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K 'A- ' K
V
THE ROSS
INSTITUTE
INFORMATION AND
ADVISORY SERVICE
BULLETIN No. 12
JUNE 1974
PROTEIN CALORIE
MALNUTRITION
IN CHILDREN
Published by THE ROSS INSTITUTE
THE LONDON SCHOOL OF HYGIENE AND TROPICAL MEDICINE
Keppel Street (Gower Street), London, WC1E 7HT
Contents
I.
DESCRIPTION AND DIAGNOSIS
2.
CAUSES
3-
PREVENTION
4-
TREATMENT
Mild Cases
13
Severe Cases
15
.4 ppendices
■
la
Milk Diets
b
Preparation and Dosage
c
Recipe Chart
II
Alternative Diets
III
Tube Feeding
IV
Solutions
25
V
Paediatric Diet and Requirements
25
VI
Recipes
26
VII
Nutrient Contents
27
21
25.
VIII Bottle Feeding
28
IX
Weight Chart
29
X
Feeding Schedule
30
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32
'pCCUPM’-O'’*’. H“n
FOREWORD
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Protein-calorie malnutrition is one of the most widespread and serious
childhood diseases in developing countries. It brings much misery, sick
ness and death—yet it is easily preventable by good feeding. It is hoped
that this booklet may help nurses and other medical workers (especially
those in rural areas) successfully to prevent and to treat this disease.
This booklet is produced by Dr. H. J. L. Burgess and his wife, both
of '.'.bom worked on nutrition in Uganda for six years. For the last five
■ : s Dr. Bn >c;.s has been WHO nutrition consultant for Eastern and
' >1 Africa i countries. They write from extensive experience and with
•ithority an the subject and have made their advice as practical as
. A'e are grateful to them for granting us permission to reproduce
th
.!■■■ ns one of the Ross Institute’s Bulletins.
The .Authors wish to acknowledge their indebtedness to the publica
tions and comments of the late Professor Dean, Professor Jelliffe, Dr.
Wharton, Dr. Morley, Miss Rutishauser and many doctors and nurses
in the missions, Government Service and research units in East Africa.
Mrs. Goodwin assisted in the production of the booklet, and Fran Powell
with the drawings.
Prof. L. J. Bruce-Chwatt
Director, Ross Institute
Dr. O. J. S. Macdonald
Assistant Director, Ross Institute
London
September 1969.
3
THE ROSS INSTITUTE INFORMATION
ADVISORY SERVICE
AND
Reprinted June, 1974
{Originally issued October, 1969; Revised August, 1970)
Bulletin No. 12
PROTEIN CALORIE MALNUTRITION IN CHILDREN
i DESCRIPTION AND DIAGNOSIS
A malnourished child may lack either adequate food or the right kind
of food or both. This lack, if continued, may lead to protein-calorie
malnutrition (PCM).* PCM is a disease that is most common between the
ages of 6 months and 4 years. Severe cases are often fatal.
Poorly nourished children have a lowered resistance to infections. An
infection is likely to precipitate such a child into severe PCM.
Common diseases such as respiratory infections, malaria, anaemia,
tuberculosis, gastroenteritis and measles are much more likely to be fatal
among malnourished than well nourished children.
PCM is not only the direct or indirect cause of death among
many little African children. If it does not kill it may leave the child
both physically and mentally backward all its life.
Although there are two distinct forms of the disease—marasmus and
kwashiorkor—the majority of cases seen in medical units will show signs
of both forms. It is, however, often possible to classify them as predomin
antly one form or the other.
SIGNS OF PROTEIN CALORIE MALNUTRITION
Sign
Growth failure
Muscle wasting
Fat wasting
Oedema
(puffiness)
Serum protein
Marasmus
Marked, usually very
low weight for age.
Marked, best seen or
felt on upper arm.
Marked, severe cases
look like little old
men.
None.
Low in severe cases.
Kwashiorkor
Marked, sometimes con
cealed by oedema.
Quite marked, sometimes
hidden by oedema and
fat. Better felt than seen.
Fat usually retained.
Most common in feet,
lower legs and often on
hands, lower back and
face. Can be detected by
pressing thumb on shin
for 5 seconds to see if a
dent is left.
Always low.
'Sometimes referred to as protein-calorie deficiency (PCD).
4
Hair changes
Sometimes soft and
straight.
Often normal.
Skin
Appetite and bebchaviour
Loose stools due
to poor digestion
Infective diarrhoea
and dehydration
Moderate anaemia
Liver size
Vitamin
cies
deficien
Often hungry and
alert and anxious
looking.
Sometimes. (May
complain of constipa
tion.)
Sometimes.
Sometimes.
Normal.
Sometimes present.
Usually soft, fair, straight
and easily pulled out.
Sometimes pale skin most
obvious on face. Some
times ‘flaky paint rash’
—dark patches of skin
that peel off leaving light
coloured skin or ulcera
tion underneath.
Usually poor appetite,
miserable, feeble whin
ing cry.
Often.
Often.
Sometimes.
Often enlarged due to
accumulation of fat.
Usually present.
B
Marasmus
(Medical Research Council, Child Nutrition Unit, Kainpala)
Many cases will show features of both these extremes.
Diagnosis
The signs just given make it easy to reeognisc severe PCM.
Mikl PCM or undernutrition is much more difficult to diagnose.
