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4                                                    Nutrition                                                    The nutr...
78    NUTRITION4-4 What are the main nutrients in the diet?        Meat, dairy products, beans, peas and lentils          ...
NUTRITION     79formula feeds should be given. If a formula         different nutritional problems. While obesityhas to be...
80    NUTRITIONMalnutrition or a chronic illness should be                                                          Malnut...
NUTRITION      81•     Kwashiorkor                                      address their nutritional problems before they•   ...
82      NUTRITION     facial oedema they may appear ‘chubby’             4-27 How can you determine whether a     and thei...
NUTRITION     83malnutrition while a third of all the world’s               tuberculosis, measles and AIDS oftenchildren a...
84   NUTRITIONSome stunted children are not malnourished        7. Measure the haemoglobin concentrationbut have a medical...
NUTRITION    85   formula 100 ml/kg/24 hours is used for                NOTEA blood transfusion is only used for severe   ...
86      NUTRITION4-42 What is the effect of severe mal-                       planned to fortify both maize flour and brea...
NUTRITION        874-48 How is vitamin A deficiency prevented?             NOTE  The other group B vitamins are thiamine, ...
88      NUTRITION4-53 What is rickets?                                    TRACE ELEMENT ANDRickets is a clinical syndrome ...
NUTRITION    89                                                        Examining a blood smear is a useful way Iron defici...
90       NUTRITION4-61 What are the presenting symptoms                      haemoglobinometer but is more accuratelyand s...
NUTRITION    91medical reason for being underweight-for-age.       is important to watch this child’s weight overThe famil...
92   NUTRITION5. How could the marasmus be prevented?           5. What feeds should be given to this child?If she had bee...
NUTRITION    93deficiency. Cow’s milk is a poor source of iron.   plus a typical smear or low serum ferritinShe may also h...
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Child Healthcare: Nutrition

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Child Healthcare addresses all the common and important clinical problems in children, including:immunisation history and examination growth and nutrition acute and chronic infections parasites skin conditions difficulties in the home and society.

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Child Healthcare: Nutrition

  1. 1. 4 Nutrition The nutritional state is evaluated by clinical Objectives examination to determine whether the child is underweight or overweight, stunted, wasted When you have completed this unit you or obese, or shows any signs of nutritional should be able to: deficiency. Therefore, the nutritional state is an • Define normal nutrition and mal- indirect measure of the child’s diet. nutrition. • List the main food groups. Nutrition is what we eat, while our nutritional • List the important forms of mal- state is what we look like. Good nutrition in a nutrition. healthy child results in a normal nutritional state • Diagnose and manage protein-energy and normal growth. malnutrition. • Diagnose and manage vitamin deficiencies. 4-3 What is normal nutrition? • Diagnose and manage iron deficiency. Children with normal nutrition receive the • List the common causes of anaemia. correct amount of all the essential types of food necessary for normal growth and good health. They have a diet which contains theINTRODUCTION correct amount of each nutrient (food type). Although the type of food varies with age, it is4-1 What is nutrition? important that all children have an adequate diet which contains all the main nutrients inNutrition is the food (diet) that a child eats the correct proportion. If the amount of one orand drinks. more of the nutrients is inadequate, the result is malnutrition. Excessive nutrients can also4-2 What is the nutritional state? cause problems, especially obesity.The nutritional state (or the state of nutrition)is the child’s physical appearance which Good nutrition is a diet which contains the correctindicates whether he/she is well nourished or amount of all the main nutrients.poorly nourished. The nutritional state canalso be affected by medical conditions such aschronic diarrhoea or tuberculosis.
  2. 2. 78 NUTRITION4-4 What are the main nutrients in the diet? Meat, dairy products, beans, peas and lentils contain high quality protein rich in essentialThe major nutrients (food groups) are: amino acids. Maize contains poor quality• Energy foods protein.• Protein foods• Micronutrients 4-9 What are micronutrients?• Water • Minerals and electrolytes such as sodium, potassium, calcium, chloride and4-5 What are energy foods? bicarbonate• Carbohydrates • Trace elements such as copper, zinc, iodine• Fats and oils and selenium • Vitamins such as fat soluble vitamins (A, DBoth carbohydrates and fats are important and E) and water soluble vitamins (B and C)because they provide the body with energy. Too • Ironmuch energy food causes obesity while too littleresults in failure to thrive or even weight loss. 4-10 What is a well-balanced diet?4-6 Which foods are carbohydrates? A well-balanced diet contains adequate amounts of all the major food groups. A dietSugars (simple carbohydrates) and starches that contains too much or too little of one or(complex carbohydrates). Household sugar is more food groups is not balanced. Ideally eachan important source of carbohydrates while meal should contain fat, carbohydrate, proteinsyrup, honey and fruit juice are rich in sugars. and all the essential micronutrients.Common foods that are rich in starches arebread, porridge, potatoes, maize and rice. Many foods are made up of more than one food group, e.g. nuts contain carbohydrates,4-7 Which foods are rich in fats and oils? oils and proteins. Mixing foods can give a balanced meal, e.g. maize for energy withFats are present in food from animals while beans for protein or milk for protein andoils are found in vegetable foods and fish. porridge for energy.Both fats (solids) and oils (liquids) are highin energy. Vegetable oils are better for goodhealth than animal fats. A well-balanced diet contains adequate amountsFoods rich in fat include meat and dairy of all the major food groups.products (milk, cream, butter). 4-11 What foods are needed by children?Foods rich in oils include maize, sunflower oil,margarine, peanuts and fish. All children need a balanced diet, but a child’s age, maturity and physical size determines4-8 Which foods are rich in protein? how this is best achieved. Young children have relatively bigger nutritional requirements perMany animal and vegetable foods contain kg than adults because of their need to grow.proteins. Proteins are made up of amino acids.Unfortunately, many animal sources of protein Infants under 6 months need a liquid dietare expensive. because chewing and swallowing must still develop and mature. Breast milk alone is theAnimal sources of protein include meat, eggs ideal diet (designed by nature) for these infants.and dairy products. It meets the nutritional needs and is a balancedVegetable sources of protein include legumes diet. Breastfeeding avoids the risks attached(beans, peas, lentils), nuts, millet (sorghum) to unsafe handling and contamination ofand, to a lesser degree, maize. alternative feeds. If breast milk is not available,
