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MSc nursing- pediatrics
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WelcomeMs. Shesly P. JoseII yr MSc Nursing
MALABSORPTION SYNDROME
AND MAL NUTRITION
MALABSORPTION SYNDROME
Malabsorptionsyndromes encompass
numerous clinical entities that result in chronic diarrhea, abdominal distention, and failure to thrive.
MALABSORPTION SYNDROME
Celiac disease (CD) or Gluten- induced enteropathy
(GSE ) and celiac sprueDisease of the small intestine characterized by abnormal mucosa and permanent intolerance to gluten.
CD is second only to cystic fibrosis as a case of malabsorption in children
Steatorrhea( fatty , foul , frothy , bulky stool)
General malnutrition
Abdominal distension and
Secondary vitamine deficiencies
Page 12
Diagnosis:• Clinical picture
• History of improvement ……recurrence of diarrhea on ……..
• Serum xylose levels less than 20 mg / 100ml 2 hours after administration of 0.5 gm of xylose per kg of body weight
• Jejunal biopsy - villous atropy
• Evidence of secondary lactose deficiency
Complication•Osteoporosis•Lymphoma of the small intestine•Infertility•Autoimmune liver disease
Nursing diagnosis1. Imbalanced nutrition less than body requirement related
to poor absorption of the nutrients2. Chronic pain – abdomen related to the disease condition3. Fluid electrolyte imbalance related to underlying
pathology4. High risk for complication – anemia, bleeding related
reduced thrombin level5. Risk for infection6. Alteration in comfort related to the disease condition7. Anxiety related to the unexpected outcome of the disease8. Altered parental coping related to the need for long term
care
Nursing interventions This can be divided as :
Assisting with the diagnosis Assisting parents in their adjustment to the
diagnosis Providing nutritious diet Correcting nutritional deficiencies Prevention and care during celiac crisis Educating the child and parents during
longterm follow up care
Nursing interventions In genrral;
Eliminate all gluten from the food Prolonged i/v before oral feed Gradual introduction of foods in acute cases Give the child corn and rice product , soy and potato
flour, breast milk or soy – based formula, and fresh fruits
Replace vitamins and calories ; give small frequent meals
Monitor for staetorrhoea its disappearance
Fruits and vegetablesFresh meats (beef,
poultry, lamb, pork)SeafoodMany dairy productsCornRicePotatoesBeansAmaranth
BILIARY ATRESIA
Normal
Cause• Unknown
• But …..developmental malformations or abnormalities acquired before or soon after the birth as a result of a viral insult to previously normal structures.
• Incidence:– 1 in 8,000 to 20,000 live birth
Pathophysiology
Clinical manifestation• Jaundice- 2-3 wks after birth• As the olive green jaundice increases ,
– the urine becomes dark and stool become white or clay coloured and putty
• Hepatomegaly -extend upto the umbilicus• Abdominal distension• Splenomegaly• FTT• irritable, restless and difficult to hold, cuddle
and comfort
New findings in life sciences in children described from University of Alberta. 2010 JAN 11 - (NewsRx.com) -- New investigation results,
• 'Celiac disease presenting as autism,' are detailed in a study published in Journal of Child Neurology. “
• It is recommended that all children with neurodevelopmental problems be assessed for nutritional deficiency and malabsorption syndromes."
Diagnostic evaluation
Medical management:
• Cholestyramine (Questran)• Dietary management
• High in protein and low in fat• A formula such as Pregestimil , which
contain medium chain triglycerides, can be used
• MCT oil can be given
• Phenobarbital – irritability• Diuretics are given
Treatment:
• Atresia of the extrahepatic bile ductoperable or correctable type andinoperable type
– Operable type –Choledochojejunostomy– Inoperable type - Kasai procedure.
