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    T R A I N I N G M A N U A L

    3

    NUTRITION

    NUTRITIONAL REQUIREMENTS DURING PREGNANCY

    Pregnancy is physiologically and nutritionally demanding period. Adequate intake of nutritious diet is reflected in optimal weight gain during

    pregnancy (10-12 Kg) by the expectant mother.

    Advice to be given to Women During Pregnancy:

    Eat more food during pregnancy and lactation

    Eat more whole grains, sprouted grams and fermented foods

    Take milk/meat/eggs

    Eat plenty of fruits and vegetables

    Avoid superstitions and food taboos

    Do not use alcohol and tobacco

    Take medicines only when prescribed

    Take iron, folate and calcium supplements regularly, after 14-16 weeks of pregnancy and continue the same during lactation.

    FOOD GROUPS

    On the basis of the predominant nutrient contained in foodstuffs, the later are classified in to the following Food Groups (Table 1). This

    grouping of foods may not be the ideal but it is practical and easy to follow. It serves as a general guide to chose a Balanced Diet. It also

    provides information as to which of the different foodstuffs can be substituted for one that may be temporarily unavailable.

    Table 1 : Food Groups

    Major Nutrients Other Nutrients

    Group I : Energy Rich Foods Carbohydrates and fats

    Whole grain cereals, millets Protein, fibre, minerals calcium, iron andB-complex vitamins

    Vegetable oils, ghee, butter Fat soluble vitamins(A,D,E,K), essential fat ty acids

    Nuts and oilseeds Proteins, vitamins/minerals

    Sugars Nil

    Group II : Body Building Foods Proteins

    Pulses, nuts and oilseeds B-complex vitamins, invisible fat, fibre

    Milk and Milk products Calcium, vitamin A, riboflavin, vitamin B12

    Meat, Fish, polutry B-complex vitamins, iron, iodine, fat

    Group III : Protective Foods Vitamins and Minerals

    Green leafy vegetables Antioxidants, fibre and other cartenoids

    Other vegetables/fruits Fibre, sugar and antioxidants

    Eggs, milk and milk products Protein and fat

    and flesh foods

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    Table 2 : Balanced Diet for a pregnant woman

    Food Group Food stuff Amount per day

    Group I : Energy Rich Foods Rice, wheat and millets +300gOil, ghee, butter etc. 30gSugar and jaggery 20g

    Group II : Body Building Foods Milk, curds etc. 500mlPulses, dried beans, nuts 60gMeat, fish, egg 20g

    Group III : Protective Foods Fruits 200gVegetables 350gGreen leafy vegetables 150gOther vegetables 120g

    Roots and tubers 100g

    Table 3 : Balanced Diet during lactation

    Food Group Food stuff Amount per day

    Group I : Energy Rich Foods Rice, wheat and millets 330gOil, ghee, butter etc. 30gSugar and jaggery 20g

    Group II : Body Building Foods Milk, curds etc. 500mlPulses, dried beans, nuts 90gMeat, fish, egg 30g

    Group III : Protective Foods Fruits 200gVegetables 350g

    Other vegetables 130gRoots and tubers 120g

    Table - 4 : Sample Menu for a pregnant woman

    Meal time Food group Approximate serving

    Breakfast Milk with sugar One cupBreak fast item 1 serving

    Mid Morning Fruit One

    Lunch Rice 1 KatoriChapati 2 no.

    Dhal 1 KatoriVegetable curry 1 KatoriVegetable salad 7-8 slicesCurd 1 Katori

    Tea Tea/Coffee 1 cupSnack item 1 serving

    Dinner Rice 1 KatoriChapati 2 no.Any vegetable curry 1 KatoriDhal 1 KatoriVegetable Raita 1 Katori

    Fruit Seasonal

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    Table -5 : Sample Menu for a lactating woman

    Meal time Food group Approximate serving

    Early morning Milk with sugar One cup

    Breakfast Break fast item 1 serving

    Milk preparation/curd 1 cup

    Mid Morning Fruit One

    Lunch Rice 1 Katori

    Chapati 2 no.

    Dhal 1 Katori

    Vegetable curry 1 Katori

    Dry vegetable Katori

    Vegetable salad 7-8 slicesCurd 1 Katori

    Tea Milk/Milk Preparation 1 cup

    Snack item 1 serving

    Dinner Rice 1 Katori

    Chapati 2 no.

