Nutritional deficiency disorders in children

PEM- Kwashiorkor and marasmus, Vitamin and mineral deficiency disorders and management in children

1. Nutritional Deficiency Disorders Kiran Kaur (Lect.) College of Nursing PGIMS, Rohtak

2. Malnutrition It is a condition that occurs due to deficiency or excess of one or more essential nutrients. Types- Protein – Energy Malnutrition Vitamin Deficiency Disorders Mineral deficiency Diseases

3. Protein Energy malnutrition Protein–energy malnutrition  ( PEM ), sometimes called  protein-energy undernutrition  ( PEU ), is a form of  malnutrition that is defined as a range of pathological conditions arising from lack of dietary protein and/or energy (calories) in varying proportions. 

4. Classification of PEM Syndromal Classification Kwashiorkor Nutritional Marasmus Pre kwashiorkor Nutritional Dwarfing

5. Classification by Indian Academy of Paediatrics Grade I- Between 71 and 80 percent of expected weight for the age Grade II- Between 61 and 70 percent of expected weight for the age Grade III- Between 51 and 60 percent of expected weight for the age Grade IV- 50 percent or less of expected weight for the age * if edema is present in the child the letter K is placed in front of the grade of malnutrition.

6. Gomez Classification Grade I- Weight between 75 and 90 percent of expected weight for the age Grade II- Weight between 61 and 75 percent of expected weight for the age Grade III- Weight less than or equal to 60 percent of expected weight for the age

7. WHO Classification Stunting- child below 2 standard deviation (SD) score from median height for age Underweight- child below 2 standard deviation (SD) score from median weight for age Wasting- child below 2 standard deviation (SD) score from median weight for height

8. Clinical Features of PEM Kwashiorkor: - Insufficient protein consumption - Child weaned: mother’s milk to starchy vegetables • Marasmus - Energy deficiency • Marasmic -Kwashiorkor - Deficiency of both calories and protein

9. Kwashiorkor Weight loss: -arms and legs - decrease of muscle mass •Swollen abdomen - ascites: increase of capillary permeability - enlarged liver: fatty liver •Peripheral oedema: decrease of oncotic pressure • Anemia : lethargy •Hair and skin changes

10. Marasmus Weight loss: “skin and bones” • Prominent of ribs • Drastic loss of adipose tissue • Growth retardation • Chronic diarrhea • Muscle atrophy • Skin folds • “old man” face

11. Management of PEM PEM is managed according to the degree of severity It could be either managed at home, nutritional Rehabilitation Centres or in the hospital Mainly it is managed through nutritional rehabilitation.

12. Domiciliary Management Who can be managed at home- Mild to moderate malnutrition No infections or complications present Availability of suitable care taker at home How- Educate the parents about the needs of the child Nutritional counselling should be provided Teach the recommended diet and availability of locally available rich sources of proteins and calories Regular home visits by anganwadi worker Follow up for medical supervision and evaluation

13. Nutritional Rehabilitation Centre Who- Mild to Moderate malnutrition Domiciliary management not ensured adequately How- Government institutions or NGOs provide rehabilitation service Correction of water and electrolyte balance Dietary support - 3-4g protein and 200 cal / kg body weight/day Vitamins and minerals Counsel parents and plan future including immunization and diet supplements

14. Hospital/ Health Centre Who- Advanced cases with infections Other complication may be present How- Treatment of complications Start intensive feeding (if oral not possible then NG feeds may be given) Initially milk based small feeds as per child’s tolerance Gradually moved to semisolid food, high in proteins and calorie 80-100 kcal/kg/day for maintenance, gradually increased to 150 kcal/kg/day of energy and 2-3g/kg/day of proteins

15. Cont …. Fluid intake should be within 100-125 ml/kg/day Fat should also be supplemented Minerals and trace elements are also added Iron and vitamin B Complex are not useful in initial therapy Emotional and physical stimulation is also required Mother should also be trained for home care (Continuation of nutritional support, necessary hygiene measures, immunization, routine care, regular follow up, prevention of relapse)

16. Vitamin deficiency disorders Fat soluble vitamins- Vitamin A, D, E, K Water soluble vitamins- Vitamins B complex and Vitamin C

17. Vitamin- A (Retinol and beta carotene) Sources- Animal sources- Liver, egg yolk, butter, cheese, ghee, whole milk, cheese, fish, meat and fish liver oil Pant sources- green leafy vegetables, cereals and pulses, green and yellow fruits and vegetables Deficiency leads to- Major effect on eyes, malnutrition, diarrhoea, malabsorption syndrome, cystic fibrosis, hepatic insufficiency , measles and prematurity.

