WEBVTT 1 00:00:10.700 --> 00:00:15.600 Initially by trying to give this introduction to what exactly do some 2 00:00:15.600 --> 00:00:19.400 of the common used words that we tend to use bead food, 3 00:00:19.400 --> 00:00:24.500 beet nutrition, bead growth and be a deficiency. What exactly do 4 00:00:24.500 --> 00:00:29.800 they mean? So straight away let us understand what and how nutrition 5 00:00:29.800 --> 00:00:35.200 is different from food? Food is something that we eat and nutrition 6 00:00:35.200 --> 00:00:41.200 is what tends to support life and provides energy for not 7 00:00:41.200 --> 00:00:45.400 just a growth and development but also for the regular metabolic activity 8 00:00:46.600 --> 00:00:51.200 So it is this nutrition and growth which tends to have an 9 00:00:51.200 --> 00:00:54.300 outcome on what we are going to be in terms of a 10 00:00:54.300 --> 00:00:58.300 way to the height or what we call as adults structure. And 11 00:00:58.300 --> 00:01:04.100 of course, the subsequent Health outcomes Now, having 12 00:01:04.100 --> 00:01:07.900 seen this as to what nutrition and growth is, let us understand 13 00:01:07.900 --> 00:01:13.000 how these deficiencies in nutrition can limit our 14 00:01:13.000 --> 00:01:17.300 potential. In terms of our growth, in terms of our immunity and 15 00:01:17.300 --> 00:01:22.300 all its been found that this is the worldwide 16 00:01:22.300 --> 00:01:27.300 cause for The increased morbidity as well 17 00:01:27.300 --> 00:01:32.900 as mortality, especially for children less than five years of age. Now 18 00:01:32.900 --> 00:01:37.100 having seen this is not just under nutrition, which can be the 19 00:01:37.100 --> 00:01:41.100 cause for this mobility and mortality. But also in case there is 20 00:01:41.100 --> 00:01:46.500 any excess intake. This can possibly result in. Obesity can definitely 21 00:01:46.500 --> 00:01:51.700 result in diabetes and related cardiovascular conditions of early 22 00:01:51.700 --> 00:01:56.700 heart attacks or for that matter. Hyperlipidemia and strokes in an 23 00:01:56.700 --> 00:02:01.700 adult. so, strictly speaking, the definition of 24 00:02:01.700 --> 00:02:06.700 nutrition is The provision of materials, which is necessary 25 00:02:06.700 --> 00:02:10.300 for the organism in the form of food. To be able to 26 00:02:10.300 --> 00:02:15.800 support life. And food per se would be consisting 27 00:02:15.800 --> 00:02:20.100 of essential. Nutritions of children, natural substances, which could be called as 28 00:02:20.100 --> 00:02:24.800 nutrients, and which further provide energy for metabolism and the growth and 29 00:02:24.800 --> 00:02:30.100 development of the child. In related relation to this malnutrition would 30 00:02:30.100 --> 00:02:34.200 be a State of Nutrition in which any kind of imbalance in 31 00:02:34.200 --> 00:02:39.500 any kind of deficiency. Or imbalance of energy of 32 00:02:39.500 --> 00:02:45.000 protein energy, and other nutrients can possibly cause adverse effects. Both 33 00:02:45.000 --> 00:02:50.400 on structure, as well as the functioning of the body. Now, 34 00:02:50.400 --> 00:02:55.200 when it comes to nutrients, there are seven major classes which could 35 00:02:55.200 --> 00:03:00.600 be classified as fats, fiber proteins, 36 00:03:00.600 --> 00:03:05.700 carbohydrates minerals. Vitamins. And of course water, which 37 00:03:05.700 --> 00:03:10.800 is the biggest constituent of our body. Roughly, they can 38 00:03:10.800 --> 00:03:15.900 be grouped into macronutrients and micronutrients macronutrients as 39 00:03:15.900 --> 00:03:20.100 the word says something, which is required in large quantities. And they 40 00:03:20.100 --> 00:03:25.100 are constructed by the fats, the proteins, and the carbonates, and which 41 00:03:25.100 --> 00:03:30.200 generally form the building blocks of the body. while micronutrients are 42 00:03:31.200 --> 00:03:36.500 tiny in requirements. But definitely not unimportant because they 43 00:03:36.500 --> 00:03:40.100 are the ones which are crucial for our metabolic pathways. And in 44 00:03:40.100 --> 00:03:45.400 this are the ones which constituted by the vitamins 45 00:03:45.400 --> 00:03:49.400 and the minerals. now, there are a few terms, which we need 46 00:03:49.400 --> 00:03:54.600 to understand as to what Average daily requirement for 47 00:03:54.600 --> 00:03:59.400 50% of the population and that would be known as estimated average. 48 00:03:59.400 --> 00:04:03.200 Requirement. And then, there is something called as what would be required 49 00:04:03.200 --> 00:04:07.800 for most of us to avoid deficiency. And that would be going 50 00:04:07.800 --> 00:04:11.800 by the term of average, daily nutrient intake, or also called, as 51 00:04:11.800 --> 00:04:18.100 RDA, or recommended dietary allowance to be able to avoid deficiency. Now, 52 00:04:18.100 --> 00:04:23.600 what's energy, energy includes both intake as well as expenditure. And 53 00:04:23.600 --> 00:04:28.900 there we have three components. In the energy expenditure which 54 00:04:28.900 --> 00:04:33.900 would be required one. Firstly to be able to have the human 55 00:04:33.900 --> 00:04:39.200 body maintain a base metabolic rate so that it can just about 56 00:04:39.200 --> 00:04:44.200 survive. Then there is something which is required for the food that 57 00:04:44.200 --> 00:04:49.300 we have taken. and this to be absorbed and digested, it 58 00:04:49.300 --> 00:04:54.400 would require another set of energy requirement Thirdly is the energy requirement 59 00:04:54.400 --> 00:04:57.900 for our day to day physical activity. But in case of children, 60 00:04:57.900 --> 00:05:02.000 a fourth component occurs and that is for the growth as well 61 00:05:02.000 --> 00:05:06.700 as development. So out here is another third term that we will 62 00:05:06.700 --> 00:05:11.700 be introducing. That is estimated energy requirement, which is required 63 00:05:11.700 --> 00:05:17.000 for maintaining our energy balance for the dietary energy to be supported. 64 00:05:18.600 --> 00:05:23.300 In this. Also, is the term that we need to understand as 65 00:05:23.300 --> 00:05:27.200 to what are the nutrients, which produce energy, or which provide energy 66 00:05:27.200 --> 00:05:32.500 in this first. Comes back. Which provides about nine. Calories per gram 67 00:05:32.500 --> 00:05:38.100 of the fat content. Second is the carbohydrate and 68 00:05:38.100 --> 00:05:42.700 third is the protein carbohydrate and protein gives about the same energy 69 00:05:42.700 --> 00:05:48.000 per gram of their constituents, which should be roughly half 70 00:05:48.000 --> 00:05:53.500 of the fat. This is 4 calories per gram. Generally, we 71 00:05:53.500 --> 00:05:58.300 need to have more than half of our energy requirement coming from 72 00:05:58.300 --> 00:06:03.300 carbohydrates. One, third of it coming from fat and half 73 00:06:03.300 --> 00:06:07.600 of that fat content should be able to come from protein as 74 00:06:07.600 --> 00:06:12.600 far as our energy requirements. Now, let's take one by one 75 00:06:12.600 --> 00:06:17.600 of these macro nutrients and the micronutrients. fats are a diverse 76 00:06:17.600 --> 00:06:22.700 group of Esters of fatty acids, which in our body, Form, 77 00:06:22.700 --> 00:06:27.700 the triglycerides, the phospholipids and the cholesterol, their generally derived from 78 00:06:27.700 --> 00:06:33.900 milk animal products and vegetable oils. And the requirement 79 00:06:33.900 --> 00:06:39.300 of this particular fats is 25 to 30% and fats function 80 00:06:39.300 --> 00:06:44.400 as our energy dense foods because they give out almost nine calories 81 00:06:44.400 --> 00:06:50.200 per gram. And here is the term of essential fatty acids, which 82 00:06:50.200 --> 00:06:55.200 are formed by fatty acids, like linoleic acid, which is omega-3 fatty 83 00:06:55.200 --> 00:07:00.200 acid, linoleic acid, which is Omega 6, fatty acid, which is formed 84 00:07:00.200 --> 00:07:05.200 by erected. Generally a part of our cell membrane They 85 00:07:05.200 --> 00:07:09.200 play both structural as well as functional role and generally, they are 86 00:07:09.200 --> 00:07:14.000 derived from cholesterol, which form the precursor for cell membranes hormones, and 87 00:07:14.000 --> 00:07:19.400 are Bilal acids. They also facilitate absorption of fat soluble 88 00:07:19.400 --> 00:07:25.200 vitamins. Like vitamin A, vitamin D, vitamin E, and vitamin K. Continue 89 00:07:25.200 --> 00:07:30.400 with this. Fats could be saturated or unsaturated. Depending 90 00:07:30.400 --> 00:07:36.000 on what fatty acid forms. This particular fat. Saturated fats 91 