Nutrition
Section 3: Nutrition
3.2 PROTEIN-ENERGY MALNUTRITION (PEM) AND NUTRIENT DEFICIENCIES
Figures 3.2.1A and B: Dermatosis of kwashiorkor
Photo Courtesy: Meenakshi Mehta, Mumbai
The dermatosis of kwashiorkor are varied, mainly on lower limbs and lower abdomen and include patchy erythema, areas of hypo/
hyperpigmentation, desquamation followed by depigmentation and exposing dermis, resembling
“Flaky Paint Dermatosis”, “Mosaic dermatosis”. In severe cases, petechiae and ecchymoses may appear.
No specific treatment of dermatosis.
Improves with treatment of kwashiorkor.
Kwashiorkor
Figure 3.2.2: Kwashiorkor
Photo Courtesy: Meenakshi Mehta, Mumbai
PEM due to predominant protein deficiency compared to calorie deficiency. Common age 1 year to 3/4 years. Characterized by general edema, pallor, apathy, irritability, occasionally dermatosis and hair changes associated with anorexia and diarrhea.
Right from postweaning phase ensure proper administration of adequate food both quality/
quantity wise, treatment of diarrhea and other complications if any, preventive immunizations.
Marasmic Kwashiorkor
Figure 3.2.3: Marasmic kwashiorkor Photo Courtesy: Meenakshi Mehta, Mumbai
Patient has combined
manifestations of marasmus and kwashiorkor, i.e. wasting of whole body with edema of lower limbs and rarely upper limbs.
Dietary management involves administration of both protein and calories with Type I and Type II nutrients, i.e. micronutrients.
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Marasmus
Figures 3.2.4A and B: Marasmus
Photo Courtesy: Meenakshi Mehta, Mumbai
PEM due to predominant calorie deficiency. Common age 6 months to 3/4 years. Characterized by thin, severely undernourished/
wasted child, loss of subcutaneous fat, absence of edema,
hepatosplenomegaly, alert look, in advanced cases wasting of muscles, delayed growth.
Right from weaning phase, 6 months onwards, proper care of quantity and quality of food intake, prevention of micronutrient deficiencies, immunization and deworming.
Figure 3.2.5: Marasmus
Photo Courtesy: Dheeraj Shah, Delhi
Severe form of undernutrition resulting in marked muscle wasting, loss of subcutaneous fat, skeleton like look. Child appears alert.
Stepwise management involves:
• Treatment of complications, e.g.
hypoglycemia, infections.
• Initiation of dietary therapy involving F–75.
• Energy dense feeding during recovery phase.
• Follow-up care.
Micronutrient Deficiency
Figures 3.2.6A and B: Micronutrient deficiency Photo Courtesy: Rural Health Training Center, Vaitarna, Department of Community Medicine, LTMM College and General Hospital, Sion, Mumbai (for both photos)
• Angular stomatitis: During health check-up of students of a tribal school in taluka Shahpur, district Thane. Disease due to deficiency of micronutrients are commonly seen in tribal children. In this picture, a male child with angular stomatitis is shown. It occurs due to deficiency of riboflavin.
• Pale and Fissured tongue: Another student had deficiency of iron and vitamin B2 and B3.
• The children were given the micronutrient supplements riboflavin and multivitamins.
Health education regarding the nutrition was also provided with.
• The child was treated with iron and multivitamins. The nutritional health education was given for long-term benefit.
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Picture Note Management
Rachitic Rosary
Figure 3.2.7: Rachitic rosary Photo Courtesy: Dheeraj Shah, Delhi
Prominence of costochondral junctions resulting from accumulation of unmineralized matrix in vitamin D deficiency (Rickets).
Rachitic rosary has more rounded appearance in comparison to scorbutic rosary where angulation is sharp and may be tender.
Treatment of vitamin D deficiency rickets involves administration of 600,000 U of vitamin D orally or intramuscularly. Adequate intake of vitamin D and calcium should be ensured during follow-up besides adequate exposure to sunlight.
Radiological Changes of Scurvy
Figure 3.2.8: Radiological changes of scurvy Photo Courtesy: Dheeraj Shah, Delhi
Changes of scurvy are most prominently seen around knee.
The metaphysis of long bones show dense white line (WL) of Frankel.
Zone of rarefaction or Trummerfeld zone (TZ) is seen in submetaphysial region. The extension of WL over TZ produces appearance of a spur which is called Pelkan spur (PS).
Oral administration of vitamin C 100 to 300 mg/day for up to 12 weeks.
Vitamin A Deficiency
Figure 3.2.9: Vitamin A Deficiency Photo Courtesy: Rural health training center, Vaitarna, Department of Community Medicine, LTMM College and General Hospital, Sion, Mumbai
In this picture, a tribal school student is having phrynoderma or toad skin which is a sign of vitamin A deficiency.
For treatment vitamin A was given orally. 2,00,000 IU was given on 0,1 and 14 days along with the dietary advice to consume the locally available vitamin A enriched food like drumsticks, papaya and ripe mangoes.
