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Treatment with antibiotics such as amoxicillin or cefdinir improve the response and survival rate of severely malnourished children to an outpatient treatment plan which provided therapeutic food. This confirms the recommendation, "In addition to the provision of RUTF [ready-to-use therapeutic food], children need to receive a short course of basic oral medication to treat infections." contained in "Community-based management of severe acute malnutrition, A Joint Statement by the World Health Organization, the World Food Programme, the United Nations System Standing Committee on Nutrition and the United Nations Children’s Fund."
Infants and children who have had unpleasant eating experiences (e.g. acid reflux or food intolerance) may be reluctant to eat their meals. Additionally, force feeding an infant or child can discourage proper self-feeding practices and in-turn cause undue stress on both the child and their parents. Psychosocial interventions can be targeted at encouraging the child to feed themselves during meals. Also, making mealtimes a positive, enjoyable experience through the use of positive reinforcement may improve eating habits in children who present with FTT. If behavioural issues persist and are affecting nutritional habits in children with FTT it is recommended that the child see a psychologist.
Measures have been taken to reduce child malnutrition. Studies for the World Bank found that, from 1970 to 2000, the number of malnourished children decreased by 20 percent in developing countries. Iodine supplement trials in pregnant women have been shown to reduce offspring deaths during infancy and early childhood by 29 percent. However, universal salt iodization has largely replaced this intervention.
The Progresa program in Mexico combined conditional cash transfers with nutritional education and micronutrient-fortified food supplements; this resulted in a 10 percent reduction the prevalence of stunting in children 12–36 months old. Milk fortified with zinc and iron reduced the incidence of diarrhea by 18 percent in a study in India.
Medication is used to relieve fever, seizures, and weight loss or dehydration. When medication is use for opiate withdrawal in newborn babies is deemed necessary, opiates are the treatment of choice; they are slowly tapered down to wean the baby off opiates. Phenobarbital is sometimes used as an alternative but is less effective in suppressing seizures; however, phenobarbital is superior to diazepam for neonatal opiate withdrawal symptoms. In the case of sedative-hypnotic neonatal withdrawal, phenobarbital is the treatment of choice. Clonidine is an emerging add-on therapy.
Opioids such as neonatal morphine solution and methadone are commonly used to treat clinical symptoms of opiate withdrawal, but may prolong neonatal drug exposure and duration of hospitalization. A study demonstrated a shorter wean duration in infants treated with methadone compared to those treated with diluted tincture of opium. When compared to morphine, methadone has a longer half-life in children, which allows for less frequent dosing intervals and steady serum concentrations to prevent neonatal withdrawal symptoms.
The treatment of tube dependency is tube weaning. The best time to make the transition from exclusive tube feeding to oral feeding is between the ages of 6–12 months.
The earlier the tube is removed and the younger the child, the easier the transition. At the same time, the intended nutritional goals of ENS (enteral nutrition support) must be defined and assessed critically and individually.
Small studies of children undergoing cardiac surgery have shown that they have the easiest transition and highest success rate (n=20) and it has been postulated that this is due to them being able to maintain oral intake throughout the feeding period.
There are a few techniques that are used to aid tube weaning when initial attempts have failed.
- A single paper report of an approach uses analgesic medication based on the theory that children experience pain with oral intake. A study in 2009 showed a 82% (n=9) success rate.
- Behavioral treatment has been used in small samples. A randomised control trial in 2000 showed a 47% (n=32) success rate.
- The Graz approach uses a combination of multiple theories and therapeutic inputs and Play Picnics and has a 92% (n=221) success rate.
Treatment depends on the drug involved, the infant's overall health, abstinence scores and whether the baby was born full-term or premature. Clinicians will watch the newborn carefully for up to a week after birth for signs of withdrawal, feeding problems, and weight gain. Babies who vomit or who are very dehydrated may need to get fluids through a vein (IV).
Some babies with severe symptoms need medicines such as methadone and morphine to treat withdrawal symptoms. These babies may need to stay in the hospital for weeks or months after birth. The goal of treatment is to prescribe the infant a drug similar to the one the mother used during pregnancy and slowly decrease the dose over time. This helps wean the baby off the drug and relieves some withdrawal symptoms.