00:07:36.000 --> 00:07:40.800 are not to exceed more than 7% of our intake. As this 92 00:07:40.800 --> 00:07:46.400 could possibly lead to obesity and increase cardiovascular risk factors. Well, 93 00:07:46.400 --> 00:07:50.200 poly and saturated fatty acids are the ones which we require more 94 00:07:50.200 --> 00:07:54.300 than 10% in our diet. And then the third component is the 95 00:07:54.300 --> 00:07:59.600 triglycerides, which depending on how much carbon chains. They have there 96 00:07:59.600 --> 00:08:03.800 been classified into short chain fatty acid, medium chain fatty acid, long 97 00:08:03.800 --> 00:08:07.700 chain fatty acids, launches of the ones where the carbon chains are 98 00:08:07.700 --> 00:08:12.700 more than 12. And between 6, to 12 form, the medium chain 99 00:08:12.700 --> 00:08:18.400 triglyceride acid, which finally, provide as the essential fatty acids a 100 00:08:18.400 --> 00:08:23.700 word about medium chain, triglycerides, the unique part about the mark 101 00:08:23.700 --> 00:08:28.500 that they are directly absorbed. Directly transported to liver and thus they 102 00:08:28.500 --> 00:08:33.900 provide energy just like our glucose. Then increase the metabolic rate. And 103 00:08:33.900 --> 00:08:39.300 more importantly, they are lower the cholesterol, one 104 00:08:39.300 --> 00:08:44.300 of the best sources, the coconut oil part, any essential 105 00:08:44.300 --> 00:08:49.300 fatty acid deficiency can cause this Commission. Thrombocytopenia 106 00:08:49.300 --> 00:08:53.900 impaired. Immunity and also brought deficit, ideally, we all should aim at 107 00:08:53.900 --> 00:08:58.900 a ratio of omega-6 To omega-3 fatty 108 00:08:58.900 --> 00:09:04.000 acids between almost 10 to 10 is to 1 for a better 109 00:09:04.000 --> 00:09:09.300 essential fatty acid requirement for the body. Coming to the second part. 110 00:09:10.100 --> 00:09:15.500 That is the proteins. after water proteins form the second most abundant 111 00:09:16.700 --> 00:09:21.800 Substance in our body. They have a structural functional role in every 112 00:09:21.800 --> 00:09:26.900 cell. Basically requiring for us to be able to provide 113 00:09:26.900 --> 00:09:32.100 for synthesis of tissues growth formation of digestive juices and 114 00:09:32.100 --> 00:09:37.400 enzymes are moons, hemoglobin, plasma proteins. But more importantly, 115 00:09:37.400 --> 00:09:41.100 they can also act as a buffer in our acid basic equilibrium, 116 00:09:41.100 --> 00:09:45.900 or also what we call as maintenance of Billy interior and also 117 00:09:45.900 --> 00:09:49.700 can be forming as a alternate source of energy. When we do 118 00:09:49.700 --> 00:09:54.700 not have enough. Carbohydrates source of the fatty acid source to take 119 00:09:54.700 --> 00:09:59.900 care of a energy requirement. Essential amino acids, amino 120 00:09:59.900 --> 00:10:03.400 acids per se form, the building blocks of proteins. But there are 121 00:10:03.400 --> 00:10:07.800 some of these essential amino acids, cannot be synthesized, and they are 122 00:10:07.800 --> 00:10:12.800 to be depend on the dad that we take. Specifically is 123 00:10:12.800 --> 00:10:18.500 losing isoleucine lysine methionine. and 124 00:10:18.500 --> 00:10:23.500 trypsin 309 and valine while a histamine and 125 00:10:23.500 --> 00:10:27.000 Arginine are definitely required in infancy. They may not be required in 126 00:10:27.000 --> 00:10:29.900 an adult, but these are the ones which are required in infancy 127 00:10:29.900 --> 00:10:33.200 and you will see as to how breast milk tends to be 128 00:10:33.200 --> 00:10:38.500 able to provide this better than the dietary parts. The protein quality. 129 00:10:39.300 --> 00:10:43.900 does is also depending on the amino acid profile that they have 130 00:10:43.900 --> 00:10:49.100 got this is what factors in for our digestive 131 00:10:49.100 --> 00:10:54.700 ability as when it comes to, Add generally cereals, like rice 132 00:10:54.700 --> 00:10:59.500 and wheat that tend to be deficient in lysine. Where are pulses 133 00:10:59.500 --> 00:11:03.700 are rich in lysine but the different name, hence, when they're taking 134 00:11:03.700 --> 00:11:07.400 in combination, we are able to make up for the deficiencies of 135 00:11:07.400 --> 00:11:12.900 these essential amino acid. In a children's, right proteins, 136 00:11:12.900 --> 00:11:17.300 as we said, they provide for four calories per gram. There is 137 00:11:17.300 --> 00:11:21.300 another factor that we need to know in proteins unlike in carbohydrates 138 00:11:21.300 --> 00:11:26.300 and fats. Their digestibility, the digestibility is 139 00:11:26.300 --> 00:11:31.800 determined by how much nitrogen of this protein is absorbed by 140 00:11:31.800 --> 00:11:35.700 the amount of nitrogen intake that we have. And that would tell 141 00:11:35.700 --> 00:11:40.500 us about their Majesty quotient Second term that we need to know 142 00:11:40.500 --> 00:11:44.500 is the biological value. It's quite possible that we might observe all 143 00:11:44.500 --> 00:11:47.500 the nitrogen that is there in the protein but how much of 144 00:11:47.500 --> 00:11:53.200 it is retained? Manages to tell us about its biological value. And 145 00:11:53.200 --> 00:11:57.900 the nitrogen protein utilization is a product of both true, digestibility and 146 00:11:57.900 --> 00:12:02.900 biological value a percentage of it. Thus We are able to 147 00:12:02.900 --> 00:12:06.500 have a protein as the reference protein because it has got a 148 00:12:06.500 --> 00:12:11.900 high biological value and net protein utilization. Generally speaking animal 149 00:12:11.900 --> 00:12:16.600 proteins, have a higher biological value as compared to plant proteins. And 150 00:12:16.600 --> 00:12:21.600 as far as possible, protein should not be. Providing 151 00:12:21.600 --> 00:12:26.700 more than 12% of our energy. Requirement rest 152 00:12:26.700 --> 00:12:29.800 of it can definitely come from the carbohydrates, as well as the 153 00:12:29.800 --> 00:12:34.900 facts. Now, the third macronutrient that 154 00:12:34.900 --> 00:12:39.000 is carbohydrate this forms, the main source of energy, not diet and 155 00:12:39.000 --> 00:12:44.800 that divided to simple carbohydrates and complex carbohydrates. Simple are the monosaccharides 156 00:12:44.800 --> 00:12:50.500 and disaccharides complex of the oligo Sacred. And the polysaccharides glucose 157 00:12:50.500 --> 00:12:53.900 generally is the main source of energy that is required. And it 158 00:12:53.900 --> 00:12:58.200 is derived from starch and sugars. And this glucose when it is 159 00:12:58.200 --> 00:13:02.500 in excess, it is converted into glycogen and liver as well as 160 00:13:02.500 --> 00:13:07.800 in muscle and any excess carbohydrate that consumed tends to get converted 161 00:13:07.800 --> 00:13:12.800 into fat. A different form of carbohydrate, 162 00:13:12.800 --> 00:13:16.800 is the fiber. Which is very, again, essential as essential as the 163 00:13:16.800 --> 00:13:21.800 digestible carbohydrate. This is generally derived from plants and it is 164 00:13:21.800 --> 00:13:28.800 in the form of cellulose pectin gum lignin, cavallin as well. fiber 165 00:13:28.800 --> 00:13:34.400 plays a big role in the fermentation of the colonic bacteria because 166 00:13:34.400 --> 00:13:39.300 this tends to release the carbon dioxide, which is required for And 167 00:13:39.300 --> 00:13:43.900 also acts as a Prebiotic and the form of oligo fructose. Generally, 168 00:13:43.900 --> 00:13:48.400 the short chain fatty acids is the one along with this particular 169 00:13:48.400 --> 00:13:53.500 fiber, that tend to stimulate the colonic blood flow. All. So 170 00:13:53.500 --> 00:13:58.300 it has got other role to play in diluting the toxins carcinogens, 171 00:13:58.300 --> 00:14:03.600 which are there in the diet and does it promotes expulsion 172 00:14:03.600 --> 00:14:07.600 due to its bulk and as well as the ability to improve 173 00:14:07.600 --> 00:14:13.000 the colonic or the gut motility? It also tends to graduate 174 00:14:13.000 --> 00:14:18.700 the absorption of the sugars and thus has a huge role 175 00:14:18.700 --> 00:14:24.300 to play in insulin sensitivity. And the third or fourth function, fiber 176 00:14:24.300 --> 00:14:29.300 tends to do, is it binds to luminol cholesterol? Thus reduces the 177 00:14:29.300 --> 00:14:33.900 absorption of unwanted fat and also improves the entire hepatic, circulation of 178 00:14:33.900 --> 00:14:39.500 cholesterol and bile salts, and thus decreases the cholesterol absorption. 