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Nutritional Support 31

is generally well nourished herself. On weaning, however, gender
Food in gastrointestinal tract differences in nutritional status in most communities in Africa are more
likely to develop, with the boys being favoured.
A history of nutritional intake will be essential. A detail of the
composition of the diet for a typical day will give a good indication of
Direct effects Indirect effects the type of nutritional deficiency that may exist. A history of the source
of water may help to identify potential micronutrient deficiencies. If
these are found to be present, they should then be added to the diet.
Increased Increased local Hormone Motility Teenage and unmarried mothers are more likely to have undernourished
desquamation nutrition release secretion or malnourished children because they generally belong to the lower
socioeconomic classes and thus may not be able to obtain adequate
food. The specific disease conditions listed in the previous section may
Paracrine be indications for additional nutritional support.
effects Endocrine
effects Physical Examination of the Child
Physical examination of the child will help to determine the degree of
nutritional deprivation. The traditional parameters to measure include
Nerve the weight and height, which can be compared with standard age,
Growth stimulation weight, and height charts, and the triceps skinfold thickness or midarm
circumference determination. Among the various indices that help in
determining nutritional status in children are anthropometric indicators,
Source: Courtesy of European Society for Clinical Nutrition and Metabolism (ESPEN),
Guidelines on Enteral Nutrition. specifically weight-for-age, height-for-age, weight-for-height, weight/
height index, upper arm anthropometry, and head circumference. For
8
Figure 6.1: Normal intestinal function.
preterm infants, crown-heel length and weight gain are the most sensi-
tive indices of the adequacy of intake of nutrients. 6,8,9
fistulas; and those with surgical conditions that result in an increase in Investigations
nutritional needs from increased catabolism, such as occurs in burns
Basic investigations required to confirm the proposed clinical diagnosis
and conditions of prolonged sepsis (e.g., peritonitis due to bowel perfo- will be covered in the relevant chapters of this book. The discussion
ration in complicated enteric fever). 7
in this chapter is confined to the diagnosis of nutritional deficiency.
Food in the intestinal tract has both direct and indirect beneficial
The most helpful diagnostic indices of nutritional status are the physi-
effects, as indicated in Figure 6.1.
cal examination findings noted in the preceding section. Laboratory
Prolonged chronic illnesses that result in overall reduction in total
investigations should include serum albumin and protein determina-
caloric intake will result in poor nutritional state. In addition, any
tion, although there are some limitations to their utility, as they may
condition in which there is injury to the intestinal mucosa or reduction in
be normal even with significant malnutrition. They can be low in
total absorptive surface area of the bowel, either from local or systemic
circumstances of excess losses or decreased synthesis. Before paren-
disease or any condition in which there is a reduction in overall length
teral nutrition is given, it is important to check baseline levels of liver
of bowel, may result in quantitative nutritional deficiencies and a need
function tests, as well as levels of serum urea, electrolytes, and minerals
for nutritional support. These conditions include, but are not limited to,
(specifically, calcium, phosphorus, and magnesium). A chest x-ray will
the following:
be needed to confirm the adequate placement of the total parenteral
• the neonate with an ileostomy; nutrition (TPN) catheter tip.
• antenatal rupture of exomphalos or gastroschisis; Management of Undernutrition and Malnutrition
• extensive intestinal resection with short gut and decreased transit time; Methods of Feeding
• necrotising enterocolitis; Oral feeding
• intestinal atresia ; Indirect methods of improving the caloric content of the food being given
orally include cup and spoon feeding. Oral supplements may also need to
• midgut volvulus where there is extensive mucosal damage;
be given. Antiemetics may be given for nausea and vomiting, or agents to
• massive injury, especially to the gastrointestinal tract, in conflict and help improve gastric emptying can be tried. If all these fail to improve the
various situations of violence, where enteral feeding is not feasible; patient’s nutritional status, the next step will be to give enteral feeding.
Normally available local foodstuffs can be used if their caloric value can
• inflammatory bowel disease;
be determined. These can be blended and fed to the patient as needed.
• paediatric burns;
Enteral feeding
• complicated bowel perforations in enteric fever; Tube feedings can be delivered either as bolus or by slow infusion,
depending on the patient’s nutritional requirements, the composition
• oesophageal strictures from ingestion of corrosives; and
of the feed being given in terms of solute load, and the capacity of the
• achalasia of the cardia. child’s stomach to accommodate the quantities being fed. Various avail-
Clinical Evaluation able commercial preparations can be used. In resource-poor settings,
a dietitian can be engaged who will be able to use locally available
History foodstuffs to prepare high-energy blends to which additional nutrients
Generally, most communities in Africa place more value on boys can be added based on any identified deficiencies. It is important when
than girls. After birth and until babies are weaned, there is usually no enteral feedings are being given to ensure that the required amount of
difference in nutritional status between girls and boys if the mother energy is actually being delivered. 6,9,10