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PEM
Dr. BABU LAL MEENA
MD PEDIATRICS
PGIMER CHANDIGARH
DEFINITION
Undernutrition-
• Inadequate consumption, poor absorption
or excessive loss of nutrients.
Overnutrition-
• Over...
DEFN CONT…
Protein energy malnutrition
Range of pathological conditions arising from
lack , in varying proportions , of pr...
EPIDEMIOLOGY
 Global burden- more prevalent in developing
countries. “Often starts in the womb and ends in
the tomb”
 PE...
INDIAN SCENARIO
 Childhood malnutrition underlying cause of
death in 35% of all deaths under 5.
 During 1st 6 months, wh...
CHILD MORTALITY
The major contributing factors are:
• Diarrhea 20%
• ARI 20%
• Perinatal causes 18%
• Measles 07%
• Malari...
INDICATORS
Indicator Interpretation Interpretation
Stunting Low height for age Chronic malnutrition
Prolonged food
depriva...
CLASSIFICATION
 WEIGHT-FOR-AGE
 HEIGHT-FOR-AGE
 WEIGHT-FOR-HEIGHT
WEIGHT-FOR-AGE
GOMEZ CLASSIFICATION
• Only wt for age taken into account
• No comment about height
• All cases of edema in 3rd degree
ire...
JELLIFFE’S CASSIFICATION
Nutritional status WEIGHT FOR AGE
( % of expected )
normal 90
1st degree PEM 80-90
2nd degree PE...
WELLCOME TRUST / INTERNATIONAL CLASSIFICATION
Based on wt-for-age and presence of edema.
Weight-for-
age(Boston)
(% of exp...
IAP CLASSIFICATION(1972)
Grade of malnutrition Weight for age of the
standard
(median) %
Normal >80
Grade I 71-80 (mild ma...
CLASSIFICATIONS- WHO
Moderate
malnutrition
Severe
malnutrition
Symmetrical
oedema
No Yes
(oedematous
malnutrition)
Weight-...
AGE INDEPENDENT INDICES
 Weight for height
 Mid arm circumference
 Body mass index
 Index ( Kanawati, Dughdale, Rao &
...
SHAKIR TAPE
RATIOS
Name of index Calculation Normal value Value in
malnutrition
Kanawati and Mc
laren
MUAC(cm)/HC(c
m)
0.32-0.33 <0.25...
RISK FACTORS
 LBW
 Multiple birth
 Closely spaced birth
 Early stoppage of breast feeding
 Too early or late weaning
...
PATHOGENESIS
•Protein defficiency
•Gopalan theory
•Golden theory
MARASMUS
KWASHIORKOR
CLINICAL FEATURES
• Depends on the severity and duration
nutritional deprivation, the age, presence or
absence of associat...
KWASHIORKOR
• Essential Features
• Marked growth retardation
• Psychomotor changes
• Wasting of muscles
• Dependent pittin...
• General appearance- fat sugar baby
appearance.
• Skin changes-
• Hyperpigmentation, desquamation and
dyspigmentation.
• ...
• Mucus membrane lesions
 Smooth tongue
 Cheilosis, angular stomatitis
 Herpes simplex stomatitis
• Edema
• Muscle wast...
Hair Changes
• Hypopigmented hair.
• Sparseness (alopecia)
• Change in texture (coarse / silky)
• Easy pluckbility
• Flag ...
– GI Manifestations
• Diarrhoea
• Infections / Parasitic infestations
• Mucosal atrophy
• Enteraopathy sec. to anemia
• Li...
MARASMUS
Essential Features
• Gross wasting of muscles – skin and bones.
• Emaciation- loss of buccal pad of fat-monkey fa...
CONT…
Grade 1 : Wasting starts in axilla & groin
Grade 2 : Wasting extended to thigh and
buttocks
Grade 3 : Chest and abdo...
SEVERE ACUTE
MALNUTRITION
 Weight-for-height of 70% (extreme wasting)
 Presence of bilateral pitting edema of
nutritiona...
COMPLICATIONS OF SAM
 ARI
 Diarrhea
 Gram negative septicemia
 Poor feeding
 Electrolyte abnormalities
CAUSES OF DEATH
Hypoglycemia
Hypothermia
Dehydration
Infection
Severe anemia
MANAGEMENT
Mild and moderate malnutrition
 Mainstay of treatment is to give adequate amounts of
protein and energy
 Atle...
