MATERNAL AND CHILD HEALTH, MALNUTRITION, PROTEIN.pptx

Public health department

1. MATERNAL AND CHILD HEALTH, MALNUTRITION, PROTEIN ENERGY MALNUTRITION Dr. Elizabeth Nji

2. Maternal And Child Health The term “maternal and child health” refers to the promotive, preventive, curative and rehabilitative health care for mothers and children. It includes the sub-areas of maternal health, child health, family planning, school health, handicapped children, adolescence and health aspects of care of children in special settings such as day care. Objectives of MCH Reduction of maternal, perinatal, infant and childhood mortality and morbidity. Promotion of reproductive health, and; Promotion of the physical and psychological development of the child and adolescent within the family

3. Maternal health In many developing countries, complications of pregnancy and childbirth are the leading causes of death among women of reproductive age. According to WHO, about 95% of all maternal deaths occur in low and middle income countries. In 2020, a maternal death occurred every 2 minutes in 2020. The following are objectives of maternal services The objectives of the maternal services are to ensure that, as far as possible, pregnant women should: remain healthy throughout pregnancy; have healthy babies; recover fully from the physiological changes that take place during pregnancy and delivery

4. Maternal Death A maternal death is the death of a woman while pregnant or within 42 days of termination of pregnancy, regardless of the site or duration of pregnancy, from any cause related to or aggravated by the pregnancy or its management. Maternal deaths are subdivided into direct and indirect obstetric deaths. Direct obstetric deaths result from obstetric complications of pregnancy, labour , or the postpartum period. They are usually due to one of five major causes – haemorrhage (usually occurring postpartum), Sepsis, Eclampsia, Obstructed labour , and; Complications of unsafe abortion - as well as interventions, omissions, incorrect treatment, or events resulting from any of these.

5. Indirect obstetric deaths result from previously existing diseases or from diseases arising during pregnancy (but without direct obstetric causes), which were aggravated by the physiological effects of pregnancy; examples of such diseases include malaria, anaemia , HIV/AIDS and cardiovascular disease.

6. MATERNAL HEALTH SERVICES Ideally, every pregnant woman should have access to a minimal module of maternal health services consisting of three elements: Community-based services (primary health care); Essential obstetric care at a first referral centre to deal with complications; Effective communication and transportation between the community-based services and the first referral centre . Components The services provided in each facility to each community are; antenatal care; delivery services; postnatal care.

7. Antenatal care – this is the care of the woman during pregnancy. The primary aim of antenatal care is to achieve at the end of a pregnancy a healthy mother and a healthy baby. Ideally this care should begin soon after conception and continue throughout pregnancy. Ideally the mother should attend antenatal clinic once a month during the first 7 months, twice a month during the next month and thereafter, once a week, if everything is normal.

8. Objectives of antenatal care The following are the objectives of antenatal care To promote, protect and maintain the health of the mother during pregnancy To detect “high-risk” cases and give them special attention To foresee complications and prevent them To remove anxiety and dread associated with delivery To reduce maternal and infant mortality and morbidity To teach the mother elements of child care, nutrition, personal hygiene, and environmental sanitation. To sensitize the mother on the need for family planning, including advice to cases seeking medical termination of pregnancy, and; To attend to the under-fives accompanying the mother

9. Danger signals during pregnancy and childbirth Swelling of woman's feet and hands. Severe headache or fits. Fever. Smelly vaginal discharge. Vaginal bleeding before labour . Any part of the baby showing other than the head. Heavy bleeding during or after labour . Labour lasting more than one nightfall to one sun rise or vice versa

10. Essential components of every antenatal check-up Take the patients history Conduct a physical examination - measure the weight, blood pressure and respiratory rate and check for pallor and oedema Conduct abdominal palpation for foetal growth, foetal lie and auscultation of foetal heart sound according to the stage of pregnancy. Carry out laboratory investigations, such as haemoglobin estimation and urine tests for sugar and proteins.

