd degree- weight is 60-70% of the expected wt• 3rd degree- wt is < 60 % of the expected wt
  15. 15. wAter low clASSificAtionHeight Weight for age expressed as percentagefor age <80 80-120 >120<90% Chronic Stunted but Stunted and malnutrition no obese malnutrition> 90% Acute Normal Obese malnutrition
  16. 16. welcome clASSificAtion Edema present Edema absentWeight for Kwashiorkor Ponderalage 80-60 % Retardationof standardWeight for Marasmic Marasmusage < 60 % kwashiorkorof standard
  17. 17. hArvArd clASSificAtion• If the wt falls 50th percentile- healthy child• Grade I- if wt is 71-80% of 50th percentile• Grade II- if wt is 61-70% of 50th percentile• Grade III- if wt is 51-60% of 50th percentile• Grade IV- if wt is 50% of 50th percentile
  18. 18. generAl clASSificAtion Mid arm circumference – measured with a measuring tape• At 12 months- 16.5 cm• Between 12-48 months= 12.5-16.5 cm• Cut off point- 75 % of the expected mid arm circumference• If less than the cut off point (<14 cm)= malnourished
  19. 19. Skin fold thickness• Herpeden caliper• Triceps/back of shoulder• Normal= 9-11 mm• If < 9 mm- malnourished
  20. 20. Quac strip• Special tape having colors on it Up to green Normal colour Yellow colour Borderline malnutrition(14-12 cm) Red colour Malnourished (< 12 cm)
  21. 21. • Body mass index (BMI) weight in kg height in m² <16 Malnourished >25 Obese 16-25 Normal
  22. 22. etiologY Primary malnutrition Secondary malnutritionFailure of lactation Parasitic infestations, Measles, whooping cough, Primary tuberculosis, Urinary tract infectionIgnorance of weaning Congenital heart disease, Urinary tract anomaliesPoverty Giardiasis,Lactose intolerance, Celiac disease, Tuberculosis of the intestine Cystic fibrosisCultural patterns and food Inborn errors of metabolism,galactosemiafadsLack of immunization andprimary careLack of family planning
  23. 23. kwashiorkor marasmusDerived from Ghanian dialect derived from the Greekmeaning first second- after birth marasmos, which meansof the second baby, the first wastingbaby is deprived from the Due to dietary deficiencybreast feeding, which is the only /severely restricted food intakesource of proteinUnderweight Extremely underweight below < 60%Edema is always present Edema is always absentThin lean muscles, fat is present Muscle wasting with loss of subcutaneous fatHair changes are present-fine, No hair changesstraight,sparse,discolored
  24. 24. kwashiorkor marasmusPoor appetite and anorexic Good appetitieFlaky paint dermatitis, ulcers, Normal skinhypo/hyperpigmentationMiserable looking and apathetic Appearance of monkey face or little old man face,alert faciesLiver enlarged (fatty infiltration) No hepatomegaly
  25. 25. Initial assessment of the severely malnourished child
  26. 26. hiStorY• Recent intake of fluids & foods• Usual diet (before the current illness)• Breast feeding• When was weaning started• Duration & frequency of diarrhea & vomiting• Type of diarrhea (bloody/watery)• Loss of appetite
  27. 27. • Time when urine was last passed• Family circumstances-literacy level, socioeconomic status, housing, family members, vaccination• Chronic cough• Contact with tuberculosis• Recent contact with measles• Milestones reached
  28. 28. exAminAtion• Proper exposure of the child• General look /appearance: Stunted,wasted,edematous, alert, apathetic, emaciated• Anthropoetic measurements: weight, height, head circumference, mid arm circumference- plot in the centile chart
  29. 29. • Signs of dehydration & shock – cold hands, absent tears, slow capillary refill, weak & rapid pulse• Hypo/hyper thermia• Head- depressed and open fontanelle,fine sparse hair, hypo/ hyper pigmented, easily pluckable• Hands –severe palmar pallor, clubbing, pulse, widening of wrist
