Manage Nutritional Problem and its managment.pptx

Nutritional problem and its management. it is important to give attention to nutrition related problems

1. Manage Nutritional Problems & Provide Dietry Services _ ___________________________________________________ By Menber Y. ( Bsc , Msc Fellow) February/2024 4/26/2024 1

2. Learning Outcomes At the end of this lesson you will able to: Describe different classes of nutritions Differentiate elements of food Identify the sources and components,compositions and functions of food. 4/26/2024 2

3. Definitions of Terms Nutrition : is the science of Food, the nutrients and other substances in food Their actions. interactions and balance in relation to health and disease and The process by which the organisms ingest, digests, absorbs, transports, utilizes and excreted food substances. 4/26/2024 3

4. Cont... Human nutrition : is a scientific discipiline concerned with access and utilization of food and nutrients for life, health, grouth, development and well-being. Public health nutrition: studies the relation ship between dietary intake and disease at communtiy level. 4/26/2024 4

5. ConT’D Dietetics/clinical nutrition it the science or art of applying the principles of nutrition in feeding tailored to individual needs. Diet: is the sequence of meals in a day (per 24 hours). Food: is anything edible (defined by culture and religion. 4/26/2024 5

6. Cont’D Rauphage is fibrous un digestible material in foodstuffs which aids the passage of food and waste products through the gut. Nutrient is an active ingredient in the food that play specific structural or functional role in the body’s lively activity. Macronutrients are nutrients required by our body in large quantities and need to be transformed in to smaller units by the body. 4/26/2024 6

7. Cont... Micronutrients are required in smaller quantities by the body Nutritional Assessment is the interpretation of Anthropometric, biochemical, clinical & dietary data in order to determine whether a person is well nourished or malnourished. 4/26/2024 7

8. Cont’D Malnutrition is a pathological state resulting from a relative or absolute deficiency or excess of one or more essential nutrients. Under-nutrition :- is the consumption of an inadequate quality/quantity of food over an extended period of time it results a deficiency disease Over-nutrition : is the consumption of an excess quantity of food over an extended period of time. 4/26/2024 8

9. Classification of Nutrients Based on the amount that each person needs to consume on a daily basis, nutrients are categorized in to two groups. 1. Macronutrients: 2. Micronutrients: Micronutrients Micronutrients Micro means small are required only in small amount. includes - vitamins and - minerals. 4/26/2024 9

10. Cont... Macronutrients macro means large required in a fairly large amount. includes : - Carbohydrates - lipids and - Proteins they provide a lot of calories but the amount of calories provided varies, depending on the source of food. each gram of carbohydrate and protein provide four calories each gram of fat provides nine calories Macro nutrients are needed for metabolism 4/26/2024 10

11. Cont. Metabolism : is the chemical reactions in the body's cells that change food into energy. 4/26/2024 11

12. Types of nutrients Functionally, foods are classified in to three body building energy giving pretective 4/26/2024 12

13. CarbohydrateS are refered as energy giving foods. ( up to 65 % of energy) provide energy in the form of ATP that the body needs to be able to work. is one of the macronutrients are the body’s main source of energe in the form of glucose are atored in the muscles and liver 4/26/2024 13

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16. Protiens are one of the macronutrients about 10 - 35 % of calories come from protien are needed in our diets For growth To improve immune functions To make essential hormones and enzymes For tissue repair To provide ennergy in times when carbohydrates are not available. To make breast milk in breast feeding mothers. 4/26/2024 16

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18. Lipids (Fats and Oils) A lipid is an organic substance found in living systems that is insoluble in water but is soluble in organic solvents. Lipids vary widely in their structures. They have mostly C,H and O. 4/26/2024 18

19. Cont.. . Lipids include: fats and oils steroids waxes Fats & oils make up 95% of the nutritional lipids, the other 5% are steroids. Fats are solid at room temprature Oils are liquid at room temprature Oils come from different plants and from fish 4/26/2024 19

20. Funtions of Lipid Supplies heat (insulation) dissolve Vitamin A,D,E,K (the fat soluble vitamins) Adds flavor to food Satisfies hunger, feel fuller longer Protects organs from shock and injury Promotes healthy skin 4/26/2024 20

21. Cholesterol a steroidal alcohol (atherosclerosis ) High – red meat, egg yolks, dairy products Low – egg whites, yoghurt None ! – fruits, veggies, vegetable oils 4/26/2024 21

22. Classification of Fats Saturated fats Are usually solids at room temprature Are not good for a person’s health, ( cause heart heart and blood vessel problems mostly of animal origin Example fatty meat chicken skin cheese butter, cream coconut oil, palm oil, cococa butter 4/26/2024 22

23. Unsaturated fats Are usually liquid at room temprature. Are healthy fats Mostly have plant origion Includes fats from Fish Oil seeds (sunflower), maize oil and ground nut oil Breast milk 4/26/2024 23

24. Water Water is an essential calorie-free vital nutrient for life at every age, It accounts for about 60% of an adult’s body weight. Water helps to restore fluids lost through metabolism, breathing, sweating, and the removal of waste. Water serves as the body’s transportation system. It is the medium by which other nutrients and essential elements are distributed throughout the body. Water also works as the transport for body waste removal. 4/26/2024 24

25. It also helps to keep the body from overheating, It regulated body temprature It lubricates the joints and tissues, The presence of water in and around body tissues helps defend the body against shock. 4/26/2024 25

