MalnutritionalMalnutritional DisordersDisorders

Prepared ByPrepared By

Dr. Sahar FaroukDr. Sahar FaroukLecturer Of Pediatric NursingLecturer Of Pediatric Nursing

Out LinesOut Lines Introduction Introduction Definitions Definitions Prevalence of malnutrition Prevalence of malnutrition Etiology of malnutritionEtiology of malnutrition Consequences of malnutritionConsequences of malnutrition

Comparison between marasmus and kwo in relation to:-Comparison between marasmus and kwo in relation to:- – Definition Definition – Incidence and etiology assessment of child and infant with Incidence and etiology assessment of child and infant with

marasmus & kwo marasmus & kwo – ComplicationsComplications– IvestigationsIvestigations– Treatment & prevention of marasmus &kwo Treatment & prevention of marasmus &kwo

Nursing management Nursing management

Out LinesOut Lines (Cont.) (Cont.)RicketsRickets Definition of ricketsDefinition of rickets Information about vit. D Information about vit. D Causes of ricketsCauses of rickets Contributing factors of ricketsContributing factors of rickets Clinical picture of ricketsClinical picture of rickets Complication of ricketsComplication of rickets Laboratory investigations Laboratory investigations treatment of rickets treatment of rickets Nursing careNursing care

Infantile tetanyInfantile tetany DefinitionDefinition EtiologyEtiology Clinical ManifestationsClinical Manifestations TreatmentTreatment Nursing careNursing care

IntroductionIntroduction Malnutrition means more than feeling hungry or not Malnutrition means more than feeling hungry or not

having enough food to eat. It is a condition that having enough food to eat. It is a condition that develops when the body does not get the proper develops when the body does not get the proper

amount of protein, calories, vitamins and other amount of protein, calories, vitamins and other nutrients it needs to maintain healthy tissues and nutrients it needs to maintain healthy tissues and

organ function. It occurs in children who are either organ function. It occurs in children who are either undernourished or over nourished. Children who are undernourished or over nourished. Children who are

over nourished may become over weight or obese over nourished may become over weight or obese and those who are under nourished are more likely and those who are under nourished are more likely

to have severe long term consequences.to have severe long term consequences.

DefinitionDefinition

Malnutrition includes: under nutrition and Malnutrition includes: under nutrition and over nutrition.over nutrition.

- Under nutrition- Under nutrition:: is a consequence of is a consequence of consuming little energy and other consuming little energy and other essential nutrients or using or excreting essential nutrients or using or excreting them more.them more.

– Malnutrition:Malnutrition: is a term referring to poor or is a term referring to poor or inadequate nutrition.inadequate nutrition.

Prevalence of malnutritionPrevalence of malnutrition

Malnutrition remains of the worlds highest Malnutrition remains of the worlds highest priority health issues not only because its effects are priority health issues not only because its effects are so widespread and long lasting, but also because it so widespread and long lasting, but also because it can be eradicated. can be eradicated.

More than 35% of all preschool age children in More than 35% of all preschool age children in developing countries are under weight.developing countries are under weight.

The The unicefunicef report found that report found that 146146 million children million children under five years in the developing world are suffering under five years in the developing world are suffering from insufficient food intake, repeated infections from insufficient food intake, repeated infections diseases, muscle wasting and vitamin deficiencies.diseases, muscle wasting and vitamin deficiencies.

EtiologyEtiology The cause of malnutrition may be due to:-The cause of malnutrition may be due to:- Poor food availability &preparationPoor food availability &preparation Recurrent infections (GE)Recurrent infections (GE) Lack of nutritional educationLack of nutritional education Lack of sanitation Lack of sanitation Erratic health care provisionErratic health care provision Chronic diarrhea Chronic diarrhea Hook worm & malaria Hook worm & malaria Chronic infection by (T.B, otitis media) Chronic infection by (T.B, otitis media) Congenital mal formations as (pyloric stenosis)Congenital mal formations as (pyloric stenosis)

Consequences of malnutrition Consequences of malnutrition (long term effects)(long term effects)

1.1. Slowed growth & delayed development Slowed growth & delayed development

2.2. Difficulty in school Difficulty in school

3.3. High rates in illnesses High rates in illnesses

4.4. social stresssocial stress

Protein – energy malnutritionProtein – energy malnutrition

1- Marasmus1- MarasmusDefinitionDefinition::

It is a clinical syndrome and a form of under nutrition It is a clinical syndrome and a form of under nutrition characterized by failure to gain weight due to inadequate caloric characterized by failure to gain weight due to inadequate caloric intake.intake.

