MALNUTRITION IN CHILDREN final.pptxnnnbn

bb

1. MALNUTRITION IN CHILDREN

2. Outline Introduction Epidemiology Pathophysiology Clinical features Diagnostic criteria Complications Management Reference's

3. Introduction Malnutrition is defined as a state of cellular imbalance between supply of nutrients and energy and the body's demand for them to ensure optimal growth, maintenance, and specific functions . It can be categorized into: Under nutrition- this is when there is i ncreased demand of nutrients with low intake. For example, high nutritional demands in children due to rapid growth. Over nutrition- this is when there is d ecreased demand of nutrients with high intake

4. Malnutrition contributes to children deaths up to 54% in most developing countries including Tanzania Malnourished children have weak immune systems and suffer more frequent and more severe infections Malnutrition during pregnancy and up to two years of age causes permanent, irreversible damage to a child’s development, and lower the capacity to learn in school

5. Epidemiology Approximately 41 million children below 5 years are overweight , 159 million are stunted, and 50 million are wasted worldwide Undernutrition contributes to half of all deaths in children < 5yrs in developing countries .Children are most vulnerable to the effects of malnutrition in infancy and early childhood .( Unicef data Jan 2018) Stunting is higher in Tanzania Mainland (35%) than in Zanzibar (24%). Considering zonal differences, the prevalence of stunting is very high in the Southern Highlands (45%) and South West Highlands (43%) zones. ( TDHS-MIS 2015-2016)

6. Cont …

7. Indicators of under nutrition. Stunting ; Child is short for his/her age Also known as chronic malnutrition Result of long-term poor nutrition Wasting ; Child is thin (low weight for height) Also known as acute malnutrition Result of recent poor nutrition Underweight ; Child has a low weight for his/her age A child may be underweight if he/she is stunted or wasted

8. Etiology The causes of malnutrition can be grouped into; Immediate causes These operate at the level of the individual patient; for example inadequate d ietary intake is and existence of disease (chronic diarrheal diseases , HIV/AIDS, and PTB ). Underlying causes These operate at the level of the family or household, eg insufficient access to food, Poor water/sanitation , Inadequate maternal and child-care practices and unhealthy environment.

9. Cont … Basic causes These are related to the community and the nation . Eg economic structure, government policy on distribution of health services, access to and distribution of land

10. Cont … The UNICEF conceptual framework for malnutrition

11. Pathophysiology The pathophysiology of SAM relies on the concept of reductive adaptation When intake is insufficient, the body conserves energy by either reducing physical activity, reducing growth, reducing inflammatory and immune responses or reducing basal metabolism by: slowing protein turnover reducing functional reserve of organs slowing and reducing Na+/K+ pumps Various complications are observed to major body organs as a results of these responses which includes;

12. C ont … Liver : Gluconeogenesis decreases which increases the risk of hypoglycemia. Hepatic metabolism and excretion of toxins is reduced. Reduced hepatic synthesis of proteins including albumin. Kidney: Decreased capacity to excrete sodium and excess water (risk of fluid overload) Urinary tract infections are common Heart: Smaller, weaker, reduced cardiac output. Risk of going into heart failure Can not cope with fluid overload

13. Cont … GIT: Atrophication of the mucosa leading to impairment of all functions of the GI system. Reduced production of gastric acid, digestive enzymes, membrane nutrient transporters, and absorption of all nutrients . (limited digestion/absorption) There is luminal bacterial over growth which can lead to bacteremia and sepsis. Immune system: Atrophication of Lymph glands, tonsils, and the thymus. Impaired production of immune mediated cells, eg complement system, immunoglobins increasing the risk of infection

14. Muscles: Decreased bulkiness (wasting) loss of K, Mg, Zn, Cu. Less glycogen Skin and glands: The skin and subcutaneous fat are atrophied, which causes loss of skin folds, dryness of mouth and eyes, and reduced sweat production because of atrophied sweat, tear, and salivary glands.

15. Cont … Red cell mass is reduced Liberates ‘free’ iron; ( no ferritin to carry the iron) ‘Free’ iron makes infections worse . Other complications include; convulsion due to hypoglycemia, hypothermia/ sign of infection or with bradycardia which signify a decreased metabolic rate to conserve energy .

16. Micronutrient deficiencies associated with malnutrition in children FAT-SOLUBLE VITAMIN DEFICIENCIES Vitamin A   N ight blindness , xerosis (dryness) of the conjunctiva and cornea and development of Bitot spots. keratomalacia , ulceration, perforation, and scarring of the cornea; prolapse of the lens; and blindness.

