Protein Energy Malnutrition in Children.pptx

Description on Protein Energy Malnutrition

1. PROTEIN ENERGY MAL NUTRITION

2. INDEX DEFINITION CAUSES & RISK FACTORS INDICATORS OF MALNUTRITION CLINICAL FEATURE’S CLASSIFICATION ASSESSMENT OF NUTRITIONAL STATUS COMPLIATIONS OF SAM MANAGEMENT (MILD , MODERATE , UNCOMPLICATED & COMPLICATED SAM DISCHARGE CRITERIA & POST DISCHARGE CARE AT HOME FOLLOWUP CARE PREVENTION

3. DEFINITION Pathological conditions arising from coincident lack, in varying proportions of protein and calories, Occuring most frequently in infants and young children. Commonly associated with infections.

4. CAUSES & RISK FACTORS OF UNDERNUTRITION Immediate determinants --LBW(20 %) , INFECTION(25 %) , LOW FOOD INTAKE(55%) Underlying determinants –household food security , resources , income , maternal health , food intake , physical status, knowledge , cultural beliefs , education residential area , safewater supply, sanitation. Basic determinants --------- political and economical structure sociocultural environment .

5. Malnutrition and infection vicious cycle

6. CAUSES OF UNDERNUTRITION ( WEB OF CAUSATION ) KNOWLEDGE PARENTAL

7. RISK FACTORS OF MALNUTRITION LBW Multiple births Closely spaced birth <3 yrs Early stoppage of bf or late weaning with insufficient cf Recurrent infections Illiteracy Poverty Secondary to malabsorption .

8. INDICATORS OF UNDERNUTRITION 3 sub groups 1. STUNTING - Ht for Age < -2SD to median in WHO growth charts (Chronic M ) 2 . WASTING -- Wt for Ht < -2SD to median in WHO growth charts (Acute M ) 3. UNDERWEIGHT – Wt for Age < -2SD to median in WHO growth charts 4.All subgroups are considered severe if < -3SD to median according to WHO growth charts ( severe -- stunting , wasting , underweight ) 5. <6months – wt / ht < -3SD , Bipedal edema , visible severe wasting in < 45cm baby

9. AGE GROUP PARAMETERS TO BE TAKEN INTO CONSIDERATION & DEFINING DISORDERS ACCORDING TO AGE INFANCY ( LENGTH , WEIGHT , HEAD CIRCUMFERENCE , CHEST CIRCUMFERENCE ) FOR AGE WEIGHT FOR LENGTH FAILURE TO THRIVE , MALNUTRITION 1 – 5 YEARS ( HEIGHT , WEIGHT ) FOR AGE , MUAC , WEIGHT FOR LENGTH , BMI STUNTING , WASTING ,FAILURE TO THRIVE > 5 YEARS HEIGHT , WEIGHT , BMI STUNTING , WASTING

10. CLINICAL SYNDROMES 1. MARASMUS – severe wasting - acute starvation over borderline nutritional status 2 . KWASHIORKOR -- pitting edema is main sign , uncommon in india 3. MARASMIC KWASHIORKOR – edema with varied manifestations of marasmus 4. SAM ( severe acute malnutrition ) -- among 6-72 months of age any child fulfilling any 1/3 criteria i ) Severe wasting Wt / Ht < -3SD on WHO growth standard ii) Bipedal edema iii) MUAC -- < 11.5 cm 5. Rule out other causes of edema – nephrotic syndrome , CHF.