18. Ocular manifestation Conjunctival xerosis (wrinkled conjunctiva) Bitot’s spot(pearly white spot on conjunctiva on either side of cornea) Corneal xerosis and ulceration Inefficient formation of rhodopsin Night blindness Keratomalacia Blindness

19. Extraocular Manifestation Phrynoderma (toad skin) Hyperkeratosis Dry scaly skin Hypertrophy of tongue Growth retardation Susceptible to infections Renal stone Interference to reproductive functions

20. Treatment of VAD Oral Vitamin- A administration Parenteral water soluble vit A may be administered in case of impaired oral intake, persistent vomiting and malabsorption

21. Excess of Vitamin A Toxic effects like vomiting, dizziness, increased ICP, tension and papilledema. Chronic intoxication can cause anorexia, dry itchy skin, sleep disorders, painful extremities, sparse hair, enlargement of liver and spleen, hypoplastic anaemia, teratogenicity etc.

22. Prevention of VAD Vitamin A oral supplementation- one dose of 1 lakh IU at 9 months with measles vaccination followed by eight more doses of 2 lakh IU every 6 months interval (18, 24, 30, 36, 42, 48, 54 and 60 months) upto 5 years of age Intake of food items rich in Vitamin A Reduction, early detection and management of childhood illnesses like PEM, ARI, diarrhoea, measles, worm infestation etc. Early detection of any deficiency and prompt management Creating public awareness regarding preventive measures

23. Vitamin D ( Calciferol and cholecalciferol) Functions- Regulates mineralisation of bones and teeth Promotes intestinal absorption of calcium and phosphorus Helps in normal growth and development of children Sources- Sunlight and animal food (liver, egg yolk, butter, cheese, fish, milk) RDA- 5 micrograms (200 IU) for infants and 5-10 micrograms ( 200-400 IU) for children

24. Deficiency of Vit . D Rickets Bone deformity Growth Retardation Muscular hypotonia Osteomalacia in adult woman

25. Rickets Usually seen in children between 6 months to 2 years of age Initially the symptoms will be vague with irritability, restlessness and sweating over the head especially during sleep Early sign- craniotabes (delayed fusion of fontanels and soft and thin skull bones which feel like ping pong ball) Large size of head Frontal bossing and box shape head Prominent costochondral junction ( rachitic rosary) Pigeon chest deformity Horizontal depression of lower border of chest (Harrison’s grove) Violin shapes deformity of chest (pectus excavatum) Spinal deformities (scoliosis, kyphosis or lordosis) Knock knees (genu valgum ), bow legs (genu varum ) Broadening of wrist and ankles Flat feet, delayed eruption of teeth, pot belly, growth failure

26. Management Administration of single massive dose of vitamin D orally or intramuscularly Gross orthopaedic deformity corrected surgically Animal food sources of vit . D should be added in food Child should be encouraged to play outside for longer period for exposure to sunlight Overdose of V it . D may lead to toxic symptoms (nausea, abdominal cramps, diarrhoea, irritability, pallor, polydipsia, failure to thrive, calciuria , calcification of soft tissue, cardiac arrhythmias and renal failure)

27. Vitamin E (Tocopherol) Functions- Helps in cell maturation and maintenance of stability of biological membranes It has antioxidant and antineoplastic effects Sources- V egetable oil, sunflower oil, soya bean, wheat, germs, leafy vegetables, egg yolk, nuts, seeds etc. Deficiency - P rematurity, haemolytic anaemia, skin changes, jaundice, edema , ROP, intraventricular haemorrhage, bronchopulmonary dysplasia, muscular dystrophy and growth failure. Prevention- D ietary improvement of mother and child Creating awareness regarding functions, sources and deficiency

28. Vitamin K Functions- Stimulate the production and release of certain coagulation factors in the liver Sources- Green leafy vegetables, soya bean, tomato, fruits, liver, egg yolk and milk. Deficiency- Prolonged blood clotting time due to decreased prothrombin level Manifested in newborns as bleeding from GIT, IC haemorrhage, bleeding from umblical stump In infants vit . K def. may be related to chronic diarrhoea, malabsorption syndrome, worm infestation, prolonged use of oral antibiotics Prevention- Inj. Vit K (1 mg) IM given to the newborns Early weaning and intake of food containing Vit . K

