Transcript Acute Gastroenteritis in Children

Acute Gastroenteritis in
Children
• infections of the gastrointestinal tract caused by bacterial, viral, or
parasitic pathogens
• Many of these infections are foodborne illnesses
• The most common manifestations are diarrhea and vomiting, which
can also be associated with systemic features such as abdominal pain
and fever.
• Diarrheal disorders in childhood account for a large proportion (9%)
of childhood deaths, with an estimated 0.71 million deaths per year
globally,
ETIOLOGY OF DIARRHEA
• Gastroenteritis is the result of infection acquired through the fecal–
oral route or by ingestion of contaminated food or water
• Gastroenteritis is associated with poverty, poor environmental
hygiene, and development indices.
• rotavirus and the noroviruses (small round viruses such as Norwalklike virus and caliciviruses) are the most common viral agents,
followed by sapoviruses, enteric adenoviruses and astroviruses
• Shigella, Salmonella, E. coli, Campylobacter are examples of bacterial
causes
• Giardia and Entamoeba histolytica are examples of paracytic causes
PATHOGENESIS OF INFECTIOUS DIARRHEA
1- non-inflammatory diarrhea through enterotoxin production by
some bacteria, destruction of villus (surface) cells by viruses, adherence
by parasites, and adherence and/or translocation by bacteria
2- Inflammatory diarrhea is usually caused by bacteria that directly
invade the intestine or produce cytotoxins
Risk factors for diarrhea
• Lack of exclusive breastfeeding (0-5 mo)
• No breastfeeding (6-23 mo)
• Underweight,stunted,wasted(malnourished)
• Vitamin A deficiency
• Zinc deficiency
• Crowding (>8 persons/kitchen)
• Indoor air pollution
• Unwashed hands
• Poor water quality
• Inappropriate excreta disposal
definition
Acute diarrhea is defined as the abrupt onset of 3 or more loose stools
per day and lasts no longer than 14 days
Increase frequency and/or liquidity of stool
Stool output >10 g/kg/24 hr, or more than the adult limit of 200 g/24
hr.
Rotavirus infection
typically begins after an incubation period of <48 hr with mild to
moderate fever as well as vomiting, followed by the onset of frequent,
watery stools. All 3 symptoms are present in about 50-60% of cases.
Vomiting and fever typically abate during the 2nd day of illness, but
diarrhea often continues for 5-7 days. The stool is without gross blood
or white blood cells. Dehydration may develop and progress rapidly,
particularly in infants. The most severe disease typically occurs among
children 4-36 mo of age. Malnourished children and children with
underlying intestinal disease, are particularly likely to acquire severe
rotavirus diarrhea
Shigella
• Four species of Shigella are responsible for
bacillary dysentery:
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S. dysenteriae
S. flexneri
S. boydii
S. sonnei
• It is most common in the 2nd and 3rd year of life, infection in
the 1st 6 mo of life is rare (may be due to Breast feeding)
• The colon is the target organ for shigellae
• Symptoms:
• generalized toxicity
• urgency, and painful defecation characteristically occur.
• watery → bloody mucoid stools
• Convulsions, headache, lethargy, confusion, nuchal rigidity, or
hallucinations may be present before or after the onset of
diarrhea.
Escherichia Coli :
 gram-negative bacilli
 5 major groups of diarrheagenic E. coli:
(1) enterotoxigenic E. coli (ETEC)
(2) enteroinvasive E. coli (EIEC)
(3) enteropathogenic E. coli (EPEC)
(4) Shiga toxin–producing E. coli (STEC)also known
as enterohemorrhagic E. coli (EHEC)
(5) enteroaggregative E. coli (EAEC).
Giardia Lamblia
It infects the duodenum and small intestine
Clinically: asymptomatic, acute infectious diarrhea
(insidious onset of progressive anorexia,
nausea, gaseousness, abdominal distention,
watery diarrhea) or chronic diarrhea with
persistent GIT signs and symptoms, including
FTT and abdominal pain or cramping.
There is usually no extraintestinal spread.
Entamoeba histolytica
Clinical
presentations
range
from
asymptomatic cyst passage to amebic colitis,
amebic
dysentery,
ameboma,
and
extraintestinal disease as amebic liver disease.