179 00:14:39.500 --> 00:14:44.000 That needs to be there. Having seen what nutrition is let us 180 00:14:44.000 --> 00:14:49.200 now. Try and understand what nutrition is malnutrition basically means both under 181 00:14:49.200 --> 00:14:53.700 as well as over patient under his protein energy malnutrition and the 182 00:14:53.700 --> 00:14:58.600 example of over nutrition is obesity and overweight How big is this 183 00:14:58.600 --> 00:15:02.400 problem? Quite big. If you look at it from the worldwide point 184 00:15:02.400 --> 00:15:08.000 of view, one in every fourth child, Tends to be malnourished. Debris 185 00:15:08.000 --> 00:15:10.800 over when it gives them the figures. It is being found that 186 00:15:10.800 --> 00:15:15.300 in developing countries, one, in three children are malnourished and this is 187 00:15:15.300 --> 00:15:20.300 quite high in South Central, Asia and Eastern Africa, where the figure 188 00:15:20.300 --> 00:15:24.700 could go up to almost one in two children, who could be 189 00:15:24.700 --> 00:15:29.900 malnourished, and this is almost five times. That of the West 190 00:15:29.900 --> 00:15:34.800 part of the world. It in India per se. The problem is 191 00:15:34.800 --> 00:15:40.000 quite High. Almost half of our children are underweight, you'll see. As 192 00:15:40.000 --> 00:15:45.000 to what this underweight wasting and stunting means Almost 1/3 of our 193 00:15:45.000 --> 00:15:50.000 children are stunted and out of these stunted children, almost 1 194 00:15:50.000 --> 00:15:54.500 and 4 children could be wasted. So this is how big a 195 00:15:54.500 --> 00:15:59.600 problem is and this has got a relation to the hunger 196 00:15:59.600 --> 00:16:05.000 as well has been found. That India is almost on the 67th 197 00:16:05.000 --> 00:16:09.900 list out of the 18 Nations. Having the worst situation almost one 198 00:16:09.900 --> 00:16:15.000 fourth of her children and people are hungry as of 199 00:16:15.000 --> 00:16:20.400 2019 and 2021 National Family, Health survey fifth 200 00:16:20.400 --> 00:16:25.400 index Having seen that? The children who come to 201 00:16:25.400 --> 00:16:30.400 us into the hospital are just a very, very minor fraction who 202 00:16:30.400 --> 00:16:35.700 come to us. There is a huge Iceberg kind of effect where 203 00:16:35.700 --> 00:16:40.800 almost 9:10 of those children are not even coming 204 00:16:40.800 --> 00:16:46.000 to us because they are in the community. And they 205 00:16:46.000 --> 00:16:51.300 are definitely not being taken 206 00:16:51.300 --> 00:16:55.400 care of in our hospital setting. So almost nine tenth of them 207 00:16:55.400 --> 00:16:59.200 are in the community, and only one tenth of them are reaching 208 00:16:59.200 --> 00:17:04.900 our hospital with complications, or with severe recruitment nutrition. Having 209 00:17:04.900 --> 00:17:08.600 said that, let us see. What is the range of this protein 210 00:17:08.600 --> 00:17:14.700 energy malnutrition? This is the first recognized in 1990 while Dr. Cecil 211 00:17:14.700 --> 00:17:19.700 Williams was working in Ghana's Gold Coast Area. Very attributed 212 00:17:19.700 --> 00:17:25.200 children, who were coming who was with underway or with edema as 213 00:17:25.200 --> 00:17:30.300 protein deficiency. That is the time he gave this term. That cautionary 214 00:17:30.300 --> 00:17:35.100 was a local term in Ghana. Where they found in the community 215 00:17:35.100 --> 00:17:40.200 that the second child came. The first child almost became totally underweight 216 00:17:40.200 --> 00:17:46.900 lost appetite becomes Poland started, having all these pigmentary things 217 00:17:46.900 --> 00:17:51.000 on a skin, and of course, when you clinically examine this child, 218 00:17:51.000 --> 00:17:56.800 they had anemia and high liver with 219 00:17:56.800 --> 00:18:01.200 very unique hair and skin changes. Well, marasmus was the term which 220 00:18:01.200 --> 00:18:04.400 was given to a old man appearance where there was extreme wasting 221 00:18:04.400 --> 00:18:10.100 and marasmic. Question core was the combination of both these so, 222 00:18:10.100 --> 00:18:15.200 what was the basis of classification of this particular Malnutrition. So 223 00:18:15.200 --> 00:18:21.000 they tend took almost these fake criteria where the children were 224 00:18:21.000 --> 00:18:24.100 able to relate to wait for age, or wait for age and 225 00:18:24.100 --> 00:18:29.100 edema wait for height. And height for age where we 226 00:18:29.100 --> 00:18:33.300 did have the age of the child there. And you we used 227 00:18:33.300 --> 00:18:38.300 up the standard deviation scores from the normal growth as that 228 00:18:38.300 --> 00:18:41.400 we tend to have and the 5th parameter was the middle of 229 00:18:41.400 --> 00:18:46.400 circumference. Having seen this? Let us see what Indian 230 00:18:46.400 --> 00:18:51.300 Academy of Pediatricians to use. It tends to use. the wait for 231 00:18:51.300 --> 00:18:56.800 age, a very in the normalized, anyone more than 80% tile, and 232 00:18:57.600 --> 00:19:02.800 Downgrades to grade 1 grade 1, 2 3 4 depending 233 00:19:02.800 --> 00:19:06.400 on, what is the severity of the spine color, kind of wait 234 00:19:06.400 --> 00:19:10.800 for each and wherever there was any kind of Edema. Alphabet, Kay 235 00:19:10.800 --> 00:19:17.100 was being used for Indian Academy of pediatric classification for malnutrition. And 236 00:19:17.100 --> 00:19:21.100 then there was this drug company by the name of Welcome which 237 00:19:21.100 --> 00:19:26.100 had its own way of assessing malnutrition where it 238 00:19:26.100 --> 00:19:31.800 says that anyone having less than 60% of the weight. Was 239 00:19:31.800 --> 00:19:37.500 wait for Aged less than 60% of that particular percentile 240 00:19:37.500 --> 00:19:42.900 was treated as marasmus. And between 6 to 80% was underweight, 241 00:19:42.900 --> 00:19:47.400 if they had edema a question for word was used and if 242 00:19:47.400 --> 00:19:51.000 it was less than 60% he or she would be going into 243 00:19:51.000 --> 00:19:56.400 the category of marasmic question. Then there's a Waterloo classification 244 00:19:56.400 --> 00:20:00.400 that is which would use both of weight for height as well 245 00:20:00.400 --> 00:20:05.400 as height for age. And there came the terminology of being stranded 246 00:20:06.600 --> 00:20:11.900 If the weight was less than 80% less 247 00:20:11.900 --> 00:20:17.700 than 90%, here should be considered as started. But if both 248 00:20:17.700 --> 00:20:22.700 weight as well as the height was less than 90%, he or 249 00:20:22.700 --> 00:20:27.500 she would be considered as wasted as well as started. While for 250 00:20:27.500 --> 00:20:33.100 wait for height, anyone less than 80% would be considered as having 251 00:20:33.100 --> 00:20:38.200 only wasting, and not stunting. Having said this, let us see 252 00:20:38.200 --> 00:20:43.700 what who tends to consider as malnutrition. Anyone 253 00:20:43.700 --> 00:20:48.100 having edema and that is symmetrical. Not just one leg or one 254 00:20:48.100 --> 00:20:53.700 limb, they would be going into the state of severe malnutrition. But 255 00:20:53.700 --> 00:20:57.900 if you had to take the parameter of only wait for height 256 00:20:57.900 --> 00:21:03.900 and if that fell into standard deviation, which was between minus 257 00:21:03.900 --> 00:21:09.200 3, and minus 2 standard deviation roughly, this would constitute to the 258 00:21:09.200 --> 00:21:14.300 7279 percent. This would be moderate monetization, but anyone 259 00:21:14.300 --> 00:21:19.400 falling to less than three standard deviation or less than 70% of 260 00:21:19.400 --> 00:21:24.600 the weight for height. Curve. They would be considered 261 00:21:24.600 --> 00:21:30.200 as severely wasted. in case we have the age parameter 262 00:21:30.200 --> 00:21:35.500 also, with us, in that case, anyone between third to Second standard 263 00:21:35.500 --> 00:21:40.500 deviation, It would be considered as moderate stunting. And less 264 00:21:40.500 --> 00:21:46.800 than 3 standard deviation would be considered a serious standing. Now 265 00:21:46.800 --> 00:21:49.900 in case where we do not have the age, we do not 266 00:21:49.900 --> 00:21:55.500 have the height, can be possibly screen these children with 267 00:21:55.500 --> 00:21:58.800 the weight and height that we have. Yes we can. We do 268 00:21:58.800 --> 00:22:03.800 use this W. Choke mid upper arm, circumference tape. Which is a 269 00:22:03.800 --> 00:22:07.400 not stretchable one we try and look at it from the acromion 270 00:22:07.400 --> 00:22:12.600 to the electronic of the arm and a non-dependent arm. 271 00:22:12.600 --> 00:22:15.200 We tend to use not the right arm but if it's a 272 00:22:15.200 --> 00:22:19.800 left leaning hand of the left dependency so we try to do 273 00:22:19.800 --> 00:22:24.900 it on the left hand. Anyone less than 11.5 centimeter 274 00:22:24.900 --> 00:22:29.600 would be Categorized, especially between the ages of six months to five 275 00:22:29.600 --> 00:22:34.900 years as severe recruitment nutrition. And between 13.2 12.5, 276 00:22:34.900 --> 00:22:39.900 centimeter would be considered as moderate equipment nutrition more than 277 00:22:39.900 --> 00:22:44.400 13.5 and a green color. It actually has got these three things, 278 00:22:44.400 --> 00:22:49.500 green, yellow and red, A green would be considered as normal. 