in children principles of dehydration 脱水儿童营养不良的原则课件

MALNUTRITION IN CHILDREN. PRINCIPLES OF DEHYDRATION CORRECTION.,Sakharova Inna Ye., MD, PhD,2,Malnutrition will be responsible for 3,000 deaths globally, mostly women, infants and children, during this lecture! Malnutrition accounts of 30 million deaths per year (about 1 death per second),3,Some Major World Risk Factors Causing Deaths,4,A healthy diet provides a balanced nutrients that satisfy the metabolic needs of the body without excess or shortage. Dietary requirements of children vary according to age, sex & development.,Dora, 3, receives a dose of vitamin A outside a mobile health clinic in Namurava village in Mozambique.,5,“Hidden Hunger” deficit of vitamins and microelements in diet.,6,Around the world, billions of people live with vitamin and mineral deficiencies. For instance, approximately one third of the developing worlds children under the age of five are vitamin A-deficient, and therefore ill-equipped for survival. Iron deficiency anaemia during pregnancy is associated with 115,000 deaths each year, accounting for one fifth of total maternal deaths. WHO Report, 2009,7,Lab Assesment,Full blood counts Blood glucose profile Septic screening Stool & urine for parasites & germs Electrolytes, Ca, Ph & ALP, serum proteins CXR & Mantoux test Exclude HIV & malabsorption,8,NON-ROUTINE TESTS,Hair analysis Skin biopsy Urinary creatinine over proline ratio Measurement of trace elements levels, iron, zinc & iodine,9,OVERVIEW OF PEM (Protein Energy Malnutrition),The majority of worlds children live in developing countries Lack of food & clean water, poor sanitation, infection & social unrest lead to LBW & PEM Malnutrition is implicated in 50% of deaths of 5 children (5 million/yr),10,OVERVIEW OF PEM,In 2000 WHO estimated that 32% of 5 children in developing countries are underweight (182 million). 78% of these children live in South-east Asia & 15% in Sub-Saharan Africa. The reciprocal interaction between PEM & infection is the major cause of death & morbidity in young children.,11,12,Definitions of Malnutrition,Kwashiorkor: protein deficiency Marasmus: energy deficiency Marasmic/ Kwashiorkor: combination of chronic energy deficiency and chronic or acute protein deficiency Failure to thrive: marasmus in U. S. children under 3.,13,Definitions of Malnutrition,Primary: inadequate food intake Secondary: result of disease Mixed,14,Diagnosis,Normal: 1 SD Mild: -1.1 to -2 SD Moderate -2.1 to -3 SD Severe greater than -3 Less than 5th percentile BMI in adolescents Moderate 15 ages 11-13, 16.5 ages 14-17 Severe 13 ages 11-13, 14.5 ages 14-17,15,CLASSIFICATION OF MALNUTRITION IN CHILDREN,16,Gomez Classification: The childs weight is compared to that of a normal child (50th percentile) of the same age. It is useful for population screening and public health evaluations. percent of reference weight for age = (patient weight) / (weight of normal child of same age) * 100 Interpretation: 90 - 110% normal 75 - 89% Grade I: mild malnutrition 60 - 74% Grade II: moderate malnutrition 60% Grade III: severe malnutrition,17,Wellcome Classification: evaluates the child for edema and with the Gomez classification system. 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,18,KWASHIORKOR,Cecilly Williams, a British nurse, had introduced the word Kwashiorkor to the medical literature in 1933. The word is taken from the Ga language in Ghana & used to describe the sickness of weaning (“the sickness the older child gets when the next baby is born”).,19,ETIOLOGY,Kwashiorkor can occur in infancy but its maximal incidence is in the 2nd yr of life following abrupt weaning. Kwashiorkor is not only dietary in origin. Infective, psycho-socical, and cultural factors are also operative.,20,ETIOLOGY,Kwashiorkor is an example of lack of physiological adaptation to unbalanced deficiency