Incidence:Incidence:

commonly in infants between the age of 6mo. - 2years (Infantile commonly in infants between the age of 6mo. - 2years (Infantile atrophy).atrophy).

EtiologyEtiology

1- 1- Dietary errorsDietary errors 2 – 2 – Infection :Infection :Acute or chronic as T.B, otitis media pyelo nephritisAcute or chronic as T.B, otitis media pyelo nephritis 3- 3- Gastroenteritis:Gastroenteritis: (acute or chronic )(acute or chronic ) 4- 4- parasitic inf estuations as:parasitic inf estuations as: Ascaris, ankylostoma ,giardia Ascaris, ankylostoma ,giardia 5-5-Congenital anomalies as:Congenital anomalies as: Cardiac (P.D.A,V.S.D,F4) ,Renal (renal Cardiac (P.D.A,V.S.D,F4) ,Renal (renal

agenesis, obstructive uropathy) ,G.I.T (pyloric stenosis , cleftlip or palat agenesis, obstructive uropathy) ,G.I.T (pyloric stenosis , cleftlip or palat 6-6-Metabolic diseases.:Metabolic diseases.: Galactosemia, Fructose intolerance, Idiopathic Galactosemia, Fructose intolerance, Idiopathic

hypocalcaemia hypocalcaemia 77-- PrematuretyPrematurety 8-8- Some cases of mental retardationSome cases of mental retardation 9- 9- Low socio economic statusLow socio economic status 10-Endocrine causes10-Endocrine causes ( DM.hyperthyroidism )( DM.hyperthyroidism )

Assessment of Marasmic Assessment of Marasmic Child/InfantChild/Infant

failure a to thrive ,loss of weight (weight < 60%of expected)failure a to thrive ,loss of weight (weight < 60%of expected) loss of subcutaneous fat : measured at many parts of the body loss of subcutaneous fat : measured at many parts of the body

according to the degress:-according to the degress:- 1 st degree : s.c fat in the abd. wall1 st degree : s.c fat in the abd. wall 2 nd degree : s.c fat in the abd. wall and limbs2 nd degree : s.c fat in the abd. wall and limbs 3 rd degree : s.c fat in the abd. wall and limbs and face3 rd degree : s.c fat in the abd. wall and limbs and face

Assessment of Marasmic Assessment of Marasmic Child/InfantChild/Infant (Cont.) (Cont.)

Muscle wasting ( thin muscles and prominence of bony surfaces )Muscle wasting ( thin muscles and prominence of bony surfaces ) G.I.T disturbances as anorexia in advanced cases, hungry, G.I.T disturbances as anorexia in advanced cases, hungry,

constipation or diarrhea or starvation diarrhea constipation or diarrhea or starvation diarrhea liability to infection liability to infection Hypovolemia Hypovolemia Weak feeble pulse, subnormal temp, pulse rate Weak feeble pulse, subnormal temp, pulse rate Senile face and pallorSenile face and pallor

Complications of MarasmusComplications of Marasmus

1.1. Intercurrent infection : Broncho Intercurrent infection : Broncho pneumonia . is the cause of death pneumonia . is the cause of death

2.2. Gastro enteritis Gastro enteritis

3.3. Hemorrhagic tendency, purpuraHemorrhagic tendency, purpura

4.4. Hypothermia Hypothermia

5.5. HypoglycemiaHypoglycemia

6.6. Edema(marasmic kwashiorkor )Edema(marasmic kwashiorkor )

Investigations for Marasmic InfantInvestigations for Marasmic Infant

1.Blood analysis1.Blood analysis : (W.B.C ,Electrolytes : (W.B.C ,Electrolytes Sugars, ketones,Plasma proteins , normal or Sugars, ketones,Plasma proteins , normal or lowered )lowered )

2.2. Urire analysisUrire analysis: culture, sugar, ketones, : culture, sugar, ketones, ca, phosphate, aminoacidsca, phosphate, aminoacids

3.Stool analysis 3.Stool analysis for parasitesfor parasites 4. 4. X- rayX- ray for chest and heart for chest and heart 5. 5. Tuberculin testTuberculin test for T.B for T.B 6. 6. E.N.T examinationE.N.T examination for otitis media for otitis media

