Nutritional rehabilitation of a child with PEM using stanfield’s

technique

• BY DR.ARTHI.K

INTRODUCTION

WHO DEFINED PEM AS A RANGE OF PATHOLOGICAL CONDITIONS ARISING FROM COINCIDENTAL LACK IN VARYING PROPORTIONS OF PROTEINS AND CALORIES,OCCURING MOST FREQUENTLY IN INFANTS AND YOUNG CHILDREN AND COMMONLY ASSOCIATED WITH INFECTION.

CLASSIFICATION

PERCENTAGE OFWEIGHT FOR AGE

GRADE OFMALNUTRITION

> 80% NORMAL

71 – 80 % GRADE – 1

61 – 70 % GRADE - 2

51 – 60 % GRADE - 3

< 50 % GRADE - 4

IAP CLASSIFICATION

CLASSIFICATION

WELLCOME CLASSIFICATION

WT FOR AGE% OFEXPECTED

OEDEMAPRESENT

OEDEMAABSENT

60 – 80 % KWASHIORKOR UNDERWEIGHT

< 60 % MARASMICKWASHIORKOR

MARASMUS

CLINICAL FEATURESMARASMUS KWASHIORKOR

USUAL AGE 0 – 3 YRS 1 – 3 YRS

ESSENTIALFEATURES

EDEMA NONE PRESENT

WASTING GROSS LOSS OFS.C FAT

SOMETIMESHIDDEN

MENTALCHANGES

APATHETIC,QUITE

IRRITABLE,MOANING

GROWTHRETARDATION

OBVIOUS SOMETIMESHIDDEN

CLINICAL FEATURES

MARASMUS KWASHIORKOR

VARIABLEFEATURES

APPETITE GOOD POOR

DIARRHOEA OFTEN OFTEN

SKIN CHANGES SELDOM DIFFUSEDEPIGMENTATION,FLAKYPAINT OR ENAMELDERMATOSIS

HAIR CHANGES SELDOM SPARSE,GREY ORREDDISH,FLAG SIGN

CLINICAL FEATURES

MARASMUS KWASHIORKOR

BIOCHEMISTRY

SERUM ALBUMIN NORMAL LOW

ANAEMIA UNCOMMON COMMON

LIVER BIOPSY NORMAL ORATROPHIC

FATTY CHANGES

NUTRITIONAL REHABILITATION

• THE SETTINGS IN WHICH REHABILITATION CAN BE DONE

• RESEDENTIAL UNITS• DAY CARE CENTRES• DOMICILLARY REHABILITATION• NRC - NUTRITIONAL REHABILITATION

CENTRES

STANFIELD’S PRINCIPLES

• THE PRINCIPLES OF NUTRITION EDUCATION CAN BE CONVENIENTLY DEALT WITH UNDER SEVEN I’S

• IDENTIFICATION• INVOLVEMENT• INDIGENOUS• INFLUENCERS• INDOCTRINATION• INTEGRATION• INDIVIDUAL

IDENTIFICATION

ONE OF THE MOST FUNDAMENTAL ESSENTIALS OF COMMUNICATION IS THE DEVELOPMENT OF A ‘WE’ RATHER THAN A ‘THEY/YOU’ RELATIONSHIP. THE MOTHER MUST BE ENCOURAGED TO FEEL THAT SHE HAS REHABILITATED HER CHILD WITH ADVICE FROM STAFF AND THROUGH MEANS WITHIN HER REACH.