• Liver transplantation
Nursing management1. Imbalanced nutrition less than body
requirement related to poor absorption of the nutrients
2. Chronic pain – abdomen related to the disease condition
3. Fluid electrolyte imbalance related to underlying pathology
4. Alteration in comfort- irritability5. High risk for complication – kernicterus, seizure6. Anxiety related to the unexpected outcome of
the disease7. Altered parental coping related to the need for
long term care8. Knowledge deficit
Nursing management
• Advise the calcium intake is increased
• salt is restricted
Short Bowel Short Bowel SyndromeSyndrome
occurs as a result of occurs as a result of decreased mucosal decreased mucosal
surface areasurface area
Common cause of SBS Common cause of SBS
►Congenital anomalies – jejunal and Congenital anomalies – jejunal and ileal atresia, gastrochisisileal atresia, gastrochisis
► IIschemia-NECschemia-NEC►Trauma and vascular injury- volvulusTrauma and vascular injury- volvulus►other causesother causes
bowel resection - Hirschsprung disease bowel resection - Hirschsprung disease and omphaloceleand omphalocele
►Radiation enteritisRadiation enteritis
Therapeutic management:Goals1.To preserve as much length of bowel as possible during surgery2.To maintain the child’s nutritional status, growth and development while intestinal adaptation occurs3.To stimulate intestinal adaptation with enteral feeding4.To minimize the complication related to the disease process and therapy
Nutritional care becomes the longterm focus of careThe initial phase of therapy ;•TPN as primary source of nutritionThe second phase;•Is the introduction of enteral feeding- soon after the surgery-NG or gastrostomy tube+ TPNThe final stage;•Exclusive enteral feeding
Nursing considerations:•Administration and monitoring of the nutritional therapy•Check for infections of the I/V line, occlusion, disloadgement, or accidental removal•Care should be taken during enteral feeding•Meet the child’s developmental and emotional needs •Complication of longterm TPN
•central venous catheter infection or occlusion,• catheter migration, thrombosis or emboli, bacterial growth, metabolic complications, cholestasis and liver dysfunction
Macro v. micro nutrients• Macro-nutrients
– Protein (amino acids)– Energy (carbohydrates)– Fat (fatty acids)– Water
• Micro-nutrients– Water soluble vitamins (assist in energy-release of
carbohydrates and red blood cell formation)– Fat soluble vitamins (development & metabolism)– Minerals
Definitions of Malnutrition
Kwashiorkor: protein deficiency Marasmus: energy deficiency Marasmic/ Kwashiorkor: combination of
chronic energy deficiency and chronic or acute protein deficiency
MalnutritionWorld Health Organization definition:
The term is used to refer to a number of diseases, each with a specific cause related to one or more nutrients (for example, protein, iodine or iron) and each characterized by cellular imbalance between the supply of nutrients and energy on the one hand, and the body's demand for them to ensure growth, maintenance, and specific functions, on the other.
Child malnutritiondeath and disability
Inadequate DiseaseDiet
Insufficientaccess to food
Inadequatematernal and
child care
Poor water/ sanitationinadequate health
services
Causes of malnutrition
BabyLow Birth
Weight
ChildStunted
AdolescentStunted
WomanMalnourished
Pregnancy Low Weight Gain
ElderlyMalnourished
Highermortality rate
Impairedmental
developmentIncreased risk of
adult chronic disease
Untimely/inadequateweaning
FrequentInfections
Inadequatecatch upgrowth
Inadequatefood, health
& care
Reducedmental
capacity
Inadequatefood, health
& care
Reducedmental
capacity
Inadequatefetal
nutrition
Inadequatefood, health& care
Inadequatefood, health
& care
Highermaternalmortality
Reducedcapacityto care
for baby
Vicious cycle- Malnutrition
Pathogenesis of nutritional deficiency
1 º(DIETARY) DEFICIENCY 2º (CONDITIONED) DEFICIENCY
Nutritional deficiency
Depletion of Nutrient reserves
Biochemical changes
Functional changes
Morphologic leisions
PEM
• “The range of pathological conditions arising from coincidental lack of protein and
Calories in varying proportions occurring most frequently in infants and young children and commonly associated with infection”
(WHO 1973)
CLASSIFICATION
– A. CLINICAL ( WELLCOME )– Parameter: weight for age + oedema– Reference tandard (50th percentile)– Grades:
• 80-60 % without oedema is under weight• 80-60% with oedema is Kwashiorkor• < 60 % with oedema is Marasmus-Kwash• < 60 % without oedema is Marasmus
IAP classificationNutritional status Weight for age(%
of expected)
Normal >80
Grade I 71-80
Grade II 61-70
Grade III 51-60
Grade IV <50
Assessment of PEM
Gomez Classification