  3. 3. NUTRITION 79formula feeds should be given. If a formula different nutritional problems. While obesityhas to be chosen, select a suitable commercial is also a form of abnormal nutrition, thestarter formula feed and follow the mixing term malnutrition is usually used to refer toinstructions and recommended volumes as children with undernutrition.given on the tin. Usually one scoop (providedby the manufacturer) of milk powder is addedto 25 ml water. Children with malnutrition are not receiving adequate amounts of one or more importantBeyond 6 months of age the infant’s nutritional nutrient.needs can no longer be met completely bybreast milk or formula alone. Solids must In wealthy countries, obesity is the NOTEbe introduced. Breast milk or formula feeds commonest form of abnormal nutrition.should, however, still form an importantpart of the diet. Soft family foods such as 4-13 How is malnutrition recognisedporridge, mashed vegetables or fruit should clinically?be started. By 8 months children can chew Most children with malnutrition areand ‘finger foods’ can be started. Solids should underweight, stunted or thin. Therefore,be given 3 times a day to infants that are still a child’s size for age can be used to helpbreastfeeding or are formula fed. diagnose malnutrition. These children usuallyBy one year of age most children can be given are deficient in a number of different nutrients.family foods 5 times a day. Small children However, some children may be deficient inhave small stomachs and therefore need more only a single nutrient, e.g. a vitamin deficiency.frequent meals than adults to achieve anadequate total nutritional intake. Breastfeed 4-14 Which children are underweight?as often as the child wants. If possible,breastfeeding should be continued until at least These are children who have a body weight2 years of age. Most children will tolerate cow’s for their age that is below the 3rd centile.milk from 1 year of age. After 1 year of age, a Therefore, they weigh less than the normalnormal child who is not breastfed should not range for their age. Many have beenreceive more than about 500 ml milk per day. underweight for months or years while others have only recently lost weight. MalnutritionComplementary foods are given to fill the should be considered in all underweightgap between the total nutritional needs of the children. There are, however, many causes ofinfant and the nutrition provided by breast being underweight other than malnutritionmilk or formula feeds. Complementary foods (e.g. being born preterm).are usually not needed before 6 months. NOTE The advantages and risks of breastfeeding Malnutrition must be considered in all must be carefully considered in infants born to HIV positive women. underweight children. 4-15 Which children are stunted?MALNUTRITION These children have a height less than the 3rd centile. They are, therefore, shorter than normal. Stunting suggests slow growth4-12 What is malnutrition? for a long time. Most stunted children areAn abnormal nutritional state can be caused also underweight but often do not appearby too little or too much of one or more wasted. As a result their poor growth is oftenof the important food groups in the diet. not recognised if they are not measured.Abnormal nutrition leads to a number of
  4. 4. 80 NUTRITIONMalnutrition or a chronic illness should be Malnutrition is a common cause of childhoodconsidered in all stunted children. death, especially in poor countries. Stunting always suggests a chronic health 4-18 How is a clinical diagnosis of problem or malnutrition. malnutrition confirmed? By taking a careful dietary history. You must4-16 Which children are wasted? ask about the type of food, amount of foodA wasted child has lost weight with a weight and frequency of feeds. If the diet appears tofor height below the 3rd centile Wasting be good according to the mother’s history,can be diagnosed by clinically examining consider a disease such as chronic diarrhoeathe child. These children have very little or infection as the cause of the child’s poorsubcutaneous fat and muscle. Their arms and nutritional state. Many illnesses can lead tolegs are particularly thin and they have loose malnutrition, e.g. measles. Sometimes, only askin and soft tissue around the upper arms response to a good diet confirms the diagnosisand thighs. Wasting is an important sign and of malnutrition due to a poor diet.must always be taken seriously. It indicatesa recent serious loss of weight. Wasting in The diagnosis of malnutrition is confirmed bychildren indicates either fairly recent onset taking a careful dietary history.of malnutrition or they have a serious illnesssuch as malabsorption, malignancy or chronicinfection (such as tuberculosis or HIV). 4-19 What are the common forms of malnutrition? Wasting is an important sign of malnutrition. • Protein-energy malnutrition • Vitamin deficienciesAssessing weight, height and weight for height • Trace element deficiencyby the correct use of centile charts is discussedin Unit 3. PROTEIN ENERGY NOTE Measuring the mid upper arm circumference is a good screening test for MALNUTRITION wasting. These children will also have a low body mass index. 4-20 What is protein-energy malnutrition?4-17 Why is malnutrition important? Protein-energy malnutrition (PEM) consistsBecause malnutrition is common, especially of a range of clinical conditions caused by ain poor countries. It is directly or indirectly lack of both protein and energy in the diet (i.e.responsible for half of all deaths worldwide in general undernutrition). PEM ranges from mildchildren under 5 years of age. Unless managed to severe and the clinical presentation dependscorrectly, the mortality rate from severe on the degree of deficiency and precipitatingmalnutrition can be as high as 50%. factors such as infection. Most children with PEM have both weight and height below theMalnutrition is closely linked with both normal range, i.e. they are stunted.poverty and ignorance. Preventingmalnutrition is one of the main goals of 4-21 What are the forms of protein-energyprogrammes that address poverty. malnutrition? • Underweight for age (UWFA) • Marasmus
