SAM latest guideline

PROTEIN ENERGY MALNUTRITION

DR. SANDEEP LATHER

Malnutrition is globally the most important risk factor for illness and death.

 There were 925 million malnourished

people in the world in 2010(Global Hunger Index)

In India 65% (80 million) under 5 yrs age malnourished.

The single largest common denominator in

global child deaths is malnutrition

MalnutritionMalnutrition (mal-bad,nutrition) is the condition that

results from taking an unbalanced diet in which certain nutrients are either lacking, or in excess (too high an intake), or in the wrong proportions

World Health Organization definition:The term is used to refer to a number of diseases, each

with a specific cause related to one or more nutrients (for example, protein, iodine or iron) and each characterized by cellular imbalance between the supply of nutrients and energy on the one hand, and the body's demand for them to ensure growth, maintenance, and specific functions, on the other. “

DEFINATION

HEALTH- Complete Physical , Mental , Social and Spiritual wellbeing .

PEM- Pathological condition arising from coincidently lack in varying proportion of Protein and calories , occuring most frequently in infant and childern and commenly associated with Infection

Under nutrition is a condition in which there is inadequate consumption, poor absorption or excessive loss of nutrients.” O P GHAI

Amongst the highest in the world,

nearly double that of Sub-Saharan Africa.

22 percent of the country’s burden of disease.

.

PREVALANCE IN INDIA

PEM A

MULTIFACTORIAL ENTITY

MALNUTRITIONMALNUTRITION

improper and / or inadequate food intake

inadequate absorption of food

Deficient supply of food

poor dietary habitsilliteracy

emotional factors metabolic abnormalities

diseases

Keith West

•1 ) Feeding on artificial milk formulas - reconstituting wrongly.•2)Feeding on diluted fresh milk• 3)Breast feeding for a long time• 4)Delayed weaning• 5)Feeding via dirty feeding bottles• 6)working mothers

•1 ) Feeding on artificial milk formulas - reconstituting wrongly.•2)Feeding on diluted fresh milk• 3)Breast feeding for a long time• 4)Delayed weaning• 5)Feeding via dirty feeding bottles• 6)working mothers

Malnutrition and Faulty feeding  

Effect of Maternal nutrition on child heallth

Malnutrition of pregnant women may lead to serious problems for children.

More commonly, likely to be small at birth.

Low birth weight is associated with increased risk of mortality and with a range of health and developmental problems.

Cretinism resulting from severe maternal iodine deficiency

Effect of Malnutrition amongst

adolescent girls Undernutrition in childhood can cause

stunting and influence the size of the child a woman can bear later in life.

Maternal pelvic size is a strong determinant of neonatal survival and universally correlated with height in populations.

Protein Energy Malnutrition- ,

Kwashiorkor

mild form to severe form malnutrition

•Severe form malnutritionSevere form malnutrition•Kwashiorkor: protein deficiencyKwashiorkor: protein deficiency•Marasmus: energy deficiencyMarasmus: energy deficiency•Marasmic Kwashiorkor: combination of chronic Marasmic Kwashiorkor: combination of chronic energy deficiency and chronic or acute protein energy deficiency and chronic or acute protein deficiencydeficiency•PreKwashiorker: Poor nutrition +Kwashiorker PreKwashiorker: Poor nutrition +Kwashiorker feature except oedema.feature except oedema.

mild form to severe form malnutrition

•Severe form malnutritionSevere form malnutrition•Kwashiorkor: protein deficiencyKwashiorkor: protein deficiency•Marasmus: energy deficiencyMarasmus: energy deficiency•Marasmic Kwashiorkor: combination of chronic Marasmic Kwashiorkor: combination of chronic energy deficiency and chronic or acute protein energy deficiency and chronic or acute protein deficiencydeficiency•PreKwashiorker: Poor nutrition +Kwashiorker PreKwashiorker: Poor nutrition +Kwashiorker feature except oedema.feature except oedema.

Invisible PEM:---- Toddler shows breast addiction, look entirely normal but small for age, lowered resistance to infection(6 -24 month age group).

Early lactation Failure syndrome: Abrupt stoppage of Breastfeeding and early introduction of dilute starch based liquid diet without any good quality protine.

Classification of PEM

WHO classification

Moderate Malnutrition

Severe Malnutrition

Symmetrical Oedema No Yes edematous malnutrition

Weight for Height SD SCORE(Z Score) b/w-2 to -3

SD SCORE < -3Severe wasting

Height for age SD SCORE(Z Score) b/w-2 to -3

SD SCORE < -3Severe stunting

IAP Classification

Grade of malnutrition

Weight for age of the standard

Normal >80%

Grade 1 71-80% Mild malnutrition

Grade 2 61-70% Moderate malnutrition

Grade 3 51-60% Severe malnutrition

Grade 4 <50% Vere severe malnutrition

GOMEZ Classification

Nutritional status Weight for age

Normal >90

First degree malnutrition 75-90

Second degree malnutrition 60-75

Third degree malnutrition <60

ALL CASES WITH OEDEMA TO BE INCLUDED IN GRADE THREE PEM IRRESPECTIVE FOR AGE Reference standard WHO growth chart

