Malnutritional DisordersPrepared ByDr. Sahar FaroukLecturer Of Pediatric Nursing

Out Lines Introduction Definitions Prevalence of malnutrition Etiology of malnutritionConsequences of malnutritionComparison between marasmus and kwo in relation to:- Definition Incidence and etiology assessment of child and infant with marasmus & kwo ComplicationsIvestigationsTreatment & prevention of marasmus &kwo Nursing management

Out Lines (Cont.)RicketsDefinition of ricketsInformation about vit. D Causes of ricketsContributing factors of ricketsClinical picture of ricketsComplication of ricketsLaboratory investigations treatment of rickets Nursing careInfantile tetany DefinitionEtiologyClinical ManifestationsTreatmentNursing care

Introduction Malnutrition means more than feeling hungry or not having enough food to eat. It is a condition that develops when the body does not get the proper amount of protein, calories, vitamins and other nutrients it needs to maintain healthy tissues and organ function. It occurs in children who are either undernourished or over nourished. Children who are over nourished may become over weight or obese and those who are under nourished are more likely to have severe long term consequences.

Definition

Malnutrition includes: under nutrition and over nutrition.- Under nutrition: is a consequence of consuming little energy and other essential nutrients or using or excreting them more.Malnutrition: is a term referring to poor or inadequate nutrition.

Prevalence of malnutrition Malnutrition remains of the worlds highest priority health issues not only because its effects are so widespread and long lasting, but also because it can be eradicated. More than 35% of all preschool age children in developing countries are under weight. The unicef report found that 146 million children under five years in the developing world are suffering from insufficient food intake, repeated infections diseases, muscle wasting and vitamin deficiencies.

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

Consequences of malnutrition (long term effects)Slowed growth & delayed development Difficulty in school High rates in illnesses social stress

Protein energy malnutrition 1- MarasmusDefinition: It is a clinical syndrome and a form of under nutrition characterized by failure to gain weight due to inadequate caloric intake.

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

Etiology 1- Dietary errors2 Infection :Acute or chronic as T.B, otitis media pyelo nephritis3- Gastroenteritis: (acute or chronic )4- parasitic inf estuations as: Ascaris, ankylostoma ,giardia 5-Congenital anomalies as: Cardiac (P.D.A,V.S.D,F4) ,Renal (renal agenesis, obstructive uropathy) ,G.I.T (pyloric stenosis , cleftlip or palat 6-Metabolic diseases.: Galactosemia, Fructose intolerance, Idiopathic hypocalcaemia 7- Prematurety8- Some cases of mental retardation9- Low socio economic status 10-Endocrine causes ( DM.hyperthyroidism )

Assessment of Marasmic Child/Infant failure a to thrive ,loss of weight (weight < 60%of expected)loss of subcutaneous fat : measured at many parts of the body according to the degress:-1 st degree : s.c fat in the abd. wall2 nd degree : s.c fat in the abd. wall and limbs3 rd degree : s.c fat in the abd. wall and limbs and face

Assessment of Marasmic Child/Infant (Cont.)Muscle wasting ( thin muscles and prominence of bony surfaces )G.I.T disturbances as anorexia in advanced cases, hungry, constipation or diarrhea or starvation diarrhea liability to infection Hypovolemia Weak feeble pulse, subnormal temp, pulse rate Senile face and pallor

Complications of Marasmus Intercurrent infection : Broncho pneumonia . is the cause of death Gastro enteritis Hemorrhagic tendency, purpuraHypothermia HypoglycemiaEdema(marasmic kwashiorkor )

Investigations for Marasmic Infant1.Blood analysis : (W.B.C ,Electrolytes Sugars, ketones,Plasma proteins , normal or lowered )2. Urire analysis: culture, sugar, ketones, ca, phosphate, aminoacids3.Stool analysis for parasites4. X- ray for chest and heart 5. Tuberculin test for T.B6. E.N.T examination for otitis media

Treatment 1- Prevention :-proper diet ( balanced nutritional diet )encourage breast feeding up to weaning proper weaning proper vaccination as measles , T.B. whooping coughEducation regarding the cheap sources of balanced diet, family planning. Proper follow up of the growth rate Early treatment of defects or associated diseases

Treatment (Cont.) 2 Curative treatment:-A- Proper dietary management:-Adequate balanced feeding. teaching about nutritional needs.preparation of diet, technique of administration of foodIf there is vomiting or anorexia, give IV fluids or naso gastric tube feeding.Gradual increase the amount and concentration of formula (total calories is120-200cal kg d)B Treatment of the cause C- Emergency treatment for complications D Blood transfusionE Vitamins and minerals supplementation