11. MARASMUS Main sign is severe wasting shoulders , arms , buttocks , thighs Emaciated , markedly stunted Loss of buccal pad of fat – wrinkled face – monkey face appearance Baggy pants – loose skin folds of buttocks hanging down Irritable child , hungry Sunken fontanelles in infant Skin and bone appearance , indolent ulcers and sores Dry , brittle hair Appears alert Liver is shrunk No edema Normal plasma amino acids , no fat deposits in liver

12. BAGGY PANTS MARASMUS

13. Grading of marasmus clinically Grade I – wasting starts in axilla and groin Grade II – wasting till thighs and buttocks Grade III – chest and abdomen wasting Grade IV – wasting of buccal pad of fat

14. KWASHIORKOR Uncommon in india Pitting edema starting legs & feet proceeding to hands and face in severe cases. Fat sugar baby appearance. Edema constitute upto 20% body weight. Muscle wasting – hypotonia,weakness,inability to stand or walk. Flaky paint dermatosis – buttocks, perineum, upper thigh. Smooth tongue , cheilosis and angular stomatitis . Lustreless , thin , easily pluckable hair with flag sign , with sparseness.

15. KWASHIORKOR

16. FLAKY PAINT DERMATOSIS KWASHIORKOR

17. Unhappy , apathetic , sad , intermittent cry , no signs of hunger. Tremors. Anorexia , vomiting , abd distension , hepatomegaly , fatty liver , vitamin deficiency. Nutritional anemia . Bradycardia, hypotension , decreased cardiac output. Aminoaciduria , acidemia . Hypoalbuminemia , decreased lipoproteins , Fatty infiltrates in liver , increased FFA’s .

18. GRADING of kwashiorkor Grade I – Pedal edema Grade II – Pedal edema + facial edema Grade III – Pedal + facial + paraspinal + chest edema Grade IV – Generalized edema with ascites

19. CLASSIFICATION OF UNDERNUTRITION GOMEZ CLASSIFICATION - ( Wt for Age % ) IAP CLASSIFICATION - ( Wt for Age % ) NCHS (WHO) CLASSIFICATION ( Wt for Ht % ) and ( Ht for Age ) and edema ARNOLDS CLASSIFICATION - ( MUAC ) WELLCOME TRUST/INTERNATIONAL CLASSIFICATION – ( Wt for Age % and Edema )

20. GOMEZ CLASSIFICATION NUTRITIONAL STATUS % WEIGHT FOR AGE OF EXPECTED NORMAL >90% 1 ST DEGREE PEM 75-90% 2 ND DEGREE PEM 60-75% 3 RD DEGREE PEM <60% OR ALL CHILDREN WITH EDEMA

21. IAP CLASSIFICATION NUTRITIONAL STATUS % WEIGHT FOR AGE OF EXPECTED NORMAL >80% GRADE 1 PEM 71-80% GRADE 2 PEM 61-70% GRADE 3 PEM 51-60% GRADE 4 PEM <50%

22. WHO CLASSIFICATION MODERATE MALNUTRITION SEVERE MALNUTRITION EDEMA NO YES WEIGHT/HEIGHT ( % OF EXPECTED ) 70 – 79% / <-2 to -3 SD < 70% / <- 3SD HEIGHT/AGE ( % OF EXPECTED ) 85 – 89% / <-2 to -3 SD <85% / <-3SD

23. ARNOLDS CLASSIFICATION NUTRITIONAL STATUS MUAC NORMAL >/= 13.5 CM MILD TO MODERATE PEM 12.5 – 13.4 CM SEVERE PEM <12.5 CM

24. WELLCOME TRUST / INTERNATIONAL CLASSIFICATION WEIGHT FOR AGE ( % of expected ) EDEMA CLINICAL TYPE OF PEM 60 - 80% ABSENT UNDER WEIGHT 60 - 80% PRESENT KWASHIORKOR <60% ABSENT MARASMUS <60% PRESENT MARASMIC KWASHIORKOR

25. ASSESSMENT OF NUTRITIONAL STATUS Nutritional anthropometry Clinical examination Assessment of dietary intake Laboratory tests Radiological tests

26. NUTRITIONAL ANTHROPOMETRY Age dependent criteria – weight for age , height for age. Age independent criteria – MUAC , weight for height , skin fold thickness , kanawati & Mclaren index , dugdale , Rao & singhs , jeliffs ratio , BMI.