WATERLOW Classification

Nutritional status Height for age(% of expected)

Normal >95

First degree stunting 90-95

Second degree stunting 85-90

Third degree stunting <85

Age independent indicesAge independent indices

Name of IndexName of Index CalculationCalculation Normal value Normal value Value in Value in malnutrition malnutrition

Kanawati and Kanawati and McLaren’s indexMcLaren’s index

Mid arm Mid arm circumference / circumference /

head head circumference circumference

(cm)(cm)

0.32-0.330.32-0.33Severely Severely

malnourished malnourished <0.25<0.25

Rao and Singh’s Rao and Singh’s indexindex

(weight (in kg) / (weight (in kg) / heightheight2 2 (in cm)) x (in cm)) x

1001000.140.14 0.12-0.140.12-0.14

Dugdale’s indexDugdale’s index weight (in kg) / weight (in kg) / heightheight1.6 1.6 (in cm)(in cm) 0.88-0.970.88-0.97 <0.79<0.79

Quaker arm Quaker arm circumference circumference

measuring stick measuring stick (quac stick)(quac stick)

Mid-arm Mid-arm circumference circumference that would be that would be expected for a expected for a given heightgiven height

75-85% 75-85% malnourished malnourished <75% severely <75% severely malnourishedmalnourished

Jeliffe’s ratioJeliffe’s ratio

Head Head circumference / circumference /

chest chest circumferencecircumference

Ratio <1 in a Ratio <1 in a child >1 year child >1 year malnourishedmalnourished

Cont..

Bangle test

Shakir’ tape Mid arm circumfence

MAC/Height <.29-severe malnutrition

0.32-0.33 normal nutrition

Ponderal index-weight/Height2

>2.5—normal2-2.5-borderline<2-svevere malnutrition

BODY MASS INDEX-weight in kg/height(cm)2

Mid arm muscle circumference

18.5-25 normal<13 –severe underweight<15-moderate malnutrition

MAC-(3.14*SFT)

CLASSIFICATION

CLINICAL ( WELLCOME ) Parameter: weight for age + oedema Reference tandard (50th percentile)

Grades: 80-60 % without oedema is under weight 80-60% with oedema is Kwashiorkor < 60 % with oedema is Marasmus-Kwash < 60 % without oedema is Marasmus

KWASHIORKAR

First recognized by prof cicely willamsPretend not to mind the second one(Krokor)The disease of first child. Red boy. Sugar baby, Disposed child,

Floor dystrophy,Triad: Growth retardation, pshycomotor

changes,and oedema Can affect anyone who suffers from a lack of

protein in the diet, and an excess of carbohydrates.

Kwashiorkor PIC.

Not only dietary in origin. infective, psycho-

social, and cultural factors are also operative.

Because of lack of physiological adaptation to

unbalanced diet.

Height and weight are accelerated with treatment

but never equal to those of consistently well-

nourished children.

Grading of kwashiorker

1-pedal oedema2-1+facial oedema3-2+paraspinal and

chest oedema4-3+ascites

MARASMUS

Severe form  protein-energy malnutrition characterized by energy deficiency and lack of nutrition in diet.

Greek word MARASMOS-STARVATION

characterized by gradual wasting of somatic fat and muscle stores and preservation of visceral proteins.

In Marasmus the body utilizes all fatstores before using muscles.

No Subcutaneous fat

Grading of Marasmus

1) Wasting in Axilla +Groin.2)Thigh and Buttock .3)Chest and Abdomen.4) Buccal pad of fat.

Wasting of Brown fat occur first because it is more metabolically active.

most commonly in the first year of life due to lack of breast feeding and the use of dilute animal milk.

higher risk of developing marasmus.Ignorance & Poverty / famine poor maternal nutrition, low socio-economic status, children with chronic disease

• and diarrhoea,,

Diffefence b/w marasmus and kwashiorkarKWASHIORKAR MARASMUS

wet form of PEM, sugar baby ,red boy

Dry form of PEM

Mainly protein deficiency but also EFA, micronutrients deficiency

Lack of calorie and protien in diet

Lack of adaption-less cortisol adaptive mechanism involve Cortisol and anabolic hormone

Mostly >1 yr of age <1 yr of age

Very thin,

General appearance

Lethrgic ,moderate malnourished , distended abdomen, moon facies

Fretful, irratable ,monkey facies severe malnourished

edema Present absent

Mental change

Apatheic, lethrgic, staring look,

Alert, roving eye-searchig, food, irritable

appetite Decrease good

Skin change

Phrynoderma,thin shiny ,taut Flanky paint dermatosis, Ulcer

Loose skin fold, lose of fat pad

Cont….