26. The brain, eyes, and spinal cord are among the sensitive structures that depend on a protective water layer. Water is present in the mucous and salivary juices of our digestive systems. This is especially important for moving food through the digestive tract. As a lubricant, water also is helpful for smooth movement of bone joints. 4/26/2024 26

27. how much water should we drink? Fever, exercise, exposure to extreme temperature climates (very hot or cold), and excessive loss of body fluids (such as with vomiting or diarrhea) will increase fluid needs . We should drink at least 8 cups of water daily 4/26/2024 27

28. Is It Possible To Drink Too Much Water? This hyponatremia in which blood levels of sodium fall too low as too much water is taken. The excess total body water dilutes blood sodium levels, which can cause symptoms like confusion, nausea, seizures, and muscle spasms. 4/26/2024 28

29. Body dehydration Dehydration occurs when the some one lose more fluid than he or she is take in, and the body doesn't have enough water and other fluids to carry out its normal functions. Anyone may become dehydrated, but the condition is especially dangerous for young children and older adults. 4/26/2024 29

30. Symptoms of dehydration Includes Fatigue Confusion or short-term memory loss Mood changes like increased irritability or depression Can increase the risk of certain medical conditions: such as Urinary tract infections Kidney stones Gallstones Constipation 4/26/2024 30

31. Infant or young child Dry mouth and tongue No tears when crying No wet diapers for three hours Sunken eyes, cheeks Irritability 4/26/2024 31

32. In adult Dehydration causes Extreme thirst Less frequent urination Dark-colored urine Fatigue Dizziness Confusion 4/26/2024 32

33. Prevention People may need to take in more fluids if they are experiencing conditions such as: Vomiting or diarrhea. Strenuous exercise.  Hot or cold weather. Illness, feber 4/26/2024 33

34. Fiber fiber is undigestible part of carbohydrates Health benefits of fiber including: They improve the functioning of the digestive system, helping the absorption of nutrients and prevent constipation. They reduce the risk of inflammation of the intestines and gastrointestinal disorders. They prevent type 2 diabetes, slow down the absorption of blood sugar, keep blood sugar under control and improve insulin sensitivity. 4/26/2024 34

35. They lower bad cholesterol (LDL) in the blood, preventing cardiovascular diseases such as heart attacks and strokes. They reduce the risk of colon and rectal cancer, thanks to the maintenance of an optimal intestinal pH. They give a feeling of satiety and fullness, helping to control body weight and blocking hunger attacks. They also help fight obesity. 4/26/2024 35

36. The best sources of fiber are Undoubtedly foods of plant origin, Such as: all fruit and vegetables. legumes whole grains dried fruit and nuts. 4/26/2024 36 FOODS RICH IN FIBER

37. Micronutrients Micronutrients are nutrients required by the body in smaller amounts, but they’re still essential for carrying out bodily functions I nclude all of the essential ; 16 minerals and 13 vitamins. 4/26/2024 37

38. CONT... They are not a source of energy, but they assist in the process of energy metabolism as cofactors or components of enzymes (known as coenzymes) 4/26/2024 38

39. Minerals Minerals are inorganic substances. They are classified in to two depending on how much the body requires. Trace minerals , such as molybdenum, selenium, zinc, iron, and iodine, Are only required in amounts of a few milligrams or less per day. Major minerals , such as calcium, magnesium, potassium, sodium, and phosphorus, Are required in amounts of hundreds of milligrams or more per day . 4/26/2024 39

40. Uses of Minerals Many minerals are critical for enzyme function, and Others are used to: M aintain fluid balance, Build bone tissue, Synthesize hormones, Sransmit nerve impulses, Contract and relax muscles, and Protect against harmful free radicals in the body. 4/26/2024 40

41. Major Minerals Major Function Sodiu Fluid balance, nerve transmission, muscle contraction Chloride Fluid balance, stomach acid production Potassium Fluid balance, nerve transmission, muscle contraction Calcium Bone and teeth health maintenance, nerve transmission, muscle contraction, blood clotting Phosphorus Bone and teeth health maintenance, acid-base balance Magnesium Protein production, nerve transmission, muscle contraction Sulfur Protein production 4/26/2024 41

42. Minoro Minerals Major Function Iron Carries oxygen, assists in energy production Zinc Protein and DNA production, wound healing, growth, immune system function Iodine Thyroid hormone production, growth, metabolism Selenium Antioxidan Copper Coenzyme, iron metabolism Manganese Coenzyme Fluoride Bone and teeth health maintenance, tooth decay prevention Chromium Assists insulin in glucose metabolism Molybdenum Coenzyme 4/26/2024 42

43. Vitamins Vitamins are organic nutrients based on their solubility, vitamins are classified in to two: Water-soluble vitamins are vitamin C and all of the B vitamins. Fat-soluble vitamins are vitamins A, D, E, and K. Vitamins are required to perform many functions in the body, such as Making red blood cells, Synthesizing bone tissue, and Playing a role in normal vision, nervous system function, and Immune function. 4/26/2024 43

44. Water-Soluble Vitamins Major Functions Thiamin (B1) Coenzyme, energy metabolism assistance Riboflavin (B2 ) Coenzyme, energy metabolism assistance Niacin (B3) Coenzyme, energy metabolism assistance Pantothenic acid (B5) Coenzyme, energy metabolism assistance Pyridoxine (B6) Coenzyme, energy metabolism assistance Biotin (B7) Coenzyme, amino acid and fatty acid metabolism Folate (B9) Coenzyme, essential for growth C (ascorbic acid) Collagen synthesis, antioxidant 4/26/2024 44

