NUTRITION
PREPARED BY DR BNN MBANGA
Steady supply of nutrients is required by the body for;
• Maintenance of biological function
• Normal growth and development in childhood
Normal nutritional state is vital for normal health.
Basal Metabolic Rate – 60-70%
Physical status/ activity – 30-40%
NUTRITIONAL REQUIREMENTS
Age dependent.
Infant (0-3 months). Older child
>12 years 150ml/kg 55ml/kg
Fluid 100kcal/kg 50kcal/kg
Calories 2.1g/kg 1g/kg
Protein 2-3mmol/kg 2mmol/kg
Sodium 1.5-3mmol/kg 2mmol/kg
Potassium
• Nutrients and micronutrients are also
important.
• Balance in fat vs protein vs
carbohydrates
Ideal nutrition for babies- high protein, low
sugar
Reduced risk of disease; IgA
BREASTFEEDI
NG BENEFITS Promotes baby’s healthy weight; Leptin
NEUROLOGICAL DEVELOPMENT- Studies
suggesting that neurological development is
enhanced in BF infants
Reduced risk of developing diabetes
Same energy content
Same amount of fat but different in
quality
BREAST MILK
VS COW’S Human milk has more carbohydrates
and less protein
MILK
Cow’s milk has a higher casein content
Preterm formula has and more minerals except zinc and
more electrolytes, copper.
calories and minerals.
Also has higher
energy, protein,
carbohydrates, fat,
osmolality,
Na2+/K+/Mg2+/PO42-/
Fe2+
COMPLEMENTARY FEEDING
• Introduced from 6 months due to increased requirements of some nutrients incl
protein, zinc and iron
• Semisolid food recommended, initially single grain cereal mixed with milk or
water, later vegetables and fruits. Introduce 1 every 2-3 days and monitor for
allergies.
• Juice not recommended. Can start in toddlers (1-3 year) only 250ml 100%
unsweetened juice per day. 7-18 years 500ml/day
• Honey should be avoided in < 1year (Risk of infant botulism)
• Avoid preservatives, 250ml solids at each daily meal
• Cows milk better tolerated >1 years. 1- 2years
CAREFUL HISTORY- Important factors to
consider
Conditions that interfere with intake
Conditions that interfere with absorption
NUTRITIONAL Conditions associated with increased losses
ASSESMENT
Conditions associated with increased needs
Conditions that restrict intake
FULL HISTORY incl PMH; dietary, drug, family
and social
GROWTH AND ANTROPOMETRY
Disturbances in Standard Signs of
health and antropometry undernutrition:
nutrition affect indices: • Poor weight gain
• Weight, • Slowing of linear
child growth. growth
• Height/Length, and
• Head circumference.
WEIGHT-
FOR-AGE
• Marker for nutritional status
HEIGHT/LENGTH-FOR-AGE
• Marker for chronicity of malnutrition
WEIGHT-FOR-
HEIGHT/LENGTH
(<5YEARS)
HEAD CIRCUMFERENCE-FOR-AGE (<5 YEARS)
• Helps assess brain growth
• Last to slow down in chronic
malnutrition.
BODY MASS INDEX (BMI)
• BMI= weight (kg)/ (height (m))2
• Used after 2 years of age
MID UPPER ARM
CIRCUMFERENCE
• Different colour banded strips used
• Used to screen for malnutrition.
• Independent of age between 6-59
months
• Mainly identifies children for further
evaluation
NB !! Skin fold thickness estimates
body fat- not routinely used in
clinical setting.
PHYSICAL EXAMINATION
• Full examination incl. temperature
• Signs of shock
• Signs of dehydration may be unreliable in a malnourished child
• Skin changes ; PEM- dysquamated, pigmented dermatosis
Vit A- follicular keratosis, dry skin, and acneiform lesions
Vit C- perifollicular haemorrhages, ecchymosis, and petechiae (also
Vit K)
Niacin (B3)- erythema and hyperpigmantation
Zinc- perioral and perianal (acral) erythematous, easily denuded skin
• SKIN APPENDAGES;
Hair- Brittle, discolored (PEM, copper def)
-Alopecia, easily pluckability (PEM)
Nails – thinning and brittle (PEM, calcium)
- koilonychia (iron def)
• EYES;
Xeropthalmia- Bitot”s spots, keratomalacia, corneal clouding and ulceration ( Vit
A Def)
Pale mucosa- (Haematinic Def)
• MOUTH AND TOUNGE;
Angular stomatitis- PEM, Vit B2 (riboflavin), Vit B6 (pyridoxine), Vit B12
Atrophic glossitis and mucosa- PEM, riboflavin and niacin
Toungue colour changes: magenta (purple red)- riboflavin ; scarlet (bright red)-
niacin
Bleeding gums- Vit C
Cheilosis (inflamed lip)- riboflavin, niacin
• Subcutaneous oedema- Hypoalbumineamia, Na/K disturbances
• Bones- rickets- Vit D, calcium
ORGANOMEGALY
• Liver- fatty infiltration of PEM
• Thyroid- iodine
• Mental state; irritability/apathy- iron, PEM, Niacin
• Loss of deep tendon reflexes- Vit B1 (Thiamine), Vit B12
CLASSIFICATION OF MALNUTRITION
STUNTING- Height-for-age z score <2 SD. Most common; reflects chronic
malnutrition.
WASTING- Weight-for-height z score <2 SD. Indicates acute malnutrition.
UNDERWEIGHT- Weight-for-age z score < 2SD. Combination of stunting
and wasting.
