Pediatrics

Dr. Haydar Lec: -4-

8-Oct-06

Treatment of malnutrition
Main step in treatment are :-

1) Treatment of acute problems like dehydration . …etc .

2) Treatment of infections and infestations .
3) Replacement of missing nutrients .
4) Nutritional rehabilitation to catch up the normal growth for the same age and
gender .

After treatment of acute problems like infection , infestation , dehydration …dietary

treatment or rehabilitation should be started gradually and advanced slowly because
G.I.T. may not tolerate a rapid increase in intake , when nutrients are provided the
metabolic rate increases stimulating anabolism and thus increasing nutrient
requirements .
The initial management consist of administration of low volume , diluted milk
feeds with nutrient supplementation , the feeding started with small frequent feeds of
dilute milk ; strength or concentration and volume are gradually increased and
frequency decreased over the next 5-7days , by day 6-8 the child should receive 150
ml /kg/day of high energy milk .

• In day 1-2 feeding every 2 hr , in day 3-5 every 3 hr and in day 6 and later
every 4 hr .
• Special food from UNICEF used for dietary rehabilitation containing lactose
free milk , fruit oil , sugar , A.A. mixture and other nutrient .
• There are 2 formula : F 75 (~ 75 k.cal /100ml ) used in initial phase and F100 (
~ 100 k.cal /100 ml ) used in later stage .
• Caloric intake can be increased 10-20 % /day starting from 50-75% initially of
ideal caloric requirements .
• The treatment should be given by the nurse or the mother either by cup and
spoon or in weak child by dropper or in case of anorexia by N-G tube , and
feeding by bottle should not be used .
• When high caloric and high protein diet are given too early and too rapidly ,
the liver may become enlarged , the abdomen become markedly distended and
the child improved very slowly .
• When dehydration is present so should be treated either by Rehydration
Solution for Malnutrition ( Re-So-Mal ) given orally or by N-G tube , or by
given Ringer solution intravenously , and if not possible to find I.V. line so
given by intraosseous rout 70 ml /kg or by intraperitoneal rout .

• In severe anemia ( Hb <4 gm/dl ) there is a risk for developing heart failure
and should be treated with blood transfusion 10 ml/ kg of packed R.B.S. over
3 hr , iron should be avoided because it may has a toxic effect and may reduce
resistant to infection .

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Complications of rehabilitation :

1- nutritional recovery syndrome .

2- pseudo-tumor cerebri .
3- encephalitis like syndrome .

Preventive measures for malnutrition :

1) Education of the publics ( parents ) about the value of protein and caloric
intake .
2) Encouragement of breast feeding .
3) Immunization against infectious diseases like measles , T.B. , whooping cough
…etc .
4) Family planning .
5) Early treatment of the diseases that may cause malnutrition .

Vitamins deficiencies
Water soluble vitamins deficiencies

Vitamin Source Deficiency

state

B1 thiamine Liver , meat, Beri-beri

nuts

B2 riboflavin Milk , cheese , Anorexia,

eggs, liver anemia ,
mucositis
B3 niacin Meat , fish Pellagra :
,green veg. dermatitis
,dementia
,diarrhea
B6 pyridoxine Meat , liver , Seizures
peanuts ,microcytic
anemia
B12 Meat , fish , Megaloblastic
cheese , eggs anemia

C ascorbic acid Citrus fruit , Scurvy

green veg.

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Fat soluble vitamins

Vitamin source Deficiency state

Vitamin A Liver , milk , eggs Night blindness ,

, fruits , green and xerophthalmia ,
yellow veg. Bitot spots ,
hyperkeratosis .
Vitamin D Fortified milk , Rickets : reduce
liver , cheese bone
mineralization .

Vitamin E Seeds , veg . Hemolysis in

preterm infant ,
ataxia , areflexia

Vitamin K Liver , green veg Prolonged PT ,

., made by hemorrhagic
intestinal flora disease of
newborn .

Vitamin C deficiency ( Scurvy )

Infant born with adequate amount of vitamin C , cord blood contains 2-4 times of
vitamin C than maternal blood . Breast milk contains adequate amount of vitamin C if
the nutrition of the mother is good and with enough vitamin C .
So deficiency of vitamin C in infant may result if the mother diets contains
insufficient amount of vitamin C and also occur in infant with evaporated milk
formula that not fortified with vitamin C .
The need for vitamin C increase in febrile illness especially infectious and
diarrhea diseases , in iron deficiency state , in cold exposure and in protein depletion .
Clinical features :
Include irritability , tachycardia , digestive disturbances , loss of appetite , bone
tenderness , loss of appetite , bone tenderness especially in legs ( notice when diaper
is changed ) , also there is subperiosteal hemorrhage , a rosary ( swelling in the
costochondral junctions which is tender and sharper than rachitic rosary ) , other signs
are peticheal hemorrhages which may occur in skin and mucous membranes , wound
healing is delayed , swelling of the joints and follicular hyperkeratosis may occur also
.

Diagnosis :

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 Based mainly on history of poor intake of vitamin C , clinical features and on X-
ray appearance of the long bones ( ground glass appearance , reduced cortical
thickness like pencil thinness and sharp out line appearance of epiphyseal ends ) .

Treatment :

Daily administration of 3-4 oz of orange juice or tomato juice , but ascorbic acid
preparation is better for therapeutic purposes in a daily dose of 100-200 mg orally or
paranterally .

Written by:
Rand Aras Najeeb