279 00:22:49.500 --> 00:22:54.300 We expect that a normal child would be having a mid-term circumference 280 00:22:54.300 --> 00:22:59.700 between 16.5 to 17.5 centimeters. Having 281 00:22:59.700 --> 00:23:03.100 said that. What if I do not know the age of the 282 00:23:03.100 --> 00:23:08.500 child can? I also possibly know whether the child is malaria. 283 00:23:08.500 --> 00:23:13.000 Not. So, we used to have these particular indices. But we do 284 00:23:13.000 --> 00:23:17.800 not generally use these indices now, but suffice it to say that 285 00:23:17.800 --> 00:23:22.300 with the middle problem. Circumference, with a weight in height, in relation 286 00:23:22.300 --> 00:23:26.200 to height in, centimeter, to the power 1.6, or to the power 287 00:23:26.200 --> 00:23:31.200 2. Or meet a problem. Circumference, in relation to 288 00:23:31.200 --> 00:23:35.600 head, circumference. We can have these other indices which can tell us 289 00:23:35.600 --> 00:23:40.600 about the malnutrition. Other than that then 290 00:23:40.600 --> 00:23:44.200 we have the body mass index which used to be called as 291 00:23:44.200 --> 00:23:49.200 quarterly index through this. Also we can definitely find whether we 292 00:23:49.200 --> 00:23:53.800 can categorize For someone to be in a state of protein and 293 00:23:53.800 --> 00:23:59.400 nutrition. And also the grading if BMI is less than 15 with 294 00:23:59.400 --> 00:24:03.400 this criteria of weight by height in meters square. It would be 295 00:24:03.400 --> 00:24:07.500 considered as mild PM less than 30 would be considered as severe 296 00:24:07.500 --> 00:24:11.700 PM more than 25 would be overweight and more than 30 would 297 00:24:11.700 --> 00:24:16.800 be obese. I haven't seen how to assess, malnutrition let 298 00:24:16.800 --> 00:24:22.000 us see the causes of malnutrition. So the ecology is basically 299 00:24:22.000 --> 00:24:27.400 of these three reasons, it could be because of conditioning influences because 300 00:24:27.400 --> 00:24:33.800 of cultural practices or it could be social economic factors. Conditions, 301 00:24:33.800 --> 00:24:37.900 it could be right from the birth. The child was born. No 302 00:24:37.900 --> 00:24:43.900 birth weight, or underwent, many infections, during its growth period, specifically, 303 00:24:43.900 --> 00:24:49.000 diarrhea respiratory infections, whooping, cough, losses, and 304 00:24:49.000 --> 00:24:55.000 warm investigation then Most 305 00:24:55.000 --> 00:24:58.300 of the time it is due to social economic factors and cultural 306 00:24:58.300 --> 00:25:03.600 practices that children are landing up with malnutrition. And in among 307 00:25:03.600 --> 00:25:08.800 social economic factors, powered not able to access enough food, ignorance about 308 00:25:08.800 --> 00:25:13.800 food substance and taboos illiteracy as to what food to eat. When 309 00:25:13.800 --> 00:25:17.600 to eat Thomas time, how many times to get lack of knowledge 310 00:25:17.600 --> 00:25:22.600 regarding particular, foot values and management environment? A large family size, 311 00:25:22.600 --> 00:25:27.000 50, more than three children and any kind of overcrowding in the 312 00:25:27.000 --> 00:25:32.300 housing. Environment per se. But added to, this could be some 313 00:25:32.300 --> 00:25:35.300 of the cultural practices, some of the food habits, some of the 314 00:25:35.300 --> 00:25:40.200 taboo, some of the misconceptions about food. Particular customs and beliefs, which 315 00:25:40.200 --> 00:25:44.900 could possibly, it could be something to do with vegetarian food. Something 316 00:25:44.900 --> 00:25:50.000 to do with substances, which are not being taken, milk or normal 317 00:25:50.000 --> 00:25:54.700 substances, traditions and religion, not allowing for a particular substance to be 318 00:25:54.700 --> 00:25:58.900 taken any kind of food, facts, personal likes and dislikes by the 319 00:25:58.900 --> 00:26:02.800 mother by the family by the in-laws, any kind of cooking practices 320 00:26:02.800 --> 00:26:07.900 which can possibly not, Cater to enough 321 00:26:07.900 --> 00:26:13.100 provision of vitamins and minerals, child rearing practices, 322 00:26:13.100 --> 00:26:18.500 which could interfere with the child, getting its enough vitamins 323 00:26:18.500 --> 00:26:23.500 and minerals and superstitions related to food. Person, could land up 324 00:26:23.500 --> 00:26:29.100 the child in nutrition. there are many theories about why 325 00:26:29.100 --> 00:26:33.700 these children of the old man appearance with this edema with those 326 00:26:34.400 --> 00:26:39.500 Pigmentary hair conditions, so I would not go 327 00:26:39.500 --> 00:26:45.300 into much into this. But one Theory which has put the A 328 00:26:45.300 --> 00:26:48.600 test of the time is what we call as the free radical 329 00:26:48.600 --> 00:26:53.400 Theory. What it tends to say is that whenever children are deprived 330 00:26:53.400 --> 00:26:58.700 of food, These free oxygen radicals are released into the blood 331 00:26:58.700 --> 00:27:04.700 and this tends to be toxic to the cell membrane specifically of 332 00:27:04.700 --> 00:27:09.900 liver of the immune cells that is blood 333 00:27:09.900 --> 00:27:15.800 cells. And this makes these children prone to various infections Also, 334 00:27:15.800 --> 00:27:21.200 because these three radicals are not being buffered by inadequate 335 00:27:21.200 --> 00:27:26.900 intake of protein. These are not being neutralized thus 336 00:27:26.900 --> 00:27:32.100 causing more damage to the cells specifically because 337 00:27:32.100 --> 00:27:37.100 of decrease intake of antioxidants, like vitamin A C E 338 00:27:37.100 --> 00:27:42.700 and mineral like selenium, also, when malnutrition, 339 00:27:42.700 --> 00:27:47.700 because they may, Damage the liver cells. This 340 00:27:47.700 --> 00:27:53.300 could also be giving rise to the typical appearance of quasar. How 341 00:27:53.300 --> 00:27:58.900 exactly it does this, do the damage because of inadequate protective 342 00:27:58.900 --> 00:28:04.100 Pathways because of the free radicals, not being neutralized. This. 343 00:28:04.700 --> 00:28:10.100 Can cause the molecular damage and this molecular damage can result 344 00:28:10.100 --> 00:28:15.100 in inadequate repair of these damaged cells. Resulting in fatty 345 00:28:15.100 --> 00:28:20.300 liver fatty liver itself trying to decrease the synthesis of the 346 00:28:20.300 --> 00:28:25.300 proteins that are needed for proper metabolism and 347 00:28:25.300 --> 00:28:31.000 that is where the Vicious Cycle tends to result in this 348 00:28:31.000 --> 00:28:36.400 kind of liver and the free radicals going basic in. Not 349 00:28:36.400 --> 00:28:41.900 neutralizing. The metabolic pathways that need to be having their proper integrity. 