Locally produced RUTF
Hyderabad mix
120 g = 500 Kcal
(Wheat, black gram, groundnut flour)
Limited success in uncontrolled ...
INPATIENT TREATMENT OF SEVERE
ACUTE MALNUTRITION
WHO TEN STEPS to recovery in
Malnourished Children
In 2 phases
•Initial s...
TIME FRAME FOR TEN STEPS
STEP 1
PREVENT/TREAT HYPOGLYCEMIA
Blood glucose <54mg/dl
If cant be measured assume hypoglycemia
TREATMENT
Asymptomatic-
•...
Symptomatic
 10% dextrose i.v 5ml/kg
 Follow with 50ml of 10% glucose or sucrose
solution NG
 Feed with starter F-75 q ...
STEP 2
PREVENT AND TREAT HYPOTHERMIA
Rectal temp <35.5 C/95.5 F or axillary <35
C/95 F
Treatment
 Clothe the child with ...
STEP 3
TREAT/PREVENT DEHYDRATION
 Assume all SAM with watery diarrhoea to have
some dehydration.
 Hypovolemia can co exi...
STEP 4
CORRECT ELECTROLYTE IMBALANCE
Supplemental potassium at 3-4meq/kg/d for
atleat 2 weeks
On day1, 50% MgSO4 i.m onc...
STEP 5
TREAT/PREVENT INFECTION
 Multiple infections common
 Usual signs of infection such as fever often
absent
 Majori...
Treatment
 Ampicillin iv for atleast 2 days f/b oral amoxycillin
 i.v. gentamicin or amikacin for 7 days.
If no imroveme...
STEP 6
CORRECT MIRONUTRIENT DEFICIENCIES
1. Use upto twice the RDA of various vitamins
and minerals
2. On day1, Vit A oral...
STEP 7
INITIATE RE-FEEDING
 Initiate feeding as soon as possible as frequent small
feeds
 If unable to take orally- NG f...
STEP 8
ACHIEVE CATCH UP GROWTH
• Once appetite returns in 2-3 days, encourage higher feeds
• Increase volume offered in ea...
STEP 9
PROVIDE SENSORY STIMULATION AND
EMOTIONAL SUPPORT
 A cheerful, stimluating environment
 Age appropriate structure...
STEP 10
PREPARE FOR FOLLOW UP AFTER
RECOVERY
Said to have rcovered when wt for ht is 90% of NCHS
median and has no edema
P...
Complication during rehabilitation
Nutritional Recovery Syndrome
Treated with very high proteins
Abdominal distension (h...
REFEEDING SYNDROME
Definition
Refeeding syndrome (RFS) is a term that describes
the metabolic and clinical changes that oc...
RISK FACTORS
PATHOPHYSIOLOGY
Starvation
- Increased catabolism
- Increased glycogen depletion
- Breakdown of proteins to aminoacids for
gluconeogenesis...
ON REFEEDING
• Altered membrane
potenial – Cardiac
arrythmias
• Neuromuscular
dysfunction
• Sodium retention
• Fluid overload
• Fatty l...
CLINICAL FEATURES
< 2 weeks
- Increased weight gain, tachypnoea, features of cardiac failure,
dilutional hyponatermia – s/...
 2 weeks
- Prominient thoraco-abdominal venous network
- Hypertrichosis (after 60 days)
- Parotid swelling
- Gynaecomasti...
DIAGNOSIS AND EARLY RECOGNITION IS
THE KEY
- There is no defined diagnostic criteria for refeeding syndrome in
children.
-...
MANAGEMENT
- Stop all sources of calorie and protein until the electrolyte
imbalances are corrected.
- Start with 50% of t...
PREVENTION
A) MONITORING
Before initiating refeeding through any route and during initial 3 –
5 days,
- Hydration and flui...
B) ORAL FEEDING REGIMEN
1. Initial volume and calories
• In more severe cases an initial starting volume of 75% of total d...
2. PROTEIN
• If a milk-based feed induces diarrhoea with positive faecal
reducing substances, a hydrolysate may be used.
•...
TAKE HOME MESSAGES
- Refeeding syndrome is due to the metabolic and hormonal
changes that occur due to aggressive nutritio...
