Nutrition Flashcards by Courtney Whitfield

What’s the difference between kwashiorkor and marasmus

Prognosis and treatment is different

Kwashiorkor = oedema
Low protein diet
Marasmus = wasted
Low energy diet

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What is the criteria for SAM?

Weight for height plots less than -3 z-score
OR
MUAC <11,5cm (1-5years)
OR
Bilateral pitting oedema of nutritional origin

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What is the diagnostic criteria for MAM?

Weight for height z-score plots between -2 and -3
OR
MUAC 11,5-12,5cm (children 1-5 years)
OR
No bilateral pitting oedema of nutritional origin

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Red flags/danger signs for Acute malnutrition

refusing feeds/anorexia
vomiting all feeds
dehydration
shock
lethargy
convulsions
respiratory distress
bleeding
hypothermia
hypoglycaemia
jaundice
weeping skin lesions

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WHO routine care steps for SAM patients

Treat/prevent hypoglycaemia
Treat/prevent hypothermia
Treat/prevent dehydration
Correct electrolyte balance
Treat/prevent infection
Correct micronutrient deficiencies
Start cautious feeding
Achieve catch-up growth
Provide sensory stimulation and emotional support
Prepare for follow up after recovery

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What is a growth spurt?

Increase in growth velocity

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What is a growth lag?

Decrease in expected growth velocity

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What is catch-up growth?

Return towards size that would have been attained had growth lag not occurred

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What is protein energy malnutrition?

An illness due to inadequate intake or protein/total energy

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Describe the malnutrition - infection cycle

Inadequate intake = weight loss, mucosal damage, immune deficiency = susceptibility to infection = anorexia, man absorption, ↑ nutrient loss, ↑ nutrient requirements = inadequate intake…

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What are clinical features of SAM kwashiorkor?

• moon face
• angular stomatitis
• hair changes
• dermatitis
• failure to thrive
•Bilateral pitting oedema of nutritional origin
• anorexia
• diarrhoea
• skin & mucus membrane lesions
• misery + apathy
• excess subcutaneous fat from high carb diet
• muscle wasting

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What are medical complications of SAM?

•Pneumonia.
• sepsis
• diarrhoea with shock
• metabolic
-hypothermia
- hypoglycaemia

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Why does kwashiorkor present with oedema?

Low intravascular oncotic pressure (low protein)
Increased vascular permeability (infections and inflammation)
High body sodium = fluid leaks out

Starlings principle

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How do you grade the oedema in SAM patients?

O = no oedema
+= mild (below ankle)
++= moderate (pitting below knee)
+++= severe (generalized )

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What vitamin deficiencies cause immunosuppression?

• Vit A deficiency
• Vit C deficiency
• zinc, iron, folate, trace elements

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What infections are common when there is decreased cell immediated immunity?

• Measles
•Tb
• hsv
•Gastroenteritis
• infective mononucleosis
• gram negative septicaemia
•Gardia lambda parasites

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The presence of jaundice in SAM patients indicates what?

It’s a poor prognostic sign = long standing liver infection. Increased risk of hypoglycaemia

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What are danger signs in SAM?

•Hypoglycaemia
•Jaundice
• collapse due to dehydration
• hypothermia
• severe infection

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How do you assess appetite of an acute malnutrition patient?

Prepare RTUF (energy dense micronutrient paste)
Give food 2-5ml/kg in 1 go - if eat well with NO complications = OPD management

What is the timespan/urgency of correcting each WHO step?

Day 1-2: hypoglycaemia, hypothermia, dehydration, electrolytes

Day 1 to Week 6: Infection prevention, initiate feeding.

Day 3 to Week 6: iron (first few days it would feed the infection), sensory stimulation

Week 2 onwards: catch-up growth, prepare follow-up

How do you treat/prevent hypoglycaemia?

All malnourished children must have a blood glucose on admission. (Dextrostix/lab blood)

If child is conscious and dextrostix <3mmol give:
• immediate feed of DF-75
OR
•10% sugar solution oral 5ml/kg
OR
• dextrose 10% IVI bolus

Prevention - feed two hourly, start straight away. Rehydrate first
Give feeds throughout the night

How do you monitor hypoglycaemia treatment?

If was low, check every hour.
Once treated, should stabilise within 30 mins

Continue feeds (if remains <3 give IV bolus 10% dextrose water 5ml/kg.

How do you prevent and treat hypothermia?

Axillary <36 or rectal <35,5
① feed straight away

② Rewarm the child by:
• clothing the child
• cover with warm blanket and place heater nearby
• put child on moms bare chest and cover them
• do not use not water bottle (scolding)

If a patient has hypothermia, what else should you look for? (And visa versa)

Hypoglycaemia

How do you treat/prevent dehydration?

