Chronic Liver Disease in pediatric: a case presentation and discussionDr Abdalla M. Gamal
A presentation from a tutorial about an interesting case that came to the Pediatric Department of Sebha Medical Center and was imaged by the Radiology Department.
The tutorial was a joint effort between Dr Zeinab Salem Ali (from Pediatric Department) and me (from Radiology Department). In her slides, Dr Zeinab presented the case history, examination, investigations, differential diagnosis and discussed the clinical presentation, investigations and management for chronic liver diseases in pediatric patients.In my slides, I discussed the definition, etiology, natural history of this condition and explained the role of imaging in its diagnosis.
These are my slides after some modifications. I added an aknowlegement page to illustrate Dr Zeinab effort and to thank Dr Khaled Aljasem from Pediatric Department for his effort in revising the original presentations and the constructive feedback he provided which improved the quality of the presented material. Then I added a summary for the parts Dr Zeinab has presented to make this powerpoint presentation complete.
This presentation was presented by Dr Zeinab Salem (from Pediatric Department) and me in a joint tutorial between Pediatric Department and Radiology Department of Sebha Medical Center.
Chronic Liver Disease in pediatric: a case presentation and discussionDr Abdalla M. Gamal
A presentation from a tutorial about an interesting case that came to the Pediatric Department of Sebha Medical Center and was imaged by the Radiology Department.
The tutorial was a joint effort between Dr Zeinab Salem Ali (from Pediatric Department) and me (from Radiology Department). In her slides, Dr Zeinab presented the case history, examination, investigations, differential diagnosis and discussed the clinical presentation, investigations and management for chronic liver diseases in pediatric patients.In my slides, I discussed the definition, etiology, natural history of this condition and explained the role of imaging in its diagnosis.
These are my slides after some modifications. I added an aknowlegement page to illustrate Dr Zeinab effort and to thank Dr Khaled Aljasem from Pediatric Department for his effort in revising the original presentations and the constructive feedback he provided which improved the quality of the presented material. Then I added a summary for the parts Dr Zeinab has presented to make this powerpoint presentation complete.
This presentation was presented by Dr Zeinab Salem (from Pediatric Department) and me in a joint tutorial between Pediatric Department and Radiology Department of Sebha Medical Center.
Approach to neonatal jaundice - Simplified
references : Cloherty And Stark's Manual Of Neonatal Care
AIIMS Protocol In Neonatology
Care Of The Newborn – Meherban Singh
A Broad overview for management of PEM. Very important topic for MBBS Students. Seminars ,Lectures and exam preparation can be done using my presentaion. Helpful for CMC Vellore Seminars
Management of SEVERE ACUTE MALNUTRITIONRAVI PRAKASH
MANAGEMENT OF SEVERE ACUTE MALNUTRITION :-
DEALT WITH INVESTIGATION AND TREATMENT OF CHILD SUFFERING FROM SEVERE ACUTE MALNUTRITION, ESSENTIAL AND LATEST GUIDELINES FOR MANAGEMENT
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
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Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
2. IDENTIFICATION OF SEVERE ACUTE
MALNUTRITION
• Recommended criteria for identifying SAM in infants > 6 months of
age:
• 1. Weight-for-height less than –3 Z score according to WHO median
growth chart and/or
• 2. Visible severe wasting and/or
• 3. Mid arm circumference <11.5 cm and/or
• 4. Oedema of both feet
3. • Recommended criteria for identifying SAM in infants <6 months age:
Any infant more than 49 cm who has following features are treated as
severe acute malnutrition:
• 1.Weight-for-length less than -3 Z score according to WHO growth
charts and/or
• 2. Visible severe wasting and/or
• 3.Oedema of both feet*
4. PATHOPHYSIOLOGY OF SAM
• Child's intake is insufficient to meet his daily requirements
•
• Process of REDUCTIVE ADAPTATION sets in
• 1. Fat stores are mobilised for energy --> mobilisation of protein in
muscles, skin and GI tract
• 2. Reduced activity , BMR, reduced infalmmatory and immune
responses
5. CHANGES SEEN IN BODY ORGANS AND
METABOLISM
• 1. Liver - a. Reduced glucose production lead to HYPOGLYCEMIA
b. Reduced ability to synthesis albumin, transferrin,
transport proteins
c. Reduced ability to cope with dietary proteins and toxins
• 2. Reduced thermogenesis lead to HYPOTHERMIA
• 3. Kidneys – Reduced renal excretion of excess fluids and sodium
leads to FLUID OVERLOAD
6. • 4. Heart-Smaller and weaker and has reduced cardiac output and fluid
overload readily leads to cardiac failure
• 5. Sodium- Reduced activity of Na-K pump + and leaky cell
membranes increased intracellular sodium leads to FLUID RETENTION
AND ODEMA
• 6. Potassium – Cell leakage and urinary excretion
• 7. Muscle protein loss accompanied by loss of K, Mg, Zn and Cu.