350 00:28:43.700 --> 00:28:48.400 Aflatoxin poisoning. Is what was generally said that because of very low 351 00:28:48.400 --> 00:28:53.600 protein diet The growth tends to stop and causes hunting or 352 00:28:53.600 --> 00:28:58.000 so resulting in loss of appetite or energy. And that is what 353 00:28:58.000 --> 00:29:02.300 is the picture that we tend to see of marasmus. Insufficient diet 354 00:29:02.300 --> 00:29:06.900 weight loss. And this can cause all these three features of wasting 355 00:29:06.900 --> 00:29:12.000 and stunting Now, the spectrum of PM we 356 00:29:12.000 --> 00:29:15.500 have already seen, I would not like to well much into this. 357 00:29:15.500 --> 00:29:20.400 But suffice it to say that one term of invisible protein, and 358 00:29:20.400 --> 00:29:24.900 demand nutrition or hidden under is what we tends to see especially 359 00:29:24.900 --> 00:29:29.700 in the community especially between these 6 to 34 months. And this 360 00:29:29.700 --> 00:29:34.700 cannot be found clinically or cannot be glaringly 361 00:29:34.700 --> 00:29:38.600 seen by the parents or the caretakers. Unless you tend to chart 362 00:29:38.600 --> 00:29:45.300 this, in the growth chart, Each 363 00:29:45.300 --> 00:29:50.300 of these clinical manifestations. Marasmus tends to present as 364 00:29:50.300 --> 00:29:55.000 severe wasting of muscle and subcutaneous fat. Giving the child old man 365 00:29:55.000 --> 00:29:59.800 appearance, they would be severe growth retardation, there'd be no edema or 366 00:29:59.800 --> 00:30:04.200 hair changes or fatty liver, but the child is alert irritable, but 367 00:30:04.200 --> 00:30:09.100 very hungry as compared to marasmus. This is how the child tends 368 00:30:09.100 --> 00:30:13.200 to look who old man appearance. And as you can see, the 369 00:30:13.200 --> 00:30:18.500 subcutaneous fat is melted all over the place. The arms 370 00:30:18.500 --> 00:30:24.500 the thighs and also a wiser to look on his face. In 371 00:30:24.500 --> 00:30:28.000 contrast to, that is question code where the Cardinal features of that 372 00:30:28.000 --> 00:30:33.500 of Edema irritable, psychomotor changes, irritability, growth, tradition 373 00:30:33.500 --> 00:30:38.600 and muscle wasting, additionally, the child will have a moon phase a 374 00:30:38.600 --> 00:30:42.700 typical hair changes or what we call as black and appearance skin 375 00:30:42.700 --> 00:30:47.800 changes. Where edema cracked skin. Flaky pain dermatitis could be there. When 376 00:30:47.800 --> 00:30:52.900 you check this child, they could be anemia liver. And last cardiac 377 00:30:52.900 --> 00:30:56.600 failure dehydration and other vitamin deficiencies as well. This is how the 378 00:30:56.600 --> 00:31:00.000 child is going to look. We can see the skin flaky pain 379 00:31:00.000 --> 00:31:05.000 dermatosis. The skin is peeled off. Discouraging. And at places even 380 00:31:05.000 --> 00:31:10.100 ulcerated the legs are swollen, the hands are swollen but when 381 00:31:10.100 --> 00:31:14.100 you check the weight, the weight will be decreased and all. So 382 00:31:14.100 --> 00:31:17.800 they could be other vitamin deficiencies. You could be seen kilos in 383 00:31:17.800 --> 00:31:22.300 the lips. Vitamin A deficiency in the form of zero of Tanya, 384 00:31:22.300 --> 00:31:27.300 and if you check the hair, the hair would be discoloration 385 00:31:27.300 --> 00:31:32.400 at places. So this particular syndrome is 386 00:31:32.400 --> 00:31:37.700 combination of both harassment as well as cost and vitamin 387 00:31:37.700 --> 00:31:42.000 deficiency would be very glaring in this case. so how do we 388 00:31:42.000 --> 00:31:47.400 differentiate between management and partial for generally management is a Thing, 389 00:31:47.400 --> 00:31:50.400 which is seen in a child less than one year, while would 390 00:31:50.400 --> 00:31:54.500 be between 1, to 3 years, edema would be prominent. In case 391 00:31:54.500 --> 00:31:58.400 of partial core, while wasting will be prominent, in case of marasmus, 392 00:31:59.000 --> 00:32:03.100 Muscle wasting will be very obvious in marasmus, but is it in 393 00:32:03.100 --> 00:32:08.200 by the edema that you see in question? Mentally question, 394 00:32:08.200 --> 00:32:13.000 cut children are very irritable morning. Very apathetic while harassment children are 395 00:32:13.000 --> 00:32:19.600 active and they would be hungry and very good appetite. Also 396 00:32:19.600 --> 00:32:24.000 skin and hair changes with diffused deep pigmentation both of hair as 397 00:32:24.000 --> 00:32:29.100 well as the skin would be seen in caution car and albumin. 398 00:32:29.100 --> 00:32:34.100 As well as urinary urea, will be much more low in 399 00:32:34.100 --> 00:32:39.600 case of caution and that possibly gives rise to this. Typical 400 00:32:39.600 --> 00:32:44.500 appearance in partial Court. Anemia would be more commonly seen her and 401 00:32:44.500 --> 00:32:49.400 we do a liver back. See In these children, fatty changes are 402 00:32:49.400 --> 00:32:54.600 remarkable to that, of course. let 403 00:32:54.600 --> 00:32:59.900 us see what is the Immunity that is seen 404 00:32:59.900 --> 00:33:05.800 in PM children. PM children, that is protein energy, malnutrition children tend 405 00:33:05.800 --> 00:33:11.000 to have infectious diseases much more. basically, because the resistance 406 00:33:11.000 --> 00:33:14.900 to infection is not there, and this tends to visit in high 407 00:33:14.900 --> 00:33:18.900 mortality, in children, between the ages of six months to five years 408 00:33:20.500 --> 00:33:25.600 What exactly tends to happen? These children tend to have higher incidents 409 00:33:25.600 --> 00:33:31.100 of diary and diseases, pneumonia septicemia measles tuberculosis 410 00:33:31.100 --> 00:33:36.500 malaria. And UTI, also interested specifically 411 00:33:36.500 --> 00:33:41.500 with roundworms hookworms and Giada is more frequent. And 412 00:33:41.500 --> 00:33:46.600 why is that? Because the humoral immunity is maintained that is if 413 00:33:46.600 --> 00:33:52.100 you check their much 414 00:33:52.100 --> 00:33:57.100 more Not so much affected as compared 415 00:33:57.100 --> 00:34:01.700 to the CMI. That is a cell mediated immunity. This is affected 416 00:34:01.700 --> 00:34:07.300 specifically in very severe severe PMs 417 00:34:07.300 --> 00:34:12.300 and this is what explains that these children tend 418 00:34:12.300 --> 00:34:18.300 to have a negative. To test. and 419 00:34:18.300 --> 00:34:23.600 so, these children have very Decreased, 420 00:34:23.600 --> 00:34:28.100 serum reactive protein, which is the acute phase reactant in these children 421 00:34:28.100 --> 00:34:32.400 and this tends to rise in the presence of infection. And that 422 00:34:32.400 --> 00:34:36.100 is one thing which can be used as a screening tool. If 423 00:34:36.100 --> 00:34:41.600 you have the facility for creating these children, What are the investigations 424 00:34:41.600 --> 00:34:44.500 that we can possibly do in these children and, which are important. 425 00:34:44.500 --> 00:34:51.600 Obviously, that glucose their examination 426 00:34:51.600 --> 00:34:56.000 and chest x-ray, and want to test other tests, which will not 427 00:34:56.000 --> 00:34:58.900 be useful, right? In the beginning of treatment of these children will 428 00:34:58.900 --> 00:35:05.000 be serum proteins and HIV. Children 429 00:35:05.000 --> 00:35:10.200 tend to die off very high mortality. Almost, 40% of them, 430 00:35:10.200 --> 00:35:22.000 may not survive. The next two to three months. Hypoglycemia. 431 00:35:22.900 --> 00:35:28.400 Hypothermia. Infections. Hypokalemia hyponatremia, 432 00:35:28.400 --> 00:35:32.700 dehydration and shop. And if these are also not treated, they tend 433 00:35:32.700 --> 00:35:36.300 to die of heart failure. So what would be some of the 434 00:35:36.300 --> 00:35:40.300 criteria for Edition? Do we need to? Preach, and admit, all these 435 00:35:40.300 --> 00:35:43.100 children in a hospital setting. No, we don't need to do that. 436 00:35:44.000 --> 00:35:48.200 We'll see what the criteria is uncomplicated. That is a child more 437 00:35:48.200 --> 00:35:53.200 than six months of age alert, good appetite, clinically assist student. 438 00:35:53.200 --> 00:35:56.900 Well and living in a conducive home and Alignment where can be 439 00:35:56.900 --> 00:36:02.300 given they may not require hospitalization, but yes, if 440 00:36:02.300 --> 00:36:04.900 a child is less than six months and access to me having 441 00:36:04.900 --> 00:36:10.100 severe cute or the more than six months. but 442 00:36:10.100 --> 00:36:15.100 also, Having other complications we might have to 443 00:36:15.100 --> 00:36:20.100 admit the child to hospital setting and treat them so let 444 00:36:20.100 --> 00:36:24.000 us quickly see what exactly this is. Who are the children? Who 445 00:36:24.000 --> 00:36:29.000 would be required in patient admission? Anyone whose weight 446 00:36:29.000 --> 00:36:34.200 for height? is less than three standard deviation and 447 00:36:35.400 --> 00:36:40.400 as also got a mid upper arm, circumference less than 11.5, 448 00:36:40.400 --> 00:36:45.700 centimeter Having bilateral pitting edema, and also having 449 00:36:45.700 --> 00:36:50.800 any medical competitions, specifically with poor appetite, and what is a 450 00:36:50.800 --> 00:36:55.100 failed appetite test. We'll see. or as being referred from another inpatient 451 00:36:55.100 --> 00:37:00.500 unit, could be a sub District Hospital or it could be A 452 00:37:00.500 --> 00:37:05.600 hospital where they do not have enough, ambulatory treatment care there. 