Recognition,TreatmentandPreventionofMalnutritioninAfricanChildren

DR.RÜDIGERSCHULTZ,MD.PHD,PEDIATRICIAN,TAMPEREUNIVERSITYHOSPITAL

DRSIBUTIKESANTA,ASSISTANTMEDICALOFFICERATILEMBULAHOSPITAL,PROJECTCOORDINATOR

SUVIMUJUNEN,PEDIATRICNURSE,TAMPEREUNIVERSITYHOSPITAL

YaliyomokatikakitabuDIRECTORY1 DIBAJI 3

2 MTOTOMWENYEUTAPIAMLO 4

2.1 AINAZAUTAPIAMLO 42.2 JINSIYAKUMTATHMINIMTOTOMWENYEUTAPIAMLO 62.3 MATIBABUYAMTOTOMWENYEUTAPIAMLOHATARISHI 72.3.1 MATIBABUYAAWALI 72.3.2 MATIBABUMUENDELEZO 92.3.3 VIPIMOVYAKUFANYABAADAYAMTOTOKUTOKAKATIKAHALIYAHATARI 102.3.4 NINICHAMUHIMUCHAKUKUMBUKA 11

3 KUZUIAUTAPIAMLO 12

4 LISHEBORA 15

5 THAMANIYAKUNYONYESHA 16

5.1 MAZIWAYAMAMA 165.2 JINSIYAKUNYONYESHA 185.2.1 KUMWEKAMTOTOKWENYEZIWA 195.2.2 PICHAZAKUONYESHAUNYONYESHAJIBORANAUNYONYESHAJIUSIOBORA 195.3 UNYONYESHAJIKATIKAUJAUZITO 205.4 HIVNAUNYONYESHAJI 20

6 AFYAYAMIFUPA 21

PAGEDESIGN:ANTTIKOIVISTO

1 DIBAJIPREFACEUtapiamlo katika mifumo yake yote ni tatizo kubwa sana la afya ya jamii katika nchizinazoendeleanaunahusikakwa sehemukubwakwa zaidi ya50%yavifomilioni10-11vya watoto wa umri wa chini ya miaka mitano wanaofariki kila mwaka kutokana namaradhiyanayozuilika.KutokananatakwimuzaUNICEFzamwaka2015,idadiyawatotowenyeuzitopungufu zinapungua japokuwawatotomilioni156wenyeumriwa chini yamiaka 5 walikuwa na uzito pungufu. (http://data.unicef.org/wp-content/uploads/2016/09/UNICEF-Joint-Malnutrition-brochure.pdf)

Malnutritioninallitsformsremainsamajorpublichealthproblemthroughoutthedevelopingworldandisanunderlyingfactorinover50%ofthe10-11milliondeathsinchildrenunder5yearsofagewho die each year from preventable causes. On account of UNICEF statistics stunting rates aredroppingbut156millionchildrenunder5yearsofagearoundtheworldwerestillaffectedin2015(http://data.unicef.org/wp-content/uploads/2016/09/UNICEF-Joint-Malnutrition-brochure.pdf).

KitabuhikikinaangaziautapiamlokatikakatayaIlembulanavijijivinavyozungukanchiniTanzania.Lengoletunikuwapaujuziwahudumuwaafyakuwezakuwatambuawatotowautapiamlomapema, kuwatumawatotowenye utapiamlowa kati na uliozidi hospitalinimapemakwaajiliyatiba,kuwapaelimuwakaziwawilayayaWanging’ombekuhusujinsiya kuzuia kutokuwiana kwa vyakula vya kuleta nguvu na vile vya kujengamwili katikavyakula vyao vya kila siku, kuhimiza akinamama kuwanyonyesha watoto wao, kupatavyakulavyenyevirutubishovingi,kwabeinafuukwaajiliyakuzuiautapiamlonajinsiyakutunzavyakulakatikasehemukavuilikukwepafangasiwanaohusishwanaKwashiokor.

