NUTRITIONAL DISORDERS Dr.Khalid Hama salih, Pediatrics specialist M.B.Ch.; D. C.H F.I.B.M.S.ped.

NUTRITIONAL DISORDERSNUTRITIONAL DISORDERSNUTRITIONAL DISORDERSNUTRITIONAL DISORDERS

Dr.Khalid Hama salih,

Pediatrics specialist M.B.Ch.; D. C.H

F.I.B.M.S.ped

NUTRITIONAL NUTRITIONAL DISORDERSDISORDERS

MALNUTRITIONMALNUTRITION))))

MALNUTRITIONMALNUTRITION

A pathological state due to a relative A pathological state due to a relative or absolute deficiency or excess of or absolute deficiency or excess of one or more essential nutrients; one or more essential nutrients; clinically manifested or detected clinically manifested or detected only by biochemical, anthropometric only by biochemical, anthropometric or physiological testsor physiological tests..

ClassificationClassification::

11..UndernutritionUndernutrition:: Marasmus Marasmus

22..OvernutritionOvernutrition:: Obesity,Hypervitaminoses Obesity,Hypervitaminoses

33..Specific DeficiencySpecific Deficiency:: Kwashiorkor,HypovitaminosesKwashiorkor,Hypovitaminoses , ,

44..Mineral DeficienciesMineral Deficiencies

55..ImbalanceImbalance:: Electrolyte Imbalance Electrolyte Imbalance

AetiologyAetiology::A.child related:A.child related: Low birth wt.Low birth wt. Absence or early cessation of breast feedingAbsence or early cessation of breast feeding Delay weaningDelay weaning Incorrect dietary habitIncorrect dietary habit Recurrent infection:diarrhea,measlesRecurrent infection:diarrhea,measles

B.Maternal factor:B.Maternal factor:

Maternal malnutritionMaternal malnutrition

Ignorance about feedingIgnorance about feeding

separationseparation

C. socio-economical factor:C. socio-economical factor:

Povertyand unemploymentPovertyand unemployment

Large family sizeLarge family size

Unhygienic living conditionUnhygienic living condition

Disadvataged children Disadvataged children

D. cultural factor:wrong believfsD. cultural factor:wrong believfs

E. community factor:E. community factor:

Natural/man made disasterNatural/man made disaster

Generalized economic depressionGeneralized economic depression

Inadequateprimary health careInadequateprimary health care

ETIOLOGYETIOLOGY

Classification of UndernutritionClassification of Undernutrition

1.1. Gomez Classification:Gomez Classification: uses uses weight-for-age measurements; weight-for-age measurements; provide grading as to prognosisprovide grading as to prognosisWeight-for-Age%Weight-for-Age% StatusStatus

91-10091-100 NormalNormal76-9076-90 11stst degree degree61-7561-75 22ndnd degree degree<60<60 33rdrd degree degree

2.2. Wellcome Classification:Wellcome Classification: simple since simple since based on 2 criteria only - wt loss in based on 2 criteria only - wt loss in terms of wt for age% & presence or terms of wt for age% & presence or absence of edemaabsence of edema

Wt-for-Age%Wt-for-Age% EdemaEdema No EdemaNo Edema

80-6080-60 KwashiorkorKwashiorkorUndernutritionUndernutrition

< 60< 60 Marasmic-Marasmic- MarasmusMarasmus

KwashiorkorKwashiorkor

Protein Energy Malnutrition Protein Energy Malnutrition IcebergIceberg

MarasmusMarasmus Common in the 1st Common in the 1st

year of lifeyear of lifeEtiology:Etiology: ““Balanced Balanced

starvation”starvation” Insufficient breast Insufficient breast

milkmilk Dilute milk mixture or Dilute milk mixture or

lack of hygienelack of hygiene deficiency of ALL nutrientdeficiency of ALL nutrient

MarasmusMarasmusClinical Manifestations:Clinical Manifestations:1.1. WastingWasting2.2. Muscle wastingMuscle wasting3.3. Growth retardationGrowth retardation4.4. Mental changesMental changes5.5. No edemaNo edema6.6. Variable-subnormal Variable-subnormal

temp, slow PR, good temp, slow PR, good appetite, often appetite, often w/diarrhea, etc.w/diarrhea, etc.

