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Case Based Learning: Nutrition

A medical camp was set at a remote area in Balochistan (1) by the CMH Quetta team. A 2 years old (2)girl was brought there by her mother. The mother had six children the younger of whom was 6 months of age (3). The father was a drug addict and had not been working for years (4). Family income was thus low. They were not able to buy milk (5) and meat (6) on regular basis and the diet was high in carbohydrates and low in proteins.(7)  The mother stated that the daughter had been eating poorly for a few months (8), had intermittent diarrhea (9), had a recently developed a cough (10), a fever(11) and had become very irritable (12) and apathic (13).

On examination, the girl was both underweight for her height and small for her age (14). She was pale (15), weak (16) and drowsy (17). Her skin was flaky and her hair dry and brittle (18). Her temperature was 1000 F (19), mid arm circumference well below normal (20). Abdomen was distended (21) and liver moderately enlarged (22). Generalized edema was evident (23) . Crepts were heard over the left lung base (24) . The doctor made a diagnosis of Kwashiorkor, diarrhea, and pneumonia (25).

Investigations:

Parameters Patient values Normal values
Hemoglobin 6.0g/dL 11-14 g/dL (2 year old)
Total serum protein 4.4g/dL 6-8g/dL
Serum albumin 2.0 g/dL 3.5-5.5g/dL
White blood cell count 18,000/uL 7,000-11,000/uL

Learning Objectives:

1.     Balanced diet.

2.     Diet in pregnancy and lactation.

3.     Malnutrition.

1. Balochistan: Largest province of Pakistan but least populated one. Like its population its education and living standard are worse as compared to other provinces. People are mostly nomadic and tribal. Income is generally low and food is not easy to come by.

2. 2 Years old: Kwashiorkor develops after weaning in age 1-5 years, whereas marasmus develops before 1 year of age1

3. Six children …: It indicates early weaning in the child as the youngest child is 6 months old so the patient is most likely weaned2 (stopped breast-feeding).

4. The Father …: Drug addiction impairs individual’s cognitive3 and motor functions. The drug addicts become useless and a burden on the society. He can certainly not support his family.

5. Milk: Milk contains almost all the essential ingredients required for normal development of an infant. It contains short and medium-chain fatty acids, casein and whey proteins and lactose. Human milk contains 1.1% proteins and cow milk contain3.4% proteins by weight.

6. Meat: Meat is an excellent source of A-class proteins4.

7. High in Carbs, Low In Proteins: This indicates that the energy requirement of the body is being met or is moderately deficient and proteins are deficient which is indicative of kwashiorkor.

8. Eating Poorly …: Indicates malnutrition.

9. Intermittent Diarrhea: Diarrhea is due to infection of GIT6. Infections will occur due to atrophic changes of the skin and mucosal membranes secondary to malnutrition.

10. Cough: It will be due to infection or irritation of the respiratory tract.

11. Fever: Infectious agents and WBCs produce pyrogens which increase the set point of temperature in hypothalamus. Malnutrition may depress temperature regulatory mechanisms.

12. Irritatbility: It is an emotional response to a stimulus. In this case it may be due to infection or mental disorders due to malnutrition.

13. Apathic: It is a state of indifference or suppression of emotions.It might be due to muscle weakness or impaired mental functions.

14. Underweight: Growth of child is monitored by specific charts which shows normal ranges of height and weight for a given age.

15. Pale: Anemia due decreased erythropoiesis.

16. Weak: Degeneration of muscle proteins.

17. Drowsy: Lack of nutrients impairs brain activity and affects level of consciousness.

18. Flaky …: It is due to decreased proteins, which are needed to make keratin a component of hair.

19. Temperature: See 11.

20. Mid arm circumference …: The mid-upper arm circumference is the circumference of the upper arm at that same midpoint, measured with a non-stretchable tape measure. Decrease indicates loss body mass. Click Me

21. Abdomen Was Distented: Lack of amino acids leaves liver deficient with nutrients to form proteins, specifically albumin.

22. Liver Enlargement: For same reasons VLDL will not be secreated resulting in fatty liver.

23. Edema: It is due to hypoalbumnemia.

24. Crepts: These are the crackling sound heard when ascultating lungs at their base. It is due to the opening up of the collapsed passages. It may be present in pneumonia ,atlectasis, pulmonary fibrosis , bronchitis etc.

25. Pneumonia: It is due to atrophy of the respiratory membrane coupled with infections.

Investigations:

1. Decreased due to lack of amino acids.

2. Same as above.

3. Same as above.

4. Increased levels indicate infection.

Learning objectives:

1.     Balanced diet: A balanced diet must contain all the dietary ingredients(carbohydrates, proteins, fats, vitamins, minerals and fibers).in sufficient amount for that particular age and sex group. It should be wholesome and adequate. Must not have harmful stuff and must not contain any component in excess.(Maj Amir).

2.     Guyton.

3.     Davidson pg 510.

1.        Infant

2.        stopped breast-feeding.

3.        Compare new sensory information with the stored information.

4.        Having all the essential amino acids.

~A.D

We cannot escape knowledge, science is knowledge’~ Late Proff. Dr Abdus Salam.

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