11. Interventions and counselling Iron and folic acid supplementation and medication as needed. Immunization against tetanus Group or individual instruction on nutrition, family planning, self-care, delivery and parenthood Home visiting by a health worker Referral services where needed

12. Post-natal care Post-natal care refers to care of the mother and newborn after delivery. This care is broadly divided into two parts, care of the mother which is handled by the obstetrician and care of the baby which is jointly handled by the obstetrician and the paediatrician . The objectives of postpartal care are as follows: To prevent complications of the postpartal period To provide care for the rapid restoration of the mother to optimum health To check adequacy of breast feeding To provide family planning services To provide basic health education to mother/family

13. Complications of the postpartal period Certain complications may arise during the postpartal period which should be recognized early and dealth with promptly. These are; 1. puerperal sepsis – infection of the genital tract within 3 weeks after delivery 2. thrombophlebitis – infection of the veins of the legs, frequently associated with varicose veins 3. secondary haemorrhage – bleeding from the vagina anytime from 6 hours after delivery to the end of 6 weeks, this may be due to retained placenta or membranes. 4. others; urinary tract infection and mastitis

14. 12 critical areas of concern for women's advancement and empowerment 1. Poverty 2. Education and training 3. Health 4. Violence 5. Armed conflict 6. Economy 7. Decision-making 8. Institutional mechanisms 9. Human rights 10. Media 11. Environment 12. The girl-child

15. CHILD HEALTH The three major objectives of the child health services are to: ■ Promote the health of children to ensure that they achieve optimal growth and development both physical and mental ■ Protect children from major hazards through specific measures (immunization, chemoprophylaxis, dietary supplements) and through improvement in the level of care provided by the mothers and the family. ■ Treat diseases and disorders with particular emphasis on early diagnosis. The aim is to provide an effective remedy at an early stage before dangerous complications occur.

16. Child Health Problems The main health problems encountered in the child population comprise the following; Low birth weight Malnutrition Infections and parasitosis Accidents and poisoning Behavioural problems Other factors like maternal health, family, socio-economic circumstances, environment and social support and health care.

17. Strategies for promoting the health of under-five children in communities The interventions for promoting child health are summarized under the following acronym G – Growth monitoring O – Oral rehydration Therapy B – Exclusive Breastfeeding I – Immunization F – Family planning F – Food Fortification F – Female Education

18. NUTRITION Nutrition is critical for health and survival. It is the cornerstone of sustainable development. It is a key universal factor that affects as much as it defines the health of all. This is why the saying “you are what you eat”. Nutrition is defined as the intake of food, considered in relation to the body’s physiological needs. Nutrition is a dynamic process in which food is consumed and utilized in the body for the purpose of liberation of energy, building up of tissue for growth and repair and the maintenance of vital functions of the cells. Public health nutrition is the promotion and maintenance of nutrition-related health and well-being of populations through the organized efforts and informed choices of society. Public health nutrition focuses on nutrition issues that affect the whole population rather than the specific dietary needs of an individual

19. The core functions of public/community health are to To promote and maintain nutritional health, and prevent nutritional related disease. Nutrition and health There is a strong link between nutrition and health and a vicious cycle between nutritional status and health status. Diet and nutrition are important factors in the promotion and maintenance of good health throughout one’s entire life. What we choose to eat can have a direct effect on our ability to enjoy life to its fullest. Our food choices play a major role in promoting and maintaining good health; promoting optimal growth in infants, children and adolescents; preventing many chronic diseases and treating some; and speeding recovery from injuries and surgery. Due to changes in dietary and lifestyle patterns, diet-related diseases, including obesity, diabetes mellitus, cardiovascular diseases, hypertension and stroke, and various forms of cancers are increasingly becoming significant causes of disability and premature death in both developing and developed countries.

20. MALNUTRITION Malnutrition has been defined as the pathological condition brought about by inadequacy or excess of one or more of the essential nutrients that the body cannot make or make in sufficient quantities but are necessary for survival, growth, and reproduction and for capacity to work learn and function in the society This could result from deficiency or imbalance of the nutrients contained in the diet itself relative to requirements of the body or from defects in the absorption of nutrients or in the biochemical processes within the cells that govern the utilization of nutrients. Types of nutritional disorder Primary nutritional disorders are mainly due to inadequate or excessive intake. The term also denotes that when the nutrient(s) is removed or consumed in adequate quantity/quality the deficiency symptoms disappear but the prognosis is dependent on the severity and duration of the deficiencies. Examples: Scurvy (deficiency of vitamin C)

21. Secondary Nutritional disorders These are conditioning factors with or without deficiency or excessive intake such as a) Poor absorption (liver and bile duct disease, b) Decreased utilization c) Impaired transportation d) Increased excretion ( diarrhea ) e) Increased destruction (oxygenation and oxidation) f) increased requirement