If the symptoms are severe, especially if other drugs were used, a second medicine such as phenobarbital or clonidine may be added. Breastfeeding may also be helpful if the mother is in a methadone or buprenorphine treatment program without other drug use.
Babies with this condition often have severe diaper rash or other areas of skin breakdown. This requires treatment with special ointment or cream. Babies may also have problems with feeding or slow growth. These problems may require higher-calorie feedings that provide greater nutrition and smaller portions given more often. Objectives of management are to minimize negative outcomes and promote normal development.
The decision to begin enteral feeding is made in most cases by a specialized medical team with a clear plan of treatment goals, the existence of some existing tube maintenance strategies and nutritional counselling and some idea of exit strategies.
During the phase of ENS (enteral nutrition support), patients are recommended to receive regular input from speech and language therapists, occupational therapy, physiotherapy and physicians with the aim of preserving oral functions, exposure to taste and texture preferences and supporting the patient and family to maintain some oral intake unless contraindicated.
A woman may elect to discontinue alcohol once she knows that she is pregnant. A woman can have serious symptoms that accompany alcohol withdrawal during pregnancy. These symptoms can be treated during pregnancy with benzodiazepine.
In colder environments where bedding is required to maintain a baby's body temperature, the use of a "baby sleep bag" or "sleep sack" is becoming more popular. This is a soft bag with holes for the baby's arms and head. A zipper allows the bag to be closed around the baby. A study published in the "European Journal of Pediatrics" in August 1998 has shown the protective effects of a sleep sack as reducing the incidence of turning from back to front during sleep, reinforcing putting a baby to sleep on its back for placement into the sleep sack and preventing bedding from coming up over the face which leads to increased temperature and carbon dioxide rebreathing. They conclude in their study, "The use of a sleeping-sack should be particularly promoted for infants with a low birth weight." The American Academy of Pediatrics also recommends them as a type of bedding that warms the baby without covering its head.
Treatment consists primarily of supportive care including providing bowel rest by stopping enteral feeds, gastric decompression with intermittent suction, fluid repletion to correct electrolyte abnormalities and third-space losses, support for blood pressure, parenteral nutrition, and prompt antibiotic therapy. Monitoring is clinical, although serial supine and left lateral decubitus abdominal x-rays should be performed every six hours. Where the disease is not halted through medical treatment alone, or when the bowel perforates, immediate emergency surgery to resect the dead bowel is generally required, although abdominal drains may be placed in very unstable infants as a temporizing measure. Surgery may require a colostomy, which may be able to be reversed at a later time. Some children may suffer from short bowel syndrome if extensive portions of the bowel had to be removed.
Over the counter medications are those medications that do not require a prescription to purchase in the US. Medications that require a prescription to purchase in the US may be available in other countries without a prescription. The following guidelines are recommended:
- taking oral medications after breastfeeding rather than before will allow some of the medication to leave the mother's body through her kidneys between nursings.
- in most women without kidney disease, nonsteroidal anti-inflammatory drugs and paracetamol (acetaminophen) are used safely.
- aspirin can cause rashes and even cause bleeding in infants.
- limit the use of antihistamines for long periods of time. These anti-allergy medications can cause crying, sleep problems, fussiness, exsessive sleepiness in babies. Antihistamines have an effect on the amount of milk the body produces and decrease the supply.
- carefully observe the infant for changes or side effects when first taking a medication to watch for side effects. Side effects indicating that the medication is having an affect on the baby is difficulty breathing, rash and other questionable changes that occurred after the medication was started by the mother.
- many times other young children are in the home and keeping these over the counter medications out of their reach is a safe practice.
Other substances or chemicals have been evaluated regarding their safe use during pregnancy. Hair dye or solutions used for a 'permanent' do not pass to breastmilk. No adverse reports of using oral antihastamines and breastfeeding are found. Some of the older antihistamines used by a nursing mother can cause drowsiness in the infant. This may be a concern if the infant misses feedings by sleeping instead of nursing.
