Diet has a central role in treatment of nutritional deficiency disorders. Food itself does not contain nutrients in high enough concentrations and so concentrated preparations of nutrients are administered orally, intravenously or intramuscular. In addition underlying causes of deficiency such as hookworm infestation or a infection have to be treated as well, otherwise the problem cannot be cured. A checklist of signs and symptoms of nutritional deficiency disorders was given in Block 5 of Course 1.
Now look at Table. It summarizes the salient features of dietary management in some of the major nutritional deficiencies in our country namely PEM, vitamin A deficiency, anaemia and iodine deficiency disorders.
The table gives you the main features of therapy in the case of the four major nutritional deficiency disorders.
severe PEM is often associated with dehydration and infection as we mentioned earlier. These are life threatening and have to be tackled immediately. If the patient can take in fluids orally, ORS solution is administered. ORS solution consists of the following salts dissolved in one litre of clean, boiled and cooled drinking water: sodium chloride 3.5g; sodium bicarbonate 2.5g; potassium chloride 1.5g and glucose 20.0g. Between 50 and 100 ml of ORS solution per kg body weight depending on whether the dehydration is mild or moderate usually restores nonnal hydration. This amount should be given in the fist 4-6 hours of treatment in small quantities every few minutes.
If the signs of dehydration disappear, maintenance therapy with ORS solution begins and is continued till the diarrhoea stops. For mild diarrhoea, 100 mlkg body weight per day is adequate. In the case of severe diarrhoea, 2-4 times this amount may be needed. During maintenance therapy other fluids in addition to ORS can be offered.
Within 8-12 hours full rehydration should be achieved. By this time half strength milk preparations (i.e. half the strength normally taken by the infant) can be started for older children and adults. Water should be available throughout therapy with ORS solution.
What should be done in the case of children who vomit constantly? Or suppose the child cannot be fed orally? In such cases nasogasnic feeding is tried. The volume of fluid to be given by nasogastric tube is 120 ml/kg body weight for'the first 6 hours divided into 12 portions. One portion is, of course. given every half hour.
But what if this also fails? In such cases and in patients with severe dehydration intravenous fluid is the only answer to correct the dehydration. 70 ml/kg body weight of fluid is administered during the first three hours of treatment i.e. 30 ml in the first hour of treatment and the rest over the next two hours.
The fluid administered is Ringer's Lactate with the following composition:
Lactic acid - 2.4 ml
Sodium hydroxide - As needed to adjust pH
Sodium chloride - 6.0g
Potassium chloride - 0.4g
Chloride - As needed to adjust volume to 1000 ml.
After the first three hours, therapy is continued only if ORS solution cannot be accepted by mouth or if signs of dehydration remain.
Now let us look at infections and their treatment. The severely malnourished child who does not have clear cut signs of specific infection should be administered a combination of procaine benzylpenicillin and ampicillin. When the causative agent is known or suspected, he antibiotic therapy of choice for that agent should be used.
Remember that treating underlying infections is crucial. An important point about severe infection in malnourished children is that fever may not be present. Instead there may be hypothermia i.e. low body temperature!
Let us assume at this point that we have successfully corrected the dehydration and that diarrhoea and vomiting have stopped. We can then follow this typical feeding schedule.
The'table clearly indicates how oral feeding can be started with small frequent feeds of dilute milk in the case of patients who are not dehydrated or in whom dehydration has been corrected. Why do you think this is done? The answer obviously is that such feeds would provide some energy and protein. Also since they are dilute they would not provoke either vomiting or diarrhoea. Look at the table again. Do you also notice the fact that the strength and volume of feeds is gradually increased while frequency of feeding is decreased?
As soon as the patient is able to tolerate milk feeds well. there is a need to switch to high energy feeds usually based on milk. Why? You are aware that PEM is associated with growth failure. Since the major problem is a shortage of energy and also protein. the feeds must provide these nutrients in sufficient amounts. When the child is given these milk feeds of high energy content the growth rate is astonishing, as the child seeks to catch up. This is, in fact, called catch up growth.
However. it is commonly observed that during the.first week or so of high energy feeding malnourished patients may not gain weight. This is due to the body taking the to adjust-body composition itself alters in response. Such a situation is nothing to worry about.
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