453 00:37:06.500 --> 00:37:10.000 These are the children we need to admit or children who have 454 00:37:10.000 --> 00:37:15.100 been diagnosed as having moderate equipment but with severe medical complications 455 00:37:15.100 --> 00:37:20.200 need to be treated. So the first three will Define a child 456 00:37:20.200 --> 00:37:23.800 having severe recruitment literation but it is a less rest of the 457 00:37:23.800 --> 00:37:29.900 three which should decide whether the child is to get hospitalized. Now, 458 00:37:29.900 --> 00:37:33.000 a word about what do you mean by having a good appetite? 459 00:37:33.700 --> 00:37:39.000 So we try and give these children, good. What 460 00:37:39.000 --> 00:37:44.100 we call as? Therapeutic feed. The therapeutic field could be coming to 461 00:37:44.100 --> 00:37:49.200 us. from the Balaam that we tend to have 462 00:37:49.200 --> 00:37:52.500 in most of the Indian conditions, but if it's in an international 463 00:37:52.500 --> 00:37:57.500 condition you have this Rutf based or 464 00:37:57.500 --> 00:38:01.300 a biscuit which can possibly give to the child and how much 465 00:38:01.300 --> 00:38:04.600 should the child be having? We have certain criteria based on the 466 00:38:04.600 --> 00:38:08.900 Age based on the weight of the child has this much of 467 00:38:08.900 --> 00:38:13.400 it being taken. This particular therapeutic feed in the form of a 468 00:38:13.400 --> 00:38:16.400 biscuit or in the form of a paste. If he's able to 469 00:38:16.400 --> 00:38:19.900 have this much bar, or this much chassis, or this, much of 470 00:38:19.900 --> 00:38:24.300 the water along with this drink and within that one hour time, 471 00:38:24.300 --> 00:38:28.500 where we have these criteria then that is considered as a good 472 00:38:28.500 --> 00:38:33.600 appetite. Good appetite. Sam case can be treated as we seen in 473 00:38:33.600 --> 00:38:38.600 the previous slide can be treated in a Unity center but 474 00:38:38.600 --> 00:38:43.400 poor appetite. Still having Sam, these are the children who needs to 475 00:38:43.400 --> 00:38:49.200 be hospitalized and treated in a Nutritional Rehabilitation Center. So 476 00:38:49.200 --> 00:38:53.500 let us see what are the guidelines for impatient treatment? Once you 477 00:38:53.500 --> 00:38:57.700 have decided to admit the child. And what exactly do we need 478 00:38:57.700 --> 00:39:01.500 to do for that particular, child. So let us see one by 479 00:39:01.500 --> 00:39:05.100 one. What are these 10 steps that we need to take care 480 00:39:05.100 --> 00:39:10.500 of? Generally, these are the five topics 481 00:39:10.500 --> 00:39:14.800 under which we need to treat. What are the general principles for 482 00:39:14.800 --> 00:39:18.600 the routine care. What is the emergency treatment for shock and severe 483 00:39:18.600 --> 00:39:23.600 anemia? How do we go about treating Associated conditions? And what 484 00:39:23.600 --> 00:39:26.900 do we need to do? When they fail to respond to treatment 485 00:39:26.900 --> 00:39:32.100 and what are the discharge guidelines? Once the recovery is complete, So 486 00:39:32.100 --> 00:39:35.700 let us see one by one. If it is the routine care, 487 00:39:35.700 --> 00:39:40.600 we need to do this under two faces. One is stabilization phase 488 00:39:40.600 --> 00:39:45.900 and Second is a rehabilitation phase 489 00:39:45.900 --> 00:39:51.700 in the stabilization phase. We need to take care of these complications 490 00:39:51.700 --> 00:39:56.700 that child. Possibly might have hypocrisy me a hypothermia dehydration has to 491 00:39:56.700 --> 00:40:02.000 be taken care of and the first Three days. And 492 00:40:02.000 --> 00:40:07.700 rest of the complications to do with the electrolyte. Immune infections micronutrient 493 00:40:07.700 --> 00:40:12.600 supplementation, feeding guidelines, catch up. Growth has to be taken care of, 494 00:40:12.600 --> 00:40:18.500 in the third to seventh day. While all the rest from 4th 495 00:40:18.500 --> 00:40:23.900 to 10th complications, we need to take care of during the rehabilitation 496 00:40:23.900 --> 00:40:29.000 phase. A quick word about how to treat hypoglycemia. We 497 00:40:29.000 --> 00:40:33.500 check the blood sugar less than 54 milligrams per deciliter conscious child, 498 00:40:33.500 --> 00:40:37.100 try and give it by a nasogastric field or orally If the 499 00:40:37.100 --> 00:40:40.300 child can take 50 mL of it. But if it's a unconscious 500 00:40:40.300 --> 00:40:45.500 or complicated child fire milk per kg of 10% glucose. This 501 00:40:45.500 --> 00:40:49.400 is to be given by giving too early Feats and these feeds 502 00:40:49.400 --> 00:40:54.100 have to continue even during night time. How do we prevent hypothermia? 503 00:40:54.100 --> 00:40:59.800 Check the temperature less than 35 degree. Centigrade by axilla, or 504 00:40:59.800 --> 00:41:04.900 35.5 degree, Centigrade by rectal temperature rev. The child either 505 00:41:04.900 --> 00:41:10.300 buy kangaroo the care or buy clothing. The child completely to layer 506 00:41:10.300 --> 00:41:15.600 clothing of the body. Cap socks and gloves 24 507 00:41:15.600 --> 00:41:20.900 into 7. Dehydration. It will be very difficult to estimate deer 508 00:41:20.900 --> 00:41:25.400 Direction in a clinical setting, but as you every child, who comes 509 00:41:25.400 --> 00:41:30.500 to us with diarrhea as having dehydration, and here is, unless 510 00:41:30.500 --> 00:41:35.200 the child is in shock, treat this by the nationalistic field, or 511 00:41:35.200 --> 00:41:38.800 by Oral field by continuing to feed every two to four hourly 512 00:41:38.800 --> 00:41:44.300 by continuing to give The ores in the, As 513 00:41:44.300 --> 00:41:49.400 for the category of a b or c here, the basic format 514 00:41:49.400 --> 00:41:55.500 of rehydration Remains the Same. But if you have to further diagnose, 515 00:41:55.500 --> 00:41:59.200 see the mental state of the child. If it's alert, look at 516 00:41:59.200 --> 00:42:04.700 the mouth tongue and tears and the skin tag. But Please 517 00:42:04.700 --> 00:42:08.900 be aware that these three are commonly there in most of the 518 00:42:08.900 --> 00:42:14.600 children who have with marasmus as well as the 519 00:42:14.600 --> 00:42:19.900 so called. Question. So what are the signs? We specifically look 520 00:42:19.900 --> 00:42:24.400 for in a child with malnutrition? Look at the diarrhea that would 521 00:42:24.400 --> 00:42:29.800 give you one. Clue increased thirst, any recent Sankara. Nice drive 522 00:42:29.800 --> 00:42:34.800 filling time absent radial pulse 523 00:42:34.800 --> 00:42:39.700 or decrease or absent urine flow. These will be some signs which 524 00:42:39.700 --> 00:42:43.800 will try and give you an idea. Whether the child is having 525 00:42:43.800 --> 00:42:49.500 dehydration along with malnutrition. So how 526 00:42:49.500 --> 00:42:53.400 do we treat them? We treat them by solution called as resume, 527 00:42:53.400 --> 00:42:58.500 which is nothing but rehydration solution, which is meant specifically for malnourished 528 00:42:58.500 --> 00:43:03.700 children, which is God decreased sodium consequent while 529 00:43:03.700 --> 00:43:08.700 having a higher potassium content and having a higher glucose content 530 00:43:08.700 --> 00:43:13.600 because these are the ones we require in malnourished children. So if 531 00:43:13.600 --> 00:43:18.300 you do not have resumed, at least use the who lower osmolarity 532 00:43:18.300 --> 00:43:23.300 solution for creating these children. This 533 00:43:23.300 --> 00:43:28.200 since it has got higher, potassium, and higher glucose content, this will 534 00:43:28.200 --> 00:43:33.300 ensure the child gets the requisite, electrolyte, 535 00:43:33.300 --> 00:43:39.500 as well as the glucose content for treating them. Treat the electrolyte 536 00:43:39.500 --> 00:43:44.600 immune by ensuring that the we give half sodium content, but 537 00:43:44.600 --> 00:43:49.600 higher, potassium, and magnesium. Supplementation 538 00:43:49.600 --> 00:43:56.100 in these children. So that the children. Yes, 539 00:43:56.100 --> 00:44:04.400 because 540 00:44:04.400 --> 00:44:09.900 of decreased. Protein content. Ensure the fifth 541 00:44:09.900 --> 00:44:13.700 step of treating or preventing infection ensure. If the child is overly 542 00:44:13.700 --> 00:44:17.100 able to take give core Prime axis. All, if not able to 543 00:44:17.100 --> 00:44:22.100 take core primex result, orally give Epsilon and Gentamicin review 544 00:44:22.100 --> 00:44:27.400 the infection parameters after 48 Hours. Generally they tend to respond 545 00:44:27.400 --> 00:44:32.400 by good appetite. By decreased episodes of hypothermia and 546 00:44:32.400 --> 00:44:37.400 hypoglycemia if the infection has been treated. In case, there 547 00:44:37.400 --> 00:44:42.400 are evidence of infection by blisters or bioder 548 00:44:42.400 --> 00:44:46.900 lesions in the skin. Also add proxalin to be able to treat 549 00:44:46.900 --> 00:44:51.900 the staphylococcal infection. But if a child is in septic 550 00:44:51.900 --> 00:44:56.700 shock or no improvement after 48 hours or evidence of any major 551 00:44:56.700 --> 00:45:01.700 disagree, you might have to add a philosopher in either by subtracting 552 00:45:01.700 --> 00:45:07.400 or subtract Zone and his entry, you might have to add ciprofloxacin. 