  30. 30. • Eyes- signs of vitamin A deficiency• Ear – discharge from the ear, (serosanguneous or purulent)• Neck-Goitre, lymph nodes• Mouth- angular stomatits,Oral hygiene, gum (bleeding/hyperplasia),dentition, tongue( flat , loss of papilla, red and beefy), ulcer, oral thrush
  31. 31. • Skin – colour, whether dry and lusterless, any exudative changes (resembling severe burn) often exist with secondary infecttion (including Candida),petechiae and bruises• Chest- shape, prominent costochondral junction, Chest ricket rosary, crowding of ribs, Harrisons sulcus• CVS- signs of heart failure CVS
  32. 32. • Edema , jaundice• Skin changes of Kwashiorkor• Abdomen - distended, protuberant, tone of the muscles, bowel sounds, tender hepatomegaly
  33. 33. inveStigAtionS• Full blood counts, peripheral smear for MP• Blood glucose level• Septic screening• Stool for cysts, ova, and C/S, fat globules (Malabsorption)
  34. 34. • Urine microscopy and C/S• Electrolytes, Ca, Ph & ALP, Serum albumin & total proteins• CXR & Mantoux test• Exclude HIV
  35. 35. comPlicAtionS• Hypoglycemia• Hypothermia• Hypokalemia• Hyponatremia• Heart failure• Dehydration & shock• Infections (bacterial, viral & thrush)
  36. 36. mAnAgement• INITIAL TREATMENT (emergency treatment)• REHABILITATION• FOLLOW UP
  37. 37. • Stabilization Rehabilitation• 1 week 2-6 weeks• Hypoglycemia• Hypothermia• Dehydration• Electrolytes• Infections• micronutrients No iron Add iron• Initiate feeding• Catch up growth• Sensory stimulation• Follow up
  38. 38. Initial treatment ( First phase) (usually 2-7 days)
  39. 39. fluidS And electrolYte bAlAnce• Iv infusion - indicated in a severely malnourished child with circulatory collapse (otherwise N/G feeding)• ½ strength Darrow’s solution with 5% dextrose• Half normal saline(0.45%) with 5% dextrose• Give i/v fluid 15 ml/kg over 1 hour
  40. 40. • Measure the vital signs( pulse rate, respiratory rate) at the start & every 5-10 minutes• If signs of improvement, then repeat i/v 15 ml /kg over 1 hour, then switch to oral /NG rehydration with ReSoMal 10 ml/kg/hour up to 10 hour• Initiate refeeding with starter F-75 ( 75 calories/100 ml)• If the child fails to improve, assume the child has septic shock
  41. 41. • Give maintenance i/v fluid (4ml/kg/hr) while waiting for blood• Transfuse fresh whole blood 10 ml/kg slowly over 3 hours (packed cells used if in failure)• Start antibiotics• If the child comes out of shock, then start 70 ml/kg of RL(if not available, NS) over 5 hours in infants (<12 months) and over 2/12 hours in children (aged 12 months to 5 years)
  42. 42. • Reassess the child every 1-2 hours• As soon as the child can drink, give ORS solution• Reassess after 6 hours(in infants) and 3 hours(in children)• Classify dehydration and then choose the appropriate plan (A,B,or C) to continue treatment
  43. 43. • If available, add selenium & iodine• Solution stored in sterilized bottles in fridge• Discards if it turns cloudy• Add 20 ml of the concentrated electrolyte/mineral solution to each 1000 ml of milk feed
  44. 44. how to mAke reSomAl???• ORS 1 packet• Water 2 litres• Sugar 40 gram• Mineral mix 33 ml ( Zn given as syrup zincate, Mg given as I/V, K= 100 gm of KCl in 1 litre of water (take 40 ml of KCl)
  45. 45. correction of hYPoglYcemiA PREVENTION: By feeding every 2 -3 hours/day TREATMENT:o Conscious child- 50ml of 10% glucose/sucrose POo Unconscious child- 5ml/kg of 10% glucose I/V followed by 50ml of 10% glucose/sucrose by N/G Tube
