PHARMA COLLEGE SHASHEMENE CAMPUS

DEPARTMENT OF NURSING

PROVIDING CHILD HEALTH CARE

FOR LEVEL –IV NURSING STUDENT

By:- Fikadu Abera (BSc.N ,MPH)

Feb, 2013/2021 1
 Introduction to child health
• Child health: - although it is difficult to define health in
children as it is in adult, “it is the ability to fulfill an
expected role by the child.”
• Paediatrics definition: a study and care of children in
sickness and health.
• The word paediatrics comes from the Greek and means
“child cure”
• This field is one of the most broadest of all medical
specialities b/c it includes:
―A study of growth and development of a total person
from conception to adolescence
―Prevention, diagnosis and Rx of disorders affecting
children during their growing years
By:-Fike, Feb, 2013
 Introduction …cont’d

• High neonatal mortality rates are preventable proven, simple

& low cost solutions exist.
• Up to 70% of neonatal deaths could be prevented through
intervention for the mother.
• Child deaths in low income countries comprise 98% of the
world’s, of which 60% are preventable.
• Main causes of morbidity are:
• PEM
• Anemia & vitamin A deficiency
• Acute respiratory infections (ARI),
• Malaria & vaccine preventable diseases.

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 General Facts and Rationales of Child Health
• Ethiopia is similar to many other low income countries in
having a young population: those under the age of 15 years
make up 44% of the population.
• The infant mortality rate is 59 per 1000 live births
(EDHS,2011). Low birth weight deliveries are 10%.

• Child mortality(31/1000LB),

• under five mortality (88/1000LB) &

• Neonatal mortality (37/1000LB) (EDHS,2011)

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 Definitions of terms
• Foetus – From conception to birth (From 9 months of
conception in the mother’s womb to birth

• Neonate- The first month of life (birth to 28 days)

• Infant – The first years of life (From 1 month to1 years)

• Preschool child – Under five year-old

• School child – From 6 year to 12 year old

• Puberty – The period from about 9 years to 15 years

By:-Fike, Feb, 2013

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 Identifying Age and disease patterns
1. Intrauterine Fetal life
• Maternal infection
• Maternal toxaemia
• Maternal malnutrition
• congenital and inherited abnormality
• unknown causes

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By:-Fike, Feb, 2013
 Age and disease patterns ………

2. Birth to one month (Neonatal period)

• Obstetric complications and birth injuries
• Asphyxia (Failure to breathe at birth)
• Low birth weight babies
• Congenital abnormalities
• Infection leading to septicaemia
• Neonatal tetanus
• Death of the mother

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 Age and disease….

3. First year of life (Period of infancy)

•Respiratory disease
•Malaria
•Diarrheal disease
•Measles
•PEM (especially marasmus)
•Sudden weaning and deprivation

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 Age and disease….

4. Second to the fifth year of life

• Malnutrition (Marasmus or kwashiorkor) some
times both together
• Pneumonia often caused by measles or whooping
cough
• Diarrhea diseases
• Measles
• Malaria
• Anemia, some times accused by hook worm
• Tuberculosis
• Accidents
• Streptococcal tonsillitis

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 Age and disease….
5. After 5 years
• Infectious diseases( Hook worm round worm)
• Malnutrition
• Malaria
• Skin diseases
• Respiratory diseases and other age specific diseases
NB. Most of the above childhood diseases are
preventable; so a great emphasis must be put on
preventive programmes
E.g.
o Education on nutrition
o Immunization
o Environmental sanitation

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 Health Priorities in children
A. Perinatal mortality rate
• the total number of still-births plus the
number of deaths under one week old, per
1000 birth or
• The sum of late fetal and early neonatal
deaths.
• The causes of Perinatal mortality are:
o trauma and stress of labor,
o toxemia ante partum hemorrhage,
o maternal disease (particularly malaria &
malnutrition),
o congenital anomalies
o infection and induced abortions
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 Health Priorities in children………..

B. Neonatal mortality rate

• The number of deaths under 28 days of age per 1000 live
births.
• The neonatal death reflects not only the quality of care
available to women during pregnancy and childbirth but
• also the quality of care available to the newborn during
the first months of life

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By:-Fike, Feb, 2013
 Health Priorities in children….

C. Post-natal mortality rate

• The number of deaths over 28 days but under one year of
age per 1000 live births.
D. Infant mortality rate
• The number of infant under one year of age dies per 1000
live births.
• It is the sum of neonatal & postnatal deaths.
• The 1ry cause is immaturity & the 2nd leading cause is
gastroenteritis, which can be prevented by putting the
newborn immediately with the mother and advocating
breast-feeding.

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 Health Priorities in children….

E. Child mortality rate

• The number of deaths between 1 & 4 years in a
year per 1000 children.
• This rate reflects the main environmental factors
affecting the child health, such as nutrition,
sanitation, communicable diseases and
accidents around the home.
• It is a sensitive indicator of socioeconomic
development in a community

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By:-Fike, Feb, 2013
 Care of the Under-Fives
• In most countries of the world, there is a relative neglect of the
children of pre-school age.
• Preschool age are a vulnerable or special risk group in any
population.
• The reasons why they need special health care are:
̶ Large numbers
o constitute 15 – 20% of population in developing
countries.
̶High mortality
o The major causes of death in this group are due to
malnutrition and infection, both preventable.
̶ Morbidity
o The major diseases which affect this preschool age group are:
diphtheria, whooping cough, tetanus, diarrhea, dysentery,
malnutrition, accidents all are preventable 15
By:-Fike, Feb, 2013
Major childhood problems
oPneumonia
oDiarrhea
oMalaria
o Tuberculosis
o HIV ( mother to child transmission)
oPerinatal infection
o Malnutrition

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 PEDIATRIC HISTORY
&
PHYSICAL EXAMINATION

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Differences of a Pediatric History
Compared to an Adult History:
I. Content Differences
oPrenatal and birth history
oDevelopmental history
oSocial history of family - environmental risks
oImmunization history
II. Parent as Historian
A.Parent’s interpretation of signs, symptoms
oChildren above the age of 4 may be able to provide
some of their own history
oReliability of parents’ observations varies

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 D/C….cont’d

B. Observation of parent-child interactions

oDistractions to parents may interfere with history taking

oQuality of relationship

C. Parental behaviors/emotions are important

oParental guilt - nonjudgmental/reassurance

oThe irate parent

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Outline of the Pediatric History

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 Pediatric hx….
V. Chief Complaint
oBrief statement of primary problem (including duration) that
caused family to seek medical attention
VI. History of Present Illness(HPI)
o this is a chronologic description and duration of the chief
complaint.
We try to answer the following questions;
o Duration of disease onset
o Severity
o Aggravating and alleviating factors
o Associated symptoms
o Any treatment and response to treatment
o History of contact with similar illness
o Relevant pediatric history (like history of
immunizations) related to chief complaints or history
present illness
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 Pediatric hx….
VII. Past Medical History
this is made up of the illness the patient has had in
the past.
Medical Hx of paediatrics contains:
o Major medical illnesses
o Major surgical illnesses-list operations and dates
o Trauma-fractures, lacerations
o Previous hospital admissions with dates and
diagnoses
o Current medications
o Known allergies (not just drugs)

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By:-Fike, Feb, 2013
 Pediatric hx….

VIII. Pregnancy and Birth History

A.Maternal health during pregnancy: bleeding,
trauma, hypertension, fevers, infectious illnesses,
medications, alcohol, smoking, rupture of membranes
B.Gestational age at delivery
C.Labor and delivery - length of labor, fetal distress,
type of delivery (vaginal, cesarean section), use of
forceps, anesthesia, breech delivery
D. Neonatal period - Apgar scores, breathing
problems, use of oxygen, need for intensive care,
hyperbilirubinemia, birth injuries, feeding problems,
length of stay, birth weight

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By:-Fike, Feb, 2013
 Pediatric hx….
IX. Immunization History
oAsk both mother’s and her child’s immunization status
o be specific, not just up to date
X. Developmental History
oAges at which milestones were achieved and current
developmental abilities - smiling, rolling, sitting alone,
crawling, walking, running, 1st word, toilet training, riding
tricycle, etc.
oSchool-present grade, specific problems, interaction with
peers
oBehavior - enuresis, temper tantrums, thumb sucking, pica,
nightmares etc

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 Pediatric hx….
XI. Nutritional History
oBreast or bottle fed, types of formula, frequency and
amount, reasons for any changes in formula
oSolids - when introduced, problems created by specific
types
oCurrent history

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By:-Fike, Feb, 2013
 Pediatric hx….cont’d

XII. Family History

oIllnesses - cardiac disease, hypertension, stroke,
diabetes, cancer, abnormal bleeding, allergy and asthma,
epilepsy
oMental retardation, congenital anomalies, chromosomal
problems, growth problems, consanguinity, ethnic
background

