Nutrition and Nutritional Disorders ITE

7/26/2019 Nutrition and Nutritional Disorders ITE

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Nutrition and

NutritionalDisordersDra. Marina Martínez GarriChief Resident 2016-2017

Pediatric Residency Program!" Re#ie$

%&ne 2016



Malnutrition• 'ndern&trition res&(ts from inade)&ate inta*e+

a,sor tion+ or digestion of n&trients+ orins& cient inta*e for increased meta,o(ic needs.

• Caref&( (otting of height+ $eight + and ,ody massinde/ as a f&nction of time on a standard gro$thchart great(y aids in the diagnosis.

• traditiona( c(assi cation of e/treme roteinenergy ma(n&trition inc(&des marasm&s+*$ashior*or+ and marasmic *$ashior*or.



Marasmus• Predominant(y caloric/

energy de ciency+ ischaracterized ,y mar*edemaciation (oss of

s&,c&taneo&s fat andm&sc(e ,ritt(e+ s arse hairand oor nai( gro$th.

• Marasm&s is &s&a((y seen

$ithin the rst year of (ife atthe time of $eaning+ d&ringfamine+ or at any time $henthere is a consistent ande/treme de ri#ation ofca(ories.







Kwashiorkor• Res&(ts from a diet rich in

ca(ories ,&t low in protein . !he initia( 3moon face4 of*$ashior*or is often mista*en

for ro er n&trition.

• 5e atomega(y and menta(stat&s changes are common.

• *in changes in atients $ith*$ashior*or inc(&de hyper-or hypopigmentation witha scaly, weepingdermatitis that mayulcerate and desquamate .



“faky paint dermatosis













!ailure to "hri#e• descri ti#e term &sed to

depict inadequate weight gain o#ertime + often &sed $hen $eight for age crosses t$o ercenti(es or$hen $eight for age fa((s ,e(o$ the rd ercenti(e for age.

• Ca&tion m&st ,e &sed $hen $eight gain consistent(y trac*s ,e(o$the rd ercenti(e+ as this may re8ect a norma( gro$th attern,ased on standard $eight distri,&tion atterns.

• Most fai(&re to thri#e is mar*ed ,y decreased $eight for height+$ith initia( s aring of height for age and head circ&mference forage+ $ith grad&a( (oss in height and head circ&mference for age as

the &nderno&rished state contin&es.

• more acc&rate descri tion of this a,norma( attern of gro$th can,e c(assi ed as inade)&ate inta*e+ ma(digestion+ ma(a,sor tion+ine9ecti#e &se of ca(ories+ or increased meta,o(ic demand.







!ailure to "hri#e



!ailure to "hri#e• :a,oratory testing can ser#e as

;1< a diagnostic too( for de ning an&nder(ying condition

;2< a mar*er for the degree of ma(n&trition; < a screening too( for s eci c n&trient or

micron&trient de ciencies.

• (tho&gh (a,oratory tests can ,e he( f&(+they are not mandatory and the decision fortesting sho&(d ,e deri#ed from the history

and hysica( e/amination.









$peci%c Nutrient De%ciencies



=itamin D De ciency• Presents at $eight-,earing age and

res&(ts in oor gro$th+ c&r#at&re of$eight-,earing ,ones+ $idening ofe i hyses+ and costochondra(3rachitic rosary4 ,eading.

• Craniota,es + or softening of thes*&((+ may ,e seen in infants.

• >ith a ro riate #itamin andminera( s& (ementation+reso(&tion occ&rs fo((o$ed ,y ,one

remode(ing.

• =itamin D de ciency is es ecia((yre#a(ent in &reast'ed in'ants +

infants $ith darker skin + andinfants and chi(dren $ith

decreased sun e(posure .



:a,oratories• :oo* 'or high )"*,

low + - *-#itaminD and high

alkalinephosphatase.

• !he P!5 is high as ahormona( res onseto try to maintainnorma( ca(ci&m(e#e(s



Mani'estations o'ickets



Ric*ets

?e a$are that the mostfre)&ent com (aint in infants

and chi(dren is nothing Physicians most fre)&ent(ydiagnose ric*ets thro&gh an

incidenta( nding on hysica(e/am.











0itamin 1 De%ciency

• :eads to@-night ,(indness- /ero htha(mia-fo((ic&(arhy er*eratosis-?itot s ots

;*eratinization ofthe cornea<-cornea( o acities-gro$th fai(&re.



0itamin 2 De%ciency• !oco hero(• Mem,rane ,o&nd

antio/idant that ser#es torotect the ,ody from

,io(ogic rocesses thatdamage ce((&(arstr&ct&res.

• Ae&ro(ogic dysf&nction;ne&roa/ona(

degeneration and (oss ofre8e/es<

• n the reterm infant@hemo(ytic anemia.



0itamin 3 De%ciency4$cur#y5

• nitia( sym toms arenons eci c;irrita,i(ity+ digesti#edist&r,ances+anore/ia<

• Bo((ic&(arhy er*eratosis

•

Cor*scre$-coi(edhairs• Gingi#a( ,(eeding• Peri&ng&a(

hemorrhages



0itamin 3 De%ciency• Res&(ts in im aired formation

o' collagen andchondroitin sul'ate.

• Res&(ts in fragi(e ca i((aries+gingi#al hemorrhages.

• Bai(ed osteoid formation ,yosteo,(asts (eading todecreased &one 'ormation .;fragi(e and ,ritt(e ,ones thatfract&re easi(y<.

• Most ,one a,norma(ities arefo&nd in metahysis andsterna(-ri, E&nction4!rankel lines5.



