Pedia Exam 2 Malnutrition Anchores 071415

UPHR – JONELTA FOUNDATION SCHOOL OF MEDICINE S.Y. 2015 – 2016

Pedia II MALNUTRITION AND VITAMIN DEFICIENCIES - Dra. Anchores MALNUTRITION AND VITAMIN DEFICIENCIES Basic Assumptions: - Deficiency state seldom occurs alone - Anatomic lesion is an indicator of chronic nutritional disorder - Children are more vulnerable to nutritional insults Type of Nutrients: 1. Macronutrients – needed in large amounts and primarily function as sources of energy. (Carbohydrates, Fats, Proteins) 2. Micronutrients – needed in minute amounts and function mainly as cofactors in many chemical processes. (Vitamins, Minerals, Trace elements) Food Security: - Access by all people at all times to SUFFICIENT foods in terms of quality, quantity, and diversity for an active and healthy life without risk of loss of such access. - 3 dimensions:  Availability –supply of food  Access – household level reflecting purchasing power as well as transfer program; food shared equally within the household  Utilization – reflect the fact that even when the household has access to food, it does not necessarily achieve nutritional security Food Insecurity: - Limited or uncertain availability of nutritionally adequate and safe foods - Due to lack of resources to assure adequate production, importation and distribution of food

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May lead to anxiety that food may soon become inadequate - More prevalent in developing countries (18%) - Tx: make the mother complete a 35day food diary appropriate dietary advice and or supplement nutritional counseling Hunger - The uneasy sensation that results from lack of food - Difficult to define bec concepts differ from each individual - USA: 8% of poor children +2 (obese) -

Etiology:  excess intake of food, exceeds expenditure  genetic constitution  gender  psychological, metabolic or endocrine disturbances  abundance of food in the Western society  decrease opportunities for energy expenditure due to sub-urban living Manifestaions:  most frequent: 1st year of life 5-6 years of life (gain appetite)

BATCH 2017 TRANS TEAM: Magbitang, Magkalas, Maluto, Mercado, Mijares, Besana, Dacanay, Contreras “With all your heart, you must trust the Lord and not your own judgment. Always let him lead you, and he will clear the road for you to follow.” – Proverbs 3:5-6 

UPHR – JONELTA FOUNDATION SCHOOL OF MEDICINE S.Y. 2015 – 2016

Pedia II MALNUTRITION AND VITAMIN DEFICIENCIES - Dra. Anchores Adolescence (gain appetite) small mouth and nose, doublechin  adiposity in mammary regions  pendulous abdomen with white or purple striae  disproportionately small external genitalia (boys)  Tall stature, advanced bone age, early puberty  Acanthosis nigricans ( hypertrophic hyperpigmentation of the skin commonly seen on the posterior neck and in skin creases) à seen at the back of the neck; reduce the weight and that will disappear Laboratory Findings: Those that evaluate CVS disease risks and diabetes risk (Plasma lipid profiles, FBS insulin levels, HbA1c), test for sleep apnea Prevention:  breastfeeding (look lighter and thinner than those infants in milk or formula fed)  delay in introduction of solid foods (increase sugar in milk formula)  counseling mothers to give food only in response to hunger not as a pacifier  reorientation of family life towards low calorie food  promotion of physical exercise Treatment: 1. Diet therapy - caloric requirement depends on age and gender - energy balance should be emphasized 2. Exercise therapy - schools should provide special programs - brisk walk (250 cal/hr) 

- regular physical exercise at school and at home should be planned - limit and monitor TV viewing time 3. Psychological therapy ( with severe or extreme obesity; requires certain intervention for their apnea) - emotional support - parental counseling - psychiatric referral “hard core group” 4. Other forms of therapy - fasting - intestinal by-pass operation - gastric stapling (hazardous, should not be advocated) Pickwickian Syndrome rare complication severe cardiorespiratory distress with hypoventilation CM: polycythemia o hypoxemia o cyanosis o somnolence weight reduction is extremely important TABLE 44-6 -- Anticipatory Guidance: Establishing Healthy Eating Habits in Children Do not punish a child during mealtimes with regard to eating. The emotional atmosphere of a meal is very important. Interactions during meals should be pleasant and happy.

Do not use foods as rewards. Parents, siblings, and peers should model healthy eating, tasting new foods, and eating a well-balanced meal. Children should be exposed to a wide range of foods, tastes, and textures. Foods should be offered multiple times. Repeated exposure to initially disliked foods will break down resistance. Offering a range of foods with low energy density helps children balance energy intake.

