Nutritional disorders
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NUTRITIONAL DISORDERS. MAO Meng, MD Professor of Pediatrics School of Medicine, Sichuan University. NUTRITIONAL DISORDERS. OBESITY. MALNUTRITION. PROTEIN MALNUTRITION [PCM, Protein-Calorie (Energy) Malnutrition, Kwashiorkor]. MARASMUS (Infantile Atrophy). MALNUTRITION.

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Nutritional disorders

NUTRITIONAL DISORDERS

MAO Meng, MD

Professor of Pediatrics

School of Medicine, Sichuan University


Nutritional disorders

NUTRITIONAL DISORDERS

OBESITY

MALNUTRITION

PROTEIN MALNUTRITION

[PCM, Protein-Calorie (Energy) Malnutrition, Kwashiorkor]

MARASMUS

(Infantile Atrophy)


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MALNUTRITION

Malnutrition, from a worldwide perspective, is one of the leading causes of morbidity and mortality in childhood


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improper and / or inadequate

food intake

inadequate absorption

of food

poor dietary habits

food faddism

MALNUTRITION

diseases

Deficient supply of food

metabolic abnormalities

emotional factors


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Diseases

 Diarrhea or digestive system diseases

Upper Respiratory Infection and Pneumonia

Malformations


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Mortality rate of diarrhea patients with malnutrition is fourfold of the diarrhea patients without malnutrition.


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INDICATORS

FOR EVALUATION OF MALNUTRITION

an accurate dietary history

evaluation of present deviations from average height, weight, head circumference, and past rates of growth

comparative measurements of midarm circumference and skinfold thickness

chemical and other tests


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CLINICAL INDICATORS

FOR EVALUATION OF MALNUTRITION

 weight-for-age (underweight): weight is lower than -2SD of mean value of the reference population of the same age and sex

height-for-age (stunting): height is lower than

-2SD of mean value of the reference population of the same age and sex

weight-for-height (wasting): weight is lower than -2SD of mean value of the reference population of the same height and sex


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About the Reference Population in different countries

The reference population from your own country

NCHS-CDC-WHO Reference Population (1976 and 2006) 

Reference: De Onis M, Habicht JP. Anthropometric reference data for international use: recommendations from a World Health Organization Expert Committee [J]. The American Journal of Clinical Nutrition. 1996, 64(4):650-658


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Laboratory data

Protein----- serum albumin, transferring, hemoglobin, prealbumin, or retinol-binding protein

sodium, potassium, chloride

Immunologic insufficiency


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CLINICAL MANIFESTATIONS

Failure to gain weight or loss of weight

Thin, subcutaneous fat reduced or despaired

(orderly abdomen, buttocks, limb and finally face)

Disturbulence of functions of organs


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MARASMUS

(Infantile Atrophy, energy-deficiency or energy-protein deficiency)


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ETIOLOGY

  •  Inadequate caloric intake: insufficiency of diet, improper feeding habits

  •  Metabolic abnormalities or congenital malformations

  • Severe impairment of any body system

    may result in malnutrition


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CLINICAL MANIFESTATIONS


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 Failure to gain weight followed by loss of weight until emaciation results

 Loss of turgor in skin which becomes wrinkled and loose as subcutaneous fat disappears

 Edema


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Low temperature and slow pulse

Reduced basal metabolic rate

Fretful or listless

Diminished appetite and constipation followed by the so-called starvation type of diarrhea, with frequent, small stools containing mucus


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 Emaciation

Skin wrinkled

Subcutaneous fat disappears from abdomen first, then extremities, and finally face


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PROTEIN MALNUTRITION

(PCM or PEM, Protein-Calorie (Energy) Malnutrition,

Kwashiorkor)


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ETIOLOGY

deficient intake of protein of good biologic value

impaired absorption of protein, as in chronic diarrheal states

abnormal losses of protein in proteinuria

Infection

hemorrhage or burns

failure of protein synthesis, as in chronic liver diseases


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KWASHIORKOR

 a clinical syndrome resulted from a severe deficiency of protein & inadequate caloric intake

 the most serious and prevalent form in industrially underdeveloped areas

 “deposed child” may become evident from early infancy to 5 yr of age, usually after weaning

 height and weight are accelerated with treatment but never equal those of consistently well-nourished children.