22. TYPES OF MALNUTRITION Types of malnutrition ( i ) Undernutrition: this is a pathological state resulting from inadequate intake of nutrients relative to needs over an extended period of time. E.g. marasmus; Anorexia nervosa   (ii) Overnutrition : this is a pathological state resulting from excessive intake of nutrients relative to needs over an extended period of time. Obesity, Hypervitaminosis A   (iii) Specific nutrient deficiency : a relative or absolute lack of individual nutrient. E.g Scurvy due to lack of vitamin C, Pellagra lack of Niacin, Beriberi lack of vitamin B 1

23. Causes of nutritional disorders ( i ) Poor agricultural practices that may lead to food unavailability (ii) Poverty (iii) Ignorance (iv) Food and nutrition insecurity – insufficient food production (v) Improper food selection and food preparation (vi) Customs/Religion inimical to good nutrition (vii) Poor policy (viii) Large population or large family size (ix) Lack of nutrition education (x) Poor intra-household food distribution (xi) Genetic disposition (xii) Inadequate dietary intake

24. NUTRITION THROUGH THE LIFE CYCLE Certain groups of people are particularly vulnerable to under nutrition/malnutrition. Infants, young children, pregnant and nursing women, disabled people and the elderly within poor households are the most nutritionally vulnerable groups and priority must be given to protecting and promoting their nutritional wellbeing. Also at risk of malnutrition are adolescents who are considered to be in one of the defining stages of life. Nutrition in pregnancy Pregnancy induces special nutritional demands in women due to the physiological changes taking place at this time. These physiological changes are: A change in general metabolism. The basal metabolic rate increases which relates to increase in temperature Alimentary function is also altered. A). In some, there is a crave for unusual food early in pregnancy. B). There might be vomiting or nausea mainly due to reduced gastric secretion. C). Constipation due to slowing down of bowel movement

25. Renal function has also been found to be altered during pregnancy – urinary nitrogen loss Blood volume in pregnancy increases than in a non-pregnant woman due to mainly plasma component There is also an increase in total body water Change in energy requirement for growing foetus and activities of the mother. There is increase of additional food/nutrients to lay down tissues for lactation, for foetal growth, for high metabolic rate and for normal activities

26. Diet requirement of pregnancy Poor nutrition in pregnancy has been associated with poor foetal outcome, the effect of which may persist throughout the life time. The following are nutrient requirements during pregnancy Energy increased by 350Kcal Protein 30g Increased demand for essential micronutrients (Vit D, calcium and folic acid) Folic acid for collagen & tissue formation Iron for red blood cell formation Vitamin C for collagen & tissue formation

27. Nutrition during lactation The fat stores built up during pregnancy are released during lactation. The nutrient requirement during lactation are more than during pregnancy. A lactating woman requires additional 550Kcals/day. Iron supplementation throughout lactation is recommended to replenish the maternal store.

28. Nutrition in infants and young children Infancy is a period of rapid growth – and high metabolic rate and rapid turnover of nutrients and they require more nutrients as well as body weight. They also have larger surface areas which permit greater losses of heat and water through the skin. As the infant grows, requirement for protein falls more than for calories since growth slows down. Breastfeeding for the first year of life is recommended because of its many benefits to infants and their mothers. Appropriate infant and young child feeding practices include; Exclusive breastfeeding for the first 6 months of life Timely initiation of nutritionally adequate and safe complementary foods while continuing breastfeeding up to 2years or beyond; and Appropriate feeding of infants and young children living in especially difficult circumstances (low-birth-weight infants, infants of HIV positive mothers, infants in emergency situations, malnourished infants, etc.).

29. NUTRITIONAL DEFICIENCIES PROTEIN ENERGY MALNUTRITION The term PEM has been used to describe a range of clinical disorders primarily characterized by growth failure or growth retardation in children. At one end is kwashiorkor (due to qualitative and quantitative deficiency of protein) but in which energy intake may be adequate. At the other end is marasmus (due to a continued restriction of both dietary energy and protein, as well as other nutrients) Infants and young children are the most severely affected by PEM because of their high energy and protein needs, relative to body needs and their particular vulnerability to infections. PEM is the most important public health problem in under developed countries in the world today. It is largely responsible for the situation where about half of the children born in some regions do not make it up to five years old. Death rates in such areas may be 20-50 times the rate in rich and prosperous communities in Europe and North America.