Amebic colitis, gradual onset of colicky
abdominal pains and frequent bowel
movements (6–8/day). Diarrhea is frequently
associated with tenesmus. Stools are blood
stained and contain a fair amount of mucus
with few leukocytes. Generalized constitutional
symptoms and signs are characteristically
absent, with fever documented in only ⅓ of
patients.
Clinical Evaluation of Diarrhea
1- Assessing the degree of dehydration and acidosis and provide rapid
resuscitation and rehydration with oral or intravenous fluids as
required
2- Clinically determining the etiology of diarrhea for institution of prompt antibiotic therapy, if
indicated
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Stool characteristics (eg, consistency, color, volume, frequency)
Presence of associated enteric symptoms (eg, nausea/vomiting, fever, abdominal pain)
Use of child daycare (common pathogens: rotavirus, astrovirus, calicivirus;Campylobacter, Shigella, Giardia,
and Cryptosporidium species [spp])
Food ingestion history (eg, raw/contaminated foods, food poisoning)
Water exposure (eg, swimming pools, marine environment)
Camping history (possible exposure to contaminated water sources)
Travel history (common pathogens affect specific regions; also consider rotavirus and Shigella, Salmonella,
and Campylobacter spp regardless of specific travel history, as these organisms are prevalent worldwide)
Animal exposure (eg, young dogs/cats: Campylobacter spp; turtles:Salmonella spp)
Predisposing conditions (eg, hospitalization, antibiotic use, immunocompromised state)
Although nausea and vomiting are nonspecific symptoms, they indicate
infection in the upper intestine.
• Fever suggests an inflammatory process(inflammatory diarrhea) but also
occurs as a result of dehydration or coinfection (e.g., urinary tract infection,
otitis media)called also parenteral diarrhea(etiology outside the G.I system)
• Severe abdominal pain, tenesmus and bloody diarrhoea indicate
involvement of the large intestine and rectum.
Features such as nausea and vomiting and absent or low-grade fever with
mild to moderate periumbilical pain and watery diarrhea indicate small
intestine involvement and also reduce the likelihood of a serious bacterial
infection.
InvestigationS
1-Stool Examination
A-Microscopic examination of the stool: Fecal leukocytes and RBC
indicate bacterial invasion of colonic mucosa, stool microscopy must
include examination for parasites causing diarrhea, such as G. lamblia
and E. histolytica
B- Stool culture is required if the child appears septic, if there is blood
or mucus in the stools or the child is immunocompromised.It may be
indicated following recent foreign travel, if the diarrhoea has not
improved by day 7 or the diagnosis is uncertain
3- Plasma electrolytes, urea, creatinine and glucose should be checked
if intravenous fluids are required or there are features suggestive of
hypernatraemia.
4- If antibiotics are started, a blood culture should be taken.
5- urinalysis to exclude UTI (parenteral diarrhea)
6- Enzyme immunoassay for rotavirus or adenovirus antigens
BLOODY DIARRHEA
• Causes of bloody diarrhoea (real or apparent) in infants and children
Infants aged <1 year
1- Intestinal infection(shigella,salmonella,E-coli,campylobacter,Yersinia)
And Entamoeba histolytica
2- Infant colitis(Cow’s milk colitis)—non specific allergic colitis
3- rare causes like Intussusception, Malrotation and volvulus
• Infants aged >1 year
1- Intestinal infection
2- Inflammatory bowel disease
3- Juvenile polyp
4- rare causes Intussusception , Malrotation and volvulus and HenochSchönlein purpura
Recent antibiotic use raises suspicion for antibiotic-associated colitis
and Clostridium difficile colitis.
DEHYDRATION (total body deficit of sodium
and water)
• The following children are at increased risk of dehydration:
• Infants, particularly those under 6 months of age or those born with
low birthweight.