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Figures 3.2.10A and B: Vitamin A Deficiency Photo Courtesy: Rural Health Training Center, Vaitarna, Deptartment of Community Medicine, LTMM College and General Hospital, Sion, Mumbai (for both photos)
1) In first picture, a tribal school student is having ‘Bitot’s spot’ which is a sign of vitamin A deficiency.
2) In second picture, a case of
‘Xerophthamia’ is seen. The patient had come for treatment in Urban Health Center, Dharavi.
Prophylactic vitamin A
supplementation is given every 6 months to children below 5 years of age under universal immunization program to prevent deficiency disorder.
Starting at 9 months with measles as a first dose : 1,00,000 IU
At 15 months : 2,00,000 IU Every 6 monthly up to the age of 5 years : 2,00,000 IU
Under national program for prevention of Blindness the prophylactic vitamin A supplementation is given up to 5 years of age to prevent the vitamin A deficiency.
For treatment, vitamin A was given orally and the patient was referred to ophthalmology for further management.
Immediately on diagnosis
< 6 months 50,000 IU 6–12 months 1,00,000 IU
> 12 months 2,00,000 IU Next day and at least 2 weeks later: Same age specific dose.
Child Nutrition: Infant Milk Food Unsafe—Etiology of PEM
3.3 NUTRITION EDUCATION
Figure 3.3.1: Child nutrition: Infant milk food unsafe
Photo Courtesy: Meenakshi Mehta, Mumbai
Bottle-feeding in uneducated families, in poor socioeconomic circumstances, unhygienic environment with restricted water supply leads to recurrent morbidity, malnutrition and finally death.
Avoid bottle-feeding, instead advice fresh animal milk with cup/wati, spoon/“bondla”, when supplementary feeding is advocated.
Health Education Program
Figures 3.3.2A and B: Health Education Program Photo Courtesy: Urban health center, vaitarna, Department of Community Medicine, LTMM College and General Hospital, Sion, Mumbai (for both photos)
Health education session is being carried out during breastfeeding week.
The department of community medicine is carrying out the health educational activities in the community to spread the awareness regarding malnutrition. This is effective tool to bring about the community participation.
Vitamin A Deficiency
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Picture Note Management
Malnourished Child
Figures 3.3.3A and B: Malnourished child Photo Courtesy: Urban health center, Dharavi, Department of Community Medicine, LTMM College and General Hospital, Sion, Mumbai (for both photos)
Malnutrition is commonly seen in infants after 5 to 6 months of age. The child in picture had come to Urban Health Center, Dharavi for treatment.
The child was referred to Nutritional Rehabilitation Center (NRC) run in Urban Health Center (UHC), Dharavi.
Health education about weaning food was given. Emphasis was given to inclusion of energy rich semisolid food—NRC, UHC, Dharavi. Under ICDS program, anthropometric measurements are taken on monthly basis by Anganwadi worker to identify cases of malnutrition.
Nutrition Education: Eating Balanced Food for Good Growth
Figure 3.3.4: Eating balanced food for good growth
Photo Courtesy: Meenakshi Mehta, Mumbai
Shows how children grow well by eating proper balanced diet covering all food groups
The teaching of nutrition must stress that there is a connection between good and proper food for growing tall, strong and healthy.
Nutrition Education: Foods Rich in Vitamin A, Dairy Products and Vegetables, Fish
Figures 3.3.5A to D: Foods rich in vitamin A, dairy products and vegetables, fish
Photo Courtesy: Meenakshi Mehta, Mumbai
Shows foods rich in vitamin A: Dairy products, eggs and dark green leafy vegetables, pappaya and carrots, fish and other vegetables.
Advice adequate consumption from these foods as per the socio- economic status of the family.
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Prevention of Kwashiorkor
Figure 3.3.6: Three plank protein bridge for prevention of malnutrition
Photo Courtesy: Meenakshi Mehta, Mumbai
Shows three plank protein bridge in order of priority: (1) Prolonged breast feeding, (2) Use all
available vegetable proteins, (3) Use all available animal proteins whenever possible, to prevent child developing kwashiorkor.
Judicious use of breast milk (proteins), vegetable and animal proteins starting from six months onwards—postweaning phase to about 2 to 3 years of age by the time the child has full adult diet to prevent the child falling in the river of kwashiorkor.
ARF—The Miracle of Germinated Cereal Powders
Figure 3.4.1: The miracle of germinated cereal powders
Photo Courtesy: Meenakshi Mehta, Romeen Lavani, Mumbai
The problem: Vast majority of infants (after 6 months of age and onwards) develop malnutrition because of weaning with bulky, viscous yet low nutritious porridges/
gruels of cereals consumed in different communities. The infants are unable to consume the gruels in adequate amount per feeding and hence get less calories.
Porridges/gruels treated with ARF will have decreased viscosity, less bulky, hence the children will be able to consume more and will have more calories.
Figure 3.4.2: ARF—The possible solutions Photo Courtesy: Meenakshi Mehta Romeen Lavani, Mumbai
The solutions: To increase the calories, of the feed the alternative solutions are:
1. Addition of oil 2. Fermentation
3. Increasing ingredients 4. Germination of cereals and
adding the product/powder to the main gruel.
Amongst the solutions suggested, the first 3 methods are commonly employed hence the germination of cereals producing amylase, a less known method yet, simple and cheap, is demonstrated here.