7. 8. GI – Reduced production of enzymes and gastric acid, reduced
motillity easy bacterial colonization of stomach and small
intestine,damaging the mucosa and deconjugating bile salts leading to
IMPAIRED DIGESTION AND ABSORPTION.
9. Reduction in cell replication and repair leading to easy translocation
of organisms through gut mucosa
10. Impaired immune function , especially cell mediated immunity
leading to increased risk of undiagnosed INFECTIONS
8. 11.RBC mass reduced , releasing iron which requires of glucose and
amino acids to be converted to ferritin, increasing the risk of
hypoglycemia and amino acid imbalance.
If conversion to ferritin is incomplete, unbound growth and formation
of free radicles.
12. Micronutrient deficiency leads to reduced free radical deactivation
cell damage
9. SCREENING OF SAM
• a. Active screening by ASHA through house to house visit
with MUAC tape and to look for b/l pitting pedal edema
• b. Passive screening during growth monitoring, village health
and nutrition days ( VHND) using MUAC and b/l pitting
edema AND screening of children coming to opd/ inpatient
ward
11. • Features of SAM with Medical complications - NRC
• If no medical complications Refer to subcentre for
assessment by ANM and transfer to community based
programme for SAM
• No features of SAM -- Nutritional counselling to mother
12. APPETITE TEST
• Decides if the patient should be sent for in-patient or out patient
management
• The appetite test has been standardised using Ready to use
Therapeutic Food (RUTF).
• For children 7–12 months: Offer 30-35 ml/kg of Catch-up diet. If the
child takes more than 25 ml/kg
• then the child should be considered to have good appetite.
• For children >12 months: Feed locally prepared with the following
food items may be offered.
13. • Amount of local therapeutic feed that a child with SAM should take to
PASS the appetite test.
BODY WEIGHT(KG) MINIMUM AMOUT OF RUFT TO BE
CONSUMED FOR PASSING
3-4.9 105-130g/day
5-6.9 200-260g/day
7-9.9 260-400g/day
10-14.9 400-460g/day
14. • DAVNGERE MIX:
-Ragi hittu
-Bengal gram-roasted and powdered
-Groundnut - roasted and powdered
-Jaggery syrup
TOTAL: 100 g ball
Calories : 400kcal
Protein : 14g
16. • Children with SAM who do not have criteria for admission
can be managed under outpatient program.
• There is a need to provide therapeutic food broadly adhering
to the WHO and UNICEF specifications.
• One form of therapeutic food is RUTF.