XIII. Social History

oLiving situation and conditions - daycare, safety issues

oComposition of family
oOccupation of parents, monthly income
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By:-Fike, Feb, 2013
 Pediatric hx….cont’d

XIV. Review of Systems:

oWeight - recent changes, weight at birth

oSkin and Lymph - rashes, adenopathy, lumps, bruising and

bleeding, pigmentation changes
o HEENT - headaches, concussions, unusual head shape,
strabismus, conjunctivitis, visual problems, hearing, ear
infections, draining ears, cold and sore throats, tonsillitis,
mouth breathing, snoring, apnea, oral thrush, epistaxis, caries
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By:-Fike, Feb, 2013
 Pediatric hx….

oCardiac - cyanosis and dyspnea, exercise tolerance,

squatting, chest pain, palpitations
oRespiratory - pneumonia, bronchiolitis, wheezing,
chronic cough, sputum, hemoptysis, TB

oGI - stool color and character, diarrhea, constipation,

vomiting, hematemesis, jaundice, abdominal pain, colic,
appetite

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By:-Fike, Feb, 2013
 Pediatric hx….cont’d

oGU - frequency, dysuria, hematuria, discharge, abdominal

pains, quality of urinary stream, polyuria, previous
infections, facial edema
oMusculoskeletal - joint pains or swelling, fevers, scoliosis,
myalgia or weakness, injuries, gait changes
oPubertal - secondary sexual characteristics, menses and
menstrual problems, pregnancies, sexual activity
oAllergy - urticaria, haigh fever(seasonal rhinitis), allergic
rhinitis, asthma, eczema, drug reactions

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By:-Fike, Feb, 2013
 Content of pediatric history
oPersonal details oPast medical history
oSource of referral oFamily history
oSource of history oSocial history
oPrevious admission oImmunization history
oChief complaints oNutritional history
oHistory of present illness oDevelopmental history
oPregnancy and Birth oReview of system
History

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By:-Fike, Feb, 2013
 II. Physical assessment
Principles and techniques of physical examination:
• To examine the whole body we start with the head and end at feet
(cephalocaudal)
• In case of small child you should make it a habit undress the child and
examine the whole body
• To examine the whole body we start with the head and end at the feet
• Do unpleasant procedures last and quickly eg rectal exam.
• Examine the child according to what you expect to find from the Hx.
• The most important method of examination is inspection of the child
N.B- The most important tools for medical examination are your eyes
and fingers and not the stethoscope

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 Physical examination….cont’d
Differences in Performing A Pediatric Physical Exam.
Compared to an Adult:

I.General Approach
• Gather as much data as possible by observation first
• Position of child: parent’s lap vs. exam table
• Stay at the child’s level as much as possible. Do not
tower!!
• Order of exam: least to most distressing

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 P/E….cont’d
o Rapport with child
• Include child - explain to the child’s level
• Distraction is a valuable tool
oExamine painful area last-get general impression of
overall attitude
o Be honest. If something is going to hurt, tell them
that in a calm fashion. Don’t lie or you lose
credibility!
oUnderstand developmental stages’ impact on
child’s response. For example, stranger anxiety is
a normal stage of development, which tends to
make examining a previously cooperative child
more difficult.
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 II. Vital signs
oNormally differ from adults, and vary according to age
a.Temperature:- New born → axillary 36.1- 37.7 oC
b.Heart rate
• Auscultate or palpate apical pulse or palpate femoral
pulse in infant
• Palpate antecubital or radial pulse in older child
c.Respiratory rate- Observe for a minute. Infants normally
have periodic breathing so that observing for only 15
seconds will result in a skewed number
d.Blood pressure
• Appropriate size cuff - 2/3 width of upper arm
• Site

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By:-Fike, Feb, 2013
 Normal age-related variations in resting pulse
Normal Range Average Rate/Minute
Newborn 100–170 140
1 yr 80–170 120
3 yr 80–130 110
6 yr 75–120 100
10 yr 70–110 90
14 yr 60–110 90
In fever, the pulse rate generally rises.
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Normal age-related variations in resting respiration

 Age Normal Range Average Rate/Minute

• Newborn 30–50 40
• 1 yr 20–40 30
• 3 yr 20–30 25
• 6 yr 16–22 19
• 14 yr 14–20 17
• A rapid respiration of 60 or more in a small, febrile child is a very
good indicator of pneumonia

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 Blood Pressure

Systolic Diastolic
• Age (mm Hg) (mm Hg) Average
• Newborn 65–95 30–60 80/60
• Infant 65–115 42–80 90/61
• 3 Years 76–122 46–84 99/65
• 6 Years 85–115 48–64 100/56
• 10 Years 93–125 46–68 109/58
• 14 Years 99–137 51–71 118/61

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 Normal values of vital signs

Age Heart rate B/P mmhg Respiratory

Beats/min rate
Breaths/min
Premature 120-170 55-75/35-45 40-70
0-3months 100-150 65-85/45-55 35-55
3-6months 90-120 70-90/50-65 30-45
6-12months 80-120 80-100/55-65 25-40
1-3years 70-110 90-105/55-70 20-30
3-6years 65-110 95-110/60-75 20-25
6-12years 60-90 100-120/60-75 14-22 38
 Vital signs….cont’d

E. Anthropometry
•Anthropometric measurements include weight, height or
length, head circumference, chest circumference, mid upper
arm circumference, body ratios (upper/lower segment ratio)

Growth parameters
o must plot on appropriate growth curve
• Weight
• Height/length
• OFC: Across frontal-occipital prominence so
greatest diameter (Occipital Frontal Circumference)

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 Physical Examination
I. General Appearance
A. Statement about striking and/or important features.
oNutritional status, level of consciousness, toxic or
distressed, cyanosis, cooperation, hydration,
dysmorphology, mental state
B. Obtain accurate weight, height and OFC

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• FACE
• It should be examined for
• Expression e.g. dull and expressionless face
indicate mental retardation
• Symmetry
• Paralysis
• Bridge of nose
• Size of the maxilla and mandible
• Tenderness over sinuses

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By:-Fike, Feb, 2013
III. Eyes
 General
• Strabismus
• Slant of palpebral fissures
• Hypertelorism or telecanthus(Lateral displacement of the
inner canthi.)
III. Conjunctiva, sclera, cornea
IV. Plugging of nasolacrimal ducts
V. Epicanthus folds
VI.photophobia
VII.squint
VIII.exophthalmoses
IX.pupils
X.cataract
XI.corneal opacities
XII.exophthalmia

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III. Ears
Note the shape, size and position of ears- deformities
may be painters of kidney anomalies.
 Position of ears
•Observe from front and draw line from inner canthi to
occiput
 Tympanic membranes
 Hearing- Gross assessment only usually
Check the tenderness of mastoid bones
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IV. Nose
• Nasal septum
• Mucosa (color, polyps)
• Sinus tenderness
• Discharge
V. Mouth and Throat
• Lips (colors, fissures)
• Buccal mucosa (color, vesicles, moist or dry, Koplik spots)

• Tongue (color, papillae, position, tremors)

• Teeth and gums (number, condition)
• Palate (intact, arch)
• Tonsils (size, color, exudates)
• Posterior pharyngeal wall (color, lymph hyperplasia,
bulging)
• Gag reflex
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 Sequence of dentition
Deciduous Eruption Shedding

Central incisor 6-7months 6-7years

Lateral incisor 7-8months 7-8years
First molar 10-16months 10-12years
Canine 16-20months 9-11years
Second molar 20-30months 12-13years
Permanent teeth eruption
Central incisor 6-7years
First molar 6-7years
Lateral incisor 7-8years
Canine 9-11years
First premolar 10-12years
Second premolar 11-13years
Second molar 12-13years
Third molar 17-22years 45
VI. Neck
• Thyroid
• Trachea position
• Masses (cysts, nodes)
• Presence or absence of nuchal rigidity
VII. LGS-their location, size, consistency, mobility, tenderness
and warmth
VIII. Lungs/Thorax
A. Inspection
• Pattern of breathing
 Abdominal breathing is normal in infants
• Period breathing is normal in infants (pause < 15 secs)
• Respiratory rate
• Use of accessory muscles: retraction location,
degree/flaring
• Chest wall configuration
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B. Auscultation
o Equality of breath sounds
o Rales, wheezes, rhochi
o Upper airway noise

C. Percussion and palpation often not possible and

rarely helpful

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IX. Cardiovascular
Pulses
• Quality in upper and lower extremities
oInspection- bulge, activity, apical beat
oPalpation- PMI, thrill, heave
oAuscultation

• Rhythm
• Murmurs
• Quality of heart sounds
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X. Abdomen
A. Inspection
o Shape

• Infants usually have protuberant abdomens

• Becomes more scaphoid as child matures
• Umbilicus (infection, hernias)
• Muscular integrity (diasthasis recti)

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 B. Auscultation
C. Palpation
. Tenderness - avoid tender area until end of exam
• Liver, spleen, kidneys
• May be palpable in normal newborn
• Rebound, guarding
• Have child blow up belly to touch your hand

D. Percussion
• Rectal examination
oNote any anal fissure, polyp, prolapse
• Rectal examination is undertaken with little finger.