27. NAME OF INDEX CALCULATION NORMAL VALUE VALUE IN MALNUTRITION KANAWATI & MCLAREN MUAC/HC in cm’s 0.32 - 0.33 <0.25 RAO & SINGH Wt (kg)/ Ht (cm)2 0.14 0.12-0.14 DUGHDALE Wt (kg)/ Ht (cm)1.6 0.88 – 0.97 <0.79 QUACKER ARM CIRCUMFERENCE MAC expected for given height 75 – 85%-- MALNOURISHED <75% -- SEVERELY MALNOURISHED JELIFE’S RATIO HC/CC <1 in a child > 1 year --MALNOURISHED

28. RED : < 11.5 cm ( Severe Acute Malnutrition )

29. Between tip of acromion to tip of olecranon

30. STADIOMETER

31. INFANTOMETER

32. HARPENDEN SKINFOLD CALIPER

33. Skin fold thickness measurement T riceps

34. Skin fold thickness measurement S ubscapular

35. DIGITAL WEIGHING SCALE – sensitive to 5g

36. RDA– energy and calorie intake according to age GROUP AGE ENERGY PROTEIN INFANTS 0 – 6 MONTHS 6 – 12 MONTHS 90Kcal/kg/day 80Kcal/kg/day 1.2g/kg/day 1.7g/kg/day CHILDREN 1 – 3 YEARS 4 – 6 YEARS 7 – 9 YEARS 1050Kcal/day 1350Kcal/day 1700Kcal/day 17g/day 20g/day 30g/day BOYS 10 – 12 YEARS 2200Kcal/day 40g/day GIRLS 10 – 12 YEARS 2000Kcal/day 40g/day

37. RDA for vitamins and minerals

38. MANAGEMENT OF MALNUTRITION MILD , MODERATE CAN BE MANAGED AT HOME UNCOMPLICATED SAM CAN BE PROCEEDED WITH SUPERVISED HOME MANAGEMENT COMPLICATED SAM NEEDS INPATIENT MANAGEMENT IN FACILITY

39. CRITERIA FOR HOSPITAL ADMISSION-- if any of the following present Visible severe wasting , Bipedal edema , Wt/Ht < -3SD , Medical conditions like sepsis , diarrhoea, pneumonia. Inability of oral intake(failed appetite test).

40. INVESTIGATION CBC WITH PS WITH RETIC COUNT WITH DIFFERENTIAL COUNT SE , LFT WITH SERUM PROTEINS , RFT RBS MONITORING URINE ROUTINE MICROSCOPY URINE CULTURE AND SENSITIVITY TESTING BLOOD CULTURE AND SENSITIVITY TESTING SERUM CALCIUM AND MAGNESIUN CHEST XRAY XRAY WRIST CRP , TSH level PREALBUMIN LEVEL Stool for ova and cyst Serum amylase , lipase , complete bone profile Mtx .

41. MILD TO MODERATE MALNUTRITION To prevent complications Min 150 kcal/kg/day CALORIE Min 3g/kg/day PROTEIN RUTF usage 7 times feeding frequent intervals energy dense foods Increase density of energy by adding ghee , oil Vitamins and mineral supplements Timely vaccination Hygiene Tender loving care Weight monitoring as it is the best measure of treatment efficacy in mild to moderate malnutrition.

42. SAM TREATMENT SAM --- DIAGNOSIS ---COMPLICATIONS Absent Present uncomplicated SAM complicated SAM

43. Complications Lack of appetite , poor feeding Severe edema Severe anemia , Pneumonia, diarrhoea, dehydration, TB, HIV Heart disease, Convulsions, lethargy / stupor Vomiting, difficulty in feeding, Gram neg septicemia , Electrolyte abnormalities, death. Cause of death – hypoglycemia , hypothermia , dehydration , infection , severe anemia

44. APPETITE TEST Let mother comfortably in a room with her baby comfortably seated in her lap Hand over to the mother RUTF Ask her to feed the baby as much as she can over a period of 2 hours Even if baby vomits initially mother is advised to feed after 10 to 15 minutes After 2 hours calculate the amount took by the baby If the amount took is 5 times the babies weight then the baby can be discharged for supervised home management . Ex- 3kg baby must eat a minimum amount of 15 grams RUTF in over 2 hours to pass the test If the amount is lesser baby is declared failed appetite test and needs inpatient management on hospital

