7

Ms. Shesly P. Jose

II yr MSc Nursing
Welcome
MALABSORPTION
SYNDROME
AND
MAL NUTRITION
MALABSORPTION
SYNDROME
 syndromes encompass
Malabsorption 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 sprue
Disease of the
small CD is second
intestine only to cystic
characterized
fibrosis as a
by abnormal
mucosa and case of
permanent malabsorption
intolerance to in children
gluten.
Steatorrhea( fatty , foul , frothy , bulky
stool)
General malnutrition
Abdominal distension and
Secondary vitamine deficiencies
 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

Page 12
Complication
•Osteoporosis
•Lymphoma of the small intestine
•Infertility
•Autoimmune liver disease
Nursing diagnosis
1. 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. High risk for complication – anemia, bleeding related
reduced thrombin level
5. Risk for infection
6. Alteration in comfort related to the disease condition
7. Anxiety related to the unexpected outcome of the disease
8. 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 vegetables
Fresh meats (beef, poultry,
lamb, pork)
Seafood
Many dairy products
Corn
RicePotatoes
Beans
Amaranth
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 duct
 operable or correctable type and
 inoperable type
– Operable type –Choledochojejunostomy
– Inoperable type - Kasai procedure.
• Liver transplantation
 Nursing management
1. 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- irritability
5. High risk for complication – kernicterus, seizure
6. Anxiety related to the unexpected outcome of the
disease
7. Altered parental coping related to the need for long
term care
8. Knowledge deficit
 Nursing management

• Advise the calcium intake is increased

• salt is restricted
 occurs as a result of
decreased mucosal
surface area

Short Bowel Syndrome

 Common cause of SBS
► Congenital anomalies – jejunal and ileal
atresia, gastrochisis
► Ischemia-NEC
► Trauma and vascular injury- volvulus
► other causes
 bowel resection - Hirschsprung disease and
omphalocele
► Radiation enteritis
 Therapeutic management:
Goals
1.To preserve as much length of bowel as possible
during surgery
2.To maintain the child’s nutritional status, growth
and development while intestinal adaptation occurs
3.To stimulate intestinal adaptation with enteral
feeding
4.To minimize the complication related to the
disease process and therapy
Nutritional care becomes the longterm focus
of care
The initial phase of therapy ;
•TPN as primary source of nutrition
The second phase;
•Is the introduction of enteral feeding- soon after
the surgery-NG or gastrostomy tube+ TPN
The 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
Malnutrition
World 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.
Causes of malnutrition
Child malnutrition
death and disability

Inadequate Disease
Diet

Poor water/ sanitation Inadequate

Insufficient
inadequate health maternal and
access to food
services child care
 Higher Impaired
mortality rate mental
development
Reduced Increased risk of
capacity adult chronic disease
Baby
to care
Low Birth Untimely/inadequate
Elderly for baby
Weight weaning
Malnourished
Frequent
Infections
Inadequate Inadequate
catch up food, health
Inadequate
Inadequate growth & care
fetal Child
food, nutrition
health Stunted
& care Reduced
mental
Woman capacity
Malnourished
Adolescent
Pregnancy Inadequate
Stunted
Low Weight food, health
Gain & care

Reduced
Inadequate mental
Higher
food, health capacity
maternal
& care
mortality

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 classification
Nutritional 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 Status
Between 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 Malnutrition

Kwashiorkor (low protein)
Marasmus (low calories)

Marasmus Kwashiorkor
 Comparison
FEATURES KWASHIORKOR
Definition Protein deficiency with
sufficient calorie
Intake
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
MARASMUS
Starvation in infants
with overall
lack of calories
- Common in infants
under 1 year of age
- Growth failure
- Wasting of all tissues
including muscles and
adipose tissues
- Oedema absent
- No hepatic
enlargement
 - Oedema,localised or
Generalised ,present
Comparison
- Enlarged fatty liver
- Serum proteins low
- Moon face
- Anemia present
- Flag sign- alternate bands
of light ( depigmented)
and dark
(pigmented) hair
Morphology  Enlarged fatty liver
 Atrophy of different
tissues and organs but
subcutaneous fat
preserved
- Oedema present
- No hepatic
enlargement
- Serum proteins low
- Monkey- like face,
- Anemia present
Protuberant
abdomen,thin limbs
 No fatty liver
 Atrophy of different
tissues and organs
including
subcutaneous fat
Kwashiorkor