  46. 46. hYPothermiAMarasmic infants and children are more at risk of hypothermia if underarm temperature < 350C (950F)The child is rewarmed by: Kangaroo Method Warm Blanket & Lamp method
  47. 47. control of infectiono MILD INFECTIONS: Cotrimoxazole BD x 5 dayso SEVERE INFECTIONS WITH COMPLICATIONS: Ampicillin:50mg/kg I/M, I/V 6hr x 2days Amoxicillin:15mg/kg oral 8hr x 5 days Gentamicin:7.5mg/kg I/M,I/V O.D x 7days
  48. 48. • Measles vaccination if the child is 6 months old & not immunized or if the child is > 9 months old & has been vaccinated before• Mebendazole 100 mg PO OD x 5 days
  49. 49. orS Solution for SeverelY mAlnouriShed children• Malnourished children- deficient in K+ & abnormally high Na+• ORS soln should contain high K and low Na than the standard WHO- recommended solution• Mg, Zn & Cu should also be given•
  50. 50. Composition of ReSoMalComponent Concentration (mmol/l)Glucose 125Na 45K 40Cl 70Citrate 7Mg 3Zn 0.3Cu 0.045Osmolarity 300 mosmol
  51. 51. • ReSoMal available commercially• Can also be made by diluting one packet of the standard WHO-recommended ORS in 2 litres of water; 50 g of sucrose (25g/l) and 40 ml (20 ml/l) of mineral mix• Mineral mix supplies  K+ - affects cardiac function & gastric emptying  Mg2+ - essential for K+ to enter the cells and be retained  does not contain iron• Mineral mix is stored at room temp and added to ReSoMal or liquid feed at a conc. Of 20 ml/l
  52. 52. Mineral mix solutionSubstance gramsKCl 89.5Tripotassium citrate 32.4MgCl2.6H2O 30.5Zinc acetate.2 H2O 3.3CuSO4.5 H2O 0.56Sodium selenate 0.01Potassium iodide 0.005Water make upto 2500 ml
  53. 53. Vitamins Amount per litre of liquid dietWater solubleB1 0.7 mgB2 2 mgNicotinic acid 10 mgB6 0.7 mgB12 1µgB5 3 mgC 100 mgBiotin 0.1 mgFolic acid 0.35 mgFat solubleVit A 1.5 mgVit D 30 µgVit E 22 mgVit K 40 mg
  54. 54. Types of formula feed• F-75 (75 Kcal/ 3215kJ/100 ml)-used during the initial phase• F-100 (100 Kcal/420kJ/100 ml)-used during the rehabilitation phase
  55. 55. F-75 (starter) F-100 (catch-up)Dried skimmed milk (g) 25 80Sugar (g) 70 50Cereal flour (g) 35 -Vegetable oil (g) 27 60Electrolyte/mineral 20 60solution (ml)Vitamin mix (mg) 140 140Water, make up to (ml) 1000 1000
  56. 56. Constituent Amount per 100 ml F-75 F-100Energy (kCal) 75 100Protein (g) 0.9 2.9Lactose(g) 1.3 4.2Potassium (mmol/l) 3.6 5.9Sodium (mmol/l) 0.6 1.9Magnesium (mmol/l) 0.43 0.73Zinc (mmol/l) 2 2.3Copper (mmol/l) 0.25 0.25%age of energy from• protein 5% 12%• fat 32% 33%Osmolarity 333 419(mOsmol)
  57. 57. how to PrePAre??• F-75/F-100• Add the dried skimmed milk,, sugar, cereal flour and oil to some water and mix• Boil for 5-7 mins• Allow to cool• Add the mineral mix and vitamin mix and mix it again• Make up the volume to 1000ml with water• If dried skimmed milk not available, then 300 ml of fresh cow’s milk can also be used
  58. 58. • F-75 diet should be given to all children during the initial phase of treatment• At least 80 kcal/kg should be given but not > 100 kcal/kg• If < 80 kcal/kg given- the tissues continue to break down & the condition will deteorate• If >100 kcal/kg be given- serious metabolic imbalance will develop
  59. 59. Feeding after the appetite improves• The initial phase of Tx ends when the child becomes hungry• Now transfer to F-100 diet with an equal amount of F-100 for 2 days before increasing volume offered at each meal
  60. 60. Recording the food intake• Type of feed given• Amounts offered and taken must be recorded accurately after each feed and deducted from the total intake• Once a day the energy intake for the last 24 hours should be determined & compared with the child’s weight