Oedema may be absent or minimal, and muscle wasting not easy to detect
clinically. However, growth failure—best measured by failure to gain
weight, or weight loss—is a constant feature of all degrees of PCM. It
can be best detected by serial follow-ups, and is the reason why all chib.'i n
should be routinely weighed each month at clinics and, if possi’.T .
weights plotted on individual charts. If comparison with a recent
weight is not possible, the child’s weight should be compare.
standard weight for its age (see p. 29). This will usually e
:
questioning of the parents to determine the age to the nearest n ■
.
rough guide it may be taken that children who weigh less th . ..
standard should be carefully examined, their parents advisee
progress closely watched, while those below 6o°o must bn see:.
To distinguish kwashiorkor from hookworm raflnephritis
In nephritis and sometimes in heavy hookworm inf.cd, . ■ . .
oedema but no other signs of kwashiorkor (such as skin or li.dr
In hookworm infection the stools contain a very large number
worm ova, and in nephritis the urine contains albumin and thtt
.
ascites (i.e. the accumulation of fluid in the abdominal cavity).
2
.
CAUSES OF PROTEIN CALORIE MAI,NUTRIT:
PCM occurs when the amounts of nutrients eaten at. not
sufficient to satisfy the child’s nutritional requirements.
If the child does not consume its requirements of protein and calories
marasmus results, while if mainly protein is inadequate kwashiorkor occurs.
A. The following increase a child’s re
quirements:
(i) The first is GROWTH. As they get
bigger their requirements increase (see
p. 25). That is why breast-fed babies
grow well until they are about 5 months
old. Breast milk supplies all the nutri
ents they need. But after 5-6 months
they outgrow the supply of breast-milk
nutrients, and additional food must be
given.
Because many children are not given
enough foods to cover their increase in
requirements of protein, calories, min
erals or vitamins they become mal
nourished.
(ii) Worms and other parasites may con
sume some of the child’s food. There
fore the child needs extra food to have
enough for itself.
6
An infected child is feverish, it burns up calorics and uses protein
to fight the infection. Therefore its nutritional requirements rise.
Common infections amongst children arc respiratory infections,
measles, malaria, gastro-entcritis, whooping cough and tubercu
losis.
B. The reasons for an inadequate food intake are various:
(i) The child may not be given enough to eat because of:—
(a) Food habits. Traditional diets arc often high in carbohydrate
and low in protein, fat and sometimes vitamins and minerals,
and therefore do not provide enough nutrients for small
children. Some people believe that certain foods such as fish
or eggs will harm their children; others restrict food when a
child is ill. Breast milk is usually withdrawn abruptly and not
replaced by other protein-rich foods.
(b) . ack of knowledge that a child needs an especially nutritious
diet, and of how to produce, prepare and give such a diet.
c; Poverty—the family may not have enough money to buy
foods like milk or meat, they may not be able to produce
these foods or grow sufficient beans, groundnuts, etc., or
they may have to sell most of what they produce.
(d) Bad neve ideas, such as bottle feeding replacing breast milk,
Cassava replacing cereals, result in the child receiving less
nutrients.
(ii) The child may not eat enough because:—
(a) It has no appetite (i.e. it has anorexia) perhaps because of
illness. Maybe it is unhappy because it has been sent away
from its mother; or it is jealous of a new baby; or its mother
has died; or its mother neglects it or it is upset by trouble at
home.
(b) It is given infrequent bulky meals so that it gets quickly
filled with starchy food and is just unable to cat enough to get
sufficient protein or calorics into its stomach.
(c) It has a sore mouth because of measles, thrush or other
reasons.
(iii) The child may not digest or absorb enough of the food it has
eaten because:—
(a) It has eaten food too hard to be digested properly—foods
like whole beans or maize go straight through.
(b) Diarrhoea that causes some food not to be digested.
(c) Vomiting.
(d) Febrile disease that decrease absorption.
(e) An illness that interferes with metabolism,* e.g. diabetes.
Of course, in many malnourished children more than one of these
things may be the cause of PCM. In almost all severe cases there is a historjof illness or emotional stress as well as an inadequate diet.
(iii)
♦Metabolism is the total of the physical and chemical processes which convert
simpler compounds in the body into living organised substance.
7
Thus children aged 6 months to 4 years are the most likely to become
malnourished because of their high requirements for growth, because the
traditional diet is usually bulky with a low protein content and because they
have not yet acquired immunity to many infections.
Babies who cannot be breast fed are often undernourished because
they are not given enough milk and have gastro-enteritis due to the
unhygienic preparation of their feeds (see p. 28).
SOME CAUSES OF PCM
Some of the things that might cause this child to become ma nc
Poor Feeding
Habits e.g.
no eggs
poverty
no fish
Infrequent mainly
starchy meals
Bad new
ideas e . g Weak,dirty
milk
Malaria
Infection
Worms
Deprived
of mother
Infections
New babyno appetite .
No breast
milk.
8
3
PREVENTION
Anyone seeing the misery of a malnourished child will want not only
to cure that child, but to prevent other children getting the same disease.
PCM can, and has been, prevented by:—
A.
National measures
Improving the food supply. The best encouragement to grow more
food comes from making available better seeds, fertilisers and
knowledge of improved techniques, providing easily accessible
markets and ensuring fair prices.
(ii) Improving the economic level so that people have more money to
buy foods.
' '■ Improving the general level of education so that people more easily
■maerstand the value of what they are taught.