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CLINICAL MANIFESTATIONS

 Early clinical evidence----vague, including lethargy, apathy, and irritability

 Inadequate growth, lack of stamina, loss of muscular tissue, increased susceptibility to infections, and edema

 Dermatitis and dyspigmentation

 Secondary immunodeficiency

 Anorexia, flabbiness of subcutaneous tissues, and loss of muscle tone


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Lethargy, apathy

Inadequate growth, loss of muscular tissue

Infections, and edema and dermatitis

 Flabbiness of subcutaneous tissues, and loss of muscle tone


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 Liver enlargement early or late

 Fatty infiltration

 Edema usually develops early (failure to gain weight may be masked by edema, which is often present in internal organs before it can be recognized in the face and limbs)

 Renal plasma flow, glomerular filtration rate, and renal tubular function are decreased

 The heart may be small in the early stages and enlarged later


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LABORATORY DATA

 Concentration of serum albumin decreased

 Aminoaciduria

 Ketonuria in the early stage

 Low blood glucose values

 Potassium and magnesium deficiencies

 Amylase, esterase, transaminase, lipase, alkaline phosphatase, pancreatic enzymes decreased

 normocytic, microcytic, or macrocytic Anemia

 Bone growth delayed and GH increased


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Diagnosis

  • The feeding history

  • Low body weight, loss of muscular tissue and disturbances of system functions

  • Laboratory data

  • Excluding other diseases


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Comparing with children in the same age group (or height) and sex:

Underweight: weight for age is lower than -2SD

Stunting: height for age is lower than -2SD

Wasting: weight for height is lower than -2SD

One or two or three may present to one child. Having any one of the three, the child can be diagnosed malnutrition.


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DIFFERENTIAL DIAGNOSIS

 Protein deprivation: chronic infections, diseases in which there is an excessive loss of protein through urine or stool

 The diseases of metabolic inability to synthesize protein


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PREVENTION

 Diet containing an adequate quantity of protein of good biologic quality

Adequate dietary instruction and food distribution

Treatment of diseases


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TREATMENT

Immediate management of any acute problems such as those of severe diarrhea, renal failure, and shock and, ultimately, the replacement of missing nutrients are essential.


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DEHYDRATION

 For mild to moderate dehydration, feedings are administered orally or by nasogastric tube, when culturally appropriate, to prevent aspiration. A breasted infant should be nursed as often as he of she wants.

 For severe dehydration, intravenous (IV) fluids are necessary


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MILK

 When dehydration is corrected, oral or nasogastric feeding starts with small, frequent feeds of dilute milk (66 kcal and 1.0g protein/100 ml at ~120/ml/kg/24 hr) with nutrient supplementation;


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 Strength and volume are gradually increased and frequency decreased over the next 5-7 days;

 By day 6-8, the child should receive 150 ml/kg/24 hr in ~6 feeds of high-energy milk (114 kcal and 4.1 g protein /100 ml). Cow’s milk, or yogurt for the lactose-intolerant child, should be made with 50 g of sugar/L.


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ANTIBIOTICS

The routine administration of antibiotics such as co-trimoxazole has also been advocated. Other antimicrobials are used only to treat overt infection because of concerns about emergence of microbial resistance.


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Vitamins and minerals, especially vitamin A, potassium, and magnesium, are necessary from the outset of treatment. Iron and folic acid usually correct the anemia.


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CHILD MANUTRITION —— Multiple choices

  • What are the factors contributing to malnutrition?

    • Deficient supply of food

    • Poor dietary habits

    • Food faddism and emotional factors

    • Certain metabolic abnormalities

  • The indicators for evaluation of nutritional status are:

    • Weight for age

    • Height for age

    • Weight for height

    • 24hr creatinine excretion


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CHILD MANUTRITION —— Multiple choices

  • The lower weight for height indicates:

    • The child has acute malnutrition

    • The child is stunted

    • The child is wasted

    • The child is normal

  • Protein reserves in malnourished child are assessed from:

    • Serum albumin

    • Transferring

    • Hemoglobin

    • Prealbumin

    • High density lipid protein


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