BATCH 2017 TRANS TEAM: Magbitang, Magkalas, Maluto, Mercado, Mijares, Besana, Dacanay, Contreras “With all your heart, you must trust the Lord and not your own judgment. Always let him lead you, and he will clear the road for you to follow.” – Proverbs 3:5-6 

UPHR – JONELTA FOUNDATION SCHOOL OF MEDICINE S.Y. 2015 – 2016

Pedia II MALNUTRITION AND VITAMIN DEFICIENCIES - Dra. Anchores

Restricting access to foods will increase rather than decrease a child's preference for that food. Forcing a child to eat a certain food will decrease his or her preference for that food. Children's wariness of new foods is normal and should be expected. Children tend to be more aware of satiety than adults, so allow children to respond to satiety, and let that dictate servings. Do not force children to “clean their plate”. Adapted from Benton D: Role of parents in the determination of food preferences of children and the development of obesity. Int J Obes Relat Metab Disord 2004;28:858–869. Copyright 2004. Reprinted by permission from Macmillan Publishers Ltd.

Vitamin Deficiencies and Excesses  Vitamin A deficiency - deficient diet - inadequate intestinal absorption (chronic intestinal disorder and infections) - increase excretion (chronic infection, UTI, cancer) Clinical Manifestations:  Eye Signs(first manifestation to expect) - nyctalopia/night blindness (early sign) - photophobia - xerosis conjunctivae/corneal dryness - keratomalacia - cloudiness of cornea - Bitot’s spots-dry, silver-gray plagues on the bulbar conjunctiva  Skin Signs - dry and scaly - follicular hyperkeratosis - oral mucosa and vagina/epithelium cornified  Increased ICP - Hydrocephalus - Apathy, mental and physical retardation - Anemia - Hepatosplenomegaly Treatment: Measles

>= 12mos : 200,000 IU po 6-11 mos : 100,000 IU po 10 years old - 1.4 - 2.0 mg daily Adults – 0.025 mg/g of dietary protein Treatment: - 2.5 mg PO daily plus vitamin B complex  Niacin deficiency (Pellagra) - Diets low in niacin and tryptrophan ( nicotinic acid)

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Amino acid imbalance Malabsorption Related to excessive corn consumption poor source of tryptophan Clinical manifestations (Classical picture)  Diarrhea  Dermatitis - predilection for the back of hand wrists and forearms (pellagrous glove) face and neck (Casal’s necklace) lower legs (pellagrous boot)  Dementia - nervous system include depression, disorientation, insomnia, delirium. Diagnosis: - Urinary levels of N-methylnicotinamide are low or absent Prevention: RDA : Infants/children, 6-10 mg Older children/adults, 10-20 mg Treatment: - 50- 300 mg plus vitamin B complex  Vitamin B6 (Pyridoxine) deficiency - Malabsorption - loss of vitamin during processing, cooking and storing - pyridoxine antagonist ( INH, hydralazine, contraceptives ) increase the requirement for pyridoxine Clinical Manifestations:  convulsions  skin and mucous membrane lesions  poor response to antibiotics 4 Clinical Disturbances: 1. convulsion in infants – generalized 2. peripheral neuritis 3. dermatitis 4. anemia Prevention: RDA : Infants, 0.3- 0.5 mg/day Children, 0.5 – 1.5 mg/day Adults, 1.5 – 2.0 mg/day

BATCH 2017 TRANS TEAM: Magbitang, Magkalas, Maluto, Mercado, Mijares, Besana, Dacanay, Contreras “With all your heart, you must trust the Lord and not your own judgment. Always let him lead you, and he will clear the road for you to follow.” – Proverbs 3:5-6 

