(underweight) malnutrition

What is MALNUTRITION??

Case

• Baby Shanmuga Priya, 7 months old, weighing 4kg and length 58cms.

• Case of malnourishment

Indian and TN Scenario

• 65% of under 5 years children are malnourised• i.e 80 million (total population is 1.2 billion-

2011 census)• 10% of total 6.8million children are in the age

group of 0-6 years (6,80,000) out of which 30% are underweight (2,04,000)

Why Malnutrition??

sociodemographic factorsenvironmental factorsnutritional factors

Neglect to girl childLarge family sizeLack of child spacing and unplanned ma-ternity

Education of parentsSE statusSanitationStandard of livingPaternal attitudes towards chil-dren

Breastfeeding practisesDiet (normal and during illness)

classification

According to weight for age• GOMEZ’S classification• JELLIFFE’S classification

• WELCOME TRUST or INTERNATIONAL classification

• IAP classification

NUTRITIONAL STATUS WT for AGE (% expected)

Normal >90

First degree PEM 75-90

Second degree PEM 60-75

Third degree PEM <60

GOMEZ’S classification

NUTRITIONAL STATUS WT for AGE (% expected)

Normal >90

First degree PEM 80-90

Second degree PEM 70-80

Third degree PEM 60-70

Fourth degree PEM <60

JELLIFFE’S classification

WEIGHT for AGE OEDEMA CLINICAL TYPE OF PEM

60-80 + K

60-80 - UW

<60 - M

<60 + M.K

WT classification

NUTRITIONAL STATUS WT for AGE (% EXPECTED)

NORMAL >80

GD 1 PEM 71-80

GD 2 PEM 61-70

GD 3 PEM 51-60

GD 4 PEM <50

IAP classification

According to height for age

• WATERLOW’S classification• McLAREN’S classification

• VISWESHWARA RAO’S classification

HT for AGE (% EXPECTED

WATERLOW’S McLAREN’S VISWESHWARA RAO’S

NORMAL >95 >93 >90

FIRST DEGREE STUNTING

90-95 80-93 80-90

SECOND DEGREE STUNTING

85-90 - -

THIRD DEGREE

STUNTING

<85 <80 <80

According to weight for height• WATERLOW’S classification• McLAREN’S classification

WEIGHT for HEIGHT WATERLOW’S McLAREN’S

NORMAL >90 >90

MILD/FIRST DEGREE 80-90 85-90

MODERATE/SECOND DEGREE

70-80 75-85

SEVERE / THIRD DEGREE

<70 <75

WHO cut-off for assessment of malnutrition in community studies

CUT-OFF H/A W/H H/A & W/H

> MEAN – 2 SD

N N N

< MEAN – 2 SD

STUNTED WASTED STUNTED & WASTED

Standard deviation score (Z score)WHO classification

• ACUTE AND CHRONIC MALNUTRITION

W/A H/A W/H Interpretation

N N N N

N A.M

N C.M

A-on-C M

•MODERATE AND SEVERE MALNUTRITION

FEATURES MODERATE SEVERE

OEDEMA NO YES

WT-for-HT (WASTING)

70-79% <70%

HT-for-AGE (STUNTING)

85-89% <85%

• Calorie or protein intake• Time period• Adaptation• Free radical theory

Who can get marasmus or kwashiokor

Management of SAM (scu)

Diagnosis• Wt-for-Ht < 70% of expected

• Visible wasting• MAC <11 cm• Oedema

Guidelines by WHO for SAM treatment

General routine careEmergency treatment of shock and

anemiaTreat associated conditionsFailure to respond to treatmentDischarge before recovery is

complete

• HYPOGLYCEMIA treatmentConsious 50ml bolus of 10% glc by NG tubeUnconcious IV sterile 10% glc , 50ml of 10% glc by NG

tube

• HYPOTHERMIA treatment• DEHYDRATION treatment• ELECTROLYTE CORRECTIONNa NK, Mg YOedema NO DIURETICS

• INFECTION treatment

IV AMPICILLIN (50mg/kg/6hrly) + IV GENTAMICIN (2.5mg/kg/8hrly)IV CLOXACILLIN (100mg/kg/6hrly) if staph infection present