  5. 5. NUTRITION 81• Kwashiorkor address their nutritional problems before they• Marasmic kwashiorkor become worse.Children with marasmus, kwashiorkor ormarasmic kwashiorkor have severe mal- 4-24 What is marasmus?nutrition. These different forms of severe This is the commonest form of severemalnutrition are often considered together as malnutrition. The child’s weight is far belowtheir causes are similar and they are managed the 3rd centile and lies below 60% of the 50thin the same way. centile (the ‘marasmus line’). These children usually appear very thin (severely wasted) Children with severe malnutrition have signs of and are often ill. They do not have oedema. Marasmus is usually due to starvation or marasmus or kwashiorkor or both. severe illness such as malabsorption or AIDS.These different forms of malnutrition areidentified by the child’s weight for age, the Children with marasmus are severelydegree of wasting, and by the presence or underweight for their age.absence of oedema of the feet. In addition toexamining and measuring these children, it is NOTE Children with marasmus have a weight-important to also obtain as detailed a dietary for-height less than 60% of expected (underhistory as possible. 3 SD below the mean). Some serious medical conditions (e.g. malabsorption) can also result in marasmus.4-22 Which children are underweight-for-age? The severe wasting is best seen on the buttocks, thighs and upper arms where the skin hangsUnderweight-for-age (or ‘low weight’) is in folds. The ribs and shoulder blades stickdefined as a weight for age that falls below the out and the abdomen is usually distended due3rd centile. This means that they weigh less to decreased muscle tone. They are anxious,than the normal range. Many of these children irritable, cry easily and look like an old person.are ‘failing to thrive’. They appear clinically welland do not look undernourished. They do not NOTE Anorexia nervosa causes marasmus in olderhave oedema. Unless they are weighed, and children and adolescents.their weight is plotted on a centile chart, thediagnosis is frequently missed. Underweight- 4-25 What is kwashiorkor?for-age is the commonest form of malnutrition. This is another severe form of protein-energy malnutrition. These children present with Being underweight-for-age is the commonest a characteristic syndrome which always form of malnutrition. includes oedema, especially of both feet and legs. Kwashiorkor usually occurs in children NOTE Using the Wellcome classification of PEM, between 6 months and 2 years of age. It is an children who are UWFA have a weight which acute problem which is often precipitated by is between 60 and 80% of the median (50th an infection such as gastroenteritis in a child centile). who is already underweight for age. These children have a typical appearance:4-23 Why is it important to detect • They are miserable, with a poor appetite.underweight-for-age children? • They have oedema of their legs and theirMarasmus and kwashiorkor are always face looks swollen with fat cheeks. Pressingpreceded by ‘underweight-for-age’. Therefore, on the back of each foot for a few secondsit is important to identify these children and will show the pitting of oedema. Due to the
  6. 6. 82 NUTRITION facial oedema they may appear ‘chubby’ 4-27 How can you determine whether a and their wasting is often missed. child has malnutrition?• Their hair is sparse, fine and may have a 1. Take a careful dietary and family history. reddish colour. 2. Examine the child fully.• They have areas of increased or decreased skin pigmentation with scaling, especially in the nappy area (flaky-paint rash). There 4-28 How can the history help in the may also be areas of skin which are wet and diagnosis of malnutrition? look like burns. The skin is easily damaged The following needs to be known: and may be ulcerated. Secondary bacterial skin infection is common. 1. Is the child still breastfed?• They have a distended abdomen and an 2. What is the usual diet (type, amount and enlarged liver. frequency of feeds or meals)?• Angular stomatitis is common with painful 3. What is the child’s appetite like? cracking at the angles of the mouth. 4. Are there any signs of illness, e.g.• Their nails are pale. diarrhoea, vomiting or cough?• Their weight usually falls below the 3rd 5. The family background (income, parents, centile but above 60% of the 50th centile. carers, abuse) Some infants have a normal weight because 4-29 How can a general examination help of their oedema. in the diagnosis of malnutrition?• They often have signs of anaemia and vitamin deficiency. The weight and length must be measured and plotted on a growth chart. NOTE While the underlying cause of PEM is an intake of protein and energy that is insufficient A full general examination must be done, to maintain health, not all children with severe looking particularly for signs of: malnutrition develop kwashiorkor. The clinical disease is precipitated by an additional stress • Severe malnutrition (e.g. oedema and such as infection. wasting) • Vitamin deficiencies NOTE Using the Wellcome classification of PEM, children with kwashiorkor have a weight which • Dehydration is usually below the 3rd centile together with • Pallor (due to anaemia) nutritional oedema. • Illness, e.g. diarrhoea, tuberculosis or AIDS Most children with severe malnutrition will4-26 What is marasmic kwashiorkor? have other signs of kwashiorkor or marasmus.These severely malnourished children have They may also have signs of vitamin or traceclinical features of both marasmus and element deficiencies. Severe malnutrition is,kwashiorkor. They are severely underweight therefore, a clinical diagnosis which can be(below 60% of the 50th centile) but also have made by examining the child and plotting theoedema. Children with marasmus may rapidly child’s weight and height.deteriorate, especially if they develop aninfection, and present with oedema to become Malnutrition is a clinical diagnosis based onmarasmic kwashiorkor. history and examination. NOTE Using the Wellcome classification of PEM, children who have marasmic kwashiorkor have a 4-30 How common is protein-energy weight which is below 60% of the median (50th centile) and also have oedema. malnutrition? This is very common in poor countries. It is estimated that 170 million children in the world suffer from severe protein-energy
