pem & vitamin a deficiency
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PEM & Vitamin A deficiency
Dr.Praseeda.BK
PEM
The cellular imbalance between
To ensure growth, maintenance, and specific functions
supply of nutrients & energy
and the body's demand for them
Malnutrition
Reasons..
• Inadequate intake of food (Quality & Quantity)
• Infections
Malnutrition infection cycle
Factors related to Malnutrition
Social & EconomicBiological factors
Poverty Ignorance Female genderRural areaLow birth weightIlliterate mother Scheduled caste/
scheduled tribe Cultural & social practices
Maternal malnutrition, prematurityBirth spacing < 47 monthsAge of mother: 18 – 23 yrsBirth order > 3Underweight status of mothers
Infectious diseaseDiarrhea, TB, measles, Malaria, AIDS
Environmental Unsanitary living, Droughts, floods, wars, forced migrations
Nutritional intakes
Nutrition needs
Nutritionalintakes
Nutritional status
The result is Under- Nutrition
UNDERNUTRITION
ACUTE UNDERNUTRITION
CHRONIC UNDERNUTRITION
• Marasmus• kwashiorkor• Marasmic- kwashiorkor• Wasting
• Stunting• Underweight
Features Marasmus Kwashiorkor
Clinical Always Present
Muscle Wasting Obvious Sometimes hidden by edema & fat
Fat wasting Severe Loss of subcutaneous fat
Often retained but not firm
Oedema None In lower legs ,face, forearms.
Weight for height Very low Low but masked by edema
Mental changes Quiet & Apathetic Irritable , moaning , apathetic
Features Marasmus Kwashiorkor
Clinical Sometimes Present
Appetite Usually good Poor
Diarrheoa Often Often
Skin changes None Flaky paint dermatosis
Hair changes Seldom Sparse , silky ,easly pulled out
Hepatic enlargement
None Sometimes due to fat accumulation
Features Marasmus Kwashiorkor
Biochemical Sometimes Present
Serum albumin Normal or slightly decreased
Low
Urinary Urea per g Creatinine
Normal or slightly decreased
Low
Hydroxyproline creatinine ratio
Low Low
Plasma aminoacid ratio
Normal Elevated
Physical examination• History- including detailed dietary history.
-Anthropometric measurements.» Weight »Length/height »Mid upper arm circumference MUAC)»Chest circumference»Head circumference»Anthropometric Measurements of
Nutritional Status
WEIGHTAt 5-6 month double of birth weight
At 3 years weight 5 time double of birth weight
At 6 years weight 6 times double of birth weight.
HEIGHT
• 1 yr 72-75 cm• 2 yrs 88-90 cm • 4 yrs 100 cm.
>13.5
13.513.5
Prevention
1. Health Promotion
1. Measures directed to pregnant & lactating women
2. Promotion of breast feeding3. Development of low cost weaning food4. Measures to improve family diet 5. Nutrition education 6. Home economics 7. Family planning & spacing of births 8. Family environment
2. Specific Protection
1. Child’s diet must contain protein & energy rich foods
2. Immunization
3. Food fortification
3. Early diagnosis & Treatment1. Periodic Surveillance 2. Early diagnosis of any lag in growth 3. Early diagnosis & treatment of infections and
diarrhoea4. Development of programmes for early
rehydration of children with diarrhoea 5. Development of supplementary nutrition
programmes during epidemics 6. Deworming of heavily infested children
Rehabilitation
• Nutritional rehabilitation services
• Hospital treatment
• Follow up care
Vitamin A deficiency
Sources 1. Animal foods – Retinol(preformed vit A) Liver, Eggs,Cheese,Fish, Meat
2.Plant foods – Carotene(provitamines) GLV ,mango, papya, carrots, yellow pumkin,
red palm oil.
3.Fortified foods – vanaspati, margarine, milk
xerophthalmia
• The term xerophthalmia was given by a joint WHO and USAID committee in 1976 to cover all ocular manifestations of Vitamin A deficiency in human.
