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

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.

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.

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)

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 .

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.

PEM--PRECIPITATING FACTORS

•  LACK OF FOOD ( poverty)

•  INADEQUATE BREAST FEEDING

•  WRONG CONCEPTS ABOUT NUTRITION

•  DIARRHOEA & MALABSORPTION

•  INFECTIONS (worms, measles, T.B)

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

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

Assessment of Nutritional status

¨ Direct 1.Dietary history 2.Anthropometric measurements 3. Clinical assessment 4.Laboratory

¨  Indirect ¤ Health statistics

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.

ANTHROPOMETRY

¨  Objective with high specificity & sensitivity ¨  Measuring Ht, Wt, MUAC, HC, skin fold thickness,

& BMI

¨  Non-expensive & need minimal training

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

Eye signs of vitamin A deficiency

Sign of vitamin A deficiency

Clinical Assessment

¨ ADVANTAGES ¤ Fast & Easy to perform ¤ Inexpensive ¤ Non-invasive

¨ LIMITATIONS ¤ Doesn't not detect early cases ¤ Trained staff needed

LABORATOY ASSESSMENT

¨ Biochemical ¤ Serum proteins,

¨ Hematological ¤ CBC, iron, vitamin levels

¨ Microbiology ¤ Parasites/infection

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

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 %

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.

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.

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.

CLINICAL PRESENTATION

¨  Kwash is characterized by certain constant features in addition to a variable spectrum of symptoms and signs.

CONSTANT FEATURES OF KWASH

n OEDEMA

n PSYCHOMOTOR CHANGES

n GROWTH RETARDATION

n MUSCLE WASTING

USUALLY PRESENT SIGNS

¨ MOON FACE

¨ HAIR CHANGES

¨ SKIN DEPIGMENTATION

¨ ANAEMIA

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

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.

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.

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.

Clinical Features of Marasmus

¨  Severe wasting of muscle &loss of subcutaneous fats

¨  Severe growth retardation

¨  Child looks older than his age

¨  Hungry

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

Complications of P.E.M

¨  Hypoglycemia ¨  Hypothermia

¨  Hypokalemia.

¨  Hyponatremia

¨  Heart failure

¨  Dehydration & shock ¨  Infections,sepsis (bacterial, viral & thrush)

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

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

Any Questions?