UPHR – JONELTA FOUNDATION SCHOOL OF MEDICINE S.Y. 2015 – 2016

Pedia II MALNUTRITION AND VITAMIN DEFICIENCIES - Dra. Anchores Treatment: - 2-10 mg IM - 100 mg P.O  Vitamin C (Scurvy) deficiency - 6-24 months (peak) - improper cooking practices Clinical Manifestations:  painful, immobile legs (pseudoparalysis)  gums, bluish purple, swollen  depression of sternum (scorbutic beads)  irritability, tachypnea, GIT disturbances  slow wound healing  Scurvy - formation of collagen and chondroitin sulfate is impaired  defective tooth dentin, loosening of the teeth, hemorrhage  follicular hyperkeratosis  Sicca Syndrome of Sjogren Xerostomia,  Keratoconjunctivitis sicca, enlarged salivary glands Diagnosis: - clinical picture - history of poor Vit. C intake - X-ray findings of long bones:  “ground glass appearance”  “pencil point thinness”  irregular and thickened white line at the metaphysis ( Fraenkel lines) Prevention/Treatment: - Vit C, second week of life - All age, 30mg daily - Tx: 200-500 mg; 100-150ml fruit juice  Vitamin K deficiency - Vitamin K1 (natural form) - Vitamin K2 ( bacterial origin and synthetic) - faulty intestinal absorption (diarrhea) - prolonged administration of antibiotics - liver disease

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hemorraghic manifestation (Hallmark) - Hypoprothrombinemia and decreased hepatic synthesis proconvertin - Hemorrhagic disease of the Newborn Prevention: - bile of normal composition - diet - normal absorption surface - normal liver Prophylaxis: 0.5 – 1.0 mg - single IM dose 1.0 – 2.0 mg - single oral dose Treatment: 5mg IM, for severe Hemorrhagic manifestation  Vitamin D deficiency (Rickets) - lack of access of skin to UV radiation - malabsorption - predominantly CHO-vitamin-D-lessdiet - maternal malnutrition - anticonvulsant Tx – Phenytoins or Phenobarbital 2 Forms Vitamin D: 1. Vit. D2 2. Vit. D3 are of practical importance - facilitation of intestinal absorption of calcium and phosphorus - renal absorption of phosphorus and direct effect on bone deposition Clinical manifestations:  Craniotabes - early sign  thinning of outer table of skull  Caput quadratum (box-like appearance)  Rachitic rosary  Mental and motor delay  Bowing of lower extremities  Harrison’s groove (horizontal depression along the lower border of the chest) Treatment:

BATCH 2017 TRANS TEAM: Magbitang, Magkalas, Maluto, Mercado, Mijares, Besana, Dacanay, Contreras “With all your heart, you must trust the Lord and not your own judgment. Always let him lead you, and he will clear the road for you to follow.” – Proverbs 3:5-6 

UPHR – JONELTA FOUNDATION SCHOOL OF MEDICINE S.Y. 2015 – 2016

Pedia II MALNUTRITION AND VITAMIN DEFICIENCIES - Dra. Anchores -

1,200 IU – moderate to severe rickets Artificial and natural lights Infantile Tetany may occasionally accompany rickets, seen in patients with steatorrhea if calcium increase < 3-4 mg/dl

 Hypervitaminosis D - Symptoms develop after 1 – 3 months of large intake  Hypotonia, anorexia, constipation, polydipsia, polyuria, pallor  Hypercalcemia, hypercalciuria  Vomiting, Hypertension, retinopathy,  Corneal clouding Tx: vitamin D and calcium intake  Megaloblastic Anemia - deficiency of either folic acid or vitamin B12 or both 2 – 7 months Etiology: - Dietary lack - Defective Absorption - Presence of folic antagonists (methotrexate and anti-epileptic drugs) - Pure goat’s milk Clinical Manifestations:  Pallor, irritability  FTT  Persistent respiratory infection  Intermittent fever and diarrhea Diagnosis: - Macrocytic type - Hypersegmentation of the neutrophils Treatment: - Folic Acid 2-5 mg/day x 2-3 weeks Ascorbic acid 200 mg  Folic Acid - Folate deficiency before becoming pregnant or during pregnancy results in serious dysmorphic

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effects in the fetus ( neural tube defects) 400 ug before conception or all child bearing age Vitamin C needed for folic acid conversion

 Vitamin E (alpha tocopherol ) - Fat soluble anti oxidant - Involve in nucleic acid metabolism - Malabsorption states - Premature infants Clinical Manifestations:  Creatinuria, ceroid deposition in smooth muscle  Anemia or Kwashiorkor  Hemolytic anemia retinopathy in premature infants  Increased platelet adhesiveness Diagnosis: Severe 1. alpha - tochopherol : lipid ratio of < 0.8mg/g and or 2. erytrocyte hemolysis in hydrogen peroxide of more than 10% (should be done 3 days after an oral vit E.) Treatment and Prevention: - Premature: 15-25IU per day - 0.7 mg/g of unsaturated fat in the diet - Higher dose in children with biliary atresia  Iron Deficiency Anemia (IDA) - most common form of anemia - peak: 6-24 months Incidence * - 31.8% (1998) & 32.4% (2003) – 6 mos to 5 years - 53.0% - 1 yr old children - 34.8% - 2 yr old children - 24.8% - 3 yr old children - 18.8% - 4 yr old children - 14.0% - 5 yr old children Etiology: - Inadequate supply of iron - Inadequate intake