ThislittlebookletwantstofocusonmalnourishmentfortheIlembulawardandsurroundingvillagesoftheSouthernHighlandsinTanzania.Ouraimistotrainpublichealthworkerstorecognizecasesofmalnutritionearly, referringmoderateandseverecases to IlembulaHospital forproper treatmentandtoeducatepeopleinthevillagesoftheWanging´ombedistricthowtopreventanimbalanceofprotein-energycontent intheirdailydiet,encouragingmotherstocontinuebreast feeding, findingvaluable,cheapfood-itemsfortheiroffspringtopreventmalnutritionandtostorefood items inasufficient dry environment to prevent formation of moulds which promote the development ofKwashiorkor.

MradihuuwakuzuiautapiamloniushirikianokatiyaWizarayaMamboyaNjeyaFinland,WizarayaAfya,UstawiwaJamii, Jinsia,WazeenaWatoto,Tanzania,Kanisa laKiinjili laKiluterilaTanzania,ShirikalaRotaryDoctorBanklaFinland,ChuoKikuuchaSayansichaDiaconia,FinlandnaShirikalaKikristolaAfyalaFinland.

TheprojecttopreventmalnutritionisacollaborationbetweentheForeignMinistryofFinland,theTanzanianMinistryofHealth,theEvangelicalLutheranChurchofTanzania,theRotaryDoctorBankofFinland,theDiaconiaUniversityofappliedSciencesinHelsinkiandtheChristianMedicalSocietyofFinland.

2 MTOTOMWENYEUTAPIAMLOTHEMALNOURISHEDCHILDUtapiamlohatarishiunaotokeaghaflaunatambuliwakamauwianowauzitonaurefuwachiniya70%yauzitowawastanikamailivyoainishwakatikatakwimuzanchiaukipimochasehemuyajuuyamkonokuwanamzingowachiniya110mm.Kwamtotowaumriwakatiyamwaka1na5tatizohililinaitwaMarasmus(picha1na2).Utapiamloukiambatanana uvimbe mwilini tatizo linaitwa Kwashiorkor (picha 3). Katika eneo la Afrika lililopokusini mwa jangwa la Sahara watoto wengi wenye utapiamlo hatarishi huwa pia namaambukiziyaVVUauKifuakikuu.Kundilingineambalohupatwanautapiamlohatarishiniwatotowalemavuaumtindiowaakili.KatikaWilayayaWanging’ombe,kwenyemiezisitayakwanzaya2016,kulikuwanawatoto790wautapiamlowakati,watoto30wenyeutapiamlohatarishiilhaliwatotowawiliwalikuwanautapiamloulioambatananauvimbemwilini(kwashiorkor).

Severe,acutemalnutritionisdefinedasaweight-for-heightmeasurementof<70%ofthemedianor≥3standarddeviations(SD)belowthemeanNationalCentreofHealthstatisticsreferencevaluesoramidupperarmcircumference(MUAC)of<110mm.Inachildbetween1and5yearsofageistermedwaistingorMarrasmus(Seepictures1and2).ThepresenceofbilateralpittingoedemaofnutritionaloriginistermedoedematousmalnutritionorKwashiorkor(Seepicture3).Insub-SaharanAfrica,ahighproportionofseverelymalnourishedchildrenadmittedtonutritionalrehabilitationunitsareHIVpositiveand/orhavetuberculosis.Anothergroupofchildrenatrisktodevelopseveremalnutritionarehandicappedormentallyretardedchildren.IntheWanging´ombedistrictofTanzania,atthefirsthalfof2016,790casesofmoderatemalnutritionweredetected,30caseswereclassifiedasbeingsevereand2caseswerediagnosedasoedematicmalnutrition.

2.1 AinazaUtapiamloSyndromesofmalnutrition

Kunaainambilizautapiamlokulingananamuonekanowamgonjwanauponajiwake.

Malnutritionisusuallydividedintotwosyndromesaccordingtotheirdifferentappearancesandprognosis.