Infection Sparse
hair

Swollen
belly

Decreased
muscle
mass

Apathy

Kwashiorker occurs in children

between 2-3 years of age
Kwashiorkor
Marasmus (low calories)

Ravenously
hungry

Gross
weight
loss &
no fat
 Hypothesized Mechanisms
alterations in
development
of CNS

emotional reactivity, poor mental

poor impaired
development &
nutrition stress response
behavior

“functional
isolation”
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 counts
 Blood glucose profile
 Septic screening
 Stool & urine for parasites & germs
 Electrolytes, Ca, P, serum proteins
 CXR & Mantoux test
 Exclude 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 Milk 100ml=60kal
Sugar 1 tsp= 20 kal
ORS High energy milk Oil½ tsp= 20 kal
Total 100ml=100 kal

Cereal milk Milk 100ml=60kal
Sugar 1 tsp= 20 kal
Milk Cereal Flour1½tsp=20 kal
Total 100ml=100 kal
Milk 100 ml= 60 kal
 Cereal Pulse milk
Family pot feeding SAT mix (cereal, pulse, sugar)
 Deworming 2tsp= 40 kal
Total 100 ml=100ml
 Mineral and vitamin supplementation
 Nutrition supplimentation
 Nutrition
 Immunisation
 Medical care
 Family health education
 Stimulation
Severe Malnutrition: Consequences
• 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
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 DIAGNOSES
1. 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 feeds
 Use liquid diet
 Give vitamin A & folic acid on admission
 With diarrhea use lactose-free or soya
bean formula
 XEROPHTHALMIA(DRY EYE)

Disease due to
deficiency of Vitamin A
Also Called Xeroma
Absence of tears
Xerophthalmia 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
Treatment
WHO/UNICEF treatment schedule of
xerophthalmia
Children 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

Treatment
Nicotinamide,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

•Infantile scurvy is characterised by

gross irritability, excessive crying and
tenderness to touch,more so in the
lower limbs.

 Administer loading dose of 500 mg of

vitaminC followed by a daily dose of 100 to
300 mg for several weeks.
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 ANEMIA
A 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 iron

Poor bioavailability (only less than 5 percent is
absorbed)
Excessive loss of iron (menstruation, rapid
pregnancies, hookworm infestations, other illnesses)
Interventions

Iron and folic acid supplementation

Nutritional 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 IDD
Deficient 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 Goiter
Cretinism
Cretinism
Severe form of IDD
Occurs during fetal stage
Interfere with brain development causing brain
damage and death
Result in Growth failure, MR, Speech and hearing
defects
Where do we go from here?

Poverty
reduction Economic growth

Increased
productivity Improved child Social sector
nutrition investments

Enhanced human
capital

From UNICEF, State of the World’s Children: Adapted from Stuart Gillespie, John
Mason and Reynaldo Martorell, How nutrition improves, ACC/SCN, Geneva 1996.
OBESITY
Most Prevalent form of malnutrition
Abnormal growth of adipose tissue due to enlargement
of fat cells(Hypertrophic),Increase in no. of fat cells
(hyperplasic)or Combination of both
OBESITY
Obesity - 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
BMI
BMI= Height in kilogram
(Weight in Meter)2
20-25 IDEAL
26-30 OVERWEIGHT
31-40 OBESE
40+ VERY OBESE
BIBLIOGRAPHY:
 Wong D.L etal . Essentials Of Paediatric Nursing. 6 th edition. Missouri: Mosby;2001
 Marlow D.R. Redding B. Textbook of Paediatric nursing. 1 st edition.Singapore: Harwourt
Brace & company; 1998
 Dr.Chaudari KC. Indian Journa of Paediatrics. Nov22 2007
 Parthasarathy IAP textbook of Paediatrics. 2 nd edition. jaypee: NewDelhi; 2002
 Kumar Vinay,Cotran.R.S,Robbins S.L.Basic Pathology.6 th 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:JaypeePublishers;20
08
 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.3 rd 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
 http://www.google.co.in/imgres?imgurl=http://www.mo
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rl=http://www.mountnittany.org/wellness-library/healths
heets/documents%3FID%3D6595&usg=__73roDFvHjY
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 http://www.google.co.in/imgres?
imgurl=http://www.mountnittany.org/assets/images/kra
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%3D7312&usg=__5wNKugTFhgPAbvy8tiXC5IHy9Fo
=&h=301&w=350&sz=104&hl=en&start=6&itbs=1&tb
nid=A8-dHtqV6sCvh
   Journal of Indian Association of Pediatric Surgeons
Thank U…