!olate De%ciency• "he + nd cause o'

nutritionalanemia 46 st causeis iron

de%ciency5• Ae&ra( t&,e defects• Goat s mi(*• (ea( resection

atients are themost at ris*F ;A"C+Crohns+

int&ss&sce tion<



0itamin 76+ De%ciency

• Patients with terminalileum disease or resectionare at artic&(ar ris* of#itamin ?12 de ciency+$hich res&(ts in amacrocytic anemia,hypersegmentedneutrophils and orneurologic %ndings d&e

to oor mye(ination of ner#e,ers.

• Ae&ro(ogic ndings $hendetected ear(y can ,e

re#ersi,(e.



- " 8 N D 2 ! 8 3

8 2 N 3 9







:hat is the diagnosis;;

!he c(assic a earance of eosino hi(ic eso hagitis on endosco y is

eso hagea( f&rro$ingand an e/&dati#e eso hagitis



2osinophilic 2sophagitis• "osino hi(ic eso hagitis is an

in8ammatory disorder of theeso hag&s that is a commonca&se of dys hagia in chi(dren.

•

ym toms can inc(&dedysphagia, 'eeding re'usal,epigastric a&dominal pain,early satiety, and e#en 'oodimpaction.

• ym toms of re8&/ or eso hagitiscan com (icate the diagnosis.

• ther ndings inc(&de theformation of concentric rings or“tracheali<ation of theeso hag&s









Malrotation/0ol#u#lus• ntestina( ma(rotation is the

res&(t of an incom (eterotation of the intestined&ring em,ryonic (ife.

ntestina( ma(rotation ca&sesthe intestines not to ,e

ro er(y 3 /ed4 at themesentery.

• !he res&(ting 3sta(*(i*e4

mesentery may ser#e as afoca( oint for t$isting orvolvulus of the intestine.

• 0ol#ulus resents $ith thes&dden onset of ,i(io&s

emesis and a,domina( ain.



Malrotation :8"* ="#ol#ulus



Malrotation :8"*

#ol#ulus











nos



y l o r i c $ t e

n o s



3eliac Disease• Ca&sed ,y the a&toimm&ne

destr&ction of intestina( #i((id&e to anti,odies formed inres onse to g(&ten e/ os&reand the mimicry of the g(&tencom onent gliadin to theenterocyte rotein tiss&etransg(&taminase.

• !he c(assic a earance ofma(a,sor tion d&e to ce(iacdisease is simi(ar to that ofma(n&trition $ith fai(&re tothri#e+ chronic diarrhea,short stature, and wasting

o' e(tremities





i e a se



r o h n s D i s e a s e

egmenta(narro$ing

of the (eft co(on.

narro$ and irreg&(ar termina( i(e&m

a se



o h n s D i s e a

s e

trict&ring of the d&oden&m Di9&se a htho&s&(cers in the

stomach

e



r o h n s D

i s e a s

e



3 r o h n

s D i s e

a s e

draining eriana( st&(a





lit is



c e r a t i #

e 3 o l i t i s

(ead i e or feat&re(essa earance to the co(on

olit is



Aarro$ing and (ossof ha&stra( mar*ings are a

sign of co(onic in8ammation

ty ica( of &(cerati#e co(itis

Aarro$ingand irreg&(ar

,orders+

indicating co(onin8ammation

c e r a t i # e

3 o l i t i s

lit is



c e r a t i #

e 3 o l i t i s

!he entire co(onic m&cosa isin8amed+

fria,(e+ and gran&(ar $ith o,#io&se/&date and ,(eeding



steoarthropathy ;c(&,,ing<Aote thic*ening and (oss of the ang(eat the nai( ,ed in a chi(d $ithin8ammatory ,o$e( disease

)yoderma gangrenosum !his is a c(assic+ a(tho&gh &ncommon+

rash associated $ith in8ammatory,o$e( disease. nitia( a &(o &st&(es$i(( coa(esce to form a dee necrotic(esion.



)yoderma gangrenos

2rythema nodosum



2 r o s i # e e s o p h a g i t i s



2 s o p h a g e a l = l c e r



2 s o p h a g e a l 0 a r i c e s







8ntussusceptio

Mec*e( di#ertic&(&m can ,e a (eadoint for int&ss&sce tion.



. e c t a l ) r o l a p s e



3 o n s t i p a t i o n

Aote the di(ation of the rect&mand co(on

,e(o$ the e(#ic rim

* i



* i r s c h s p r u n g d i s e a s

!a ered transition zone to anorma(-ca(i,er co(on



1lagille $yndrome• Ca&se of intrahepatic cholestasis .

• rteriohe atic dys (asia

• Patients $ith this disorder may ha#e acharacteristic face of deeply set eyesand a narrow chin a(ong $ith eri hera(pulmonic stenosis or cardiacanomalies + and &utterfy #erte&rae .

• :i#er histo(ogy sho$s paucity o' the

interlo&ar &ile ducts . Many atients

sho$ #aria,(e feat&res of the disorder andprognosis is #aria&le . #er time+atients $ith disorders of cho(estasis can

s&9er from intracta&le pruritus d&e to,i(e acid acc&m&(ation and (anthoma'ormation as the res&(t of cho(estero(de osition.



1lagille $yndrome



7 u t t e r f y 0 e r t e & r a e


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K ay



a y s e r - ! l e i s c h e r r i n g s

"ar(y Hayser-B(eischerrings may ,e seen on(y

,y s(it-(am e/aminationand ,egin atthe s& erior and inferior

o(es.



$ p i d e r - N e # u s

3 hr



h r o n i c l i # e r d i s e a s

e









"*2 2ND

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Nutrition and Nutritional Disorders ITE

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