17. Other features of vitamin A deficiency include follicular hyperkeratosis, pruritus, growth retardation, and increased susceptibility to infection

18. Vitamin E   —  progressive sensory and motor neuropathy, ataxia, retinal degeneration, and a hemolytic anemia Vitamin K  —  bleeding diathesis. Bleeding may be seen in the skin, gastrointestinal tract, genitourinary tract, gingiva, lungs, joints, or central nervous system.

19. Vitamin D  —  is associated with hypocalcemia , hypophosphatemia, and rickets in children and osteomalacia in adults Craniotabes , caused by thinning of the outer table of the skull Enlargement and delayed closure of the anterior fontanelle , Frontal bossing of the skull Delayed eruption of the teeth and tooth enamel defects, Beading of the ribs (rachitic rosary) Scoliosis, Exaggerated lordosis , Bowlegs in older infants,Greenstick fractures in the long bones

20. WATER-SOLUBLE VITAMIN DEFICIENCIES Folate  —  hypersegmentation of neutrophils, megaloblastosis , and anemia . Thiamine  —  is associated with beriberi, characterized by high-output cardiomyopathy and polyneuritis Niacin   — Niacin (vitamin B3) deficiency results in pellagra with dermatitis, diarrhea, dementia, and weakness

21. Riboflavin   —  characterized classically by angular stomatitis, glossitis (magenta tongue) seborrheic dermatitis around the nose and scrotum, and vascularization of the cornea

22. Pyridoxine  —  manifests as nonspecific stomatitis, glossitis cheilosis , irritability, confusion, weight loss, and depression. Peripheral neuropathy occurs in adolescents, whereas younger children develop encephalopathy with seizures Ascorbic acid   — Ascorbic acid (vitamin C) deficiency results in the clinical manifestations of scurvy.

23. Marasmus (wasting malnutrition) insufficient energy intake so the body draws on its own stores causing emaciation. Energy Metabolism during Starvation Glycogen levels become depleted. Gluconeogenesis occurs by synthesizing glucose from protein compounds from muscle breakdown. Fat is used to make ATP and is used as an alternative energy source Adaptation to starvation depends on ketone production Needs for gluconeogenesis decline because brain and nervous system start using alternative sources (ketones)

24. MINERAL AND TRACE ELEMENT DEFICIENCIES Calcium, phosphate, and magnesium  — Calcium deficiency occurs in conjunction with deficiency of vitamin D or parathyroid hormone. Clinical manifestations of hypocalcemia include tetany , Chvostek sign, Trousseau sign, and seizures. Severe hypophosphatemia (less than 1 mg/ dL ) can cause myopathy, rhabdomyolysis , bone pain, and osteomalacia or rickets

25. Zinc  — Zinc deficiency was originally described in a group of children with low levels of zinc in their hair, poor appetite, diminished taste acuity, hypogonadism , and short stature . Selenium – Dilated cardiomyopathy Iron- anaemia Others .. Copper and iodine

26. Head that appears large relative to the body, with staring eyes Weak appearance ( Oldman face) Irritable. Thin and dry skin with desquamation/dermatosis Shrunken arms, thighs, and buttocks with redundant skin folds. Cachexic/edema Thin, sparse, brittle brownish hair that is easily plucked and turns a dull brown or reddish color.

27. Cont … Generally wasted Thin arms Ribs visible Sunken eyes Lack of skin turgor

28. Kwashiorkor (Edematous malnutrition) Decreased protein consumption hence decreased synthesis of visceral proteins. Hypoalbuminemia contributes to extra vascular fluid accumulation. Impaired synthesis of lipoprotein produces a fatty liver . Protein deficiency and lack of immunoglobulin's predispose these children to frequent infections. Lack of substrate(amino acids) and coenzyme for the synthesis of hair pigment leads to changes in hair and skin pigmentation.