45. Fat-Soluble Vitamins Major Functions A Vision, reproduction, immune system function D Bone and teeth health maintenance, immune system function E Antioxidant, cell membrane protection K Bone and teeth health maintenance, blood clotting 4/26/2024 45

46. ENERGY-YIELDING NUTRIENTS Macronutrients are the only nutrients that provide energy to the body. The energy from macronutrients comes from their chemical bonds. This chemical energy is converted into cellular (heat) energy that can be utilized to perform work, allowing cells to conduct their basic functions. 4/26/2024 46

47. Cont’D Although vitamins also have energy in their chemical bonds, our bodies do not make the enzymes to break these bonds and release this energy. Food energy is measured in kilocalories (kcals). A kilocalorie is the amount of energy needed to raise 1 kilogram of water by 1 degree Celsius. The kilocalories stored in food can be determined by putting the food into a bomb calorimeter and measuring the energy output (energy = heat produced). 4/26/2024 47

48. Energy Sources (kcal/g) Carbohydrates 4 kcal/g Protein 4 kcal/g Alcohol 7 kcal/g Lipids 9 kcal/g 4/26/2024 48

49. ORGANIC & INORGANIC NUTRIENTS Organic Nutrients An organic nutrient contains both carbon and hydrogen. Include the macronutrients (carbohydrate, protein, and fat) and vitamins. Organic nutrients can be made by living organism Are complex, made up of many elements (carbon, hydrogen, oxygen, and sometimes nitrogen) bonded together. In a sense, they are “alive,” and therefore can be destroyed or broken down. 4/26/2024 49

50. Inorganic nutrients Include both water and minerals. They do not contain both carbon and hydrogen, Are not created or destroyed. Minerals can’t be destroyed, so they are the ash left when a food is burned to completion . Minerals are also not digested or broken down, as they are already in their simplest form. 4/26/2024 50

51. Summary Classification Nutrient Macronutrient Carbohydrate, protein, lipids, water Micronutrient Vitamins, minerals Energy-Yielding Carbohydrate, protein, fat Organic Carbohydrate, protein, lipids, vitamins Inorganic Minerals, water 4/26/2024 51

52. Excercise Which of the following nutrients are categorized as both organic and energy-yielding? Protein. Minerals. Carbohydrate. Fat. Vitamins Which of the following nutrients are categorized as micronutrients? Vitamins. Carbohydrate. Protein. Fat. Water. Minerals . 4/26/2024 52

53. If you dropped your hot dog into the campfire and it burned up into ash, which of the 6 classes of nutrients would this ash be composed of? protein. fat. minerals. vitamins If you are eating a serving of wheat crackers that has 5 grams of fat, 22 grams of carbohydrates, and 2 grams of protein, how many total calories should be in this serving? You can not determine the calories with the information given. 166 kcals. 116 kcals. 141 kcals 4/26/2024 53

54. MAL-NUTRITION 4/26/2024 54

55. Malnutrition : WHO defnition ‘Is the cellular imbalance between supply of nutrients energy & the body's demand for them to ensure growth, maintenance, and specific functions.’ Severity classification of malnutrition Mild Moderate Sever The prevalence of sever malnutrition in E thiopia among under five children was 15 % which ranges 4..58 % in Addis A baba 4/26/2024 55

56. malnutrition in Ethiopia 4/26/2024 56 80% of the death due to malnutrition is contributed by Mild and moderate malnutrition Only 1 in 5 malnutrition-related deaths is due to severe malnutrition moderate Severe Mild

57. Malnutrition is the result of a lack or an excess in the provision of nutrients (under nutrition or overweight/obesity ) Includes Macronutrient deficiency Micronutrient deficiency ( Hidden Hunger ) Over nutrition- Overweight and obesity 4/26/2024 57

58. TERMS OF UNDER nutrition Wasting : means that the infant/child is thin: she/he has lost fat and muscle mass Stunting: means that the infant/child is short in stature: she/he did not grow in length/height Underweight: means that she/he weighs less than she/he should. A child can be both wasted and stunted 4/26/2024 58

59. Cont’d Wasting is usually due to a recent lack of food or illness (infections) that prevents the child from eating or absorbing nutrients of foods Stunting is a long term process, often starting in uters which is due to the mother’s malnutrition, to food intake lacking quality. Overweight and obesity are due to excessive energy intake and lack of physical activity 4/26/2024 59

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62. UNDERNUTRITION ACUTE UNDERNUTRITION CHRONIC UNDERNUTRITION Marasmus kwashiorkor Marasmic -kwashiorkor Wasting Stunting Underweight TYPES OF UNDERNUTRITION 4/26/2024 62

63. CONT’D ACUTE MALNUTRITION R esult of a relatively short period of inadequate nutrition (protein & carbohydrate), which leads to wasting and, if severe, may also lead to edema Children with primary acute malnutrition are common in developing countries as a result of inadequate food supply caused by social, economic, and environmental factors. Chronic Malnutrition Chronic malnutrition is the result of prolonged episodes of inadequate nutrition and leads to stunting. 4/26/2024 63

