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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