• If they have passed ≥6 diarrhoeal stools in the previous 24 h
• If they have vomited three or more times in the previous 24 h
• If they have been unable to tolerate (or not been offered) extra fluids
• If they have malnutrition
Infants are at particular risk of dehydration because they have a greater
surface area to weight ratio than older children, leading to greater
insensible water losses .They have higher basal fluid requirements
(100–120 ml/kg per day, i.e. 10–12% of bodyweight) and immature
renal tubular reabsorption. In addition, they are unable to obtain fluids
for themselves when thirsty.
treatment
ORS
• The low-osmolality World Health Organization (WHO) oral
rehydration solution (ORS) containing 75 mEq of sodium, 64 mEq of
chloride, 20 mEq of potassium, and 75 mmol of glucose per liter, with
total osmolarity of 245 mOsm/L, is now the global standard of care
and more effective than home fluids, including decarbonated soda
beverages, fruit juices, and tea. These are not suitable for rehydration
or maintenance therapy because they have inappropriately high
osmolalities and low sodium concentrations.
• Oral rehydration should be given to infants and children slowly,
especially if they have emesis. It can be given initially by a dropper,
teaspoon, or syringe, beginning with as little as 5 mL at a time .The
volume is increased as tolerated.
• Oral rehydration can also be given by a nasogastric tube if needed;
this is not the usual route.
• Limitations to oral rehydration therapy include shock, an ileus,
intussusception, carbohydrate intolerance (rare), severe emesis, and
high stool output (>10 mL/kg/hr)
Hypernatraemic dehydration ( sodium
concentration >150 mEq/L)
• Infrequently, water loss exceeds the relative sodium loss and plasma
sodium concentration increases (hypernatraemic dehydration). This
usually results from high insensible water losses (high fever or hot,
dry environment)or from profuse, low-sodium diarrhea. The
extracellular fluid becomes hypertonic with respect to the
intracellular fluid, which leads to a shift of water into the extracellular
space from the intracellular compartment. Signs of extracellular fluid
depletion are therefore less per unit of fluid loss, and depression of
the fontanelle, reduced tissue elasticity and sunken eyes are less
obvious. This makes this form of dehydration more difficult to
recognise clinically , particularly in an obese infant.
• It is a particularly dangerous form of dehydration as water is drawn
out of the brain and cerebral shrinkage within a rigid skull may lead to
jittery movements, increased muscle tone with hyper reflexia, altered
consciousness, seizures and multiple, small cerebral haemorrhages.
• If the serum sodium concentration is lowered rapidly, there is
movement of water from the serum into the brain cells to equalize
the osmolality in the 2 compartments . The resultant brain swelling
manifests as seizures or coma.
• Because of the associated dangers, hypernatremia should not be
corrected rapidly. The goal is to decrease the serum sodium by
<12 mEq/L every 24 hr-- The fluid deficit should be replaced over at
least 48 h and the plasma sodium measured regularly
Isonatraemic dehydration (sodium 135-150
meq/l)
• the losses of sodium and water are proportional and plasma sodium
remains within the normal range
• Most common type
hyponatraemic dehydration: (serum sodium
level <135 mEq/L)
When children with diarrhoea drink large quantities of water or other
hypotonic solutions, there is a greater net loss of sodium than water,
leading to a fall in plasma sodium (hyponatraemic dehydration). This
leads to a shift of water from extra- to intracellular compartments. The
increase in intracellular volume leads to an increase in brain volume,
which may result in convulsions, whereas the marked extracellular
depletion leads to a greater degree of shock per unit of water loss. This
form of dehydration is more common in poorly nourished infants in
developing countries.
Severe dehydration(TREATMENT)
• Phase 1 : focuses on emergency management. Severe dehydration is
characterized by a state of hypovolemic shock requiring rapid treatment.
Initial management includes placement of an intravenous or intraosseous
line and rapid administration of 20 mL/kg of an isotonic crystalloid (eg,
lactated Ringer solution, 0.9% sodium chloride). Additional fluid boluses
may be required depending on the severity of the dehydration. The child
should be frequently reassessed to determine the response to treatment.
As intravascular volume is replenished, tachycardia, capillary refill, urine
output, and mental status all should improve. If improvement is not
observed after 60 mL/kg of fluid administration, other etiologies of shock
(eg, cardiac, anaphylactic, septic) should be considered. Hemodynamic
monitoring and inotropic support may be indicated.
• Phase 2: focuses on deficit replacement, provision of maintenance fluids,
and replacement of ongoing losses. Maintenance fluid requirements are
equal to measured fluid losses (urine, stool) plus insensible fluid losses.