  7. 7. NUTRITION 83malnutrition while a third of all the world’s tuberculosis, measles and AIDS oftenchildren are undernourished (30% of all precipitate kwashiorkor.children are underweight and 37% stunted). • Hypoglycaemia due to loss of energy stores NOTE In South Africa 10% of children are • Hyothermia underweight and 25% stunted. Less than 5% • Heart failure due to a small, weak heart are wasted. Therefore, chronic malnutrition is • Bleeding, usually purpura common. • Anaemia due to protein and iron deficiency4-31 What factors are commonly associated • Electrolyte imbalances, especiallywith malnutrition? potassium deficiency • MalabsorptionMalnutrition is usually due to an inadequate diet. • Tremors (‘kwashi shakes’)However, the cause is often complex and related • Sudden deathto poverty. Common associated factors are: About 25% of children with kwashiorkor die• Poverty despite treatment. The long-term effect of• Ignorance severe malnutrition on growth and mental• Parental neglect and deprivation development remain uncertain as these• Poor health services children are also affected by a deprived• Frequent infections, especially diarrhoea environment. and measles• AIDS• Displaced families, drought, famine and war Hypoglycaemia, hypothermia, infection and heart failure are the main causes of death inPoor education of women, unemployment,young mothers, poor social support in the severe malnutrition.community, war and violence, neglect andabuse, no breastfeeding, and low birth weight NOTE Children with kwashiorkor have a low serum albumin, potassium, magnesium, sodium,are all common in communities with a copper and zinc. Also low glucose, transferrin andhigh prevalence of malnutrition. Failing to clotting factors.breastfeed in poor, rural communities willalmost certainly lead to malnutrition. 4-33 How are malnutrition and infectionIn some children, malnutrition is not caused related?by a poor diet but is due to an illness which Severe malnutrition weakens the immuneprevents the body from using food that is eaten. system and makes the child more susceptibleChronic diseases and malabsorption may result to infections such as gastroenteritis, measles,in malnutrition in spite of a normal diet. tuberculosis and AIDS. In turn infection (especially diarrhoea) often precipitates severe Poverty, infection and malnutrition commonly malnutrition in a child who is underweight- form a devastating cycle in poor communities. for-age.4-32 What are the complications of severe 4-34 Is malnutrition always due to a poormalnutrition? diet?These are usually seen in kwashiorkor and No. Some children who fail to thrive aremarasmic kwashiorkor: receiving a good diet. They usually have a severe, chronic illness, such as tuberculosis,• Serious infections, especially septicaemia AIDS, malignancy, bowel or liver disease, or or pneumonia. Gastroenteritis, cerebral palsy. AIDS is a common cause of failure to thrive in Africa.
  8. 8. 84 NUTRITIONSome stunted children are not malnourished 7. Measure the haemoglobin concentrationbut have a medical condition or had a very and treat anaemia with oral iron.low birth weight. Chronic emotional stress canalso cause stunting. Good nutrition will correct growth in most children that are underweight.4-35 What is the management of anunderweight-for-age child? 4-36 What is the management of severe1. A careful history, physical examination and malnutrition? review of the weight and height (and head circumference in infants) growth curves is The management of children with marasmus, essential to establish the pattern of growth kwashiorkor and marasmic kwashiorkor (i.e. and the underlying cause of the failure to severe malunutrition) is very similar and, thrive. Treat any medical problem. therefore, can be considered together.2. The child should be given a normal, These children are seriously ill and all well-balanced diet (a trial of feeding) if must be urgently admitted to hospital. The malnutrition is diagnosed. Frequent small management consists of: feeds increase the total food intake and should be given at least 5 times per day. 1. Initial resuscitation Peanut butter, vegetable oil or sugar added 2. Nutritional rehabilitation to the staple diet can be used to increase 3. Follow up energy intake. Cheap forms of protein (milk powder, peas, beans) must be encouraged. 4-37 What resuscitation is needed? Food supplements are available at clinics Infants presenting with severe malnutrition and hospitals under the state’s nutrition (especially kwashiorkor) are very sick and programme for qualifying families. a number will die within a week of starting3. The child must be closely followed for treatment. They must all be hospitalised 2 weeks. If there is no weight gain, the immediately. This phase of treatment usually child must be admitted to hospital for a lasts about a week: controlled trial of feeding and possibly further investigation. 1. Correct and avoid hypoglycaemia,4. If there is weight gain, the child must hypothermia or dehydration. Check the be carefully followed with repeat weight blood glucose 6 hourly for the first few checks to ensure that weight gain days and whenever the child’s temperature continues. Height will only be gained after falls below 35.5 °C. A feed of 50 ml a few months of satisfactory weight gain. of 10% glucose orally should correct5. The underlying cause of the poor feeding hypoglycaemia. Correct any dehydration must be addressed or the problem will slowly with oral fluids. Avoid intravenous simply recur. Nutritional education of the fluids if possible. Do not use diuretics to mother is essential. Financial aid may be reduce the oedema. needed. 2. Give broad spectrum antibiotics (ampicillin6. It is best to deworm the child and give and gentamicin if clinically septic or co- vitamin A according to the national vitamin trimoxazole if there is no obvious site of A policy as many underweight for age infection) to all children for a week. Assume children have worms and are likely to have that all children with severe malnutrition mild vitamin A deficiency. Multivitamin have a bacterial infection. syrup is needed during the phase of catch- 3. Start with oral or nasogastric feeds every up growth and also if the usual diet is 3 hours, both day and night, as soon as deficient in fresh vegetables or fruit. possible. Usually a starter formula or, if diarrhoea is present, a lactose-free
