Nutrition and PEM Dr Malak PDF

Lecture 4 Department of Pediatrics Prof Malak Shaheen Objectives of the Lecture Identify nutritional needs for children Recognize the practice of breast feeding. Define the indications and types of formula feeding. Recognize the weaning process. Describe different types of malnutritio...

Lecture 4 Department of Pediatrics Prof Malak Shaheen Objectives of the Lecture Identify nutritional needs for children Recognize the practice of breast feeding. Define the indications and types of formula feeding. Recognize the weaning process. Describe different types of malnutrition in the pediatric age group. The First 1000 Days continuum -9 to 24 months 270 + 365 + 365 = 1000 1000 Days Early postnatal / Antenatal Early Childhood Infancy -9 -6 -3 0 3 6 9 12 15 18 21 24 Conception Birth https://nurturing-care.org/  Phase I: First 4-6 months of life (Milk Feeding) Breast feeding Phases of Formula feeding child Phase II: (Complementary feeding Feeding) Weaning Food Modified adult food Human milk is the most suitable feeding, Why? › All nutrients in the right quantities › Protective substances › Easy to digest › Always available › Right temperature (body temp) › Hygienic and cost-less › Bonding between mother & child  Decreases infant mortality Decreases risk of Sudden Infant Death Syndrome (SIDS) Decreases necrotizing enterocolitis Decreases ER and urgent physician visits Decreases recurrent ear infections Decreases diarrheal illnesses Decreases inflammatory bowel disease Decreases Type 1 and 2 diabetes Decreases leukemia and lymphoma  “Breast feeding is the mother’s Gift to Herself, her Baby and the Earth” MILK OF THE BREAST IS TRULY THE BEST Normal range in milk volume Volume increases rapidly in the first 2-3 days after birth, and then more slowly to an average of about 750-800 ml/day Range of normal milk intake of exclusively breastfed infants is wide: 550-1200 ml/day Physiological regulation of milk volume Endocrine: Infant suckling causes neural loop in hypothalamus o Anterior pituitary: Prolactin and other hormones for maintenance of lactation o Posterior pituitary: Oxytocin for milk ejection reflex Autocrine: In each breast, emptying accelerates milk synthesis Stages of human milk production 1- Colostrum: starts in the 3rd trimester till 3-5 days after delivery 2- Transitional milk: 3-5 days till 2-3 weeks 3- Mature (established) milk: within 2-3 weeks Composition of Breast milk Colostrum: It is yellowish and sticky Colostrum differs from mature milk because it contains: More protein. Less fat and lactose. More sodium and Zinc. Higher level of Vit A. Much more IgA, lactoferrin and WBCs to protect the baby against dangerous neonatal infection. More intestinal growth factors. Is the infant getting enough breast milk? At least 6-8 wet diapers every day. At least 4 or more bowel movements daily. Audible swallowing while BF. The infant is satisfied after each nursing period or sleeps 2-4 hrs. By two weeks, is back up to birth weight then proper weight gain. Common Breastfeeding Problems Bottle Feeding  Attention !! Whether the baby’s condition allows normal suckling or he gets the expressed breast milk, we should encourage on demand breast feeding for a total of 24 months, the first 6 of which are preferably exclusive. Alternatives to mother’s breast milk are wet nurses and breast milk banks. The types of formula feeding A) Complementary feeding: to complete breast feed with a milk formula B) Supplementary feeding: to add some complete formula feeds C) Substitutive feeding: formula feeds only Milk formula can be the replacement nutrition in infants who don’t breast feed for any reason. Bases of formula Cow milk-based Soy-based Goat milk-based ‘* & Preparation of milk + If cow or buffalo milk,boil properly' boiling makes caesin curds finer’ and easily digestible + Commercially available dried powered milks are reconstitued by mixing — one level mcasurc of milk powder 30 ml of water Forms of formula: Ready to use formula Liquid concentrate formula Powdered formula: dilution 1 leveled measure/30 ml water  Medicinal formula Type Indication Example Soy-based Lactose intolerance Isomil Anti-reflux GE reflux Bebelac AR Lactose-free Lactose intolerance Bebelac LF Galactosemia Premature and LBW LBW and premature Bebelac premature infants Phenyl alanine-free phenylketonuria Lofenalac Amino acid-based Cow milk allergy Neocate Risk factors related to Bottle feeding  Lactose intolerance Family disruption Atherosclerosis pregnancy Poor parent Poor learning child abilities relationship Definition of weaning The first introduction of solid foods is the true beginning of weaning It does not mean total cessation of breast feeding but gradual withdrawal of milk with gradual introduction of a wide range of ‘non milk’ foods so that by age of one year, the baby will be joining in family meals with some precautions.  