CRITERIA FOR DISCHARGE FROM
NON-RESIDENTIAL CARE
 Weight-for-height has reached -1 SD (90%) of NCHS/WHO median
reference ...
FOLLOW UP
 Child should be seen after 1week, 2 weeks, 1
month, 3 months and 6 months. More frequently if
any problem foun...
PREVENTION
At national level
1. Nutrition supplementation- Fortification, iodination
2. Nutritional surveillance- define t...
PREVENTION
At community level-
• Health and nutritional education
• Promotion of education and literacy in the
community
•...
PREVENTION
At family level
 Exclusive breast feeding
 Complementary feeds at 6 months
 Vaccination
 Spacing between pr...
THANK YOU
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Protein energy malnutrition

This presentation included approach and classification of protein energy malnutrition and it's management, related complications in children

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Protein energy malnutrition

  1. 1. PEM Dr. BABU LAL MEENA MD PEDIATRICS PGIMER CHANDIGARH
  2. 2. DEFINITION Undernutrition- • Inadequate consumption, poor absorption or excessive loss of nutrients. Overnutrition- • Overindulgence or excessive intake of specific nutrients Malnutrition- • Refers to both undernutrition as well as overnutrition.
  3. 3. DEFN CONT… Protein energy malnutrition Range of pathological conditions arising from lack , in varying proportions , of protein and calories.  Marasmus: weight for age < 60% expected  Kwashiorkor: weight for age < 80% + edema  Marasmic kwashiorkor: wt/age <60% + edema
  4. 4. EPIDEMIOLOGY  Global burden- more prevalent in developing countries. “Often starts in the womb and ends in the tomb”  PEM affects every 4th child world-wide  More than 50% of deaths in 0-4 years are associated with malnutrition  Median case fatality rate is-23.5% in severe malnutrition reaching 50% in edematous malnutrition
  5. 5. INDIAN SCENARIO  Childhood malnutrition underlying cause of death in 35% of all deaths under 5.  During 1st 6 months, when most babies are breastfed, 20-30% are already malnourished.  By 18-23 months, during weaning, 30% are severely stunted, 1/5th are underweight.
  6. 6. CHILD MORTALITY The major contributing factors are: • Diarrhea 20% • ARI 20% • Perinatal causes 18% • Measles 07% • Malaria 05% 55% of the total have malnutrition
  7. 7. INDICATORS Indicator Interpretation Interpretation Stunting Low height for age Chronic malnutrition Prolonged food deprival/disease Wasting Low weight for height Acute malnutrition Recent food deficit/illness Underweight Low weight for age Combined indicator to reflect both acute on chronic malnutrition.
  8. 8. CLASSIFICATION  WEIGHT-FOR-AGE  HEIGHT-FOR-AGE  WEIGHT-FOR-HEIGHT
  9. 9. WEIGHT-FOR-AGE
  10. 10. GOMEZ CLASSIFICATION • Only wt for age taken into account • No comment about height • All cases of edema in 3rd degree ireespective of wt for age Nutritional status Wt FOR AGE ( % of expected ) normal > 90 1st degree PEM 75-90 2nd degree PEM 60-75 3rd degree PEM < 60
  11. 11. JELLIFFE’S CASSIFICATION Nutritional status WEIGHT FOR AGE ( % of expected ) normal 90 1st degree PEM 80-90 2nd degree PEM 70-80 3rd degree PEM 60-70 4TH degree PEM < 60
  12. 12. WELLCOME TRUST / INTERNATIONAL CLASSIFICATION Based on wt-for-age and presence of edema. Weight-for- age(Boston) (% of expected ) Oedema Clinical type of PEM 60-80 + Kwashiorkor 60-80 _ Underweight < 60 _ Marasmus < 60 + Marasmic kwashiorkor