Hair change Red colour,Flag sign

Sparse hypopigmented

occurence Less common More common

prognosis Good Better than k

Other feature Hepatomegaly-fatty infiltration of liver,

absent

Associated micronutrient deficiency

Present ,but sign appear during recovery phase

Anaemia-dimorphic anaemia

Circulatory insufficiency, cardiomyopathy,

Dehydration

Renal function also impair

recovery Late to recover early

Pathological changes in malnutrition in various organ systemsPathological changes in malnutrition in various organ systems

Upper GITUpper GIT Mucosa shiny and atrophic. Papillae of tongue flattened. Mucosa shiny and atrophic. Papillae of tongue flattened.

Small and large Small and large intestineintestine

Mucosa and villa atrophic; brush border enzymes reduced; hypotonic, rectal Mucosa and villa atrophic; brush border enzymes reduced; hypotonic, rectal prolapse prolapse

LiverLiver Fatty liver, deposition of triglycerides. Fatty liver, deposition of triglycerides.

PancreasPancreas Exocrine secretion depressed ; glucagon production decreases; insulin levels Exocrine secretion depressed ; glucagon production decreases; insulin levels low; atrophy and degranulation or hypertrophy of islets seen. low; atrophy and degranulation or hypertrophy of islets seen.

Endocrine Endocrine systemsystem

Elevated growth hormone; thyroid involution and fibrosis; adrenal glands Elevated growth hormone; thyroid involution and fibrosis; adrenal glands atrophic and cortex thinned; increased cortisol, catecholamine activity unaltered. atrophic and cortex thinned; increased cortisol, catecholamine activity unaltered.

Immune systemImmune system

Humoral immunity- decreasae level of secretory igA level ,prone to GIT and Humoral immunity- decreasae level of secretory igA level ,prone to GIT and respiratory infection.respiratory infection.Cellular immunity-low, Thymus involuted; lymphoenia; paracortical areas of Cellular immunity-low, Thymus involuted; lymphoenia; paracortical areas of lymph nodes depleted of lymphocytes; germinal centers smaller and fewerlymph nodes depleted of lymphocytes; germinal centers smaller and fewer

CNSCNS Head circumference and brain growth retarded ; cerebral atrophy on CT / MRI ; Head circumference and brain growth retarded ; cerebral atrophy on CT / MRI ; abnormalities in auditory brainstem potentials and visual evoked potentials. abnormalities in auditory brainstem potentials and visual evoked potentials.

CVSCVS Cardiac volume, muscle mass and electrical properties of the myocardium Cardiac volume, muscle mass and electrical properties of the myocardium changes ; systolic functions affected more . changes ; systolic functions affected more .

Biochemical indices in children with malnutritionBiochemical indices in children with malnutrition

TransferrinTransferrin <0.45 mg/ml indicative of severe malnutrition <0.45 mg/ml indicative of severe malnutrition

Albumin Albumin Albumin concentration <3g /dl is associated with early Albumin concentration <3g /dl is associated with early illness; between 2.5 and 2.9 are low and below 2.5 g / illness; between 2.5 and 2.9 are low and below 2.5 g / dl are pathological dl are pathological

Pattern of Pattern of circulating amino circulating amino acids in bloodacids in blood

Essential amino acids Essential amino acids non essential amino acids are non essential amino acids are normal or normal or therefore their ratio is therefore their ratio is Mean value 1.5; Mean value 1.5; subclinical illness 2-4; frank kwashiorkor >3.5subclinical illness 2-4; frank kwashiorkor >3.5

24 hr urinary 3-24 hr urinary 3-methylhistidine methylhistidine excretion excretion

Present exclusively in skeletal muscle and white muscle Present exclusively in skeletal muscle and white muscle fibers ; released when actin and myosin catabolized; fibers ; released when actin and myosin catabolized; excreted in urine; reflects muscle mass 24 hr excretion excreted in urine; reflects muscle mass 24 hr excretion in malnutrition in malnutrition

Urinary creatinine Urinary creatinine height index (CHI)height index (CHI)

Breakdown product of creatinine ; reflects muscle mass Breakdown product of creatinine ; reflects muscle mass Ranges 0.25-0.75 in Kwashiorkor and 0.33-0.85 in Ranges 0.25-0.75 in Kwashiorkor and 0.33-0.85 in marasmus; recovered child -1marasmus; recovered child -1

height) same of child (normal creatinine urinehour 24

creatinine urinehour 24CHI

PATHOPHYSIOLOGY

Adaptive Starvation In the face of inadequate intakes, activity and energy

expenditure decrease. Despite this adaptive response ,fat stores are mobilized

to meet energy requirements.

Energy Metabolism during Starvation

Glycogen levels become depleted. Fat is used to make ATP and is used as an energy source. Gluconeogenesis occurs by synthesizing glucose from

protein compounds/muscle breakdown_after fat stores are depleted.

ETIOLOY OF KWASHIORKAR AND MARASMUS

Classical theory of protein deficient

Gopalan theory of dysadaptation Marasmus occur as a result of adaptation to chronic

nutritional deficiency via cortisol while k is an acute condition body fail to response to nutrtitional stress resulting in edema poossibly because of excess carbohydrate

Golden theory of free radical

Clinical signs and symptoms of micronutrient deficiencies

Iron – fatigue, anemia, developmental delay and mental retardation.