29. Must have bilateral , (usually) pitting edema Commonly associated features: Apathetic/miserable Enlarged liver Dermatosis/skin depigmentation Mucous membrane changes/angular chelitis Moon face Thin muscles Signs of anemia Signs of infection Hair changes: Thin/sparse Discolored; fragile

30. ACUTE MALNUTRITION Acute malnutrition is a result of inadequate nutrient intake leading to rapid weight loss or failure to gain weight normally. WHO classify acute malnutrition as follows:- Moderate Acute Malnutrition (MAM) WHO Z score weight for height/length between -2 sd and -3 sd Mid Upper Arm Circumference. (MUAC) between 11.5 cm and 12.5 cm No oedema Severe Acute Malnutrition (SAM) Weight for length/ ht < -3 sd MUAC < 11. 5 cm Oedema of both feet. (+/-)

31. Cont … Weight measuring Undress the child or cover with thin cloth

32. Cont …

33. Cont … Measuring height/length

34. Cont … Mid upper arm circumference(MUAC) measurement It is measured at the mid point btn acromium and olecranon process, Severe Wasting is MUAC <11.5cm

35. Management Initial assessment Assess for general danger signs or emergency signs and take a history concerning: recent intake of food and fluids usual diet before the current illness Breastfeeding duration and frequency of diarrhoea and vomiting type of diarrhoea (watery/ bloody)

36. loss of appetite family circumstances cough > 2 weeks contact with TB recent contact with measles known or suspected HIV infection/exposure

37. On examination look for; shock: lethargic or unconscious; with cold hands , slow capillary refill (> 3 s), or weak (low volume), rapid pulse and low blood pressure signs of dehydration severe palmar pallor bilateral pitting oedema eye signs of vitamin A deficiency : It is important to examine the eyes very gently to prevent corneal rupture.

38. Cont … Localizing signs of infection, including ear and throat infections, skin infection or pneumonia signs of HIV infection fever (temperature ≥ 37.5 °C or ≥ 99.5 °F) or hypothermia (rectal temperature < 35.5 °C or < 95.9 ° F) mouth ulcers

39. Cont … skin changes of kwashiorkor: – hypo- or hyperpigmentation – desquamation – ulceration (spreading over limbs, thighs, genitalia, groin and behind the ears) – exudative lesions (resembling severe burns) often with secondary infection (including Candida ).

40. Lab investigations; Complete blood count with differentials Sedimentation rate Serum electrolytes Urinalysis Culture HIV testing TB screening RFT and LFT

41. WHO’S 10 Steps: Management of Severe Acute Malnutrition T reat hypoglycemia Correct hypothermia Correct dehydration Correct electrolyte imbalances Treat infections Correct micronutrient deficiencies Start cautious feeding Give catch-up diet Sensory stimulation Discharge and follow-up

42. Cont …

43. Step 1: Hypoglycemia All severely malnourished children are at risk of hypoglycaemia Measure blood glucose using Glucometer ( RBG < 3mmol/l) Assume hypoglycaemia and treat if no glucometer available , WHY??? Reduced glucose supply: Less food intake Reduced gluconeogenesis in liver Less glucose stored in muscle Increased glucose demand: Used to fight infections Used to try to keep warm

44. How to treat hypoglycemia Give 50 ml of 10% glucose or sucrose solution ( one rounded teaspoon of sugar in three tablespoons of water ) orally or by NGT, followed by the first feed as soon as possible. Give the first feed of F-75 therapeutic milk, if it is quickly available, and then continue with feeds every 2 h for 24 h; then continue feeds every 2 or 3 h, day and night. If the child is unconscious, treat with IV 10% glucose at 5 ml/kg or, if IV access cannot be quickly established, then give 10% glucose or sucrose solution by nasogastric tube

45. Cont … Encourage mothers to watch for any deterioration, help feed and keep the child warm. Keep children warm to preserve glucose Start antibiotics immediately to cover both gram-positive and gram-negative bacteria (IV or IM)

46. Monitoring If the initial blood glucose was low, repeat the measurement (using finger or heel prick blood and measure with the glucometer, when available) after 30 min. • If blood glucose falls to < 3 mmol /litre (< 54 mg/dl), repeat the 10% glucose or oral sugar solution. • If the rectal temperature falls to < 35.5 °C, or if the level of consciousness deteriorates, repeat the glucometer measurement and treat accordingly

47. Step 2: Hypothermia Hypothermia is very common in malnourished children and often indicates coexisting hypoglycemia or infection Hypothemia is present if the a xillary Temperature is ≤ 35 C (<95 F) (or does not register on a normal thermometer ) or Rectal Temp ≤ 35.5 C (<95.9 F) (when a low reading thermometer is available) Why malnourished children are at risk of hypothermia??? Less insulation from fat Less food intake, so less energy and heat from food Lethargic, so less heat produced from movement Hypoglycaemia

48. How to treat/prevent hypothermia Routine treatment for hypoglycaemia and infections Feed every 2 hours , unless they have abdominal distension; if dehydrated, rehydrate first. Re warm the child; Cover with blankets or warm clothing, and place a heater (not pointing directly at the child) or lamp nearby . Make the room warm

49. Child to sleep in body contact with the mother / care taker (Kangaroo method) Keep the bed, clothes and nappies dry Dry children quickly after bathing. Keep the child away from draughts. Give appropriate IV or IM antibiotics

50. Monitoring Take the child’s rectal temperature every 2 h until it rises to > 36.5 °C. Take it every 30 min if a heater is being used. • Ensure that the child is covered at all times, especially at night. Keep the head covered, preferably with a warm bonnet, to reduce heat loss. • Check for hypoglycaemia whenever hypothermia is found.

