Growth and Nutrition
Related Medical
Disorders in Childhood
SE MINAR GROUP 3
20/ 10/ 2023
Outline…
o Introduction
o Growth related Disorders
o Nutrition related Disorders
o Moderate Acute Malnutrition
o Severe Acute Malnutrition
o Clinical variants of Severe Malnourishment
o Short stature
o Tall stature
o Summary
o References
Introduction
What is growth?
How to assess growth?
Factors affecting growth?
Growth is…
Increase of cell number, cell size, and intercellular space
over the time
Growth Assessment
HEIGHT/LENGTH, WEIGHT, OFC
IMPORTANT PARAMETERS OF GROWTH
• Weight for Height or Length
• BMI
• Upper segment : Lower segment Ratio
• Height Velocity
• Mid Parental Height Range
• Bone Age
Growth charts
COMMONLY USED WHO GROWTH CHARTS
• Weight for age chart (Birth to 5 years)
• Length for age chart (Birth to 2 years)
• Height for age chart (2 to 5 years)
• Weight for length/Height chart (Birth to 5
years)
• Head circumference for Age chart (Birth to 3
years)
• Body mass index for Age chart (2 to 20 years)
Factors affecting Growth
BIOLOGICAL FACTORS
ENVIRONMENTAL FACTORS
• Genetic potential
• Socio-economic background
• Nutrition
• Parental education and parenting
abilities
• Endocrine factors : GH, Thyroxin,
Insulin, Sex hormones
• Fetal Health
• Chronic Disease/ Syndromes
• Emotional support for child
• Adverse environmental and natural
disasters (eg; famines)
Low
• Poor growth
Nutrition
Nutrition
Excessive • Over growth
Nutrition
High
• Poor growth
Demand
Growth
Growth Related Disorders
Primary weight
related disorders
Under weight
Under weight
with wasting
Under weight
with stunting
Under weight
with wasting and
stunting
Over weight
Primary stature
related disorders
Short stature
Proportionate
Disproportionate
Tall stature
Proportionate
Disproportionate
Malnutrition
Overweight, Obesity &
Diet related noncommunicable disease
Under weight
Micronutrient related
malnutrition
Under Nutrition
Stunting
Wasting
MAM
SAM
Micronutrient
Deficiencies
Micronutrient
Excess
Moderate Acute Malnutrition (MAM)
When to suspect ?
Moderate Acute Malnutrition Cont.
Diagnosis
• Mid Upper Arm Circumference (MUAC) 115 to 124 mm, or
• Weight-for-height Z-score (WHZ) -2 to -3, and
• No bilateral pitting edema
MAM Associated Risk
 Progression to Severe Acute Malnutrition
 Faltering growth
 Cognitive deficits
 Acquired immunodeficiency
Management
In-patient
Care
Community
Based
Community-Based management of MAM
• Supplementary feeding
◦ Ready-to-use therapeutic food (RUTF)
◦ Ready-to-use supplementary food (RUSF)
◦ Fortified flours
• Preventive care
Community-Based Preventive Care
• Recognition of at-risk populations
o Diarrheal illness
o HIV
• Supplementation strategies for prevention of malnutrition
•Nutrition Counselling and Education
Severe acute Malnutrition (SAM)
 Major problem in many low and middle income
countries.
 Due to severe protein-calorie malnutrition.
 Contributes to about 1/3 of childhood deathsworldwide.
Definition of SAM
• Weight-for-height <-3 z-score of the
child growth standards median
• MUAC less than 115 mm in children,
6 months to 5 years old
• +/- Bilateral oedema
Complications of SAM
 Loss of appetite & Hypoglycaemia (<54mg/dl)
 Hypothermia (<35.5°C body temp. / <35°C under arm temp.)