  9. 9. NUTRITION 85 formula 100 ml/kg/24 hours is used for NOTEA blood transfusion is only used for severe the first week. High volume feeds may anaemia with associated cardiac failure. Extra cause heart failure. magnesium is often added to feeds.4. Give oral potassium chloride 0.5 g/kg/day (4 to 6 mmol/kg/day) as these children 4-39 How can you prevent malnutrition are severely potassium depleted, especially recurring? children with kwashiorkor. Also give extra 1. The mother or caregiver must be given the magnesium, 0.4 to 0.6 mmol/kg/day, as well education and financial support to provide as zinc 2 mg/kg/day, folic acid 5 mg per a good diet. day, multivitamin syrup 10 ml per day and 2. Regular follow up with weighing is essential. vitamin A 50 000 to 100 000 units on day 1.5. Do not give oral iron yet. Iron can be very There is a real risk that malnutrition will recur dangerous as these children do not have in a previously malnourished child as it is enough protein to carry iron safely in the very difficult to correct social and economic blood stream. problems in a family and community. Give frequent, small lactose-free feeds for the Start treating the malnutrition immediately and first week. do not wait to treat the infection first.4-38 What nutritional rehabilitation is 4-40 How should you address therequired? underlying causes of malnutrition?This phase of treatment starts when the appetite An aggressive attempt must be made to breakimproves and the child is looking better: the cycle of ignorance, poverty, malnutrition and emotional deprivation. Socio-economic1. Once the appetite has returned and any factors are most important. The answers lie oedema has improved, a weaning (follow- in the family and community rather than in on) formula with a higher protein content the primary health care system. Employment, can be started in infants. As the older education, social upliftment, pride and child improves, porridge and mixed foods, responsibility are vitally important. The level especially maize, beans and dried peas, can of childhood malnutrition is a good measure be started. Vegetable oils can be added for of the health and wellbeing of the community. energy. A high energy and protein diet is needed. Start introducing solid foods slowly. The sources of inexpensive protein, such as During this phase, children are often very beans, must be stressed. hungry and take a lot of food. The first sign of recovery is when the child starts to smile. 4-41 What can be done to prevent2. Continue folic acid 5 mg daily for 5 days. malnutrition in poor communities?3. Continue multivitamin syrup 10 ml daily. • Breastfeeding to 6 months of age or longer4. Treat for worms with mebendazole 100 mg • Complementary feeding from 6 to 24 twice daily for 3 days and metronidazole months (breast milk plus solids) (Flagyl) 7.5 mg/kg 8 hourly for 7 days for • Prevent infections, especially diarrhoea Giardia. • Routine weighing, immunisation and use5. Oral iron 6 mg elemental iron/kg/day for of the chart in the Road-to-Health Card 12 weeks, starting ONLY when the child • Social support for mothers is gaining weight and any oedema has • School feeding projects disappeared.6. Monitor daily weight gain.
  10. 10. 86 NUTRITION4-42 What is the effect of severe mal- planned to fortify both maize flour and breadnutrition on a child’s mental development? with folate, vitamin A and vitamin B complex.Severe malnutrition results in poor growth 4-46 Which children are at greatest risk ofand wasting of the brain. These children are vitamin A deficiency?lethargic, not interested in their surroundings,irritable and unhappy. Often they are not given • Infants who are not breastfedthe stimulation and love needed for normal • Low birth weight infantsmental and behavioural development. • Underweight infants on a poor diet • Infants with diarrhoea, measles,Once they start recovering and smiling, they tuberculosis or AIDSneed to be stimulated and given a lot of lovingattention. The hospital ward should provide a Vitamin A deficiency is particularly importanthappy, stimulating environment with play and as it is common in most poor countries andphysical contact. With good nutrition, loving contributes to the death of many children.care and stimulation, many children will It is estimated that as many as 25% of youngrecover physically and intellectually. children in South Africa are deficient in vitamin A, especially in rural areas.4-43 What are micronutrients?In contrast to the major components of Vitamin A deficiency is common in South Africa,the diet (proteins, carbohydrates and fats), especially in poor rural communities.micronutrients are needed in much smalleramounts. Micronutrients can be divided into: 4-47 How does vitamin A deficiency• Vitamins present?• Trace elements (minerals) Mild vitamin A deficiency usually does not• Iron present with any gross clinical signs. Yet it is very important because it is associatedVITAMIN DEFICIENCIES with loss of appetite, poor growth and severe infections (especially gastroenteritis and measles) and increased mortality.4-44 What are vitamins?Vitamins are essential items in the diet, which Vitamin A deficiency results in an increased risk ofare needed for healthy growth and normal severe infections.metabolism. A deficiency of one or morevitamins (hypovitaminosis) causes nutritional Severe vitamin A deficiency causes eyeillness. problems and presents with photophobia (keep eyes closed in bright light), night4-45 What are the common vitamin blindness (unable to see in poor light) anddeficiencies in children? xerophthalmia (dry eyes). It also causes• Vitamin A deficiency corneal clouding, ulcers and softening• Vitamin B group deficiencies (e.g. pellagra) (keratomalacia) which can lead to corneal• Vitamin C deficiency (scurvy) scarring and blindness. Severe vitamin A• Vitamin D deficiency (rickets) deficiency is the commonest preventable cause• Vitamin K deficiency (haemorrhagic of blindness in children in poor countries. disease in newborn infants) NOTE A patch of dry, raised conjunctiva (appears foamy) over the sclera is called a Bitot’s spot. NOTE In South Africa maize meal is now fortified Vitamin A deficiency causes blindness in half a with folic acid. Many bakeries also fortify their million children worldwide annually. wheat flour used for bread with folic acid. It is