where the body utilized proteins and conserve S/C fat. One theory says Kwash is a result of liver insult with hypoproteinemia and oedema. Food toxins like aflatoxins have been suggested as precipitating factors.,21,CONSTANT FEATURES OF KWASH,OEDEMA PSYCHOMOTOR CHANGES GROWTH RETARDATION MUSCLE WASTING,22,USUALLY PRESENT SIGNS,MOON FACE HAIR CHANGES SKIN DEPIGMENTATION ANAEMIA,23,OCCASIONALLY PRESENT SIGNS,HEPATOMEGALY FLAKY PAINT DERMATITIS CARDIOMYOPATHY & FAILURE DEHYDRATION (Diarrh. & Vomiting) SIGNS OF VITAMIN DEFICIENCIES SIGNS OF INFECTIONS,24,25,26,DD of Kwash Dermatitis,Acrodermatitis Entropathica Scurvy Pellagra Dermatitis Herpitiformis,27,MARASMUS,The term marasmus is derived from the Greek marasmos, which means wasting. Marasmus involves inadequate intake of protein and calories and is characterized by emaciation. Marasmus represents the end result of starvation where both proteins and calories are deficient.,28,MARASMUS,Marasmus represents an adaptive response to starvation, whereas kwashiorkor represents a maladaptive response to starvation In Marasmus the body utilizes all fat stores before using muscles.,29,EPIDEMIOLOGY & ETIOLOGY,Seen most commonly in the first year of life due to lack of breast feeding and the use of dilute animal milk. Poverty or famine and diarrhoea are the usual precipitating factors Ignorance & poor maternal nutrition are also contributory,30,Clinical Features of Marasmus,Severe wasting of muscle & s/c fats Severe growth retardation Child looks older than his age No edema or hair changes Alert but miserable Hungry Diarrhoea & Dehydration,31,32,33,Complications of P.E.M,Hypoglycemia Hypothermia Hypokalemia Hyponatremia Heart failure Dehydration & shock Infections (bacterial, viral & thrush),34,TREATMENT,Correction of water & electrolyte imbalance Treat infection & worm infestations Dietary support: 3-4 g protein & 200 Cal /kg body wt/day + vitamins & minerals Prevention of hypothermia Counsel parents & plan future care including immunization & diet supplements,35,KEY POINT FEEDING,Continue breast feeding Add frequent small feeds Use liquid diet Give vitamin A & folic acid on admission With diarrhea use lactose-free or soya bean formula,36,PROGNOSIS,Kwash & Marasmus-Kwash have greater risk of morbidity & mortality compared to Marasmus and under weight Early detection & adequate treatment are associated with good outcome Late ill-effects on IQ, behavior & cognitive functions are doubtful and not proven,37,Pediatric Fluid Therapy Principles,Assess water deficit by: 1. weight: weight loss (Kg) = water loss (L) OR 2. Estimation of water deficit by physical exam: Mild moderate severe Infants 10 % Older children 6 %,38,39,MANAGEMENT OF DEHYDRATION -Replace Phase 1: Acute Resuscitation : Give Lactated Ringer OR Normal Saline at 10-20 ml/kg IV OR 5 % albumin over 30-60 minutes. May repeat bolus until circulation stable -Calculate 24 hour maintenance requirements Formula: First 10 kg: (100 cc/kg/24 hours) Second 10 kg: (50 cc/kg/24 hours) Remainder: (20 cc/kg/24 hours) Example: 35 Kilogram Child Daily: 1000 cc + 500 cc + 300 cc = 1800 cc/day -Calculate Deficit: Mild Dehydration: (40 ml/kg) Moderate Dehydration: (80 ml/kg) Severe Dehydration: (120 ml/kg),40,MANAGEMENT Continue -Calculate remaining deficit: Substract fluid resuscitation given in Phase 1 -Calculate Replacement over 24 hours: First 8 hours: 50% Deficit + Maintenance Next 16 hours: 50% Deficit + Maintenance Determine Serum Sodium Concentration Hypertonic Dehydration (Serum Sodium 150) Isotonic Dehydration Hypotonic Dehydration (Serum Sodium 10 Kilograms: 20 meq KCl /liter glucose,41,Hypertonic dehydration,Serum Na+ 150 meq/L (up to 213) Deficit replacement over 48 hours 0.18% 0.3% saline Regular daily maintenance Fluid evenly distributed over time Dialysis option in severe hypernatremia,42,Hypotonic (hyponatriemi