• The amount to be given in 2-3hourly with plenty of water
• Breast feeding should be continued while the child is on
therapeautic food. Other foods my be given if child has good
appetite and has no diarrhea
17. • OUTCOME OF TREATMENT AS FOLLOWS:
a) NON RESPONDER/PRIMARY FAILURE:
1)Failure to gain weight for 21 days (or)
2)Weight loss since admission to program for 14 days
b)SECONDARY FAILURE OR RELAPSE:
1)Failure of appetite test at any visit (or)
2)weight loss of 5% body weight at any visit. Non responders and
children who develop danger signs at any time, during first 4 weeks
should be referred to hospital
c)DEFAULTERS:Not traceable for at least 2 visits
18. • Children can be discharged from the progam if any of the
following criteria are satistifed:
a)children admitted to SAM prgram on the basis of W/H
criteria should be discharged when W/H becomed > or equal
to -2 Zscore
b)Children admitted on basis on MUAC or b/l pedal edema
should be discharged when MUAC becomes > or equal to
12.5cm and there is no edema
19. CHILDREN WITH MEDICAL COMPLICATIONS
ADMITTED TO NRC
• Very weak, Apethic
• Persistent vomitings
• Diarrhoea with dehydration
• Fast breathing/chest indrawings/cyanosis
• Fever>38.5c / Hypothermia < 35c
20. • Presence of any emergency signs
• Odema
• Extensive skin lesions, eye lesions
• Severe anemia
• Any general sign that clinician warrents transfer to in-
patient
21. • NRC is a unit in a health facility where children with
SAM are admitted and managed
• Services provided:
a. 24 hr care and monitoring
b. Treatment of medical complications
c. Therapeutic feeding
22. d. Providing sensory stimulation and emotional care
e. Social assessment of family and counselling on feed,
care and hygiene
f. Demonstration and practice
g. follow up of discharged children.
23. • STABILISATION PHASE: 1-2 days for treating hypoglycemia,
hypothermia and dehydration. Then F-75 feeding formula is started.
• TRANSITION PHASE: 2-3 days to correct electrolyte imbalances, treat
infections and correct micronutrient deficiencies. Transition from F-
75 to F-100 diet in same amount
• REHABILITATION PHASE:For catch-up growth.
24.
25. TREATMENT OF HYPOGLYCEMIA
1. If the child is conscious with blood glucose
<54mg/dl, immediately give the child a 50 ml bolus of
10% glucose or 10% sucrose.
26. 2. If the child is unconscious, lethargic or convulsing give
IV sterile 10% glucose (5ml/kg), followed by 50ml of 10% glucose or
sucrose by NG tube.
Start feeding with starter diet, 1/2hour after giving glucose.Give it half-
hourly during first 2 hours.
For a Hypoglycemic child, the amount to give every half-hour is 1/4th of
2 hourly amount.
27. TREATMENT OF HYPOTHERMIA
• If the Axillary temperature < 35 degrees or rectal temperature < 35.5
degrees
• ACTIVELY REWARM THE HYPOTHERMIC CHILD:
- Ask the mother to hold the child with skin to skin contact(kangaroo
technique). Keep the child’s head covered.
28. -Provide heat with overhead warmer, incandescent lamp or radiant
heater.
-Monitor temp every 1/2 hourly during rewarming.Stop rewarming if
temp becomes normal.
If the rectal temp<32 degrees c, child has severe hypothermia:
-Give humidified oxygen
-Give 5ml/kg of 10% IV Dextrose immediately or 50ml of 10%Dextrose
by NG tube
-Start intravenous antibiotics
29. -Give warm feeds if childs takes orally, else feed through NG tube
-Start maintenance IV fluids(prewarmed),if there is feed intolerace or
contraindication for NG feeding.
