Growth charts and PEM Flashcards by Rachel Glass

Why is it NB to plot patients

Opportunity to check growth
Idea of how well baby is doing
Opportunity counselling on feeding and development
High malnutrition rate in our country
Pick up poor growth early to intervene early

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Criteria for SAM and MAM

SAM
Weight for height z score < -3 or
MUAC < 11.5cm or
Bilateral pitting oedema of nutritional origin

MAM
-3 < Weight for height z score < -2
11.5cm < MUAC < 12.5cm
NO bilateral pitting oedema of nutritional origin

AGE = 6m - 5 years

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When to treat inpatient?

Pneumonia
Diarrhoea with shock
Sepsis
Metabolic - hypothermia or hypoglycaemia

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When to worry

Severe infection 
Hypothermia
Collapse due to dehydration 
Jaundice 
Hypoglycaemia

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Features of Kwashiorkor

Flag sign
Moon face
Pot belly
Oedema
Dermatosis - dry scaly pigmentation, crazy paving, pseudopurpura - due decreased platelets, bullous desquamation, angular cheilitis
Decreased cell mediated immunity
Liver enlarged fatty changes
Hypokalaemia - ileus, anaemia, poor contractility
MEALS - malnutrition, oedema, anaemia, liver malfunction, skin lesions

Growth failure 
Oedema 
Dermatosis 
Immune suppression infections - measles, HSV, TB, gastroenteritis  
Other 
     Mental and neurological changes 
     Atrophic bowel - diarrhoea 
     Liver changes - fatty 
     Glucose intolerance - hypoglycaemia 
     Anaemia 
     Purpura due thrombocytopaenia

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Step 1: Prevent and treat hypoglycaemia

Prevent - feed two hourly start straight way or if Necessary rehydrate first always give feed throughout night

Treat
1. conscious + destrostix < 3mmol/l
immediate feed of DF 75
OR 10% sugar solution oral 5ml/kg - 10ml/kg
OR dextrose 10% ivi bolus - 5ml/kg
2. monitor BG if this was low - repeat hourly, once treated most stabilise in 30min
3. Continue feeds
4. If BG remains < 3 mmol/L give ivi bolus 10% dextrose water 5ml/kg

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Step 2: Prevent and treat hypothermia

axillary T < 36 or rectal T < 35.5
feed straight away
rewarm by
- clothing child including head
- cover warmed blanket and place a heater or lamp nearby
- pit child on mother bare chest - skin to skin and cover them
- do not use hot water bottle - scolding

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Step 3: Prevent and treat dehydration

do not use IV route except in cases shock
1. Assume all children watery diarrhoea may have dehydration
2. SOROL 5ml/kg every 30min for 2 hours orally/NGT
3. 5-10ml/kg/h for next 4-10 hours
exact amount determines - child wants, stool loss, vomiting
oral rehydration safe - assume
4. replace SOROL doses at
4,6,8,10 Hours with F-75 if rehydration is continuing at these times
continue feeding starter F-75
5. observe half hourly for 2 hours then hourly for next 6-12 hours
= PR, RR, urine F, stool/vomit F

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Signs of over hydration

increasing RR
increasing PR
increasing oedema
puffy eyelids

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Step 4: Correct electrolyte imbalances

excess body sodium
deficiency potassium and magnesium
causes oedema = NOT diuretic
KCl 25-50mg/kg/dose oral 3x daily until oedema subsides
- < 10kg = 250 mg
- > 10kg = 500 mg
Mg 0.4-0.6 mmol/kg/d (0.2ml/kg of 50% IVI solution orally)

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Step 5: Prevent and treat infection

Infections often hidden 
Broad-spectrum AB 
- ampicillin AND aminoglycoside: gentamicin, amikacin 
ADD specific AB if appropriate 
antimalarial treatment 
GIT - metronidazole - flagyll 
Dysentery - cefotaxime or ceftriaxone

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Step 6: Correct micronutrient deficiencies

Vit A orally - > 12m = 200 000 IU 
6-12 m = 100 000 IU 
0-5 m = 50 000 IU 
MVT supplement 5ml daily - if not available additional Mg 0.2ml/kg 
FA - 2.5mg daily po 
Zinc - 2mg/kg/d 
Copper - 0.3mg/kg/d 
Iron 3-6 mg/kg/d - only when gaining weight or from second week in divided doses

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Step 7: Start cautious feeding

begin feeding immediately
if hypoglycaemia or danger signs - 2 hourly
refused or no taken via NGT
DF-75 = lower fat and protein content
130ml/kg/day
monitor - amount offered and left over, vomiting, frequency watery stool, daily BW
increase up to 150ml/kg/day

