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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
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