Dr.S.K.M.SASTRY M.D(Hom.)
PHYSICIAN’ S SOCIAL RESPONSIBILITY
“§4. He is likewise a preserver of health if he knows the things that derange health and cause disease, and how to remove them from persons in health.”
Introduction: It is a serious concern of every physician to look into nation’s immediate problem on infant mortality. Survival of child up to the age of first 12 months after birth is the most important period of life. They are highly vulnerable to extreme malnutrition and emaciation (especially in children); can result from inadequate intake of food or from malabsorption or metabolic disorders.
What is Malnutrition: Malnutrition is defined as a pathological state resulting from relative or absolute deficiency of one or more essential nutrients. It is primary when there is deficiency of food available or secondary when food is available but the body cannot assimilate it for one or another reason. Malnutrition is common in children between age of 3 months and 3 years
Anthropometric Indices in Malnutrition
Weight for age is the best screening tool. Weight for age below 2 Standard Deviation from median is taken as Malnutrition. It is used for mass screening of children to detect under nutrition. Weight for Height below the 5th Centile classifies the child as Wasted ( Acute Malnutrition). Height for age below the 5th centile classifies the child as Stunted (Chronic Malnutrition)
Malnutrition in India:
o 38% of Children are Low Weight for Age. (14% of Children are Wasted)
o 36% or Urban and 44% of rural Children are Stunted.
o Malnutrition is responsible as underlying factor for 55% of Deaths in Children under 5 years of age. amongst whom very high rates are infants less than 6 months.
Etiology of Malnutrition
o Failure of Lactation.
o Improper Weaning Practices
o Poverty
o Food Taboos
o 2 or more children under 5 years of age in same household
o Death of Mother
o Incompetent/ Ignorant Mother.
o Lack of Family Planning
Potential resources _ Economic structure _ Political and ideological superstructure _ Formal and non formal Institutions _Inadequate education _Insufficient _ health services and unhealthy environment _ Inadequate care for mothers and children _ Inadequate access to food _ Disease Inadequate dietary intake _ Malnutrition and death
Homoeopathic Point of view: Master Hahnemann clearly describes the causes for the menace of various diseases in aphorisms §
4, §5, §7, §74, §75, §76, §77 and the same is applicable even to Malnutrition infants.
§
4, §5, Exciting causes: , §5 Pay attention to the exciting cause and the fundamental cause (which is usually a chronic disease) including the patient's character, activities, way of life, habits, etc. Acute conditions caused by exposure to unhealthy food, weather, water, thermal factors etc.
§7, §77: Maintaining causes: §7. Now, as in a disease, from which no manifest exciting or maintaining cause ( causa occasionalis ) has to be removed …§77 Those diseases are inappropriately named chronic, which persons incur who expose themselves continually to avoidable noxious influences, who are in the habit of indulging in injurious liquors or aliments, are addicted to dissipation of many kinds which undermine the health, who undergo prolonged abstinence from things that are necessary for the support of life, who reside in unhealthy localities, especially marshy districts, who are housed in cellars or other confined dwellings, who are deprived of exercise or of open air, who ruin their health by overexertion of body or mind, who live in a constant state of worry, etc. These states of ill-health, which persons bring upon themselves, disappear spontaneously, provided no chronic miasm lurks in the body, under an improved mode of living, and they cannot be called chronic diseases.
Fundamental causes: Psora, Syphillis. Sycosis and their combinations
§74, §75, §76, Iatrogenic causes: §
74. The worst Chronic diseases are produced by unskilled physicians using allopathic medicines. § 75 These inroads on human health effected by the allopathic non-healing art (more particularly in recent times) are of all chronic diseases the most deplorable, the most incurable; and I regret to add that it is apparently impossible to discover or to hit upon any remedies for their cure when they have reached any considerable height.
Constitutional causes: Dr.Von Grauvogl Oxygenoid, Hydrogenoid
Carbo - Nitrogenoid constitutions
Etiology of Secondary Malnutrition
o Lack of Immunization
o Congenital Diseases: ASD, VSD, cleft palate etc.
o Malabsorption: Celiac Disease, Lactose intolerance, Giardiasis, Cystic Fibrosis
o Metabolic: Inborn errors of Metabolism, CRF, Renal tubular Acidosis etc.
o Infections: Tuberculosis ( very common in India)
Clinical features in Marasmus
o Marked muscle wasting and loss of subcutaneous fat.
o Monkey Facies
o Skin becomes loose and hangs in folds
o Abdomen protuberant due to hypotonic muscles
o Temperature is usually sub-normal
o Child is alert
Clinical features of Kwashiorkor
o Generalized Edema more marked in Lower Extremeties.
o Apathy and Irritability
o Fine, sparse and discoloured hair
o Anemia
o Usually Flaky Paint Dermatitis
o Enlarged Liver due to Fatty Changes
Lab Investigations in Malnutrition
o Check Hemoglobin in all cases. It is usually low. Sometimes it may be normal despite severe pallor in child because of the associated dehydration and hemo-concentration, the Hb apparently seems to be normal.
o If there is no BCG Scar, do Diagnostic BCG and read after 72 hours. If more than 10 mm of induration, treat as Tuberculosis.
o Do Stool R/E and Urine R/E.
o Do Chest X-ray in all cases of Malnutrition.
o Serum Pre-Albumin level. This is the most sensitive prognostic indicator in Kwashiorkor. Do on Day1, Day 5 and before discharge of the patient.
o Plasma Proteins and Serum Albumin level. These are usually very low in Kwashiorkor.
