Nutritional disorders--objectives Develop a plan for taking history for a child of nutritional disorders. Diagram outlines of nutritional assessment Revise the classification of protein energy malnutrition(pem) Interpret the clinical signs of PEM from head to toe. List Complications of PEM Plan the management for PEM Dr. Mai Mohamed Elhassan---Assistant Professor
HUMAN NUTRITION A healthy diet provides a balanced nutrients that satisfy the metabolic needs of the body without excess or shortage. Dietary requirements of children vary according to age, gender & stage of development.
HUMAN NUTRITION q Nutrients are substances that are crucial for human life, growth & well-being. 1-Macronutrients (carbohydrates, lipids, proteins & water) 2-Micronutrients are trace elements & vitamins, which are essential for metabolic processes.
Definition of malnutrition People are malnourished if their diet does not provide adequate calories and protein for growth and maintenance or they are unable to fully utilize the food they eat due to illness (undernutrition). They are also malnourished if they consume too many calories (overnutrition). (Unicef)
Protein Energy Malnutrition-PEM Deficiency of several nutrients Inadequate dietary intakes of protein of protein & energy,either because the dietary intake of the two nutrients are less than required for normal growth or because the needs for growth are greater than can be supplied.
Protein Energy Malnutrition---- EPIDEMIOLOGY The term protein energy malnutrition has been adopted by WHO in 1976. Highly prevalent in developing countries among children <5 years.
PEM--PRECIPITATING FACTORS LACK OF FOOD ( poverty) INADEQUATE BREAST FEEDING WRONG CONCEPTS ABOUT NUTRITION DIARRHOEA & MALABSORPTION INFECTIONS (worms, measles, T.B)
Causes of Protein Energy Malnutrition Inadequate dietary intake Malnutrition Disesase MANIFESTATIONS IMMEDIATE CAUSES Insufficient Household food Inadequate Maternal Childcare Insufficient Health Services/Unhealthy Environment UNDERLYING CAUSES Political and Economical powers BASIC CAUSES
The evil cycle of Malnutrition Inadequate Dietary Intake Weight loss Immunity lowered Growth faltering Mucosa damaged Apetite loss Nutrient Loss Malabsorbtion Altered metabolism Disease: Incidence Severity Duration Adapted from Andrew Tomkins and Fiona Watson, Malnutrition and Infection, ACC/SCN, Geneva, 1989, State of the World s Children 1998
Assessment of Nutritional status Direct 1.Dietary history 2.Anthropometric measurements 3. Clinical assessment 4.Laboratory Indirect Health statistics
Assessment of Nutritional status Dietary assessment Breast & complementary feeding details 24 hr dietary history Feeding technique & food habits Calculation of protein & Calorie content of children foods.
ANTHROPOMETRY Objective with high specificity & sensitivity Measuring Ht, Wt, MUAC, HC, skin fold thickness, & BMI Non-expensive & need minimal training
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. Chronic illnesses should be excluded
Eye signs of vitamin A deficiency
Sign of vitamin A deficiency
Clinical Assessment ADVANTAGES Fast & Easy to perform Inexpensive Non-invasive LIMITATIONS Doesn't not detect early cases Trained staff needed
LABORATOY ASSESSMENT Biochemical Serum proteins, Hematological CBC, iron, vitamin levels Microbiology Parasites/infection
Classification of malnutrition A. WELLCOME classification Parameter: weight for age + oedema Reference standard (50th percentile) Grades: n 80-60 % without oedema is under weight n 80-60% with oedema is Kwashiorkor n < 60 % with oedema is Marasmus-Kwash n < 60 % without oedema is Marasmus
CLASSIFICATION (2) B. GOMEZ classification Parameter: weight for age Reference standard (50th percentile) WHO chart Grades: n I (Mild) : 90-70 % n II (Moderate): 70-60 % n III (Severe) : < 60 %
KWASHIORKOR Cecilly Williams, a British nurse, had introduced the word Kwashiorkor to the medical literature in 1933. The word is taken from the Ga language in Ghana & used to describe the sickness of weaning.
KWASHIORKOR --ETIOLOGY Kwashiorkor can occur in infancy but its maximal incidence is in the 2nd yr of life following abrupt weaning. Kwashiorkor is not only dietary in origin. Infections, psycho-socical, and cultural factors are also operative.
KWASHIORKOR -ETIOLOGY Kwashiorkor is an example of lack of physiological adaptation to unbalanced deficiency where the body utilized proteins and conserve subcutaneous fat. One theory says Kwash is a result of liver insult with hypoproteinemia and oedema. Food toxins like aflatoxins have been suggested as precipitating factors.
CLINICAL PRESENTATION Kwash is characterized by certain constant features in addition to a variable spectrum of symptoms and signs.
CONSTANT FEATURES OF KWASH n OEDEMA n PSYCHOMOTOR CHANGES n GROWTH RETARDATION n MUSCLE WASTING
USUALLY PRESENT SIGNS MOON FACE HAIR CHANGES SKIN DEPIGMENTATION ANAEMIA
OCCASIONALLY PRESENT SIGNS n HEPATOMEGALY n FLAKY PAINT DERMATITIS n CARDIOMYOPATHY & FAILURE n DEHYDRATION (Diarrh. & Vomiting) n SIGNS OF VITAMIN DEFICIENCIES n SIGNS OF INFECTIONS
MARASMUS The term marasmus is derived from the Greek marasmos, which means wasting. Marasmus involves inadequate intake of protein and calories and is characterized by emaciation. Marasmus represents the end result of starvation where both proteins and calories are deficient.
MARASMUS Marasmus represents an adaptive response to starvation, whereas kwashiorkor represents a maladaptive response to starvation In Marasmus the body utilizes all fat stores before using muscles.
MARASMUS--EPIDEMIOLOGY & ETIOLOGY Seen most commonly in the first year of life due to lack of breast feeding and the use of dilute animal milk. Poverty and diarrhoea are the usual precipitating factors Ignorance & poor maternal nutrition are also contributory factors.
Clinical Features of Marasmus Severe wasting of muscle &loss of subcutaneous fats Severe growth retardation Child looks older than his age Hungry
Investigations for PEM Full blood counts Blood glucose profile Septic screening Stool & urine for parasites Electrolytes, Ca, Ph & ALP, serum proteins CXR & Mantoux test Exclude HIV & malabsorption
Complications of P.E.M Hypoglycemia Hypothermia Hypokalemia. Hyponatremia Heart failure Dehydration & shock Infections,sepsis (bacterial, viral & thrush)
TREATMENT--PEM 1-Emergency Treatment Correction of water & electrolyte imbalance Prevention of hypothermia &hypoglycemia Treat infection 2-Dietary support: kwash milk150-200 kcal /kg body wt/day + vitamins & minerals (vitamin A, folic acid) 3-Counsel parents & plan future care including immunization & diet supplements
PROGNOSIS--PEM Kwash & Marasmic-Kwash have greater risk of morbidity & mortality compared to Marasmus and under weight Early detection & adequate treatment are associated with good outcome Late effects on IQ, behavior & cognitive functions
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