; improving the medical facilities, particularly those concerned with
'. jventive medicine.
■ : most the practical health workers in the field can do about these
.1’ measures is to bring the problems they see to the notice of their
supt .iors and to the leaders of the community amongst whom they are
working.
I lowever, there is a great deal these workers can do immediately
themselves.
(i)
B.
Local measures
(i)
Nutritional and health education is of great importance and every
health worker, whatever his or her job, must also be an educator.
Health education does not mean just standing up at a clinic
and giving a lecture—it means using every possible opportunity
to influence people so they want to improve their habits, and
providing them with the knowledge they need to make this
change.
A health worker cannot be a good educator unless he or she
knows the local customs and beliefs of the people and can give
practical advice that will be accepted by them. You must adapt
new ideas to suit the local way of life. I f people do not follow your
advice, the fault is yours not theirs.
It is important to talk over nutritional problems with your
colleagues in the health, agricultural, educational and community
development departments so you may work out sensible solutions
to the problem and all teach the same things.
It is impossible in a small booklet to discuss in detail how
this education can be done, but some ideas are given below:—
(a) Whom you can influence will vary with the position you hold,
but remember that you will have more effect if you persuade
the leaders of the people to improve their feeding habits
because other people are likely to follow them.
9
Another important group to educate are schoolchildren
as they are the parents of the future. Parents—fathers as well
as mothers—of malnourished children need advice as part of
the treatment of these children. A parent who is convinced
that his child has recovered because of good feeding will tell
his friends and therefore be an educator himself.
(b) How you try to persuade people to improve their ft’
habits will depend on whom you arc teaching
'
facilities you have.
The following suggestions might give some i
—Set a good example yourself so that people cop
<■,.
—Discussions led by the educator during
nutritional problems, habits and possible s-?‘
proposed.
—Cooking demonstrations of local, cheap ft ■
utensils.
—Demonstrations on how to feed children at nw t
people in your audience to help you.
—Display of local foods on a notice board or tab1
be used in clinics, wards or schools.
—Individual advice to parents or patients when c;..
treating or feeding them.
—Telling a story that is illustrated with big pictures on a
flip-board or fiannelgraph.
Cooking demonstration
10
(c)
What you teach will vary with the local problems and the
local foods and feeding habits. Here are some things that
might be taught in your area.
■—‘Foods for Growth’ are:
Eggs
All kinds of milk
Meats
Pulses
Oil Seeds
Groundnuts
—Encourage breast feeding as the best and natural way to feed
a baby. Do not confuse mothers with schedules. The baby
will cry when it is hungry and that is when it needs food,
whether it be day or night. Most mothers know how to breast
feed their babies.
—Discourage bottle feeding. There are few homes where
bottles can be kept safely clean or which can afford to buy
sufficient milk (see p. 28).
An orphan is a child at risk and its guardians need your
help and encouragement to care for it successfully. Try to
arrange for a foster mother to breast feed it or teach an
intelligent relative how to spoon feed it until it is old enough
to drink from a cup.
—Show how to introduce soft, clean foods such as gruel with
added protein foods at 4-5 months using a cup and spoon.
The child should be accustomed to these foods by the time
it is 6 months old, at w’hich age breast milk is insufficient to
cover its nutrient requirements.
■—Show how to prepare protein-rich foods such as mashed
beans, pounded groundnuts, fish flesh, scraped meat,
mashed green leaves in a local way that is suitable for small
children.
11
—Explain how to wean the child from the breast gradually
when it is 1I-2 years old, while at the same time giving it
extra protein foods.
-—Show how to put the children’s portion of good foods such
as meat, beans and green leaves on their own plates so that
they get a large share.
■—Encourage parents to get their children immunised against
infectious diseases.
Immunisation prevents disease
(ii)
Improvement of preventive health services such as immunisation,
control of worms and malaria, ante and post-natal and child care
services means that the children are less likely to get ill, and this
removes one of the stresses that can cause severe PCM.
(iii)
Distribution of protein-rich food supplements such as dried milk
to underweight children. This will only be effective if regular
quantities are given out, but it may encourage attendance at
clinics where health education can be given and progress watched
so that growth failure and illnesses are detected early.
12
Regular weighing detects growth failure early
Milk should never be given out to breast-fed babies unless
they are definitely malnourished, as this may encourage bottle
feeding. It should only be given out to children as a preventive
measure if there is ample left for the treatment of both severe
and mild cases.
4
TREATMENT
The aims of treatment are to:—
(i)
(ii)
(iii)
A.
supply what has been lacking in the diet
prevent and treat infections and other diseases
teach parents how to prevent a relapse
MILD CASES
—Explain to the parents that their child is ill because it has not
been having enough of the foods that build its body.
13
—If possible ask the mother to come with the child into the ward
for a short period (about five days) so that treatment can be
started and the child’s improvement seen by the mother. In this
way she may be convinced that she must continue feeding her
child well when she goes home.
—If admission is not possible, discuss with the mother what
protein-rich foods she can give her child and explain the import
ance of this. You can keep some local protein-rich foods such as
eggs, beans, etc., on your table as examples.
—If available give the mother a protein-rich food such as dried
milk and instructions on how to use it.
The amount given will depend on supplies, and the age and
condition of the child, but a useful amount is:—
1-1} lb (J kg) a week or roughly a 4.1 lb bag (2 kg) a month.