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XI. Gento Urinary system
A. External genitalia
B. Hernias and Hydroceles
• Almost all hernias are indirect
• Can gently palpate; do not poke finger into the
inguinal canal
C. Cryptorchidism :-
Distinguish from hyper-retractile testis
• Most will spontaneously descend by several months of life
D.Tanner staging in adolescents
E.Rectal and pelvic exam not done routinely - special
indications may exist.

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By:-Fike, Feb, 2013
 CLASSIFICATION OF SEXUAL MATURITY
STATES IN GIRLS
Stages Pubic hair Breasts
1 Preadolescent Preadolescent
Sparse, lightly pigmented, at Breast elevated areola
2 medical bolder of labia, diameter increased
Darker and increased amount Breast and areola
3
enlarged
Coarse, abundant but less than Secondary areola form
4
adults
Adult feminine triangle spread to Mature nipple projects
5 medial surface of thighs

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CLASSIFICATION OF SEX MATURITY STATES IN
BOYS
Stages Pubic hair Penis Testes

1 None Preadolescent Preadolescent

Scanty, long and slightly Slight enlargement Enlarged

2 pigmented scrotum, pink
Darker, small amount Longer Larger
3
Resembles adult type but Larger, glans Larger scrotum
4 less in quantity: coarse breadth increase in dark
size
Adult distribution, Adult size Adult size
5 spread to medial surface
of thighs
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Spine and back
Examine for:
•Scoliosis, kyphosis, lordosis, dimples, spinal
bifida, stiffness of the neck.
Neurologic examination
•Check sense of touch or pain during rest of the
examination
•Check muscle tone by lifting the child by shoulders.
•Tendon reflexes are exaggerated in young
children.
•Test cranial nerves

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Growth and Development

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 Introduction
oGrowth
• The increase in size and development of a living
organism from a simple to a more complex form
 Hyperplasia: - an increase in the number of cells
 Hypertrophy:- increased in the size of cells
• It is due to multiplication of cells and an
increase in intracellular substances.
• Growth begins from conception and continues
through out child hood and adolescent until
maturity.
• Unlike in the adult, it is an essential feature of
the child’s life.

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By:-Fike, Feb, 2013
 Introduction…
oDevelopment
• An increase in skill and maturation of organs &
systems .It suggests modification in capacity to
function
• A measure of functional or physiological maturation
and myelination of the nervous system.
• It signifies the accomplishments of mental, emotional
and social abilities.
• acquisition of function by the tissue or the organism as
a whole, and it is since conception to death
• Development means increase of function (what a child
can do)

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By:-Fike, Feb, 2013
 Intro…..

oGrowth and development in

• physical, intellectual, emotional and social
terms
• are the essential Biological characteristics of
childhood
• Growth and development go together, but at
different speeds
oA child is not a small adult, but is
• A developing human being who changes from a
new born through infancy, toddlerhood and
early school years in to and adolescent and
finally, a mature adult
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 General Principles
• The sequence of each pathway of development is the
same in all children but the rate of development
varies from child to child
• Motor development proceeds in a cephalo-caudal
direction. An infant can do much with his hands
before he can walk
• Some primitive reflexes must be lost before
voluntary movement occur

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 Factors affecting growth and development

oHeredity
oPre & postnatal environment
oSex
oEndocrine system
oNutrition
oDisease

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 Milestones at different ages
oInfancy (0-12 months)
• Physical development: Average wgt of a newborn
is 3.2kg.
• The full term infant doubles his birth wgt by 5th &
triples by 1yr of his age
• The anterior fontanel closes b/n 9 & 18 months,
the posterior closes by 4 months of age
• Head circumference at birth is around 34-35cm &
at 6 month it increases to 44cm, by 1yr it attains
47cm

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• The 1st deciduous teeth erupt by 5-9 month
• The 1st are the lower central incisors followed by
upper central incisors
• By 1 yr of age most will have 6-8 teeth
• Normally length of newborn- 50cm. By first year- 75cm
Weigh an average of 10 Kg at 12 months, length increases by
25 cm, and head circumference by 12 cm
• Length or height Measurement
o It rises to 60cm at 3months,
o ----//-------70cm at 9months,
o ----//--------75cm at one year and
o ----//---------85cm at 2years

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Standard Ht/Lt
o At birth = 50cm
o At 1yr = 75cm
o At 2-12yr of age = Age (year) X 6 +77
o Doubles at 4yr & triple at 12yr of age
o 3months = 60cm
o 6mo=65cm
o 9mo=70cm
o 1yr=75cm
o 2yr=90cm
o Then increase 5cm each year till 10yr.
o At 10-20yr increase about 12.7-40.6cm/year

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By:-Fike, Feb, 2013
 SUMMARY OF NORMAL DEVELOPMENT MILESTONES

Average Motor Language and social

Age development behaviours
1 month Can lift head when Can fix with eyes, often smiles
prone
3-6 month Good head control Can follow an object with eyes, play with
hands
6-9 month Can sit unsupported Grasps actively, makes loud
noises
9-12 month Able to stand Understands a few words, tries to use them

12-18 month Able to walk Grasps small objects with thumb and
fingers
2 years Able to run around as Can say several words or even
much as he/she wants some sentences

3 years Actively playing, Starts talking a lot, curious and

clever in climbing and inquisitive
jumping 64
 Common changes that occur during the three periods are:
Variable Early Adolescence Middle Adolescence Late Adolescence

Age/yrs 10-13 14-16 17-20& beyond

Somatic 20 sexual charac., Ht peak, acne & odor, Slower growth
beginning of rapid G menarche, spermarche
Sexual Sexual interest Sex drive urges Consolidation of
experimentation sexual identity

Cognitive concrete operation, Abstract thought, Idealism,

conventional self-centered
& Moral absolution
morality
Family Bids for Continued struggle for Practical,
greater autonomy independent, family
independence
remains secure base
Peers Same sex groups, Dating, peer groups Intimacy, possibly
conformity, cliques less important commitment

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 Nutrition E-SE
• Nutrition is the provision of adequate energy and nutrients
(in terms of amount, mix and timeliness) to the cells for them
to perform their physiological function (of growth,
reproduction, defense, repair, etc).
• Study of food in relation to man, and study of man in relation
to food
• Science of food as it relates to optimal health and
performance.
• Study of foods in relation to needs of living organisms
Human Nutrition:
• A scientific discipline, concerned with the access and
utilization of food and nutrients for life, health, growth,
development and well-being.
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 Nutrition…
• Impaired nutritional status is called malnutrition
a. Under nutrition: A pathological state resulting from the
consumption of inadequate quality or quantity over an
extended period of time/starvation/
• Kwashiorkor
• Marasmus
• Marasmic-kwashiorkor
b. Specific deficiency: the pathological state resulting from
a relative or absolute deficiency of an individual nutrient

a. Over nutrition/obesity/: pathological state resulting

from the consumption of an excess quantity of food, and
hence energy excess over an extended period of time.

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Four major forms of malnutrition

• Protein Energy Malnutrition (PEM )

• Iron Deficiency Anemia (IDA)

• Vitamin A Deficiency (Vi, A. D)

• Iodine Diets Deficiency (IDD)

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 Assessment of Nutritional Status

1. Nutritional Hx & Dietary measurement:

• Hx of breast feeding (frequency, day & night ?),
• Total duration of breast feeding,
• Any additional food (when was it started? If cow’s milk is
used, is it diluted/not?),
• Amount, frequency, & type of additional food.
Nutritional hx should continue until present age.
• Dietary measurement
• measuring the diets the child is getting,
• referring to the reference diet .

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 ASSESSING CHILD N.....cont’d
2. Biochemical measurements
• Involves measurement of a nutrient or its metabolites in
reselected biological material (blood, body fluids, urine)
E.g . Serum ferritin level
• Serum HDL
• Erythrocyte folate
• Tissue store of vit A, and D
3. Clinical methods
• Used to detect deviations from normal state of nutrition
(by observation and interpretation of clinical data- sign
and symptom)
• E.g. PEM (especially sever PEM)
• Marasmus
• Kwashiorkor 70
70
4. Anthropometric Measurement

• Weight
• height/length
• MUAC
• Head Circumference, & skin fold thickness (SFT).