 LRTI
 Severe pallor
 High fever
 Severe dehydration
 Not alert
 Convulsion
SAM at Health Care
WITH COMPLICATION
WITHOUT COMPLICATION
• Admit to hospital for inpatient
treatment
• Follow up in a clinic or health post
every week or fortnightly
• Take home ration of RUTF
• Ensure that they receive other
services (Deworming, Vitamin A,
Immunization, etc…)
Identify SAM in the Community
When children between 0 to 59 months are brought to the clinic or health post
OR
Door to Door visits by Pubic Health Staff
 Measure Height/length
 Measure Weight
 Check for Oedema
Identify SAM in the community Contd.
Bilateral pitting
oedema
Refer to a
PEDIATRITION
Weight-for-height
<3SD
Management of SAM
GENERAL PRINCIPLES FOR ROUTINE
CARE (the ‘10 Steps’)
1.
Treat/prevent Hypoglycaemia
2.
Treat/prevent Hypothermia
3.
Treat/prevent Dehydration
4.
Correct Electrolyte imbalance
5.
Treat/prevent Infection
6.
Correct Micronutrient deficiencies
7.
Start cautious Feeding
8.
Achieve Catch-up growth
9.
Provide Sensory stimulation and Emotional support
10. Prepare for Follow-up after recovery
GENERAL PRINCIPLES … Cont.
These steps are accomplished in 02 phase
1. Stabilization phase (2-7 days)
2. Rehabilitation phase (several weeks)
I
1
Step 01:Treat /prevent Hypoglycaemia
Treatment-
ASYMPTOMATIC
SYMPTOMATIC / <1.5MG/DL
• Feed of F-75* OR Give 50ml bolus of 10%
glucose orally
• Recheck in 30 minutes
• If not corrected, repeat above
• IV 10% dextrose 5ml/kg followed by 50ml of
10% glucose by NG tube
• Start feed F-75 after 30minutes & continue it
every 1/2hourly for 2 hours
• Monitor RBS after 2 hours
• If blood glucose >3mmol/L, feed F-75 2 hourly
• If blood glucose <3mmol/L, repeat F-75 every ½ hourly & start antibiotics
*(F-75; milk base formula that contain 75kCal/100ml & 0.9g protein /100ml)
Step 02:Treat /prevent Hypothermia
TreatmentKangaroo care & wrap both with blankets
Clothed and wrap the child, if mother is absent
Monitor temperature 2 hourly to prevent hyperthermia during re-warming
PreventionMonitor temperature 3 hourly
Kangaroo care
Avoid exposure to cold
Step 03:Treat/Prevent Dehydration
 Hypovolaemia co exist with oedema
 Difficult to estimate dehydration status in severely malnourished children
 Do not use iv route for rehydration except in case of shock & then do with care.
 Infusion slowly to avoid overload to heart.
 Standard oral rehydration solution contain too much sodium and too little potassium for
severely malnourished children.
 Therefore give special Rehydration Solution for Malnutrition(ReSoMal)
Step 03:Treat/Prevent Dehydration
contd.
Treatment•
ReSoMal 5ml/kg ever 30 minutes for 2 hours
5-10ml/kg/hour for next 4-10 hours (doses at 4,6,8,10 hours)
• Monitor progress of rehydration ½ hourly for 2hours,then hourly for next 6-12
hours
• If signs of fluid overload occur, stop fluids immediately and reassess after one hour.
Step 4:Correct Electrolyte Imbalance
Mainly K and Mg
Treatment• Combined electrolyte/mineral solution
Prevention• When rehydrating, give low sodium rehydration fluid (Eg: ReSoMal)
• Prepare food without salt
NOTE:- Oedema is partly due to electrolyte imbalance. So Do NOT treat with
diuretics
Step 05:Treat /Prevent infections
Management• Measles vaccine if child is > 6m and not immunized (delay if the child is in shock)
• If no complications
If complications present
Give Amoxicillin oral 15mg/kg 8 hourly for 5 days
Gentamycin IV or IM 7.5 mg/kg
once daily for 7 days
+ Ampicillin IV or IM 50mg/kg every 6
hors for 2 days
Followed by Amoxicillin Oral
15mg/kg every 8 hourly for 5days
If child fails to improve
within 48 hours
ADD: Cefotaxime
NOTE- If the child is not passing urine, gentamicin may accumulate in the body and cause
deafness. Do not give the second dose until the child is passing urine
Step 6. Correct Micronutrient Deficiencies
Anemia, vitamin and mineral deficiencies.