64. Definition of terms Protein-energy-malnutrition (PEM): A clinical syndrome present in infants and children as a result of deficient intake and/or utilization of food ( mainly protein). Marasmus : form of acute malnutrition that is characterized by wasting of body tissues. Marasmic children are extremely thin Kwashiorkor : form of acute malnutrition characterized by bilateral edema and weight-for-height of less or equal to -2 SD Marasmic -Kwashiorkor : form of acute malnutrition characterized by bilateral edema and weight-for-height of less than -2 SD 4/26/2024 64

65. 4/26/2024 65 PROTEIN-ENERGY MALNUTRITION

66. EPIDEMIOLOGY The majority of world’s children live in developing countries Highly prevalent in developing countries All children with PEM have micronutrient deficiency. 4/26/2024 66

67. Which countries are home to the stunted child ren ? 4/26/2024 67

68. CAUSES OF UNDER NURTIRION No Single cause: Primary Cause inadequate food availability Secondary Causes are Other disease lead to low food ingestion inadequate nutrient absorption or utilization , increased nutritional requirements , increased nutrient losses 4/26/2024 68

69. CAUSE ….. Social and Economic Factors Poverty Ignorance Cultural problems Biological factors Maternal malnutrition Infection Dietary factor bulky foods with low nutritional value 4/26/2024 69

70. Cont’d Environmental factors Overcrowded and/or unsanitary living conditions Agricultural patterns, droughts, floods, wars, Age of the host More frequent among infants and young children 4/26/2024 70

71. 4/26/2024 71 DETERMINANATS OF MALNUTRITION

72. Classification of PEM A . Community (Gomez) Parameter: weight for age Reference standard (50th percentile) WHO chart Grades: I (Mild ): 90-70 II (Moderate ): 70-60 III (Severe ): < 60 4/26/2024 72

73. Classification of PEM B. Welcome system: Parameter: weight for age Reference standard Harvard curve 4/26/2024 73 Weight for age Edema- Edema + 60-80% Underweight Kwashiorkor <60% Marasmus Marasmic-kwash

74. Cont’d C. Water low classification asses severity of wasting and stunting 4/26/2024 74 Grade of malnutrition Wt/ht (Wasting ) Ht /age (Stunting ) Normal > or=90% > or=95% Mild 80-89% 90-94% Moderate 70-79% 85-89% severe <70% <85%

75. The malnourished child has abnormal physiology that has implications for case management. With severe malnutrition, the physiological systems slow down or ‘shut down’ and do less to allow for survival on limited nutrients . This slowing down of the systems is called reductive adaptation. 4/26/2024 75 Abnormal Physiology in Malnutrition

76. Assignment Physiologic changes in malnutrition Liver function Cardio Vascular System Gastro Intestinal System Genitourinary System Skin, Muscle and B one Immune system Brain development 4/26/2024 76

77. Infection-Malnutrition Synergism 4/26/2024 77 Weight loss Growth faltering Immunity lowered Appetite loss Nutrient loss Malabsorption Altered Metabolism Inadequate dietary intake Disease Incidence Severity Duration

78. 4/26/2024 78

79. Pathophysiology of Severe Acute Malnutrition 4/26/2024 79 Severe acute malnutrition can result in profound metabolic, physilogical and anatomical changes . Virtually all physiological processes are altered due to severe acute malnutrition. Every organs and systems are involved in reductive adaptation .

80. Illness – via increasing susceptibility to infection Intelligence loss Reduced productivity Mortality 4/26/2024 80 Functional consequences of malnutrition

81. Kwashiorkor 4/26/2024 81 FLAKY PAINT DERMATITIS

82. kwashiorkor 4/26/2024 82 Definition Kwashiorkor is lack of physiological adaptation to unbalanced deficiency where the body utilized protein Etiology ( Causes)…………Protein deficiency Lack of knowledge about diet Poverty D rought , earthquakes , Repeated infections like diarrhoea , measles, etc )

83. Kwashiorkor ... 4/26/2024 83 Incidence is more in: Low birth weight……what is the normal birth weight? Broken families In children with whose parents are unemployed Large families

84. Kwashiorkor ... 4/26/2024 84 Symptoms Edema : decrease oncotic pressure, Recent: greater Increase Renin activity, Na and fluid retention. Hepatomegaly due to fatty infiltration from lipogenesis of excess CHO Dermatitis Skin lesion Loss of Appetite

85. Kwashiorkor 4/26/2024 85 FLAKY PAINT DERMATITIS

86. Marasmus 4/26/2024 86 The term marasmus is derived from the Greek marasmos , which means wasting . A nutritional disorder due to deficiency of all macronutrients (carbohydrates protein and fats, particularly carbohydrates ,) C haracterized by: Growth failure Gross wasting Absence of oedema

87. Marasmus… 4/26/2024 87 Marasmus represents the end result of starvation where both proteins and calories are deficient. Affects all age but common < 1 year. In Marasmus the body utilizes all fat stores before using muscles.