45. UNCOMPLICATED SAM Nutritional rehabilitation with high energy food Min 175kcal/kg/day (7 times a day) + BF + TLC + cooperative play & activity Amoxicillin oral for 5 days Albendazole stat dose ( 1-2 yrs 200 mg), (>2yrs – 400 mg ) Mega dose vit A ( 1lakh IU ) in presence of clinical deficiency ( xerophthalmia, bitot’s spots , keratomalacia ) Age appropriate vaccination Weekly monitor ( Wt , Ht , MUAC, edema , anemia )

46. RUTF – in addition to above , also contains mineral mix , vitamin mix , emulsifier , antioxidant. 3-4 months duration for total Rehabilitation. RUTF FOOD VALUE PER 100 g ENERGY 543Kcal PROTEIN 15g LIPIDS 35g CARBOHYDRATES 43g

47. COMPLICATED SAM MANAGEMENT Once diagnosed treatment is in 10 steps in 2 phases STABILIZATION phase -- 2-7 days REHABILITATION phase -- several weeks to months

48. DETAILED HISTORY Dietary , infective , social , economical , environmental , infective history , HIV , TBcontact , diet before the current illness , hot or cold intolerance , thyroid meds. SIGNS fever , hypothermia , dehydration , shock , vitamin A deficiency , thyroid , HIV infection , mouth ulcers , skin changes , hair changes. ANTHROPOMETRY – note Ht , Wt , HC , CC, MUAC, BMI. Check RBS stat on admission , along with temp and other vitals.

49. STEPS IN MANAGEMENT HYPOGLYCEMIA --- F75 feeds 2hrly HYPOTHERMIA DEHYDRATION --- ResoMAL ELECTROLYTE ABNORMALITIES INFECTION MICRONUTRIENT INITIATE FEEDING CATCHUP GROWTH SENSORY STIMULATION PREPARE FOR FOLLOWUP WF FAILURE AND REFEEDING SYNDROME

50. HYPOGLYCEMIA On admission RBS If no hypoglycemia initiate F75 (75kcal/100ml ) 2 hrly feeds including nights . Asymptomatic hypoglycemia ( RBS <54mg/dl) – 50ml 10% glucose or sucrose solution PO fb feeding Symptomatic hypoglycemia – lethargy , hypotonia , seizure , hypothermia peripheral circulatory failure 5ml/kg 10% D IV fb 50ml 10%D PO then check RBS ½ hrly till normal and stable RBS once RBS is stable then RBS 2hrly

51. HYPOTHERMIA - axillary temp <35 degrees C MILD & MOD HYPOTHERMIA – rewarm slowly using overhead warmer , heat convertor , skin contact monitor for hypoglycemia , 2hrly temp monitor till temp >37.5 degrees C SEVERE HYPOTHERMIA -- warm humidified O2 , 5ml/kg 10D IV , warm feeds or warm IVF’s 2hrly monitor until >37.5 degrees C PREVENTION --------------------warm clothes , warm blanket , head covered , socks , mitten ,cover head , body , soles KMC , 2hrly feeding , keeping dry , child’s bed away from windows and doors

52. DEHYDRATION without SHOCK Dry oral mucosa , thirst , hypothermia , weak pulses , oliguria , low blood volume. Low osmolarity ORS ( + ) 2L water ( + ) 50g sugar(4 table spn’s ) ( + ) 45ml kcl (10% sugarless syrup ) Rx – 5ml/kg 30 minutely for 2hours fb 10ml/kg/hr alternate hours for 10 hours for deficit therapy. Rx – ORS (50 ml -- <2years , 100 ml -- >2years ) per loose stool Breastfeeding along with therapy Refeeding started 3 hours after starting rehydration – alternately given F75 feeds @2,4,6 hours while ResoMAL @ 1,3,5 hours

53. Monitor PR , RR , O mucosa , Urine frequency , vomiting , volume and frequency of stools , return of tears. Once hydrated well then shift to ongoing losses + F75 diets.