Normal insensible fluid loss is approximately 400-500 mL/m2 body surface
area and may be increased by factors such as fever and tachypnea.
• Alternatively, daily fluid requirements may be roughly estimated as follows:
• Less than 10 kg = 100 mL/kg
• 10-20 kg = 1000 + 50 mL/kg for each kg over 10 kg
• Greater than 20 kg = 1500 + 20 mL/kg for each kg over 20 kg
• Severe dehydration by clinical examination suggests a fluid deficit of
10-15% of body weight in infants and 6-9% of body weight in older
children. The daily maintenance fluid is added to the fluid deficit. In
general, the recommended administration is one half of this volume
administered over 8 hours and administration of the remainder over
the following 16 hours. Continued losses (eg, emesis, diarrhea) must
be promptly replaced.
• If the child is isonatremic (130-150 mEq/L), the sodium deficit
incurred can generally be corrected by administering the fluid deficit
plus maintenance as 5% dextrose in 0.45-0.9% sodium chloride.
Potassium (20 mEq/L potassium chloride) may be added to
maintenance fluid once urine output is established and serum
potassium levels are within a safe range.
Enteral Feeding and Diet Selection
• Continued enteral feeding in diarrhea aids in recovery from the
episode, and a continued age-appropriate diet after rehydration is the
norm.
• Once rehydration is complete, food should be reintroduced while oral
rehydration is continued to replace ongoing losses from emesis or
stools and for maintenance. Breastfeeding or non diluted regular
formula should be resumed as soon as possible. Foods with complex
carbohydrates (rice, wheat, potatoes, bread, and cereals), lean meats,
yogurt, fruits, and vegetables are also tolerated
• Fatty foods or foods high in simple sugars (juices, carbonated sodas)
should be avoided
Zinc Supplementation
• Zinc administration for diarrhea management can significantly reduce
all cause mortality by 46% and hospital admission by 23%. Also
reduce duration and severity of diarrhea
• All children older than 6 mo of age with acute diarrhea in at-risk areas
should receive oral zinc (20 mg/day) in some form for 10-14 days
during and continued after diarrhea
Additional Therapies
• The use of probiotic nonpathogenic bacteria for prevention and
therapy of diarrhea has been successful in some settings
• Saccharomyces boulardii is effective in antibiotic-associated and in C.
difficile diarrhea, and there is some evidence that it might prevent
diarrhea in daycare centers. Lactobacillus rhamnosus GG is associated
with reduced diarrheal duration and severity, which reduction is more
evident in cases of childhood rotavirus diarrhea
• Antimotility agents (loperamide) are contraindicated in children with
dysentery and probably have no role in the management of acute
watery diarrhea in otherwise healthy children.
• Because persistent vomiting can limit oral rehydration therapy, a
single sublingual dose of an oral dissolvable tablet of ondansetron (4
mg 4-11 yr and 8 mg for children older than 11 yr [generally 0.2
mg/kg]) may be given.However, most children do not require specific
antiemetic therapy;careful oral rehydration therapy is usually
sufficient.
Antibiotic Therapy
• antibiotic therapy in select cases of diarrhea related to bacterial
infections can reduce the duration and severity of illness and prevent
complications
• Although these agents are important to use in specific cases, their
widespread and indiscriminate use leads to the development of
antimicrobial resistance.
PREVENTION
1- Promotion of Exclusive Breastfeeding (administration of no other
fluids or foods for the 1st 6 mo of life)
2- Improved Complementary Feeding Practices
3- Rotavirus Immunization
4- Improved Water and Sanitary Facilities and Promotion of Personal
and Domestic Hygiene
5- Improved Case Management of Diarrhea
Complications(Extraintestinal Manifestations
of Enteric Infections)
1- Focal infections from systemic spread of bacterial pathogens,
includingvulvovaginitis, urinary tract infection,endocarditis,
osteomyelitis, meningitis,pneumonia, hepatitis,
peritonitis,chorioamnionitis, soft-tissue infection,and septic
thrombophlebitis
2- Reactive arthritis
3- Guillain-Barré syndrome
4- Glomerulonephritis
5- Immunoglobulin A (IgA) nephropathy
6- Erythema nodosum
7- Hemolytic uremic syndrome: Escherichia coli O157:H7
8- Hemolytic anemia
CHRONIC DIARRHOEA
• chronic or persistent diarrhea is defined as an episode that lasts longer
than 14 days.