TreatmentTreatment

1- Prevention1- Prevention :- :-– proper diet ( balanced nutritional diet )proper diet ( balanced nutritional diet )– encourage breast feeding up to weaning encourage breast feeding up to weaning – proper weaning proper weaning – proper vaccination as measles , T.B. whooping coughproper vaccination as measles , T.B. whooping cough– Education regarding the cheap sources of balanced Education regarding the cheap sources of balanced

diet, family planning. diet, family planning. – Proper follow up of the growth rate Proper follow up of the growth rate – Early treatment of defects or associated diseases Early treatment of defects or associated diseases

Treatment (Cont.)Treatment (Cont.) 2 – 2 – Curative treatment:-Curative treatment:-

A- Proper dietary management:-A- Proper dietary management:- Adequate balanced feeding. teaching about nutritional Adequate balanced feeding. teaching about nutritional

needs.preparation of diet, technique of administration of foodneeds.preparation of diet, technique of administration of food If there is vomiting or anorexia, give IV fluids or naso gastric tube If there is vomiting or anorexia, give IV fluids or naso gastric tube

feeding.feeding. Gradual increase the amount and concentration of formula (total Gradual increase the amount and concentration of formula (total

calories is120-200cal kg d)calories is120-200cal kg d)

B – Treatment of the cause B – Treatment of the cause

C- Emergency treatment for complications C- Emergency treatment for complications

D – Blood transfusionD – Blood transfusion

E – Vitamins and minerals supplementation E – Vitamins and minerals supplementation

KwashiorkorKwashiorkor

DefinitionDefinition It is a clinical syndrome and a form of It is a clinical syndrome and a form of

malnutrition characterized by slow rate of malnutrition characterized by slow rate of growth due to deficient of protein intake, growth due to deficient of protein intake, high CHO diet and vitamins & minerals high CHO diet and vitamins & minerals deficiency (adequate supply of calories).deficiency (adequate supply of calories).

IncidenceIncidence Commonly in toddlers between the age Commonly in toddlers between the age

1-3years, following or with weaning1-3years, following or with weaning

EtiologyEtiology

1.1. Un balanced diet (of protein, CHO.)Un balanced diet (of protein, CHO.)2.2. improper weaning (during and post weaning improper weaning (during and post weaning

period )period )3.3. faulty management of marasmic baby faulty management of marasmic baby 4.4. Ignorance poverty due to lack of basic Ignorance poverty due to lack of basic

health education health education 5.5. precipitating factors as(acute infection with precipitating factors as(acute infection with

measles, diarrhea and malaria, parasitic measles, diarrhea and malaria, parasitic infestations)infestations)

AssessmentAssessment

1- Essential features 1- Essential features (cardinal manifestation):(cardinal manifestation):

– Growth retardation :-Growth retardation :- Weight is diminished (60-80%) of Weight is diminished (60-80%) of

expectedexpected

– EdemaEdema : : It is due to hypo proteinemia. It is It is due to hypo proteinemia. It is

starts in the feet and lower parts of the starts in the feet and lower parts of the legs) then becomes generalized legs) then becomes generalized edema . The cheeks become bulky, edema . The cheeks become bulky, pale, waxy in appearance (doll-like-pale, waxy in appearance (doll-like-cheeks) cheeks)

11 - -Essential featuresEssential features

- Diminished muscle fat ratio:- Diminished muscle fat ratio:

Generalized (muscle wasting) with Generalized (muscle wasting) with subcutaneous fat subcutaneous fat

- Fatty liver :- Fatty liver : It is detected by liver biopsyIt is detected by liver biopsy

- Mental changes :- Mental changes : The infant has apathy never smile, looks The infant has apathy never smile, looks

sad his cry is weaksad his cry is weak

2-Early features2-Early features (usual manifestation) (usual manifestation)

Hair changes :Hair changes : The hair is sparse , dys pigmentation( reddish or greyish),atrophic ,easily pickable.The hair is sparse , dys pigmentation( reddish or greyish),atrophic ,easily pickable.