  11. 11. NUTRITION 874-48 How is vitamin A deficiency prevented? NOTE The other group B vitamins are thiamine, riboflavin, B12 and pyridoxine. Folate can beOne of the major challenges to health care of added to basic foods to reduce the prevalence ofchildren in the world today is to get vitamin neural tube defect in newborn infants.A supplementation or fortification intocommon foods. Vitamin A supplementation 4-51 What is pellagra?significantly reduces children’s risk of dyingfrom infectious diseases. This is a condition caused by niacin deficiency. It is seen in communities who depend on aOne method of supplementing vitamin A maize diet. In children, pellagra presents withis to give a single 50 000 unit dose of oral a skin rash on areas exposed to the sun (face,vitamin A to all children at 6 weeks as part neck and chest in a necklace distribution, armsof the routine immunisation schedule. This and legs). The rash is erythematous (red) oris followed by 100 000 units at 9 months and pigmented and may be scaly.then 200 000 units at 12 months and every 6months thereafter until 5 years. All children Pellagra is treated with nicotinic acid 100 mgwith measles should be given 200 000 units of orally, every 4 hours for 3 days. Advise onvitamin A orally daily for 2 days. a balanced diet with beans and peas added to maize. Pellagra patients are usually alsoThe body can make vitamin A from carotene generally malnourished.which is present in yellow fruits and vegetables(e.g. mangoes, pawpaws, carrots, pumpkin,butternut, sweet potatoes) as well a green leafy Pellagra presents with a pigmented, scaly rash onvegetables (e.g. spinach). Vitamin A is present exposed areas.in breast milk, liver, butter and margarine.Vitamin A fortification of basic foods is 4-52 What is scurvy?another method of ensuring adequate amountsof vitamin A in the diet. Scurvy is caused by a lack of vitamin C, which is found in fruits and vegetables. It is uncommon in older children but sometimes Yellow fruit and vegetables are rich in vitamin A. is seen in infants on a poor diet without breast milk (which is rich in vitamin C). Scurvy4-49 How is vitamin A deficiency treated? causes painful, tender bones (due to bleeding under the periosteum) which presents inChildren with signs of severe vitamin A infants with irritability and crying whendeficiency (eye signs) are treated with 100 000 handled. They do not like moving their legsunits of oral vitamin A daily for 2 days followed and may be misdiagnosed as osteitis, paralysisby a third dose at 6 weeks. Children with mild or battering. Bleeding gums are rare as theysigns only should receive 100 000 units once if only occur in children old enough to havethey are one year or less, and 100 000 units daily teeth. An X-ray of the long bones showsfor two days if they are over one year. diagnostic lifting of the periosteum.4-50 What are the B group vitamins? Scurvy is treated with 250 mg vitamin C orally 4 times a day for 5 days. Correct the diet.These are a group of water-soluble vitaminsthat are not stored in the body and therefore NOTE The prevention of scurvy, through the provision of fruit and vegetables, on the longhave to be present in the diet on a continuous sea voyage from Europe to the spice islands ofbasis. While folic acid deficiency may be Indonesia and Malaysia, was the reason for theseen with severe malnutrition and intestinal colonisation of the Cape by the Dutch in 1652.parasites, only niacin deficiency is common insome areas in South Africa. Deficiencies of theother group B vitamins are rare.
  12. 12. 88 NUTRITION4-53 What is rickets? TRACE ELEMENT ANDRickets is a clinical syndrome of deformities of MINERAL DEFICIENCIESgrowing bones and delayed physical milestonesusually caused by a lack of vitamin D. VitaminD is present in a mixed diet and can be made 4-54 What are trace element and mineralin the skin if the child is exposed to sunlight. deficiencies?In South Africa nutritional rickets is usuallyseen in preterm infants who are exclusively The important trace elements are iodine,breastfed and not exposed to sunlight. Breast fluoride and zinc, while the common mineralsmilk contains little vitamin D. Infant formulas are sodium, potassium, calcium, magnesiumare supplemented with vitamin D. Once infants phosphate and iron.start walking, they usually have adequate sun • Iodine deficiency causes thyroidexposure to make their own vitamin D. enlargement (goitre) and hypothyroidismRickets in infants presents with soft, deformed (with retarded mental development).bones, resulting in: This is uncommon in South Africa due to iodine being added to table salt. However,• A ‘rickety rosary’ with swelling of the ribs it is still seen in mountainous regions where bone meets cartilage where rock salt or non-iodated salt is used.• A chest deformity with a horizontal groove • Fluoride deficiency is common in some overlying the diaphragm attachment to the regions of South Africa and results in ribs (Harrison’s sulcus) dental caries. It is prevented by fluoridation• Craniotabes with a softened ‘ping-pong’ of drinking water. skull above the ears • Zinc deficiency may result in growth• Thickened wrists and ankles failure and an increased risk of infections.• Decreased muscle tone, giving a distended Weekly zinc supplements decrease the abdomen incidence and severity of both pneumonia• Delayed physical milestones and diarrhoea. Zinc fortification of food is• An increased risk of pneumonia an important method of providing adequateTreatment consists of 1000 units of oral amounts of zinc in the diet. .vitamin D daily for a month by which time • Calcium and phosphate deficiency maythere should be radiological confirmation cause rickets and increase the risk ofof healing. Increase exposure to sunlight for osteoporosis in adult life. It is prevented by30 minutes a week. For prevention vitamin including milk in the diet.D 400 units daily (in 0.6 ml of multivitamin Trace element and mineral deficiency is bestdrops or 5 ml vitamin syrup) should be given avoided by taking a well-balanced diet.to preterm infants for 6 months as they are athigh risk of developing rickets. NOTE Rickets due to calcium deficiency can IRON DEFICIENCY occur in older children on a diet which has adequate vitamin D but is low in calcium (e.g. maize without milk). There are also rare renal and 4-55 How common is iron deficiency? metabolic causes of rickets in children who do not respond to the standard treatment. Vitamin Iron deficiency is common in South Africa D deficiency in adolescents (osteomalacia) and many poor countries. It is usually seen in presents with bone pain, muscle weakness and young children, especially between the ages of hypotonia. Hypovitaminosis D can be confirmed 6 months and 2 years when breastfeeding has by finding a low concentration of serum 25 been stopped. hydroxycholecalciferol.