  13. 13. IAP CLASSIFICATION(1972) Grade of malnutrition Weight for age of the standard (median) % Normal >80 Grade I 71-80 (mild malnutrition) Grade II 61-70 (moderate malnutrition) Grade III 51-60 (severe malnutrition) Grade IV <50 (very severe malnutrition)
  14. 14. CLASSIFICATIONS- WHO Moderate malnutrition Severe malnutrition Symmetrical oedema No Yes (oedematous malnutrition) Weight-for-height SD score between -2 to -3 SD score < -3 Severe wasting Height-for-age SD score between -2 to -3 SD score < -3 Severe stunting
  15. 15. AGE INDEPENDENT INDICES  Weight for height  Mid arm circumference  Body mass index  Index ( Kanawati, Dughdale, Rao & Singh’s )  Skin fold thickness
  16. 16. SHAKIR TAPE
  17. 17. RATIOS Name of index Calculation Normal value Value in malnutrition Kanawati and Mc laren MUAC(cm)/HC(c m) 0.32-0.33 <0.25 Rao and Singh wt (kg)/Ht (cm)2 X 100 0.14 0.12-0.14 Dughdale wt (kg)/ht in cm 1.6 X100 0.88-0.97 <0.79 Quaker arm circumference MAC expected for a given height 75-85%- malnourished <75%-severely malnourished Jellife’s ratio HC/CC <1 in a child >1year: malnourished
  18. 18. RISK FACTORS  LBW  Multiple birth  Closely spaced birth  Early stoppage of breast feeding  Too early or late weaning  Recurrent infections  Illiteracy, poverty  Secondary due to malabsorption
  19. 19. PATHOGENESIS •Protein defficiency •Gopalan theory •Golden theory
  20. 20. MARASMUS
  21. 21. KWASHIORKOR
  22. 22. CLINICAL FEATURES • Depends on the severity and duration nutritional deprivation, the age, presence or absence of associated infections.
  23. 23. KWASHIORKOR • Essential Features • Marked growth retardation • Psychomotor changes • Wasting of muscles • Dependent pitting edema
  24. 24. • General appearance- fat sugar baby appearance. • Skin changes- • Hyperpigmentation, desquamation and dyspigmentation. • Flaky paint dermatosis( confluent areas ) • Enamel spots( individual spots ) • Typically involving buttocks, perineum and upper highs.
  25. 25. • Mucus membrane lesions  Smooth tongue  Cheilosis, angular stomatitis  Herpes simplex stomatitis • Edema • Muscle wasting- weak, hypotonic and unable to stand or walk.
  26. 26. Hair Changes • Hypopigmented hair. • Sparseness (alopecia) • Change in texture (coarse / silky) • Easy pluckbility • Flag sign Mental Changes : • Lethargy • Apathetic • Poor appetite – difficult to feed
  27. 27. – GI Manifestations • Diarrhoea • Infections / Parasitic infestations • Mucosal atrophy • Enteraopathy sec. to anemia • Liver enlargement • Fatty liver –Mineral & Vitamin deficiency –Super added infections • Tuberculosis, bronchopneumonia, measles, enteritis..
  28. 28. MARASMUS Essential Features • Gross wasting of muscles – skin and bones. • Emaciation- loss of buccal pad of fat-monkey facies, loose skin of buttocks hanging down- baggy pants appearance • Marked stunting • No edema Non -essential Features •Mineral and vitamin deficiency • Indolent ulcers and sores • GI symptoms – hungry • Liver is shrunk • Psychomotor changes – irritable
  29. 29. CONT… Grade 1 : Wasting starts in axilla & groin Grade 2 : Wasting extended to thigh and buttocks Grade 3 : Chest and abdomen Grade 4 : Wasting of buccal pad of fat also
