3. • Trophic=relating to nutrition
• Atrophy= wasting away=losing
• Malnutrition =undernutrition
• Hypotrophy =undernutrition
• Hypotrophy=Malnutrition
• Failure to thrive= Hypostature
• Severe Malnutrition =
protein-energy malnutrition
(PEM)(marasmus, kwashiorkor)
4. • Hypotrophy
(=undernutrition,
malnutrition) is the
chronic disturbance of
nutrition and digestion,
characterized by lag of
growth and weight and
accompanied by
disorders of metabolic
and trophic processes,
decrease of immunity
and development of
micronutrient
deficiency.
7. MALNUTRITION
WHO defines 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.“
Malnutrition is the condition that develops when the
body does not get the right amount of the vitamins,
minerals, and other nutrients needed to maintain healthy
tissues and organ function.
Definitions
8.
9. AETIOLOGY
Different aetiological factors can lead to
malnutrition. They are:
Social, political,enviromental and Economic Factors
Metabolism disorders
Chronic diseases
Insufficiency of food (inadequate)
Problems with digestion and absorption as well
as GIT anomalies.
10. Insufficiency of food (inadequate)
Lack of breast feeding and giving diluted formula
Improper complementary feeding
Over crowding in family
Ignorance
Illiteracy
Lack of health education
Poverty
Infection
11. Role of Free Radicals : Two new theories have been
postulated recently to explain the pathogenesis of
kwashiorkor. These include Free Radical Damage to
liver cells giving rise to kwashiorkor.
Age of Host :People at high risk
Frequent in Infants & young children whose rapid
growth increases nutritional requirement.
PEM in pregnant and lactating women can affect the
growth, nutritional status & survival rates of their
fetuses, new born and infants.
Elderly can also suffer from PEM due to alteration of
GI System
13. Metabolic Changes
• Protein metabolism:
Total plasma proteins, albumin
gamma globulins
Carbohydrate metabolism:
The glucose level
glycogen stores
Fat metabolism:
Blood lipid levels
14. Practical nutritional assessment
1. Complete history,
including a
detailed dietary
history.
2. Growth
measurements,
(weight and
length/height).
3. Complete physical
examination.
15.
Protein-Energy Malnutrition
PEM is also referred toas
protein-calorie malnutrition.
It is considered as the primary
nutritional problem. Also
called the 1st National
Nutritional Disorder.
The term protein-energy
malnutrition (PEM) applies to
a group of related disorders
that include marasmus,
kwashiorkor, and
intermediate states of
marasmus-kwashiorkor.
PEM is due to “food gap”
between the intake and
requirement.
16. PROTEIN ENERGY MALNUTRITION
It is a group of nutritional deficiency diseases which include
kwashiorkor, marasmus and the intermediate stages.
MARASMUS
The term is derived from the Greek word marasmos, which
means wasting. Represents acute starvation. Marasmus
results from the inadequate intake of protein and calories.
However, to avoid confusion, the term severe wasting is
preferred.
KWASHIORKOR
The term is taken from the language of Ghana and means “the sickness of
the weaning”, It is the body’s response to insufficient protein intake but
usually sufficient calories for energy. caused when very young children
are weaned from their mother's milk and placed on a diet high in calories
and carbohydrates, but low in protein.
17. Severe protein deficiency
• Generally result of a diet deficient in
protein.
Symptoms range from:
• Edema in legs, feet, and stomach
• Muscles strength are wasting and
diminish.
• Bloated abdomen.
• Hair is brittle and easy to pull out
• Appear pale, sad, and apathetic
• Prone to infection, rapid heart rate,
excess fluid in lungs, pneumonia,
septicemia, and water and electrolyte
imbalances
(Image from http://www.thachers.org/pediatrics.htm)
Types of PEM: Kwashiorkor
18. Wasting disease results from a
sever deficiency of protein and
other calories nutrients.
Symptoms and signs:-
• Most often affects infants.
• Weak and many cannot stand
without support.
• Hair is thin and dry.
• More susceptible to infection
dehydration and disease.
• Muscles and tissues of these
children begin to waste away.
Types of PEM: Marasmus
19. Chronic deficiency in kilocalories
and protein.
• Have edema and Bloated
abdomen Have a “skin and
bones” appearance.
• With treatment the edema
subsides and appearance
becomes more like someone
with marasmus.