54. Signs of lethargy unconsciousness ,cold hands , weak thready pulse , CRT>3sec Signs of severe dehydration / impending shock Improving – give another 15ml/kg ivf over 1 hr then 10ml/kg/hr ORS NG tube for 10 hours fb feeding with starter formula F75 Fails to improve or deteriorating – assume septic shock i ) give IV maintainance 4ml/kg/hr ii) review antibiotic therapy iii) start DOPAMINE infusion iv) initiate refeeding As soon as possible Give IV 10D @ 5ml/kg slow bolus fb IV 15ml/kg ½ NS +5D over 1 hour

55. ELECTROLYTE IMBALANCE Low sodium diet to prevent water retention Potassium and Mg supplementation If K+ <2mEq/L or <3.5mEq/L with ECG changes ( ST depression , T inversion , U waves) then give K+ @ 0.3-0.5 mEq /kg/hr infusion with ECG monitoring until ECG improves or k + level > 2mEq/L. then oral supplementation of 3-4 mEq /kg/day for atleast 2 weeks.

56. Mg – 50% MgSo4 – 0.3ml/kg max 2ml IM --- on day 1. Day 2 onward Mg – 0.8-1.2 mEq /kg/day PO mixed with feeds for 13 days. Do not treat edema with diuretics.

57. INFECTION Hypoglycemia , hypothermia and infection coexist as a triad. Investigate Hb , TLC , DLC , PS exam for abn cells and malaria parasite , urinalysis , urine culture blood culture , s proteins chest x ray , Mantoux , GA for AFB and CBNAAT if suspicion CSF examination if meningitis is suspected screen for HIV , Thyroid disease if suspicion TIER 2 investigations – metabolic screening , genetic testing , MRI brain , IGF-1 level estimation , serum IgA/IgG antigliadin antibodies , xrays for bone age estimation , sweat chloride test.

58. NO OBVIOUS INFECTION OR COMPLICATION PO cotrimoxazole or amoxicillin for 5 days INFECTED CHILD OR WITH COMPLICATIONS IV AMPICILLIN 200mg/kg/day + IV GENTAMYCIN 7mg/kg/day revise therapy based on culture reports Add IV CLOXACILLIN 100mg/kg/day if staphylococcus is suspected SEPTIC SHOCK OR WORSENING SYMPTOMS ADD IV CEFOTAXIM 150mg/kg/day or IV CEFTRIAXONE 100mg/kg/day + IV GENTAMICIN 7.5mg/kg/day MENINGITIS IN INITIAL 48 HOURS IV CEFOTAXIM 200mg/kg/day + IV AMIKACIN 15mg/kg/day DYSENTRY CIPROFLOX 30mg/kg/day BD 3days or CEFTRIAXONE 50mg/kg/day for 5 days

59. DURATION OF ANTIBIOTIC THERAPY IN SAM Clinical sepsis –-------------- 7 days minimum UTI –-------------------------- 7-10 days Culture positive Sepsis –- 10–14 days Meningitis –---------------- 14-21days Deep seated infections ( arthritis , osteomyelitis ) – 4weeks minimum Ventriculitis –---------------- 6-8 weeks minimum PREVENTION Standard hand hygiene Give Measles vaccination if > 6 months

60. MICRONUTRIENT DEFICIENCIES Vit A – No signs of xerophthalmia – 50kIU(<6m) 1L IU(6m-1yr , >1yr wt <8kg) 2lakh IU (>1yr wt>8kg) stat fb 6mnthly doses. signs of xerophthalmia -- The above dose @ 0,1,15 th day 3 doses followed by 6monthly doses. Vit K – single dose 2.5mg IM. Daily Multivitamin supplementation (ACED,B6B12) twice the RDA. FA – 5mg on day 1 fb 1mg/day. Zinc – 2mg/kg/day. Cu – 0.2-0.3mg/kg/day. Fe – 3mg/kg/day only after gaining weight after stabilization phase after 2-3wks Emergency treatment of severe anemia Hb<4/ Hb<6 with respiratory distress needs blood transfusion 10ml/kg whole blood over 3 Hrs.