29. Vitamin B Complex Vitamin B complex group includes Vitamin B1 - Thiamine Vitamin B2 - Riboflavin Vitamin B5 - Niacin/ Nicotinic acid Vitamin B6 - Pyridoxine Vitamin B12 - Cyanocobalamin Folic acid/ Folate/ folacin

30. Vitamin B1 (Thiamine) Functions- Essential for metabolism of carbohydrates and proteins Essential for synthesis of Acetylcholine which helps in nerve conduction Vital role in the nutrition of heart and peripheral nerves Sources- A ll natural foods i.e. whole grain cereals, wheat, gram, pulses, oilseeds and nuts. Meat, fish, eggs, vegetables and fruits contain less thiamine. Deficiency- Beri Beri Wernicke- Korsakoff syndrome Subacute necrotising encephalopathy

31. Beri b eri Dry Beriberi Chronic neurologic involvement characterised by anorexia, indigestion, weight loss, weakness, diarrhoea, constipation, edema , apathy, ataxia, peripheral neuritis, hoarseness, vocal cord paralysis and diminished deep tendon reflexes Wet Beriberi Acute cardiac involvement characterised by congestive cardiac failure with dyspnea , cyanosis, tachycardia, edema and hepatomegaly Infantile Beriberi Found between 2-4 months of age of breast fed baby of a thiamine deficit mother with peripheral neuropathy Meningitis with beriberi is manifested with convulsions, dialited pupils, bulging anterior fontanel and coma

32. Prevention of Thiamine deficiency Health education on balanced diet and thiamine rich food (parboiled and undermilled rice) Adequate antenatal diet Treatment of prolonged illnesses Improvement of socioeconomic status Prophylactic use of thiamine to the children with persistent vomiting or prolonged gastric aspiration and for those who go on long fasts, prevents the deficiency state

33. Vitamin B2 (Riboflavin) Functions- Essential for metabolism of carbohydrates, fatty acids and proteins Helps in cellular oxidation Sources- Milk, egg, liver, green leafy vegetables etc. cereals and pulses are poor sources but germination increases their riboflavin content Deficiency- Angular stomatitis, cheilosis , magenta tongue, glossitis, nasolabial seborrheic dermatitis, dysquamination , keratitis, watering of eyes, photophobia,blurring of vision, peripheral neuropathy and growth failure Prevention- Promoting intake of riboflavin containing food and prevent faulty absorption

34. Vitamin B5 (Niacin) Functions- Essential for metabolism of carbohydrates, fat and proteins Helps in normal functioning of skin, GIT, nervous and hemopoietic system Sources- Natural food like milk, liver, cheese, cereals, pulses, groundnut and fish etc. Deficiency- Pellagra (3 Ds- diarrhoea, dermatitis and dementia), glossitis, stomatitis, dysphagia, nausea, vomiting, loss of appetite, anemia , mental changes Dermatitis is found in exposed skin as pigmented scaly cracked area on neck, back of hand, lower legs and face Mainly seen in jawar and maize eaters Prevention- Promoting intake well balanced diet including leguminous food and animal protein Improvement of socioeconomic condition and agriculture development Health education and awareness

35. Vitamin B6 (Pyridoxine) Functions- Helps in metabolism of carbohydrates, fatty acids and proteins Essential for normal functioning of brain and nervous system Role in blood formation and maturation of polymorphonuclear cells Sources- Natural food like liver, egg, meat, wheat germ, soyabean , peas, pulses, cereals etc. Deficiency- Convulsions, peripheral neuritis, irritability, hypochromic anaemia (not responding to iron therapy) and seborrheic dermatitis around nose and eyes, GI upset, loss of appetite, abdominal discomfort and diarrhoea Prevention- Promoting well balanced diet Supplemental pyridoxine is required in children on INH therapy, hydralazine, penicillamine etc.

36. Vitamin B 12 (cyanocobalamin) Functions- Synthesis of DNA along with folate Synthesis of fatty acid in myelin Growth of lactobacilli in intestine and maturation of RBC Sources- Only the animal food as liver, meat, egg, milk, cheese etc. It is synthesised in the colon by bacteria Deficiency- Juvenile pernicious anaemia and megaloblastic anaemia due to lack of intrinsic factors in stomach It is found in strict vegetarians May lead to demyelinating lesions of spinal cord with numbness and tingling sensation of fingers and toes Prevention- Adequate amount od animal food and balanced diet