GENERAL MEASURES TO PREVENT HYPOTHERMIA
Feed immediately,Cover the child including head, Maintain Room temp
of 25-30 degree c, change wet cloths or bedding
30. ASSESSMENT AND CLASSIFICATION OF
DEHYDRATION IN SAM
IF ANY TWO OF THE FOLLOWING SIGNS ARE
PRESENT
-LETHARGIC OR UNCONSCIOUS
-SUNKEN EYE
-NOT ABLE TO DRINK OR DRINKING POORLY
-SKIN PINCH GOES BACK VERY SLOWLY
THE CHILD HAS SEVERE
DEHYDRATION
IF ANY TWO OF THE FOLLOWING SIGNS ARE
PRESENT
-RESTLESS,IRRITABLE
-SUNKEN EYES
DRINKS EAGERLY, THIRSTY
SKIN PINCH GOES BACK SLOWLY
THE CHILD HAS SOME
DEHYDRATION
31. DIAGNOSIS OF DEHYDRATION IN SAM
• IN CHILDREN WITH SAM CLASSICAL SIGNS OF DEHYDRATION ARE
UNRELIABLE THUS:
-IN SEVERELY WASTED CHILD, SKIN NORMALLY IS IN FOLDS AND IS
INELASTIC SO SKIN PINCH WILL BE POSITIVE WITHOUT BEING ANY
DEHYDRATION
-EYES ARE NORMALLY SUNKEN WITHOUT BEING ANY DEHYDRATION
32. THEREFORE DIAGNOSIS COMES FROM HISTORY:
-H/O SIGNIFICANT RECENT FLUID LOSS-USUALLY DIARRHOEA WHICH IS
CLEAR LIKE WATER AND FREQUENT WITH A SUDDEN ONSET
-H/O RECENT CHANGE IN CHILD’S APPERANCE
-EYES HAVE CHANGED TO BECOME SUNKEN SINCE DIARRHOEA
STARTED
33. TREATMENT OF DEHYDRATION IN SAM CHILD
WITHOUT SHOCK
• WHO RECOMMENDS USE OF REHYDRATION SOLUTION FOR
MALNOURISED CHILDREN (ReSoMal)
HOW OFTEN TO GIVE ReSoMal AMOUNT TO GIVE
EVERY 30 MINUTES FOR THE 1ST 2 HOURS 5ML/KG BODY WEIGHT
ALTERNATE HOURS FOR UP TO 10 HOURS
(STARTER DIET F-75 IS GIVEN IN ALTERNATE
HRS)
5-10 ML/KG
34. *AFTER REHYDRATION ,WHEN THE CHILD HAVE 3 OR MORE SIGNS OF
HYDRATION, STOP GIVING ORS IN ALTERNATE HOURS.
• FOR EVERY EPISODE OF WATERY STOOL GIVE ORS(ReSoMal) TO
REPLACE STOOL LOSSES
-FOR <2 YEARS : 50ML AFTER EACH LOOSE STOOL
2 YEARS AND OLDER : 100ML AFTER EACH LOOSE STOOL
*DURING REHYDRATION BREAST FEEDING SHOULD NOT BE
INTERRUPTED
*RESOLUTION OF THE SIGNS OF DEHYDRATION:
-Stop all rehydration treatment and start the child on starter diet of F-
75
37. MANAGEMENT OF SHOCK IN SAM
• Shock is a dangerous condition with severe
weakness,lethargy,unconsciouness,cold extremities, and fast, weak
pulse. Consider shock if :
-Has cold hands with
-Slow capillary refill(longer than 3 seconds), AND
-Weak and fast pulse
* 2months-12 months : 160bpm
*12months-5 years : 140bpm
40. -Give maintenance IV fluid (4 ml/kg/hr)
-Transfuse whole blood 10ml/kg over 3 hours. If there are
signs of heart failure give packed cells @ 5-7ml/kg
-Start broad spectrum antibiotics(3rd generation
cephalosporins)
*INJ CEFOTAXIME 150MG/KG/DAY IN 3 Divided doses
(OR)
41. *INJ CEFTRIAXONE 100MG/KG/DAY IN 2 Divided doses
+
INJ GENTAMYCIN 7.5MG/KG in Single dose
- If no improvement with fluid bolus, Start DOPAMINE @
10MCG/KG/MIN
42. CORRECTION OF ELECTROLYTE IMBALANCE
• Electrolyte status: High sodium, Low potassium and magnesium
- Potassium supplementation at 3-4 meq/kg/day upto 2 weeks (most
commonly as syrup available as 20meq/15ml. It should be diluted in
water.)
- Magnesium supplementation-
• Day 1- Inj. 50% magnesium sulphate at 0.3 ml/kg IM (2 ml max).