553 00:45:07.400 --> 00:45:11.400 If it is not been able to be treated by the core 554 00:45:11.400 --> 00:45:18.200 Prime, dysentery, most of the cases, Micronutrient 555 00:45:18.200 --> 00:45:21.200 deficiency. You have to take care because most of these children have 556 00:45:21.200 --> 00:45:26.700 high micronutrient deficiencies, specifically of zinc. And 557 00:45:26.700 --> 00:45:30.000 vitamin A vitamin A you need to give on the first day. 558 00:45:30.000 --> 00:45:32.700 Second day as well as on the second week, if the child 559 00:45:32.700 --> 00:45:37.100 is still there with you on the second week, if not multiple 560 00:45:37.100 --> 00:45:42.200 vitamins supplement, do add folic acid. Do give 561 00:45:42.200 --> 00:45:47.000 zinc from day one specifically, if they're having diarrhea and iron is 562 00:45:47.000 --> 00:45:52.000 to be given from the 8th day onwards. some of these 563 00:45:52.000 --> 00:45:57.300 electrolytes and minerals Solutions tend to come as a package, Can 564 00:45:57.300 --> 00:46:00.900 we started to give right from day one, so that it takes 565 00:46:00.900 --> 00:46:06.000 care of the policemen, requirement. Are requirements requirement and 566 00:46:06.000 --> 00:46:11.500 copper requirement? the most important part is the cautious 567 00:46:11.500 --> 00:46:16.800 feeding small but frequent feeds oral gastric feeds and 568 00:46:16.800 --> 00:46:21.800 start with F75 if you have 75 has got certified. Look 569 00:46:21.800 --> 00:46:26.600 calories. And 0.9 gram protein. This cautious feed is during the stabilization 570 00:46:26.600 --> 00:46:31.500 phase. And this is the time that we start with the start 571 00:46:31.500 --> 00:46:36.400 with about 150 milliliters per kg per day over 6 to 8 572 00:46:36.400 --> 00:46:43.000 feet. If the child is breastfed, continue the breastfeeding To 573 00:46:43.000 --> 00:46:47.400 avoid risk of heart, failure or refilling syndrome. You have to monitor 574 00:46:47.400 --> 00:46:53.000 the vital parameters, like respiration, as well as heart rate. Anytime 575 00:46:53.000 --> 00:46:57.600 respiration rate as increase by more than 5 from the baseline, or 576 00:46:57.600 --> 00:47:02.000 the pulses increase, more than 15% line, you have to go slow. 577 00:47:03.500 --> 00:47:07.900 Once the appetite is returned, basically tends to happen between 48 to 578 00:47:07.900 --> 00:47:13.300 72 hours. We switch to F100 which is got 100 kilocalories and 579 00:47:13.300 --> 00:47:18.800 2.9 gram protein per 100 ml and or keep checking about 580 00:47:18.800 --> 00:47:24.100 the weight gain. Generally, we hope that the child starts gaining 5 581 00:47:24.100 --> 00:47:28.600 gram per kg per day. The increase the feeding has been done 582 00:47:28.600 --> 00:47:33.600 in this particular fashion. Increased the feed volume by 583 00:47:33.600 --> 00:47:38.200 at least 10 ml per day. And this will ensure that the 584 00:47:38.200 --> 00:47:42.700 child will be able to reach from 130 ml to 200 mL 585 00:47:42.700 --> 00:47:46.700 per kg per day, depending on the appetite, and the progress of 586 00:47:46.700 --> 00:47:52.800 the child, this is the constituents of 7500 And 587 00:47:52.800 --> 00:47:56.800 but the ninth component that we need to ensure the child gets 588 00:47:56.800 --> 00:48:01.900 sensory stimulation and emotional support. Both for the family for the 589 00:48:01.900 --> 00:48:05.700 mother and for the caretaker ensuring that the child is given this 590 00:48:05.700 --> 00:48:09.800 feed in a manner. Where Kendall Loving Care is part of it, 591 00:48:09.800 --> 00:48:13.100 where the child is taken care of in a cheerful and stimulating 592 00:48:13.100 --> 00:48:18.400 environment. That's why the structured play therapy with age appropriate toys 593 00:48:18.400 --> 00:48:22.800 has to be given to the child, at least for half an 594 00:48:22.800 --> 00:48:25.400 hour in a if it can be done morning and evening nothing 595 00:48:25.400 --> 00:48:30.100 like it, physical activity is a must and maternal environment to be 596 00:48:30.100 --> 00:48:33.000 able to give that Comfort the right. Kind of feeding the right 597 00:48:33.000 --> 00:48:36.700 kind of breathing, the right kind of clean is a very important 598 00:48:36.700 --> 00:48:42.700 part of providing sensory stimulation and emotional support. Follow-up. 599 00:48:43.900 --> 00:48:46.700 When do we discharge or think of discharging the child has to 600 00:48:46.700 --> 00:48:51.000 go to 90% weight for height or length? That is the child 601 00:48:51.000 --> 00:48:56.000 reading, reaching to minus 1, standard deviation and 602 00:48:56.000 --> 00:49:00.900 also along with this weight gain. The child is able to have 603 00:49:00.900 --> 00:49:04.300 a parent or caregiver, who was understood the frequency of the feeds, 604 00:49:04.300 --> 00:49:08.000 the making of the feeds, and also the ability to be able 605 00:49:08.000 --> 00:49:13.100 to give that structured play therapy. Once the child is discharged, the 606 00:49:13.100 --> 00:49:17.800 child has to come for regular checkups at least in the first 607 00:49:17.800 --> 00:49:23.400 week to the hospital. If not to the anganwadi center and ensure 608 00:49:23.400 --> 00:49:27.100 that the immunizations are given and vitamin E is given along with 609 00:49:27.100 --> 00:49:32.100 the string a world about emergency treatment of shock and severe anemia 610 00:49:32.100 --> 00:49:37.300 in children with severe recruit malnutrition. If the child comes to us 611 00:49:37.300 --> 00:49:42.400 with severe dehydration, we give not the whole of ringa lactate, but 612 00:49:42.400 --> 00:49:46.500 we make it as half of wrinkle acted or normal cell with 613 00:49:46.500 --> 00:49:51.700 5% exposed at 15 ml per kg per hour and continue 614 00:49:51.700 --> 00:49:55.000 to monitor the pulse rate as well as the heart rate, see 615 00:49:55.000 --> 00:49:58.700 if the heart rate as well as the pulse rate has come 616 00:49:58.700 --> 00:50:03.400 down that means we know the child is improving. Give another bolus 617 00:50:03.400 --> 00:50:09.000 of 50 million. Give another 15 ml per kg. If the 618 00:50:09.000 --> 00:50:14.300 child is improved, it could be You further keep giving auras. 619 00:50:14.300 --> 00:50:18.200 In this particular thing, the child is not improved. That is the 620 00:50:18.200 --> 00:50:21.300 time you need to consider the possibility. The child has got a 621 00:50:21.300 --> 00:50:23.800 big shock and that is the time you might have to add 622 00:50:23.800 --> 00:50:28.800 dopamine. Also to this. It could be another child who 623 00:50:28.800 --> 00:50:33.000 could be having severe anemia anyone having hemoglobin less than 4 gram 624 00:50:33.000 --> 00:50:38.400 per deciliter. These are children, who would be helped by giving blood 625 00:50:38.400 --> 00:50:43.400 supplements? Ideally, is to give transfusion packed red cells 626 00:50:43.400 --> 00:50:47.000 at a rate of 5 to 7 ml per kg given over 627 00:50:47.000 --> 00:50:51.700 3 hours. If bad grid cells are not available next, best is 628 00:50:51.700 --> 00:50:55.600 to give whole blood animal per kg over 3 years. You can 629 00:50:55.600 --> 00:51:00.400 start with furious mind before the start of this, but keep monitoring 630 00:51:00.400 --> 00:51:04.300 respiratory rate, and heart rate to ensure that there is no override 631 00:51:04.300 --> 00:51:08.500 ration or no cardiac failure occurring. Iron supplements will have to be 632 00:51:08.500 --> 00:51:13.600 giving at least two to three months. Associated conditions. Vitamin A deficiency 633 00:51:13.600 --> 00:51:18.500 as a said, 0 doors. Next day after 24 hours, and on 634 00:51:18.500 --> 00:51:21.900 the 14th day, depending on the age of the child. Less than 635 00:51:21.900 --> 00:51:27.300 6 months, 50,000 international units. 