MICRO NUTRIENTS DEFICIENCY

Iron

The commonest sign of iron deficiency is anaemia (see 17.1. anaemia).

Iodine

Iodine deficiency leads to deficiency of thyroxine hormone (see 7.2. hypothyroid)

Vitamin A

A retinol ester, can either be ingested or synthesized within the body from plant carotene.

Its deficiency is a major cause of blindness among poor communities worldwide.

Vitamin A is important in:

• Epithelial membrane integrity

• Night vision

• Immunity

• Growth

• Reproduction

• Maintenance of life

Source:

• Animal products eg. Liver, milk, kidneys

• Dark green leafy vegetable.

Consequences of deficiency: Reduced immunity, keratinizing metaplasia of epithelial membranes, xerophthalmia, night blindness, keratomalacia and blindness.

Vitamin A supplementation has been shown to result in 23-34% reduction of all childhood mortality (6-59 months), 50% reduction in measles mortality and 33% reduction in diarrhoeal disease mortality.

Prevention of Vitamin A deficiency

Vitamin A supplementation in health (see 11. immunization)

Disease targeted supplementation

Give a dose of Vitamin A for any of the following conditions:

• Malnutrition

• Diarrhoea

• Malaria

• TB

• Pneumonia

• Worm infestation

• Fever.

NB. Ensure that the child has not received Vitamin A in the last 1 month.

Treatment for xerophthalmia

Give Vitamin A on day 1, 2 and a third dose between 1-4 weeks after 2^nd dose. Give children with measles vitamin A as for xerophthalmia.

MACRONUTRIENT MALNUTRITION

Presents as Protein Energy Malnutrition (PEM). PEM is a common disorder which covers a wide spectrum of deficiency in nutrition ranging from mild or underweight to severe forms like marasmus and kwashiorkor. The first sign of PEM is poor weight gain.

The Wellcome Classification of PEM

Clinical Features

MILD MALNUTRITION (Grade I)

Child <5 yrs who is foiling to gain weight for 3 months and who is between 75-89.9% of the expected weight for age.

Management

• Bi-weekly attendance at the clinic

• Treat any intercurrent problem e.g. diarrhoea, pneumonia, malaria.

Admit

• For further assessment if no change after 3 months

• If child develops moderate to severe malnutrition.

Advice to mothers

• Nutrition counselling.

MODERATE MALNUTRITION (Grade II)

Child <5 yrs who is between 60-74.5% of the expected weight for age.

Investigations

• Blood slide for malaria parasites

• Stool for ova/cyst Hb, PBF

• Urinalysis - microscopy, C&S

• CXR - to rule out pneumonia and PTB

• Mantouxtest.

Management

• Admit child

• Treat underlying disease eg. pneumonia, malaria

• Intensive feeding regime:

- Calories - - 120-150 cal/kg/day

- Protein 2-4 gm/kg/day

Give high protein, high calorie diet such as special milk with 1 calorie per 1 ml

• Folic acid 2.5-5 mg OD

• Ferrous sulphate 30 mg/kg/day

Advice to mothers

• Nutrition counselling.

SEVERE MALNUTRITION(Grade III)

Child who is <60% of expected weight for age or with generalised oedema.

Investigations

• Blood slide for malaria parasites

• Stool for ova/cysts

• Hb, PBF

• Urinalysis - microscopy, C&S

• CXR - to rule out pneumonia, PTB.

• Mantouxtest

Management

• Admit child

• Intensive feeding regime:

- high energy milk (via nasogastric tube if necessary). Start with 2 hourly feeds then reduce to 3 hourly. Increase from 100 to 200 ml/kg/24 hrs as tolerated

• Frequent spaced feedings throughout 24 hrs are essential to prevent hypoglycaemia

• Multivitamin syrup 2.5 to 5 ml OD for I month

• Folic acid 2.5-5 mg OD for I month

• Ferrous sulphate 30 mg/kg/day after infections have been treated.

• Give antibiotics:

- cotrimoxazole 24 mg/kg BD for 5 days OR if sepsis crystalline penicillin 25,000 units/kg IM QDS and gentamicin 3-5 mg/kg IM TDS for 5 days

• Keep baby warm. Heat room, mother's warmth

• If hypoglycaemic give dextrose 50% 1 ml/kg IV STAT then 5% dextrose 2 ml/kg/hour

• Update immunizations

• Soak skin ulcers in Eusol solution

• Mouth ulcers: clean mouth with normal saline (or salt water) and apply Gentian violet. If already on other antibiotics add metronidazole 7.5 mg/kg TDS orally for 7 days

• Give Vitamin A

• Dietary education. Involve mother.

Prevention

• Appropriate nutritional advice in the MCH clinic

• Use of growth chart in the MCH clinic for all under 5 years

• Health education to mothers attending hospitals, on child rearing and appropriate feeding.

Advice to mothers

• Involve the mother in feeding the child i.e. encourage active feeding

• Advice mother on how to mix nutritious food from the 3 food groups.

• Show the mother how well the child is doing on the weight chart.