• Day 2 onwards- oral magnesium supplementation at 0.4 to 0.6
mmol/kg/day for 2 weeks
- Salt restricted diet
43. TREATMENT OF INFECTIONS
• In SAM children the usual signs of infections are often absent, hence
appropriate antibiotics should be started as a part of initial
management
• SELECTION OF ANTIBIOTICS:
-If the child appears to have no complications give oral AMOXICILLIN
15MG/KG, 8TH hourly x 5 days
-If the child has complications select antibiotic as follow:
44.
45. • Duration of antibiotic therapy depends on the diagnosis.
• The following guideline can be followed in general:
-Suspicion of clinical sepsis: at least 7 days
-Urinary tract infection: 7-10 days
-Culture positive sepsis: 10-14 days
-Meningitis: at least 14-21 days
-For Deep seated infections like arthritis and osteomyelitis: at least 4
weeks.
*Treat associated conditions like malaria,TB,amoebiasis or HIV as per
the national guidelines.
46. CORRECTION OF MICRONUTRIENT DEFICENCY
• Multivitamin supplements- Vit A,C,D,E and Vit B12 at twice
the RDA
• Folic acid- 5 mg on day 1,
then 1 mg/day
• Elemental Zinc – 2 mg/kg/day
• Copper- 0.3 mg/kg/day
• Iron- no iron in stabilization phase. Started after 2 days of
catch up feed, @ 3 mg/kg/day BD,preferably between meals
47. START CAUTIOUS FEEDS
• FEATURES OF FEEDING IN STABILISATION PHASE: a.Small,
frequent, low osmolarity, low lactose STARTER DIET F-75 is
used
• Started diet is specially made to meet the child’s needs
without overwhelming the body’s systems at this early stage.
• Recipe for starter diet as follows
48. CONTENTS (PER 1000ML) STARTER DIET (F-75) STARTER DIET (F-75)
CEREAL BASED
FRESH COW’S MILK OR
EQUIVALENT MILD (Eg.TONED
MILK)
300 300
SUGAR (g) 100 70
CEREAL FLOUR(powered puffed rice - 35
VEGETABLE OILD 20 20
WATER MAKE UTO (ML) 1000 1000
ENERGY (KCAL/100ML) 75 75
PROTEIN (G/100ML) 0.9 1.1
LACTOSE (G/100ML) 1.2 1.2
50. • DETERMINE FREQUENCY OF FEEDS:
• On 1st day feed the child every 2 hourly(12 feeds/24hrs, including
night).
• -After the 1st day increase the volume per feed gradually.
DETERMINE AMOUNT OF STARTER DIET NEEDED PER FEED
-Given the child’s starting weight and the frequency of feeding, use the
reference table to look up the amount needed per feed
-If the child has severe(+++) edema, his weight maybe 30% higher due
to excess fluid. To compensate give only 100ml/kg/day of starter diet.
54. ADJUST THE CHILDS FEEDING PLAN FOR NEXT
DAY
• Criteria for increasing/decreasing frequency of feeds
- If vomiting, lots of diarrhoea, or poor appetite, continue 2-hourly
feeds.
- If little or no vomiting, modest diarrhoea and finishing most feeds,
change to 3-hourly feeds.
- After a day on 3-hourly feeds: If no vomiting, less diarrhoea, and
finishing most feeds, changes to 4-hourly feeds.
55. REHABILITATIVE PHASE
CATH UP GROWTH
When the child is stabilized(usually 2-7 days), ‘catch-up’ formula or
catch-up diet is used to rebuild wasted tissues. Catch up diet contains
100kcal and 2.9 g protein per 100ml
1)FEED THE CHILD IN TRANSITION
-It is extremely important to make the transition to free feeding on
catch-up diet gradually and monitor carefully.If transition is too rapid,
heart failure may occur
56. a)Recognize readiness for transition:
-Following signs after 2-7 days
*Return of appetite (easily finishes 4-hourly feeds of started
diet)
*Reduce edema or minimal edema
*Child may also smile at this stage
57. b)Begin giving catchup diet slowly and gradually:
Transition takes 3 days with catch-up diet
FIRST 48 HOURS(2 DAYS): Catch up diet given every 4 hours in the same
amout as last starter diet. Do not increase for 2 days
THEN, ON THE 3RD DAY: Increase each feed by 10ml as long as the child
is finishing feeds------->if does not finish feed offer the same amount at
the next feed------> if the feed is finished, increase by 10ml.