The child should have about two large spoonfuls (1 oz28-35 g) two or three times a day (20-30 g protein a day).
Dried milk should be mixed with gruel or sauce. It should not be
mixed with water as dangerous bacteria grow in it very easily
(see p. 28).
It is a good idea to write down for parents how to use high
protein foods using local measures. Even if the mother cannot
read, someone else in the family often can.
—Treat any other illness the child may have such as malaria,
diarrhoea, tuberculosis, or worms.
—Tell the parents to bring the child back to the clinic frequently.
—If a baby under 6 months is malnourished encourage the mother
to increase her own breast milk by telling her to drink a lot and
eat protein-rich foods. If you have plenty of dried milk give her
some to mix into her own food—warn her that it is dangerous to
give it to the baby in a bottle (see p. 28).
—If a small baby is urgently in need of additional food (supplemen
tation) try to admit it and its mother or foster mother to the
hospital so that it is given clean, adequate feeds; so that breast
feeding can be got going properly and so that the mother learns
how to give extra feeds at home using a cup and spoon.
—Although there is usually little time for home visiting, it is well
worth going into the homes of a few cases as you will learn a lot
about the problems facing parents and so be able to give more
practical advice.
14
B.
SEVERE CASES
Children with severe muscle wasting, much oedema, marked skin
changes, misery or dehydration must be admitted with their mothers
as emergencies.
Severe PCM is a dangerous and often fatal disease. Good
nursing is an essential part of treatment and can save the lives of
many of these little children.
(i) Diet
This is the most important part of treatment and should provide
about 2 g protein/lb (4g/kg) body weight every day. Cases of kwashiorkor
need 50 calories/lb (too cals/kg) body weight while cases of marasmus
need about too cals/lb/day. (See p. 21 for some suitable diets.)
Diets containing Casilan* are the best for treating PCM and are
unlikely to cause loose stools, but they are expensive and should be kept
for the severest cases or those with persistent diarrhoea.
Reinforced milk (dried skim milk/sugar/oil) can be used as a routine
diet for most cases of PCM and for all undernourished children in the
ward.
Electrolytes should be given to those children on Casilan diets w'ho
arc not eating other food and to all those with diarrhoea. A suitable
solution is given on p. 25.
Vitamins should be given until the child is having the full ward diet
as its stores are likely to be low.
Give:
ABIDECf
0-3 mis daily or 0-6 mis alternate days.
Folic Acid
1’0 mg daily or 5 mg per week.
Dosage
All but dehydrated children should be fed the milk diet at the rate
of 2 fl oz/lb (120 mls/kg) body weight. Kwashiorkor cases will consume less
than marasmics. The total quantity should be divided into 6-8 feeds given
every two to three hours. Severe cases should be fed regularly at night to
prevent hypoglycaemia. Marasmics and recovering kwashiorkor cases
should be given the protein-rich foods from the ward diet after their
milk feeds.
In practice it will be found that most cases need and can consume
about 2 pints (1 litre) of milk diet each day.
•Casilan (Glaxo) a roller dried whole protein powder containing all essential
amino-acids. Contains 90% of protein, sodium content is less than o-r%.
fABIDEC—a proprietary polyvitamin preparation (Parke Davis & Co.). A solution
containing in each 0-6 ml Vitamin A 5000 units, Vitamin D 1000 units, aneurine
hydrochloride l mg, riboflavinc 0-4 mg, nicotinamide 5 mg, ascorbic acid 25 mg,
and pyridoxine hydrochloride 0-5 mg.
15
For children with diarrhoea, vomiting or dehydration see p. 17.
Preparation (see p. 21)
Great care must be taken to ensure absolute cleanliness of the
ingredients and utensils (and the nurses’ hands). Milk feeds should be
prepared immediately before use. If a refrigerator is available, the amount
for the whole day can be prepared, the portion needed at each feed being
taken out only a few minutes before use. Liquid milk can easily carry
infections in a ward and these may quicklv kill a malnourished child.
Method offeeding
Most children can be fed with a cup and spoon. The best person to do
this is the mother who must be taught that on\y food can cure her child,
and be shown how to feed it.
If the child refuses food, has difficulty in breathing or heart failure,
feed by intragastric tube (see p. 23), preferably using a drip which allows
the child to be continuously nourished without effort and which saves
the nurse’s time. The mother can be shown how to watch the drip.
(ii) General Care
After a good diet the thing the malnourished child needs most is
the constant love and care of its mother. Its mother will make it feel less
frightened and lonely, and this will help it eat better and recover faster.
Its mother will have time to keep it clean if it has diarrhoea and, most
important, time to play with it and carry it around and thus reduce the risk
of hypostatic pneumonia.
16
Time spent by the nurse in teaching mothers how to nurse their
children will save her work in the long run.
Malnourished children cannot always maintain their body temperature
and temperatures below 97°F (36°C) can be fatal. This is most likely to
occur in places where the nights are cold, and among very small or
underweight children. It is therefore important to keep the children warm
by allowing them to sleep with their mothers and by keeping them warmly
covered. In severe cases use heated cots or frames (as for premature babies),
check temperatures every three hours with a thermometer before feeding,
feed hourly and do not bath.