Laboratory Data:Laboratory Data:1.1. Serum albumin NSerum albumin N2.2. Urinary urea/ Urinary urea/

creatinine Ncreatinine N

3.3. Urinary hydroxyproline/ Urinary hydroxyproline/ creatinine low creatinine low

4.4. Serum essential a.a. Serum essential a.a. index Nindex N

5.5. Anemia uncommonAnemia uncommon6.6. hypoglycemiahypoglycemia7.7. KK+ + deficiency presentdeficiency present8.8. Serum cholesterol lowSerum cholesterol low9.9. Diminished enzyme Diminished enzyme

activityactivity10.10. Bone growth delayedBone growth delayed11.11. Liver biopsy N or Liver biopsy N or

atrophicatrophic

Clinical classification of Clinical classification of marasmusmarasmus

Grade 1Grade 1

Grade 2Grade 2

Grade 3Grade 3

Grade 4Grade 4

Loss of axiillary fatLoss of axiillary fat

Loss of fat from gluteal Loss of fat from gluteal regionregion

Loss from chest & backLoss from chest & back

Loss of Loss of buccal&temporal buccal&temporal

KwashiorkorKwashiorkor Between 1-3 yrs oldBetween 1-3 yrs old

Etiology:Etiology: Very low protein but Very low protein but

calories from CHOcalories from CHO In places where In places where

starchy foods are starchy foods are main staplemain staple

Never exclusively Never exclusively dietarydietary

KwashiorkorKwashiorkor

Clinical Manifestations:Clinical Manifestations:

A.A. Diagnostic SignsDiagnostic Signs

1.1. EdemaEdema

2.2. Muscle wastingMuscle wasting

3.3. Psychomotor changesPsychomotor changes

B.B. Common SignsCommon Signs

1.1. Hair changesHair changes

2.2. Diffuse Diffuse depigmentation of skindepigmentation of skin

3.3. MoonfaceMoonface

4.4. AnemiaAnemia

C.C. Occasional Signs:Occasional Signs:1.1. Flaky-paint rashFlaky-paint rash2.2. NomaNoma3.3. HepatomegalyHepatomegaly4.4. AssociatedAssociated

Laboratory:Laboratory:1.1. Decreased serum Decreased serum

albuminalbumin2.2. EEG abnomalitiesEEG abnomalities3.3. Iron & folic acid Iron & folic acid

deficienciesdeficiencies4.4. Liver biopsy fatty or Liver biopsy fatty or

fibrosis may occurfibrosis may occur

LaboratoryLaboratoryThe following data will be less than normal : The following data will be less than normal : Hb , serum albumin , blood sugar , plasma A.A. , Hb , serum albumin , blood sugar , plasma A.A. ,

vitamins , minerals , electrolytes , alkaline vitamins , minerals , electrolytes , alkaline phosphatase , pancreatic enzymes , thyroxin , phosphatase , pancreatic enzymes , thyroxin , cholesterol and G.F.R.cholesterol and G.F.R.

While the following data will be more than normal While the following data will be more than normal levels :levels :

Ketonuria , aminoaciduria , G.H., epinephrine and Ketonuria , aminoaciduria , G.H., epinephrine and steroid .steroid .

Marasmic kwashiorkorMarasmic kwashiorkor

State intermediate phase between marasmus State intermediate phase between marasmus &kwashiorkor when a previously marasmic child &kwashiorkor when a previously marasmic child

develops edema dueto higher nutritional requirementdevelops edema dueto higher nutritional requirement

Differences between Marasmus and Kwashiorkor

KwashiorkorKwashiorkorMarasmusMarasmus

ageage1year1yearanyany

Deitary historyDeitary historyEarly cessation of bfEarly cessation of bfDelay weaningDelay weaning

Onset Onset acuteacutegradualgradual

History of infectionHistory of infectionfrequintfrequintuncommonuncommon

Body weight Body weight 60-80% of the ideal 60-80% of the ideal body wt.body wt.

Less than 60% of Less than 60% of the ideal body wt.the ideal body wt.