Treatment• Multivitamin supplement
• Folic acid 1 mg/d (give 5 mg on Day 1)
• Zinc 2 mg/kg/d
• Copper 0.3 mg/kg/d
• Iron 3 mg/kg/d - but only when after start of gaining weight(DO NOT give
iron initially as it can make infections worse)
Step 7. Start Cautious Feeding
Feeding should start immediately to prevent death.
Management• Give F-75 formula 2hourly (or breast feeding + F-75)
• Keep a 24-hour intake chart
• Weigh daily and plot weight
Target100 kcal/kg/d
1-1.5 g protein/kg/d
130 ml/kg/d of fluid (100 ml/kg/d if the child has severe oedema)
Step 8. Achieve Catch-up Growth
 In the rehabilitation weight gain of >10 g gain/kg/d
Management• Replace starter F-75 with the same amount of catch-up formula F-100 for 48
hours & then Increase the amount subsequently
• Frequent feeds (at least 4-hourly) of unlimited amounts of a catchup formula
• If the child is breastfed, encourage to continue with formula feeds (Note:
breast milk does not have sufficient energy and protein)
Target150-220 kcal/kg/d
4-6 g protein/kg/d
Step 9. Provide Sensory stimulation
and Emotional support
 Care, play and stimulation
• A cheerful, stimulating environment
• Structured play therapy 15-30 min/d
• Physical activity as soon as the child is well enough
• Maternal involvement when possible (e.g. comforting, feeding, bathing, play)
Step 10. Prepare for follow-up after
recovery
• Closest outpatient care facility from week 1
• Give the mother a weekly ration of RUTF
Advise parent or carer to:
• Bring child back for regular follow-up checks
• Ensure booster immunizations are given
• Ensure vitamin A is given every six months
Clinical variants of Severe Malnourishment
Marasmus
Kwashiorkor
Marasmic kwashiorkor
Marasmus
Malnutrition without oedema
“Wasting”
Due to inadequate intake of all nutrients, but specially dietary energy
sources
Causes depletion of body fat stores & wasting of muscle mass
An ADAPTIVE state
Marasmus cont.
Typically seen in infants, who are breast fed when the amount of
milk is markedly reduced or
In those who are artificially fed
Earliest manifestation is ‘failure to thrive’
Associated with irritability or apathy
Marasmus Clinical Features
• Thin and wasted appearance with emaciated arms, thighs and
buttocks
• Head appears large relatively to the body with staring eyes
• Stunting
• Thin and dry skin
• Thin, sparse hair
• Irritable and fretful affect
Kwashiorkor
 Oedematous malnutrition
 Due to very low intake of proteins
 “Sickness the baby gets when the new baby comes”
 Marked muscle atrophy with normal or increased body fat (fat maldistribution
-> fatty liver)
 MALADAPTIVE state
Kwashiorkor cont.
 Characterized by symmetrical peripheral pitting oedema in
dependent regions and proceed cranially
 Profoundly low levels of albumin leads to oedema in these children
◦ Mild – Odema involving feet
◦ Moderate – feet,legs +/- Upper limbs
◦ Severe – generalized oedema or moderate + facial odema
Kwashiorkor Clinical features
Variable weight for age
Moon face with or without facial oedema
Oedematous extremities
Distended abdomen/ pot belly
Hepatomegaly (fatty liver)
Marked muscle atrophy
Apathetic, listless behaviour
Kwashiorkor Clinical features cont.
Skin Manifestations
Flaky paint dermatosis
Hair depigmentation
Flag sign (due to intermittent adequate dietary intake)
Dry, brittle, thin, lusterless hair
Fissured or ridged nails
Short Stature
A height below – 2SD for the age and the sex of the child
Causes for Short Stature
Familial – within MPHR, normal development, normal onset of puberty.