71
By:-Fike, Feb, 2013
a. WEIGHT FOR AGE /Underweight/
• assess the acute and chronic malnutrition.
• It is good for ongoing monitoring
• And sensitive to small changes single instrument is used
• Accurate age is required

72
By:-Fike, Feb, 2013
B. HEIGHT FOR AGE /Stunting/
•Detect chronic malnutrition
•Because height is affected very slowly
•It is not concerned about acute malnutrition.
•Relays on accurate age
C. WEIGHT FOR HEIGHT /Wasting/
Shows recent nutritional status
No age data is required

73
By:-Fike, Feb, 2013
Arm circumference :- ( 1-5 yrs)

• AIM of measuring:-

1. Helps to diagnose malnutrition in quick way of children

2. Helps to assess nutritional status of the community

Degree of malnutrition: - In related to arm circumference
Measurement

a. MUAC = less than 11.5cm indicate severe Malnutrition

b. MUAC = b/n 12.cm & 14 cm indicate moderate malnutrition

c. MUAC = above 14cm is normal.

74
 Normal feedings patterns:
The main rule for feedings children
• Only breast milk during the first 6 months start adding porridge at 6
months.
• Add some protein to every meal after 6months of age.
• Plain porridge is not enough for more than a few weeks.
• Add fruits and vegetable to at least one meal every day start when the
child is 6 months old.
• Give a child at least three meals /day. Infants may require four to six
small ones.
• Continue breast feeding until the child is able to manage on other foods
probably this will be at 18-24 months of age.
• Use the common local carbohydrate food and add a suitable protein
food.
• Prepare balanced meals. Make sure that the added protein is well mixed
with the staple
• Carbohydrate food and that both are given in a suitable amount.
75
Feeding during the second 6 month of life
• By 6 month of age infants capacity to
―Digest and absorb a variety of dietary components
―Metabolize, utilize and excrete the absorbed
products of digestion is near adult capacity
―Teeth are beginning to erupt
―Begin to explore his surrounding
• Addition of other foods is recommended ( weaning)
• Complementary foods – additional foods including
formulas, given to breast fed infants
• Replacement foods – foods other than formula given
to formula fed infants
76
 Feeding during…

• Weaning should be stepwise to both breast fed and

formula fed infants
oCereals, a good source of iron, usually should be the first
food
oVegetable and fruits are introduced next
oMeats follows shortly and finally eggs
oOne new food should be introduced at a time
oAdditional new foods should be spaced by 3-4 days
oAdverse reactions (families with food or other allergies)

77
 Feeding during…

• Either home prepared or manufactured complementary

foods can be used
• The latter are more convenient and likely to contain less salt
– have supplemental nutrients ( eg Iron)
• Egg containing products should be delayed
• Food should be served 3 -5 time per day including night
• With this most infants receive adequate nutrients

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By:-Fike, Feb, 2013
 IMPORTANT PRINCIPLES FOR WEANING
• Begin at 4-6 month of age
• At the proper age, encourage a cup than a bottle
• Introduce 1 food at a time
• Energy density should exceed that of breast milk
• Iron-containing foods (meat, iron-supplemented cereals)
are required
• Zinc intake should be encouraged with foods such as meat,
dairy products, wheat, and rice
• Breast milk should continue to 18-24 mo, formula or cow's
milk is then substituted.
• Fluids other than breast milk, formula, and water should be
discouraged.

79
 Feeding problems during the 1st year of life
• Underfeeding
• Suggested by restlessness and crying
• Failure to gain wt
• Possible causes
Check frequency of feeding, mechanics of feeding
Abnormal mother infant bonding
Possible systemic disease
• Rx – instructing mother about the art of BF and
psychological support
- specific management of systemic illnesses

80
 Feeding problems…

• Overfeeding
―Regurgitation and vomiting
Reg. –return of small amount of swallowed food
Vomiting – more complete emptying of stomach
―Too high in fat – delay in gastric emptying, cause
distention and abdominal Discomfort,
―Too high in CHT- distention and flatulence
• Loose stools
• Milk stool – loose, greenish yellow containing mucus
with freq. of 6-8 times/24hrs
• All diarrhea - infectious

81
 Feeding problems…
• Colic – infantile colic
―Common in infants younger than 3 month
―The attack usually begins suddenly with a loud
continuous cry
―Etiology is not usually apparent
―Holding the infant upside helps and burping
―Occasionally sedation for prolonged attack

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By:-Fike, Feb, 2013
 Feeding during the 2nd year of life
• By the end of 1st year- 3 meals a day plus 1-2 snacks
• Changes in eating behavior
―Reduced food intake –rate of growth declines
―Lack of interest in food – temporary
―Never force feed
―Self selection of diets – should be respected
―Self feeding by infant
• Basic daily diets
―Grains, fruits, vegetables, meats and dairy products-balanced
diet with
―Snacks between meals- orange or other fruit juice with biscuit
―Vegetarian diet – vitamin B12 and trace mineral deficiency

83
 Feeding during later childhood
• After the age of 2 years
• The child's diet – the same as family diet
• Emphasis on grains, fruits, and vegetables
―Restriction of dietary fat to 30% of total energy
―Saturated fatty acid -< than 10%
―Cholesterol – not more than 100mg/1000kcal
―Poly unsaturated fatty acid -7-8% of energy
―Unsaturated fatty acid – 12-13% of energy
• Such diet support normal growth of children

84
Formula feeding

Formula Feeding

85
By:-Fike, Feb, 2013
 ?What is formula feeding

It is a food product designed to provide the nutritional

. needs of newborns & infants

86
By:-Fike, Feb, 2013
:Reasons for choosing formula-feeding include

.There is an inadequate supply of maternal breast milk-1

.The baby is sucking inefficiently-2
Some parents want to know exactly how much their baby -3
is receiving at each feeding, and formula/bottle-feeding
.allows exact measurement
To avoid the transferring of certain drugs from the mother -4
.through the breast milk to the infant
A practical alternative for mothers who may not be able to-5
.breastfeed due to work schedules
.Death of the mother-6
.Institutions-7
.Infant's metabolic disorders-8 87
:The types of formula feeding
A-Complementary feeding: (each feed) breast is given
1st until it is emptied then formula is given to complete
.the feeding

B- Supplementary feeding: formula is given to

.substitute one or more feeds

.C-Substitutive feeding: no breast feeding ,formula only

88
By:-Fike, Feb, 2013
 :Forms of formula
:Formulas come in three basic forms
Ready-to-use formula no mixing or measuring required,-1
just open and serve recycle all of the cans or bottles. Once
opened, it must be used within 48 hours.
2-Liquid concentrate formula requires you to mix equal
parts of water and formula, so read the instructions on
the container carefully.
3-Powdered formula. is the most economical choice, and
you must follow the directions exactly, but it has a one-
.month shelf life after the container has been opened
89
By:-Fike, Feb, 2013
 Types of formula
.There's a formula to suit every baby's needs

Cow's-milk-based formula: Most formula available-1

2-Soy-based formula: If the baby has trouble
digesting cow's milk protein
Lactose-free formula: If the baby is lactose-intolerant, or unable-3
to digest lactose. The doctor may suggest this formula if the baby
.has colic

90
By:-Fike, Feb, 2013
:Extensively hydrolyzed formula-4

In these formulas, the protein is broken down into smaller parts that
.are easier for the baby to digest than larger protein molecules
The baby may need a hydrolyzed formula if he has allergies or
.trouble absorbing nutrients
The doctor may also suggest trying a hydrolyzed formula if the baby
.colic has

:Formulas for premature and low-birth-weight babies-5

.These formulas often contain more calories and protein

91
:Human milk fortifier-6
This product is used to enrich the nutrition of breastfed babies
.who have special needs
Some are designed to be mixed with breast milk, and some
.can also be fed alternately with breast milk

: Iron Fortification -7
Proper level of iron-fortification is necessary for normal
.infant growth and cognitive development

92
By:-Fike, Feb, 2013
There are six main ingredients in formula:

1-Carbohydrate.
2-Protein.
3-Minerals.
4- Fat.
5- Vitamin.
6- & other nutrients.

93
By:-Fike, Feb, 2013
 The advantages
1-Formula-fed babies often need to eat less frequently than
do breastfed babies because breast milk moves through
the digestive system more quickly. Thus, breastfed babies
may become hungry more frequently.
2-A The entire family can involved in all aspects of the baby's
care, including feedings. The mother can therefore get
more rest.
3-Allows exact measurement of how much of food the baby is
receiving at each feeding.
4-The mother does need not to care about what she eating.

94
The dis-advantages:
1. The formulas are expensive.
2.The lack of maternal infection-fighting antibodies that are
in breast milk treatment that the baby will get sick easily.
3.No formula can exactly duplicate the ideal composition of
breast milk
4.The formula may will be difficult to digest.