Appetite Appetite PoorPoor GoodGood

Hair&skine changes Hair&skine changes common common rarerare

Edema Edema essential essential abscentabscent

Mental changeMental changeapathetic apathetic alert alert

Vitamin deficiencyVitamin deficiencycommoncommonmaskedmasked

Hepatomegally Hepatomegally PresentPresentAbsentAbsent

hypoproteinemiahypoproteinemia++/++++++/++++++

KwashiorkorKwashiorkor

TreatmentTreatment Step1:emergency phase:during 1Step1:emergency phase:during 1stst 24-48hr 24-48hr A.hypothermia dueto less subcut A.hypothermia dueto less subcut

fat,infection,hypoglycemia:graddual warming with fat,infection,hypoglycemia:graddual warming with blanket,warmer with moniteringblanket,warmer with monitering

B.infection:emperical anti biotic indicateB.infection:emperical anti biotic indicate C.hypoglycemia:should be treated C.hypoglycemia:should be treated D. dehydrationurine out put is the most reliable D. dehydrationurine out put is the most reliable

indicatorindicator

Mild –moderate:5-10ml/kg/hrwith ResomalMild –moderate:5-10ml/kg/hrwith Resomal

Sever with i.v fluidSever with i.v fluid

E.Dyselectrolytemia:hypok,hyponatremia,hypocE.Dyselectrolytemia:hypok,hyponatremia,hypocalcemia,hypomagalcemia,hypomag

F.Nutreintdeficiency:vit A,IN 2F.Nutreintdeficiency:vit A,IN 2NDND Weak give Weak give ironiron

g. Congestiveheart failure:duetog. Congestiveheart failure:dueto

1.impaire cardiac function.2.fluid over load1.impaire cardiac function.2.fluid over load

treatment with diuretic ,supportive measuretreatment with diuretic ,supportive measure

Step 2:deitary managementStep 2:deitary management A.calculate nutritionalo requirment:begin with A.calculate nutritionalo requirment:begin with

100cal/kg& 2gm/kg protein increase by 10-20% 100cal/kg& 2gm/kg protein increase by 10-20% every alternate day untill reach 150cal/kg of every alternate day untill reach 150cal/kg of expcted wtexpcted wt

b,.select of appropriate feed ,frequency,mode of b,.select of appropriate feed ,frequency,mode of administrationadministration

Monitering: a.dietary intake b.sign of recoveryMonitering: a.dietary intake b.sign of recovery c.recovery complication:diarrhea,CHF,c.recovery complication:diarrhea,CHF,

Sign of recoverySign of recovery

11..general improvement in apperancegeneral improvement in apperance

22..social smilesocial smile

33..return of apetitereturn of apetite

44..Wt gain50-70gm/dayWt gain50-70gm/day

5disapperance of edema5disapperance of edema

66..reduction of hepatomegalyreduction of hepatomegaly

77..increase serum albuminincrease serum albumin

Prognosis of PEMPrognosis of PEM Permanent impairment of physical & Permanent impairment of physical &

mental growth if severe & occurs early mental growth if severe & occurs early especially before 6 months oldespecially before 6 months old

First 48 hours critical, with poor First 48 hours critical, with poor treatment mortality may exceed 50%treatment mortality may exceed 50%

Even with thorough treatment, 10% Even with thorough treatment, 10% mortality may still occurmortality may still occur

Some mortality causes are endocrine, Some mortality causes are endocrine, cardiac or liver failure, electrolyte cardiac or liver failure, electrolyte imbalance, hypoglycemia & hypothermiaimbalance, hypoglycemia & hypothermia

Diseases of Nutritional ExcessesDiseases of Nutritional Excesses

FLUROSISFLUROSIS Causes due to excess of Causes due to excess of

Fluorine.. Fluorine.. Dental Flurosis :Dental Flurosis :

Teeth lose white color and Teeth lose white color and shine.shine.

Mottling of teeth.Mottling of teeth. Skeletal Flurosis :Skeletal Flurosis :

Nerves are effected.Nerves are effected.Back PainBack Pain..

OBESITYOBESITY Product of Energy Product of Energy

ImbalanceImbalance Leads to undue weight Leads to undue weight

on organs.on organs. HypertensionHypertension Heart DiseasesHeart Diseases DiabetesDiabetes

Nutritional DisordersNutritional DisordersObesity: body wt more than97th over wt orBMI 25Obesity: body wt more than97th over wt orBMI 25

Wt more than 120 % of expcted wt or BMI`` more than Wt more than 120 % of expcted wt or BMI`` more than 3030

In infant and children of normal weight , increase in In infant and children of normal weight , increase in adipocytes size account for most of increase in adipose mass adipocytes size account for most of increase in adipose mass during the first year of life . Obese children have larger fat cell during the first year of life . Obese children have larger fat cell size than normal weight controls children and may have size than normal weight controls children and may have increase in number of adipocytes .increase in number of adipocytes .