  30. 30. SEVERE ACUTE MALNUTRITION  Weight-for-height of 70% (extreme wasting)  Presence of bilateral pitting edema of nutritional origin, “edematous malnutrition  Mid-upper-arm circumference of less than 115 mm in children age 1-5 years old
  31. 31. COMPLICATIONS OF SAM  ARI  Diarrhea  Gram negative septicemia  Poor feeding  Electrolyte abnormalities
  32. 32. CAUSES OF DEATH Hypoglycemia Hypothermia Dehydration Infection Severe anemia
  33. 33. MANAGEMENT Mild and moderate malnutrition  Mainstay of treatment is to give adequate amounts of protein and energy  Atleast 150kCal/kg/day, protein intake of 3g/kg/day  Best measure of efficacy of the treatment is weight gain
  34. 34. Locally produced RUTF Hyderabad mix 120 g = 500 Kcal (Wheat, black gram, groundnut flour) Limited success in uncontrolled studies
  35. 35. INPATIENT TREATMENT OF SEVERE ACUTE MALNUTRITION WHO TEN STEPS to recovery in Malnourished Children In 2 phases •Initial stabilisation – 2 to 7 days •Rehabilitation – several weeks
  36. 36. TIME FRAME FOR TEN STEPS
  37. 37. STEP 1 PREVENT/TREAT HYPOGLYCEMIA Blood glucose <54mg/dl If cant be measured assume hypoglycemia TREATMENT Asymptomatic- • 50ml of 10% glucose or sucrose solution orally or NG f/b 1st feed • Feed with starter F-75 q 2hrly
  38. 38. Symptomatic  10% dextrose i.v 5ml/kg  Follow with 50ml of 10% glucose or sucrose solution NG  Feed with starter F-75 q 2hrly  Start appropriate antibiotics Prevention  Feed 2 hrly starting immediately  Prevent hypothermia
  39. 39. STEP 2 PREVENT AND TREAT HYPOTHERMIA Rectal temp <35.5 C/95.5 F or axillary <35 C/95 F Treatment  Clothe the child with warm clothes  Provide heat  Avoid rapid rewarming  Feed the child  Give appropriate antibiotics
  40. 40. STEP 3 TREAT/PREVENT DEHYDRATION  Assume all SAM with watery diarrhoea to have some dehydration.  Hypovolemia can co exist with edema. Treatment  Use reduced osmolarity ORS with potassium supplements for rehydration and maintenance.  Initiate feeding within 2-3 hrs of starting rehydration with F-75 formula on alt hrs with reduced osmolarity ORS  Be alert for signs of overhydration.
  41. 41. STEP 4 CORRECT ELECTROLYTE IMBALANCE Supplemental potassium at 3-4meq/kg/d for atleat 2 weeks On day1, 50% MgSO4 i.m once (0.3 ml/kg, max upto 2ml) thereafter give extra Mg(0.8-1.2 meq/kg daily) Excess body sodium exists even though plasma sodium may be low. Prepare food without adding salt.
  42. 42. STEP 5 TREAT/PREVENT INFECTION  Multiple infections common  Usual signs of infection such as fever often absent  Majority of blood stream infections due to gram negative bacteria.  Assume serious infections and treat.  Hypoglycemia and hypothermia are markers of severe infections.
  43. 43. Treatment  Ampicillin iv for atleast 2 days f/b oral amoxycillin  i.v. gentamicin or amikacin for 7 days. If no imrovement within 48hrs,  i.v. cefotaxime  Ceftriaxone Prevention  Follow standard precautions like hand hygiene  Give measles vaccine if >6 months and not immunised or if the child is more than > 9 months.
  44. 44. STEP 6 CORRECT MIRONUTRIENT DEFICIENCIES 1. Use upto twice the RDA of various vitamins and minerals 2. On day1, Vit A orally (if age>1yr 2lac IU, 6- 12 mon 1 lac IU, 0-5 mon 50,000 IU) 3. Folic acid 1mg/day ( 5mg on D1) 4. Copper 0.2-0.3 mg/kg/d 5. Iron 3mg/kg/d, once child starts gaining wt, after the stabilisation phase.