G.I.T Manifestations:G.I.T Manifestations: Anorexia ,vomiting in severe cases, diarrhea due to k Anorexia ,vomiting in severe cases, diarrhea due to k

33--Occasional or variable featuresOccasional or variable features

- Vitamins and minerals defection and vit.D , A,C - Vitamins and minerals defection and vit.D , A,C minerals as iron, zinc, Mg, minerals as iron, zinc, Mg, – Hepatomegaly.Hepatomegaly.– Skin changes (dermatitis in areas due to Skin changes (dermatitis in areas due to

pigmentation ,napkin dermatitis, petechiae over the pigmentation ,napkin dermatitis, petechiae over the abdomen, fissures,ulcerationabdomen, fissures,ulceration

– Poor resistance and liability to infectionsPoor resistance and liability to infections

Complication of kwashiorkorComplication of kwashiorkor

1.1. Secondary infection ,fungal and Secondary infection ,fungal and bacterial infectionbacterial infection

2.2. Hemorrhagic tendency, purpuraHemorrhagic tendency, purpura

3.3. Gastroenteritis Gastroenteritis

4.4. HypoglycemiaHypoglycemia

5.5. HypothermiaHypothermia

6.6. Heart failure due to anemia and Heart failure due to anemia and infection.infection.

Investigations for kwashiorkorInvestigations for kwashiorkor

1. Blood analysis: (1. Blood analysis: (Albumin < 2.5gmld) , total Albumin < 2.5gmld) , total protein, amino acids, Enzymes (amylase ,lipase, protein, amino acids, Enzymes (amylase ,lipase, alkaline phosphate, ,alkaline phosphate, , Glucose (hypoglycemia)Glucose (hypoglycemia) , , kk ( hypokalemia )( hypokalemia )

2. Low pancreatic and intestinal enzymes2. Low pancreatic and intestinal enzymes 3. Urine analysis, 3. Urine analysis, culture for infectionculture for infection 4. Stool analysis for parasites4. Stool analysis for parasites 5. Chest x-ray 5. Chest x-ray 6. Tuberculin test6. Tuberculin test

Common Nursing Diagnoses Common Nursing Diagnoses of Marasmus and KWOof Marasmus and KWO

1.1. Altered nutrition :less than body requirements related Altered nutrition :less than body requirements related to knowledge deficit, infection, emotional problems, to knowledge deficit, infection, emotional problems, physical deficitphysical deficit

2.2. Body temperature alteration (hypothermia) related to Body temperature alteration (hypothermia) related to low subcutaneous fat and deficiency of food intake low subcutaneous fat and deficiency of food intake

3.3. Impaired skin integrity related to vitamins deficiencyImpaired skin integrity related to vitamins deficiency

4.4. Fluid volume deficit related to diarrhea Fluid volume deficit related to diarrhea

5.5. High risk for infection related to low body resistance.High risk for infection related to low body resistance.

Nursing care of MarasmusNursing care of MarasmusSupport the infant and parentsSupport the infant and parents

1.1. provide nutrition rich in essential nutrientsprovide nutrition rich in essential nutrients

2.2. Give small amounts of foods limited in proteins, carbohydrates and fats Give small amounts of foods limited in proteins, carbohydrates and fats

3.3. Maintain body temperature Maintain body temperature

4.4. Provide periods of rest and appropriate activity and stimulationProvide periods of rest and appropriate activity and stimulation

5.5. Record intake and output Record intake and output

6.6. Weight dailyWeight daily

7.7. Change position frequently Change position frequently

8.8. Proper treatment is given for infection Proper treatment is given for infection

9.9. Protection from infected persons and injuries Protection from infected persons and injuries

10.10. Refer family to social worker for financial support Refer family to social worker for financial support

11.11. Education for parents about proper nutrition Education for parents about proper nutrition

Nursing care of KwashiorkorNursing care of Kwashiorkor

Support the infant and parentsSupport the infant and parents1.1. Proper diet intake proteins and CHO vitamins Proper diet intake proteins and CHO vitamins

2.2. Nursing care for vomiting, diarrhea or dehydrationNursing care for vomiting, diarrhea or dehydration

3.3. Skin care for child for edema , injuriesSkin care for child for edema , injuries

4.4. Avoid any infection and follow hygienic measures for childAvoid any infection and follow hygienic measures for child

5.5. Frequent assessment of growth and development Frequent assessment of growth and development

6.6. Safety measures to avoid injuries Safety measures to avoid injuries

7.7. Nutritional counseling Nutritional counseling

8.8. Record intake and out put Record intake and out put

9.9. Health education about medications and follow up Health education about medications and follow up

10.10. Frequent monitoring for any complicationsFrequent monitoring for any complications

3-Marasmic Kwashiorkor3-Marasmic Kwashiorkor

DefinitionDefinition– Its a combination of caloric deficiency (marasmus ) and Its a combination of caloric deficiency (marasmus ) and

protein deficiency (KWO) .protein deficiency (KWO) .