(iii)
Management of Accompanying Conditions
Dehydration. Cases of PCM, even those with oedema, are quite often
dehydrated on admission. This is an emergency and must be dealt
with immediately. The principle is to replace most of the lost fluid by a
route (oral, intraperitonal or intravenous) appropriate to the severity of
dehydration in the first twenty-four hours, and thereafter to supply normal
daily requirements plus the replacement of any further loss by diarrhoea
and vomiting. Half strengthDarrow’s solution (sec p.25) in 2-5% glucose is
one of the most useful replacement fluids. For details on quantities and
methods consult ‘Medical Care in Developing Countries’* Chapters 15-6
and 30-2.
Diarrhoea. Loose stools which are non-infectious often accompany
PCM. Even without dehydration there will have been some loss of salts
and it is important to add the 15 mis (A fl oz) of electrolyte solution to each
pint of any fluid being used. If the loose stools do not improve within
forty-eight hours, change to the Casilan diet. This has a lower content of
lactose which some children cannot digest well. The feeds can also be
diluted (not lower than half-strength) for a day or two and then increased
to full strength over two or three days.
*Mcdical Care in Developing Countries. A symposium from Makerere. Edited by
Dr. Maurice King. Oxford University Press, 1966.
17
Most diarrhoeas recover without drugs—those few of infective origin
should be treated with antibiotics, such as tetracycline or chloramphenicol
used with the usual precautions. (Sulphonamides have little effect.)
Anaemia. Protein deficiency causes mild anaemia which will disappear
with good feeding. More severe anaemia may be caused by malaria,
hookworm or lack of iron, folic acid or vitamin B12 and should be treated
accordingly. A haemoglobin of less than jg too ml (34%) often calls for
transfusion.
Treatment of hookworm infection can usually be left until the child
is beginning to recover.
Prevention and treatment of infections. In PCM the normal reactions
to an infection such as rise in temperature may be absent. Therefore in
units with limited diagnostic facilities 400,000 units procaine penicillin
may be given routinely to all severe cases for five days to treat and prevent
any hidden infection. This should not give a false sense of security as many
bacteria arc insensitive. At the slightest sign of infection a broader spectrum
antibiotic effective against Gram negative organisms must be given.
Falsely negative results may be obtained from Heaf testing mal
nourished children. Negative reactors should be retested when recovery
is established.
Routine antimalarials should be given in endemic areas.
(iv)
Danger Signs
Hypothermia (low body temperature)
Hypoglycaemia (low blood sugar) especially with convulsions
and coma
Cardiac failure and pulmonary oedema—always preceded by a
weight increase
Drowsiness
The above signs must be reported immediately as they may lead to
sudden death.
(v)
Recovering Cases
Cases of kwashiorkor who have lost most of their oedema and are
starting to regain weight and appetite, together with all cases of marasmus
should be offered some of the ordinary food. This should consist of the
most nutritious items (e.g. eggs, meat, groundnuts, vegetables and fruits)
and be given in gradually increasing amounts after the child has drunk its
milk diet.
When recovery is fully established the milk feeds can be gradually
decreased and the balance of the dry milk mixed into part of the food—
such as porridge, banana or sauce. Thus the mother learns how to continue
treatment at home.
18
Other nutritious foods, obtainable by the family, such as eggs,
pounded groundnuts, mashed beans, etc. should also be demonstrated.
Children eat best sitting all together with their mothers on a mat or
small chairs. This speeds up serving out and encourages children to eat.
A GOOD DIET IS OF NO USE UNLESS IT IS EATEN
It is cruel to leave a sick child alone trying to feed itself.
Remember that hospital is a strange and frightening place to a little
child, especially if it has no mother to comfort it. Ask all your ward staff
and mothers of other children to help and play with these lonely ones.
Make sure that no child is left alone at visiting hours. Unhappiness slows
down recovery.
(vi) Education of Mothers
There is little point curing malnutrition if the child immediately
goes home to its original poor diet and environment.
The treatment of PCM is not complete until the mother has
been effectively taught how to care for and feed her child when
at home.
Mothers are best taught by seeing their children recovering on a good
diet in hospital and by talks, demonstrations and friendly discussions
explaining the cause, prevention and treatment of the child’s illness.
Daily teaching of the mothers is a routine part of the treatment of mal
nutrition.
19
Nurses should also try to welcome the fathers during visiting hours
and explain to him his child's illness.
Discharge and Follow-up
Before any case of PCM is discharged it should have lost its oedema,
be steadily gaining weight and eating well. Its mother should know how to
feed and care for it at home. A mother often finds it easier to get the
co-operation of her husband if she is given a letter for him, explaining
why the child has been ill and asking him to make sure that the child gets
the body-building foods it needs.
The child should be seen as an out-patient a few times soon after
discharge so that its progress is watched and its mother is reminded how
to feed it. When recovery is complete the child should attend the nearest
children’s clinic.
Try to visit some children in their homes after they have left hospital
so that you can see the kind of utensils, food and problems the parents have.
This will enable you to give more sensible, sympathetic and practical
advice to mothers in the ward.*
(vii)
’’Treatment of Severe Kwashiorkor and Marasmus in Hospital’, East African
Medical Journal, Vol. 45, No. 6, p. 399, 1968.