61. REFEEDING Start refeeding as soon as possible with frequent small feeds Feed should be low osmolarity (<350mOsm) , low lactose ( </= 3g/kg/day ) through NG tube or if intake is < 80% of target intake . Total fluid is 130ml/kg/day ( 100 if presence of generalized edema ) Start with F75 ( 75kcal/100ml + 0.9 g protein/100ml) Start with 80kcal /kg/day gradually increase to 100kcal/kg/day Start with 11ml/kg/feed 2hrly on day1 Increase volume slightly and change to 3hrly on day 2 If no vomiting and intolerance change to 4 hrly on day 3 If diarrhoea continues start on low lactose or lactose free F75 feeds.

62. ACHIEVE CATCHUP GROWTH Gradually change from F75 to F100 in over 2-3 days after attaining appetite. F100 ( 100 kcal+ 3 g protein /100ml) if gaining minimum 5g/kg/day over 3 days. Increase volume per each feed until daily intake is 200ml/kg/day of F100 and decrease frequency gradually upto 6 feeds per day , BF adlibitum .

63. Increase energy upto 200Kcal/kg/day and protein upto 4-6g/kg/day. 200ml/kg/day achieved and gaining weight then shift to RUTF 2-3 HRLY along with breast feeding and water. Home foods added once stable oral acceptance of adequate RUTF. Low lactose diet or lactose free diet can be given in cases of diarrhoea.

64. GOOD WEIGHT GAIN -- 10 g/kg/day MODERATE WEIGHT GAIN -- 5-10 g/kg/day POOR WEIGHT GAIN -- < 5 g/kg/day SCREEN FOR SYSTEMIC INFECTION R/o inadequate feeding , untreated infection , psychological problems , coexisting TB/HIV.

65. F75 IN RESOURCE LIMITED CONDITIONS Milk based in infants , cereal based in lactose intolerant infants and older children Milk based INGREDIENT AMOUNT COW MILK or TONED MILK ( undiluted boiled and cooled ) 300 ml SUGAR ( grinded and powdered ) 100 grams VEGETABLE OIL OR GHEEOIL( any edible oil – coconut , MCT oil , vegetable oil except mustard oil 20 grams LUKE WARM WATER ( boiled and cooled to lukewarm) For filling at the end till the total mixture is 1000 ml FINAL 1000 ml F75

66. CEREAL BASED F75 INGREDIENT AMOUNT MILK ( boiled and cooled ) COW or TONED 300 ml SUGAR ( powdered ) 70 grams PUFFED RICE /MURMURE ( POWDERED ) 35 grams VEG OIL OR GHEE 20 grams LUKEWARM WATER ( boiled and cooled to lukewarm) For filling at the end till total mixtue is 1000 ml FINAL 1000 ML F75

67. F100 IN RESOURCE LIMITED SETTINGS Milk based F100 INGREDIENT AMOUNT MILK (boiled and cooled ) COW or TONED 880 ml SUGAR (powdered ) 75 grams VEGETABLE OIL or ghee (except mustard oil ) 20 ml LUKEWARM WATER ( boiled and cooled to lukewarm) For filling at the end till total mixture is 1000 ml FINAL 1000 ml of F100

68. Ready to use therapeutic food Weight Amount to be consumed in 2-3 hrly 3 – 4.9 KG 105 – 130 g 5 – 6.9 KG 200 – 260 g 7 – 9.9 KG 260 – 400 g 10 – 14.9 KG 400 – 460 g

69. SENSORY STIMULATION AND EMOTIONAL SUPPORT Cheerful environment Tender love and care Structured play therapy 30 min per day Physical activity

70. STRUCTURED PLAY THERAPY

71. FOLLOWUP PREPARATION Discharge criteria for SAM – Complications settled ( wt gain 15% , > 5g/kg/day for 3 consecutive days ) Edema is resolving , Good appetite with adequate RUTF , mother confident & can prepare at home. Clinically well and alert , upto date immunized. Followup until weight for height is -1SD to median in WHO chart after 1week , fortnightly 1 st month , then monthly thereafter. Antihelminthic dose before discharge ALBENDAZOLE 200/400 -- 1-2/>2 yrs.

