Growth charts and PEM Flashcards
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
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
When to treat inpatient?
Pneumonia
Diarrhoea with shock
Sepsis
Metabolic - hypothermia or hypoglycaemia
When to worry
Severe infection Hypothermia Collapse due to dehydration Jaundice Hypoglycaemia
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
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
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
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
Signs of over hydration
increasing RR
increasing PR
increasing oedema
puffy eyelids
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)
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
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
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
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)
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
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
When does major growth and development take place?
<5yo
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
What are the phases of growth and what do they depend on?
Intrauterine
Infantile (nutrition)
Childhood (GH)
Puberty (GH and sex hormones)
By how many years is the pubertal growth spurt of boys delayed vs girls?
2 years
Explain growth vs development
Growth = incr in size, composition, distribution Development = incr in complexity
What kinds of age are there?
Chronological
Corrected
Bone
Mental
When do you calculate corrected age and how?
<1500g or <37w
How do you measure bone age?
Osseous maturation in long bones (hand and wrist)
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