  61. 61. dietArY mAnAgemento 2-3 weekso Calorie : 120 -140 cal/kg/dayo Protein :3- 5 gm/kg/dayo Elemental iron: 3-6 mg/kg/day (ferrous sulphate)o Vitamin A: 300,000I.U then 1500I.U/day
  62. 62. o Vitamin D: 4000 I.U/dayo Vitamin k: 5mg I/M, I/V once onlyo Folic acid: 5 mg on day 1, then 1 mg/dayo Copper: 0.3 mg/kg/day
  63. 63. Basic principle of dietary management• Improve the nutritional level of the child as quickly as possible by providing a diet with sufficient energy producing foods & high quality proteins
  64. 64. initiAl refeedingo Frequent small feeds of low osmolarity & low lactoseo Oral/NG feeds (never parenteral preparation)o 100 cal/kg/dayo Continue breast feeding if the child is breast fed
  65. 65. • Increase each successive feed by 10 ml until some feed remains uneaten• Assess progress: weigh the child every morning before being fed, plot the weight• Calculate weight gain every 3rd day• If the weight gain is poor (<5 g/kg/day), check whether the intake targets are being met• good wt gain = (>10g/kg/day)
  66. 66. SenSorY StimulAtionProvide• Tender loving care• A cheerful stimulating environment• A structural play therapy for 15-30 mins / day• Physical activity as soon as the child is well enough• Maternal involvement as much as possible
  67. 67. criteriA for trAnSfer to nutritionAl rehAbilitAtion• Eating well• Improvement of mental state• Sits, crawls stands or walks• Normal temperature• No vomiting/diarhea/edema• Gaining wt > 5 gm/kg body wt/day x 3 consecutive days
  68. 68. nutrtionAl rehAbilitAtiono Infants <24 months fed exclusively on liquid/ semi solid foodo Older children given solid food
  69. 69. Feeding < 2 years• F-100 diet be given every 4 hours, night & day• Increase the amount of diet at each feed by 10 ml• When feed is not finished, the same amount should be offered at the next feed• process is continued until some feed is left after most feed• Any feed not taken should be discarded, should never be reused
  70. 70. • If the intake is <130 Kcal, the child is failing to respond• F-100 should be continued until the child achieves -1SD (90%) of the media WHO reference values for weight for height
  71. 71. Feeding children >2 years• Introduce solid food, local foods should be fortified to increase their content of energy, mineral and vitamins• Oil added to increase the energy content• The mineral & vitamin mixes used in F-100 should be added after cooking• Other ingredients-dried skimmed milk may also be added to increase the protein content• Supplementation of food with folic acid and iron
  72. 72. • Daily weight and plotted on a graph• Mark the point that is equivalent too -1SD (90%) of the median/WHO reference values for wt. for ht. on the graph which is the target weight for children• Usual weight gain is 10-15/kg/day
  73. 73. how to cAlculAte the cAlorieS• Required calories = currently required for age + 25% calories for catch up growtho for e.g. calculation of calories for one year old child with weight 6.5 kgo expected wt at one year = 10 kgo So the required calorie should be = 1000 ( 100 cal/kg/day)+ 250 (25% of 1000 calories)o Start with 625 cal/day or whatever the child is taking and if it
  74. 74. • Then increase by 10% per day 24 2/3 solid 1/2 18months 1/2 1/2 12 1/3 2/3 6 liquid 0 Calories required
  75. 75. Source of cAlorie SuPPlY• Carbohydrate : 50-55%• Fat: 30-35%• Protein: 10-15%
  76. 76. • Daily increment• < 6 months= 50 calories/day• 6-9 months= 75 calories/day• > 1 year=100 calories/day
  77. 77. micronutrient deficiencieS• Iron & folic acid for anemia• Iron dose : 3mg/kg/day in 2 divided doses• Folic acid :5mg on day one then 1mg/day• Zinc : 2-3 mg/kg/day• Copper : 0.3 mg/kg/day• Ferrous sulphate (3-6 mg/kg/day)