72. DISCHARGE INSTRUCTIONS Nutritional advice + supplementary micronutrients and vitamins and iron and medications. Supplementary feeds. Danger signs explained to mother Failure criteria to be explained If failure identified – look for failure causes feeding problems , corrected feeds correct amount offered, leftover feeds recorded, child encouraged to eat.

73. POST DISCHARGE CARE AT HOME Child is considered treatment complete if no edema for 2wks + wt / ht reaches -1SD or MUAC >/= 12.5 cm according to WHO charts Frequent high energy dense diets. Regular followup visits. Booster vaccinations. Vit A 6 monthly.

74. FAILURE TO RESPOND Primary failure to respond – after feeding freely on catchup diet failure to gain appetite by D4 failure to start loosing edema by D4 failure to gain atleast 5g/kg/day by D10 presence of edema on D10 Secondary failure if failure to gain 5g/kg/day for 3 consecutive days in rehabilitation phase.

75. Look for causes of failure Insufficient food intake Amount, frequency, technique, leftovers, night feeds to be checked. Unrecognized infections should be checked Vitamins and minerals deficiency should be corrected.

76. COMPLICATIONS DURING REHABILITATION NUTRITIONAL RECOVERY SYNDROME – When treated with high proteins , Abdominal distension(HSM , ascites ) , Prominent veins, Hypertrichosis , parotid swelling, gynaecomastia Eosinophilia , hyper Ig , Increasing estrogen. KWASHI SHAKE / ENCEPHALITIS STATES. PSEUDOTUMOR CERIBRI – vitamin A high doses

77. REFEEDING SYNDROME when feeding started in severely malnourished child whose body is in severe catabolic state , sudden glucose will cause insulin release leading to ( hypophosphatemia , hypokalemia , hypomagnesemia ) – increased glucose uptake. Fluid overload due to Na and water retention in kidneys.

78. Features of – Dilutional hyponatremia , cardiac failure, weakness paresthesias , cramps, muscle weakness. Abdominal distension ( Ascites,Hepatomegaly,fatty liver ) Late >2wks – Parotid swelling, gynaecomastia , Eosinophilia , splenomegaly .

79. Rx–following the WHO prescribed stabilization fb rehab phase with appropriate treatment according to guidelines can prevent refeeding syndrome. ½ calorie of previous diet protein – 1.5g/kg/day rich in essential aminoacids supplement multivitamins limit Na and fluid intake gradually increase Calorie requirement every 3 days final target 150Kcal/kg/Day start low and go slow

80. Monitoring s- Po4, k+ , RBS , Alb , daily Wt , I/O charting , mental status , BP. Goal of weight gain – not > 1kg/week , daily electrolytes , ECG.

81. PREVENTION OF UNDERNUTRITION IN CHILDREN MOTHER Care of adolescent girl Childbirth after 20 years Minimum 3 yrs spacing btw pregnancies No more than 2 children Routine antenatal checkups as per national programmes IFA supplementation , hygiene in home , bathroom , safe food practices. SOCIETY Safe water and sanitation Maternity and child care BF at workplace Cash support to pregnant and lactating women.

82. CHILD Initiating BF asap Exclusive BF for 1 st 6 months Special care and support for LBW babies Complementary feeds at 6 months Vaccination especially measles ,BCG, rotavirus, H influenza and pneumococcal. Prompt treatment of diarrhoea , pneumonia & other illnesses , growth monitoring and periodic checkups.

83. References Ghai textbook of pediatrics Nelson textbook of pediatrics Elizabeth nutrition IAP STANDARD TREATMENT GUIDELINES 2021 WHO charts Pediatric nutritional care manual

84. THANK YOU