    Any vegetable curry 1 Katori

    Dhal 1 Katori

    Vegetable Raita 1 Katori

    Fruit Seasonal

    NUTRITION FOR INFANTS

    From birth - till 6 months of age Exclusive breast feeding is recommended.

    In cases where breast feeding is contraindicated/ lactation fails/mother is unable to breast feed the child:

    Infant needs to be fed on animal milk or commercial infant formula

    Milk should be boiled before being fed to the baby.

    Full strength milk may be started in early neonatal period for term infants.

    Infants fed on animal milk should receive supplements of Iron and Vitamin C.

    The baby should receive about 120-180 ml of milk 6-8 times over the day. Sugar should be added to milk to increase its caloric

    density.

    While reconstituting the infant formula, the instructions given on the label should be strictly followed.

    The feeds should be prepared and given using sterile cup and spoon, taking utmost care.

    Use of bottle should be discouraged.

    Overfeeding should be avoided in artificially fed infants to prevent obesity.

    Low cost home made weaning foods are preferred. However, commercially available preparations may be used by those who can

    afford them.

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    For Consideration:

    1. The formula milk or animal milk is not as advantageous as breast milk

    2. Utmost cleanliness is required for preparation of formula feed to prevent gastro-intestinal infections

    3. Traditional method of feeding with spoon and bowl is more hygienic and safer as compared to bottle.

    WEANING:

    It is the process of gradually introducing foods other than breast milk in a childs feeding schedule. This process starts when any food

    besides mothers milk is introduced in the childs diet and is completed only when the child has been entirely put off the breast. The

    introduction of supplementary foods not only ensures the fulfillment of nutritional requirements but also introduces the child gradually to the

    normal family eating patterns. The supplementary foods which can be given to the child from time to time are listed below.

    Table-6 : Weaning Foods for Infants

    Infants age Supplementary foods Frequency of supplements

    4-6 months Mashed banana, porridge from wheat flour, Start with 1 feed / day, gradually increase the

    ground rice, ragi, ground millet, etc. mixed frequency to 3 feeds/day by 6th month of age.

    with oil (start with only one cereal)

    6-9 months Banana, mango, chikoo ripe, 4-5 times/day

    Boiled egg yolk

    Mashed rice with dhal (Khichri)

    Mashed vegetables

    Chapati softened with milk

    Green leafy vegetables can be added to

    dal or khichriAdd little oil to all the above preparations

    9-12 months In addition to the above, 4-5 times/day

    Fruit variety

    (but apple, apricot or peer should be given

    only after stewing)

    Khichri, Idli, Upma, Chapati, curd rice

    Variety of vegetables

    Eggs (boiled or scrambled)

    Minced meat, fish

    Whenever new foods are introduced in a childs diet, the following points must be kept in mind

    It is wise to continue breast milk through 6 months to 1 year when the infant receives supplementary feeding. Animal milk should not

    substitute for breast milk before the age of one year. Consumption of breast milk along with age-appropriate solid foods and juicesduring the first 12 months of life allows for balanced nutrition.

    Only one food should be introduced at a time.

    The consistency of food should be suitable as per the childs age. Liquid supplements should be given initially and their consistency

    gradually needs to be changed from liquid to semi solid and then to solid with advancing age of the child.

    Food should be given in small quantities in the beginning and the amount should be gradually increased as the child develops a liking

    for the food.

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    The child should never be forced to eat. If the child dislikes a particular food, it should be removed from his / her diet for some time and

    re-introduced at a later stage. If the child shows a persistent dislike for that food, it should not be forced upon. No food is indispensable

    and some other substitute can always be given.

    The childs food should not be spicy. Fried food should also be avoided.

    Variety should be introduced in the childs diet to make it more appealing.

    As the child grows older colour, flavor, texture and shape of the food should be given special consideration so as to attract the childs

    attention.

    To make the child learn to eat all types of foods and to inculcate good eating habits among children, the parents should not showpersonal prejudices and dislike towards any foods.

    It is not always necessary to cook separately for the child, as the family meals can be easily modified in consistency, spicing, etc., for

    the amount needed to feed the child.