88. Marasmus… 4/26/2024 88

89. Causes Cause: The same as PEM. but Primary causes Lactation failure – the commonest cause introduction of dilute & dirty formula Infections ( diarrhoea ) starvation therapy due to diarrhea Marasmus 4/26/2024 89

90. Causes … 4/26/2024 90 2 . Secondary causese Birth weight: common in premature & LBW Cardiovascular diseases like VSD, ASD, and PDA due to: Recurrent respiratory infections Feeding and growth failure Cough & breathlessness

91. Causes … 4/26/2024 91 c. Respiratory causes : TB, etc d. Gastrointestinal causes Congenital hypertrophic pyloric stenosis- vomiting Congenital mega colon- diarrhoea Cleft lip & palate – inadequate intake of feeds, mainly breast feeds e. Infections Repeated diarrhoea Severe infections like congenital syphilis Malabsorption syndrome

92. Causes … 3. CNS causes Hydrocephalus and CNS infections like tuberculosis meningitis, pyogenic meningitis can cause marasmus due to decreased intake & chronic vomiting 4/26/2024 92

93. Clinical manifestations Growth retardation or growth failure (wt. for age <60% or wt. for Ht < 70%) Sunken eye balls Mood change (irritable) Good appetite Diarrhea “Old man face” appearance Mild skin & hair change (less common sign ) 4/26/2024 93

94. Clinical manifestations … Abdomen may be large or distended Wasting of subcutaneous tissue Steps – Remove the child’s cloths. Look for severe wasting of the muscle of buttocks & legs. The child has no fat & look like bone & skin. When the wasting is extreme there are many fold of skin on the buttocks & thigh. It look as if the child is wearing baggy pants 4/26/2024 94

95. Anthropometric Indicators of Malnutrition Anthropometry is the determination of nutritional status by physical measurements and comparing them to relevant reference charts. 4/26/2024 95

96. cont’d To determine the nutritional status of an individual, all those variables are necessary: Weight Height Presence of bilateral edema MUAC Age Sex Anthropometric surveys based on three indices: Weight/height index (W/H) Height/age index (H/A) Weight/age index (W/A) 4/26/2024 96

97. MUAC MID-UPPER ARM CIRCUMFERENCE It's a screening tool for adults and children to assess and determine their nutritional status 4/26/2024 97

98. 4/26/2024 98

99. MALNUTRITION INDICATORS 4/26/2024 100 NUTRITION INDICATOR MEASUREMENT INDICATOR CLINICAL INDICATOR Acute Malnutrition (SAM & MAM) Weight-for-Height Wasting, kwashiorkor Chronic Under nutrition Height-for-Age Stunting Underweight (composite indicator) Weight-for-Age Underweight Over nutrition Body Mass Index (weight/Height2 Overweight/Obesity Micronutrient Deficiencies Biochemical indicators Hypoalbuminemia , Xerophthalmia (vit-A deficiency) , stomatitis etc

100. Cont’d Which children are stunted? Childrens with Low Height for Age • Children in a given population whose height is <-2 SD of the median height of children of the same age in the reference population • Reflects past nutritional status (chronic malnutrition) 4/26/2024 101

101. cont’d Which children are stunted? Childrens with Low Height for Age • Children in a given population whose height is <-2 SD of the median height of children of the same age in the reference population • Reflects past nutritional status (chronic malnutrition) 4/26/2024 102

102. Cont’d Which children are wasted? Children with Low Weight for Height • Children in a given population whose weight is <-2 SD of the median weight of children of the same height in the reference population • Reflects present nutritional status (acute) 4/26/2024 103

103. Classification of Acute Malnutrition 4/26/2024 104 Acute Malnutrition (W/H index) Z-Score Normal: ± 1 SD Mild: - 1to -2 SD Moderate -SD -2 to -3 Severe less -3

104. Diagnosis of malnutrition Malnutrition is usually diagnosed through anthropometry (weight-for-height, MUAC , or other). However, the main symptom that reveals the metabolic status of the child is “lack of appetite”. Patients with no appetite usually present a severe complication -visible or not- that need specialized treatment. 4/26/2024 105

105. Investigations Blood CBC Serum electrolytes, plasma protein estimation Blood culture & sensitivity for evaluation of septicaemia Urine Albumin, sugar, urine culture & sensitivity Stool Ova of parasite, culture & sensitivity if there is diarrhoea Chest X-ray: to r/o TB & other infections 4/26/2024 106

106. Complications Sever Acute Malnutrition (SAM) Children with ‘complicated ’ SAM have clinical features of infection metabolic disturbance, severe oedema poor appetite . Children with ‘ uncomplicated’ SAM are clinically well, alert and have retained their appetite 4/26/2024 107

107. direct causes of deaths Hypoglycemia Hypothermia Dehydration Infection Sever Anemia 4/26/2024 108

108. management of medical complications of malnutritio n 4/26/2024 109

109. Hypoglycemia Hypoglycemia is a low level of glucose in the blood. In severely malnourished children, the level considered low is <54 mg/dl . The hypoglycemic child is usually hypothermic (low temperature) as well. Other signs of hypoglycemia include lethargy, limpness, and loss of consciousness. 4/26/2024 110

110. Hypoglycemia mgt 5 to 10 ml/kg of sugar water ‘PO’ for conscious pt. 5 to 10 ml/kg of sugar water by NG-tube or 5 ml/kg a single injection of 10% glucose solution for unconscious pt. All malnourished patients with suspected hypoglycemia should be treated with second-line antibiotics 4/26/2024 111

111. Hypothermia A severely malnourished child is hypothermic if the rectal temperature is below 35.5 C or auxiliary temperature is below 35 C . Severely malnourished children are at greater risk of hypothermia than other children and need to be kept warm. The hypothermic child has not had enough calories to warm the body. 4/26/2024 112

112. cont’d If the child is hypothermic, he is probably also hypoglycemic. Both hypothermia and hypoglycemia are signs that the child has a serious systemic infection 4/26/2024 113