Katika utapiamlo usioambatana nauvimbehakunaathariinayotokeakwenyeutumbo kwa hivyo watoto hawa wanauwezo wa kuongezeka uzito na kurudikatikaafyanjemawakipaalishebora.

InwaistingorMarrasmusforunknownreasonsthebowelremainsunharmedandthesechildrenarecapabletoregainweightandanormalnutritionalstatusifasufficientandbalancedcalorie-proteindietisstarted.Noticethemarkedatrophyoftheadductormusclegroupleavinganemptysack.

Picture1 Picture2

Uvimbe unaozidi zaidi kwenyemaeneo yamiguuni pamoja na usoni. Katikakwashiorkorhakunaprotinikwenyemkojo.

Typicaloedematouschangeswithpittinginthelowerextremitiestogetherwithswellingoftheeyelidssimilartofindingsobservedinnephroticsyndrome.InKwashiorkorproteinuriaisabsent.

Utapiamlo unaoambatana na uvimbe wa mwili mara nyingi hupatikana katika sehemuambazowanaupungufuwavyakulavyakujengamwili. Japokuwasasahivi inafahamikakuwa ukosefu wa vyakula vya kujenga mwili peke yake sio chanzo cha tatizo hili.Utapiamlo unaoambatana na uvimbe wa miguuni unasababishwa na matatizo yakimazingira, kwa jina la kitaalam Noxae. Kinga za kumlinda mtoto dhidi ya tatizo hilihuharibiwa na upungufu wa virutubisho vingi. Pia chanzo kingine cha utapiamlounaoambatana na uvimbewamwili ni kutokuwa na uwiano kati ya utengenezwaji wasumu mbalimbali mwilini na uondoaji wa sumu hizo mwilini. Sumu mwilini zinawezakutokananamaambukizimbalimbaliausumuzavyakulakwamfanoAflatoxinambayonisumu kali na yenye uwezo wa kusababisha saratani. Sumu hii hutengenezwa na ainafulani ya fangasi (Aspergillus flavusandAspergillus parasiticus) wanaostawi kwenyeudongo, majani yanayooza, majani ya kulishia mifugo na nafaka. Mara nyingi fangasihawa wanapatikana katika vyakula ambavyo havijatunzwa kwa usalama kwa mfanomihogo,pilipili,mahindi,mbeguzapamba,ulezi,karanga,mchele,alizeti,korosho,nganonaviungombalimbali.Hivyobasiutunzajiwanafakakatikamazingirayaukavunisehemumuhimu sana katika kuzuia utengenezwaji wa aflatoxin. Vyakula vyenye fangasivinapotumiwa aflatoxin huingia kwenye mzunguko wa chakula ambapo imeonekanakupatikana katika vyakula vya binadamu na wanyama wafugwao. Mifugo ikilishwavyakula vyemye aflatoxin basi sumu ya aflatoxin inaweza kupita hadi kwenye mayai,maziwanabidhaazitokanazonamaziwanakwenyenyama.Kwamfanovyakulavyakukuambavyovimetunzwapasipoumaakinivimehusishwanakuwepokwasumuyaaflatoxinkwenye nyama ya kuku na mayai. Kwa watoto aflatoxin inasababisha ukuaji hafifu,unyafuzi,utapiamlounaoambatananauvimbewamwili,uharibifuwa ininasarataniyaini.

Oedematousmalnutritioniscommonlyseeninareaswherehighenergy-lowproteinfoodsarethestaplediet.However,theconceptthatproteindeficiencycausesthisformofmalnutritionhasnowbeenrefuted.Itisthoughtthatoedematousmalnutritionisprecipitatedbyavarietyofenvironmentalinsults,termednoxae.Thechildsprotectivemechanismsarecompromisedbyawholerangeofdietarydeficienciesordepletions.Oedematousmalnutritionresultsfromanimbalancebetweentheproductionoftoxicradicalsbythenoxae(substancesorenvironmentalstimuliwhichhaveaharmful,pathogenicinfluenceonthebody)andtheirsafedisposal.Important