58. 2) FEED FREELY WITH CATCH UP DIET
-Transition usually takes 3 days. After transition, the child is in
Rehabilitation phase and can feed freely on catchup diet to upper limit
of 220kcal/kg/day.
-Most children will consume at least 150kcal/kg/day(max of
220kcal/kg/day); any amount less than this indiactes the child is not
being fed freely or is unwell.
59. CRITERIA FOR TRANSFER TO A REHABILITATION CARE
-Eating well
-Responds to stimuli, interest im surroundings
-Minimal or no odema no NG tube, IV infusions stopped
-Gaining weight >5m/kg pe day for 3 successive days
60. F-100 DIET: FOR CATCH UP
CNTENTS PER 100ML CATCH UP DIET CATCHUP DIET
COWS MILK/TONED DAIRY
MILK(ML)
900 750
SUGAR 75 25
VEGETABLE OIL 20 20
PUFFED RICE - 70
WATER TO MAKE (ML) 1000 1000
ENERGY(KCAL/100ML 100 100
PROTEIN(G/100ML) 2.9 2.9
LACTOSEG/100ML) 4.2 3
61. PROVIDE SENSORY STIMULATION AND
EMOTIONAL SUPPORT
• A cheerful, stimulating environment
• Emotional and physical stimulation plays crucial role for child recovery
• When mothers are involved in care at the hospital they learn how to
continue care at home
• Encourage mother to prepare food,feed child,bath and change
• Structured play activity (15-30 mins /day ): Language skills, motor
activities, in and out toys with blocks
• Physical activity
62.
63. CRITERIA FOR DISCHARGE
• Achieved weight gain of ≥ 15% ,and has satisfactory weight gain for 3
consecutive days (>5 gm/kg/day)
• Odema has resolved
• Child eating an adequate amount of nutritious food that the mother
can prepare at home
• All infections and other medical complications have been treated
• Child is provided with micronutrients
• Immunization is updated
64. Treatment for Helminthiasis
Treatment for helminthic infections should be given to all
children with SAM before discharge. Give a single dose of any
of the following antihelminthics orally:
*200 mg albendazole for children aged 12-23 months
* 400 mg albendazole for children aged 24 months or more
OR
*100 mg mebendazole twice daily for 3 days for children aged
24 months or more.
65. FOLLOW UP AFTER DISCHARGE
• A child with 90% weight-for-height (-1 SD) : Recovery
• Teach parents to feed frequent energy rich food and give structured
play environment
• Regular follow up checks: every 2 weeks 1st month then monthly, If
WFH >-1SD.
• Booster immunisations as per schedule
• 6 monthly Vit A supplementation(9-59 months)
66. • DBF and EBM for breast fed infants is preferred, mixture of breast feed and
non cereal starter diet for inadequately breast fed infants and sole non
cereal starter diet for non breast fed.
• Support to re-establish breast feeding. SST.
• Good diet and micronutrient support to the mother.
• Diluted catch up diet in rehabilitation phase (diluted by 1/3rd extra water
to make 135 ml instead of 100 ml)
• Non breast fed infants to be fed locally available animal milk on discharge
• Discharge when gaining weight for 5 days on breast feed alone and no
complications
69. • May occur if high energy feeding is started too soon or vigorously
and it may lead to sudden death with signs of heart failure.
• Onset is usually 24-48 hours after the start of high energy feed
• Clinical signs and symptoms :
• BREATHLESSNESS, RAPID PULSE, WATERY DIARRHEA, RAPID
ENLARGEMENT OF LIVER
• Increase supply of carbohydrates-----> increase Na+ pump
activity-----> Rapid release of accumulated Na from cells----->
expansion of extra cellular and plasma volumes.
• Increase uptake of Potassium, Magnesium,Phosphate----->leads
to lowered serum concentration of above electrolytes.
