3.2. malnutrition ppt. Pediatrics for malnutrition.

Medics

1. HYPOTROPHY: MALNUTRITIONAND
GROWTHINHIBITIONINCHILDREN
Ovsyannikov D.Yu.
Khaled M.

2. DEFINITIONOFMALNUTRITION
”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)

3. NCHS 1978
CHILDGROWTHREFERENCES
Measures made 1960-75
American Children-geographically
restricted area.
With formula milk
High socioeconomic background

4. WHO 2006
CHILDGROWTHSTANDARDS1997-2003

5. Boys at age 11 with high, normal, reduced
nutrition (left to right)

7. NUTRITIONAL DEFICIENCY DISEASES
On global scale the five principal nutritional deficiency
diseases are:
1.Kwashiorkor
2.Marasmus
3.Xerophthalmia
4.Nutritional anemia
5.Endemic goiter
7

8. MANIFESTATIONS OF OVERNUTRITION
In the more developed countries of the world, over
nutrition is encountered much more frequently than
under nutrition.
The health hazards from over nutrition are:
1.Obesity,
2.Diabetes,
3.Hypertension,
4.Cardiovascular diseases,
5.Renal diseases,
6.Disorders of liver and gall bladder.
8

9. MALNUTRITION(HYPOTROPHY)
Intrauterine (intrauterine growth retardation) IUGR
Failure of the fetus to chieve the expected weight for a
given gestation

10. Newborn with intrauterine
growth retardation
(left)
and with normal physical
development (right)

11. IUGR, REASONS
poor diet, chronic diseases in pregnant, smoking
and alcohol consumption, exposure to industrial
hazards
pathological course of pregnancy, accompanied by
blood circulation in the placenta
intrauterine infection of the fetus, genetic
syndromes

12. Which maternal medical conditions result in IUGR?
•HPT
•PET
•DM with vascular involvement
•SLE
•Anemia
•Sickle cell disease
•Antiphospholipid syndrome
•Renal disease
•Malnutrition
•Inflammatory bowel disease
•Intestinal parasites
•Cyanotic pulmonary disease

13. What infections result in IUGR?
Congenital infections:
•CMV
•Rubella
•Herpes
•Vericella zoster
•Toxoplasmosis
•Malaria
•Listeriosis
5-10% of IUGR

14. Which drugs can result in IUGR?
•Alcohol
•Cigarette smoking 3-4X
•Heroin & coccaine
•Methotrexate
•Anticonvulsants
•Warfarin
•Antihypertensives /ß-blockers
•Cyclosporin

15. What are the genetic disorders that can result in IUGR?
•Down’s syndrome T21
•Trisomy 13,18
•Turner syndrome
•Neural tube defects
•Achondroplasia
•Osteogenisis imperfecta
•Abdominal wall defects
•Duodenal atresia
•Renal agenesis/ Poter’s S
15% of IUGR

16. CLINIC
trophic disorders
Changes in the functional status of CNS
Reduction of food tolerance
Reduction of immunobiological reactivity

17. PHYSICALAPPEARANCE:
•Heads are disproportionately large for their trunks and
extremities
•Facial appearance has been likened to that of a
“wizened old man”.
•Long nails.
•Scaphoid abdomen

18. COMPLICATION
Hypoxia
-Perinatal asphyxia
-Persistent pulmonary hypertension
-meconium aspiration
Thermoregulation
-Hypothermia due to diminished subcutaneous fat and elevated
surface/volume ratio
Metabolic
-Hypoglycemia
-result from inadequate glycogen stores.
-diminished gluconeogenesis.
-increased BMR
-Hypocalcemia
-due to high serum glucagon level, which stimulate calcitonin
excretion

19. COMPLICATIONS
Hematologic
-hyperviscosity and polycythemia due to increase
erythropoietin level sec. to hypoxia
Immunologic
-IUGR have increased protein catabolism and
decreased in protein, prealbumin and
immunoglobulins, which decreased humoral and
cellular immunity.