Why is weaning essential? Why should weaning be started at age of 6 months? Is the child ready for solids? Baby can sit up well without support. Baby has lost the tongue thrust reflex and does not automatically push solids out of his mouth. Baby is ready and willing to chew. Baby is developing a "pincer" grasp, where he picks up food or other objects between thumb and forefinger. Baby is eager to participate in mealtime and may try to grab food and put it in his mouth. https://www.youtube.com/watch?v=LAfn4s8Jcps&ab_channel=EmmaHubbard Test yourself The best source of Iron for a 2-months infant of a normal mother is: a) Cows milk. b) Breast milk. b) Medicinal iron. c) Milk adapted formula. d) None of the above. The best source of Iron for a 2-months infant of a normal mother is: a) Cows milk. b) Breast milk. b) Medicinal iron. c) Milk adapted formula. d) None of the above. All are indications of adequate breast milk supply except: a) The infant appears satisfied and contented after feeding. b) The infant sleeps about 2 hours after feeding. c) Adequate gain in weight. d) A negative let-down reflex. e) Normal stools in number and consistency. All are indications of adequate breast milk supply except: a) The infant appears satisfied and contented after feeding. b) The infant sleeps about 2 hours after feeding. c) Adequate gain in weight. d) A negative let-down reflex. e) Normal stools in number and consistency. The main protein in breast milk is : a) Casein. b) Thyroglobulin. c) Lactoferrin. d) Lactalbumin. e) Gamma globulin. The main protein in breast milk is : a) Casein. b) Thyroglobulin. c) Lactoferrin. d) Lactalbumin. e) Gamma globulin. Pediatric Nutritional Disorders Department of Pediatrics LOs – by the end of this lecture the student should be able to: Identify different types of malnutrition in the pediatric age group. Recognize its causes and appropriate management. Define vitamin deficiency diseases.  INTRODUCTION According to World Health Organization, protein energy malnutrition (PEM) refers to “an imbalance between the supply of protein and energy and the body's demand for them to ensure optimal growth and function.” The WHO defines malnutrition as "the cellular imbalance between supply of nutrients & energy and the body's demand for them to ensure growth, maintenance, and specific functions” It includes: Overnutrition Consumption of too many calories or too much of any specific nutrient such as protein, fat, vitamin, mineral, or other dietary supplement. Undernutrition Usually thought of as a deficiency primarily of calories (overall food consumption) or of protein. Deficiencies of vitamins and minerals are usually considered separate disorders. There are two basic types of undernutrition: Protein energy undernutrition (PEU): It is basically a lack of calories and protein. Micronutrient (vitamin and mineral) deficiency. Mortality Undernutrition contributes to 35% of the deaths under 5 years including: Fetal growth restriction Stunting Wasting Deficiencies of vitamin A and zinc Suboptimum breastfeeding Etiology Primary: Poverty and ignorance are the underlying causes, but the interaction of nutrition and infections plays the most important role. It is a result of sudden faulty weaning with deficiency of proteins. Secondary: Results from other diseases Acute severe gastroenteritis. Post enterocolitis. Whooping cough. Measles. Parasitic infestations e.g. giardiasis.  ETIOLOGY Poverty Low birth weight Infections: Infections such as diarrhea, pneumonia, malaria, measles, whooping cough and tuberculosis precipitate acute malnutrition and aggravate the existing nutritional deficit. Lack of exclusive breastfeeding for first 6 months makes the child prone to early onset malnutrition. prevailing dietary practices and cultural taboos on consumption.  