• four principle pathophysiologic mechanisms: osmotic, secretory,
dysmotility associated, and inflammatory
1- Osmotic diarrhea is caused by a failure to absorb a luminal solute,
resulting in secretion of fluids and net water retention across an osmotic
gradient(best exemplified by the common disorder of lactose malabsorption)
, either because of dissacharidase deficiencies or because the absorptive
capacity of the intestine for that sugar may be overwhelmed by excessive
consumption, eg, fructose and sorbitol. Such excessive intake may be seen
in young children drinking fruit juices
2- Secretory diarrhea occurs when there is a net secretion of
electrolyte and fluid from the intestine without compensatory
absorption, Children with a pure secretory diarrhea will therefore
continue to experience diarrhea even while fasting. (Congenital
chloride diarrhea)
3- Chronic diarrhea associated with intestinal dysmotility typically
occurs in the setting of intact absorptive abilities. Intestinal transit time
is decreased, the time allowed for absorption is minimized, and fluid is
retained within the lumen(diarrhea-predominant irritable bowel
syndrome (IBS))
4- Inflammatory diarrhea (may encompass all of the pathophysiologic
mechanisms) . Inflammation with resultant injury to the intestine may
lead to malabsorption of dietary macronutrients which, in turn, creates
a luminal osmotic gradient. Additionally, particular infectious agents
may induce secretion of fluid into the lumen, and blood in the gut may
alter intestinal motility. Diseases such as inflammatory bowel disease
(IBD) and celiac disease
AETIOLOGY
1- Enteric infections are by far the most frequent cause of chronic
diarrhea, both in developing and industrialized countries
2- Lactose intolerance or carbohydrate malabsorption may be caused
by a brush-border enzyme defect in lactase or other enzymes--More
commonly, lactose intolerance is secondary to lactase deficiency
caused by intestinal mucosal damage.
3- Allergy to cow’s milk protein and other food proteins also may
present during infancy with chronic diarrhea
4- Chronic diarrhea may be the manifestation of maldigestion caused
by exocrine pancreatic disorders. In most patients with cystic fibrosis,
exocrine pancreatic insufficiency results in steatorrhea and protein
malabsorption
5- The most benign etiology of chronic diarrhea is nonspecific diarrhea
that encompasses functional diarrhea (or toddler’s diarrhea) in
children younger than 4 yr of age and irritable bowel syndrome in
those 5 yr of age and older. The diseases fall under the umbrella of
functional disorders, in that in older children abdominal pain is often
associated with diarrhea alternating with constipation and growth and
weight gain are normal
6- In older children and adolescents, inflammatory bowel diseases,
including Crohn disease, ulcerative colitis cause chronic diarrhea that
is often associated with abdominal pain, elevated inflammatory
markers
7- Diarrhea may be the result from an excessive intake of fluid and
carbohydrate(fruit juice). If the child’s fluid intake were >150 mL/kg/24
hr, fluid intake should be reduced not to exceed 90 mL/kg/24 hr
8- A reduction of intestinal absorptive surface is responsible for
diarrhea in celiac disease, a genetically determined permanent gluten
intolerance that affects as many as 1 in 100 individuals, depending on
geographic origin. In the genetically susceptible host, gliadin, the major
protein of gluten, reacts with the immune system to cause villous
atrophy. The reduction of functional absorptive surface area is
reversible upon restriction of gluten from the diet.
DIAGNOSIS
• The diagnosis of celiac disease is based on a combination of
symptoms,antibodies, HLA, and duodenal histology
TREATMENT
• The only treatment for celiac disease is lifelong strict adherence to a
gluten-free diet .This requires a wheat-, barley-, and rye-free diet
Malabsorption
Disorders affecting the digestion or absorption of nutrients
manifest as:
• abnormal stools(The true malabsorption stool is difficult to flush
down the toilet and has an odor which pervades the whole
house,pale,bulky)
• failure to thrive or poor growth in most but not all cases
• specific nutrient deficiencies, either singly or in combination.