Clinical pictureClinical picture– The clinical picture of this disease represents The clinical picture of this disease represents

manifestations from both diseases as: manifestations from both diseases as: loss of subcutaneous fat as in marasmus loss of subcutaneous fat as in marasmus Edema, hair and skin changes as in KWO Edema, hair and skin changes as in KWO but there is but there is

no moon face.no moon face.

Rickets (Osteomalacia)Rickets (Osteomalacia)

DefinitionDefinition:: Its is a systemic metabolic disease due to of Its is a systemic metabolic disease due to of vit.D results in inadequate deposition of calcium in vit.D results in inadequate deposition of calcium in developing cartilage and bone leading to bone deformities, developing cartilage and bone leading to bone deformities, hypotonia and some times affecting cns. hypotonia and some times affecting cns.

Vitamin D:-Vitamin D:- it is a group of steroid fat soluble it is a group of steroid fat soluble compounds compounds

It affects the reabsorption of ca and phosphours by the It affects the reabsorption of ca and phosphours by the kidneys kidneys

It has two types:-It has two types:- Biologically ,Biologically ,D2D2 and and D3D3 which are present (in-active) form which are present (in-active) form

and Trans formed to (active form) in the liver as (Calcitriol)and Trans formed to (active form) in the liver as (Calcitriol) - D2- D2 called (Calciferol.) and called (Calciferol.) and D3 D3called (Chole calciferol.)called (Chole calciferol.)

Causes of vitamin D. deficiency ricketsCauses of vitamin D. deficiency rickets

Dietary def of vit. D and CaDietary def of vit. D and Ca lack of exposure to sun rays lack of exposure to sun rays Malabsorption of vit.D as in(obstructive jaundice ) Malabsorption of vit.D as in(obstructive jaundice ) Congenital rickets Congenital rickets Taking of anti convulsive drugs Taking of anti convulsive drugs poor utilization of vit.D by the tissues lead to rickets poor utilization of vit.D by the tissues lead to rickets

as in :- as in :- – hyper para thyroidism, renal disordershyper para thyroidism, renal disorders– hypo phosphatemia hypo phosphatemia – recurrent attacks of diarrhea due to G.Erecurrent attacks of diarrhea due to G.E– High proportion of phosphorous as in cow’s milk leads to High proportion of phosphorous as in cow’s milk leads to

impaired absorp. of ca.impaired absorp. of ca.

Contributing factorsContributing factors

1.1. AgeAge common in infants (6 months -2years) common in infants (6 months -2years)2.2. Preterm babies and twins Preterm babies and twins 3.3. seasonseason more in winter than in summer more in winter than in summer4.4. Diet Diet inadequate intake of vitamin D and calcium inadequate intake of vitamin D and calcium

and vitamin C in diet. and diet. the disease is and vitamin C in diet. and diet. the disease is more common in artificial feed babies than breast more common in artificial feed babies than breast feed infantsfeed infants

5.5. Heredity factorHeredity factor 6.6. Atmospheric conditionAtmospheric condition more common in big more common in big

cities and heavy crowded areas with population no cities and heavy crowded areas with population no common in tropics areascommon in tropics areas

7.7. Race Race more common in dark races more common in dark races

Clinical pictureClinical picture

During assessment of the child / infant with During assessment of the child / infant with rickets, the chief complains are: rickets, the chief complains are:

1.1. Delayed motor development specially walkingDelayed motor development specially walking2.2. Delayed dentitionDelayed dentition3.3. Deformities of the bonesDeformities of the bones4.4. presence of one of any complicationspresence of one of any complications

Physical examinationPhysical examination

A-Early manifestations:A-Early manifestations:

– Craniotabes. (In the head) infant 3-8mo.Craniotabes. (In the head) infant 3-8mo.– Rickety rosary beads (in the thorax)Rickety rosary beads (in the thorax)– Enlarged of the lower radio – ulner epiphysis.Enlarged of the lower radio – ulner epiphysis.– Sweating at fore head, irritabilitySweating at fore head, irritability

Physical examination (Cont.)Physical examination (Cont.)