Types of PEM: Marasmic Kwashiorkor
20.
Malnutrition is a special
health problem, especially
in developing countries.
95 % of all malnourished
peoples living in the sub-
tropics and tropics.
More than 70% of children
with PEM live in Asia and
26% in Africa, and 4% in
Latin America and the
Caribbean Region (WHO).
21.
Malnutrition is by far the
biggest contributor
to child mortality:
49% of the 10.4 million
deaths occurring in
children younger than 5
years in developing
countries are associated
with PEM.
6 million children die of
hunger every year.
22. Classification of hypotrophy
I degree deficiency of
10-20% of the body
weight. (Mild)
• II degree (moderate) –
the deficiency of 20-
30% of the body weight.
• III degree (severe) –
the deficiency more
than 30% of the body
weight.
23. Role of Free Radicals : Two new theories have been
postulated recently to explain the pathogenesis of
kwashiorkor. These include Free Radical Damage to
liver cells giving rise to kwashiorkor.
Age Of Host :
Frequent in Infants & young children whose rapid
growth increases nutritional requirement.
PEM in pregnant and lactating women can affect the
growth, nutritional status & survival rates of their
fetuses, new born and infants.
Elderly can also suffer from PEM due to alteration of
GI System
24. Leading cause of death (less than 5 years of age)
Primary PEM:
Protein + energy intakes below requirement for normal growth.
Secondary PEM:
the need for growth is greater than can be supplied.
decreased nutrient absorption
increase nutrient losses
Linear growth ceases
Static weight
Weight loss
Wasting
Malnutrition and its signs
AETIOLOGY of PEM:
26. Classification of Malnutrition (WHO)
Weight for
height or
length
Moderate
Malnutrition
Between 70th to
79th percentile
Mid-upper Arm Less than
Circumference 12.5 cm
Severe
Malnutrition
Less than the
50th percentile
Less than 11
cm
Bilateral
Edema Not
27. • The World Health Organization
defines severe malnutrition as
"a very low weight for height, by
visible severe wasting, or by
the presence of nutritional
oedema."
28. Height for Age: As index used to measure stunting or chronic
malnutrition. (i.e., preventing growth and development probably).
H/A: (Ht of child/Ht of normal child of same age) × 100.
INDICATORS OF PEM
Weight for Height: Low weight for height indicates
Acute Malnutrition.
W/H: (Wt of child/Wt of normal child of same height) ×
100
Weight for Age:
W/A: (Wt of child/Wt of normal child of same age) × 100
Mid Upper Arm Circumference: Used for screening
wasted children's.
29. Body mass Index: It is a screening tool for
thinness, overweight and obesity.
BMI= Weight in Kg/square of height in meters.
All measures are assessed at various ages by standard
growth chart.
30.
31. CLASSIFICATION.
Childs wt=50th percentile is healthy and is taken as
100%.
Between 80-100%of 50th percentile is healthychild
<80%malnourished
Grade 1
Grade2
Grade 3
Grade 4
71-80%of 50th percentile
61-70%of 50th percentile
51-60%of 50th percentile
<50%of 50th percentile
32. WELCOME
CLASSIFICATION.
Weight for Age Edema present. Edema absent.
80-60% of
standard.
Kwashiorkor Ponderal
retardation
< 60 % of
standard.
Marasmic
Kwashiorkor
Marasmus
34. SKIN FOLD THICKNESS
Special calipers in the region of triceps or back of
shoulder
Normal 9-11 mm
Malnourished <9mm
It is for index of body wt.
35. Reductive Adaptation System
The systems of the body begin to “shut down” with
severe malnutrition.
The systems slow down and do less in order to allow
survival on limited calories.
This slowing down is known as reductive adaptation.
As the child is treated, the body's systems must
gradually "learn" to function fully again.
Rapid changes (such as rapid feeding or fluids)
would affect the systems, so feeding must be
slowly and cautiously increased.
37. 1.Iron
Due to reductive adaptation, the severely malnourished child
makes less haemoglobin than usual.
Iron that is not used for making haemoglobin is put into
storage.
Giving iron early in treatment can also lead to “free iron” in
the body.
Free iron can cause problems in threeways:
Free iron is highly reactive and promotes the formationof
free radicals with damaging effects.
Free iron promotes bacterial growth and can make some
infections worse.