Complications of Malnutrition
o Hypothermia
o Hypoglycemia
o Cardiac Failure
o Infections
o Vitamin A Deficiency
o Severe Anemia
o Dermatosis
Treatment of Malnutrition
o Follow WHO Guidelines
n 1. Treat/prevent hypo-glycaemia
n 2. Treat/prevent hypothermia
n 3. Treat/prevent dehydration
n 4. Correct electrolyte imbalance
n 5. Treat/prevent infection
n 6. Correct micronutrient deficiencies
n 7. Initiate refeeding
n 8. Facilitate catch-up growth
n 9. Provide sensory stimulation and emotional support
n 10. Prepare for follow-up after recovery
Therapeutic Nutrition in Malnutrition
o Start slowly with F-75. If that is not available, give traditional easy to make, calorie rich foods.
o For those having severe anorexia, feed overnight with Milk given through NG tube, till appetite returns.
o Give Vitamin A, Vitamin D, Zinc, Magnesium, and folate to all children
o Treat Oral thrush, if present.
Prevention of Malnutrition
o Primary Prevention
n Health Education to mothers about good nutrition and food hygiene through Lady Health Workers
n Immunization of children.
n Growth monitoring on Growth Charts specially of all children under 3 years of age
o Secondary Prevention
n Mass Screening of high risk populations, using simple tools like Weight for age
o Tertiary Prevention
n Good Nutritional Care, supplementary feedings and rehabilitation, counselling of mothers
Objectives
o Reduction in Grade 3 & 4 malnutrition in 0-6 age group
o Special focus on health, nutrition and immunisation aspects in 0-3 age group
o Reduction in Grade 1 & 2 malnutrition in 0-6 age group
o Newborn care initiatives
o Antenatal, perinatal and postnatal care for mothers
o Focus on pre-teen/adolescent girls: nutrition and health education
o Transfer of the management function to the community
o Abrotanum, Argentum Nit. Baryta Carb, Calcarea Phosphorica. Calcarea Carbonica, Cina, Chamomilla, Hepar Sulphur, Iodine. Kali.Iod, Magnesia Carbonica, Natrum Muriaticum, Silica, Sulphur, Tuberculinum etc. are some of the medicines to be thought of.
IODIUM
o Dark complexion
o Hot baby
o Ravenous hunger
o Anxiety
o Better in open air
o Glandular enlargement
TUBERCULINUM.
o Light complexion, blue eyes, mental activity
o Ravenous hunger with rapid emaciation Anxiety
o Tubercular diathesis
Magnesia Carbonica. Marasmus.
o Puny children
o Milk <
o undigested vomiting;
o griping and colicky pains;
o sour green grassy stools,
o improperly nourished;
o ulcers in the mouth,
o swollen glands
o bloated abdomen.
o Jaundice
o offensive Sweat
Natrum Mur
o Marasmus from defective nourishment
o Thin neck,
o Ravenous appetite ,
o The child grows thin.
o Excess thirst and craves water all the time
o Gets intermittent fever frequently.
o Dry mouth and throat constipated bowels.
o Skin is scurfy with oozing eruptions.
o Craving for salt
CALC-CARB
o Marasmus
o Defective nutrition,
o Sour stools and vomiting of milk,
o Sweat on scalp, head and face, the feet are damp and cold,
o Enlargement of the glands
o Voracious appetite.
o Dwindled body,
o Prominent abdomen. morbid appetite, craving indigestible articles.
o Engorgement of mesenteric glands
o Scrofulous infants.
o Diarrhoea on beginning to eat or drink;
o Rapid emaciation with a harsh and dry skin.
o The debility, weariness and irritable restlessness
ABROTANUM
o Marasmus.
o Impaired Nutrition
o Defective digestion and assimilation
o Marked emaciation of lower limbs, ascending type
o Great weakness
o Ravenous appetite with rapid emaciation.
o Chilly
o Constipation and diarrhoea alternate
CALC .PHOS
o Emaciation
o Predisposition to glandular and osseous disease
o Large heads, defective bony development, open fontanelles and tardy development of the teeth, weak spine, curved, thin neck
o Sallow complexion
o Persistent vomitings and diarrhoea of green, slimy and undigested stools, accompanied with much offensive flatus.
o Engorgement of glands, enlarged tonsils
o Scrofulous tendency