B- Late manifestations:B- Late manifestations:1.1. Head Head

– Enlargement of the head like (box shape skull) Enlargement of the head like (box shape skull) due to frontal and parietal bossing)due to frontal and parietal bossing)

– Delayed closure of anterior fontanelDelayed closure of anterior fontanel– Delayed eruption of teethDelayed eruption of teeth

Physical examination (Cont.)Physical examination (Cont.)

B- Late manifestations:B- Late manifestations: 2-Thorax2-Thorax

– Rickety rosary beads Rickety rosary beads – Harrison sulcus (transverse groove at the Harrison sulcus (transverse groove at the

lower part of the chest at the costal insertion lower part of the chest at the costal insertion of the diaphragm)of the diaphragm)

– Longitudinal sulcus (lateral groove) Longitudinal sulcus (lateral groove) – Pigeon chestPigeon chest

Physical examination (Cont.)Physical examination (Cont.)

B- Late manifestations:B- Late manifestations:3- Spine3- Spine : kyphosis, scoliosis : kyphosis, scoliosis4- Pelvis4- Pelvis : contracted pelvis : contracted pelvis 5- Extremities5- Extremities : deformities , green stick , : deformities , green stick ,

fracturesfractures6- Muscles6- Muscles : weakness of muscles , hypotonic : weakness of muscles , hypotonic

laxity of ligaments as (In abdomen)laxity of ligaments as (In abdomen)7- Constipation, enlarged spleen7- Constipation, enlarged spleen

COMPLICATIONSCOMPLICATIONS 1.1. Bone fractures, limbs deformities as the following:Bone fractures, limbs deformities as the following:

2- Tetany due to hypocalcaemia2- Tetany due to hypocalcaemia3- Anemia3- Anemia4- G.I.T disturbances as: G.E, constipation. 4- G.I.T disturbances as: G.E, constipation. 5- Respiratory complications as pneumonia, broncho -5- Respiratory complications as pneumonia, broncho -

pneumoniapneumonia6- low resistance , liability to infection as urinary tract 6- low resistance , liability to infection as urinary tract

infectionsinfections

TreatmentTreatment

Prevention Of rickets:-Prevention Of rickets:-

– Exposure of all infants to ultra violet rays.Exposure of all infants to ultra violet rays.– Daily intake of diet rich with vit-D and Daily intake of diet rich with vit-D and

supplementation of vit.D (400-800 IU / d). The supplementation of vit.D (400-800 IU / d). The infant need 400ivld .premature baby receives infant need 400ivld .premature baby receives 800-1200 IU / d( 2nd -4th ) month of life 800-1200 IU / d( 2nd -4th ) month of life

– Pregnant and lactating mothers need vit.D Pregnant and lactating mothers need vit.D supplementation.supplementation.

Treatment (Cont.)Treatment (Cont.)

2- Active treatment :- 2- Active treatment :- Oral calcium with vit.D intake should be Oral calcium with vit.D intake should be

increased.increased. Vit-D (1500-5000)IU/ d .for 2months or Vit-D (1500-5000)IU/ d .for 2months or

shock therapy by vit-D (600-000) IU/d .by shock therapy by vit-D (600-000) IU/d .by IM injection deeply one dose every IM injection deeply one dose every 2weeks (3doses)2weeks (3doses)

After healing, give. vit.D (400-800) IU and After healing, give. vit.D (400-800) IU and repeat blood analysis for calcium.repeat blood analysis for calcium.

Surgical correction of deformitiesSurgical correction of deformities Treatment of any complicationsTreatment of any complications

Treatment (Cont.)Treatment (Cont.)

2- Active treatment :- 2- Active treatment :- Oral calcium with vit.D intake should be Oral calcium with vit.D intake should be

increased.increased. Vit-D (1500-5000)IU/ d .for 2months or Vit-D (1500-5000)IU/ d .for 2months or

shock therapy by vit-D (600-000) IU/d .by shock therapy by vit-D (600-000) IU/d .by IM injection deeply one dose every IM injection deeply one dose every 2weeks (3doses)2weeks (3doses)

After healing, give. vit.D (400-800) IU and After healing, give. vit.D (400-800) IU and repeat blood analysis for calcium.repeat blood analysis for calcium.