Obesity is based on the degree of excess fatObesity is based on the degree of excess fat..

Normal (ideal) BMI ranges between 18.5 and 25Normal (ideal) BMI ranges between 18.5 and 25..

An average BMI of a population should be 21 or An average BMI of a population should be 21 or 2222..

Less than 18.5 denotes chronic under-nutritionLess than 18.5 denotes chronic under-nutrition..

Between 25-30 considered as overweightBetween 25-30 considered as overweight..

Above 30 indicate obesityAbove 30 indicate obesity..

BMIBMIBody MassBody Mass

IndexIndex

Weight in Kilogram

Height in meters2==

34.1

45.5

56.8

102.3 113.6 12579.5

90.9

68.2

Lbs Kgs

WEIGHT

ObesityObesity Appears most frequently in the 1st Appears most frequently in the 1st

year, 5-6 years & adolescenceyear, 5-6 years & adolescenceEtiology:Etiology: Excessive intake of food compared Excessive intake of food compared

with utilizationwith utilization Genetic constitutionGenetic constitution Psychic disturbance Psychic disturbance Endocrine & metabolic disturbances Endocrine & metabolic disturbances

rarerare Insufficient exercise or lack of Insufficient exercise or lack of

activity activity

ObesityObesityClinical ManifestationsClinical Manifestations::1.1. Fine facial features on a heavy-looking taller Fine facial features on a heavy-looking taller

childchild2.2. Larger upper arms & thighsLarger upper arms & thighs3.3. Genu valgum commonGenu valgum common4.4. Relatively small hands & fingers taperingRelatively small hands & fingers tapering5.5. Adiposity in mammary regionsAdiposity in mammary regions6.6. Pendulous abdomen w/ striaePendulous abdomen w/ striae7.7. In boys, external genitalia appear small In boys, external genitalia appear small

though actually average in sizethough actually average in size8.8. In girls, external genitalia normal & In girls, external genitalia normal &

menarche not delayedmenarche not delayed9.9. Psychologic disturbances commonPsychologic disturbances common10.10. Bone age advancedBone age advanced

..

Complications of obesity :-Complications of obesity :-A- Cardiovascular complications : like hypertension , A- Cardiovascular complications : like hypertension ,

increase in serum cholesterol level increase in serum cholesterol level B- Hyperinsulinemia .B- Hyperinsulinemia .C- Cholelithiasis .C- Cholelithiasis .

D- Blount disease or slipped capital femoral epiphysis . D- Blount disease or slipped capital femoral epiphysis . E- Abnormal pulmonary function tests .E- Abnormal pulmonary function tests .

F- Pseudotumour cerebri .F- Pseudotumour cerebri .

G- Sleep apnea .G- Sleep apnea .

H- Psychological trauma H- Psychological trauma

Treatment of ObesityTreatment of ObesityA.A. 11stst principle: decrease energy intake principle: decrease energy intake

1.1. Initial med exam to R/O pathological causesInitial med exam to R/O pathological causes2.2. 3-day food recall to itemize child’s diet3-day food recall to itemize child’s diet3.3. Plan the right dietPlan the right diet

a.a. Avoid all sweets, fried foods & fatsAvoid all sweets, fried foods & fatsb.b. Limit milk intake to not >2 glasses/dayLimit milk intake to not >2 glasses/dayc.c. For 10-14 yrs, limit to 1,100-1300 cal diet For 10-14 yrs, limit to 1,100-1300 cal diet

for several monthsfor several months4.4. Child must be properly motivated & family Child must be properly motivated & family

involvement essentialinvolvement essentialB.B. 22ndnd principle: increase energy output principle: increase energy output

1.1. Obtain an activity historyObtain an activity history2.2. Increase physical activityIncrease physical activity3.3. Involve in hobbies to prevent boredomInvolve in hobbies to prevent boredom

ObesityObesity

Be master of your habits, Be master of your habits,

Or they will master Or they will master youyou..