  13. 13. NUTRITION 89 Examining a blood smear is a useful way Iron deficiency is common in South Africa. of screening for iron deficiency. Children with iron deficiency also have a low serum4-56 What are the common causes of iron concentration of ferritin. This will prove thedeficiency in children? diagnosis. With severe iron deficiency the1. Iron deficiency is usually due to inadequate child will develop anaemia. The haemoglobin amounts of iron in the diet. However it concentration is usually normal with mild iron is often made worse by chronic bleeding deficiency. from the gut due to intestinal parasites.2. Cow’s milk contains little iron. Fortunately, 4-59 How can iron deficiency be most formula feeds contain additional iron prevented? which has reduced the incidence of iron 1. By giving a good, balanced diet deficiency in most formula-fed infants. 2. By regularly deworming children3. Immediate clamping of the umbilical cord 3. By waiting until the infant cries before at birth deprives the newborn infant of clamping the umbilical cord after birth much iron, while preterm infants have low 4. Children at high risk of iron deficiency, iron stores. such as preterm infants, should be given prophylactic oral iron. Once Iron deficiency in children is usually due to a poor discharged home, preterm infants should diet and worms. receive ferrous lactate drops 0.6 ml (e.g. Ferrodrops) daily until 6 months of age.4-57 What are the clinical signs of irondeficiency? Always store iron drops, syrup and tablets away safely where children cannot get them.Iron deficiency results in lethargy, poorappetite, eating soil (pica) and poor school NOTE The prophylactic dose of iron is 1 mg ofperformance. If the iron deficiency is severe elemental iron/kg/day while the therapeutic doseenough, anaemia will develop as the result of is 1–2 mg of elemental iron/kg 3 times a day.inadequate amounts of iron to produce normalred cells. Therefore, anaemia is the commonest 4-60 What is anaemia?clinical presentation of iron deficiency.However, children with mild iron deficiency Anaemia is a haemoglobin concentrationmay not yet be anaemic and the diagnosis of below the normal range for the age of theiron deficiency is often missed. child. Children with anaemia also have a low packed cell volume. The haemoglobinMild iron deficiency, (i.e. without anaemia), concentration (Hb) normally falls for theis usually managed by improving the diet to first 3 months of life and then rises again atmake sure the child receives adequate amounts puberty. The normal Hb in children is aboutof iron. Meat, eggs and green vegetables are 11 g/dl with a lower limit of 9 g/dl. Childrenrich in iron. with a Hb below 9 g/dl are therefore anaemic.4-58 How is the diagnosis of iron deficiency Anaemia is not a disease but the result ofconfirmed? many nutritional and medical problems. Iron deficiency is not the only cause of anaemia.With iron deficiency, the red cells usuallyappear small and pale on a blood smear(microcytic and hypochromic red cells). Children with a haemoglobin concentrationTherefore, this finding strongly suggests iron below 9 g/dl are anaemic.deficiency even if anaemia is not yet present.
  14. 14. 90 NUTRITION4-61 What are the presenting symptoms haemoglobinometer but is more accuratelyand signs of anaemia? measured with a full blood count. 2. Examination of a peripheral blood smear• Tiredness and general apathy to show small, pale red cells• Pallor of the nails and mucus membranes 3. A trial of iron treatment (i.e. pale)• Heart failure, with shortness of breath on NOTE Finding a low mean red cell size and effort, in severe anaemia haemoglobin concentration on a full blood count will confirm the finding of microcytosis andAnaemia plus bruising or purpura, hypochromia on a peripheral smear.hepatosplenomegaly, bone tenderness orjaundice, suggest a serious illness and are 4-64 What is the treatment of ironindications for urgent referral to hospital. deficiency anaemia? Oral iron should be given for 4 weeks and4-62 What are the common causes of the Hb should then be checked. If the Hb hasanaemia in children? improved, the oral iron should be continued• Iron deficiency: for another 2 months to replace the iron • Early clamping of the umbilical cord stores. Therefore, full treatment is oral iron at birth (reduces the newborn infant’s for 3 months. If the Hb has not increased by iron stores) 4 weeks the child must be referred for further • Preterm birth (preterm infants have investigations. low iron stores) Iron deficiency anaemia is treated with ferrous • A diet deficient in iron gluconate (or sulphate) syrup 0.25 ml/kg 3• Intestinal parasites times a day. Always deworm the child with• Repeated nose bleeds mebendazole or albendazole.• Haemolysis, due to: • Malaria All anaemic children with signs of heart failure • Inherited blood disorders (e.g. must be urgently referred to hospital as they spherocytosis, thalassaemia or sickle may need a blood transfusion. cell disease) The commonest mistake in treating iron• Chronic illness, such as tuberculosis and deficient anaemia is stopping the oral iron too AIDS soon.• Severe malnutrition (due to lack of protein to produce haemoglobin) NOTE Less common causes include malignancies, CASE STUDY 1 bleeding disorders, folate deficiency, drug side effects and stomach ulcers. A 5-year-old child attends a clinic where heIron deficiency is by far the commonest cause is weighed. The weight is then plotted on theof anaemia of children in South Africa and weight-for-age chart in his Road-to-Healthmost poor societies. Card. His weight falls just below the 3rd centile. He appears generally well but thin. The mother Iron deficiency is the commonest cause of is out of work and has no financial support. anaemia in children in South Africa. 1. Does this child have malnutrition?4-63 What is the simplest method of Yes. He probably has mild protein-energyconfirming anaemia due to iron deficiency? malnutrition. He is underweight-for-age as his weight falls just below the 3rd centile. There1. Showing that the Hb is low (below is no evidence on the history that there is a 9 g/dl). This can be done with a