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By:-Fike, Feb, 2013
Definition of complementary feeding E-se

•Complementary feeding means giving other foods in

addition to breast milk
•These other foods are called complementary foods

96
By:-Fike, Feb, 2013
 Energy required by age and the amount
supplied from breast milk
1000 Energy Gap

800
Energy (kcal/day)

600

Energy from
400 breast milk

200

0
0-2 m 3-5 m 6-8 m 9-11 m 12-23 m
Age (months)
97
Key Message 1

• Breastfeeding for two years or longer helps a child

to develop and grow strong and healthy

98
Key Message 2

• Starting other foods in

addition to breast milk at 6
completed months helps a
child to grow well

99
 Starting other foods too soon/ Early

•Adding foods too soon may

take the place of breast milk
result in a low nutrient diet
increase risk of illness
oless protective factors
oother foods not as clean
odifficult to digest foods
increase mother’s risk of pregnancy

100
By:-Fike, Feb, 2013
 Starting other foods too late

• Adding foods too late may

•result in child not receiving required nutrients
•slow child’s growth and development
•risk causing deficiencies and malnutrition

101
By:-Fike, Feb, 2013
MALNUTRITION

102
By:-Fike, Feb, 2013
 Protein Energy Malnutrition (PEM)
Introduction
• PEM results when the body’s need for protein, energy or both
cannot be satisfied by diet

• It includes a wide spectrum of C/Ms conditioned by:

• The relative intensity of protein or energy deficiency
• Severity & duration of the deficiencies
• The age of the host
• The cause of the deficiency
• The association with other nutritional or infectious disease
103
 The origin of PEM can be:-
Primary
• Results from inadequate food intake
Secondary
• Results from other diseases that lead to:
• Low food ingestion
• Inadequate nutrient absorption or utilization
• Increased nutritional requirements &/or
• Increased nutrient losses 104
By:-Fike, Feb, 2013
 Etiology
Is multi-factorial
1. Social & Economic factors
• Poverty
• Migrations – rural to urban
• Ignorance – by itself or assted with poverty
• Lack of awareness
• Suboptimal breast feeding practice
• Social problems
•Food taboos, Child abuse, abandonment

105
 Etiology………

2. Biological factors
• Maternal malnutrition
• Infectious diseases  negative protein & energy balance
• Poor food preparation
3. Environmental factors
• Overcrowding &/or unsanitary living  frequent
infections
• Agricultural patterns
• Drought, floods, & war
• Forced migrations
106
 Classification of PEM

I. Welcome classification/Wt for age/

Wt for Age No edema With edema

60 – 80% Under weight Kwashiorkor

<60% Marasmus Marasmic

kwashiorkor

107
 Continued..

Advantage Disadvantage
• Simplicity • If the age of the patient is not
known-difficult to use
• It doesn’t take into consideration the
chronicity of the disease process

108
 II. Gomez classification/wt for age/
• Grade I – 90 -75 percent –mild malnutrition(1st )
• Grade II – 75-60 % -moderate malnutrition (2nd )
• Grade III -< 60 % -severe malnutrition (3rd )

• Drawbacks –
• combines in one number two different kinds of deficit: in
wt for ht and in ht for age
• 90% is too high as well nourished children are labeled
malnourished
• A child can have wasting but not stunting
• A child can have also wasting and stunting
• Doesn’t consider the presence of edema

109
 Classification…
III. Water-low classification/wt for ht & ht for age/

Grade of Wt for ht Ht for age

malnutrition /wasting/ /stunting/
Normal >90% >95%
Mild/ grade-I 81 – 90% 90 – 95%

Moderate/ grade-II 70 – 80% 85 – 89%

Severe /grade-III <70% <85%

110
 Marasmus
• It is deficiency of food in general & energy in particular.
• It can occur in all ages usually in less than 31/2yrs old &
more common in infants(i.e.<1yrs of age)
• Marasmus is 8-10times common than kwashiorkor.
Cause:
• Poor feeding habits
• Infections
• Preterm birth & malabsorption

111
 Clinical manifestations
Marasmus
• Wasting & loss of subcutaneous fat – wizened old man
appearance
• “skin & bone” appearance
• W/A- <60%
• Hair is sparse, thin, dry and easily pulled out
• Skin is dry, thin with little elasticity & wrinkles easily
• Watery diarrhea – common
• Heart rate, BP, & body temperature may be low
• Abdominal distension
• Anorexia - seldom
112
 Normal
hair Alert and
irritable

Severe wasting
Thin, -prominent ribs,
flaccid skin spine, scapulae
hanging in
-Old man face
folds
(baggy
pants)
Source: NutritionWorks 113
 C/m…
Marasmus

•Common complications are

• Acute gastroenteritis, Dehydration
• Hypoglycemia
• Hypothermia
• Respiratory infections
• Eye lesions due to hypovitaminosis A
• Systemic infections  septic shock or IV clotting
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By:-Fike, Feb, 2013
 kwashiorkor
• It is manifestation due to gross deficiency of
protein( essential amino acids) & few deficiency of
calories.
• Usually associated with infection
• Age group: usually between 1 to 3yrs of age
Cause
• Inadequate intake
• Inadequate utilization
• Early cessation of BM
• Exposed to high CHO diet( early weaning).
• Infections like measles & diarrheal disease.
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By:-Fike, Feb, 2013
 Clinical manifestation
Kwashiorkor
Edema
• Soft, painless, pitting /feet, & legs
• Severe – perineum, upper extremity, &
face
Skin lesions: usually present
• Pigmentation, desquamation, ulceration – flaky
paint dermatitis, +/- erythematous, (peeling of
epidermis  infection)
• Affected sites: legs, buttocks, & perineum
• Severe cases – seem burn 116
 Hair -
thinner
and lighter
Apathetic
Moon face and
No appetite miserable

Oedema
(symmetrical
oedema
involving at
Skin least the
lesions feet)
117
Source: NutritionWorks
 Kwash….

• Subcutaneous fat is preserved & Limited muscle

wasting
Mucous membrane
• Angular stomatitis, cheilosis, & smooth tongue
Hair
• Fine, straight, sparse, without its normal sheen &
pulled out easily
• Color changes usually to brown/ red/ gray/
yellowish white
• Flag sign – alternating bands of depigmentation &
normal hair
118
 Kwashiorkor….

Pallor, & cold and cyanotic extrimities

Mental changes
• Irritable, cry easily
• Expression of misery & sadness
GI system
• anorexia, post prandial vomiting & diarrhea
• Fatty infiltration of liver – hepatomegally
with soft rounded edge

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C/m…

Kwash…
• Protruding abdomen due to distended stomach &
intestinal loops
• slow & irregular peristalsis
• Reduced muscle tone & strength
• Tachycardia
• Hypoglycemia, & hypothermia

120
Complications in kwash…
• Similar with marasmus, but

• Diarrhea and infections /respiratory & skin/ are more

frequent & serious

• Severe, fatal infections could occur frequently with out

• Fever, tachycardia, respiratory distress, or
• Appropriate leukocytosis

121
 Complications in kwashiorkor

• Most common causes of death are pulmonary edema with

• Bronchopneumonia
• Septicemia
• Gastroenteritis, and
• Water & electrolyte disturbance

122
 Lab studies
• Tests that might be helpful
• Blood glucose – normal or low
• Hgb, or Hct
• Urine microscopy & culture
• S/E
CxR
• Skin test for tuberculosis
• Blood film
• Serum electrolyte
• Serum protein / albumin
123
Mgt of severe acute malnutrition
• Admission
• Inpatient mgt
I. Phase 1 (acute phase)
II. Transition phase
III. Phase 2 (recovery phase)
• Discharge
• Follow up

124
 Nutritional therapy
oAdmission criteria
• W/H < 70% or
• MUAC - < 11cm with a length 65cm or
• Presence of bilateral edema
oRoutine medicines
• Vitamin A – one capsule on the day of admission and
discharge
• Folic acid – a single dose of 5mg folic acid
• Other nutrients – no need b/c F75 and F100
• Antibiotics – should be given to all
• 1st line treatment – oral amoxicillin (ampicillin)
• 2nd line treatment – Add chloramphenicol or gentamycin
125
 Continued…

• Duration of antibiotic –
• every day during phase I and 4 more days –in patient
• 7 days total in out patient care
• Malaria
• Measles vaccine on the 4th week of treatment
• Deworming – at the start of phase II
• worm medicine is only given children who can walk
• Albendazole 400mg PO STAT
• mebendazole 100mg TWICE DAILY FOR 3 DAYS

126
 Mgt of SAM
Criteria for admission / diagnosis
• Wt for ht - < 70%
• MUAC < 11 cm for a child with length
>65cm or age > 6month
• Bilateral pitting edema (+++)
nutritional origin
• Failed appetite test
• Presence of Medical complications
• No willing / suitable care giver

