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NUTRITIONAL DISORDERS. Dr.Khalid Hama salih, Pediatrics specialist M.B.Ch.; D. C.H F.I.B.M.S.ped. NUTRITIONAL DISORDERS. MALNUTRITION) ). MALNUTRITION. - PowerPoint PPT Presentation
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NUTRITIONAL DISORDERSNUTRITIONAL DISORDERS
Dr.Khalid Hama salih,
Pediatrics specialist M.B.Ch.; D. C.H
F.I.B.M.S.ped
NUTRITIONAL NUTRITIONAL DISORDERSDISORDERS
MALNUTRITIONMALNUTRITION))))
MALNUTRITIONMALNUTRITIONA pathological state due to a relative A pathological state due to a relative or absolute deficiency or excess of or absolute deficiency or excess of one or more essential nutrients; one or more essential nutrients; clinically manifested or detected clinically manifested or detected only by biochemical, anthropometric only by biochemical, anthropometric or physiological testsor physiological tests..
ClassificationClassification::11..UndernutritionUndernutrition:: Marasmus Marasmus
22..OvernutritionOvernutrition:: Obesity,Hypervitaminoses Obesity,Hypervitaminoses33..Specific DeficiencySpecific Deficiency::
Kwashiorkor,HypovitaminosesKwashiorkor,Hypovitaminoses , , 44..Mineral DeficienciesMineral Deficiencies
55..ImbalanceImbalance:: Electrolyte Imbalance Electrolyte Imbalance
AetiologyAetiology::A.child related:A.child related: Low birth wt.Low birth wt. Absence or early cessation of breast feedingAbsence or early cessation of breast feeding Delay weaningDelay weaning Incorrect dietary habitIncorrect dietary habit Recurrent infection:diarrhea,measlesRecurrent infection:diarrhea,measlesB.Maternal factor:B.Maternal factor:Maternal malnutritionMaternal malnutritionIgnorance about feedingIgnorance about feedingseparationseparation
C. socio-economical factor:C. socio-economical factor: Povertyand unemploymentPovertyand unemployment Large family sizeLarge family size Unhygienic living conditionUnhygienic living condition Disadvataged children Disadvataged children D. cultural factor:wrong believfsD. cultural factor:wrong believfsE. community factor:E. community factor: Natural/man made disasterNatural/man made disaster Generalized economic depressionGeneralized economic depression Inadequateprimary health careInadequateprimary health care
ETIOLOGYETIOLOGY
Classification of UndernutritionClassification of Undernutrition1.1. Gomez Classification:Gomez Classification: uses uses
weight-for-age measurements; weight-for-age measurements; provide grading as to prognosisprovide grading as to prognosisWeight-for-Age%Weight-for-Age% StatusStatus
91-10091-100 NormalNormal76-9076-90 11stst degree degree61-7561-75 22ndnd degree degree<60<60 33rdrd degree degree
2.2. Wellcome Classification:Wellcome Classification: simple since simple since based on 2 criteria only - wt loss in based on 2 criteria only - wt loss in terms of wt for age% & presence or terms of wt for age% & presence or absence of edemaabsence of edema
Wt-for-Age%Wt-for-Age% EdemaEdema No EdemaNo Edema80-6080-60 KwashiorkorKwashiorkor UndernutritionUndernutrition< 60< 60 Marasmic-Marasmic- MarasmusMarasmusKwashiorkorKwashiorkor
Protein Energy Malnutrition Protein Energy Malnutrition IcebergIceberg
MarasmusMarasmus Common in the 1st Common in the 1st
year of lifeyear of lifeEtiology:Etiology: ““Balanced starvation”Balanced starvation” Insufficient breast Insufficient breast
milkmilk Dilute milk mixture or Dilute milk mixture or
lack of hygienelack of hygiene deficiency of ALL nutrientdeficiency of ALL nutrient
MarasmusMarasmusClinical Manifestations:Clinical Manifestations:1.1. WastingWasting2.2. Muscle wastingMuscle wasting3.3. Growth retardationGrowth retardation4.4. Mental changesMental changes5.5. No edemaNo edema6.6. Variable-subnormal Variable-subnormal
temp, slow PR, good temp, slow PR, good appetite, often appetite, often w/diarrhea, etc.w/diarrhea, etc.