Vitamin D – Poor growth, rickets, and hypocalcaemia

Tremor: During t/t,def. vit B,GABA↑,demylination. KWASHI SHAKE.

Vitamin A – Night blindness, xerophthalmia, poor growth, and hair

changes. phrynoderma

Folate – Glossitis, anemia (megaloblastic), and neural tube defects (in

fetuses of women without folate supplementation)

Zinc – Anemia, dwarfism, hepatosplenomegaly, hyper pigmentation and

hypogonadism, acrodermatitis enteropathica, diminished immune

response, poor wound healing.

WHY KWASHIORKOR IN SOME AND MARASMUS IN OTHERS

Variability among infants in nutrient requirements and in body composition at the time of dietary deficit.

Giving excess carbohydrate to marasmus child reverses adaptive response to low protein intake lipogenesis and less apolipoprotein synthesis.

This results in mobilization of protein stores, decreased albumin synthesis, hypoalbuminemia and edema.

Severe Acute Malnutrition …a silent life threatening emergency

Theme of special issue INDIAN PEDIATRICS(IAP JOURNAL) Aug,2010.

WHO and UNICEF propose diagnostic criteria as_Weight/height of <70% and/or

presence of bilateral pitting edema “and/or

Visible severe wasting, and/or

MUAC of < 11 cm in children , 6-60 months of age.

However, the suggested MUAC cut-offs are not based on Indian population, and need validation.

ASSESSMENT OF NUTRITIONAL STATUS OF CHILDREN

1. History Should include H/O

(i) Recent intake of food and fluids; (ii) Usual diet (before the current illness);(iii) Breastfeeding; (iv) Duration and frequency of diarrhea and vomiting,

type of diarrhea, Loss of appetite, Fever, H/O contact with tuberculosis, measles etc.

(v) Family circumstances (to understand the child’s social background),

2. Anthropometric indicatorsEvidence of deviations from average height & weightEvidence of depletion of fat depotsEvidence of decrease in muscle mass

3. Evidence of specific deficiencies

DIET HISTORY

ASSESS DAILY FOOD INTAKE WITH ASSESSMENT OF CALORIE AND PROTEIN

Daily Calories Requirement

HOLIDAY AND SEGAR FORMULA:

1-10 kg– 100 kcal/kg10-20 kg— 1000+50 kcal/kg for each kg

above 10 kg.Above 20 kg– 1500 +20 kcal /kg for each

kg above 20 kg.

Energy Expenditure in normal Child

BMR: 50%ACTIVITY: 25%GROWTH: 12%FECALLOSS: 8%SPECIFIC DYNAMIC ACTION:5%

Nutrients   Human  Cow          (gm) 

Lactose    7  4.5    Ca:P >2 <2

Protein    1.1  3      Casein:whey 40:60 80:20

Fat     3.8   3.7   Energy     67  67  

MILK 100 gm

(i) Anthropometry-weight, height/length, mid armcircumference (ii) Signs of dehydration and shock (cold hands, slow capillary refill, weak and rapid pulse)(iii) Lethargy or unconsciousness(iv) Severe palmar pallor (v) Localizing signs of infection, including ear and throat infections, skin infection or pneumonia(vi) Fever or hypothermia (vii) Mouth ulcers, skin changes of kwashiorkor (viii) Eye signs of vitamin A deficiency (ix) Signs of HIV infection.

Physical examination

ANTHROPOMETRIC INDICATORS OF NUTRITIONAL STATUS

1. Weight: index of acute nutritional status

2. Height or length: unaffected by excess fat or fluid; assesses growth failure

3. Weight for height measurement: more

accurately assesses body buildA. Measure child’s heightB. Find age for which measured height is on the 50th %

on the growth curveC. Child’s actual weight (numerator)

50th% wt based on age of plotted ht (denominator)

What is Anthropometry?

Greek Anthro- : man -pometry: measurements Literal meaning: “measurement of humans”

The study of measurements or proportions of the human body according to sex, age, etc. for identification purposes

Dimensions of bones, muscles, and adipose (fat) tissues

Measurement of Height

Without footwearHeels & back touching the wallLower border of the eye socket in the same

horizontal plane as external auditory meatus

Looking straight ahead A right angled block slides down until

touches the headGentle but firm pressure upwards applied to

the mastoids from underneathRecord to last 0.1 cm

65

Mid-Upper Arm Circumference (MUAC) for Assessment and

Admission

It increases rapidly in 1st year of life (11-16 cm) and remain stable{16-17 cm} in 1 to 5 year.

A value below 11.5 cm indicates severe malnutrition.

Wasted

13.5 <12.5

12.5 TO 13.5Normal

Use Appropriate Growth ChartsMany growth charts are availableExamples

IAP (IAP Growth Monitoring guidelines 2007) WHO (MGRS Study 2006) British 2005 ICMR 1989 Affluent Indian (Agarwal et al) 2009 Affluent Indian (Khadilkar et al)

Indicators of malnutrition

Indicator Interpretation

Stunting Low height for age Indicator of chronic malnutrition, the result of prolonged food deprivation and / or disease or illness.