37. Folic acid Functions- Normal development of bleed cells in the bone marrow Synthesis of DNA Sources- Leafy vegetables, cereals, fruits, milk, egg, liver, meat and diary products Overcooking and heat destroy folic acid in food Deficiency- Megaloblastic anaemia, weakness, anorexia, glossitis, cheilosis , GI upset Prevention- Balanced diet with proper cooking methods Adequate treatment of liver diseases, malabsorption syndrome, recurrent diarrhoea and worm infestation Treatment- 1-2 mg folic acid orally

38. Vitamin C (Ascorbic Acid) Functions- Formation of collagen and intracellular matrix in teeth, bones and capillaries. Helps in tissue oxidation, maturation of RBSs, absorption of iron Protection against infection and enhances in wound healing Sources- Amla , guava and other fresh fruits like tomato, orange and lemon Also available in green leafy vegetables, peas, beans etc. Most sensitive to heat Deficiency- Scurvy with features of swollen and bleeding gums, subcutaneous bruising, bleeding under the skin or in joints, delayed wound healing and anaemis . May also lead to weakness, irritability, apprehensive look, tenderness and pain over extremities with frog like position Prevention- Taking adequate fresh food items containing vitamin C Adequate treatment of gastrointestinal disturbances Treatment- Loading dose of 500 mg of vit . C followed by daily dose of 100-100 mg for several weeks orally

39. Minerals and their deficiency disorders Minerals are nutritionally significant They are essential for growth, repair and regulation of body functions Major essential minerals are- Calcium, phosphorus, sodium, potassium and magnesium Trace elements required for the body are- Iron, iodine, fluorine, zinc. Copper, cobalt, chromium, maganese , nickel, tin, silicon etc . Trace elements with no known functions- Lead, mercury, boron, aluminium etc.

40. Calcium Functions- Formation of bones and teeth Blood coagulation, cardiac functions, nerve conduction, muscle contraction and metabolism of enzymes and hormones Sources- Milk and milk products, egg, fish Other sources- leafy vegetables, cereals and millets. Calcium absorption is aided by vitamin D, Vitamin C and lactose and hindered by oxalic acid, phytic acid, fats, fibres and phosphate Deficiency- Rickets and hypocalcemic tetany with muscle cramps, numbness, tingling sensation of limbs etc. May also cause growth retardation, osteomalasia , skin problems, joint pain and palpitation Prevention- Increased dietary intake of calcium containing food, promoting calcium absorption

41. Phosphorus Essential in metabolism of proteins, fats and carbohydrates Essential for formation of bones and teeth Helps in regulation of acid base equilibrium Sources are- milk, meat, fish, egg yolk, cereals and pulses Deficiency occurs rarely Deficiency may lead to rickets in children Hyperphosphatemia results in renal failure

42. Sodium Important electrolyte, present in all body fluids Essential for maintaining osmotic pressure Available in common salt, drinking water, vegetables, milk egg, meat etc. Deficiency may lead to dehydration, weakness, lassitude, dizziness, nausea, anorexia, hypotension, syncope and convulsions Hypernatremia results in edema and CNS symptoms like dullness, convulsions and coma

43. Potassium Helps in muscular contraction, conduction of nerve impulses and cell membrane permeability and enzyme action Essential for maintenance of osmotic pressure, fluid electrolyte balance and integrity of cardiac muscle excitability, conduction and rhythm All food contain potassium. Mainly- meat, milk, cereals, dry fruits and fruit juices Deficiency does not occur normally. Hypokalemia develops in starvation, malnutrition, gastroenteritis, steroids and diuretic therapy, manifested by- tachycardia, ECG changes, marked muscle weakness, hypotonia, abdominal distension and drowsiness Hyperkalemia may occur due to renal failure and excess potassium therapy manifested by abdominal distension, restlessness, diarrhoea, abnormal cardiac rhythm, cardiac arrest and ventricular fibrillation

44. Iron Functions- Helps in for mation of haemoglobin and myoglobin Helps in development and function of brain, regulation of body temperature, muscle activity Main function is oxygen transport and cell respiration Sources- Heme iron sources- liver, egg, meat, fish Non heme iron- green leafy vegetables, legumes, nuts, cereals, oilseed, jiggery, dry fruits etc. Milk, egg, tea and excess fibres hinder iron absorption Vitamin C containing food promote iron absorption Deficiency- Microcytic hypochromic anemia Excess of iron may lead to deposition of abnormal iron pigment (hemosiderin) Prevention- Iron rich dietary intake by child and mother Modification in dietary habits for improvement in absorption

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