Laboratory Data:Laboratory Data:1.1. Serum albumin NSerum albumin N2.2. Urinary urea/ Urinary urea/
creatinine Ncreatinine N
3.3. Urinary hydroxyproline/ Urinary hydroxyproline/ creatinine low creatinine low
4.4. Serum essential a.a. Serum essential a.a. index Nindex N
5.5. Anemia uncommonAnemia uncommon6.6. hypoglycemiahypoglycemia7.7. KK+ + deficiency presentdeficiency present8.8. Serum cholesterol lowSerum cholesterol low9.9. Diminished enzyme Diminished enzyme
activityactivity10.10. Bone growth delayedBone growth delayed11.11. Liver biopsy N or Liver biopsy N or
atrophicatrophic
Clinical classification of Clinical classification of marasmusmarasmus
Grade 1Grade 1
Grade 2Grade 2
Grade 3Grade 3
Grade 4Grade 4
Loss of axiillary fatLoss of axiillary fat
Loss of fat from gluteal Loss of fat from gluteal regionregion
Loss from chest & backLoss from chest & back
Loss of Loss of buccal&temporal buccal&temporal
KwashiorkorKwashiorkor Between 1-3 yrs oldBetween 1-3 yrs oldEtiology:Etiology: Very low protein but Very low protein but
calories from CHOcalories from CHO In places where In places where
starchy foods are starchy foods are main staplemain staple
Never exclusively Never exclusively dietarydietary
KwashiorkorKwashiorkorClinical Manifestations:Clinical Manifestations:A.A. Diagnostic SignsDiagnostic Signs
1.1. EdemaEdema2.2. Muscle wastingMuscle wasting3.3. Psychomotor changesPsychomotor changes
B.B. Common SignsCommon Signs1.1. Hair changesHair changes2.2. Diffuse Diffuse
depigmentation of skindepigmentation of skin3.3. MoonfaceMoonface4.4. AnemiaAnemia
C.C. Occasional Signs:Occasional Signs:1.1. Flaky-paint rashFlaky-paint rash2.2. NomaNoma3.3. HepatomegalyHepatomegaly4.4. AssociatedAssociated
Laboratory:Laboratory:1.1. Decreased serum Decreased serum
albuminalbumin2.2. EEG abnomalitiesEEG abnomalities3.3. Iron & folic acid Iron & folic acid
deficienciesdeficiencies4.4. Liver biopsy fatty or Liver biopsy fatty or
fibrosis may occurfibrosis may occur
LaboratoryLaboratoryThe following data will be less than normal : The following data will be less than normal : Hb , serum albumin , blood sugar , plasma A.A. , Hb , serum albumin , blood sugar , plasma A.A. ,
vitamins , minerals , electrolytes , alkaline vitamins , minerals , electrolytes , alkaline phosphatase , pancreatic enzymes , thyroxin , phosphatase , pancreatic enzymes , thyroxin , cholesterol and G.F.R.cholesterol and G.F.R.
While the following data will be more than normal While the following data will be more than normal levels :levels :
Ketonuria , aminoaciduria , G.H., epinephrine and Ketonuria , aminoaciduria , G.H., epinephrine and steroid .steroid .
Marasmic kwashiorkorMarasmic kwashiorkor
State intermediate phase between marasmus State intermediate phase between marasmus &kwashiorkor when a previously marasmic child &kwashiorkor when a previously marasmic child
develops edema dueto higher nutritional requirementdevelops edema dueto higher nutritional requirement
Differences between Marasmus and Kwashiorkor
KwashiorkorKwashiorkorMarasmusMarasmusageage1year1yearanyanyDeitary historyDeitary historyEarly cessation of bfEarly cessation of bfDelay weaningDelay weaningOnset Onset acuteacutegradualgradualHistory of infectionHistory of infectionfrequintfrequintuncommonuncommonBody weight Body weight 60-80% of the ideal 60-80% of the ideal
body wt.body wt.Less than 60% of Less than 60% of the ideal body wt.the ideal body wt.