Wasting Low weight for height

Suggests acute malnutrition , the result of more recent food deficit or illness

Under weight

Low weight for age Combined indicator to reflect both acute and chronic malnutrition

Investigations for PEM

Full blood countsBlood glucose profileSeptic screeningStool & urine for parasites & germsElectrolytes, Ca, Ph & ALP, serum

proteinsCXR and Mantoux test.Exclude HIV & malabsorption

Additional diagnostic evaluation

Measures of protein nutritional status include serum albumin,

retinol-binding protein, prealbumin, transferrin, creatinine,

and BUN levels.

Retinol-binding protein, prealbumin and transferrin

determinations are much better short term indicators of

protein status than albumin.

a better measure of long-term malnutrition is serum albumin

because of its longer half life.

Complications

*anorexia or no appetite, intractable vomiting, convulsions, lethargy or not alert, unconsciousness, lower respiratory tract infection (LRTI), severe dehydration, severe anaemia, hypoglycaemia, or hypothermia

Immediate management

of any acute problems

such as those of severe

diarrhea, renal failure,

and shock and,

ultimately, the

replacement of missing

nutrients are essential.

TREATMENTTREATMENT

Treatment of mild –moderate malnutrition

mild to moderate malnutrition make up greatest proportion of malnourished children.

very important to intervene at this stage

at least to give 150 Kcal/kg /day

protein 3 gm/kg /day

Ten Steps to Recovery

THE WHO TEN STEPS

Treatment of Malnutrition

1. hypoglycemia

All severely malnourished children are at risk of developing hypoglycaemia (blood glucose< 54 mg \dl )

Important cause of death during the first 2 days of treatment.

Signs of hypoglycaemia – low body temperature

(< 35.5 Celcius) , lethargy, loss of consciousness. Reasons – serious systemic infection or child - not fed for 4-6 hours

Treaatment of hypoglycemia

AsymptomaticGive 50 ml of 10%

glucose or sucrose solution orally or by nasogastric tube followed by the first feed ,no i.v. fluid.

Feed with starter F-75 started every 2 hourly day and night

SymptomaticGive 10% dextrose i.v. 5

ml / kgFollow with 50 ml of 10%

dextrose or sucrose solution by nasogastric tube

Feed with starter F-75 started every 2 hourly day and night .

2. Treat/prevent hypothermia

Rectal temperature less than <35.5ºC or 95.5ºF or axillary temperature less than 35ºC or 95ºF

Due to impaired thermoregulatory control, low BMR and decreased thermal insulation from body fat.

At risk- - Infants under 12 months, - large areas of damaged skin or - serious infections - marasmic children Hypoglycemia, hypothermia and Gram negative

sepsis occur as a triad

Treatment of hypothermia

• Feed the child immediately • Cloth the child with warm clothes• head should be covered well with a scarf or a cap • Provide heat using radiation (overhead warmer), conduction (skin

contact) or convection (heat convector)• Give appropriate antibiotics

Prevention• Feed the child 2 hourly starting immediately after admission • Place the child’s bed in a draught free area • Always keep the child well covered. • The child could also be put in the contact with the mother’s bare chest or

abdomen (skin to skin) as in kangaroo mother care to provideMONITORING-

• Record the temperature half hourly till it reach 36.5 c• Measure blood glucose..

•

Dehydration

ASSESSMENT H/O diarrheoa , vomitting Thirst , Recent shunken eyeDecrease urine output, tachycardia, feeble pulse

Unreliable sign Mental state Mouth ,tongue, tear Skin turgor

It is important to recognize the fact that dehydration can co-exist with edema.

Treatment of dehydration

For rehydration in child with SAM use RESOMAL-ORS

orally or through a nasogastric tube

Every 30 minute for the first 2 hrs-5 ml/kg Alternate hr for up to 10 hrs 5-10 ml/kg

Initiate feeding within two to three hours of starting Initiate feeding within two to three hours of starting rehydration with F-75 formula on alternate hours with rehydration with F-75 formula on alternate hours with reduced osmolarity ORSreduced osmolarity ORS

Be alert for signs of overhydration Be alert for signs of overhydration (F-imnci)(F-imnci)

COMPOSITION OF ORSINGREDIENTS LOW OSMOLARITY (NEW) (mmol/l)

WHO – ORS (OLD) (mmol/l)

ReSoMal( Mg – 3;Zn – 0.3;Cu – 0.045mmol/l)

Sodium 75 90 45

Potassium 20 20 40

Chloride 65 80 70

Citrate 10 10 7

Glucose 75 111 125

Osmolarity 245 311 300

Maganese: enzymic cofactor in SOD, oxidative phosphorylation, bone mineralization.

Deficiency: Growth retadation, wt. loss, hypocholestremia, increase PT,

Daily requirement: 1-5 mg/ day excess: cholestasis, encephalopathy, goiter,

cardiomyopathy.

