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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

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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:

Mosby;2001 Marlow D.R. Redding B. Textbook of Paediatric nursing. 1st edition.Singapore:

Harwourt Brace & company; 1998 Dr.Chaudari KC. Indian Journa of Paediatrics. Nov22 2007 Parthasarathy IAP textbook of Paediatrics. 2nd edition. jaypee: NewDelhi; 2002 Kumar Vinay,Cotran.R.S,Robbins S.L.Basic Pathology.6th edition.Bangalore:

Prism Books(PVT) LTd.1997 Gupte Suraj .Recent Advances in pediatrics.1st edition .Delhi:P.L.Printers;1991 Basavanthappa.B.T.CommunityHealthNursing.2ndedition.NewDelhi:JaypeePubl

ishers;2008 GuptaPiyush.EssentialPediatricNursing.1st edition.New

Delhi:A>P>Jain&Co;2004 Ramachandran Prema.Compating child UnderNutrition.Health For The

Millions.October-November,2008 Elizabeth.K.E.Nutrition and Child Development.3rd edition.Hyderabad.Paras:

Medical Publishers;2007 Shanthi Ghosh.Nutrition & child care.2nd edition.NewDelhi:Jaypee

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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