30. Marasmus It mainly occurs in children under one year, most frequently in towns and urban areas. PATHS LEADING TO THE DEVELOPMENT OF MARASMUS Urbanising Influences – which predisposes people to: Rapid succession of pregnancies: there is a wide spread belief among uneducated women that the milk of a pregnant woman is bad for her child. Early and abrupt weaning: influenced unwisely by advertisements on billboards, radio and television which advocates the advantage of artificial food products. Another reason for early weaning is the necessity of desire to return to work as soon as the maternity leave is over.

31. Feeding the infants dirty and artificial milk and diluted products given in inadequate quantity to avoid expenses, thus the diet is low in both energy and protein, in addition, poor housing and lack of equipment for preparing of clean food is almost not available. Repeated Infections like Gastro Intestinal tract infections Starvation therapy. Cultural beliefs of withdrawing food as regimen in diarrhoea cases Features: Children with marasmus display the following symptoms; Failure to thrive, irritability, fretfulness or alternatively apathy. Diarrhoea is frequent, and many of the children are hungry and look wizened and shrunken with little or no subcutaneous fat. The skin and mucus membrane may be dried and atrophic. Their stool contains undigested food and there is frequent dehydration, watery diarrhoea with acid stools

32. KWASHIOKOR PATHS LEADING TO KWASHIORKOR Prolonged breastfeeding/late weaning Child weaned into traditional family diet e.g. pap, cassava flakes ( garri ) which may be low in protein but most times be the most affordable and available food item due to poverty. Sometimes, customs reinforced by taboos determine the limited supply of foods of animal origin which may provide more protein to the child. An example is the tradition of not giving children egg to prevent them from stealing. Acute infections, usually increases need for energy and protein where it has been marginal or below daily requirement, e.g. malaria, measles, and gastro-enteritis.

33. Features In kwashiorkor, there is oedema together with failure to thrive, anorexia, diarrhoea and a generalized unhappiness or apathy. Some times, an infection often precipitates the onset of kwashiorkor. Oedema may be slight or gross depending partly on the amount of salt and water present in the diet. The presence of some subcutaneous fat makes the weightloss less striking than in marasmus. Oedema is more marked on the lower limb although it may be distributed over the whole body. In kwashiorkor, the skin first becomes thickened, the peels off and becomes flaky. In some cases, the infected area looks as if they are burned, sparsely soft and thin and easily plucked out. There is moderate to severe fatty infiltration of the liver

34. TREATMENT OF PEM Children who are seriously ill require treatment in the hospital as their recovery depends on high standards of clinical skills and nursing care, with some laboratory support. After the acute phase, patients need several weeks of specialized feeding and some medical supervision to enable them recover very well. In areas where PEM is endemic, special rehabilitation in centers facilitates full recovery. Fluids are given if the patient is dehydrated, and the amount of fluids depends on the clinical progress and less fluids may be needed if there is oedema. The management and treatment of PEM is summarized in three phases Initial phase To treat or prevent hypoglycaemia and hypothermia To treat or prevent dehydration and restore electrolyte balance To treat incipient or developed septic shock, if present To start to feed the child To treat infection To identify and treat any other problems, including vitamin deficiency, severe anaemia and heart failure

35. 2. Rehabilitation phase To encourage the child to eat as much as possible To re-initiate and /or encourage breastfeeding as necessary; To stimulate emotional and physical development; and To prepare the mother or care-giver to continue to look after the child after discharge 3. Follow up phase After discharge, the child is followed up at home to prevent relapse, and monitor progress in physical, mental and emotional development of the child. At each visit, the mother should be asked about the child’s recent health, feeding practices and play activities. The child should be examined, weighed and measured, and results recorded. Each phase of treatment should be carried out properly by appropriately trained and dedicated health workers. When this is done, the risk of death can be substantially reduced.

36. IMAGES SHOWING CHILDREN WITH KWASHIORKOR AND MARASMUS

37. MICRONUTRIENT DEFICIENCIES Micronutrients are nutrients that ae needed in minute quantity for the effective functioning of the body. They can be described as the magic wands that keeps the body healthy and active. These are essential nutrients which the body cannot produce in the quantity that is needed and so must be supplemented in our daily diet. They are gotten from minerals and vitamins. Important micronutrient of public health significance are Iodine, Iron, Folate, vitamin A, Vitamin B complex, vitamin C, Zinc, Calcium, Vitamin D, magnesium, etc. Micronutrient Deficiencies of public health significance Iodine deficiency disorders – women of reproductive age, infants and children Iron deficiency anaemia – adolescent girls, women of reproductive age, children Vitamin A deficiency – infants and pre-school children Zinc deficiency – infants, children and women