127
Criteria for admission / diagnosis

128
 Phase - I
1. Nutritional Rx - Feed the patient F75
•provides 75 kcal per 100 ml
•8 feeds per day –larger volume feeding can
result in osmotic diarrhea
•Breast fed children should always be given
BM before the diet
2. Give routine medications
3. Monitor the patient
4. Prevent, diagnose, and• treat complications:-
Infection**
• Hypoglycemia** • Heart failure
• Severe Anemia
• Hypothermia** • Septic shock
• Dehydration** • Electrolyte disturbance 129
 Phase 1……

1. Nutritional Rx – F75
• F75 = 75kcla/100ml
• Has less Na, protein, fat, lower osmolality &
renal solute load than F100
• Is Less energy dense
• Quantities = 100kcal/130ml/kg/day
• Feed by cup or NG tube
130
 F 75:-
Use NG tube when:-
• The child is taking less than 75% of prescribed diet
• Pneumonia with fast breathing
• Painful lesions of the mouth
• Cleft palate or other physical deformity
• Impaired consciousness

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By:-Fike, Feb, 2013
 Phase 1
2. Routine medications
oVitamin A
• On day 1 & 2 of admission when there is:
• Wasting with out edema
• Vitamin A not given in the last 6 months
• For every patient on the day of discharge
• Dosage:
• 6 to 12 months = 100,000 IU
• >12 month = 200,000 IU
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By:-Fike, Feb, 2013
 Phase 1
… Routine medications
oFolic acid - 5mg po single dose
oAntibiotics
• During phase I + 4 days
• 1st line – amoxicillin
• 2nd line – chloramphenicol or gentamycin
oMeasles vaccine if not vaccinated and >6 to 9mth

133
 Monitoring
• Weight - each day

• Degree of edema – each day

• Body temperature – twice per day

• Stool, vomiting, dehydration, cough, respiratory

rate, liver size & tenderness – each day
• MUAC – each week

• Height – after 21 days 134

 Diagnosis & Mgt of Complications:
1. Dehydration:-
• Malnourished children are sensitive to excess Na +
intake
• All signs of dehydration in a normal child occur in a
severely malnourished child who is not dehydrated
• Thus only a history of recent fluid loss & very
recent change in appearance can be used
• Misdiagnosis of dehydration & giving inappropriate
treatment is the commonest cause of death in
severe malnutrition
135
By:-Fike, Feb, 2013
 Rx of dehydration...

• Give 50 -100ml/kg of ReSomal over 12 hours

• 5ml/kg/30min. ReSoMal for 2hours, then
• 5-10ml/kg/hour for 10hours

• Stop rehydration as soon as target weight is reached

• Monitor every hour:-

• The weight, RR, & PR
• The liver edge, marked before any rehydration Rx
• The heart sound
136
 Rx of dehydration…

• Make a major reassessment after two hours, and

1. If there is continued weight loss
• Increase rate of ReSoMal administration by
10ml/kg/hr &
• Reassess in one hour
2. If there is no weight gain
• Increase rate of ReSoMal by 5ml/kg/hr &
• Reassess every hour

137
By:-Fike, Feb, 2013
 Indications for IV rehydration
• Defined signs of dehydrations, &
• Patient has all of the following:-
• Semiconscious / unconscious
• Rapid weak pulse
• Cold hands & feet
• Give 15ml/kg/hour Darrow's solution i.e.
• Ringer lactate with 5% DW, OR
• Half strength saline with 5% DW, AND

138
By:-Fike, Feb, 2013
 Iv rehydration…

• Then reassess the child after an hour & decide

• If improving / weight loss continue for one more hour -
15ml/kg
• If became conscious- oral/ NG tube – ReSoMal
10ml/kg/hr
• If not improving & wt gain – consider septic shock &
stop fluid intake

139
By:-Fike, Feb, 2013
 Treatment of dehydration
Weight

Gain Stable
Loss
Clinically Clinical Not
Improved improved

continue - STOP ALL - Increase - Increase

rehydration fluid ReSoMal: ReSoMal by
Target - Give F75 5ml/kg/hr 10ml/kg/hr
weight - Re-diagnose & - Reassess - Reassess
assess every hr every hr
F75
140
How to diagnose septic shock
Signs of Septic shock present
Fast weak pulse, cold peripheries, pallor,
drowsiness
•No History of recent eyes
sinking
•No history of major fluid loss

Eye-lid drooping/normal or closed Eye-lid retracted or slightly

when asleep/unconscious
open when asleep/ unconscious

Septic shock Septic shock with

Hypoglycaemia
Note: Lid retraction without shock
– treat immediately for hypoglycaemia
141
 How to diagnose and treat Septic Shock

Septic shock
Unconscious/Loosing
Conscious conscious
- Darrow’s solution,
or 1/2 saline & 5% glucose,
or Ringer Lactate & 5% glucose
F 75 by mouth or
at 15ml/kg the first hr
NGT
- Reassess every 10min
- If possible, Blood transfusion: 10ml/kg in
3 hours, without anything else.

- If improving, F-75;
- If conscious, NGT: F75
142
 … Rx of CHF
• Stop all intake of fluids or feeds /oral or IV/
• No fluid or feed should be given until stabilization
( 24 -48 hrs)
• Small amount of sugar water can be given orally
• Give furosemide 1mg/kg/dose – usually not very effective
• Single dose digoxin can be given (5mcg/kg)
• Even if anemic don’t transfuse – heart failure treatment
takes precedence

143
 4. Anemia E-se

• Hgb < 4mg/dl or Hct <12% during the first 48 hours after
admission

• Give 10ml/kg whole blood over 3-4 hours

• All children should be fasted for 3 hours after transfusion

144
By:-Fike, Feb, 2013
 How to Diagnose and Treat Anaemia
Check Hb at admission if any
clinical suspicion of anaemia

-Hb >= 4g/l or - Hb < 4g/l or

-Packed cell vol>=12% - Packed cell vol<12%
-or between 2 and 14
days after admission ONLY during the first 48
hours after admission:
Give 10ml/kg whole or
No acute treatment
packed cells 3hours - No
Iron during phase 2 food for 3 to 5 hrs
145
 4. Hypoglycemia
• Best prevented by regular feeding
• Glucose is preferable because the body can use it more
easily; sucrose must be broken down by the body before it
can be used.
• Often there are no clinical signs at all
• If the child can drink, give the 50 ml bolus orally. If the
child is alert but not drinking, give the 50 ml by NG tube.

146
By:-Fike, Feb, 2013
 Mgt:-
• If conscious give 50ml of 5gm sugar water or F75 by
mouth
• If loosing consciousness 50 ml of 5gm sugar or Dextrose
10% via NG tube
• If unconscious:- sugar via NG tube or glucose as single IV
injection (5ml/kg Dextrose 10%)
• Start 1st & 2nd line antibiotics together
• Reassess after 15min.

147
The table below shows how to reconstitute 50 ml
of 10% glucose from available solutions..

148
 Complications….
5. Hypothermia
• Axillary temperature < 350c, rectal <35.50c
• Severely malnourished children are at greater risk of
hypothermia than other children and need to be kept warm.
• The has not had enough calories to warm the body. If the
chhypothermic child is hypothermic, he is probably also
hypoglycemic.
• Both hypothermia and hypoglycemia are signs that the
child has a serious systemic infection

149
 Hypothermia…

• Nearly all hypothermia is due to low room T0, lack of

cover, or washing
oCheck that the child sleeps with his/her mother - KMC
oThermoneutrate temp. range is 280c – 320c
oDo not wash severely sick child
• Put a hat on the head and wrap the child with the
mother
• Give hot drinks to the mother  warm skin
• Treat for hypoglycemia and
• Start IV antibiotics: 1st & 2nd line

150
By:-Fike, Feb, 2013
 Fever in SAM
• Check if the child is on routine antibiotics
• Most cases are due to high environmental temp
• Treat with sponging with room temperature
• Give extra water to drink
• Do not give antipyretics – aspirin or paracetamol
• These does not work in SAM & liver function is impaired -
poisoning

151
By:-Fike, Feb, 2013
Transition phase
Criteria to progress from phase I to transition phase
• Beginning of loss of edema
• Return of good appetite
• No NG tube, IV line, and
• No Severe medical complications

152
By:-Fike, Feb, 2013
 Transition phase

• Feed the patient in exactly the same way as in phase 1

except that

• F100 (100kcal/100ml) is given instead of F75

• The same volume is given so that energy intake is increased

by 30% & the child starts to gain tissue

• Transition phase should last 1-5 day

• Expected weight gain is 6gm/kg/day

153
 Transition phase……
• Criteria to move back to phase 1 from transition
phase
• Rate of wt gain >10gm/kg/day
• Increasing edema or development of refeeding
edema
• Increase in liver size & tenderness
• Signs of fluid overload, CHF, or respiratory distress
• Development of tense abdominal distension
• If there is sufficient diarrhea to give weight loss
• If complication develops that require IV infusion of
drugs
154
By:-Fike, Feb, 2013
 Phase II
• Criteria to progress from transition phase to phase II
• Good appetite
• At least two days for wasted patients
• Complete loss of edema
• No medical complications/ problems