    Active feeding (i.e. parents should sit by the side of the child and help and encourage him / her for self feeding) should be encouraged

    after one year of age

    Table - 7 : Diet between 1 and 5 years

    Food group Food Approximate amount

    Group I : Energy Rich Foods Cereal or starchy vegetables cooked 3 times a day

    Group II : Body Building Foods Milk At least 200 ml a day (dairy milk) for breast fed

    infant, 500 ml (dairy milk) for others

    Pulses, meat or boiled fish Once a day

    Egg prepared in any form One a day or minimum of 4 eggs a week

    Group III : Protective Foods Green leafy vegetables and other vegetables Twice a day

    Fruits Once a day

    Extra fruit may be substituted for vegetables or vice versa

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    CALORIES, PROTEIN AND FAT CONTENT OF COMMON FOOD ITEMS

    Table - 8 : Calories, protein and fat content of common food items (raw)

    (household measures)

    Item Measure Weight Energy Kcal. Protein Fatg. g. g.

    Cereals

    Rice 1 K 150 520 10 3

    Wheat flour 1 K 90 310 11 3

    Millet flour 1 K 90 300 11 3

    Pulses

    Bengalgram dhal 1 K 130 485 27 9

    Other dhals 1 K 135 460 32 3

    Whole pulses

    Greengram 1 K 140 470 34 3

    Cowpea (lobia) 1 K 135 440 33 4

    Rajmah 1 K 120 415 27 3

    Soyabean 1 K 130 530 60 27

    Green leafy vegetables 5 B 100 62 3.0 0.4

    Other vegetables 100 26 2.0 0.2

    Roots and tubers 100 105 1.0 1.0

    Nuts and Oilseeds

    Almonds 10 No. 15 85 3.0 8

    Cashewnuts 10 No. 15 95 3.0 8

    Coconut (fresh) 1 No 115 510 5.0 50

    Coconut (dry) No. 45 290 3.0 30

    Groundnuts 50 No. 15 85 4.0 6

    Sesame seeds 1 tsp. 3 15 0.6 1

    Spices

    Chillie powder 1 tsp. 7 17 1.0 1.0

    Coriander seeds 1 tsp. 7 20 1.0 1.4

    Cumin seeds 1 tsp. 5 18 1.0 0.5

    Fenugreek 1 tsp. 6 20 1.6 0.6

    Mustard seeds 1 tsp. 10 5 2.0 4.0

    Garlic 6 pods 3 4 0.2 0.02Onion 1 med. 50 30 0.9 0.1

    Animal foods

    Milk (Buffalo) 1 K 150 ml. 175 6.0 10

    Milk (cow) 1 K 150 ml. 100 5.0 6

    Egg (hen) one 60 100 8.0 8.0

    Mutton 100 194 18.0 13.3

    Fish (lean) 100 100 18.0 1.5

    Fish (fatty) 100 150 90.0 6.0

    B: Bundles K: Katori tsp: teaspoon

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    Contd...

    Table - 9 : Approximate Nutrient Value of Common Cooked Foods

    Item No. of Weight of cooked Energy Kcal. Fat Proteinserving preparationg. Kcal g. g.

    I. Cereals preparation

    Rice 1 K 100 110 0.1 2

    Idli 1 60 75 0.1 2

    Plain dosa 1 40 125 3 3

    Masala dosa 1 100 200 6 4

    Phulka 1 35 80 0 3

    Paratha 1 50 150 4 4

    Upma 1 K 130 200 9 5

    Sevian upma 1 K 80 130 4 3

    Bread toasted 2 slices 50 170 1 4

    Poha (Awal) 1 K 100 200 9 2

    Dhalia 1 K 140 165 7 5

    Kichidi 1 K 100 210 7 4

    Puri 1 25 80 3 2

    II. Pulses preparation

    Plain dhal 1 K 140 170 4 10

    Sambar 1 K 160 81 2 4

    Chole/Sundal 1 K 150 115 5 7

    III. Vegetable preparation

    With gravy 1 K 130 130 7 3Dry 1 K 100 115 7 2

    Bagara Baigan 1 K 170 230 20 3

    Vegetable kofta 1 K 145 220 14 4

    IV. Fried snacks

    Bhajji 1 7 35 3 0.5

    Samosa 1 65 210 12 2

    Kachori 1 45 200 12 3

    Patato Bonda 1 40 100 5 3

    Sago vada 1 30 100 6 1

    Masala vada 1 20 56 2 2

    Vada 1 20 65 3 3Dahi vada 1 80 170 9 5

    Vegetable cutlet 1 30 70 5 1

    V. Chutneys

    Coconut / groundnuts / til / coriander 1tbsp 25 64 5 3

    Tomato 1tbsp 20 10 0.3 0.3

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    VI. Non- Vegetarian preparations