  45. 45. STEP 7 INITIATE RE-FEEDING  Initiate feeding as soon as possible as frequent small feeds  If unable to take orally- NG feeds  Total fluid recommended is 130ml/kg/d, reduce to 100ml/kg/d if there is severe, generalised edema  Continue breast feeding ad libitum  Start with F-75 starter feeds q 2 hrly  F-75 contains 75kCal/100ml with 1g protein/100ml  If persistent diarrhea, cereal based low lactose F-75 diet as starter diet  If diarrhea continues on low lactose diets give F-75 lactose free diets
  46. 46. STEP 8 ACHIEVE CATCH UP GROWTH • Once appetite returns in 2-3 days, encourage higher feeds • Increase volume offered in each feed and decrease the frequency of feeds to 6 feeds/d • Continue breast feeding on demand • Make a gardual transition from F-75 to F-100 diet • F-100 contains 100kCal/100ml with 2.5-3g protein/100ml • Increase calories to 150-200 kCal/kg/d and proteins to 4- 6g/kg/d • Add complementary foods as soon as possible to prepare the child for home foods at discharge
  47. 47. STEP 9 PROVIDE SENSORY STIMULATION AND EMOTIONAL SUPPORT  A cheerful, stimluating environment  Age appropriate structured play therapy for atleast 15-30 mins/day  Age appropriate physical activity as soon as the child is well enough  Tender loving care
  48. 48. STEP 10 PREPARE FOR FOLLOW UP AFTER RECOVERY Said to have rcovered when wt for ht is 90% of NCHS median and has no edema Primary failure to respond if • Failure to gain appetite by D4 • Failure to start losing edema by D4 • Presence of edema on D10 • Failure to gain atleast 5g/kg/d by D10 Secondary failure to respond if • Failure to gain at least 5g/kg/d for consecutive days during the rehabilitation phase
  49. 49. Complication during rehabilitation Nutritional Recovery Syndrome Treated with very high proteins Abdominal distension (hepatomegaly, ascites, splenomegaly), prominent veins, hypertrichosis, parotid swelling, gynaecomastia, eosinophilia, hyper-Ig Incresed estrogen and recovering pituitary Kwashi shake/encephalitis states (too much of proteins) Pseudotumor cerebri Refeeding syndrome
  50. 50. REFEEDING SYNDROME Definition Refeeding syndrome (RFS) is a term that describes the metabolic and clinical changes that occur on aggressive nutritional rehabilitation of a malnourished patient. - Exact incidence in pediatric patients not known. - 30% to 38% in adults on TPN with phosphorus. - 100% in adults on TPN without phosphorus. - 25% of adults with cancer.
  51. 51. RISK FACTORS
  52. 52. PATHOPHYSIOLOGY
  53. 53. Starvation - Increased catabolism - Increased glycogen depletion - Breakdown of proteins to aminoacids for gluconeogenesis - Production of ketone bodies from fatty acids
  54. 54. ON REFEEDING
  55. 55. • Altered membrane potenial – Cardiac arrythmias • Neuromuscular dysfunction • Sodium retention • Fluid overload • Fatty liver • Hypokalemia • Increased corticosteroids. • Ketoacidosis • Altered menbrane potential • Impaired Na+K+ ATPase activity • Co-factor for enzymes in oxidative phosphorylation and ATP production • Decreased ventricular mass • Decreased sarcomere contractility • Decreased production of ATP • Rhabdomyolysis Hypo PO4 2- (onset <72 hrs, nadir 7 days) Hypomagnesemia (Onset <72 hrs) HypokalemiaHyperinsulinemia and Hyperglycemia
  56. 56. CLINICAL FEATURES < 2 weeks - Increased weight gain, tachypnoea, features of cardiac failure, dilutional hyponatermia – s/o fluid overload. - Neuromuscular symptoms like weakness, paresthesias, cramps, respiratory muscle weakness – altered membrane potential due to electrolyte imbalance. - Cardiac failure, rhabdomyolysis, altered mental status, confusion, coma, hemolysis, thrombocytopenia and leukocyte dysfunction – hypophosphatemia. - Abdominal distention, increasing hepatomegaly, ascites,– Fatty liver.
  57. 57.  2 weeks - Prominient thoraco-abdominal venous network - Hypertrichosis (after 60 days) - Parotid swelling - Gynaecomastia - Eosinophilia (after 60 days) - Spleenomegaly Cause: Not clear. Probably due to excessive intake of high quality protein during rehabilitation, leading to increase in various trophic hormones produced by the recovering pituitary gland. Gomez et al, Pediatrics 1952; 10:513-526
  58. 58. DIAGNOSIS AND EARLY RECOGNITION IS THE KEY - There is no defined diagnostic criteria for refeeding syndrome in children. - Monitoring of biochemical parameters for hypophosphatemia, hypomagnesemia, hyperglycemia, hypoalbuminemia. - Daily weight monitoring for the initial 7 days. - Goal of weight gain should not be more than 1 Kg/week. - Fluid status (intake/output) should be moniitored. - Cardiorespiratory monitoring during the initial. - Assess frequently for neuromuscular weakness and mental status.