20. MANAGEMENT
Antenatal diagnosis and management is the key to
proper management of IUGR
Delivery and Resuscitation
-appropriate timing of delivery
-skilled resuscitation should be available
-prevention of heat loss
Early feeding and caloric intake should be
100-120 kcal/kg/d
Developmental and growth f/u in all IUGR
infants

21. EVALUATIONOFSGA NEWBORN
Careful physical examination
Measure & plot head circumference &
length
CBC with differential and platelet count
Monitor glucose carefully
Further evaluation?
Urine for CMV
TORCH titers
Liver function tests
Head Ultrasound

22. WEIGHTANDGROWTHRATE
Evaluated in term infants
Ratio of the mass (g) to body length
(cm)
Standard: 60 –80
1 degree IUGR -55-59
2 degree IUGR -51-54
3 degree IUGR -less than 50

23. FETALORIGINSOFADULTDISEASES?
Coronary artery disease correlates inversely with
birth weight
Rate of non-insulin dependent diabetes mellitus is
highest in the “thinnest” babies at birth (low ponderal
index)
High serum cholesterol are linked to disproportionate
size at birth (body smaller than head)
Increased rate of hypertension in infants who were
thin, short, &/or proportionately small at birth

24. POSSIBLEMECHANISMS
Violation of DNA methylation
Permanent anatomical changes in structure of
organs

25. POSTNATALHYPOTROPHY
1 degree -10-20%
2 degree -20-30%
3 degree -more than 30%

26. CLASSIFICATION OF PEM
By wellcome -to assess a child
with edema
According to Gomez -Comparison of
patient weight to body weight of a normal
child (50th percentile) of the same age, in%
% Of
predicted
body weight
with edemawithout
edema
60-80% kwashiorkorUnderweight
< 60 % marasmus
kwashiorkor
marasmus
interpretation
90-110 % norm
75-89 % I degree -mild
60-74 % II degree -
moderate
< 60 % III degree -severe

27. Malnutrition, kwashiorkor and
nutritional marasmus

28. SEVEREMALNUTRITION
W/H <70% or bilateral oedema
Impaired immune system and electrolyte inbalance
Kwashiorkor
Marasmus

29. KWASHIORKOR
2-4yrs
Comes suddenly after some time of
Moderate Malnutrition
Low protein intake
http://www.asnom.org/image/510_nutrition/116_327_kwashiorkor.jpg
Symtoms:
•Bilateral Oedema
•Apathy
•Depigmented corse hair, easy to pull.
•Skin lesions
•Poor aptetite
•Diarrhoea

30. Mechanism of Swelling
blood consists of water, blood cells and proteins
Dissolved proteins hold water within bloodstream,
preventing it from leaking into body tissues.
As blood protein falls to low levels, water leaks
from circulation into your tissues, causing
swelling.
With kwashiorkor, the levels of sodium and
potassium in bloodstream become unbalanced,
further contributing to tissue swelling.

31. MARASMUS
•1st year of life, often failure to
breastfeed.
•Lack of proteins and calories.
•Body creates energy by dissolving
its own tissuesLoss of
subcutanous fat and muscles.
Symtoms:
•Wasting W/H <70%
•Face o an old person
•Pot belly due to lack of abd. muscles.
•Anorexia, irritability.
•Hunger

33. POSTNATALHYPOTROPHY
Exogenous
1.Nutritional deficiencies (poverty, hypogalactition
mother)
2.Infection (especially intestinal)
Endogenous
1.psychiatric disorders
2.neurological Diseases
3.Chronic lung disease
4.Chronic heart disease
5.CDF gastrointestinal
6.malabsorptionsyndrome
7.endocrine diseases
8.metabolic diseases
9.genetic syndromes
10.cancers

34. Time Magazine, August, 2008
1.Hypoglycemia
2.Hypothermia
3.Dehydration
4.Infection
5.Severe anemia
Direct causes of death:

35. POSSETING(REGURGITATION)
Physiological
not abundant
Within 2 hours after
feeding
First 6 months.
Not more often 4-6
times a day
Pathological
abundant
Later than 2 hours after
feeding
After 6 months.
More than 6 times a
day

36. CORRECTION OFREGURGITATION
Burp your baby more often (usually after one to two
ounces of formula).
Avoid overfeeding.
Feed your infant smaller portions more frequently.
Keep your baby in an upright position after feeding.
Don’t jostle the baby after feeding, as this can cause the
stomach contents to reflux.
Wait 30 minutes after feeding before putting the infant to
sleep, as positioning can affect reflux symptoms.
Dietary (antireflux mix -Frisovom, Nutrilon
antireflyuks)
Prokinetics (procaine, motilium)