51. Prevention ; Feed immediately and then every 2–3 h, day and night. Place the bed in a warm, draught-free part of the ward, and keep the child covered. Use the Kangaroo technique for infants, cover with a blanket and let the mother sleep with child to keep the child warm. Avoid exposing the child to cold (e.g. after bathing or during medical examinations). Change wet nappies, clothes and bedding to keep the child and the bed dry. Dry carefully after bathing, but do not bathe if very ill. Use a heater or incandescent lamp with caution .

52. Step 3: Dehydration It is difficult to determine dehydration accurately from clinical signs alone Assume that all children with watery diarrhea or reduced urine output have some dehydration It is important to note that poor circulatory volume or perfusion can coexist with edema

53. Cont … SHOCK Shock is defined as the inability of the body to maintain adequate tissue perfusion. Signs of Shock include lethargy or unconsciousness Cold extremities (Hands and feet) Slow capillary refill (>3 seconds) Weak or fast pulse

54. To check capillary refill: Press nail of thumb or big toe for 2 seconds until blanching of nail bed Count the seconds from release until return of pink colour If longer than 3 seconds , capillary refill is slow Fast pulse is: 2 – 12 months of age: 160 beats/ min or more 12 months – 5 years 140 beats/ min or more Check BP if special sphygmomanometer for children is available

55. Management of dehydration/shock Do not use the IV route for rehydration, except in cases of shock. Rehydrate slowly, either orally or by nasogastric tube, using oral rehydration solution for malnourished children (5- 10ml/kg per h up to a maximum of 12 hours). The standard WHO ORS solution for general use has a high sodium and low potassium content , which is not suitable for severely malnourished children. Instead, give special rehydration solution for malnutrition, ReSoMal .

56. Give the ReSoMal rehydration fluid orally or NGT, more slowly than you would when rehydrating a well-nourished child: – Give 5 ml/kg every 30 min for the first 2 h. – Then give 5–10 ml/kg per h for the next 4–10 h on alternate hours, with F-75 formula…. The exact amount depends on how much the child wants, the volume of stool loss and whether the child is vomiting.

57. Cont … If ReSoMal is not available then give half strength standard WHO ORS with added potassium and glucose, unless the child has cholera or profuse watery diarrhoea. If rehydration is still required at 10 h, give starter F-75 instead of ReSoMal , at the same times. Use the same volume of starter F-75 as of ReSoMal . If in shock or severe dehydration but cannot be rehydrated orally or by NGT, give IV fluids, either; Ringer’s lactate solution with 5% dextrose or Half-strength Darrow’s solution with 5% dextrose. If neither is available, 0.45% saline with 5% dextrose should be used

58. Cont … ReSoMal Recipe Water 2 litres WHO-ORS One 1 litre packet Sugar 50g Mineral mix solution* 40ml Alternatively, use 1 small scoop of Combined Mineral and Vitamin Mix (CMV)

59. Signs of fluid overload If you find signs of fluid overload, STOP ReSoMal immediately and assess for 1 hour Increased respiratory (RR 5 breaths/min ) Increased pulse rate (PR 15 beats/min) Increasing oedema (e.g. puffy eyelids) Ascites (as abdominal distension) Chest wall indrawing Jugular veins engorged P ulmonary oedema Cyanosis Irreversible shock (often a combination of ongoing hypovolaemia and cardiac failure)

60. Prevention of dehydration If the child is breastfed, continue breastfeeding Initiate refeeding with starter F-75 Give ReSoMal btn feeds to replace stool looses. Give 50-100 ml after each watery stool

61. Step 4: Electrolyte Imbalances Severely malnourished children have deficiencies of potassium and magnesium, WHY??? Potassium and magnesium leak out of the cells and lost into urine Potassium and magnesium are lost during diarrhoea Intake of foods containing potassium and magnesium are low Severely malnourished children have too much sodium in their cells, WHY??? Their kidneys are damaged and do not excrete excess sodium The cell walls are damaged and so sodium leaks into the cells