20
APPENDIX la
MILK DIETS
Recipes for 2 pints of each diet
Reinforced milk— Suitable for all but severest cases or those with
persistent diarrhoea.
oz
Handy measures
Nutrients
Dried skim milk
9 Dsp*
Protein 43 g
41 (120 g)
Sugar
I
2 Dsp
Calories 863
Oil
’1(35 ml) 11 fl oz (42 ml)
’ (5 Dsp)
Water
35 fl oz (1 litre)
(or make up to 2 pints)
2. Casilan skim milk-—very good but expensive
Casilan
8 Dsp
Protein 44 g
’1
Dried skim milk
Calories 1028
’1
3 DsP
Sugar
2 Dsp
’1.
Oil
2.1
3 A 02 (8-5 ml)
(9 Dsp)
Water
35 fl oz (1 litre)
(or make up to 2 pints)
3 Casilan full cream milk—for those units who cannot get dried skim
milk
Casilan
1
Protein 42 g
7 Dsp
Full cream milk
2
6 Dsp
Calories 939
Sugar
1
2 Dsp
Oil
2 fl oz (57 ml)
14
(6 Dsp)
Water
35 fl oz (1 litre)
(or make up to 2 pints)
Dsp = roundcd dessertspoon (of io ml capacity).
Preparation and dosage of milk diets
Preparation
1. Wash hands and scald all utensils in boiling water.
2. Mix together the Casilan (if used), dried milk and sugar in the
quantities needed. Replace lids on containers.
3. Stir in the correct amount of oil and mix well.
COMMUNITY HEALTH CELL
17TFii^t-F-40.0^r•>.
BANGALORE-
...
.
4.
Slowly add enough cooled boiled water to make up to correct volume,
stirring well all the time. (If there are any lumps, strain and mix lumps
with a little of the strained milk.)
5.
Use immediately or store in a refrigerator. If kept in a refrigerator,
remove only the portion required a few minutes before each feed. Do
not give the milk when it is still icy cold.
Dosage
2 fluid ounces (57 ml) per pound body weight each 24 hours given
6-8 times a day every 3-4 hours,
or approximately:—
1 pint (0.5 litre) for child weighing less than 10 lb (5 kg)
2 pints (1 litre) for child weighing 10-20 lb (5-10 kg)
3 pints (1.5 litre) for child weighing 20-30 lb (10-15 kg)
It will be found for the purposes of preparation, that if you assume
that each child will need about 2 pints (1 litre) of diet every 24 hours, you
will provide approximately the right amount for the ward.
APPENDIX Ic
Recipe chart which can be copied out, filled in and pinned in the kitchen
(Fill in from quantities given on page 21)
Quantities needed for:—
2 pints
10 pints
(1 litre)
(5-5 litres)
Diet: e.g. Reinforced Milk
1. Scald utensils
2. Mix together:
Casilan
Dried skim milk
Sugar
Dsp*
Dsp
Dsp
—
9
2
—
45
10
3. Stir in thoroughly:
Oil
fl oz
iJ
(42 ml)
7s
(210 ml)
4. Add a little cooled, boiled water to make a smooth paste.
5. Add more cooled, boiled water
to make up to:—
6.
2
to
pints
pints
(1 litre)
(5-5 litres)
Use immediately or store in a refrigerator. Stir before use.
*Dsp = rounded dessertspoon (to ml capacity).
22
APPENDIX II
ALTERNATIVE DIETS FOR PCM
Sometimes all the ingredients for the milk diets (p. 21) may not be
available. The following foods can be used instead, but the child’s recovery
will be slower and less certain.
Full cream milk. This can be used instead of the ‘reinforced milk’,
but is more expensive. Mix 6 ozs (170 ml) (18 Dsp) of full cream milk
with 1 oz (28 g) (2 Dsp) sugar and make up to 2 pints (1 litre) in the normal
way.
Dried skim milk. This diet tends to cause loose stools and is only
really suitable for mild or recovering cases who arc eating other food.
Mix 6 ozs (170 ml) (12 Dsp) of dried skim milk and 1 oz (28 g) (2 Dsp)
sugar and make up to 2 pints (1 litre).
Fresh milk. Provided this is boiled and not diluted, it is quite a good
diet. As there is less protein in 1 pint (0-5 litre) than in the other milk
diets, it must be fed at the rate of 2I fl oz (71 ml) per lb body weight per
day (i.e. 2J pints (1 -5 litres) for a 20 lb (9 kg) child).
Eggs, minced meat or fish, skinned mashed beans or peas, pounded
groundnuts. Can be mixed with a little porridge or sauce. Such mixtures
should be used to replace some of the milk diet of mild or recovering cases
so that the child becomes used to these foods.
The mother should be shown how to prepare these foods, using
simple utensils, as she may be able to get them at home.
APPENDIX III
TUBE FEEDING
Twenty-two inches of polythene, or better still, flexible nylon tubing
(size 2, internal diameter 1 mm) should be used. The end is smoothed by
rubbing with sandpaper or putting in a flame for a second. The tube
should be lubricated with water and passed through a nostril into the
stomach. It can be left down for several days because it does not cause
irritation. It is fixed in place by a piece of plaster running from under the
nose to behind the ear, the tubing being led out behind the ear.
If the child tries to pull the tube out, put its arms in a splint or
bandage its hands. The mother should stay with the child.
Polythene tubing becomes soft when put in hot water. When boiling
this tubing tie a tape around it so it can be lifted out without flattening.
Boil for one minute only to prevent it becoming hard. (Nylon tubing can
be boiled or autoclaved indefinitely.)