155
By:-Fike, Feb, 2013
 Phase II

• Medical part of treatment is now complete

• The patients takes large amount of their diet & gain weight
rapidly

• Pt can be undertaken in a nutrition unit /TFC, or take home

therapy

• Give F100 -5 times/day & plus porridge

• Ready to use therapeutic food – Plumpy nut

156
 Phase 2

• Give routine medicines

• Iron sulfate is added to the diet /200mg in 2 liters of F100/
• De-worming:- Mebendazole 100mg po , BID for 03 days
• Vitamin A
• Measles vaccine – on discharge

• If signs of morbidity – return the patient to phase 1

157
 Criteria for discharge
• Wt for ht > 85%

• No edema for 10 days

• Education has been complete

• Immunization is up to date

• Adequate arrangement have been made for follow up

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By:-Fike, Feb, 2013
Out patient Mgt

• Pts with good appetite & no complications are directly

admitted to phase 2 as out patient

• RUTF – ready to use therapeutic food is used for

nutritional treatment

• Need longer time to recover than inpatient Mgt

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By:-Fike, Feb, 2013
 Treatment failure
Primary failure to respond
Criteria Time after
admission
Failure to gain appetite Day 4
Failure to loose edema Day 4
Edema still present Day 10
Failure to enter phase 2 & gain Day 10
>5gm/kg/day
Secondary failure to respond
Failure to gain weight >5gm/kg/day During phase 2
for 03 successive days
160
Infectious disease and systemic disorders

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By:-Fike, Feb, 2013
 I. Tuberculosis
• TB- is a chronic infectious disease caused in most cases by
mycobacterium tuberculosis.
• Almost 1.3 million cases & 450, 000 deaths occur among
children each year by TB
• Tuberculosis in children almost results from primary
infection with mycobacterium tuberculosis, which occurs
after the inhalation of infective droplet nuclei containing
M. tuberculosis
• Tuberculosis in child indicates exposure to an adult with TB

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By:-Fike, Feb, 2013
 Etiology
• Mycobacterium tuberculosis is the most important cause of
tuberculosis disease in humans

• M. bovis may also cause tuberculosis in humans

• 5-10% become active

• Only contagious when active

• Primarily affect lungs but…

oKidneys, Liver, Brain, Bone

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By:-Fike, Feb, 2013
How is TB spread?
• Through the air from person to person by coughing
• Usually attacks lungs
• Two stages
a. Latent TB
• asymptomatic and not contagious
• can take medication to prevent development of
disease
b. Active TB Disease
• May spread to others
• May have abnormal chest x-ray
• Usually have positive skin test

164
 The key risk factors for TB include:
• Household contact with Pulmonary TB case;
• Younger than 5 years;
• HIV infection; and
• Severe malnutrition.

Route of Transmission
• Through an air born spread of droplets containing bacilli
expected by infectious patient and inhaled by health person
• Consumption of raw milk containing M.bovis
• Rarely occurs by direct contact with an infected discharge,

165
 Clinical manifestation
• More than 50% of infants and children with radio
graphically
• Assessed by contact tracing
• Non-productive cough and mild dyspnoea are the
most common symptoms in children/Infants
• Fever, night sweats, anorexia and decreased activity
occur less often
• Difficulty of gaining weight, failure -to- thrive
syndrome
• Localized wheezing or decreased breath sound

166
 Pediatric Tuberculosis Clinical Presentations
Primary pulmonary TB
oTypical
•Primary focus with hilar adenopathy with or
without focal infiltrates, usually mild to moderate
symptoms (could be asymptomatic)
oProgressive primary
•Progression of primary focus to produce extensive
pulmonary infiltrates and cavitation, severe
symptoms resembling pyogenic pneumonia (rare)

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By:-Fike, Feb, 2013
 Diagnosis of TB
Diagnosis of TB involves:
• History and physical examination
• WBC with differential ESR
• Microscopic examination of sputum or gastric aspirate
• Radiological examination (chest x-ray, x-ray of bones etc)
• Culture of organism
• Histo-pathological examination of biopsied tissues
• Tuberculin test
• Children should be strongly suspected of having TB when
they have contact with a known adult case of pulmonary
TB and have clinical signs and symptoms.

168
Clinical Assessment
A. Typical Symptoms
•Cough, especially persistent and non-improving
•Weight loss or failure to gain weight
•Fever and/or night sweats
•Fatigue, reduced playfulness, inactivity

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By:-Fike, Feb, 2013
B. History of Contact
• Close contact with chronic cougher or Smear Positive

• Children usually develop TB within 2 years after exposure and most (90%)
within the first year.
C. Clinical Examination
• Conduct thorough physical examination with special emphasis on weight
measurement (look for weight loss or poor weight gain), fever, signs of
respiratory distress and chest finding.

170
 Clinical assessment….

D. Tuberculin Skin Test

•TST is useful to support a diagnosis of TB in children with
suggestive clinical features who are sputum smear-negative or
who cannot produce sputum.
•At left forearm(reading the result after 48-72hr)
A positive(TST indicates infection:
•Positive in any child if≥ 10 mm, irrespective of BCG
immunization; and also
•Positive if≥ 5 mm in HIV-infected or severely malnourished child.
Caution: a positive TST does not distinguish between TB infection
and active disease.
A negative TST does not exclude TB disease.

171
 E. Bacteriological Confirmation
• All attempts must be made to confirm diagnosis of TB in a
child using whatever specimens and laboratory facilities are
available.
• Appropriate specimens from the suspected sites of
involvement should be obtained for microscopy (if
available, for culture and histopathological examination
too).
• Appropriate clinical samples include sputum, gastric
aspirates and lymph node, fine needle aspiration(FNA) or
other tissue biopsy.

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By:-Fike, Feb, 2013
 Definitions of TB Cases Classifications
A. Smear-positive pulmonary TB (PTB+)
 A patient with at least two initial sputum smear
examinations positive for AFB by direct microscopy,
Or
 A patient with one initial smear examination positive for
AFB by direct microscopy and culture positive,
Or
 A patient with one initial smear examination positive for
AFB by direct microscope and radiographic abnormalities
consistent with active TB as determined by a clinician.

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By:-Fike, Feb, 2013
 Cont’d…
B. Smear-negative pulmonary TB (PTB-)
A patient having symptoms suggestive of TB with at least 3 initial
smear examinations negative for AFB by direct microscopy, And
1.No response to a course of broad-spectrum antibiotics,
And
2.Again three negative smear examinations by direct microscopy, And
3.Radiological abnormalities consistent with pulmonary tuberculosis,
And
4. Decision by a clinician to treat with a full course of anti- tuberculosis
Or
A patient whose diagnosis is based on culture positive for M.
tuberculosis but three initial smear examinations negative by direct
microscopy

174
 Cont’d…
C. Extra-pulmonary TB (EPTB)

TB in organs other than the lungs, proven by one culture-

positive specimen from an extra pulmonary site or histo-
pathological evidence from a biopsy

Or

TB based on strong clinical evidence consistent with active

EPTB and the decision by a clinician to treat with a full
course of anti-TB therapy

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By:-Fike, Feb, 2013
 Classifications of TB Cases in HIV positive
individuals:
A. Smear-positive PTB:

• One sputum smear examination positive for Acid-fast bacilli(AFB)

and

• Laboratory confirmation of HIV infection

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By:-Fike, Feb, 2013
 Cont’d …..
B. Smear-negative PTB:
•At least three sputum specimens negative for AFB, and
•Radiologic abnormalities consistent with active
tuberculosis, and
•Laboratory confirmation of HIV infection, and
•Decision by a clinician to treat with full course of Anti-TB
chemotherapy, or
•A patient with AFB smear-negative sputum which is
culture-positive for Millar TB.

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By:-Fike, Feb, 2013
G. Investigations for Common Forms of Extra
pulmonary TB in Children

178
H. HIV Testing

• HIV counseling and testing is indicated for all TB

patients as part of their routine management.

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By:-Fike, Feb, 2013
180
181
 The Presence of any one of the
followings is diagnostic of TB in a child:

• Radiological picture of miliary pattern

• Histopathologic findings compatible with TB

• Culture positive

• Isolation of organism by AFB

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By:-Fike, Feb, 2013
 Standard Case Definitions and Treatment
Classification of TB in Children
• The standard case definitions of TB in children are similar
to that of adults.