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Step 8: Achieve catch up growth

return of appetite
replace starter DF-75 with same amount catch-up formula DF-100 for 48 hours
increase each successive feed by 10ml until some feed remains uneaten
usually when about 30ml/kg/feed (200ml/kg/d)

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Step 9: Provide sensory stimulation and emotional support

delayed mental and behavioural development
TLC
cheerful stimulating env
structured play therapy 15-30min/day
physical activity as soon child well enough
maternal involvement when possible

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Step 10: Prepare for discharge and follow up

ready for discharge when 
- no oedema 
- good appetite 
- good weight gain 
- no infection 
- playful and alert 
weight for age at least -2 Z score = considered recovered 
still low 
educate parents 
regular follow up - 2 weekly 
booster immunisations 
vit A - every 6m

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When does major growth and development take place?

<5yo

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What is the predictable amount of growth in children in 1st, 2nd and 3rd years?

1st = 25cm/y
2nd = 12cm/y
3rd = 5cm/y -> puberty

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What are the phases of growth and what do they depend on?

Intrauterine
Infantile (nutrition)
Childhood (GH)
Puberty (GH and sex hormones)

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By how many years is the pubertal growth spurt of boys delayed vs girls?

2 years

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Explain growth vs development

Growth = incr in size, composition, distribution
Development = incr in complexity

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What kinds of age are there?

Chronological
Corrected
Bone
Mental

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When do you calculate corrected age and how?

<1500g or <37w

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How do you measure bone age?

Osseous maturation in long bones (hand and wrist)

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How do you measure mental age

Cognitive function performance

What factors influence growth?

``` Genetics Environment Ethnicity Psychosocial stress Health Nutrition ```

Name causes of a short stature

Familial delay Constitutional delay Endocrine

Name endocrine causes of a short stature

``` Hypopituitarism (decr GH) Hypothyroidism Precocious puberty CAH Cushing's Pseudohypoparathyroidism Poorly controlled DM ```

Differentiate between familial and constitutional delay

Familial: skeletal = chronological age (family short) Constitutional: skeletal < chronological (family normal)

What other delay will constitutional delay cause other than growth?

Delay in sexual maturation

Name causes of a tall stature

``` Familial Obesity Thyrotoxicosis Precocious puberty Genetic (marfan's) Chromosomal (klinefelter) GH excess (pituitary adenoma) ```

What is the earliest finding in undernutrition?

Weight loss

Which measurement is affected last by chronic malnutrition?

Head circumference

What does MUAC measure?

Muscle bulk (chronicity)

What other charts can you get for anthropometry?

Turner Down's CP

At what point do you stop using the corrected age of a premature child?

3yo

Which measurements are for a child <5yo

``` Wfa Lfa Wfl MUAC HC ```

Which measurements are for a child >5yo

Wfa Hfa BMI HC if indicated

When is it length vs height for age?

``` Length = not walking Height = walking ```

How do you interpret length for age?

>3 = very tall

How do you interpret weight for age?

>1 = possible growth problem

How do you interpret weight for length?

``` >3 = morbidly obese >2 = obese >1 = overweight risk ```

How do you interpret BMI for age?

``` >3 = morbidly obese >2 = obese >1 = overweight risk ```

Define failure to thrive

Weight <3rd percentile Weight falls across 2 major percentile curves Weight <80% for height and age

What is decreased weight, normal height and normal head circumference suggestive of?

Caloric insufficiency Decreased intake Hypermetabolic state Increased losses

What is decreased weight, decreased height and normal head circumference suggestive of?

Structural dystrophies Endocrine disorder Constitutional delay Familial delay

What is decreased weight, decreased height and decreased head circumference suggestive of?

Intrauterine insult | Genetic abnormality

Name the clinical signs of FTT

``` SMALL KID Subcutaneous fat loss Muscle atrophy Alopecia Lethargy Lagging behind normal Kwashiorkor Infection Dermatitis ```

Name causes of failure to thrive

1. Parent-child relationship 2. Inadequate caloric intake 3. Inadequate absorption 4. Increased metabolism

Which factors regarding the parent-child relationship can cause FTT?

``` Dietary intake, feeding knowledge, improper formula mixing Environment Interaction and attachment Child behaviours Postpartum depression Social ```

Name causes of inadequate caloric intake that can result in FTT

Inadequate milk supply Mechanical (cleft) Oromotor dysfunction Toxin-induced anorexia

Name causes of inadequate absorption that can result in FTT

``` Biliary atresia Coeliac disease IBD CF IEM CMPA Pancreatic cholestasis ```

Name causes of increased metabolism that can result in FTT

``` Chronic infection CF Lung disease of prem Asthma Hyperthyroidism IBD Malignancy Renal failure ```

How do you calculate midparental height?