Inflammatory bowel disease
Approximately a quarter of patients present in childhood or
adolescence. Crohn disease can affect any part of the gastrointestinal
tract from mouth to anus, whereas in ulcerative colitis the
inflammation is confined to the colon
Ulcerative colitis
Diagnosis:
made on endoscopy (upper and ileocolonoscopy) and on the
histological features, after exclusion of infective causes of colitis
In contrast to adults, in whom the colitis is usually confined to the distal
colon, 90% of children have a pancolitis
TREATMENT
In mild disease, aminosalicylates (balsalazide and mesalazine) are used
for induction and maintenance therapy. Disease confined to the rectum
and sigmoid colon may be managed with topical steroids
More aggressive or extensive disease requires systemic steroids for
acute exacerbations and immunomodulatory therapy, e.g. azathioprine
to maintain remission alone or in combination with low-dose
corticosteroid therapy.
CRONH DIASEASE
Diagnosis is based on endoscopic and histological findings on biopsy.
Upper gastrointestinal endoscopy, ileocolonoscopy and small bowel
imaging are required.
TREATMENT : Remission is induced with nutritional therapy, when the
normal diet is replaced by whole protein modular feeds (polymeric
diet) for 6–8 weeks. This is effective in 75% of cases. Systemic steroids
are required if ineffective.
Failure to thrive(FTT)
The term ‘failure to thrive’ is used to describe suboptimal, weight gain
in infants and toddlers (malnourished infants and young children who
fail to meet expected standards of growth).
• FTT is a common problem in pediatrics, affecting 5% to 10% of young
children and approximately 3% to 5% of children admitted to
hospitals.
• FTT is more common in children living in poverty and foster care and
affects 15% of these group
OTHER DEFINITIONS
•
weight that falls or remains below the 5th
percentile for age.
•
weight that decreases crossing two major
percentile lines on the growth chart over time,
(i.e., from above the 75th percentile to below
the 25th)
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weight that is less than 80% of the median
weight for the height of the child
Repeated observations are therefore essential and are usually available
from the child’s personal child health record
In children with FTT, malnutrition initially results in:
• Wasting (deficiency in weight gain). then
• Stunting (deficiency in linear growth) generally occurs after months of
malnutrition.
• Head circumference generally is spared except with chronic, severe
malnutrition.
• Weight for height below the 5th percentile remains the single best
growth chart indicator of acute undernutrition
• Children with chronic malnutrition often have a normal weight for
height because both their weight and height are reduced.
Causes of FTT:
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Non organic ( psychosocial FTT).
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Organic FTT is marked by an underlying medical condition
Non organic or psychosocial FTT:
It is far more common than organic FTT.
Psychosocial FTT is most often due to poverty or poor childparent interaction.
Causes of Non organic (psychosocial FTT):
• Lack of food ( poverty)
• Lack of knowledge, (poor feeding techniques ,improper
formula preparation, improper mealtime environment)
• Parental depression ,emotional deprivation, Child abuse or
neglect .
Organic Causes of Failure to Thrive:
Any chronic disease may lead to FTT
• Gastrointestinal: GER, celiac disease, pyloric stenosis, cleft lip/ palate, lactose
intolerance, Hirschsprung's disease, milk protein intolerance, hepatitis, cirrhosis,
pancreatic insufficiency, biliary disease, inflammatory bowel disease,
malabsorption
• Renal: UTI, RTA, DI, RF
• Cardiopulmonary: Cardiac diseases leading to CHF, asthma, BPD, CF, anatomic
abnormalities of the upper airway,
• Endocrine: Hyperthyroidism, DM, adrenal insufficiency or excess, parathyroid
disorders, pituitary disorders,
• Neurologic: MR, CP, degenerative disorders, CNS tumors
• Infectious: Parasitic or bacterial infections of the gastrointestinal tract, TB, HIV
disease
• Metabolic: IEM
• Genetics, Congenital: Chromosomal abnormalities, congenital
syndromes (fetal alcohol syndrome), perinatal infections
• Miscellaneous :Lead poisoning, malignancy, collagen vascular
disease, recurrently infected adenoids and tonsils
DIAGNOSIS AND CLINICAL MANIFESTATIONS
History
•
prenatal and postnatal factors :
That influence growth, including the history of prenatal care, maternal illnesses during
pregnancy, to
1. Identify fetal growth problems (IUGR), birth size (weight, length, and head
circumference).