Kwashiorkor Definition It is a clinical syndrome and a form of malnutrition characterized by slow rate of growth due to deficient of protein intake, high CHO diet and vitamins & minerals deficiency (adequate supply of calories).Incidence Commonly in toddlers between the age 1-3years, following or with weaning

Etiology Un balanced diet (of protein, CHO.)improper weaning (during and post weaning period )faulty management of marasmic baby Ignorance poverty due to lack of basic health education precipitating factors as(acute infection with measles, diarrhea and malaria, parasitic infestations)

Assessment 1- Essential features (cardinal manifestation):Growth retardation :- Weight is diminished (60-80%) of expectedEdema : It is due to hypo proteinemia. It is starts in the feet and lower parts of the legs) then becomes generalized edema . The cheeks become bulky, pale, waxy in appearance (doll-like-cheeks)

1- Essential features- Diminished muscle fat ratio: Generalized (muscle wasting) with subcutaneous fat - Fatty liver : It is detected by liver biopsy- Mental changes : The infant has apathy never smile, looks sad his cry is weak

2-Early features (usual manifestation)Hair changes : The hair is sparse , dys pigmentation( reddish or greyish),atrophic ,easily pickable.

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

3-Occasional or variable features - Vitamins and minerals defection and vit.D , A,C minerals as iron, zinc, Mg, Hepatomegaly.Skin changes (dermatitis in areas due to pigmentation ,napkin dermatitis, petechiae over the abdomen, fissures,ulcerationPoor resistance and liability to infections

Complication of kwashiorkorSecondary infection ,fungal and bacterial infectionHemorrhagic tendency, purpuraGastroenteritis HypoglycemiaHypothermiaHeart failure due to anemia and infection.

Investigations for kwashiorkor 1. Blood analysis: (Albumin < 2.5gmld) , total protein, amino acids, Enzymes (amylase ,lipase, alkaline phosphate, , Glucose (hypoglycemia) , k ( hypokalemia )2. Low pancreatic and intestinal enzymes3. Urine analysis, culture for infection4. Stool analysis for parasites5. Chest x-ray 6. Tuberculin test

Common Nursing Diagnoses of Marasmus and KWOAltered nutrition :less than body requirements related to knowledge deficit, infection, emotional problems, physical deficitBody temperature alteration (hypothermia) related to low subcutaneous fat and deficiency of food intake Impaired skin integrity related to vitamins deficiencyFluid volume deficit related to diarrhea High risk for infection related to low body resistance.

Nursing care of MarasmusSupport the infant and parentsprovide nutrition rich in essential nutrientsGive small amounts of foods limited in proteins, carbohydrates and fats Maintain body temperature Provide periods of rest and appropriate activity and stimulationRecord intake and output Weight dailyChange position frequently Proper treatment is given for infection Protection from infected persons and injuries Refer family to social worker for financial support Education for parents about proper nutrition

Nursing care of Kwashiorkor Support the infant and parentsProper diet intake proteins and CHO vitamins Nursing care for vomiting, diarrhea or dehydrationSkin care for child for edema , injuriesAvoid any infection and follow hygienic measures for childFrequent assessment of growth and development Safety measures to avoid injuries Nutritional counseling Record intake and out put Health education about medications and follow up Frequent monitoring for any complications

3-Marasmic Kwashiorkor DefinitionIts a combination of caloric deficiency (marasmus ) and protein deficiency (KWO) .

Clinical picture The clinical picture of this disease represents manifestations from both diseases as: loss of subcutaneous fat as in marasmus Edema, hair and skin changes as in KWO but there is no moon face.

Rickets (Osteomalacia)Definition: Its is a systemic metabolic disease due to of vit.D results in inadequate deposition of calcium in developing cartilage and bone leading to bone deformities, hypotonia and some times affecting cns. Vitamin D:- it is a group of steroid fat soluble compounds It affects the reabsorption of ca and phosphours by the kidneys It has two types:- Biologically ,D2 and D3 which are present (in-active) form and Trans formed to (active form) in the liver as (Calcitriol)- D2 called (Calciferol.) and D3called (Chole calciferol.)

Causes of vitamin D. deficiency ricketsDietary def of vit. D and Calack of exposure to sun rays Malabsorption of vit.D as in(obstructive jaundice ) Congenital rickets Taking of anti convulsive drugs poor utilization of vit.D by the tissues lead to rickets as in :- hyper para thyroidism, renal disordershypo phosphatemia recurrent attacks of diarrhea due to G.EHigh proportion of phosphorous as in cows milk leads to impaired absorp. of ca.