Feeds should be sieved to avoid lumps and may then be given by:—
(a) continuous drip. This is the best method provided there is
someone to check that dripping continues steadily. Feeds are
23
put ill a transfusion bottle and given by attaching a drip set
adjusted to drip slowly (5 fl ozs (150 mis) taking about three
hours). Only enough diet for 3-4 hours should be put up to
prevent souring.
(b) syringe. Two- or three-hourly feeds can be given very slowly
through an injection needle (size 18BWG). Before each feed
check that the tube is still in the stomach, and after the feed
run a little water through to flush out any remaining milk.
24
APPENDIX IV
SOLUTIONS
Electrolyte Solution
Preparation
Mix together:—
Potassium chloride (KCI)
90 g
Magnesium hydroxide (Mg(OH)2)
9g
Water
1000 g (1 litre)
Dosage
15 cc (i fl oz) added to every pint of milk diet. 15 co electrolyte
solution provides 135 g KCI and 015 g Mg(OH)2.
Shake before use
Half Strength Darrows Solution in 2 5% glucose
Glucose (Dextrose BP)
125 g
Sodium chloride BP
10 g
Potassium chloride
6'5 g
Sodium lactate 70%
16 mis
Water
to 5 litres
APPENDIX V
SPECIMEN DAILY DIET FOR A PAEDIATRIC WARD
Ingredients
Fresh milk
Dried milk
Egg
Meat/fish flesh
| pint (140 ml)
I oz (28 g)
I
2 OZ (56 g)
Beans/peas
Groundnuts
Dark green leaves
Onion/tomato
Oil/ghec
Margarine
il- oz (42 g)
i oz (14 g)
2 oz (56 g)
21 OZ (70 g)
1 OZ (7 g)
* oz (14 g)
Orange/tangerine I
Mango/paw-paw 2 OZ (56 g)
Maizemeal/rice
Bread, 3 slices
Potato/banana
5 oz (140 g)
3 oz (84 g)
2 oz (56 g)
Sugar
1 oz (28 g)
Tea and salt
25
NUTRITIVE VALUE OF WARD DIET AND
NUTRIENT REQUIREMENTS
Protein g
Calories
Fat g
Calcium mg
Iron mg
Vitamins A (I.U.)
Thiamine mg
Riboflavin mg
Niacin mg
Vitamins C mg
Nutrients in
ward diet
66
1700
45
815
125
33°°
I -2
I 32
to-S
160
Nutrient
requirements
4-6 yrs
’-3 yrs
4°
5°
1700
13°°
—
—
400
400
10
9
2500
2000
o-6
o-8
o-9
1 -o
6
8
20
20
APPENDIX VI
RECIPES
Suitable for children aged 5 months and over and that can be easily
demonstrated to mothers. (These recipes provide approximately one third
of the daily protein and calorie requirement for a i-year-old child.)
1.
Gruel and egg. Make a gruel in the local way using:—
Flour (cereal) 3 heaped large spoons (dessert or tablespoon)
Sugar
1 heaped large spoon (dessert or tablespoon)
Oil
2.large spoons
Water
2 tea cups
When cooked add one beaten egg.
2.
Gruel and dried milk. Make gruel using:—
Flour (cereal) 3 heaped large spoons
Sugar
1 heaped large spoon
Oil
2 large spoons
Dried milk 2 large spoons
Water
2 tea cups
3.
Gruel and pounded groundnuts. Make a gruel using:—
Flour (cereal) 3 heaped large spoons (dessert or tablespoon)
Sugar
1 heaped large spoon (dessert or tablespoon)
Pounded
groundnuts 4 heaped large spoons (dessert or tablespoon)
Water
2 tea cups
4.
Mashed beans (or cowpeas, etc.)
Soak 2 handfuls of beans overnight. Skin. Cook with salt, pour off
excess water, mash very smoothly. Add 2 dessert spoons of oil.
APPENDIX VII
THE NUTRIENT CONTENT OF SOME COMMON FOODS
Protein Calorics
g
1
Breast milk
20
Cows milk
1
18
Condensed milk (no sugar) 2
50
Dried skim milk
10
100
Dried whole milk
140
7
Egg
4
45
60
Meat
5
20
Fish fresh
5
100
Fish dried
J4
Liver
6
40
100
Beans/peas
6
8
160
Groundnuts
100
2
Cereals, c.g. maize, rice
2
70
Bread
1
Potato/banana
3°
Cassava fresh
4°
1
IO
Leaves—dark green
1
Leaves—light green
7
Carrots
9
1
8
Tomato/pumpkin
Orange
i
15
14
Mango/paw-paw
15
220
0
Butter/ghce/margarine
0
250
Oil/lard
©
120
Sugar
Food
(i oz as eaten)
Iron
mg
Vitamin Niacin
nig
A (LU.)
o-i
0
o-i
0’3
0’2
0-8
0-9
0-2
1’5
3’°
2’0
07
o*4
o-3
0-2
0-3
I -o
o-i
0-2
o-i
0-1
0-1
0
0
0
45
40
95
11
340
280
0
0
0
6000
10
0
0
0
0/30
0
500
10
850
90
9
200
SOO
O
O
o-i
0
o-i
0’3
0-2
O
1’4
07
i-7
3’7
o-6
5’°
o-3
0-2
0-3
0-2
0-2
o-i
o-i
o-i
o-i
o-1
O
O
O
The nutrients shown here arc ones that arc most commonly missing
from the food in Eastern Africa.