    Boiled egg 1 50 86 7.0 7.0

    Omlette 1 65 155 14.0 7.0

    Fried egg 1 50 155 14.0 7.0

    Mutton curry 1 K 145 240 18 10

    Chicken curry 1 K 125 260 15 26

    Fish (fried) 2 pieces 85 220 12 18

    VII. Bakery products

    Biscuits 2 40 220 14 3

    Cake 1 40 220 13 3

    Vegetable puff 1 60 170 10 3

    VIII. Sweets

    Laddu, burfi etc. 1 60 250 15 8

    Halwa (Suji) 1 K 130 430 20 3Double ka meetha 1 K 105 280 18 4

    Custard/puddings 1 K 110 180 6 5

    Chikki 2 60 300 12 8

    Jam/Jelly 1 tsp. 7 20 0.04 0.04

    K= Katori tbsp= tablespoon, tsp= teaspoon.

    Calories and fat will depend on sugar and oil/ghee added.

    Table -10 : Salads and Calories

    Item No. Weight K.cals.(Medium size) g.

    Beetroot 1 65 30

    Cabbage 1 250 70

    Carrot 1 40 20

    Cucumber 1 90 12

    Lettuce 6 bundles 100 20

    Onion 1 50 25

    Radish 1 60 10

    Tomato 1 50 10

    Turnip 1 100 30

    Approximately 300-400 g. of a salad combination carries 100 calories. Wash vegetables thoroughly and use either raw or after a short exposure to steam

    in pressure cooker.

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    Table-11 : Fruits and Calories

    Item No./Quantity Weight (g.) K.cals.

    Apple 1 100 65

    Banana 1 80 90

    Grapes 30 100 70

    Guava 1 100 50

    Jack fruit 4 pieces 100 90

    Mango 1 250 180

    Mosambi/orange 1 100 40

    Papaya 1 piece 250 80

    Pineapple 1 piece 100 50

    Sapota 1 80 80

    Custard apple 1 130 130

    Watermelon/ Muskmelon 1 piece 100 15

    One banana is equal in terms of calories to two apples or two guavas or two mosambi or 8 pieces of watermelon.

    A mango is equal in terms of calories to 3 apples.

    Table-12 : Beverages and Calories

    Item Measure Quantity (ml) K.cals.

    Coffee 1 cup 150 100

    Tea 1 cup 50 60

    Carbonated beverages 1 bottle 200 150Fresh lime juice 1 glass 200 60

    Squash 1 glass 200 80

    Syrups (sherbet) 1 glass 200 200

    Table-13 : Calorie needs of children

    Weight upto first 10kg 100 K.cal / kg

    Weight upto first 10 - 20kg 1000 K.cal + 50 K.cal for each kg beyond 10 kg

    Weight upto first 20 - 30kg 1500 K.cal + 20 K.cal for each kg beyond 20 kg

    Table-14 : A rule of thumb for calorie requirement is

    100 K.cal / kg in first year; add 100 K.cal for each subsequent year

    Example :

    a) A child 9 month old weighing 8.5 kg requires 850 K.cals / day

    b) A 5 year old child needs : 1000 K.cal for Ist year and 400 K.cals for extra four years i.e. a total of 1400 K.cals.

    Given the above guidelines the parents can choose a suitable menu for child. The figures are average figures and individual variation in intake is expected.

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    Contd...