Contributing factorsAge common in infants (6 months -2years)Preterm babies and twins season more in winter than in summerDiet inadequate intake of vitamin D and calcium and vitamin C in diet. and diet. the disease is more common in artificial feed babies than breast feed infantsHeredity factor Atmospheric condition more common in big cities and heavy crowded areas with population no common in tropics areasRace more common in dark races

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

Delayed motor development specially walkingDelayed dentitionDeformities of the bonespresence of one of any complications

Physical examination A-Early manifestations:

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

Physical examination (Cont.) B- Late manifestations:Head Enlargement of the head like (box shape skull) due to frontal and parietal bossing)Delayed closure of anterior fontanelDelayed eruption of teeth

Physical examination (Cont.) B- Late manifestations: 2-ThoraxRickety rosary beads Harrison sulcus (transverse groove at the lower part of the chest at the costal insertion of the diaphragm)Longitudinal sulcus (lateral groove) Pigeon chest

Physical examination (Cont.) B- Late manifestations:3- Spine : kyphosis, scoliosis4- Pelvis : contracted pelvis 5- Extremities : deformities , green stick , fractures6- Muscles : weakness of muscles , hypotonic laxity of ligaments as (In abdomen)7- Constipation, enlarged spleen

COMPLICATIONS Bone fractures, limbs deformities as the following:

2- Tetany due to hypocalcaemia3- Anemia4- G.I.T disturbances as: G.E, constipation. 5- Respiratory complications as pneumonia, broncho -pneumonia6- low resistance , liability to infection as urinary tract infections

Treatment Prevention Of rickets:-

Exposure of all infants to ultra violet rays.Daily intake of diet rich with vit-D and supplementation of vit.D (400-800 IU / d). The infant need 400ivld .premature baby receives 800-1200 IU / d( 2nd -4th ) month of life Pregnant and lactating mothers need vit.D supplementation.

Treatment (Cont.) 2- Active treatment :- Oral calcium with vit.D intake should be increased.Vit-D (1500-5000)IU/ d .for 2months or shock therapy by vit-D (600-000) IU/d .by IM injection deeply one dose every 2weeks (3doses)After healing, give. vit.D (400-800) IU and repeat blood analysis for calcium.Surgical correction of deformitiesTreatment of any complications

Treatment (Cont.) 2- Active treatment :- Oral calcium with vit.D intake should be increased.Vit-D (1500-5000)IU/ d .for 2months or shock therapy by vit-D (600-000) IU/d .by IM injection deeply one dose every 2weeks (3doses)After healing, give. vit.D (400-800) IU and repeat blood analysis for calcium.Surgical correction of deformitiesTreatment of any complications

Common nursing diagnoses Body image disturbance related to bone deformitiesAltered nutritional requirements related to deficiency of calcium High risk for infection related to low of immunity. High risk for injury related to weakness of bones and deformities.

Infantile Nutritional Tetany(Tetany of vit.D deficiency)Definition:-

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

Etiology Hypocalcemia as by (hypo parathyroid), vit.D. deficiency intake , exchange transfusion) hypo magnesemia by (chronic diarrhea , malabsorption . of mg)alkalosis (pH) due to (severe vomiting, alkalotic therapy)Severe rickets. NB. Infantile tetany. has the some predisposing factors as in rickets.

Clinical manifestations1- Early manifestations as :serum calcium - >7mg /dlCarpo pedal spasm laryngeal spasm cyanosis Generalized convulsions in infants and newbornsN.B: infantile tetany is due to rapid deposition of serum Calcium so, spasms in hands, feet appear2- late manifestations:- serum Ca (7-9)mg /dl, bone deformities

Treatment A. Immediate: Give the child infant Ca gluconate .10% solution (5-10) cc. IV injection slowly.If no response search for etiology and correct it as (Mg deficiency ) by giving Mg solution sulface .50% (0.2 ml/kg ) IMO2 therapy for convulsions and emergency intubation. for laryngo spasm B. Maintenance:-Diet rich in calcium Ca chloride orally (1-3gm /d in milk) or Ca lactate. Vit.D. for treatment of rickets daily

Common Nursing diagnosesNursing diagnoses: High risk for injury related to convulsions High risk for infection related to lack of immunity Altered body image, related to bone deformities Ineffective breathing pattern, related to laryngeal spasmActivity intolerance, related to weakness of bones Altered parenting related to lack of knowledge about the disease process and its management.

Thank You

Separation from parents, peers, siblings and trusted adults Fear of harm ,injury , discomfort and pain Loss of control Unknown and unfamiliar events and environmentLimited number of coping mechanisms to resolve the stressful events in children Unclear limits and exceptions Dealing with new care takers.