Thiamine, vitamins E, B6, B12 Vitamin E Vitamin E, thiamine Vitamin D, Ca2+, Mg2+
Iodine, niacin Vitamin E, niacin, thiamine
Thiamine, vitamin B12 the abdomen may reveal an enlarged, soft liver with an indefinite edge. Lymph node and tonsils are commonly atrophic.Chest examination may reveal basilar rales. The abdomen isdistended, and bowel sounds tend to be hypoactive.
These children often have concurrent wasting and edema in addition to stunting. These children exhibit features of dermatitis, neurologic abnormalities, and fatty liver.
The basal metabolic rate and immediate nutrient needs decrease in cases of malnutrition. When nutrients are provided, themetabolic rate increases, stimulating anabolism and increasing nutrient requirements. The body of the malnourished child mayhave compensated for micronutrient deficiencies with lower metabolic and growth rates, and refeeding may unmask thesedeficiencies. Nutritional rehabilitation should be initiated and advanced slowly to minimize these complications. The initialapproach involves correction of dehydration and anti-infective(bacteria, parasites) therapy if indicated. Oral rehydration isrecommended over intravenous fluid to avoid excessive fluid and solute load and resultant heart or renal failure.
When nutritional rehabilitation is initiated, calories can be safely started at 20% above the child’s recent intake. If no estimate of the caloric intake is available, 50% to 75% of the normal energy requirement is safe. High-calorie oral solutions or ready-to-use therapeutic foods (a mixture of powdered milk, peanuts, sugar, vitamins, and minerals) are frequently used in developing countries. Nutritional rehabilitation can be complicated by refeeding syndrome, which is characterized by fluid retention, hypophosphatemia, hypomagnesemia, and hypokalemia. Careful monitoring of laboratory values and clinical status with severe malnutrition is essential.
When nutritional rehabilitation has begun, caloric intakecan be increased 10% to 20% per day, monitoring for electrolyte imbalances, poor cardiac function, edema, or feedingintolerance. If any of these occurs, further caloric increasesare not made until the child’s status stabilizes. Caloric intake is increased until appropriate regrowth or catch-up growth isinitiated. Catch-up growth refers to gaining weight at greaterthan 50th percentile for age and may require 150% or more ofthe recommended calories for an age-matched, well-nourishedchild. A general rule of thumb for infants and children up to3 years of age is to provide 100 to 120 kcal/kg based on ideal weight for height. Protein needs also are increased as anabolismbegins and are provided in proportion to the caloric intake.Vitamin and mineral intake in excess of the daily recommendedintake is provided to account for the increased requirements;this is frequently accomplished by giving an age-appropriatedaily multiple vitamin, with other individual micronutrientsupplements as warranted by history, physical examination,or laboratory studies. Iron supplements are not recommendedduring the acute rehabilitation phase, especially for childrenwith kwashiorkor, for whom ferritin levels are often high. Additional iron may pose an oxidative stress; iron supplementationis associated with higher morbidity and mortality.
In most cases, cow’s milk–based formulas are tolerated and provide an appropriate mix of nutrients. Other easily digested foods, appropriate for the age, also may be introduced slowly. If feeding intolerance occurs, lactose-free or semielemental formulas should be considered.