• Treatment classification of childhood TB is the same as

adults: new, previously treated and MDRTB cases.

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By:-Fike, Feb, 2013
 Standardized TB Case Definitions

Case definition by site and result of sputum smear for PTB

1.Smear positive case: At least 2 sputum smears positive

for AFBs or 1 sputum smear positive and CXR
abnormalities consistent with TB.

2.Smear negative case: At least 2 (preferably 3) sputum

smears negative for AFBs and Chest X-ray consistent with
TB.

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By:-Fike, Feb, 2013
 Case definition by previous
treatment
New case (N): a patient who has never taken treatment for
TB or has been on anti-TB treatment for less than one
month.
Relapse(R): a patient who has been declared cured or
treatment completed of any form of TB in the past, but
who reports back to the health service and is found to be
AFB smear-positive or culture positive.
Treatment failure(F): a patient who, while still on
treatment remains smear-positive or comes again sputum
smear-positive 5months or more after starting treatment

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By:-Fike, Feb, 2013
 Case definition.....cont’d

Return after default (D): a patient who has previously been

recorded as defaulted from treatment (completed at least
one month of treatment and interrupted for at least 2
months) and returns to the health service with smear-
positive sputum.
Transfer in (T): a patient registered for treatment in one
district (woreda) and is transferred to another.
Chronic case (C): a patient who remains smear-positive
after completing a supervised re-treatment regimen.
Other (O): a patient who does not easily fit into one of the
above case definition (e.g. a smear-negative PTB who
returns after default)

186
By:-Fike, Feb, 2013
 Treatment of TB
The aims of TB treatment:
•To Cure the TB patient and restore quality of life and
productivity

•To prevent death from active TB or its late effects

•To prevent relapse of TB

•To prevent the development and transmission of drug

resistance

•To decrease TB transmission to others

187
 The requirements for adequate chemotherapy
are therefore:
• An appropriate combination of drugs

• Prescribed in the correct dosage

• Taken regularly by the patient

• For a sufficient period of time

188
 Drugs used for the chemotherapy of
TB
• The drugs used for TB treatment are safe and effective if
properly used.
• First line drugs for the treatment of TB in Ethiopia
include:
• Rifampicin(R)
• Ethambutol (E)
• Isoniazid (H)
• Pyrazinamide (Z)
• Streptomycin (S)

189
The fixed dose combination (FDC) drugs available for
adult and adolescent are the following:
• RHZE 150/75/400/275 mg
• RHZ 150/75/400 mg
• RH 150/75 mg
• EH 400/150mg
These are TB drugs available as loose form:
• Ethambutol 400 mg
• Isoniazid 300 mg
• Streptomycin sulphate vials 1 gm
N.B.: Streptomycin is administered by injection while the other anti-TB drugs are
to be taken orally
All the drugs should be taken together as a single, daily dose, preferably on an
empty stomach.

190
 TB Treatment Categories
New sputum smear positive PTB & seriously ill
I smear-negative & PTB EPTB

Relapse, treatment failure and sputum

II smear positive return after default

New sputum smear negative

III EPTB (less severe forms) & TB in children

Chronic cases
IV
Multi drug resistant 191
 Recommended
Laboratory
Disease site Type of patient treatment
results
category

New CAT I
Relapse CAT II
Treatment after
CAT II
Sputum smear- failure
positive a Previously Treatment after
treated Usually CAT II
Pulmonary default

Chronic or
CAT IV
MDR-TB

Sputum smear-
CAT I or III c
negative b

Extra-
CAT I 192
or III c
pulmonary b
 Notes
• a: if only one sputum sample is positive, then
patient must be referred to a clinician for diagnosis
• b: Pulmonary sputum smear negative patients may
rarely be re-treated, diagnosis should be based on
bacteriological and pathologic evidence
• c: In some countries, CAT I and CAT III are identical
• Every patient should have DOT

193
 Phases of Chemotherapy
The treatment of TB has two phases:
I. Intensive (initial) phase
•This phase consists of treatment with combination of four
drugs for the first 8 weeks for new cases and with
combination of five drugs for the first eight weeks followed
by four drugs for the next four weeks for re-treatment cases.
•It renders the patient non-infectious by rapidly reducing the
load of bacilli in the sputum,
•usually within 2-3 weeks except in case of drug resistance .

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By:-Fike, Feb, 2013
 Phases of Chemotherapy cont’d…
II. Continuation phase
•This phase immediately follows the intensive
phase and is important to ensure cure or
completion of treatment.
•It is necessary in order to prevent relapse after
completion of treatment.
•This phase requires treatment with a combination
of two drugs, to be taken for 4 months for new
cases and treatment with a combination of three
drugs for re-treatment cases for 5months

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By:-Fike, Feb, 2013
 TREATMENT REGIMEN FOR NEW TB CASES
• New TB Patients will be treated with 2RHZE/ 4RH.
Other Previously treated Smear Negative PTB and
EPTB cases (Case definition ‘Other’) who were
previously cured or treatment completed will be
treated with New TB patient regimen.
• This regimen consists of 8 weeks treatment with
Rifampicin, Isoniazid, Pyrazinamide and Ethambutol
during the intensive phase, followed by four months
with Rifampicin and Isoniazid:
• 2RHZE/4RH

196
By:-Fike, Feb, 2013
 Treatment Regimen for Previously
Treated TB Cases
• Previously treated TB cases will be re-treated with 2S(RHZE)
/1(RHZE) / 5 (RH)E
• Defaulted patients coming with smear negative TB, EPTB, or
previously treated patients with unknown treatment outcome
(Case definition ‘Other’) are treated with regimen for previously
treated TB Cases.
• This regimen consists of eight weeks treatment with Streptomycin,
Rifampicin, Isoniazid, Pyrazinamide and Ethambutol followed by
four weeks treatment with Rifampicin, Isoniazid, Pyrazinamide and
Ethambutol during the intensive phase, followed by five months
with Rifampicin, Isoniazid and Ethambutol:
• 2SRHZE/1RHZE/5(RH)E

197
 New patient - 2[HRZE]/ 4[RH]
Duration of Drugs CHILD ADULT
treatment Pre-treatment weight Pre-treatment weight
5-10 kg 11-20 kg 21-30 kg 31-50 kg >50 kg
2 months intensive
phase, {RHZE} ½ tablet 1 2 3 4
daily observed 150/75/400/275
4 months continuation
phase, daily observed {RH} ½ tablet 1 2 3 4
OR 150/75
6 months
continuation, monthly
supply, self {EH} ¼ tablet ½ 1 2 2
administered 400/150

198
Previously treated - 2S(RHZE)/1(RHZE) / 5(RH)E
Duration of Drugs CHILD ADULT
treatment Pre-treatment weight Pre-treatment weight
5-10 kg 11-20 kg 21-30 kg 31-50 kg >50 kg
2 months S
intensive phase, i.m 15 15 mg/kg 500 mg 750 mg 1 g*
daily observed mg/kg
{RHZE} ½ tablet 1 2 3 4
150/75/400/275
1 month
intensive phase, {RHZE} ½ tablet 1 2 3 4
daily observed 150/75/400/275
5 months {RH} ½ tablet 1 2 3 4
continuation 150/150**
phase, 3 weekly E 400 ¼ tablet ½ 1 ½** 3** 4**
observation
199
 Prevention
• Adult case finding and treatment

• Chemoprophylaxis

• BCG vaccination

• Adequate nutrition

• General public health measures aimed at improving

hygiene and housing

200
By:-Fike, Feb, 2013
 MDR TB
• Mono Resistance: Resistance to a single 1st line drug
• Poly-Resistance: Resistance to more than one drug other
than Rifampicin and Isoniazid together
• Multi-Drug Resistance (MDR): Resistance to at least
Isoniazid and Rifampicin
• Extensive Drug Resistance (XDR-TB): MDR plus Resistance
to:
• A fluoroquinolone : Ciprofloxacin,Ofloxacin,
Levofloxacin, Moxifloxacin, Gatifloxacin, etc. and
• One or more of the following injectable agents:
Kanamycin, Amikacin, capreomycin, Viomycin
• Complete drug resistance (CDR): resistance to all man
made Anti TB drugs
201
 MDR TB

• 440,000 new cases of MDR-TB each year globally, with

>150,000 deaths
• Accounts for 5% of 9 million new cases of TB
• Around 40,000 XDR-TB cases emerge every year
• Ethiopia ranks15th out of the 27 global MDR-TB priority
countries with estimated 5825 MDRTB cases in 2006
• Ethiopian DRS (2003-2005/6):Proportion of MDR-TB is
1.6% and 11.8% among new and re-treatment cases
respectively.
• MDR TB is a man made treatment complication.
202
Thanks a lot !!!!!

PEACE FOR
ETHIOPIA !!
203