    Vitamin Deficiencies

    Deficiency Features Dietary supplement

    Vitamin B1(Thiamine ) Beri Beri Milk, whole grain cereals, wheat gram,

    Occurs where people consume Early: Fatigue, apathy, irritability, drowsiness, poor mental pulses, oil seeds, nuts specially

    polished rice as major food item. concentration, anorexia, nausea, abdominal discomfort groundnut, meat, f ish & eggs

    Occurs in three forms namely:

    Wet:

    Child looks undernourished, pale, edematous with dyspnoea,

    vomiting& diarrhea

    Heart weak, enlarged

    Dry:

    Peripheral neuritis. Tingling, burning & paraesthesia of toes and

    feet, decrease deep tendon reflexes, loss of vibration sense,

    tenderness & cramping of leg musclesInfantile:

    Seen in infants of 2 - 4 months of age with thiamine deficient mother

    Opthalmoplegia, polyneuritis, ataxia and mental deterioration

    Vitamin B2(Riboflavin) Ariboflavinosis Milk, peas, beans, meat, egg & green

    Cracking of skin at the corners of mouth leafy vegetables.

    Soreness and inflammation of mouth & tongue

    Eyes- Photophobia, Conjunctivitis, Keratitis, Lachrymation

    Retarded Growth in children Seborrheic dermatitis

    Vitamin B4(Niacin) Pellagra -Three Ds Beans, fish, potato, tomato, eggs,

    Dermatitis- bilaterally symmetrical, occurs only on surfaces green vegetables, meat, poultry.

    exposed to sunlight such as back of hands, lower legs,

    face & neck

    Diarrhea

    Dementia Irritability, delirium, hallucinations, disorientation

    Swelling & redness of gums & tongue

    Vitamin B6(Pyridoxine) Seizures Milk, liver, meat, egg yolk, fish, whole

    Lack of pyridoxine, a coenzyme Peripheral neuritis grain cereals, legumes, vegetables.

    usually becomes noticeable within Dermatitis

    the first 12 months of l ife in infants Anemia

    Vitamin B7 (Biotin) Dry skin, seborrheic dermatitis Biotin tabletsDeficiency occurs rarely Fungal infections

    Rashes- red patchy near mouth

    Fine & brittle hair

    Hair loss

    If untreated- hyperesthesias & paraesthesias

    Vitamin B9(Folate) Loss of apetitie, weight loss Milk, liver , meat, egg, fruits, cereals

    Commonly seen during pregnancy Weakness, headache Folic acid tablets.

    & lactation Irritability, behaviour disorders

    Womengive birth to low birth weight baby, premature infants,

    infants with neural tube defects

    DEFICIENCY DISEASES

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    Growth retardation in children

    Megaloblastic anemia in adults

    Vitamin B12 Megaloblastic anemia Liver, kidney, meat, fish, eggs, milk & Tiredness, decreased mental work capacity, decreased cheese

    concentration, irritability.

    Sub acute combined degeneration of spinal cord- numbness,

    ataxic gait

    Vitamin A (Retinol) Night blindness- inabilty to see in dim light or dark room Animal Foods- liver, eggs, butter,

    Conjunctival Xerosis- conjunctiva appears dry, not wet, milk, f ish & meat

    muddy and wrinkled Plant Foods- green leafy and cloured

    Bitot spots- triangular, pearly-white or yellowish foamy spots vegetables such as spinach,pumpkin,

    on the bulbar conjunctiva on either side of cornea. carrots, coloured fruits like papaya,

    Corneal Xerosis- cornea appears dull, dry, becomes opaque. mango.

    Keratomalacia- liquifecation of cornea i.e. cornea becomes Cod liver oilsoft, may burst leading to collapse of eye & loss of vision

    Extra ocular manifestation- follicular hyperkeratosis, anorexia

    & growth retardation.

    Vitamin D (Calciferol & Rickets in children Animal Foods- liver, eggs, butter, milk,

    cholecalciferol) Occur in children of age 6 mon.- 2 yrs fatty fish & meat, fish liver oils.

    Growth faliure, bone deformity, muscular hypotonia, tetany

    & convulsions

    Bony deformities - wide wrists, curved legs, deformed pelvis, Exposure to sunlight enhances

    pigeon chest, Harrisons sulcus, rickety rosary, kyphoscoliosis. production of Vitamin D in the body.

    Milestones like walking, teething delayed

    Osteo-malacia in adults Commonly occurs in women during pregnancy & lactation.