Appetite Appetite PoorPoor GoodGoodHair&skine changes Hair&skine changes common common rarerareEdema Edema essential essential abscentabscentMental changeMental changeapathetic apathetic alert alert Vitamin deficiencyVitamin deficiencycommoncommonmaskedmaskedHepatomegally Hepatomegally PresentPresentAbsentAbsenthypoproteinemiahypoproteinemia++/++++++/++++++
KwashiorkorKwashiorkor
TreatmentTreatment Step1:emergency phase:during 1Step1:emergency phase:during 1stst 24-48hr 24-48hr A.hypothermia dueto less subcut A.hypothermia dueto less subcut
fat,infection,hypoglycemia:graddual warming with fat,infection,hypoglycemia:graddual warming with blanket,warmer with moniteringblanket,warmer with monitering
B.infection:emperical anti biotic indicateB.infection:emperical anti biotic indicate C.hypoglycemia:should be treated C.hypoglycemia:should be treated D. dehydrationurine out put is the most reliable D. dehydrationurine out put is the most reliable
indicatorindicatorMild –moderate:5-10ml/kg/hrwith ResomalMild –moderate:5-10ml/kg/hrwith ResomalSever with i.v fluidSever with i.v fluid
E.Dyselectrolytemia:hypok,hyponatremia,hypocE.Dyselectrolytemia:hypok,hyponatremia,hypocalcemia,hypomagalcemia,hypomag
F.Nutreintdeficiency:vit A,IN 2F.Nutreintdeficiency:vit A,IN 2NDND Weak give Weak give ironiron
g. Congestiveheart failure:duetog. Congestiveheart failure:dueto 1.impaire cardiac function.2.fluid over load1.impaire cardiac function.2.fluid over load treatment with diuretic ,supportive measuretreatment with diuretic ,supportive measure
Step 2:deitary managementStep 2:deitary management A.calculate nutritionalo requirment:begin with A.calculate nutritionalo requirment:begin with
100cal/kg& 2gm/kg protein increase by 10-20% 100cal/kg& 2gm/kg protein increase by 10-20% every alternate day untill reach 150cal/kg of every alternate day untill reach 150cal/kg of expcted wtexpcted wt
b,.select of appropriate feed ,frequency,mode of b,.select of appropriate feed ,frequency,mode of administrationadministration
Monitering: a.dietary intake b.sign of recoveryMonitering: a.dietary intake b.sign of recovery c.recovery complication:diarrhea,CHF,c.recovery complication:diarrhea,CHF,
Sign of recoverySign of recovery
11..general improvement in apperancegeneral improvement in apperance22..social smilesocial smile
33..return of apetitereturn of apetite44..Wt gain50-70gm/dayWt gain50-70gm/day
5disapperance of edema5disapperance of edema66..reduction of hepatomegalyreduction of hepatomegaly
77..increase serum albuminincrease serum albumin
Prognosis of PEMPrognosis of PEM Permanent impairment of physical & Permanent impairment of physical &
mental growth if severe & occurs early mental growth if severe & occurs early especially before 6 months oldespecially before 6 months old
First 48 hours critical, with poor First 48 hours critical, with poor treatment mortality may exceed 50%treatment mortality may exceed 50%
Even with thorough treatment, 10% Even with thorough treatment, 10% mortality may still occurmortality may still occur
Some mortality causes are endocrine, Some mortality causes are endocrine, cardiac or liver failure, electrolyte cardiac or liver failure, electrolyte imbalance, hypoglycemia & hypothermiaimbalance, hypoglycemia & hypothermia
Diseases of Nutritional ExcessesDiseases of Nutritional ExcessesFLUROSISFLUROSIS Causes due to excess of Causes due to excess of
Fluorine.. Fluorine.. Dental Flurosis :Dental Flurosis :
Teeth lose white color and Teeth lose white color and shine.shine.
Mottling of teeth.Mottling of teeth. Skeletal Flurosis :Skeletal Flurosis :
Nerves are effected.Nerves are effected.Back PainBack Pain..
OBESITYOBESITY Product of Energy Product of Energy
ImbalanceImbalance Leads to undue weight Leads to undue weight
on organs.on organs. HypertensionHypertension Heart DiseasesHeart Diseases DiabetesDiabetes
Nutritional DisordersNutritional DisordersObesity: body wt more than97th over wt orBMI 25Obesity: body wt more than97th over wt orBMI 25
Wt more than 120 % of expcted wt or BMI`` more than Wt more than 120 % of expcted wt or BMI`` more than 3030
In infant and children of normal weight , increase in In infant and children of normal weight , increase in adipocytes size account for most of increase in adipose mass adipocytes size account for most of increase in adipose mass during the first year of life . Obese children have larger fat cell during the first year of life . Obese children have larger fat cell size than normal weight controls children and may have size than normal weight controls children and may have increase in number of adipocytes .increase in number of adipocytes .