INVOLVEMENT

THIS IS BASED ON THE PROVERB

“ WHAT I HEAR, I FORGAT,WHAT I SEE,I REMEMBER,WHAT I DO,I KNOW”

MOTHERS HELP COOK LOW COST TRIPLE MIXES

INDIGENOUS

MAKE USE OF WHAT THEY HAVE,KNOW AND CAN DO

MAKE USE OF FOODS EASILY AVAILABLE AND CULTURALLY ACCEPTABLE IN THAT AREA

INFLUENCERS

MAKE USE OF INDIVIDUALS WHO HAVE A PLACE OF INFLUENCE IN CARRYING ACROSS THE MESSAGE

MOTHERS OF CHILDREN WHO HAVE RECOVERED ARE USED TO DEMONSTRATE THINGS TO NEW MOTHERS

INDOCTRINATION

CONSTANT REPITION IS THE CLASSICAL WAY OF EDUCATING

INTEGRATION

IT MEANS TO PROVIDE A SOLUTION TAKING INTO CONMSIDERATION SOCIAL, ECONOMIC AND WORK RELATED ASPECTS

INDIVIDUAL

THE HIGHEST PRIORITY SHOULD BE GIVEN TO SELECTING AND TRAINING THE INDIVIDUAL WHO IS GOING TO GIVE THE HEALTH EDUCATION.

STREE IS LAID ON

1) BREAST FEEDIND AND WEANING

2) DIARRHOEA PREVENTION AND MANAGEMENT

CRITERIA FOR DISCHARGE

• CHILD• WT FOR HT HAS REACHED -1 SD (90 %) OF

NCHS/WHO MEDIAN REFERENCE VALUES• EATING AND ADEQUATE AMOUNT OF

NUTRITOIUS DIET THAT THE MOTHER CAN PREPARE AT HOME

• GAINING WEIGHT AT A NORMAL OR INCREASED RATE

• ALL VITAMIN AND MINERAL DEFICIENCES HAVE BEEN TREATED

• ALL INFECTIONS AND OTHER CONDITIONS HAVE BEEN OR BEING TREATED

• FULL IMMUNISATION PROGRAMME STARTED

CRITERIA FOR DISCHARGE

• MOTHER OR CARER• ABLE AND WILLING TO LOOK AFTER THE

CHILD• KNOWS HOW TO PREPARE APPROPRIATE

FOODS TO FEED THE CHILD• CORRECT COOKING PRACTICES• KNOWS HOW TO GIVE HOME TREATMENT FOR

DIARRHOES,ARI AND HOW TO RECOGNIZE SIGNS THAT SHE MUST SEEK MEDICAL HELP

• KNOWS HOW TO MAINTAIN A KITCHEN GARDEN

RECOMMENDATIONS FOR DIETBREAST MILK

COW AND BUFFALO MILK

RAGI ,DAL,LEGUMES AND PULSES

LEAFY VEGETABLES

GROUNDNUT

EGG,FISH,MEAT

ENERGY RICH ADDITIVES- JAGGERY , OIL

HYDERBAD MIX WHOLE WHEAT 40 GM

BENGAL GRAM 16 GM

GROUND NUT 10 GM

JAGGERY 20 GM

PREVENTION

• AT FAMILY LEVEL• PROMOTION OF EXCLUSIVE BREAST FEEDING

FROM BIRTH TO 4-6 MONTHS OF AGE• CORRECT INFANT AND CHILD REARING

PRACTICES• TO IMPOSE NO RESTRICTION ON FEEDING

DURING ILLNESS

PREVENTION

• AT COMMUNITY LEVEL• SUPPLEMENTARY FEEDING PROGRAM• AGRICULTURAL DEVELOPMENT• EDUCATION AND ENVIRONMENTAL

SANITATION• POPULATION CONTROL• NUTRITIONAL INTERVENTION PROGRAMS• UNIVERSAL IMMUNISATION PROGRAM• NATIONAL CONTROL PROGRAMMES E.G

CONTROL OF DIARRHOEAL DISEASES,ARI , MALARIA,ANAEMIA.

REFERENCES

• IAP TEXTBOOK OF PAEDIATRICS• HUMAN NUTRITION AND DIETETICES -

DAVIDSON AND PASSMORE• PROTEIN ENERGY MALNUTRITION - J.P.

STANFIELD• WHO - MANAGEMENT OF SEVERE

MALNUTRITION

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