Sleeping on the back has been found to reduce the risk of SIDS. It is thus recommended by the American Academy of Pediatrics and promoted as a best practice by the US National Institute of Child Health and Human Development (NICHD) "Safe to Sleep" campaign. The incidence of SIDS has fallen in a number of countries in which this recommendation has been widely adopted. Sleeping on the back does not appear to increase the risk of choking even in those with gastroesophageal reflux disease. While infants in this position may sleep more lightly this is not harmful. Sharing the same room as one's parents but in a different bed may decrease the risk by half.
Ensuring proper nutrition of pregnant and lactating mothers is essential. Achieving so by helping women of reproductive age be in good nutritional status at conception is an excellent preventive measure. A focus on the pre-conception period has recently been introduced as a complement to the key phase of the 1000 days of pregnancy and first two years of life. An example of this is are attempts to control anemia in women of reproductive age. A well-nourished mother is the first step of stunting prevention, decreasing chances of the baby being born of low birth-weight, which is the first risk factor for future malnutrition.
After birth, in terms of interventions for the child, early initiation of breastfeeding, together with exclusive breastfeeding for the first 6 months, are pillars of stunting prevention. Introducing proper complementary feeding after 6 months of age together with breastfeeding until age 2 is the next step.
Once a child is born prematurely, thought must be given to decreasing the risk for developing NEC. Toward that aim, the methods of providing hyperalimentation and oral feeds are both important. In a 2012 policy statement, the American Academy of Pediatrics recommended feeding preterm infants human milk, finding "significant short- and long-term beneficial effects," including reducing the rate of NEC by a factor of two or more.
A study by researchers in Peoria, IL, published in "Pediatrics" in 2008, demonstrated that using a higher rate of lipid (fats and/or oils) infusion for very low birth weight infants in the first week of life resulted in zero infants developing NEC in the experimental group, compared with 14% with NEC in the control group. (They started the experimental group at 2 g/kg/d of 20% IVFE and increased within two days to 3 g/kg/d; amino acids were started at 3 g/kg/d and increased to 3.5.)
Neonatologists at the University of Iowa reported on the importance of providing small amounts of trophic oral feeds of human milk starting as soon as possible, while the infant is being primarily fed intravenously, in order to prime the immature gut to mature and become ready to receive greater oral intake. Human milk from a milk bank or donor can be used if mother's milk is unavailable. The gut mucosal cells do not get enough nourishment from arterial blood supply to stay healthy, especially in very premature infants, where the blood supply is limited due to immature development of the capillaries, so nutrients from the lumen of the gut are needed.
A Cochrane review published in April 2014 has established that supplementation of probiotics enterally "prevents severe NEC as well as all-cause mortality in preterm infants."
Increasing amounts of milk by 30 to 40 ml/kg is safe in infant who are born weighing very little. Not beginning feeding an infant by mouth for more than 4 days does not appear to have protective benefits.
Data from the NICHD Neonatal Research Network's Glutamine Trial showed that the incidence of NEC among extremely low birthweight (ELBW, <1000 g) infants fed with more than 98% human milk from their mothers was 1.3%, compared with 11.1% among infants fed only preterm formula, and 8.2% among infants fed a mixed diet, suggesting that infant deaths could be reduced by efforts to support production of milk by mothers of ELBW newborns.
Research from the University of California, San Diego found that higher levels of one specific human milk oligosaccharide, disialyllacto-N-tetraose, may be protective against the development of NEC.
Although the etiology is unconfirmed, transient hyperammonemia is known to be caused by increased levels of ammonia in the blood stream, as well as a failure of the urea cycle to convert enough of the ammonia into urea. Since transamination of proteins is a leading producer of ammonia, protein restriction may be recommended as a therapy to reduce the symptoms of the episode. THAN can also be treated by avoiding amino acids in TPN or total parenteral nutrition or by giving a high caloric diet to limit catabolism of the tissues and therefore to minimize the breakdown of endogenous protein. The most common treatments are dialysis (both peritoneal and hemodialysis), sodium benzoate, and arginine. Sodium Benzoate combines with glycine to be excreted in the form of hippuric acid. The goal of these treatments is to convert nitrogen to a compound that can be excreted more easily.