113. Mgt Hypothermia Use kangaroo care technique with care taker put a hat on child Wrap the mother & child together. Keep the room warm. Treat hypoglycemia Treat by antibiotic 4/26/2024 114

114. Dehydration (DHN) & septic shock - Taker over load of fluid solutes - use ReSoMal solution to rehydrate SAM. Anemia - give 10ml/kg of packed RBC or whole blood Infection - Antibiotics 4/26/2024 115

115. Dehaydraton mgt. ReSoMal is an O ral rehydration solution for manutrition . World Health Organization (WHO) guidelines for the management of dehydration recommend the use of oral rehydration with ReSoMal (an oral rehydration solution (ORS) for SAM), ReSoMal is available commercially. 116 4/26/2024 ReSoMal

116. the difference b/n ors and resmole 4/26/2024 117

117. Calculate amount of ReSoMal to give For a child who has dehydration but no sign of shock, give ReSoMal as follows, in amounts based on the child’s weight: 118 4/26/2024

118. 119 4/26/2024

119. CASE MANAGEMENT OF SAM The principles of management of severe acute malnutrition, hasbased on 3 phases. Phase I Transition Phase Phase II Management of SAM 120 4/26/2024

120. Phase 1 (Stabilization phase) Children with complicated SAM are initially admitted to an inpatient facility for stabilization. These children are admitted to phase 1 room. During this phase: Life-threatening medical complications are treated Routine drugs are given to correct specific deficiencies Feeding with F-75 milk (low caloric and sodium) is begun 121 4/26/2024

121. Phase 1… The children in Phase 1 should be together in a separate room or section of the ward and not mixed with other patients Routine drugs has to be started immediately after they are admitted Amoxacilline Vitamin A Follic acid 122 4/26/2024

122. F-100 Is a milk based powdered therapeutic diet. Reconstituted F-100 milk provides an energy density of approximately 100kcal/100ml. It is intended for phase 2 (nutritional rehabilitation) treatment of children with Severe SAM. Each canister contains 400g of F-100 Therapeutic milk diet powder. RUTF Is the abbreviation for “ready-to-use therapeutic food”, Is a life-saving essential supply item that treats severe wasting in children under 5 years old . 4/26/2024 123 Transition phase

123. Transition phase Transition phase is started with F-100 or RUTF When The child appetite recovers The main medical complications are under control and Oedema start to reduce This phase is important for slow transition as the introduction of large amounts of RUTF or F100 could lead to imbalance of body fluids and severe medical complications. In this phase: Routine drugs are continued Feeding with RUTF or F100 is started 124 4/26/2024

124. Move the child back to Phase 1: If the patient gains weight more rapidly than 10g/kg/d (this indicates excess fluid retention) If there is increasing oedema If a child who does not have oedema develops oedema If there is a rapid increase in the size of the liver If any other signs of fluid overload develop. 125 4/26/2024 Criteria to move back from transition phase to phase1

125. If tense abdominal distension develops If the patient gets significant re-feeding diarrhea so that there is weight loss. If patient develops medical complication If NG-tube is needed If patient takes less than 75% of the feeds in Transition Phase 126 4/26/2024 cont’d

126. Marasmic pt. spends a minimum of 2 days and if tolerating the new diet with out complication. Completing the diet with good appetite. Complete loss of or radical decreasement of edema (in kwashiorkor). 127 4/26/2024 Criteria to move from transition phase to phase 2

127. Children that progress through phase 1 and transition phase enter phase 2 when they have good appetite and no major medical complication . During phase 2: Routine drugs, deworming tablets and iron, are started Feeding with RUTF or F100 is increased in amount Child starts gaining weight Whenever possible, phase 2 is implemented as OTP with RUTF. Otherwise, it can be implemented in in-patient centers with RUTF or F100. 128 4/26/2024 Phase 2 (Rehabilitation Phase)

128. When the patient (child ) Develops any signs of a complication Increase/development of oedema Development of re-feeding diarrhea sufficient to lead to weight loss. Weight loss for 2 consecutive weighing Static weight for 3 consecutive weighing Fulfilling any of the criteria of “failure to respond to treatment” 129 4/26/2024 Criteria to move back from phase 2 to phase 1

129. ROUTINE MEDICINES VITAMIN A On the day of admission (day 1), give vitamin A for all children except those with oedema or those who received vitamin A in the past 6 months. 130 4/26/2024

130. Providing dietary services 4/26/2024 131

131. objectives At the end of this topic , you will be able to : understand the functions of dietary services of a hospital ; outline the planning requirements of such a service; explain its management; . identify various management issues 4/26/2024 132

132. Introduction Dietary services means providing food and drink to a patient according to an order. Dietary service is one of the important hospital supportive services contributing to the recovery of health, through scientifically prepared diets , educating the patients attending the hospitals for treatment regarding use and utility of different foods and balanced diets 4/26/2024 133

133. Hospitals food service is essential to provide inpatients with notorious meals which help them to recover from their illness. Meals should be carefully planned and served per patients requirements. The objective of dietary service is to make provision of clean, hygienic and notorious meals for patients per their nutritional requirements 4/26/2024 134

134. Dieticians or the Food Service Managers have to be fully involved during the Planning , Process of dietary services of a hospital. Proper Planning and laying down clear cut ' policies and procedures will enable in smooth functioning of the service and lead to the patient satisfaction and thus better patient care. 4/26/2024 135