Picture3 Picture4

noxaeareinfectionsorexogenoustoxinslikeaflatoxinanditsmetabolites.Aflatoxinsarepoisonousandcancer-causingchemicalsthatareproducedbycertainmolds(AspergillusflavusandAspergillusparasiticus)whichgrowinsoil,decayingvegetation,hayandgrains.Theyareregularlyfoundinimproperlystoredstaplecommoditiessuchascassava,chilipeppers,corn,cottonseedmillet,peanuts,rice,sesameseeds,sunflowerseeds,treenuts,wheat,andavarietyofspices.Thereforethedrystorageofgrainisofuttermostimportanceforthepreventionofaflatoxinformation.Whencontaminatedfoodisprocessed,aflatoxinsenterthegeneralfoodsupplywheretheyhavebeenfoundinbothpetandhumanfoods,aswellasinfeedstocksforagriculturalanimals.Animalsfedcontaminatedfoodcanpassaflatoxintransformationproductsintoeggs,milkproducts,andmeat.Forexample,contaminatedpoultryfeedissuspectedinthefindingsofhighpercentagesofsamplesofaflatoxincontaminatedchickenmeatandeggs.Childrenareparticularlyaffectedbyaflatoxinexposure,whichleadstostuntedgrowth,delayeddevelopmentoedematousmalnutrition,liverdamage,andlivercancer.

2.2 JinsiyakumtathminimtotomwenyeutapiamloAssessingthemalnourishedchild

A. Utapiamlokidogonihaliambapouzitowamtotoumeshukakwakiwangokidogotuukilinganishwanaurefuwamtoto.Kiwangochadamumwilinihuendakikawapungufulakinitofautinahapodalilizinginezautapiamlohuendazisionekane.

B. Utapiamlowakatihujidhihirishakwadalilikamatulizozionahapojuunakiwangocha damu huwa kinapungua kwa kiasi cha kati (600-800mg/l). Nyayo huanzakuonyeshadalilizakuvimbanamisulihuanzakunyauka.Ininalohuanzakuvimba.Kwawatotowaumriwamitatuuotajiwamenohuwezakuchelewanapiahuwawanaanza kuonyesha dlili za matege na hasa iwapo watakuwa na ulemavuulioambatana au mtindio wa akili. Nywele hao huwa na rangi nyekundu nakupuktuikaupesi.

C. Kwenyeutapiamlohatarishi,pamojanakuwanadalilizautapiamlowakatihuwapiaanaonyeshahaliyahasira,aumanung’unikoaupiaanawezaakawanahaliyakupotezafahamu.Inihuwalinavimbakishakunakuwanamabadilikokwenyengozi( ngozi kukauka, kubanduka na kubadilika rangi). Miguu na uso huvimba sana(Kwashiokor)aumotohuishiakukondasananakupunguamisuliyake(Marasmus).Kiwango cha damu mwilini huwa cha kati au kupungua sana. Pia anawezakupungukiwanamajimwilini.

A. Mildmalnutritionisaconditionwhenthechildhasnotyetreachedthecriteriadepictedabovebutshowsacleardownslopeontheweight-for-heightcurve.Thehaemoglobinvaluemightbealreadyslightlyabnormalbutnoothersignsofmalnourishmentareyetvisible.

B. Moderatemalnutritionfitsthecriteriamentionedabove,thechildisusuallymoderatelyanaemic(Hb60-80mg/dl).Thearchesofthefeetmightbeslightlyswollenortheadductormusclegroupshowssignsofatrophy.Oninvestigationthelivermightbeslightlyenlarged.Inchildrenunderthreeyearsofageteethingmightbedelayedandsignsofricketsvisibleespecially,ifthechildishandicappedormentallyretarded.Thehairmightappeareasilypluckableandreddishincolour.