  59. 59. MANAGEMENT - Stop all sources of calorie and protein until the electrolyte imbalances are corrected. - Start with 50% of the caloric intake at which the patient developed symptoms. - Supplement with multivitamins (including thiamine) - Watch for recurrence of refeeding syndrome by monitoring clinical and biochemical parameters daily. - Limit sodium and fluid intake. - Gradually increase the caloric requirement every 3 days. “Start low and go slow”. - Protein restriction is not recommended, 1.5 g/Kg/day rich in essential aminoacids is required for anabolism to occur.
  60. 60. PREVENTION A) MONITORING Before initiating refeeding through any route and during initial 3 – 5 days, - Hydration and fluid assessment. Early weight gain may be secondary to weight gain. - Daily electrolytes: Initial glucose and albumin. Daily sodium, potassium, calcium, phosphorus, magnesium, urea and creatinine. - Cardiac status. (ECG ± ECHO)
  61. 61. B) ORAL FEEDING REGIMEN 1. Initial volume and calories • In more severe cases an initial starting volume of 75% of total daily requirements has been used - < 7 years old - 80–100 kcal/kg/day - 7–10 years - 75 kcal/kg/day - 11–14 years - 60 kcal/kg/day - 15–18 years - 50 kcal/kg/day • If the initial food challenge is tolerated, this may be increased over 3– 5 days (Target 150 kcal/kg/day – Rehabilitation phase). • Each requirement should be tailored to an individual’s need and the above values may need to be adjusted by as much as 30%. • Frequent small feeds (every 2 hrly) are recommended initially. Slowly increase the volume per feed, max of 22 ml/kg/feed (130 ml/kg/day) • Feeds should provide minimum of 1 kcal/ ml (F-100) to minimize volume overload.
  62. 62. 2. PROTEIN • If a milk-based feed induces diarrhoea with positive faecal reducing substances, a hydrolysate may be used. • An initial regimen for malnourished children suggests 0.6–1 g/kg/day • The feed should be rich in essential amino acids and gradually increased as an intake of 1.2–1.5 g/kg/ day is needed for anabolism to occur. • Slowly increase proteins to 4 – 6 g/kg/day during the catch up phase (Rehabilitation phase after 2 weeks). 3. SUPPLEMENTS • Twice the recommended daily allowance for vitamins and minerals (Na, K, Ca, PO). • Supplement with Zinc, copper, folic acid, Vit B12. • Oral Vit A on day 1.
  63. 63. TAKE HOME MESSAGES - Refeeding syndrome is due to the metabolic and hormonal changes that occur due to aggressive nutritional rehabilitation. - START LOW AND GO SLOW. - IDENTIFICATION of patients at risk and monitoring patients during nutritional rehabilitation is the key to prevention. - AWARENESS of the potential complications involved in reintroducing feeds to an undernourished patient is crucial
  64. 64. CRITERIA FOR DISCHARGE FROM NON-RESIDENTIAL CARE  Weight-for-height has reached -1 SD (90%) of NCHS/WHO median reference values  Eating an adequate amount of a nutritious diet that the mother can prepare at home  Gaining weight at a normal or increased rate  All vitamin and mineral deficiencies have been treated  All infections and other conditions have been or are being treated, including anaemia, diarrhoea, intestinal parasitic infections, malaria, tuberculosis and otitis media  Full immunization programme started
  65. 65. FOLLOW UP  Child should be seen after 1week, 2 weeks, 1 month, 3 months and 6 months. More frequently if any problem found.  After 6 months, visits should be twice yearly until the child is at least 3 years old.  The child should be examined, weighed and measured, and the results recorded.  Any needed vaccine, vit A should be given.  Training of the mother should focus on areas that need to be strengthened, especially feeding practices, and mental and physical stimulation of the child.
  66. 66. PREVENTION At national level 1. Nutrition supplementation- Fortification, iodination 2. Nutritional surveillance- define the character and magnitude of nutritional problems and strategies to tackle. 3. Nutritional planning- formulation of nutrition policy, improve food production and supplies, ensure distribution.
  67. 67. PREVENTION At community level- • Health and nutritional education • Promotion of education and literacy in the community • Growth monitoring • Integrated health package • Vigorous promotion of family planning programs
  68. 68. PREVENTION At family level  Exclusive breast feeding  Complementary feeds at 6 months  Vaccination  Spacing between pregnancies
  69. 69. THANK YOU

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