70. • Apparent worsening with increase in liver size, hypertrichosis,
gynecomastia,parotid swelling, abdominal distension, ascites,
spleenomegaly and eosinophilia during therapy marks
Refeeding syndrome.
• Self limiting tremors known as kwashi shake may also occur
• Dysmyelination,vitamin deficiencies,neurotransmitter
imbalance and high solute load on kidneys are other possible
reasons.
71.
72. PREVENTION
• to minimize the risk, initial stabilization phase which includes
providing maintenance amounts of energy and protein.
• Correcting electrolyte imbalances and micronutrient
deficiencies.
• Followed by a controlled transition to high-energy feeding.
Milkbased diets are desirable because milk is a good source of
phosphate.
73. DERMATOSIS
+ mild: discoloration or a few
rough patches of skin
+ + moderate: multiple patches on
arms and/or legs
+ + + severe: flaking skin, raw skin,
fissures (openings in the skin)
• Useful ointments are zinc and
castor oil ointment, petroleum
jelly, or paraffin gauze dressing.
74. • BITOT SPOTS: superficial foamy
white spots on conjuctiva
• CONJUCTIVAL AND CORNEAL
XEROSIS
• PUS AND INFLAMMATION: signs
of infection
• CORNEAL ULCERATION: sign of
severe vit A deficieny. It is
emergency and needs treatment
with vit A and atropine. Can
cause blindness.
76. TREATMENT
• If eye signs of deficiency, give orally: Vitamin A on days 1, 2, 14
• >12 months = 200,000 IU (Weight > 8 kg)
• 6-12 months = 100,000 IU
• 2-5 months = 50,000 IU
• <2 months, it is given with caution and preferably may be given to
the mother.
77. • Common feature but it should subside during the 1st week of
treatment with cautious feeding
• In the rehabilitation phase, loose, poorly formed stools are no cause
for concern
• provided weight gain is satisfactory.
• Mucosal damage & giardiasis
-Give Metronidazole (7.5 mg/kg ,8 hourly for 7 days)
78. • Lactose intolerance
• Treat only if continuing diarrhea is preventing general
improvement
• Substitute milk feeds with yogurt or lactose-free infant
formula.
• Reintroduce milk feeds gradually in the rehabilitation
phase.
79. • Suspected if diarrhea worsens substantially with
hyperosmolar starter F-75.
• Ceases when the sugar content is reduced and osmolarity is
<300 mOsmol/L.
• In these cases, use isotonic F-75 or low osmolar cereal-based
F-75. Introduce F-100 gradually.
80. • Hb below 4 gm/dl or PCV<12% or hb between 4 to 6 gm/dl with
Respiratory distress
• Transfuse Whole blood @ 10 ml/kg over 3 hrs with Inj. Furosemide @
1mg/kg at the start If signs of cardiac failure : PRBC @ 5-7 ml/kg
• If severe anaemia persists, donot repeat transfusion within next 4
days.
81. • Giv MEBENDAZOLE 100 MG ORALLY, TWICE FOR 3 DAYS OR
ALBENDAZOLE SINGLE DOSE
If strongly suspected (contacts with adult TB patient, poor growth
despite good intake, chronic cough, chest infection not responding
to antibiotics):
-Tuberculin test (false negatives are frequent)
-Chest X-ray & Gastric aspirate for AFB stain, culture & CBNAAT.
-If test is positive/strong suspicion of TB, treat according to
National TB Elimination Programme (NTEP) Guidelines.
82. REFERENCES:
• IAP 2013 GUIDELINES
• KE ELIZABETH NUTRITION AND CHILD DEVELOPMENT
• MINISTRY OF FAMILY AND WELFARE GOVERNMENT OF INDIA,2013
83. LOW LACTOSE CATCHUP DIET
CONTENTS PER 100 ML EGG BASED
MILK (COWS OR TONED DAIRY MILK) 250
EGG WHITE 120
VEGETABLE OIL 40
CEREAL FLOUR 120
ENERGY(KCAL/100ML) 100
PROTEIN (G/100ML) 2.9
LACTOSE(G/100ML 1