In summary, key policy interventions for the prevention of stunting are:
- Improvement in nutrition surveillance activities to identify rates and trends of stunting and other forms of malnutrition within countries. This should be done with an equity perspective, as it is likely that stunting rates will vary greatly between different population groups. The most vulnerable should be prioritized. The same should be done for risk factors such as anemia, maternal under-nutrition, food insecurity, low birth-weight, breastfeeding practices etc. By collecting more detailed information, it is easier to ensure that policy interventions really address the root causes of stunting.
- Political will to develop and implement national targets and strategies in line with evidence-based international guidelines as well as contextual factors.
- Designing and implementing policies promoting nutritional and health well-being of mothers and women of reproductive age. The main focus should be on the 1000 days of pregnancy and first two years of life, but the pre-conception period should not be neglected as it can play a significant role in ensuring the fetus and baby's nutrition.
- Designing and implementing policies promoting proper breastfeeding and complementary feeding practice (focusing on diet diversity for both macro and micronutrients). This can ensure optimal infant nutrition as well as protection from infections that can weaken the child's body. Labor policy ensuring mothers have the chance to breastfeed should be considered where necessary.
- Introducing interventions addressing social and other health determinants of stunting, such as poor sanitation and access to drinking water, early marriages, intestinal parasite infections, malaria and other childhood preventable disease (referred to as “nutrition-sensitive interventions”), as well as the country's food security landscape. Interventions to keep adolescent girls in school can be effective at delaying marriage with subsequent nutritional benefits for both women and babies. Regulating milk substitutes is also very important to ensure that as many mothers as possible breastfeed their babies, unless a clear contraindication is present.
- Broadly speaking, effective policies to reduce stunting require multisectoral approaches, strong political commitment, community involvement and integrated service delivery.
No specific treatment or cure exists. Affected children usually need total parenteral nutrition through a central venous catheter. Further worsening of liver damage should however be avoided if possible. Diarrhea will likely continue even though food stops passing through the gastrointestinal system. They can subsequently be managed with tube feeding, and some may be weaned from nutritional support during adolescence.
The first line of treatment are corticosteroids and other medicines used to suppress the immune system such as tacrolimus and sirolimus.
A intravenous nutrition such as total parenteral nutrition and/or a special diet may be necessary. Hematopoietic stem cell transplantation may be curative.
A number of antiemetics are effective and safe in pregnancy including: pyridoxine/doxylamine, antihistamines (such as diphenhydramine), and phenothiazines (such as promethazine). With respect to effectiveness, it is unknown if one is superior to another for relieving nausea or vomiting. Limited evidence from published clinical trials suggests the use of medications to treat hyperemesis gravidarum.
While pyridoxine/doxylamine, a combination of vitamin B and doxylamine, is effective in nausea and vomiting of pregnancy, some have questioned its effectiveness in HG.
Ondansetron may be beneficial, however, there are some concerns regarding an association with cleft palate, and there is little high-quality data. Metoclopramide is also used and relatively well tolerated. Evidence for the use of corticosteroids is weak; there is some evidence that corticosteroid use in pregnant women may slightly increase the risk of oral facial clefts in the infant and may suppress fetal adrenal activity. However, hydrocortisone and prednisolone are inactivated in the placenta and may be used in the treatment of hyperemesis gravidarum after 12 weeks.
Dry bland food and oral rehydration are first-line treatments. Due to the potential for severe dehydration and other complications, HG is treated as an emergency. If conservative dietary measures fail, more extensive treatment such as the use of antiemetic medications and intravenous rehydration may be required. If oral nutrition is insufficient, intravenous nutritional support may be needed. For women who require hospital admission, thromboembolic stockings or low-molecular-weight heparin may be used as measures to prevent the formation of a blood clot.