Weight for age = Weight of the child 100
Weight of normal child of the same age
Between 90 – 110% Normal Nutritional StatusBetween 75 – 89% Mild malnutrition (1st
degree)Between 60 – 74% Moderate Malnutrition (2nd
degree)Under 60% Severe Malnutrition (3rd degree)
Types of PEM
Severe Protein-Energy MalnutritionKwashiorkor (low protein)Marasmus (low calories)
Marasmus Kwashiorkor
Comparison FEATURES KWASHIORKOR MARASMUSDefinition Protein deficiency with
sufficient calorie Intake
Starvation in infants with overall lack of calories
Clinical features - Occurs in children between 2-3 years of age
- Growth failure - Wasting of muscles but preserved Adipose
tissues- Oedema,localised or Generalised ,present- Enlarged fatty liver
- Serum proteins low- Anemia present- Flag sign- alternate bands
of light( depigmented) and
dark (pigmented) hair
- Common in infants under 1 year of age
- Growth failure- Wasting of all tissues including muscles and adipose tissues- Oedema absent
- No hepatic enlargement
- Serum proteins low- Anemia present- Monkey- like face,Protuberant
abdomen,thin limbs
Morphology Enlarged fatty liver Atrophy of different tissues and organs but
subcutaneous fat preserved
No fatty liver Atrophy of different tissues and organs
including subcutaneous fat
FEATURES KWASHIORKOR MARASMUSDefinition Protein deficiency with
sufficient calorie Intake
Starvation in infants with overall lack of calories
Clinical features - Occurs in children between 6
months and 3 years of age- Growth failure - Wasting of muscles but preserved Adipose
tissues- Oedema,localised or Generalised ,present- Enlarged fatty liver- Serum proteins low- Moon face- Anemia present- Flag sign- alternate bands
of light ( depigmented) and dark
(pigmented) hair
- Common in infants under
1 year of age- Growth failure- Wasting of all tissues including muscles and adipose tissues- Oedema present- No hepatic
enlargement - Serum proteins low- Monkey- like face,- Anemia presentProtuberant
abdomen,thin limbs
Morphology Enlarged fatty liver Atrophy of different
tissues and organs but subcutaneous fat preserved
No fatty liver Atrophy of different
tissues and organs including subcutaneous fat
Comparison
Kwashiorkor
Swollen belly
Decreasedmusclemass
Sparsehair
Infection
Apathy
Kwashiorker occurs in children between 2-3 years of age
Kwashiorkor
Marasmus (low calories)
Ravenouslyhungry
Gross weightloss & no fat
poornutrition
poor mentaldevelopment &
behavior
alterations indevelopment
of CNS
“functionalisolation”
emotional reactivity,impaired
stress response
Hypothesized Mechanisms
Pathophysiology
Cardiac– Output, heart rate and blood pressure decrease– Postural hypotension
Immune system– T lymphocytes and complement decreased– Susceptible to bacterial infection
Cytokines (glycoproteins)– Poor immune response
Pathophysiology
Decreased total body potassium GI function
– Poor absorption of lipids, and sugars– Decreased enzyme and bile production– Increase incidence of diarrhea, and bacterial
overgrowth
Pathophysiology
CNS– Decreased brain growth and myelnation– Cerebral atrpy
Parental adaptation– Increased breastfeeding– Altered expectations
Investigations for PEM
Full blood countsBlood glucose profileSeptic screeningStool & urine for parasites & germsElectrolytes, Ca, P, serum proteinsCXR & Mantoux testExclude HIV & malabsorption
Mild to moderate PEM: home based rehabilitation or ambulatory care
Severe PEM, hospitalization is needed.
Hypoglycemia Hypothermia Infections Dehydration Anaemia, Water and electrolyte, imbalance
Nutritional therapy ORS High energy milk
Cereal milkMilk
Cereal Pulse milkFamily pot feeding Deworming Mineral and vitamin supplementation
Milk 100ml=60kalSugar 1 tsp= 20 kalOil½ tsp= 20 kalTotal 100ml=100 kal
Milk 100ml=60kalSugar 1 tsp= 20 kalCereal Flour1½tsp=20 kalTotal 100ml=100 kalMilk 100 ml= 60 kal
SAT mix (cereal, pulse, sugar) 2tsp= 40 kalTotal 100 ml=100ml
Nutrition supplimentation
Nutrition Immunisation Medical care Family health education Stimulation
• Mental development– Lower IQ levels– Poorer school performance
• Behaviors of recovered severely malnourished children
– shy, isolated, withdrawn – decreased attention span– immature, emotionally unstable– fewer peer relationships/reduced social skills– played less/stayed nearer to mothers
Severe Malnutrition: Consequences
Cognitive development in children with chronic protein energy malnutrition Bhoomika Retal
• Twenty children identified as malnourished and twenty as adequately nourished in the age groups of 5–7 years and 8–10 years were examined.
Conclusion• Chronic protein energy malnutrition (stunting) affects
the ongoing development of higher cognitive processes during childhood years rather than merely showing a generalized cognitive impairment.