NB do not use the IV route for rehydration UNLESS PATIENT IS IN SHOCK AND THEN 5-10ml/kg 0,9% normal saline bolus SLOWLY TO AVOID FLOODING CIRCULATION. Max 4 boluses

How do you know if your patient is in hypovolaemic shock?

Cap refill <3secs Rapid weak pulses Cool peripheries Decreased pulse volume Decreased BP (late sign) Poor urine output

Signs or express fluid/over rehydration

•increasing oedema • ↑ resp rate • pulse rate • puffy eyes

How do you treat a child with watery diarrhoea?

① Assume dehydrated ② treat: >sorol 5ml/kg every 30mins for 2 hours oral/ng tube > then 5-10ml/kg/hr for next 4-10hrs > exact amount given determined by stool loss, vomiting + how much the child wants * oral = 1st line

How do you correct electrolyte imbalance in acute malnutrition?

NO DIURETICS (Excess sodium intracellularly, extracellular space, even if intravascular sodium is low) ① Potassium > 25 - 50mg|kg|dose 8 hrly > <10kg=250mg > >10kg=500mg ② Magnesium > <10kg = 2,5ml daily > > 10 kg = 5 ml daily

How do you PREVENT infection in acute malnutrition?

Absence of danger signs = oral amoxicillin as an OPD Danger signs = IV ampicillin 50mg/kg 6hrly for 2days followed by oral amoxicillin 30mg/kg 8hrly for 5 days AND Aminoglycoside (gentamicin 6mg/kg IM/IV Once daily for 7 days

How do you TREAT infection in acute malnutrition?

On top of prophylaxis: GI infection: metronidazole oral 7,5mg/kg/dose 8hrly for 5-7 days After acute phase = mebendazole Dysentery: ceftriaxone IV 50-75 mg/kg once daily NB test for TB and HIV!

What micronutrient deficiencies would you need to treat in acute malnutrition?

Vit A Folate Iron Zinc Multivitamin Copper

How do you start cautious feeding in acute malnutrition?

• begin immediately, • more regular feeds if hypoglycaemia ( 2 hourly ) • start DF-75 (lower fat and protein content ) → if you don't have, give less volume • monitor amount given and left,vomiting, frequency of watery stool, daily body weight • ↑ volume slowly until 150 ml /kg/day

What is the frequency, vol/kg/feed and day In cautious feeding in acute malnutrition?

1-2 days: 2hrly 11ml/kg/feed. 130ml/kg/day 3-5 days: 3hrly. 16ml/kg/feed. 130ml/kg/day 6-7 days+: 4hrly. 22ml/kg/feed. 130 ml/kg/day Each stage 24hrs if no oedema + good appetite

What indicates readiness to enter rehab phase in acute malnutrition?

Return of appetite

How do you achieve catch up growth in acute malnutrition?

① replace df -75 with same volume df-100 for 48hrs ② ↑ successive feed by 10 ml until some uneaten (+-30ml/kg/feed)

When is a acute malnourished child ready for discharge?

• No oedema • good appetite • good weight gain • No infection • playful talent At least weight for age -2 Z score

What is the management for acute malnutrition post-discharge?

Teach care-giver now to feed frequent energy + nutrient dense food + structured play therapy Vit A every 6 months Regular check-ups Booster vaccines

Define growth

↑ size, composition and distribution of tissues

What is the expected velocity of growth of children?

1st year: 25cm/year 2nd year: 12cm/year 2+ years: 5cm/year until puberty

What factors influence the growth of a child?

-nutrition -genetic - environment -health (chronic disease) -ethnicity -psycho social stress -postnatal period -intrauterine period -bone disorder

What is important to remember when weighing a baby?

No nappy (very heavy)

Why is it important to plot patients growth chart?

-opportunity to check growth - opportunity to counsel on feeding and development - high malnutrition rate in our country -pick up poor growth early to intervene early

Which special growth charts are available?

- Down syndrome -Turner’s syndrome -premature birth -cerebral palsy

What are the symptoms of vitamin A toxicity?

Raised intracranial pressure =seizures

How do patients with refeeding syndrome present?

Muscle weakness Seizures Rhabdomyolysis Cardiac arrhythmias Cardiac failure Haemolysis

What causes refeeding syndrome to occur?

Following the depletion of phosphorus, magnesium, potassium and glucose, there is a sudden abundance once the child starts feeding again. The energy source of cells is ATP which needs phosphorus to be formed. This causes an intracellularly shift of phosphorus, magnesium, potassium resulting in hypokalaemia, hypophosphataemia and hypomagnesaemia.