SEVERE ACUTE MALNUTRITION
1 or more of:
• WHZ < 3
• Presence of bilateral oedema (nutritional origin)
• MUAC <11.5cm
Pathophysiology and adaptation
Cellular and circulation
• Increase in total body weight due to disappearance of
fat stores and muscle wasting.
• In Marasmus fat stores can reduce to 5%
• In Kwashiokor causes of oedema;
• Electrolyte imbalance due to reduced Na/K pump
• Increased cortisol and reduced inactivation of ADH
• Low colloidal osmotic pressure of plasma due to
hypoalbuminaemia
• Decreased cardiac output
• Lower glomerular filtration rate
Cardiovascular Liver Genito-urinary
• Cardiac myofibrils have • Hepatic glucose stores system
reduced contractility are depleted • Reduced glomerular
• Impaired gluconeogenesis filtration rate
• Reduced stroke volume • Synthetic function
and cardiac output in reasonably preserved • Reduced capacity to
proportion to weight excrete sodium, excess
• Reduced lipoprotein acid, and water load
• Hypokaelemia contributes synthesislimited ability
to poor contractility to mobilise fat fatty • Common UTIs
infiltration of liver
• Hypotension and (triglycerides)
bradycardia are common
is severe cases • Metabolism and excretion
of toxins severely
compromised
Gastrointestinal system Endocrine system
• Bowel mucosa and villous atrophy + • Glycogenolysis + gluconeogenesis are
diminished dissacharidase enzymes, stimulated.
esp. lactase.
• Reduced production of membrane • glucose intolerance; risk of
nutrient transporters increased hypoglycaemia.
intestinal permeability.
• Reduced pancreatic enzyme secretion • Plasma cortisol and growth hormone
are high therefore even more glucose
• Decreased secretion of gastric acid, required.
decreased intestinal motility, and
intestinal bacterial overgrowth is • Moonfacies in kwashiorkor due to
common. unbound cortisol (hypoalbuminaemia)
• Diarrhoea common- serious and often
fatal. • Tri-iodothyroxine (T3) level reduced,
1.Enteric infection no sign of thyroid insufficiency
2.Bacterial overgrowth
3.Abnormalities of digestion and
Immune system
• Atrophy of lymph glands,
Metabolism tonsils, and the thymus Haematological
• BMR reduced to 30% decreased cellular immunity • Low RCC anaemia due to iron
def/ RCC production/ EPO def/
• Heat generation and heat loss • Decreased complement and vit or mineral def
impaired secretory IgA loss of delayed
hypersensivity & impaired • Coagulation preserved
phagocytosis
• Increased prevelance and
severity of infections
infection-malnutrition cycle
Neurological system Skin, muscle and glands
• Behavioural changes- irritability, • Skeletal muscle amino acids,
apathy, decreased social pyruvate, lactate used in
responsiveness, and attention gluconeogenesis
deficits
• Later, fat mobilized lipolysis
• Decrease in no. of neurons, and ketogenesis
synapses and myelinations
brain atrophy • Skin and subcutaneous fat are
atrophied loose skin folds
• Nutritional insults at younger
ages have worse outcomes. • Respiratory muscles are easily
fatigued
CLINICAL FEATURES
PEM- Spectrum of nutritional disorders, with low WFA and low HFA the
most common.
SAM presenting as marasmus and kwashiorkor are the extreme forms.
KWASHIOKOR
• AGE 9 months – 3 years
• Pitting oedema on extremities depending on severity;
1. Mild: feet and ankles
2. Moderate: feet, lower legs, hands or lower arms
3. Severity: generalized pitting oedema incl face, esp peri-orbital.
• Ascites is rare- distinguishing point of
differential diagnosis.
• Abdominal distention due to poor
abdominal musculature and liver due to
fatty infiltration
• Skin changes progress over a few days-
hyperpigmented, dry, easily denuded
with pale epidermis
• Depigmented hair, dry ,sparse and
brittle
• Moon facies, unhappy, irritable or
apathetic.
• Prone to infections
•MARASMUS
• Affects all ages, infants at high risk.
• More common than kwashiorkor; childhood equivalent of starvation
• Due to deficiency of type 2 (growth) nutrients
• WHZ < -3 and MUAC <11.5cm indicate severe wasting
• Body appears to have only skin and bone with wrinkling of skin and
markedly visible ribs
• Head disproportionaly large
• Weak and lethargic, associated bradycardia, hypotension, and prone to
hypothermia
• NO DERMATOSIS, HAIR CHANGES, OEDEMA AND BIOCHEMICAL
DERANGEMENTS like Kwashiokor
•MARASMIC-KWASHIOKOR
• Not common
• Marasmic child can become a kwashiokor
LABORATORY INVESTIGATIONS
Recommended tests incl;
• Blood culture
• Blood glucose or dextrostix
• Full blood cound and smear
• Electrolytes incl CMP and Albumin
• Testing for HIV
• Urine dipstick and MCS
• Stool MCS and parasites
• CXR
MANAGEMENT
WHO 10 STEPS
1. Treat / prevent hypoglycaemia (HGT <3mmol/L)
2. Treat or prevent hypothermia
3. Treat/ prevent dehydration
4. Treat electrolyte imbalances
5. Treat infections
6. Correct micronutrient deficiencies
7. Start cautious feeding
8. Achieve catch-up growth
9. Provide sensory stimulation and emotional support
10. Prepare for discharge and follow-up