Repeated pregnancies, inadequate child spacing, food taboos, broken homes and separation of a child front his parents are the important social factors that may play a part in etiology of PEM. Such as fioods, earthquakes and droughts. Classification of PEU: Wellcome classification: based on the deficit of body weight and edema. The name Kwashiorkor is derived from the Ga language of coastal Ghana, translated as "the sickness the baby gets when the new baby comes" or "the disease of the deposed child". Teeth mottled enamel Gums Spongy. bleeding gums Glands Thyroid and parotid cnlargcment Skin Xerosis ,folliculat liyperkeraiosis petechiae, pellagtous derrnatosis ,flaky paint dermatosis Koilonychia Nails Subcutaneous tissue Edema amouni of subcuianeous far reduced Mascular system & Skeletal system Muscle casting.craniotabes,Frontaï and parietal bossing, Epiphyseal e0latgemewt (tcndcr / non tender) Clinical picture of Kwashiorkor It is an acute disease within 1 or 2 wks. When well advanced features are divided into 2 groups: Constant features: Growth retardation. Edema. Muscle wasting + some retention of SC fat. Mental changes. Variable features: Ectodermal changes. GI manifestations. Anemia. Vitamins & mineral deficiencies. Associated infections Edema Pitting soft painless bilateral edema is the main clinical feature of KWO on which the diagnosis is based. It starts in the dorsum of the hands and feet, spreading to affect the legs to the mid-thighs, in late cases the eye lids are affected. Nearly almost always there is no ascites. Causes: A- hypoalbuminemia less than 2.5gm%. B- Na retention with hyperaldosteronism C- Increased release of ADH D- Increase capillary permeability E- Thiamine deficiency. Muscle wasting & decreased Ms/Fat ratio: The muscles are wasted and flabby. This is demonstrated by palpating the biceps and the triceps and by measuring the left middle arm circumference. Subcutaneous fat is preserved or increased because of the relative CHO excess leading to carbohydrate facies (moon face baby). Mental changes: Children with KWO manifest a striking behavioral symptom: Apathy, inactivity, misery, anorexia and lack of interest in the surrounding. The look of the child’s eyes has been described as the “radar gaze”. These changes are due to: Maternal deprivation or Deficiency of aromatic amino acids, nicotinic acid, thyroxin, trace elements or serotonin. Variable features: 1. Ectodermal changes A- Hair changes: Color: progressive lightening. flag sign. Character: dry, coarse, lusterless, brittle and easily detached. Distribution: sparse. Causes: decrease of melanin, deficiency of vitamin A, nicotinic acid or EFA. B- Skin changes: -Skin changes are called “flaky paint” dermatosis. -Fissuring, crackling and ulceration may occur leading to 2ry infection. -Causes: deficiency of EFA, EAA, nicotinic acid or zinc and vitamin A. 2. Gastro-intestinal manifestations: Hepatomegaly. Anorexia and vomiting. Diarrhea. Abdominal distension. 3. Anemia: Iron and copper deficiency. Vitamin B12 and folate deficiency. Protein deficiency Repeated infections. 4. Associated vitamin and mineral deficiencies: Vitamin A keratomalacia Vitamin B2  Angular stomatitis, glossitis. Vitamin D  Atrophic rickets. Vitamin C  Scurvy. Nicotinic acid  Pellagra. Copper  Anemia, hair and mental changes. Zinc  Hair, mental and skin changes. 5. Associated infections: The common sites of infections are: *Respiratory tract (Pneumonia). *GIT (gastroenteritis). *Skin and mouth (monilia). *Urinary tract.  Marasmus is characterizedby gross wasting of muscles and subcutaneous tissue resulting in emaciation, marked stunting and no edema. Clinical picture of marasmus Onset is gradual with age between 6ms – 3yrs 1. Growth retardation: Body weight is less than 60% according to Wellcome classification. 2. Loss of subcutaneous fat: Marasmus is classified into 3 degrees according to loss of S. C. fat: 1st degree (abdomen)/ 2nd degree (limbs)/ 3rd degree (face) 3. Decreased muscle bulk: evident by decreased mid-arm circumference. 4. Muscle wasting  Stick like limbs. 4. Skin manifestation: Loss of skin elasticity, skin is thrown into multiple folds especially in the groin. 5. Abdomen: Scaphoid abdomen: due to thin abdominal muscles. Visible peristalsis: due to thin abdominal muscles. 6. Irritability: due to hunger pain. 7. Hypothermia. 8. GI manifestations. a. Constipation: Due to decreased food intake. b. Starvation stools: Which are small in amount, greenish in color and loose in consistency. It is formed of mucus & cellular debris. c. Diarrhea. 9. CVS: Weak and slow pulse (unless with dehydration where the pulse is weak and rapid). 10. Respiratory system: Shallow respiration due to weak respiratory muscles and Repeated chest infections. 11. Other vitamin and mineral deficiency 12. Infections Complications of PEU Dehydration, acid-base disturbance, and shock Hypothermia: Uncommon in KWO compared to marasmus Bleeding tendencies and purpura. Heart failure Renal failure Metabolic complications: o Hypoglycemia o Hypocalcemia. o Hyponatremia o Hypokalemia. o Hypomagnesemia. Investigations of PEU 1.Plasma proteins: Decreased total serum proteins. Decrease serum albumin 3. 3. Urea nitrogen/creatinine nitrogen