  78. 78. treAtment of the ASSociAted conditionS Eye problem• Vit A supplement• Chloramphenicol/tetracycline drops- 4 drops daily x 7-10 days• Atropine drops 1 drop tds x 3-5 day• Cover with saline soaked eye pad• Bandage the eyes
  79. 79. • Severe anemia: blood transfusion• Skin lesions in kwashiorkor: zinc supplementation, barrier cream ( Zn and castor oil ointment), nystatin cream to skin sores,oral nystatin(1000 IU QID)• Bathe or soak the affected area for 10 mins/day in 0.01% KMnO4 solution
  80. 80. • Giardiasis: metronidazole• Lactose intolerance: substitute with yogurt or lactose free formula, reintroduce milk feeds in the rehabilitation phase• Treatment of tuberculosis
  81. 81. Congestive cardiac failure• usually a complication of overhydrationn,very severe anemia, blood or plasma transfusion or giving a diet with high Na content• When due to fluid overload:  stop all oral intake and IV fluids  Diuretic IV ( furosemide 1 mg/kg)  Do not give digitalis unless the diagnosis of heart failure is unequivocal & the plasma K level is normal
  82. 82. Drugs for the treatment of malaria in severely malnourished childDrug DosagePlasmodium malaria,P.ovale &susceptible forms of P. malariaChloroquine Total dose: 25 mg of base/kg orally given over 3 days Day 1& 2= 10 mg og base/kg in a single dose Day 3: 5 mg of base/kg in a single dosePlasmodium falciparum malariaChloroquine Same as aboveQuinine 8 mg of base /kg orally TDS x 7 daysPrimethamine+sulphadoxine 5-10 Kg: 12.5 mg+250 mg orally in a single dose 11-20 kg:25 mg+500 mg orally in a single dose
  83. 83. nutrtionAl rehAbilitionChild should be weight dailyo Usual weight gain is 10 to 15Gm/kg/dayo Treatment failure: when the child doesnt gain wt at least 5Gm/kg/day for 3 consecutive dayso target wt for discharge achieved after 2 to 4 wks
  84. 84. recoverY• Takes place in 2 phases INITIAL RECOVERY PHASE It takes 2 -3 wks: edema & other signs improve CONSOLIDATION PHASE In next 2 to 3 months child regains normal weight and is clinically recovered
  85. 85. criteriA for diSchArge from hoSPitAl1. CHILD• Weight gain is adequate• Eating an adequate amount of diet• Vitamins & mineral deficiencies treated• All infections & other conditions treated• Full immunization programme started
  86. 86. 2. MOTHER• Able & willing to look after the child• Knows how to prepare & feed balance diet• Knows how to play with child• Knows how to give home treatment for diarrhea, fever and ARI. Warn for danger signs
  87. 87. FOLLOW UP• Follow up at regular intervals after discharge• Child should be seen after  every 2 days for 1 wk  once weekly for 2nd wk  at 15 days interval for 1 - 3 months  monthly for 3- 6 months• More frequent visits if there is problem• After 6 months, visits twice a year until the child is at least 3 years old
  88. 88. PrognoStic fActorS in Pem• Grade of PEM & the type• Grade III-IV marasmus & severe of Kwashiorkor are associated with increased mortality• Girls diagnosed as marasmus have been found to have a higher death rate than boys• Age: case fatality rate decrease with increase in age
  89. 89. • low weight for age is a sensitive indicator of mortality• Presence of serious complications like septicemia, pneumonia & severe diarrheal diseases with dehydration• severe hypokalaemia & hyponatremia- poor prognosis• hypoproteinemia & hypoalbuminemia- poor prognosis
  90. 90. Prevention• Education of mother• Counseling regarding family planning and spacing between children• Promotion of breast feeding• Education of the parents regarding immunization of the children
  91. 91. THANK YOU