  15. 15. NUTRITION 91medical reason for being underweight-for-age. is important to watch this child’s weight overThe family history suggests that there is not the next few months to make sure that he isenough money for an adequate balanced diet. gaining weight adequately. It would be wise to give him 200 000 units of oral vitamin A as he2. How would you confirm the diagnosis? is probably deficient in vitamin A.Firstly, by taking a dietary history andconfirming that he receives a poor diet.Secondly, by demonstrating weight gain when CASE STUDY 2his diet is improved. An 18 month old child is seen at a local hospital. The child is very thin and wasted. Her3. What is the danger of being underweight- weight falls well below the 3rd centile (alsofor-age? below 60% of the 50th centile). There is no rashChildren who are underweight-for-age are at or oedema. She is pale and has thickening ofhigh risk of developing a more severe form her wrists and ankles. The mother was drunkof protein-energy malnutrition if their diet when she brought the child to hospital.becomes worse or they have an infectionsuch as diarrhoea or measles. Children who 1. What is your diagnosis?are underweight-for-age have a weakened(suppressed) immune system and, therefore, Marasmus. The weight falls far below the 3rdare also at increased risk of a serious infection centile (below 60% of the 50th centile). Thesuch as tuberculosis. cause is almost certainly starvation and neglect.4. What is the value of examining this 2. What should be the initial treatment?child’s growth curve and growth pattern? Admit the child immediately to hospitalThe growth curve will show whether he has for resuscitation. Look for and treat anybeen underweight-for-age for a long time hypothermia, dehydration or hypoglycaemia.or has only recently lost weight. The growth Small oral or nasogastric feeds should bepattern would also be helpful as a height below started. If possible, do not start an intravenousthe normal range will indicate stunting while a infusion. Start antibiotics even if there is nonormal height will suggest recent weight loss. obvious infection. Her social circumstancesRecent weight loss may suggest an infection will have to be investigated and managed.such as AIDS. 3. Why is the child pale?5. What are energy foods? She probably has iron deficiency anaemia due• Carbohydrates such as bread, maize, to a poor diet and possibly because of chronic potatoes, rice, porridge and sugar. infection. Only once she is taking feeds well• Fats, such as dairy products, or vegetable and looking better should oral iron be started. and fish oils. 4. What additional diagnosis is suggested6. What dietary management does this by the swelling of her wrists and ankles?child need? Rickets, due to a deficiency of vitamin DHe needs enough of a balanced diet. His in her poor diet. She has probably alsomother needs to be told what cheap foods are had very little exposure to sunlight. Thehigh in protein and energy (maize together treatment would be 1000 units vitamin Dwith beans or milk mixed with porridge). She daily for a month. She almost certainly needsalso needs social and financial assistance. It a multivitamin syrup as she is probably deficient in other vitamins as well.
  16. 16. 92 NUTRITION5. How could the marasmus be prevented? 5. What feeds should be given to this child?If she had been taken to the local clinic for Children with severe malnutrition are usuallyroutine weighing every month her failure to started on lactose-free feeds. Small feeds arethrive would have been detected before she given at first as a high volume intake can causereached the stage of severe malnutrition. Steps heart failure. Potassium is added to their feedscould then have been taken to manage the as they are severely potassium depleted. Oncenutritional and social problems. he is improving he can be given follow-on formula.CASE STUDY 3 6. What cheap food gives high quality protein?A very miserable child is seen at an urban Breast milk, provided the mother can beclinic after he had been brought from a poor traced and convinced to restart breastfeeding.rural district by his grandmother. He appears Otherwise, milk powder or beans can be addedswollen, with oedema of the face and legs. to the diet to increase the amount of protein.There is a pigmented, scaly rash on the trunkand legs. His weight is plotted on the 3rd 7. What other form of malnutrition cancentile but this falls to below the 3rd centile cause a pigmented, scaly rash?during his first week in hospital. His hair isvery thin and he has a bad cough. Pellagra, due to niacin deficiency. The rash usually occurs on the face, neck and chest in1. What is wrong with this child? a necklace distribution, arms and legs (i.e. exposed areas).He has all the clinical signs of kwashiorkor:misery, oedema, thin hair and a rash. Oftenchildren with kwashiorkor are not veryunderweight when they present as they are CASE STUDY 4oedematous. Their weight often falls markedlywhen they lose their oedema. An 18 month old girl presents with a history of poor feeding and eating sand. On examination she has a normal weight for age and appears2. Why is this child severely malnourished? generally well. However her nails and tongueProbably as the result of poverty. There may are pale. The mother says that she drinks a lot ofbe a drought in the rural area. Sometimes cow’s milk and does not want to eat solid foods.only maize meal is available (which is low inprotein). 1. Why is this child pale? She is probably anaemic.3. What diagnosis could the coughsuggest? 2. How would you confirm this diagnosis?He may have tuberculosis. This will need to beinvestigated. By measuring her haemoglobin concentration which should be about 11 g/dl. A concentration below 9 g/dl at her age would indicate anaemia.4. Is kwashiorkor a fatal illness?Up to 25% of children with kwashiorkor will 3. What do you think is the most likelydie despite treatment. cause of her anaemia? Iron deficiency. Eating sand (pica) and a poor appetite are common in children with iron
  17. 17. NUTRITION 93deficiency. Cow’s milk is a poor source of iron. plus a typical smear or low serum ferritinShe may also have intestinal parasites. would confirm the diagnosis of iron deficiency. The diagnosis would be supported if the Hb4. What is a simple method of confirming increased with a month of iron treatment.iron deficiency anaemia? 5. What is the management of ironBy measuring the haemoglobin concentration deficiency anaemia?and then examining a peripheral blood smear.Small pale red cells strongly suggest iron Ferrous gluconate (or sulphate) syrup 0.25 ml/deficiency. The presence of iron deficiency kg 3 times a day for 3 months. She should alsocan be proved by a low serum ferritin be ‘dewormed.’concentration. Therefore, a Hb below 9 g/dl