C. Inseveremalnutrition,inadditiontothesignsofmoderatemalnutrition,thechildshowssignsofirritabilityorapathyorevensemi-consciousness.Theliverisclearlyenlarged(fatty

liver).Progressiveskinchangesareusuallyseen.Hyperpigmentedanddryskinisfollowedbyflaking,peelingandhypopigmentation.SevereoedematicswellingofthefootarchesandeyelidsispresentinKwashiorkor(seepicture3).Inthewaistingformofmalnutrition(Marasmus)theadductormusclegroupisseverelyatrophiedleavinganemptysackwheninvestigated.Oftenmoderatetosevereanaemiaispresentandthechildmightbeseverelydehydrated.

2.3 MatibabuyamtotomwenyeutapiamlohatarishiTreatingtheseverelymalnourishedchild

2.3.1 MatibabuyaawaliResuscitationphase

Matibabu ya mtoto yeyote mwenye utapiamlo yanatakiwa kufuatiliwa kwa karibu namuuguzi.

• Pundeafikapomgonjwaapatemililita50yamajiyasukari.Majihayahuandaliwakwakukorogasukarikiasichavijikovitatuvyachaikwenyemililita50zamajisafiyakunywa.

• Iwapomtotoatakuwaamekaukiwamajinimuhimukumrudishiamajimwilini.Njiabora kuhakikisha kuwa anapata kiasi cha kutosha ni kupitiampirawa kumlishiakupitiapuani.

• Atarudishiwa kiasi kinachohitajika kwa kutumia mchanganyiko uitwao ReSoMal(Pocket book of hospital care for children: guidelines for the management ofcommon illnesses with limited resources) ambao ni tofauti kidogo namchanganyikowaORSunaotumiwakutibuugonjwawakuharisha.

• ReSoMal hutengenezwa lita 2 za maji, pakiti moja ya ORS, gramu 50 za sukari(vijiko vitano vya chai vya sukari) na mililita 40 za mchanganyiko maalumu wamadini. Kama mchanganyiko huo haupatikani tunaweza kutumia mililita 45 zamchanganyikowapotassiumchloride.

• MpemtotohuyumgonjwamchanganyikohuuwaReSoMalkwakiasichamililita5kwakilakiloyauzitowakekilabaadayanususaakwamasaamawiliyakwanza.Baadayahapoendeleakumpakiasi chamililita5-10kwakilakiloyauzitowakekilabaadayasaamojakwamasaamannehadikumiyanayofuata.

• Kiasikamilichakumpakitategemeaunywajiwamtoto,iwapoanatapikanaiwapoanaharisha.

• Epukakumrudishiamtotomajikwanjiayadripuisipokuwapaleambapoupungufuwakemajiunaathirimzungukowakewadamumwilini.

• Iwapo baada ya masaa hayo bado mtoto atakuwa anahitaji kuongezewa majitumiadripuyaainaya½strengthDarrowssolution lakiniusimpezaidiyamililita150kwakilakiloyauzitowakendaniyamasaa24.

• IkiwaanaharishapiaapatedawayaainayaPrecosamiligramu250marambilikwasikukwasiku7auPedizinckidongekimojamarambilikwasiku7-14.

• Baada ya kumrudishia mtoto maji aliyoyapoteza anza kumlisha kila baada yamasaamawilikwakutumiamaziwaainayaLactogenkiasichamililita11kwakilakiloyauzitowake.Anatakiwakulishwausikunamchana.

• Ikiwamtotoanauvimbemwingimwilinipunguzakiasihikikiwemililita8kwakilakiloyauzitowakekilabaadayamasaamawiliusikunamchana.

• Kwa sehemu ambayo maabara ina uwezo ni bora kupima viwango vya madinikwenyedamunahasasodiumnapotassiumnaiwapomadinihayayamezidibasimtibumtotokwamatatizohayo.

• Mtibu mtoto kwa homa yoyote inayomsumbua. Iwapo hajachemka mtibu kwakutumia Cotrimoxazole (Trimethoprimmiligramu 4/ Sulfamethoxazolemiligramu20kwakilakiloyauzitowakemarambilikwasiku)

• Iwapo ana homa kali mpe dawa kwa njia ya sindano kwa kutumia Ampicillinmiligramu 50 kwa kila kilo ya uzitowake kila baada yamasaa 6 naGentamycinmiligramu5kwakilakiloyauzitowakemaramojakwasiku.