27
APPENDIX VIII
THE DANGERS OF BOTTLE FEEDING
The spread of bottle feeding increases the incidence of gastro
enteritis and marasmus among young babies, especially those living in
towns. We must do our best to prevent the use of the bottle and encourage
breast feeding—the natural, traditional and best way for al! mothers to
feed their babies.
Bottle feeding is dangerous, difficult and expensive because:—
i. Bottles and teats are difficult to clean properly and to keep clean.
Germs breed easily in dirty bottles and teats.
2. Liquid milk is a breeding ground for dangerous germs.
3. Dried milk may be reconstituted with dirty water, in dirty
utensils or with dirty hands.
4. Milk in adequate amounts is expensive. It costs about fifty East
African shillings a month to feed a baby properly, hence feeds
arc usually diluted and lead to undernutrition.
5. Preparing feeds means more work for the mother.
On the other hand BREAST FEEDING provides safe, cheap and
perfectly balanced food for small babies that requires no preparation. In
addition, mother’s milk gives the baby protection from certain diseases,
and a close and important relationship develops between the mother and
baby.
28
WEIGHTS FOR AGE
(derived from Stuart & Stevenson 1959 in WHO Monograph No. 53)
APPENDIX IX
Age in Months
STANDARD WEIGHTS FOR AGE (top line)
0
6
12
18
24
30
36
42
48
54
60
3.4
7.4
9.9
11.3
12.4
13.5
14 5
15.5
16.5
17.4
184
Kg
Weight 7/8
16/5
21/13
24/15
27/5
29/12
32/0
34/3
36/6
38/6
40/9
lb/oz
Age
months
APPENDIX X
AN EXAMPLE OF A FEEDING SCHEDULE
Months of age
o-4
Breast milk. Undiluted sweet fruit juice if cleanly prepared,
or boiled water if child is thirsty.
4-6
Breast milk. Introduce a clean, soft gruel. Gradually add
egg, milk and pounded groundnuts. Soft fruits and fruit
juices.
6-12
Breast milk. Gruel plus egg, milk, groundnuts. Gradually
introduce skinned mashed beans, peas, green vegetables,
minced or scraped meat, fish flesh, staples (e.g. bananas,
rice, potato) and fruit.
12-24
Breast milk. Give the child the soft, nutritious part of the
family meal plus gruel and eggs and milk, small pieces of
meat, liver and boneless fish. Tell mother to put this food
on a plate for the child and help it to feed.
18-30
Gradually stop breast feeding if desired. Make sure that
the child gets extra protein foods, and extra affection from
mother. Encourage attendance at clinic—watch out for
‘replacement’ by younger child.
Over 2 years
All the most nutritious parts of the family meals, with
smaller amounts of staple. Extra protein and vegetable
foods. Teach the mother to give child its own bowl so
it gets its fair share, and to supervise the child’s meals.
30
INFORMATION AND ADVISORY SERVICE
The primary object of the Ross Institute is the prevention of disease
in the tropics. In the course of working towards this end it has become
apparent that the co-operation of industry is essential if rapid progress is
to be made. Fortunately, this co-operation has never been lacking, for those
responsible for directing tropical industry were quick to appreciate the
immense value to them of healthy labour and have therefore been among
the strongest supporters of the Ross Institute since its inception.
For this reason the Ross Institute has made it an important matter
of policy to keep tropical industry informed of the progress of medical
knowledge, and of the practical methods by which the greatest benefit
may be obtained from its application. This scries of bulletins, which have
been specially written for non-medieal people, is one of the means by which
this information is made available; other publications are issued from time
to time and a list of those now current will be found on page 32.
The Ross Institute invites all those whose work is connected with the
tropics to refer to it on any matter concerned with health or welfare in
tropical countries. The Director and his staff will answer as promptly and
as fully as possible all inquiries and requests for advice.
31
PUBLICATIONS OF THE ROSS INSTITUTE
The Preservation of Personal Health in Warm Climates.
(A handbook for those going to the tropics for the first time)
Ross Institute Bulletins:—
(1)
Insecticides. {Reprinted) October, 1973.
(2)
Anti-Malarial Drugs. (Rewritten) January, 1972.
(3)
(Out of print.)
(4)
Tropical Ulcer. (Revised") Allgust, 1973.
(5)
The Housefly and its Control. (Reprinted) July, 1973.
. (6) Schistosomiasis. (Reprinted) May, 1974.
(7)
Malaria and its Control. (Reprinted) May, 1974.
(8)
Rural Sanitation in the Tropics. (Reprinted) May, 1974.
(9)
The Inflammatory Diseases of the Bowel.
(Revised) August, 1970.
(10)
Small Water Supplies. (Reprinted) May, 1974.
(11)
Anaemia in the Tropics. (Reprinted) June, 1974.
(12)
Protein Calorie Malnutrition in Children.
(Reprinted) June, 1974.
These publications are reviewed-from time to time and new and revised
editions are issued as occasion warrants. They are available at printing cost
plus postage on application to:—
'The Secretary,
The Ross Institute,
London School of Hygiene and Tropical Medicine,
Keppel Street, Gower Street,
London, WC1E 7HT. '
Tel: 01-636 8636
raixnso by e. c Berryman a sons, ltd., Greenwich. London, s.e.IO.
Position: 2603 (2 views)