2. Identify prematurity
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Indicators of medical diseases (review of systems):
such as vomiting, diarrhea, fever, respiratory symptoms, etc
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Careful dietary history is essential:
The adequacy of the maternal milk supply or the precise preparation of formula should be
evaluated.
For older infants and young children, a detailed diet history is helpful,
it is essential to evaluate intake of solid foods and liquids. Because of parental dietary
beliefs, some children have inappropriately restricted diets. Other children with FTT
drink excessive amounts of fruit juice, leading to malabsorption or anorexia for more
nutrient-dense foods..
• Social environment: poverty, unemployment,
parent-child interactions
conflict , disruptive
Physical examination :
• Growth chart: weight, height, OFC
• Systemic examination:
• Physical findings related to malnutrition, such as dermatitis,
pallor, or edema
• Additionally, severely malnourished children are at risk for a
variety of infections.
• Depending on severity, the infant with FTT may exhibit thin
extremities, a narrow face, prominent ribs, and wasted
buttocks. Neglect of hygiene may be evidenced by diaper
rash, unwashed skin, untreated impetigo, uncut and dirty
fingernails, or unwashed clothing. A flattened occiput with
hair loss may indicate that the child has been lying on his or
her back. This flattening may be due to being unattended for
prolonged periods. Delays in social and speech development
are common. Other findings may include an avoidance of eye
contact, an expressionless face, hypotonia, and the absence
of a cuddling response.
Laboratory evaluation:
There is no need for extensive laboratory search for medical diseases
Simple screening tests are recommended to screen for the common illnesses
that may cause growth failure and to search for medical problems that result
from malnutrition.
Recommended laboratory tests include:
• CBP : type of anemia, WBC abnormalities (leucocytosis, lymphopenia)
• Urinalysis, urine culture: UTI
• Serum electrolytes & RFT
• Serum protein: Degree of protein deficiency
• Blood sugar: hpoglycemia
• Stool sample for culture and ova and parasites may be indicated for children
with diarrhea, abdominal pain, or malodorous stools.
• PPD: screen for TB
TREATMENT
Most children with FTT can be treated in the
outpatient setting.
Hospitalization is required for
• Children with severe malnutrition.
• Children with underlying diagnoses that require
hospitalization for evaluation or treatment.
• Children whose safety is in danger because of
maltreatment( social issues of the family).
Nutritional management:
✎It is the cornerstone of treatment of FTT, regardless of
the etiology.
✎In general, the simplest and least costly approach to
dietary change is warranted.
Amount:
✎
✎
SLOW GRADUAL INCREMENT
•
Calories can be safely started at 20% above the child recent
intake
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If no estimate of the caloric intake is available 50-75% of,50-75% of
the normal energy requirement is safe.
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Caloric intake can be increased 10-20% per day. with monitoring
for electrolyte imbalances, poor cardiac function, edema, or
feeding intolerance. If any of these occurs, further caloric increases
are not made until the child's status stabilizes.
The final target is to provide 100 to 120 kcal/kg based on
ideal weight.
Type:
according to age of the child & type of feeding :
✎
Breast fed infant: continue breast feeding and may add cow milk or
special cows’ milk based formula (F75 or F100).
✎
Bottle fed :
Increased amount of cow milk ,or change to other types if indicated
like:
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✎
special cows’ milk based formula(F75 or F100)
calorically dense formula (for anorectic and picky eater) concentration
of formula can be changed from 20 cal/oz to 24 or 27 cal/oz
soy based (isomil) for lactose-intolerant child
hydrolyzed protein type (pregestemil) for cow milk protein intolerant
home made (oil,butter,peanut butter, others)
Toddlers:
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•
Dietary changes should include increasing the caloric density of favorite
foods by adding butter, oil, peanut butter, or other high-calorie foods.
High-calorie oral supplements that provide 30 cal/oz are often well
tolerated by toddlers.
Vitamin and mineral supplementation:
It is needed, especially during catch-up growth.
Vitamin and mineral intake in excess of the daily
recommended intake is provided to account for the
increased requirements; this is frequently accomplished
by giving an age-appropriate daily multiple vitamin.
WELLCOME CLASSIFICATION