Obesity is based on the degree of excess fatObesity is based on the degree of excess fat..Normal (ideal) BMI ranges between 18.5 and 25Normal (ideal) BMI ranges between 18.5 and 25..
An average BMI of a population should be 21 or An average BMI of a population should be 21 or 2222..Less than 18.5 denotes chronic under-nutritionLess than 18.5 denotes chronic under-nutrition..Between 25-30 considered as overweightBetween 25-30 considered as overweight..Above 30 indicate obesityAbove 30 indicate obesity..
BMIBMIBody MassBody Mass
IndexIndex
Weight in Kilogram
Height in meters2==
34.1
45.5
56.8
102.3 113.6 12579.5
90.9
68.2
Lbs Kgs
WEIGHT
ObesityObesity Appears most frequently in the 1st Appears most frequently in the 1st
year, 5-6 years & adolescenceyear, 5-6 years & adolescenceEtiology:Etiology: Excessive intake of food compared Excessive intake of food compared
with utilizationwith utilization Genetic constitutionGenetic constitution Psychic disturbance Psychic disturbance Endocrine & metabolic disturbances Endocrine & metabolic disturbances
rarerare Insufficient exercise or lack of activity Insufficient exercise or lack of activity
ObesityObesityClinical ManifestationsClinical Manifestations::1.1. Fine facial features on a heavy-looking taller Fine facial features on a heavy-looking taller
childchild2.2. Larger upper arms & thighsLarger upper arms & thighs3.3. Genu valgum commonGenu valgum common4.4. Relatively small hands & fingers taperingRelatively small hands & fingers tapering5.5. Adiposity in mammary regionsAdiposity in mammary regions6.6. Pendulous abdomen w/ striaePendulous abdomen w/ striae7.7. In boys, external genitalia appear small In boys, external genitalia appear small
though actually average in sizethough actually average in size8.8. In girls, external genitalia normal & In girls, external genitalia normal &
menarche not delayedmenarche not delayed9.9. Psychologic disturbances commonPsychologic disturbances common10.10. Bone age advancedBone age advanced
..
Complications of obesity :-Complications of obesity :-A- Cardiovascular complications : like hypertension , A- Cardiovascular complications : like hypertension ,
increase in serum cholesterol level increase in serum cholesterol level B- Hyperinsulinemia .B- Hyperinsulinemia .C- Cholelithiasis .C- Cholelithiasis .D- Blount disease or slipped capital femoral epiphysis . D- Blount disease or slipped capital femoral epiphysis .
E- Abnormal pulmonary function tests .E- Abnormal pulmonary function tests .F- Pseudotumour cerebri .F- Pseudotumour cerebri .G- Sleep apnea .G- Sleep apnea .H- Psychological trauma H- Psychological trauma
Treatment of ObesityTreatment of ObesityA.A. 11stst principle: decrease energy intake principle: decrease energy intake
1.1. Initial med exam to R/O pathological causesInitial med exam to R/O pathological causes2.2. 3-day food recall to itemize child’s diet3-day food recall to itemize child’s diet3.3. Plan the right dietPlan the right diet
a.a. Avoid all sweets, fried foods & fatsAvoid all sweets, fried foods & fatsb.b. Limit milk intake to not >2 glasses/dayLimit milk intake to not >2 glasses/dayc.c. For 10-14 yrs, limit to 1,100-1300 cal diet For 10-14 yrs, limit to 1,100-1300 cal diet
for several monthsfor several months4.4. Child must be properly motivated & family Child must be properly motivated & family
involvement essentialinvolvement essentialB.B. 22ndnd principle: increase energy output principle: increase energy output
1.1. Obtain an activity historyObtain an activity history2.2. Increase physical activityIncrease physical activity3.3. Involve in hobbies to prevent boredomInvolve in hobbies to prevent boredom
ObesityObesity
Be master of your habits, Be master of your habits,
Or they will master Or they will master youyou..
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