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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
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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.
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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.
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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)
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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 .
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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.
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PEM--PRECIPITATING FACTORS
• LACK OF FOOD ( poverty)
• INADEQUATE BREAST FEEDING
• WRONG CONCEPTS ABOUT NUTRITION
• DIARRHOEA & MALABSORPTION
• INFECTIONS (worms, measles, T.B)
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Causes of Protein Energy Malnutrition
Malnutrition
Inadequate dietary intake Disesase
Insufficient Household food
MANIFESTATIONS
IMMEDIATE CAUSES
UNDERLYING CAUSES
BASIC CAUSES
Political and Economical powers
Inadequate Maternal Childcare
Insufficient Health Services/Unhealthy
Environment
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The evil cycle of Malnutrition
Adapted from Andrew Tomkins and Fiona Watson, Malnutrition and Infection, ACC/SCN, Geneva, 1989 , State of the World’s Children 1998
Apetite loss Nutrient Loss Malabsorbtion
Altered metabolism
Disease: Incidence Severity Duration
Inadequate Dietary Intake
Weight loss Immunity lowered Growth faltering Mucosa damaged
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Assessment of Nutritional status
¨ Direct 1.Dietary history 2.Anthropometric measurements 3. Clinical assessment 4.Laboratory
¨ Indirect ¤ Health statistics
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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.
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ANTHROPOMETRY
¨ Objective with high specificity & sensitivity ¨ Measuring Ht, Wt, MUAC, HC, skin fold thickness,
& BMI
¨ Non-expensive & need minimal training
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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
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Eye signs of vitamin A deficiency
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Sign of vitamin A deficiency
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Clinical Assessment
¨ ADVANTAGES ¤ Fast & Easy to perform ¤ Inexpensive ¤ Non-invasive
¨ LIMITATIONS ¤ Doesn't not detect early cases ¤ Trained staff needed
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LABORATOY ASSESSMENT
¨ Biochemical ¤ Serum proteins,
¨ Hematological ¤ CBC, iron, vitamin levels
¨ Microbiology ¤ Parasites/infection
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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
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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 %
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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.
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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.
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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.
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CLINICAL PRESENTATION
¨ Kwash is characterized by certain constant features in addition to a variable spectrum of symptoms and signs.
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CONSTANT FEATURES OF KWASH
n OEDEMA
n PSYCHOMOTOR CHANGES
n GROWTH RETARDATION
n MUSCLE WASTING
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USUALLY PRESENT SIGNS
¨ MOON FACE
¨ HAIR CHANGES
¨ SKIN DEPIGMENTATION
¨ ANAEMIA
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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
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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.
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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.
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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.
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Clinical Features of Marasmus
¨ Severe wasting of muscle &loss of subcutaneous fats
¨ Severe growth retardation
¨ Child looks older than his age
¨ Hungry
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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
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Complications of P.E.M
¨ Hypoglycemia ¨ Hypothermia
¨ Hypokalemia.
¨ Hyponatremia
¨ Heart failure
¨ Dehydration & shock ¨ Infections,sepsis (bacterial, viral & thrush)
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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
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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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Any Questions?