Copper: Connective tissue cross linkage, Hemopoiesis, lipid metabolism.

Def: neutropenia, Hypochromic anemia, hypopigmented hair, impaired myelination, subperiosteal hematoma.

Excess: ICC, Hemolytic anemia, zinc deficiency.

ZINC:Protein and nucleic acid synthesis.Def: Growth retardation,Hypogonadism, skin

changes, diarrhoea.Daily requirement: 5-15 mg/ day,In Def: 1-2 mg/kg elemental zinc.Excess can cause Iron and Copper def. hence

can be used in Wilsons disease.Epithelial repair, T Cell immunity, intestinal

perm., Human milk-0.53 mg/100ml.

Septic Shock

•Start RL with 5% D or

•½ NS and 5% Dextrose @ 15 ml /kg/hr for 1 hour and monitor PR, RR, CRT AND URINE OUTPUT.

•.

•A)If at the end of 1 hr there is improvement (pulse slows, CRT improves), it is severe dehydration with shock, Repeat RL 15 ml/kg over 1 hour. If accept orally –start ORS,if not give RL 10 ml/kg/hr till accept orally.B)If at the end of 1 hr there is no improvement, consider septic shock and manage accordingly

Electrolyte disturbance

DO N’T treat edema with diuretic sodium-total body sodium increase but plasma total body sodium increase but plasma

sodium may be low, sodium may be low, Prepare food without adding Prepare food without adding saltsalt

serum K-serum K- <2 mEq/l or <3.5 mEq/l with ECG CHANGES give Kcl <2 mEq/l or <3.5 mEq/l with ECG CHANGES give Kcl

@0.3to0.5 mEq/kg/hr. @0.3to0.5 mEq/kg/hr. Give supplemental potassium at 3-4 mEq/kg/day for Give supplemental potassium at 3-4 mEq/kg/day for

at least 2 weeks. Syp POTCLOR 15 ml=20mEq.at least 2 weeks. Syp POTCLOR 15 ml=20mEq.

MgMg-G-Give 50% magnesium sulphate (equivalent to 4 mEq/ml.) ive 50% magnesium sulphate (equivalent to 4 mEq/ml.) I.M. (0.1-0.2 ml/kg/dose) in 2 diveded dose is given for 1-3 I.M. (0.1-0.2 ml/kg/dose) in 2 diveded dose is given for 1-3 days.days.

Anemia

Blood transfusion redquired: If Hb. <4 g/dl, or if respiratory distress and Hb. 4-6 g/dl.

Then give 10 ml/kg slowly over 3 hour.Furosemide 1 mg/kg/ i.v. at the start of

transfusion.If CARDIAC FAILURE present, transfused

packed cell(5-7 ml/kg).Give iron for 2 month at least , to replanish

iron store.

infections infections System-System-Skin,Respiratory,GIT Infection and UTI most

common Cause- multiple infection mainly

gram negative bacteria,gram negative bacteria, HIV, TB and malaria

Screen all systems for infectionFever may and may not be present

Hypoglycemia and hypothermia are considered Hypoglycemia and hypothermia are considered markers of severe infection markers of severe infection

Unbound iron in gut lead to over growth of E. COLI.Unbound iron in gut lead to over growth of E. COLI.

TREAT INFECTION

TREATMENT

Give antibiotic to all severly malnourished child A broad spectrum antibiotic if child has No complications - Oral cotrimoxazole 5mg/kg 12 hourly if child has No complications - Oral cotrimoxazole 5mg/kg 12 hourly

or trimethoprim) or Ampicllin+gentamycin for 5 days.or trimethoprim) or Ampicllin+gentamycin for 5 days. Infected child or complications present- IV ampicillin 50 mg/kg /dose Infected child or complications present- IV ampicillin 50 mg/kg /dose

6 hourly and IV gentamicin 2.5 mg/kg/dose 8 hourlY 6 hourly and IV gentamicin 2.5 mg/kg/dose 8 hourlY if staphylococcal infection is suspected -Add IV cloxacillin 100 mg if staphylococcal infection is suspected -Add IV cloxacillin 100 mg

/kg/day 6 hourly./kg/day 6 hourly. For septic shock or no improvement or worsening in initial 48 hours, For septic shock or no improvement or worsening in initial 48 hours,

and meningitis- Add third generation cephalosporin i.e. IV cefotaxime and meningitis- Add third generation cephalosporin i.e. IV cefotaxime 100 mg/kg /day 8 hourly +i.v. amikacin 15mg/kg/day 8 hourly.100 mg/kg /day 8 hourly +i.v. amikacin 15mg/kg/day 8 hourly.

Dysentery - Ciprofloxacin 30 mg/kg /day in 2 divided doses.Dysentery - Ciprofloxacin 30 mg/kg /day in 2 divided doses.

IV ceftriaxzone 50 mg /kg / day in 24 or 12 hourly if child IV ceftriaxzone 50 mg /kg / day in 24 or 12 hourly if child is sick or has already received nalidixic acid is sick or has already received nalidixic acid

• source -who guidelinesource -who guideline

Parasitic Worm: Mebendazole 100 mg orally, Twice a day for3 days.