    Bones- soft, deformed , painful, tends to fracture easily

    Bones commonly affected- pelvic girdle, ribs, femur

    Vitamin E (Tocopherol) Neurological problems like spinocerebellar ataxia, Avocado, nuts, almonds, seeds,

    myopathies. vegetable oils, wheat germ, milk,

    Anemia due to oxidative damage of Red Blood Cells asparagus

    Fat absorption in intestine delayed resulting in greasy stools

    Chronic diarrhea, bloating

    Vitamin K Stomach pains Dark green vegetables, cows milk

    Risk of massive uncontrolled bleeding

    Vitamin C (Ascorbic acid) Scurvy Fresh fruits, citrus fruits (lemons,

    Swollen & bleeding gums oranges, grape fruits), green leafy

    Subcutaneous bruising or bleeding into the skin or joints vegetables, germinating pulses, amla,

    Loosening of teeth gooseberry, guavas, tomatoes,

    Delayed wound healing potatoes, cabbage.

    Anemia, weakness

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    Mineral deficiencies

    Deficiency Feature Dietary Supplement

    Iron Anemia Meat, liver, green leafy vegetables like

    Fatigue, pallor, irritability spinach & fruits like apple, banana,

    Weakness guava.

    Pica Jaggery (gur)

    Brittle or grooved nails

    Plummer-Vinson syndrome: painful atrophy of the mucous

    membrane covering the tongue, pharynx and oesophagus

    Impaired immune function

    Iodine Cretinism in in neonates and young children Sea foods, milk, meat

    Poor activity (lethargy) vegetables, cereals, iodized salt

    Abnormal physical growth

    Mental disability Deaf- mutism

    Squint

    Disorder of stance & gait

    Constipation

    Hypothyroidism

    Goitre - abnormal enlargement of thyroid gland in older

    children and adults

    Neck swollen, Increased body weight, subnormal intellegence,

    excessive weight gain, stunting

    Calcium Seizure in neonates and infants

    Tetany in older children and adults. Perioral anesthesia, cataracts, papilledema, and laryngeal Milk, curd, cheese, green leafy

    stridor vegetables, cereals & millets.

    Acute hypocalcemia - prolongation of the QT interval in the

    ECG, which may lead to ventricular dysrhythmias. It also

    causes decreased myocardial contractility, leading to

    congestive heart failure, hypotension and angina.

    Irritability

    Zinc Women Meat, chicken, fish, milk, cheese,

    Spontaneous abortion peanuts, beans, whole grain cereals,

    Congenital malformation- anencephaly potato, yoghurt

    Low birth weight baby Intrauterine death

    Preterm delivery

    Children

    Faliure of growth

    Sexual infantilism in adolescents

    Delayed wound healing

    Loss of taste

    Hair loss

    Wasting of body tissues

    Leukonychia- white spots on finger nails

    Loss of appetite

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    Carbohydrate and Protein deficiencies

    Deficiency Feature Dietary Supplement

    Protein Energy Malnutrition Marasmus Animal sources- Milk, meat, fish, eggs, Failure to gain weight cheese

    Weight loss resulting in emaciation

    Irritability, listlessness Vegetable sources- wheat, gram,

    Hair sparse, easily pluckable, de-pigmented peanuts, soyabean, cereals, oil seed

    Weight for height very low cakes, jaggery

    Obvious muscle wasting, atrophy and atonia

    Severe loss of subcutaneous fat

    Loss of fat from sucking pads of the cheeks may occur

    late in infants

    Face may retain a relatively normal appearance as

    compared to rest of the body, eventually becoming shrunken

    and shriveled.

    Constipation or starvation diarrhea frequent small stool

    containing mucus

    Temperature subnormal

    Low pulse volume

    Kwashiorkor

    Lethargy, apathy, irritability

    Inadequate growth

    Lack of stamina

    Loss of muscle tissue

    Increased susceptibility to infections Vomiting

    Diarrhea

    Anorexia

    Flabby subcutaneous tissues

    Edema develops early and may mask failure to gain weight.

    Edema is often present in internal organs before it is

    recognized on face and limbs

    Flaky paint or crazy pavement dermatitis darkness of skin

    but not in areas exposed to sunlight.

    Desquamation of skin followed by De-pigmentation

    Hair sparse and thin, may become streaky red or gray, can

    be pulled out easily

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