IV CEFOTAXIME (100mg/kg/8hrly)

IV CEFOTAXIME (200mg/kg/6hrly) + IV AMIKACIN ((15mg/kg/8hrly)

CIPROFLOXACIN (30mg/kg/day) in 2 doses {or}IV CEFTRIAXONE (50mg/kg/12 hrly) if baby is sick or already on

Nalidixic acid

• MICRONUTRIENT deficiencyMultivitamin suppliments

FA 1mg/dZINC 2mg/kg/dIRON 3mg/kg/d

• CAUTIOUS FEEDINGSmall, frequent, oral/NG tube feeds

Starter F-75 (75kcal/100ml + 0.9g protein/100ml)130 ml/kg/d of fluid (100 ml/kg/d if the child has severe

oedema) if the child is breastfed, encourage to continue breastfeeding

• ACHIEVE CATCH-UP GROWTHF-100 (100kcal + 2.9 g protein/100ml)

Increase 10ml in successive feeds, Wt gain >10g gain/kg/d

• EMOTIONAL SUPPORT• FOLLOW-UP

• EMERGENCY TREATMENT INSEVERE DEHYDRATION- RINGER LACTATE SOLUTION + DEXTROSE (5%)

and assess after 1 hr; worsening; septic shock improving; continue therapy start ORS if accepts orally

else wait till accept

SEVERE ANEMIA- Blood transfusion , oral iron

• Other associated causesVitamin A deficiency- vitamin A supplements (for eye sign)

and antibiotics with atropine (for corneal ulceration)

Dermatosis- zinc supplement (BARRIER cream)

Diarrhoea- metronidazole

Parasitic worms- mebendazole

TB- ATT therapy

• Failure to treatment• Discharge • Early discharge

RUTF

• Community approach to malnutrition• Palatable, high energy with adequate amount

of protein and minerals (similar to F100 but no water is added)

• Also addition of antibiotics is needed

RUTF INDIArice + green gram (paccapaiyiru)

• Calories 250.4g• Total Fat 6.7 g• Saturated Fat 0.8 g• Polyunsaturated Fat 3.7 g• Monounsaturated Fat 1.6 g• Cholesterol 0.1 mg• Sodium 354.7 mg• Potassium 213.6 mg• Total Carbohydrate 40.9 g• Dietary Fiber 2.8 g• Sugars 0.3 g

• Protein 6.1 g• Vitamin A 0.5 %• Vitamin B-12 0.0 %• Vitamin B-6 6.3 %• Vitamin C 0.5 %• Vitamin D 0.0 %• Vitamin E 8.9 %• Calcium 3.2 %• Copper 4.8 %• Folate 17.3 %• Iron 16.3 %• Magnesium 4.8 %• Manganese 31.9 %• Niacin 9.1 %• Pantothenic Acid 4.6 %• Phosphorus 5.8 %• Riboflavin 1.2 %• Selenium 12.8 %• Thiamin 13.4 %• Zinc 4.4%

Health promotion

• Of pregnant and lactating women (education and drugs)

• Promote breast feed• Low cost weaning foods• Nutrition education• Home economics• Family planning

Specific protection

• Diet of child (protein and energy rich like egg, milk, fruits etc)

• Immunization

Early diagnosis and treatement

• Survillance• Early diagnosis of infection

and diarrhoea & treatment• Rehydration of children in

diarrhoea• Supplementary food• Deworming of heavily

infected child

Rehabilitation

• Nutritional rehabilitation• Hospital treatment• Follow-up

• Promoting and adapting policies to fight malnutrition

• Providing resources to fight SAM

WHO, WFP, UNICEF and other patners support these campaigns

• National Nutrition policy• The integrated child development service scheme

TN against Malnutrition

• Budget for Nutrition and health highest in the country. (Rs.5719 crore for 11th plan)

• ICDS and PTMGRNMP (puratchi thalaivar MGR nutritious meal program) are best in country.

• 11th plan was for “malnutrition free state”• 12th plan (2011-16) had also same motive

RECALL

• Malnutrition• Causes• Classification• SAM• Community and national strategies towards

malnutrition

Thank You