135. ROLE AND FUNCTIONS Dietary Department is responsible for the selection of food and other related items has to have liaison with Purchase Department . Requirernent of all items have to he worked out. Some items like vegetables, meat, chicken, etc., have to be purchased daily and some items like rice, pulses and oil call be piarcliilsed at weeklyfrnonthly t~asi 4/26/2024 136

136. As such the functions of a hospital . dietary services can be grouped in to four Inpatient Catering Diet Counselling Commercial catering Education , 'Training and research 4/26/2024 137

137. FOLIC ACID On the day of admission, one single dose of folic acid (5mg) can be given to children with clinical signs of anaemia. 138 4/26/2024

138. ANTIBIOTICS Antibiotics should be given to every severely malnourished patient, even if they do not have clinical signs of systemic infection. First line treatment : oral amoxicillin (if amoxicillin not available, use oral ampicillin) Second line treatment : Gentamycin (do not stop amoxicillin) 139 4/26/2024

139. MALARIA Based on national guideline for malaria treatment Malaria, Diagnosis and Treatment Guidelies for Health Workers in Ethiopia . Never give intravenous infusions of quinine to a severely malnourished case within the first two weeks of treatment. 140 4/26/2024

140. MEASLES (Metronidazole) All children from 9 months without a vaccination card should be given measles vaccine both on admission and discharge. 141 4/26/2024

141. DE-WORMING Albendazole or Mebendazole is given at the start of Phase 2 Worm medicine is only given to children that can walk. IRON added to F-100 in phase II 142 4/26/2024

142. WARNING: NEVER DO ANY OF THEFOLLOWING : Never give diuretics against malnutrition oedema. The oedema is partially due to potassuim and magnesium deficiency, that can easily recover in two weeks. Oedema dissapears with appropriate feeding adding a micronutrient solution. Giving diuretics would aggravate the electrolyte imbalance and would risk death. 143 4/26/2024

143. Cont’d Do not give Iron in the first days of treatment (until Phase 2 or Rehabilitation phase). It risks having toxic effects and reduce defense against infections. Do not give preparations rich in proteins (more than 1.5 g of protein per kg/day). Any excess in the first days can be dangerous, because the severely malnourished child is not able to assume the metabolic effort needed to deal with them. An excess of proteins can overload the liver, the heart and kidneys and provoke death . 144 4/26/2024

144. Cont’d Do not give liquids in perfusion. In the child with severe malnutrition liquids in perfusion can easily produce cardiac overload . These are only given when there is a diagnosis of septic shock. 145 4/26/2024

145. Vitamin A deficiency More common between 6 months to 3 years of age 50 to 80% of severe protein malnutrition patients are associated with vitamin A deficiency 4/26/2024 146

146. Functions of vitamin A Functioning of retina Growth and differentiation of epithelial tissue Growth of bone Reproduction and embryonic development Enhances immune function, reduces the incidence of infectious diseases 4/26/2024 147

147. Cont’d Infants and young children under 5 year of age are at highest risk because - poor stores at birth - milk and supplementary food ( low vit.A ) - infection including diarrheal disease and - growth sets requirement high 4/26/2024 148

148. Etiology of vitamin A deficiency At birth, the liver has a low vitamin A content that can be augmented by colostrum and breast milk Loss of vitamin A is present by cooking, canning and freezing of food stuffs, oxidizing agents etc Vitamin A deficiency is seen in fat malabsorption or chronic intestinal disorders Low intake of vitamin A Increased excretion of vitamin A present in cancer, urinary tract disease and chronic diseases Low protein intake can cause decrease of vitamin A concentration 4/26/2024 149

149. Clinical features Parameter Features Eyes Night blindness is the earliest manifestation Bitot spots: dry, silvery-gray plaques may appear on the bulbar conjunctivae Conjunctival xerosis : drying of conjunctiva Corneal xerosis : drying of cornea Xerophthalmia : cornification of the epithelium of the conjunctiva and disappearance of the mucus cells Keratomalacia : desiccation, ulceration and xerosis of the cornea & conjunctiva 4/26/2024 150

150. Clinical features ... Parameter Features Respiratory tract Increased risk of respiratory tract infections Skin Keratinization & drying of the epidermis occurred and papular eruptions involving the pilosebaceous follicles may be found especially on the extremities Genitourinary system Epithelium is damaged. The patient can develop pyuria & hematuria GI system Reduction of goblet cells; diarrhoea 4/26/2024 151

151. Clinical features ... Parameter Features CNS Mental retardation can occur Increased ICP with wide separation of cranial bones may occur Hydrocephalus with or without paralysis of the cranial nerves may occur Bone Associated with faulty modelling of bone, with production of thick, cancellous bone instead of thinner more compact bone Miscellaneous Taste and smell are impaired Hearing may be impaired It can interfere with erythropoiesis 4/26/2024 152

152. Bitot’s spot 4/26/2024 153

153. Management strategies Breast feeding Food diversification Vitamin A supplementation Food fortification 4/26/2024 154

154. Therapy Vitamin A capsule on two consecutive days immediately and another dose within 1-4 weeks Dose -200,000IU above one year -100,000IU 6 – 12 month -50,000IU less than 6 months 4/26/2024 155

155. Prevention Increase consumption of dark green leafy vegetables. Egg, livers, fat of fish and meat and cod liver oil can be provided Vitamin A should be supplemented in malnutrition, diarrhea, measles and acute respiratory infection. Distribution of vitamin A capsule should be given to the community. One capsule every 6 months up to 6 year of age One drop of vitamin A (25,000IU) for every child with immunization schedule 4/26/2024 156