``` Boy = (father + mother + 13)/2 Girl = (father + mother - 13)/2 ```

Name causes of increased upper to lower segment ratio

Achondroplasia Short limb syndromes Hypothyroid Storage disease

Name causes of decreased upper to lower segment ratio

Marfan's Klinefelter's Kallman's Testosterone deficiency

What are the caloric needs of a child <10kg?

100kcal/kg/d

What are the caloric needs of a child 10-20kg?

100cal + 50kcal/kg/d for each kg >10

What are the caloric needs of a child >20kg?

1500cal +20kcal/kg/d for each kg>20

What is a z score?

Deviation of value for an individual from median value of reference population divided by standard deviation of reference population

Differentiate kwashiorkor and marasmus

Kwashiorkor (oedematous malnutrition) vs marasmus (wasting syndrome) All kwashiorkors = SMA

How can you qualify kwashiorkor oedema?

+1 feet/lower legs +2 arms/upper body +3 face

Which group of children are at highest risk for marasmus?

Infants

Which group of children are at highest risk for kwashiorkor?

9mo-3yo

Name features of marasmus

``` Head large relative to body Emaciated arms, thighs, buttocks Baggy pants Thin, dry skin Thin, sparse hair ```

What is NAIDS?

Nutritionally acquired immunodeficiency syndrome Cell mediated immunity affected -> atrophy of T cell lymphoid tissue -> decr IgA B cells normal -> normal IgG

Give examples of immunosuppressed infections

``` TB Measles Gastroenteritis HSV Gardia lambdia Gram - septicaemia Infective mononucleosis ```

Name the IMCI danger signs

``` Lethargy Shock Bleeding Respiratory distress Weeping skin lesions Jaundice Dehydration Hypothermia Convulsions Hypoglycemia Vomiting all feeds Feed refusal ```

What are the heart rate reference ranges for all ages?

``` Neonates 100-160 Infant 90-120 2-5y 95-140 5-12y 80-120 >12y 60-100 ```

What are the SBP reference ranges for all ages?

``` Neonates 60-90 Infant 80-100 2-5y 80-120 5-12y 90-110 >12y 100-120 ```

What are the respiratory rate reference ranges for all ages?

``` Neonates 30-60 Infant 30-40 2-5y 20-30 5-12y 15-20 >12y 12-15 ```

Which nutrient deficiency(s) cause hair colour changes?

PEM | Selenium

Which nutrient deficiency(s) cause quality and hair texture changes?

PEM | Zinc

Which nutrient deficiency(s) cause alopecia?

Zinc | EFA

Which nutrient deficiency(s) cause skull deformities?

Vitamin D | Calcium

Which nutrient deficiency(s) cause mouth bleeding?

Vitamin C | Vitamin K

Which nutrient deficiency(s) cause angular stomatitis?

Riboflavin B2 Niacin B3 Iron Zinc

Which nutrient deficiency(s) cause tongue pallor, thrush, atrophy and hypertrophy?

Niacin B3

Which nutrient deficiency(s) cause glottis?

Riboflavin B2

Which nutrient deficiency(s) cause cardiomyopathy?

Thiamine B1 | Selenium

Which nutrient deficiency(s) cause pallor?

``` Microcytic - iron Macrocytic - folate Megaloblastic - B12 Haemolytic - vitamin E Sideroblastic - copper ```

Which nutrient deficiency(s) cause koilonychia?

Fe | Copper

Which nutrient deficiency(s) cause rachitic rosary, scoliosis, lordosis, genu valgus?

Vitamin D Calcium Copper

Which nutrient deficiency(s) cause hepatomegaly?

PEM | RVD

Which nutrient deficiency(s) cause xeropthalmia and bitot spots?

Vitamin A

Which nutrient deficiency(s) cause ataxia?

Vitamin E

Which nutrient deficiency(s) cause peripheral neuropathy?

Vitamin E | Pyridoxine B6

Which nutrient deficiency(s) cause polyneuritis?

Thiamine B1

Which nutrient deficiency(s) cause dementia?

Niacin B3

Which nutrient deficiency(s) cause dermatitis?

``` PEM Riboflavin B2 Niacin B3 Zinc EFA ```

Which nutrient deficiency(s) cause pruritis?

Vitamin A