62. Management of Electrolyte imbalance Give: Extra Potassium: 3-4 mmol /kg/day Extra Magnesium: 0.4-0.6 mmol /kg/day Limit sodium Use low sodium fluids for IV and oral rehydration ( ReSoMal ) Give a salt free diet Do not add salt to cooked food

63. Step 5: Infections In severe malnutrition signs of infection are often absent though multiple infections are common All children with SAM are assumed to have an infection on their arrival to hospital and treated with antibiotics immediately G ive b road-spectrum antibiotics routinely on admission; If the child appears to have no complications: Oral Amoxicillin, 40mg/kg q12h for 5 days If the child appears severely ill or has complications: Iv Ampicillin( 50mg/kg q6h for 2 Days then shift to oral amoxicillin for 5d) and Gentamicin (7.5mg/kg OD for 7 days)

64. Monitoring If the child is still anorexic after 7 days of antibiotics, continue for a full 10 day course and if anorexia persist, reassess the child fully

65. Step 6: Micronutrient Deficiencies Severely malnourished children are deficient in: Vitamin A Zinc Copper Folic Acid Multivitamins (a combination of different vitamins) Iron (not given in first two weeks of treatment as can it worsen infection) Signs of micronutrient deficiency Micronutrient Signs of deficiency Vitamin B deficiency Cracks at corners of mouth Zinc deficiency Dermatosis and/or Diarrhoea Vitamin A deficiency Dry, cloudy eye and/or frothy patch on white of eye Iron deficiency Anaemia

66. Signs of vitamin A deficiency Bitot’s spots: foamy white spots Corneal clouding: opaque appearance of cornea Corneal ulceration: break in surface of cornea

67. Treatment Give vit . A on day 1,2 and 14 only if the child has signs of vit A deficiency like corneal ulceration ( < 6 months 50,000IU, 6-12 months 100,000 IU, >12 months 200,000IU) If the child is not on ant therapeutic food, give the following daily at least for 2 weeks; Folic acid at 5 mg on day 1, then 1mg daily Multivitamin syrup at 5ml per day Zinc at 2mg/kg per day Iron ( 3mg/kg/day ) but only after transition to the rehabilitation phase usually after two weeks of treatment ;

68. Step 7: I nitiate feeding In the initial phase, re feeding should be gradual Give oral small feeds of low osmolarity and low lactose frequently every 2-3 hours Use NGT feeding if the is feeding <80% of the amount given at two consecutive feeds Calories at 100kcal/kg/day Protein at 1-1.5 g/kg/day Liquid at 130ml/kg/day or 100ml/kg/day if the child has severe edema If the child is breastfed, encourage continued breastfeeding

69. monitoring Monitor and record, A mounts of feed offered and left over Vomiting Stool frequency and consistency Daily body weight

70. Step 8: Catch-Up growth feeding Most commonly managed as outpatient after return of appetite, no episodes of hypoglycemia/ metabolically stable and reduced or disappearance of edema F-100: 100 kcal/100 ml; 2.9 g protein/100 ml Replace F-100 for F-75: same amount for at least 48 hours Then gradually increase F-100 by ~10 ml/feed until some remains uneaten Usually occurs at 200 ml/kg/day Target weight gain is at least 10 g/kg/day

71. SAM – Therapeutic formulas

72. Rehabilitation phase A phase associated with full recovery and rapid Catch up of lost weight . use either F-100 or ready to use therapeutic food. Ready to use therapeutic food - do appetite test, if passed, give 200 cal /kg per day - encourage drinking water after eating - give additional foods if demanded as long as full amount of prescribed ready-to-use therapeutic food has been consumed.

73. Step 9: Sensory Stimulation and emotional support. With severe malnutrition there is delayed mental and behavioral development Provide: Tender loving care A cheerful, stimulating environment Structured play therapy – 15-30 min/day (provide suitable toys and play activities for the child) Physical activity when child is well enough. Support for maternal involvement.

74. Step 10: Discharge/Follow-Up Give Ready To Use Therapeutic Food (RUTF ) A fortified peanut butter equivalent to F 100. Contains 500 calories/sachet Required 150 – 200 kcal/kg/day Has low water content so long shell life. No refrigeration/ preparation required.

75. Cont … Forms of undernutrition Macro nutrients deficiency; Eg Carbohydrates , Proteins, Fats It comprises syndromes of Marasmus Kwashiorkor Marasmic Kwashiokor Micro nutrients deficiency; Eg Vitamins and minerals Most commonly vitamin A, iron, iodine and folic acid deficiencies