BATCH 2017 TRANS TEAM: Magbitang, Magkalas, Maluto, Mercado, Mijares, Besana, Dacanay, Contreras “With all your heart, you must trust the Lord and not your own judgment. Always let him lead you, and he will clear the road for you to follow.” – Proverbs 3:5-6 

UPHR – JONELTA FOUNDATION SCHOOL OF MEDICINE S.Y. 2015 – 2016

Pedia II MALNUTRITION AND VITAMIN DEFICIENCIES - Dra. Anchores - Impaired absorption - Blood loss Clinical Manifestations:  Irritability/loss of appetite  Hx of repeated respiratory infections  Pallor of skin and mucous membranes  Tachycardia, systolic murmur, cardiomegaly Diagnosis: - Examination of peripheral blood - hypochromic, microcytic - Red cell indices – decrease MCHC, MCV - Determination of transferrin saturation - below 15% and serum iron < 50 mg/dl Prevention: - Infants: 10-15 mg elemental iron daily Treatment (Oral ferrous SO4): - Infant: 6 mg/kg/BW, 6 – 8 weeks - Older children: 100 – 200 mg (total daily iron) - Transfusions: Severely anemic infant/child HB level 4- 5 g/dl or less - Treat underlying factors  Pernicious Anemia - due to Vitamin B 12 deficiency - serum Vitamin B 12 level is below 80 pg/ml  Zinc Deficiency - Can reduce child mortality - No biomarker standard that is widely used as cutoff to define public health concern - Important in groeth and immunity - Cofactor in numerous metabolic pathways - Growth failure, diarrhea, dwarfism and hypogonadism

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Long term high dose interfere with copper metabolism, anorexia, vomiting

Nutritional Assessment - Primary step in the evaluation of children whose growth differs from the norm - Essential in the management of children with acute or chronic disease Methods of Assessment a. Assessment by history b. Clinical assessment c. Use of Growth Charts d. Anthropometric Indicators e. Laboratory assessment  Assessment by history - medical history - dietary history (mother’s, child) - weight and height changes - change in psychic reaction  Clinical Assessment - careful examination - observation - evidence of specific deficiencies  Use of growth charts - Growth charts are derived from longitudinal studies of a selected well-defined healthy population and from cross-sectional data on large numbers of children who participated in national surveys Data are presented as Percentile - Serial measurements are easier to interpret than single measurements  Anthropometric Indicators - weight - length - triceps skinfold thickness - head circumference - mid-upper arm circumference (MUAC)

BATCH 2017 TRANS TEAM: Magbitang, Magkalas, Maluto, Mercado, Mijares, Besana, Dacanay, Contreras “With all your heart, you must trust the Lord and not your own judgment. Always let him lead you, and he will clear the road for you to follow.” – Proverbs 3:5-6 

UPHR – JONELTA FOUNDATION SCHOOL OF MEDICINE S.Y. 2015 – 2016

Pedia II MALNUTRITION AND VITAMIN DEFICIENCIES - Dra. Anchores  Laboratory assessments - hematologic and protein status - determination of body composition to define excesses and deficiencies of specific nutrients Gomez classification Welcome classification

 Main Goal - To promote the nutritional health of children - Basic Core of Nutrition in Community Health Programs: 1. Assessment of child’s nutritional status and needs 2. Nutrition Counseling 3. Nutrition Education 4. Treatment of nutrition-related conditions 5. Follow-up and referral

“Nutrition and growth of children affects not only their survival but also their quality of life.” Waterlow classification

Community Nutrition

BATCH 2017 TRANS TEAM: Magbitang, Magkalas, Maluto, Mercado, Mijares, Besana, Dacanay, Contreras “With all your heart, you must trust the Lord and not your own judgment. Always let him lead you, and he will clear the road for you to follow.” – Proverbs 3:5-6 