Surgical correction of deformitiesSurgical correction of deformities Treatment of any complicationsTreatment of any complications

Common nursing diagnosesCommon nursing diagnoses

1.1. Body image disturbance related to bone Body image disturbance related to bone deformitiesdeformities

2.2. Altered nutritional requirements related Altered nutritional requirements related to deficiency of calcium to deficiency of calcium

3.3. High risk for infection related to low of High risk for infection related to low of immunity. immunity.

4.4. High risk for injury related to weakness High risk for injury related to weakness of bones and deformities.of bones and deformities.

Infantile Nutritional TetanyInfantile Nutritional Tetany(Tetany of vit.D deficiency)(Tetany of vit.D deficiency)

Definition:-Definition:-

– It is a disease caused by decrease in It is a disease caused by decrease in serum calcium level ( < 7mgldl) and serum calcium level ( < 7mgldl) and by a deficiency in the intake and by a deficiency in the intake and absorption of vitamin .D (not all infants absorption of vitamin .D (not all infants with rickets have tetany). This condition with rickets have tetany). This condition leads to hyper excitability of the central leads to hyper excitability of the central and peripheral nervous systemand peripheral nervous system

EtiologyEtiology

1.1. Hypocalcemia as by (hypo parathyroid), Hypocalcemia as by (hypo parathyroid), vit.D. deficiency intake , exchange vit.D. deficiency intake , exchange transfusion) transfusion)

2.2. hypo magnesemia by (chronic diarrhea , hypo magnesemia by (chronic diarrhea , malabsorption . of mg)malabsorption . of mg)

3.3. alkalosis (pH) due to (severe vomiting, alkalosis (pH) due to (severe vomiting, alkalotic therapy)alkalotic therapy)

4.4. Severe rickets.Severe rickets. NB.NB. Infantile tetany. has the some Infantile tetany. has the some

predisposing factors as in rickets.predisposing factors as in rickets.

Clinical manifestationsClinical manifestations1- Early manifestations as :1- Early manifestations as :

serum calcium - >7mg /dlserum calcium - >7mg /dl Carpo – pedal spasm Carpo – pedal spasm laryngeal spasm laryngeal spasm cyanosis cyanosis Generalized convulsions in infants and newbornsGeneralized convulsions in infants and newborns

– N.B:N.B: infantile tetany is due to rapid deposition of infantile tetany is due to rapid deposition of serum Calcium so, spasms in hands, feet appearserum Calcium so, spasms in hands, feet appear

2- late 2- late manifestations:-manifestations:- serum Ca (7-9)mg /dl, bone deformities serum Ca (7-9)mg /dl, bone deformities

TreatmentTreatment A. Immediate:A. Immediate: Give the child infant Ca gluconate .10% solution (5-10) cc. Give the child infant Ca gluconate .10% solution (5-10) cc.

IV injection slowly.IV injection slowly. If no response search for etiology and correct it as (Mg If no response search for etiology and correct it as (Mg

deficiency ) by giving Mg solution sulface .50% (0.2 deficiency ) by giving Mg solution sulface .50% (0.2 ml/kg ) IMml/kg ) IM

O2 therapy for convulsions and emergency intubation. for O2 therapy for convulsions and emergency intubation. for laryngo spasm laryngo spasm

B. Maintenance:-B. Maintenance:- Diet rich in calcium Diet rich in calcium Ca chloride orally (1-3gm /d in milk) or Ca lactate. Ca chloride orally (1-3gm /d in milk) or Ca lactate. Vit.D. for treatment of rickets dailyVit.D. for treatment of rickets daily

Common Nursing diagnosesCommon Nursing diagnosesNursing diagnoses: Nursing diagnoses:

High risk for injury related to convulsions High risk for injury related to convulsions High risk for infection related to lack of immunity High risk for infection related to lack of immunity Altered body image, related to bone deformities Altered body image, related to bone deformities Ineffective breathing pattern, related to laryngeal Ineffective breathing pattern, related to laryngeal

spasmspasm Activity intolerance, related to weakness of Activity intolerance, related to weakness of

bones bones Altered parenting related to lack of knowledge Altered parenting related to lack of knowledge

about the disease process and its managementabout the disease process and its management..

Thank YouThank You