NURSING DIAGNOSES1. Imbalanced nutrition less than body requirement
2. Fluid volume deficit
3. Risk for infection
4. Risk for impaired skin integrity
5. Risk for hypothermia(marasmus)
6. Altered growth and development
7. Altered parental coping
8. Divertional activity deficit
9. Risk for injury
10. Risk for complication- hypoglycemia, anemia, dehydration
11. Parental anxiety
12. Knowledge deficit
KEY POINT FEEDING
Continue breast feeding Add frequent small feedsUse liquid dietGive vitamin A & folic acid on
admissionWith diarrhea use lactose-free or
soya bean formula
XEROPHTHALMIA(DRY EYE)
Disease due to deficiency of Vitamin A
Also Called XeromaAbsence of tearsXerophthalmia is
most common in children aged 1-3 years
Cornea and conjunctiva become horny and necrosed
Bitot’s Spots•Collection of dried epithelium, micro organisms etc. forming shiny grayish white spot on the cornea•A sign of Vitamin A deficiency
KERATOMALACIA
Ulceration and softening of Cornea due to deficiency of vitamin A
Bilateral Blindness
TreatmentWHO/UNICEF treatment schedule of
xerophthalmiaChildren 1 to 6 years and above Immediately on diagnosis: 200,000 IU
vitamin A (0)The following day: 200,000 IU
Vit.A(0) 4 weeks later : 200,000IU
Vit.A(0)
NICOTINIC ACID DEFICIENCY
TreatmentNicotinamide,50-300mg OD х 2 Wks
VITAMIN B12 DEFICIENCY• Pernicious Anemia• If Hb <4g/dl blood transfusion should always be
given.• Physical activity until the Hb is >7g/dl.• Vitamin B12 should be given in a dosage of
1000 mcg IM BDthe first week, • then 250 mcg weekly until the blood count is
normal.• Then 1000 mcg every six weeks is given
VITAMIN C DEFICIENCY
Administer loading dose of 500 mg of vitaminC followed by a daily dose of 100 to 300 mg for several weeks.
•Infantile scurvy is characterised by gross irritability, excessive crying and tenderness to touch,more so in the lower limbs.
VITAMIN D DEFICIENCY• Treatment
• Administering a Single massive dose of vitamin D3(3,00,000 units upto1 year of age; 6,00,000 units for later ages) orally or IM togher with supplementary calcium and phosphorus.
NUTRITIONAL ANEMIAA Condition in which the Hb content of
blood lower than normal as a result of a deficiency of one or more essential nutrients
Primarily due to lack of absorbable iron in the diet
Causes of Iron deficiency anemia
Inadequate intake of ironPoor bioavailability (only less than 5
percent is absorbed)Excessive loss of iron (menstruation, rapid
pregnancies, hookworm infestations, other illnesses)
Interventions
Iron and folic acid supplementationNutritional anemia prophylaxis programme
(daily Fe & folic acid supplementation to Pregnant Women lactating mothers & Children under 12 years)
Iron fortification - Fortification of salt with iron
Control of parasite and nutrition education
IODINE DEFICIENCY DISORDERS (IDD)
IDD refers to a spectrum of disabling conditions arising from an inadequate dietary intake of iodine.
IDD affects the health of humans from fetal stage to adulthood
CAUSES OF IDDDeficient iodine Intake – Consuming foods with low
Iodine content, Crops grown in iodine depleted soil
Increased demand for Iodine in the body – Demand of Iodine is increased during the stage of rapid growth (Infancy, Puberty, pregnancy, lactation), Demand exceeds supply results in deficiency.
Presence of Goitrogens – goiter producing substances naturally present in some foods (cabbage, cauliflower etc.) interfere with Iodine utilization
IODINE DEFICIENCY DISORDERS (IDD)
Endemic GoiterCretinism
CretinismSevere form of IDDOccurs during fetal stageInterfere with brain development causing
brain damage and deathResult in Growth failure, MR, Speech and
hearing defects
From UNICEF, State of the World’s Children: Adapted from Stuart Gillespie, John Mason and Reynaldo Martorell, How nutrition improves, ACC/SCN, Geneva 1996.
Where do we go from here?
Improved childnutrition
Increasedproductivity
Enhanced humancapital
Povertyreduction Economic growth
Social sectorinvestments
OBESITYMost Prevalent form of malnutritionAbnormal growth of adipose tissue due to
enlargement of fat cells(Hypertrophic),Increase in no. of fat cells (hyperplasic)or Combination of both
OBESITYObesity - When the body weight is 20%
more than the desirable weight.Over weight - When the body weight is
between 10-20% more than the desirable weight
BMIBMI = Height in kilogram
(Weight in Meter)22
20-2520-25 IDEALIDEAL26-3026-30 OVERWEIGHTOVERWEIGHT31-4031-40 OBESEOBESE40+40+ VERY OBESEVERY OBESE
BIBLIOGRAPHY: Wong D.L etal . Essentials Of Paediatric Nursing. 6th edition. Missouri:
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Millions.October-November,2008 Elizabeth.K.E.Nutrition and Child Development.3rd edition.Hyderabad.Paras:
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Publishers;2004 Srilakshmi.B.Human Nutrition.1st edition.NewDelhi.New Age International (P)
Ltd:2009
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Journal of Indian Association of Pediatric Surgeons
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