156. Rickets (Nutritional) Bone consists of a protein matrix called osteoid and a mineral phase, principally composed of calcium and phosphate . Rickets, a disease of growing bone, occurs in children only before fusion of the epiphyses , and is due to unmineralized matrix at the growth plates . Common among children aged 6-36 months 4/26/2024 157

157. Rickets ... Because growth plate cartilage and osteoid continue to expand, but mineralization is inadequate, the growth plate thickens. There is also an increase in the circumference of the growth plate and the metaphysis . This increases bone width at the location of the growth plates, causing some of the classic clinical manifestations, such as widening of the wrists and ankles 4/26/2024 158

158. Etiology of rickets in general There are many causes of rickets including Vitamin D disorders , Calcium deficiency, Phosphorous deficiency 4/26/2024 159

159. Vitamin D disorders Nutritional vitamin D deficiency Congenital vitamin D deficiency Secondary vitamin D deficiency Malabsorption 4/26/2024 160

160. Metabolism of vitamin D Vitamin D is available in two forms: Vitamin D2 Calciferol is an ergosterol Vitamin D3 is available synthetically. It is present in skin as 7-dehydrocholesterol. It will be converted to cholecalciferol on irradiation of skin by ultraviolet rays in the range of 296-310 nm. 4/26/2024 161

161. Etiology of Nutritional vitamin D deficiency Decreased intake Lack of vitamin D in the diet Lack of exposure to UV irradiation Black children are susceptible to rickets owing to pigmentation of their skin or inadequate penetration of sunlight GIT causes Decreased absorption in the following conditions Coeliac disease, steatorrhoea, pancreatitis, or cystic fibrosis Glucocorticoids may antagonise vitamin D in calcium transport 4/26/2024 162

162. Etiology ... Liver Neonatal hepatitis, and liver cell failure may decrease absorption of vitamin D Anticonvulsants like phenobarbitone and phenytoin may convert 25(OH)D3 in to more polar vitamin D3 by P450 enzyme, which is an inactive form Kidney: chronic renal failure, tubular acidosis, etc 4/26/2024 163

163. Incidence The incidence is more during the period of rapid growth , particularly between 4 months to 2 years of age Equal in both sexes, but it is more in male children due to rapid growth 4/26/2024 164

164. Diagnosis Mainly physical examination Blood test for Calcium and phosphorus Blood test for 25-hydroxy vitamin D X- ray to check bone deformity 4/26/2024 165

165. Clinical Manifestations Most manifestations of rickets are due to skeletal changes. Craniotabes, a softening of the cranial bones, can be detected by applying pressure at the occiput or over the parietal bones. The sensation is similar to the feel of pressing into a Ping-Pong ball and then releasing. It is a normal finding in many newborns, especially near the suture lines, but it typically disappears within a few months of birth. 4/26/2024 166

166. Clinical … Widening of the costochondral junctions results in a rachitic rosary; this feels like the beads of a rosary as the examiner's fingers move along the costochondral junctions from rib to rib. Growth plate widening is also responsible for the enlargement at the wrists and ankles . The horizontal depression along the lower anterior chest known as Harrison groove occurs due to pulling of the softened ribs by the diaphragm during inspiration. 4/26/2024 167

167. Clinical … Softening of the ribs also impairs air movement and predisposes patients to atelectasis . The risk of pneumonia appears to be elevated in children with rickets; in Ethiopia, there may be a 13-fold higher incidence of rickets among children with pneumonia. 4/26/2024 168

168. Summary of clinical features GENERAL Failure to thrive Listlessness Protruding abdomen Muscle weakness (especially proximal) Fractures Tenderness HEAD Craniotabes Delayed fontanelle closure Delayed dentition; caries 4/26/2024 169

169. Summary of ... CHEST Rachitic rosary Harrison groove Respiratory infections and atelectasis BACK Scoliosis Kyphosis Lordosis 4/26/2024 170

170. Summary of ... EXTREMITIES Enlargement of wrists and ankles Valgus(outward) or varus(inward) deformities Windswept deformity (combination of valgus deformity of 1 leg with varus deformity of the other leg) Anterior bowing of the tibia and femur Leg pain 4/26/2024 171

171. Valgus and varus deformity 4/26/2024 172

172. Harrison groove 4/26/2024 173

173. Growth palate widening 4/26/2024 174

174. Rachitic Rosary 4/26/2024 175

175. Differential diagnoses Craniotabes Hydrocephalus osteogenesis imperfecta, genetics Costochondrial junction enlargement Scurvy Chondrodystrophy Congenital epiphysel dysplasia Cytomegalic inclusion disease Syphilis Copper deficiency Vitamin D resistant reckets 4/26/2024 176

176. Treatment Children with nutritional vitamin D deficiency should receive vitamin D and adequate nutritional intake of calcium and phosphorus. Vitamin D intake of 400 IU/day, typically given as a multivitamin. It is important to ensure that children receive adequate dietary calcium and phosphorus; this is usually provided by milk, formula, and other dairy products . 4/26/2024 177

177. Complications Bronchitis Bronchopneumonia Pulmonary atelectasis Anemia 4/26/2024 178

178. Prevention Exposure to sunlight Oral administration of vitamin D Daily requirement of vitamin D is 10 microgram or 400IU/day Milk fortified with vitamin D can be given 4/26/2024 179

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