The body tries to protect itself from free iron by converting it
to ferritin. This conversion requires energy and amino acids
and diverts these from other critical activities
38. 2. Provide potassium and restrict sodium
In reductive adaptation, the “pump” that usually controls
the balance of potassium and sodium runs slower. As a
result, the level of sodium in the cells rises and potassium
leaks out of the cells and is lost.
So….Rehydration Solution for Malnutrition (ReSoMal) has
less sodium and more potassium than regular Rehydration
Solution (ORS) recommended by WHO.
39. MANAGEMENT
WHO recommends that children be kept in the severe
malnutrition ward or area until they reach (90%) weight-
for-height.
41. HYPOGLYCEMIA.
In severely malnourished children, the level
considered low is less than (<) 3 mmol/litre (or <54
mg/dl).
If the child can drink, give the 50 ml bolus of 10%
glucose orally. If the child is alert but not drinking,
give the 50 ml by NG tube feeding.
42. HYPOGLYCEMIA.
If the child is lethargic, unconscious, or convulsing,
give 5 ml/kg body weight of sterile 10% glucose by
IV, followed by 50 ml of 10% glucose by NG tube. If
the IV dose cannot be given immediately, give the
NG dose first.
Start feeding F-75 half an hour after giving glucose ,
during the first 2 hours.
If the child’s blood glucose is not low, begin feeding
the child with F-75 right away. Feed the child every 2
hours, even during the night.
43. HYPOTHERMIA
Actively re-warm the hypothermic child:
keeping the child covered
keeping the room warm,
Have the mother hold the child with his skin next to
her skin and cover both of them.
Keep the child’s head covered.
Monitor temperature hourly.
Stop rewarming when rectal temperature is 36.5 C
44. SHOCK MANAGEMENT.
The severely malnourished child is considered to
have shock if he/she:
is lethargic or unconscious and
has cold hands
plus either:
slow capillary refill (longer than 3 seconds),or
weak fast pulse.
45. SHOCK MANAGEMENT.
Give oxygen.
Give sterile 10% glucose 5 ml/kg by IV.
Infuse IV fluid at 15ml/kg over 1 hour.
Use 0.45% (half-normal) saline with 5% glucose).
Observe the child and check respiratory and pulse
rates every 10 minutes.
46. SHOCK MANAGEMENT.
If respiratory rate and pulse rate are slower after 1
hour, the child is improving. stop the IV.
If the respiratory rate and pulse rate increase Repeat
the same amount of IV fluids for another hour.
Continue to check respiratory and pulse rates every
10 minutes.
After 2 hours of IV fluids, switch to oral or
nasogastric rehydration with ReSoMal (special
rehydration solution for children with severe
malnutrition).
47. SHOCK MANAGEMENT.
Give 5 − 10 ml/kg ReSoMal in alternate hours with F-
75 for up to 10 hours.
Leave the IV line in place in case it is needed again.
If the child fails to improve after the Second hour of
IV fluids, then assume that the child has septic shock.
Give maintenance IV fluids (4 ml/kg/hour) while
waiting for blood.
When blood is available, stop all oral intake and IV
fluids, give a diuretic to make room for the blood,
and then transfuse whole fresh blood at 10 ml/kg
slowly over 3 hours.
48. ANEMIA MANAGEMENT.
Mild or moderate anaemia is very common in
severely malnourished children and should be treated
later with iron, after the child has stabilized.
Very severeanaemia
If haemoglobin is less than 40 g/l, give a blood
transfusion.
If there are no signs of congestive heart failure, transfuse
whole fresh blood at 10 ml/kg slowly over 3 hours.
If there are signs of heart failure, give 5 – 7 ml/kg packed
cells over 3 hours instead of whole blood. Give a diuretic;
Furosemide (1 mg/kg, given by IV)
49. Manage watery diarrhea and/or vomiting
with ReSoMal.
ReSoMal is Rehydration Solution for Malnutrition. It
is a modification of the standard Oral Rehydration
Solution (ORS) recommended by WHO.
ReSoMal contains less sodium, more sugar, andmore
potassium than standard ORS
For children < 2 years, give 50 − 100 ml after each
loose stool. For children 2 years and older, give 100 −
200 ml after each loose stool.
It should be given by mouth or by nasogastrictube.