Constitutional delay on growth – short in childhood, delayed puberty, final height normal, FHx
Small for gestational age
Chromosomal – Down, Turner, Noonan, Russell- Silver
Nutritional – insufficient food, restricted diets, poor appetite
long term illness – Coeliac disease, Crohn’s disease, CKD
Psychological – physical and emotional deprivation
Endocrine – Hypothyroidism, GH deficiency, Cushing syndrome
Evaluating of Short Stature
Short stature
Detailed
history,
examination
History and Examination
HISTORY
EXAMINATION
• Birth weight
• Growth parameters
• When was detected
• Upper segment to lower segment proportion
• Any significant chronic illness
• Dysmorphism
• Detailed diet history
• Features of endocrine/ nutritional disorders
• Long term drugs
• Features of chronic illness
• Family history of short stature.
• Development milestones
Short stature
Detailed
history,
examination
Abnormal
Syndromic
Non
syndromic
Normal
BA=CA
Within
MPHR
BA < CA
Below MPHR
Bone Age
 Skeletal maturity
 Normally chronical and bone age should be the same
 Otherwise health child difference less than 2 years can be normal
Mid parental height
Male =
father’s ht + mother’s ht + 12.5cm
Female =
father’s ht + mother’s ht − 12.5cm
MPHR = MPH +/- 8.5cm
Syndromes/ Chromosomal disorder
Down syndrome
Turner syndrome
Noonan syndrome
Russell- silver syndrome
Short stature
Detailed history,
examination
Abnormal
Syndromic
Normal
Non
syndromic
Proportionate
BA < CA
Under nutrition
Chronic
disease
Drugs
Disproportionate
Endocrine
BA=CA
BA < CA
Within MPHR
Below MPHR
Familial Short
Stature
Constitutional
Short Stature
Short upper
segment
Short lower
segment
Thoracic
dystrophies/Scoliosis
Achondroplasia,osteogenesis
imperfecta, rickets
Investigations
Tall Stature
Height for age and sex above +2SD
Causes for Tall Stature
Familial – most common
Obesity – puberty is advanced so final height centile is less
Secondary – hyperthyroidism, excess sex steroids, excess adrenal androgen
steroids, excess growth hormone secretion
Syndromes – Marfan, Homocystinuria, Klinefelter Xn, Sotos Xn
Excessive growth at birth – maternal diabetes, primary hyperinsulinism,
Beckwith Xn
Tall Stature
Detailed History &
Examination
Syndromic
Proportionate
Non-syndromic
Disproportionate
Beckwith –
Wiedemann Xn
Marfan Xn
Weaver Xn
Klinefelter Xn
Sotos Xn
BA = CA
BA > CA
Familial tall
stature
Non obese
Normal Puberty
Growth hormone
excess
Obese
Advanced puberty
Precocious
puberty
Exogenous
obesity
Summary
MAM
SAM
Clinical
presentation
Incidental finding
Parental concern
MOH clinic
With any complication of SAM
Kwashiorkor
Marasmus
Diagnosis
MUAC – 115-124mm OR
Weight/Height -2SD to -3SD
MUAC less than 115cm
Weight/Height <3SD
Management
Mainly Community Based
Supplementation & preventive measures
Under Paediatrition
10 steps
Complications
Progression to SAM
Faltering growth
Cognitive deficits
Acquired immunodeficiency
Loss of appetite,
hypoglycemia
Hypothermia
LRTI, High Fever
Severe pallor & dehydration
Not alert, convulsions
Summary
Marasmus
Kwashiorkor
Malnutrition without
Oedema
Malnutrition with Oedema
Inadequate Calorie Intake
Inadequate Protein Intake
Adaptive state
Maladaptive state
Low weight/height
Variable weight/age
References
o Illustrated Textbook of Paediatrics
o Concise Textbook of Pediatrics
o Up to Date
o Management of Severe Acute Malnutrition – Manual for Health Workers in Sri Lanka
Q & A???
Thank You…