The mortality rate for THAN is relatively high unless immediate treatment is obtained. The duration of hyperammonemia is directly correlated to morbidity as well as the associated neurological conditions. After the first hyperammonemic episode, there is no increased risk for future hyperammonemic episodes, and normal protein consumption can be continued.
Low birthweight, pre-term birth and pre-eclampsia have been associated with maternal periodontitis exposure. But the strength of the observed associations is inconsistent and vary according to the population studied, the means of periodontal assessment and the periodontal disease classification employed. However the best is that the risk of low birth weight can be reduced with very simple therapy. Treatment of periodontal disease during gestation period is safe and reduction in inflammatory burden reduces the risk of preterm birth as well as low birth weight.
Good nutrition with adequate intake of iron may prevent this disorder. Good nutrition should also include balanced diet and exercise.
Five interventional strategies can be used:
- Adding zinc to soil, called agronomic biofortification, which both increases crop yields and provides more dietary zinc.
- Adding zinc to food, called fortification.
- Adding zinc rich foods to diet. The foods with the highest concentration of zinc are proteins, especially animal meats, the highest being oysters. Per ounce, beef, pork, and lamb contain more zinc than fish. The dark meat of a chicken has more zinc than the light meat. Other good sources of zinc are nuts, whole grains, legumes, and yeast. Although whole grains and cereals are high in zinc, they also contain chelating phytates which bind zinc and reduce its bioavailability.
- Oral repletion via tablets (e.g. zinc gluconate) or liquid (e.g. zinc acetate). Oral zinc supplementation in healthy infants more than six months old has been shown to reduce the duration of any subsequent diarrheal episodes by about 11 hours.
- Oral repletion via multivitamin/mineral supplements containing zinc gluconate, sulfate, or acetate. It is not clear whether one form is better than another. Zinc is also found in some cold lozenges, nasal sprays, and nasal gels.
Traditionally, causes of FTT have been divided into endogenous and exogenous causes. These causes can be largely grouped into three categories: inadequate caloric intake, inadequate nutrient absorption, and increased metabolism. Initial investigation should consider physical causes, calorie intake, and psychosocial assessment.
- Endogenous (or "organic"): Causes are due to physical or mental issues with the child itself. It can include various inborn errors of metabolism. Problems with the gastrointestinal system such as gas and acid reflux, are painful conditions which may make the child unwilling to take in sufficient nutrition. Cystic fibrosis, diarrhea, liver disease, anemia or iron deficiency, and coeliac disease make it more difficult for the body to absorb nutrition. Other causes include physical deformities such as cleft palate and tongue tie. Milk allergies can cause endogenous FTT. Also the metabolism may be raised by parasites, asthma, urinary tract infections, and other fever-inducing infections, hyperthyroidism or congenital heart disease so that it becomes difficult to get in sufficient calories to meet the higher caloric demands.
- Exogenous (or "nonorganic"): Caused by caregiver's actions. Examples include physical inability to produce enough breastmilk, using only babies' cues to regulate breastfeeding so as to not offer a sufficient number of feeds (sleepy baby syndrome), inability to procure formula when needed, purposely limiting total caloric intake (often for what the caregiver views as a more aesthetically pleasing child), and not offering sufficient age-appropriate solid foods for babies and toddlers over the age of six months . A recent study on toddlers with exogenous FTT has found preliminary evidence suggesting that difficulty experienced during feeding times with this condition may in fact be impacted by preexisting sensory processing problems. Such difficulties with sensory processing are more commonly observed in toddlers who have a history of growth deficiency and feeding problems; however, further research is required in order to determine a causal relationship between sensory processing problems and nonorganic FTT. In developing countries, conflict settings and protracted emergencies, exogenous faltering may be caused by chronic food insecurity, lack of nutritional awareness, and other factors beyond the caregiver's control.
- Mixed: However, to think of the terms as dichotomous can be misleading, since both endogenous and exogenous factors may co-exist. For instance a child who is not getting sufficient nutrition may act content so that caregivers do not offer feedings of sufficient frequency or volume, and a child with severe acid reflux who appears to be in pain while eating may make a caregiver hesitant to offer sufficient feedings.