T.B. : Contact with adult T.B. patient, Poor growth Despite good intake, Chronic cough, Chest infection not respond to Antibiotics.

•GIVE TO ALL CHILDREN Up to twice the RDA of various vitamins.

•Multivitamins –Formulation including vitamins A, C, D, E, and B12 , Thiamin, Riboflavin and Nicotinic acid. • Vitamin A orally on day 1 unless there is definite evidence that a dose has been given in the last month(< 6 mo- 50,000 IU, 6- 12 m -100,000 IU, >1 yr-200,000 IU) The reversible stages of keratomalacia, before liquefaction or perforation of the cornea, were effectively treated by a single I.M. injection of water-miscible vitamin A.10,000U/Kg

A daily oral supplement ( Vit A 3,000mcg/day) given after the first week to build up the liver stores

•

6. CORRECT MICRONUTRIENT DEFICIENCIES6. CORRECT MICRONUTRIENT DEFICIENCIES

Folic acid: 1 mg/d (give 5 mg on day 1).

• Zinc: 2 mg/kg/d.

• Vitamin K 2.5 mg im/iv for 2-3 days.

AnemiaAnemia: Iron 2-6 mg/kg /d, once child starts : Iron 2-6 mg/kg /d, once child starts gaining weight started after 1 week cont. in gaining weight started after 1 week cont. in stabilization phase for 3 month stabilization phase for 3 month

Copper:Copper: 0.2-0.3 mg/kg/d 0.2-0.3 mg/kg/d

Treatment of anaemiaTreatment of anaemia Oral folic acid, 200mcg/day, was given to the children with megaloblastic anemia.

If Hb<4 or 4-6 with respiratory distress,give WHOLE BLOOD 10 ml/kg slowly over 3 hrs

Treatment of Associated condition

Vitamin A deficiency classification

Diarrhoea

1)Continuing Diarrhoea:Mucosal Damage and GiardiasisStool MicroscopyMetronidazole(7.5 mg/kg 8hourly for 7 days)Lactose intolerance: Start Starter F 75 Low

lactose feed, Substitute milk.2)Osmotic Diarrhoea: when diarrhoea worsen

with Starter F -75, Sugar reduced, Osmolarity is <300 mosmol/l.

Feeding should be started as soon as possible with a diet, which has• Osmolarity less than <350 mosm/L.[F75 333]• Lactose not more than 2-3 g/kg/day.[1.3]• Initial percentage of calories from protein of 5%,Fat 33%.• Adequate bioavailability of micronutrients.• Low viscosity, easy to prepare and socially acceptable.Recommended daily energy and protein intake from initial feeds - 75 kcal/kg and 1 g/kg respectively.

7.CAUTIOUS FEEDING

After rehydration,Start oral or NG feeding with _F-75.(75 kcal and 1.0g protein/100 ml at ~130/ml/kg/24 hr) with nutrient supplementation.

If diarrhea starts or fails to resolve and lactose intolerance is suspected_ use non lactose formula.

If milk protein intolerance is suspected,a soy protein hydrolysate formula can be used.

FIRST WEEKFIRST WEEK

F_75 STARTER DIETS

Diet contents (per 100 ml)

F-75 StarterF-75 Starter

(Cereal based) Example 1

F-75 Starter (Cereal based)

Example 2

Cow’s milk or equivalent (ml)

30 30 25

Sugar (g) 9 6 3

Cereal : Powdered puffed rice* (g)

- 2.5 6

Vegetable oil (g) 2 2.5 3

Water : make up to (ml)

100 100 100

Energy (kcal) 75 75 75

Protein (g) 0.9 1.1 1.2

Lactose (g) 1.2 1.2 1.0

Feeding patterns in the initial days of rehabilitation

Days Frequency Volume / kg/feed

Volume / kg/day

1-2 2 hourly 11 ml 130 ml

3-5 3 hourly 16 ml 130 ml

6 4 hourly 22 ml 130 ml

Source : WHO guidelines

Catch up growth

• Once appetite returns in 2-3 days, encourage higher intakes

• Increase volume offered at each feed and decrease the frequency of feeds to 6 feeds per day

• Continue breast feeding ad – lib

• Make a gradual transition from F-75 to F-100 diet

• F-100 contains 100 kcal / 100 ml with 2.5-3.0 g protein / 100 ml

• Increase calories to 150-200 kcal / kg / day, and the proteins to 4-6 g/kg/day

F_100 F_100 Catch up diets Catch up diets

Diet contents Diet contents (per 100 ml)(per 100 ml) F-100 Catch upF-100 Catch up

F-100 Catch up F-100 Catch up (cereal based) (cereal based)

Example Example

Cows mild / toned Cows mild / toned dairy milk (ml)dairy milk (ml) 9595 7575

Sugar (g)Sugar (g) 55 2.52.5

Cereal : Puffed Cereal : Puffed rice (g)rice (g) -- 77

Vegetable oil (g)Vegetable oil (g) 22 22

Water to make Water to make (ml)(ml) 100100 100100

Energy (kcal)Energy (kcal) 101101 100100

Protein (g)Protein (g) 2.92.9 2.92.9

Lactose (g)Lactose (g) 3.83.8 33

Rebuild Tissues

Advance to 200 ml/kg/day div q 3 to 4 hours.

