7Macronutrient_deficiencies_of_public_health_importance_in_ethiopia.pptx

nutrition

1. DEPARTMENT OF PUBLIC HEALTH AFOMIA T. (BSC, MPH/NUTRITION)

2. Macronutrient deficiencies of public health importance in Ethiopia

3. Protein energy malnutrition (PEM) The term protein energy malnutrition has been adopted by WHO in 1976. Is a multi- deficiency state and not just a deficiency of Protein and energy. All children with PEM have micronutrient deficiency. Marasmus is a semi-starvation, which includes the deficiency Of energy, protein and other nutrients.

4. PEM The majority of children live in developing countries Lack food & clean water, poor sanitation, infection & social unrest lead to LBW & PEM. Malnutrition is implicated in >51% of deaths of <5 children (5 million/yr)

5. PEM The major contributing factors for child mortality are: Diarrhea 15% pneumonia 16% Neonatal death 18% Measles 7% Malaria 9% Malnutrition 51%

6. PEM PEM in Africa is related to: The high birth rate Subsistence farming Overused soil, draught & desertification Pets & diseases destroy crops Poverty Low protein diet Political instability (war & displacement)

7. PRECIPITATING FACTORS Lack of food (famine, poverty) Inadequate breast feeding Wrong concepts about nutrition Diarrhoea & malabsorption Infections (worms, measles, T.B)

8. Forms of P rotein energy malnutrition Kwashiorkor Marasmus Marasmus- kwashiorkor

9. CLASSIFICATION A. CLINICAL ( WELLCOME ) Parameter: weight for age + oedema Reference s tandard (50th percentile) Commonly utilized classification Grades: 80-60 % without oedema is under weig ht 80-60% with oedema is Kwashiorkor < 60 % with oedema is Marasmus-Kwash < 60 % without oedema is Marasmus

10. CLASSIFICATION (2) B. COMMUNITY (GOMEZ) Parameter: weight for age Reference s tandard (50th percentile) WHO chart Grades: I (Mild) : 90-70 II (Moderate): 70-60 III (Severe) :< 60

11. 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 .

12. 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. Infection, psycho-social, and cultural factors are also operative.

13. ETIOLOGY (2) Kwashiorkor is an example of lack of physiological adaptation to unbalanced deficiency where the body utilized proteins and conserve fat.

14. CLINICAL PRESENTATION Clinical presentation is affected by: The degree of deficiency The duration of deficiency The speed of onset The age at onset

15. CONSTANT FEATURES OF KWASH Oedema psychomotor changes growth retardation muscle wasting

16. USUALLY PRESENT SIGNS Moon face Hair changes Skin depigmentation Anaemia

17. OCCASIONALLY PRESENT S IGNS Hepatomegaly Flaky paint dermat iti s Cardiomyopathy & failure D ehydration (diarrhea. & Vomiting) Signs of vitamin deficiencies Signs of infections

18. 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.

19. MARASMUS/2 Marasmus represents an adaptive response to starvation, whereas kwashiorkor represents a maladaptive response to starvation I n Marasmus t he body utilizes all fat stores before using muscles .

20. 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 or famine and diarrhoea are the usual precipitating factors Ignorance & poor maternal nutrition are also contributory

21. Clinical Features of Marasmus Severe wasting of muscle & subcutaneus fats Severe growth retardation Child looks older than his age No edema or h air changes Alert but miserable Hungry Diarrhoea & Dehydration

22. CLINICAL ASSESSMENT P hysical examination including detailed dietary history. Anthropometric measurements Team approach with involvement of dieticians, social workers & community support groups.

23. Investigations for PEM Full blood counts Blood glucose profile Septic screening Stool & urine for parasites & germs Electrolytes, Ca , Ph & ALP, serum proteins CXR Exclude HIV & malabsorption

24. MANAGEMENT OF PEM Criteria for identifying children with severe acute malnutrition for treatment: Referring for full assessment at a treatment centre : mid-upper arm circumference <11.5 mm Any degree of bilateral oedema

25. Mgt… Immediate admission to a programme : Mid-upper arm circumference <11.5 mm Weight-for-height/length <–3 Z-score of the WHO growth standards, or Have bilateral pitting oedema

26. Mgt… Out patient Rx: pass the appetite test clinically well and alert Inpatient Rx: medical complications severe oedema (+++) poor appetite (fail the appetite test) one or more Integrated Management of Childhood Illness (IMCI) danger signs

27. Phases of treatment PHASE I The children should be admitted directly to the TFU Diet:- F75 (100ml = 75kcal) should be given Six or five feeds per day are given for day-care units Eight feeds per day are given for 24h care units Breast-fed children should always be offered breast-milk before the diet and always on demand. Naso -gastric tube (NGT) feeding is used when a patient is not taking sufficient diet by mouth(<75%)

28. Mgt…. Routine antibiotic continue for 4 more days after Phase 1 or until transferred to Phase 2 as an out-patient The criteria to progress from Phase 1 to Transition Phase are: Return of appetite Beginning of loss of oedema No IV line, no NGT.

29. Complications of PEM Hypoglycemia Hypothermia Hypokalemia Hyponatremia Heart failure Dehydration & shock Infections (bacterial, viral & thrush)

30. TRANSITION PHASE A new diet is introduced: F100 or RUTF. Prepares the patient for Phase 2 treatment either as an in-patient or, preferably, as an out-patient The number of feeds, their timing and the volume of the diet given remains exactly the same in Transition Phase as it was in Phase1.

31. Mgt… PHASE 2 (In- and out-patients) The Phase 2 can be managed in the health facility, using F100 or RUTF, or in the community, using RUTF.

32. Mgt… F100 or RUTF are used in Phase 2. Never give F100 to be used at home, use RUTF. F100(100ml = 100 kcal): five feeds of F100 are given.

33. Summary of management Correction of water & electrolyte imbalance Treat infection & worm infestations Dietary support: 3-4 g protein & 200 Cal /kg body wt /day + vitamins & minerals Prevention of hypothermia Counsel parents & plan future care including immunization & diet supplements

34. KEY POINT FEEDING Continue breast feeding Add frequent small feeds Use liquid diet Give vitamin A & folic acid on admission With diarrhea use lactose-free or soya bean formula

35. PROGNOSIS Kwash & Marasmus- Kwash 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 are doubtful and not proven

36. References United Nations Interagency Group for Child Mortality Estimation. Levels and trends in child mortality. Report 2012. New York, United Nations Children’s Fund, 2012 Black R et al. Maternal and child undernutrition and overweight in low-income and middleincome countries. Lancet, 2013;382:427–51.

37. THANK U