If the child develops a hard distended abdomen with
very little bowel sound, give 2 ml of a 50% solution of
magnesium sulphate IM
51. ELECTROLYTE IMBALANCE.
Give extra potassium (4mmol/kg/day).
Give extra magnesium (0.6 mmol/kg/day).
These should be given for atleast 2 weeks.
54. Determine frequency & Amountof
feeds.
Feed orally .
Use an NG tube if the child :
does not take 80% of the feed (i.e., leaves more than
20%) for 2 or 3 consecutive feeds.
Remove the NG tube when the child takes: 80% of
the day’s amount orally; or two consecutive feeds
fully by mouth.
55. .
On the first day, feed the child a small amount of F-75
every 2 hours (12 feeds in 24 hours, including
through the night).
If the child is hypoglycaemic, give ¼ of the 2-hourly
amount every half-hour for the first 2 hours or until
the child’s blood glucose is at least 3 mmol/l.
After the first day, increase the volume per feed
gradually so that the child's system is not
overwhelmed.
The child will gradually be able to take larger, less
frequent feeds (every 3 hours or every 4 hours).
57. .
Criteria for increasing volume/decreasingfrequency
of feeds:
If little or no vomiting, modest diarrhea (for example,
less than 5 watery stools per day), and finishing most
feeds, change to 3-hourly feeds.
After a day on 3-hourly feeds: If no vomiting, less
diarrhea, and finishing most feeds, change to 4-
hourly feeds.
58. Adjusting to F-100 during transition, or
feeding freely on F-100.
Look for the following signs of readiness usually after
2 − 7 days:
Return of appetite (easily finishes 4-hourly feeds of F
75)
Reduced oedema or minimal oedema
The child may also smile at this stage
59. .
Begin giving F-100 slowly and gradually:
Transition takes 3 days.
First 48 hours (2 days): Give F-100 every 4 hours in the same
amount as you last gave F-75. Do not increase this amount for 2
days.
Then, on the 3rd day: Increase each feed by 10 ml as long as the
child is finishing feeds.
Continue increasing the amount until some food is left after most
feeds (usually when amount reaches about 30 ml/kg perfeed).
If the child is breastfeeding, encourage the mother to breastfeed
between feeds of F-100.
60. Rehabilitation" phase .
After transition, the child is in the "rehabilitation"
phase and can feed freely on F-100 to an upper limit
of 220 kcal/kg/day.
(This is equal to 220 ml/kg/day.)
, give iron daily, Calculate and
administer the amount needed: Give 3 mg elemental
Fe/kg/day in 2 divided doses. Always give iron orally,
never by injection. Preferably give iron between meals
using a liquid preparation.
61. Monitor individual patient progress
and care:.
Good weight gain: 10 g/kg/day or more
Moderate weight gain: 5 up to10 g/kg/day
Poor weight gain: Less than 5 g/kg/day
62. Criteria for failure to respond to
treatment.
Primary failure to respond:
Day 4
Day 4
Day 10
Day 10
Failure to regain appetite
Failure to start to lose oedema
Oedema still present
Failure to gain at least 5 g/kg
of body weight per day
During rehabilitation
Secondary failure to respond:
Failure to gain at least 5 g/kg
of body weight per day for 3
successive days
63. Review patient records for common
factors in adverse outcomes.
Deaths that occur within the first 2 days are often due
to:
Hypoglycaemia.
Overhydration.
Unrecognized or mismanaged septic shock, or other
serious infection.
Deaths that occur after 2 days are often due to:
Heart failure.
64. DISCHARGE.
WHO recommends that children be kept in the severe
malnutrition ward or area until they reach −1 SD weight-
for-height. It usually requires about 2 – 6 weeks .
If a child leaves before being achieving -1 SD, he islikely
to get worse and have to return.
WHO recommends that children be kept in the severe
malnutrition ward or area until their condition is stabilized(
regained appetite, reduced edema)
65. General instructions.
In addition to feeding instructions, mothers will need tobe
taught:
how to feed the child at home and give supplements.
how to continue any needed medications, vitamins , folic
acid (for 1 − 2 weeks),
and iron (for 1 month) at home
66. General instructions.
when and where to go for planned follow-up:
at 1 week, 2 weeks, 1 month, 3 months, and 6 months; then
twice yearly visits until the child is at least 3 years old.