Complementary foods should be added as soon as

possible to prepare the child for home foods at discharge.

Khichri, dalia, banana, curd-rice and other culturally acceptable and locally available diets

can be offered.

Step 8

Complementing Proteins

Plant proteins are deficient in different essential amino acids

Cereals Low in lysine

Beans Low in methionine

Must eat both cereal and beans together to get balanced amino acids Complementing proteinsRice and Beans

Balanced Protein

Protein are made of amino acids

Essential amino acids Body cannot make Required in diet

Animal proteins have perfect balance of amino acids Meat Milk Eggs

STEP9

tender, loving care

structured play and physical activity as soon as the child is well enough

a cheerful, stimulating environment.

Encourage mother’s involvement

Stimulation, Play and Loving Care

STEP10

Preparation for Discharge

Nutritional education

Immunization

Home care sensitization

Follow Up

Before treatment and At discharge

DISCHARGE

Ready for discharge when reach 90% weight for height

No oedemaAbsence of infectioneating at least 120-130 Cal/kg/day and

receiving micronutrientCosistent weight gain(at least 5g/kg/day for 3

consecutive days) on exclusive oral feedingComplete immunization appropriate for ageCaretaker sensitized to home careReturn to social smile (elizabeth)

Children discharge early : what to do?

Child >1 yr,appetite good, weight gain,no edema ,compelete antibiotic, Vit. K every 2 weeks.

Mother : available, motivated and trained to look after have resource reside near hospital

Local health care ; can provide ,trained

•Hospital management of all children with SAMN- not operationally feasible

•Home-based management is an unavoidable alternative for a large number of children •DIET CHART USING --> Besan panjiri, khichdi, DIET CHART USING --> Besan panjiri, khichdi, parantha and enriching them with jaggery and oil.parantha and enriching them with jaggery and oil.

•Should provide 150kcal /kg/d and 4 gm / kg of proteinsShould provide 150kcal /kg/d and 4 gm / kg of proteins

•Nutritional and hygiene education to motherNutritional and hygiene education to mother

•Multivitamin for 16 wks.Multivitamin for 16 wks.

HOME BASED REHABILITATIONHOME BASED REHABILITATION

INDIAN PEDIATRICS AUG 10

Primary failure Primary failure Secondary failureSecondary failure

Failure to regain appetite by day 4

Failure to start losing edema by day 4

Presence of edema on day 10

Failure to gain at least 5 g/kg /day by day 10

Failure to gain at least 5 g/kg /day for 3 consecutive days during the rehabilitation phase

Inadequate feedingInfection,T.B.,HIV.PsycologicalNutritional Deficiency.

TREATMENT FAILURE

REFEEDING SYNDROMES•Pseudotumor cerebri– over energetic nutritional correction may cause raised ICP.

•Nutritional recovery syndrome— abdominal distension, Ascites, HSM, Parotid swelling, Gynaecomastia, Eosinophilia---related to endocrinal disturbances--- A/W using high quantity of proteins for Rx.

•Encephalitis Like Syndromes—20% cases of kwashiorkor become drowsy within 3-4 day of starting therapy d/t high protein in Rx. There may be coarse tremors, rigidity, bradykinesia and myoclonus several days later.

•Development of severe hypophosphatemia after cellular uptake of phosphate during 1st wk. Serum P <0.5 can cause weakness, rhabdomyolysis, neutrophil dysfunction, cardiorespiratory failure, arrythmia ,seizures or sudden death. MONITOR SERUM PHOSPHATE .

Direct causes of death

Hypoglycemia

Hypothermia

Dehydration

Infection

S.Anaemia

Dyselectrolytemia

Mortality rate of diarrhea patients with malnutrition is fourfold of the diarrhea patients without malnutrition.

Severe Malnutrition: Consequences Mental developmen Malnutrition affect brain development,

intelligence and school work performance.

Behaviors of recovered severely malnourished children

shy, isolated, withdrawn decreased attention span immature, emotionally unstable fewer peer relationships/reduced social skills played less/stayed nearer to mothers

PROGNOSIS

Kwashiorkor & Marasmus-Kwashorkor have greater risk of morbidity & mortality compared to Marasmus and under weight

Early detection & adequate treatment are associated with good outcome

Late ill-effects on IQ, behavior & cognitive functions occur which may be reversible to some extent if rehabilitation achived.

Nutritional programme in india

1. Vitamin A prophylaxis programme2. Prophylaxis against nutritional anaemia3. Iodine deficiency disorder control

programme4. Special nutrition programme5. Balwadi nutritional programme6. ICDS programme7. Mid day meal programme

THANKS

RELAX RELAX !!!!!!!! !!!!!!!!!!