621 units 636 00:51:27.300 --> 00:51:31.600 more than 12 months, two lakh units. But if already is, there 637 00:51:31.600 --> 00:51:35.600 often features are already started. You can still any of the broad 638 00:51:35.600 --> 00:51:40.300 spectrum, antibiotic local antibiotic. It could be tetracycline eye, drop or chlorophenol 639 00:51:40.300 --> 00:51:45.500 along with entrepreneurs specifically if there is any 640 00:51:45.500 --> 00:51:51.100 corneal ulceration Cornelia cloudy. Dermatosis, hyper hyperpigmentation 641 00:51:51.100 --> 00:51:56.300 or any evidence of discrimination ulceration and oxidative lesions? Along 642 00:51:56.300 --> 00:52:01.500 with zinc deficiency, zinc, supplements of 2 milligram per kg also apply 643 00:52:01.500 --> 00:52:06.000 barrier creams like, zinc and castor oil, ointment or any Vaseline, or 644 00:52:06.000 --> 00:52:11.000 paraffin gauze can be applied. And ensure that perineum is 645 00:52:11.000 --> 00:52:15.100 dry specifically for female children because that could be one root of 646 00:52:15.100 --> 00:52:20.900 causing urinary tract infection. If there is continuing diarrhea. Obviously, 647 00:52:20.900 --> 00:52:26.200 we have to give this replacement therapy with 5200 648 00:52:26.200 --> 00:52:30.300 ml after every, Diary episode, along with that. If you have facilities 649 00:52:30.300 --> 00:52:35.600 for stool microscopy, if there is Then 650 00:52:35.600 --> 00:52:40.300 do give metronidazole and it does of 7.5 mg per kg every 651 00:52:40.300 --> 00:52:45.600 day. If there is continuing diarrhea, very rarely. 652 00:52:45.600 --> 00:52:49.600 It could be possibly due to lactose intolerance. These are the children 653 00:52:49.600 --> 00:52:53.600 who could be helped with any kind of yogurt or lactose-free in 654 00:52:53.600 --> 00:52:59.200 front of which could be soybeans or non-sub beast. a 655 00:52:59.200 --> 00:53:02.800 sporting idea, again, this is a children where the sugar content could 656 00:53:02.800 --> 00:53:07.900 be reduced by giving low sugar formula with 657 00:53:07.900 --> 00:53:13.200 F75, or you could also try and give the 658 00:53:13.200 --> 00:53:18.200 children with albendazole dose of 400 mg More 659 00:53:18.200 --> 00:53:21.500 than two years, if child is less than two years, half of, 660 00:53:21.500 --> 00:53:25.600 that 200 milligram could be used. If at any point of time, 661 00:53:25.600 --> 00:53:28.700 the child is not gaining the weight that we expect the child 662 00:53:28.700 --> 00:53:32.500 to be gaining. These are the times you need to suspect that 663 00:53:32.500 --> 00:53:37.400 the possibility, the child could be having tuberculosis with circumstantial evidence where 664 00:53:37.400 --> 00:53:43.100 the child might have an adult. Who's having tuberculosis where 665 00:53:43.100 --> 00:53:47.900 the adults themselves be having poor growth despite good intake, the child 666 00:53:47.900 --> 00:53:52.100 continues to not gain weight or just infection or x-ray features of 667 00:53:52.100 --> 00:53:56.600 this. Maybe that is the time you suspect the child having tuberculosis 668 00:53:56.600 --> 00:54:00.800 or the mantoux test, but it could be false negative in severely 669 00:54:00.800 --> 00:54:05.800 nutrition or if there is any strongly positive amount of tests. 670 00:54:05.800 --> 00:54:08.700 That is a time, we might have to treat them as for 671 00:54:08.700 --> 00:54:13.900 the Nationals. In the scenario of failure to respond 672 00:54:13.900 --> 00:54:18.100 to treatment. Instead of having good weight gain, more than 10 gram 673 00:54:18.100 --> 00:54:23.100 per kg per day or child having an adequate. Feeding 674 00:54:23.100 --> 00:54:28.200 untreated infection specific nutrient. Deficiency is having a chili 675 00:54:28.200 --> 00:54:33.500 infection or tuberculosis. These are the time we need to consider. These 676 00:54:33.500 --> 00:54:39.000 are the reasons for cause for failure to respond to treatment. Two 677 00:54:39.000 --> 00:54:43.000 types, failure to respond to treatment. How do we suspect instead of 678 00:54:43.000 --> 00:54:47.200 regaining appetite on day 4? Nothing like that is happening or edema 679 00:54:47.200 --> 00:54:52.100 is not disappearing from day four or the edema persist even after 680 00:54:52.100 --> 00:54:57.000 date and our failure to gain weight 5 gram per kg per 681 00:54:57.000 --> 00:55:00.500 day, even on date. And that is how we classify as failure 682 00:55:00.500 --> 00:55:05.700 to respond or the child started responding, but started 683 00:55:05.700 --> 00:55:10.300 again losing weight. From day, four onwards, these are children who will 684 00:55:10.300 --> 00:55:14.300 do very well by trying to see whether the child has got 685 00:55:14.300 --> 00:55:19.700 other reasons for failure to respond. When do we discharge anyone 686 00:55:19.700 --> 00:55:25.000 who has gained more than 90%? Wait for length? Criteria or having 687 00:55:25.000 --> 00:55:30.100 no edema absence of infection. Started tolerating more than 130 688 00:55:30.100 --> 00:55:34.100 calories per kg per day or receiving between 1822 and 200 mL 689 00:55:34.100 --> 00:55:38.400 per kg per day of that F100. Consistent weight gain is their 690 00:55:38.400 --> 00:55:43.500 immunization has been covered. And caretakers show enough confidence in their ability 691 00:55:43.500 --> 00:55:48.900 to feed the child, we can discuss these children. If 692 00:55:48.900 --> 00:55:54.000 recovery is complete. And showing 693 00:55:54.000 --> 00:55:58.000 less than 90% weight gain. Who are the children, who can possibly 694 00:55:58.000 --> 00:56:03.000 be discharged? The child more than one year showing good appetite, good 695 00:56:03.000 --> 00:56:08.100 weight gain. No edema antibiotic treatment completed vitamin K has 696 00:56:08.100 --> 00:56:12.500 been given mother is available at home motivated and she is possibly 697 00:56:12.500 --> 00:56:16.400 trained to look after very well has the resources and near the 698 00:56:16.400 --> 00:56:21.500 hospital or near anganwadi Center? These children can be sent 699 00:56:21.500 --> 00:56:26.300 back home with information to the local Health worker for the requisite 700 00:56:26.300 --> 00:56:31.400 support And motivation. If, for some reason, 701 00:56:31.400 --> 00:56:36.800 they are discharged early. Because they do not have the support then 702 00:56:36.800 --> 00:56:40.700 at least tell them to feed frequently for minimum six meals a 703 00:56:40.700 --> 00:56:45.700 day, modify the Home Food to suit. The 100 intake, high 704 00:56:45.700 --> 00:56:49.500 energy snacks can be given between means they could be adding heat 705 00:56:49.500 --> 00:56:53.700 to it or oil to it. Or it could be energy, dense 706 00:56:53.700 --> 00:56:58.700 foods like milk based snacks that can be giving 707 00:56:58.700 --> 00:57:04.500 with necessary assistant to complete each meal with necessity 708 00:57:04.500 --> 00:57:09.500 necessary, education, about how to give resume and how breastfeed should continue. 709 00:57:09.500 --> 00:57:14.600 So in summary, As far as possible, if the 710 00:57:14.600 --> 00:57:18.500 child is passed the appetite test, try and manage them in community. 711 00:57:18.500 --> 00:57:23.500 Because now with enough support and enough motivation, most of these children 712 00:57:23.500 --> 00:57:28.600 can be treated in the community itself, but In case your 713 00:57:28.600 --> 00:57:34.000 clinical Instinct say that the child requires admission under those criteria, 714 00:57:34.000 --> 00:57:38.700 you can admit them with the necessary psychosocial support. Most of these 715 00:57:38.700 --> 00:57:42.400 children tend to do very well with the inpatient treatment that has 716 00:57:42.400 --> 00:57:47.500 been given in the nutritional rehabilitation center. But here is where, if 717 00:57:47.500 --> 00:57:51.800 the child is in the hospital, be very methodical about what intake 718 00:57:51.800 --> 00:57:54.600 has been given. What has been the output? What is the weight 719 00:57:54.600 --> 00:57:58.500 gain? What are the vital parameters. So that we are able to 720 00:57:58.500 --> 00:58:03.100 treat the medical complications complicated. The child who has come to us 721 00:58:03.100 --> 00:58:08.300 with moderate acute monetary, but all so review. 722 00:58:08.300 --> 00:58:13.900 Very frequently children who have been admitted the civilization or 723 00:58:13.900 --> 00:58:18.900 modern equipment notation with medical complications because they tend to deteriorate very, 724 00:58:18.900 --> 00:58:23.200 very early. So that is why once their admitted, they need to 725 00:58:23.200 --> 00:58:29.300 be monitored very frequently. At least every Thank 726 00:58:29.300 --> 00:58:33.700 you very much. These are my references for this particular thing.