- Most common in children aged 1-3 years often related to weaning.
- Marker – serum Retinol level- Normal – 7 micromol / litre(200 micro g/ litre)
• Risk factors– IgnoranceFaulty feeding practicesInfections – measles, diarrhoea, RTILack of education
Current status of VAD in India
• Clinical VAD has declined drastically during the last 40 years.
• There has been virtual disappearance of keratomalacia, and a sharp decline in the prevalence of Bitot spots .
• Prevalence of Bitot spots of 0.5 per cent and more is limited to population groups which are socio-economically backward, poverty stricken and have poor health infrastructure.
XEROPHTHALMIA CLASSIFICATION(modified)
• XN Night blindness• X1A Conjunctival xerosis• X1B Bitot’s spots• X2 Corneal xerosis• X3A Corneal ulceration /keratomalacia affecting less than 1/3rd
corneal surface• X3B Corneal ulceration /keratomalacia affecting more than 1/3rd
corneal surface• XS Corneal scar due to xerophthalmia.• XF Xerophthalmic fundus.
Ocular changes.
1. Night Blindness
• First symptom• Due to impairment in dark adaptaion• Defective rhodopsin function.• May get worse when there is diarrhoea or
other infection
2. Conjunctival xerosis
First clinical signOne or more patches of dry,
lustreless,nonwettable conjunctiva.Interpalpebral conjunctiva(commonly temporal
quadrants)Severe cases involves the entire bulbar
conjunctiva.Desribed as ‘emerging like sand banks at
receding tide’when child ceases to cry
3. Bitot’s spots
- Triangular, pearly white, yellowish foamy spots in the bulbar conjunctiva
- Usually bilateral
- Characterised by metaplasia of conjunctival epithelium and tangles of keratin admixed with gas forming bacteria(corynebacterium xerosis)
- Vitamin A is essential for cell differentiation
4. Corneal xerosis
- Serious stage - Cornea become dull, dry, non-wettable- Severe cases- ulceration leading to scars.• Bilateral punctate corneal epithelial erosions • Can progress to epithelial defects • Reversible on treatment
5. Keratomalacia
Liquefaction of cornea. Medical emergency.Rapid process.Stromal defects occur in late stages due to
colliquative necrosis leading to corneal ulceration ,softening (melting) and destruction of cornea(keratomalacia)
Assessment of Vit A deficiency• Prevalence criteria for determining
xerophthalmiaCriteria Prevalence in population
at riskNightblindness >1%
Bitot’s spots >0.5%
Corneal xerosis/corneal ulceration/keratomalacia
>0.01%
Corneal ulcer >0.05%
Serum Retinol(<10 mcg/dl) >5%
Treatment - Should be treated urgently- early stages reversed by massive doses (2L IU) orally on 2 successive days.
Prevention
Short term actions
Administration of large amount of Vit A orally to vulnerable groups in a periodic basis
Most effective strategy
Medium – term action
Fortification of foods –
dalda,sugar,salt,tea,margarineCereal based foods
Long term action
Elimination of Factors contributing to ocular diseases
Persuading people to consume dark GLVS and other Vit A rich foods.
Promotion of breast feedingImprovement of environmental healthDietary diversification
Dietary diversification
• Cultivation of variety of staple food with a high viatmin and mineral content.
• It holds the ability to concurrently cover multiple micronutrient deficiencies.
• If supported with a nutrition education programme, may be more effective in the developing countries.
Sanitation & hygiene
Safe water supplyEnvironmental sanitationProper hygieneFood safetyRegular dewormingImmunization against DPT, cholera
National programme for prevention of nutritional blindness 1970
• The programme is sponsored by the Ministry of Health and Family Welfare, Government of India
- Beneficiaries children below 5 years.- ObjectivesPromoting consumption of Vit A rich foods
Administration of massive dose of Vit a upto 5 yearsFirst dose of 1 L IU with measles at 9 monthsSubsequent dose of 2 L IU every 6 months upto 5 years
of age9 mega doses
Thank You
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