• Piani vizuri kuhakikisha kuwamtotohuyohanauambukiziwamudamrefu kwamfanomaambukiziyaVVUaukifuakikuu.

• Baadhi ya watoto wanaoumwa kwashiokor hupata vidonda kwenye ngozi namidomoni. Tumia dawa ya aina ya GV kupaka kwenye vidonda ili kusaidiakuvikaushavidonda.

• Iwapo vidonda hivyo vitakuwa vinatoa usaha au vikiwa na unyevu unyevumwogeshe mtoto kwa kutumia maji yaliyochanganywa na dawa ya Potassiumpermanganate yenye nguvu ya 1% kisha mpe dawa ya Cloxacillin kwa ajili yakuwauawadudu.

• PiampemtotodawayamatoneainayaNystatinkiasichayuniti100000ambayonisawa na mililita 1, mara 4 kwa siku. Hii ni kwasababu ya kutibu vidondavinavyosababishwanafangasimdomoni.

• Hakikisha kuwa watoto wote wenye kwashiokor wanatunzwa kwenye sehemuyenyejoto.Badilishanguozaopundezinapolowa.Njiaborayakuhakikishakuwawanapata joto la kutosha ni kuwalaza jirani na miili ya mama zao na piakuwafunikakwakutumiablanketizakutosha.

Dalili zakuonyeshakuwamatibuyaawaliyamefanikiwanimtotokupatahamuyakula.Baada ya kuwapa matibabu haya ya awali tutakuwa na uhakika wa usalama wao wakiafyanahatuaitakayofuatanitibamuendelezo.

Makeatrainednurseresponsiblefortreatmentandfollowupofeverymalnourishedchild

• Onadmissiongive50mlofsugarwater(3teaspoonfulofsugarin50mlofwater)ifbloodsugarislow.

• Ifdehydratedstartimmediatly”oral”rehydrationusinganasogastrictube,1/3dilutedORS(1000mlofORS+500mlofcleanwater).Giveto500mlofthesolutionadditional2teaspoonfulofsugar.Give5ml/kgevery30minutesforthefirsttwohours.Then5-10ml/kg/hourforthenext4-10hours.

• IfthechildhasdiarrhoeagivePrecosa250mgx2/dayforaweek.

• Ifmorerehydrationisneeded,preventtogivefluidsinexcess.Ringeror½strengthDarrow15ml/kgduringthefirsthour.Dontgivemorethen150ml/kg/24hours!

• Whenrehydratedstartoralfeeding2-hourly(dayandnight)usingLactogenmilk11ml/kg/feedforthefirsttwodays.Ifsevereoedemaispresent,reduceto8ml/kg/feed.

• Ifpossibleassesstheelectrolytestatus.Treathypo-orhypernatraemia,hypo-orhyperkalemia.

• Treatinfectionspromptly.EvenifnofeverispresentgiveCotrimoxazolesyrup:8mg/40mg/kg/day=1ml/kg/daydividedin2doses.Ifnecessaryivantibiotics:ampicillin50mg/kg6hourlyorchloramphenicol25mg/kgivandgentamycin5mg/kgimx1/day.ConsiderchronicinfectionslikeTBorHIVlater.

• GentianaVioletpaintisgoodforsmallinfectedareasontheskinandlips.• GiveNystatin100.000Unitsx4/day• Septicskinlesionscanbetreatedforinstancewithsitbathsin1%potassiumpermanganate.

Ifneededgivecloxacilliniv.• KEEPTHECHILDWARM,sleepingclosetomothersbody.Changewetclosesimmediatly,give

extrablanket.

• Measuretheweightofthechildeveryseconddayduringthefirstweekoftreatment

2.3.2 MatibabumuendelezoStabilizationphase

• Mpemtotowautapiamlovitamininamadini.ApateVitaminApundeanapolazwa:o umriwachiniyamiezi6:50.000Unitso miezi6-12:100.000Unitso zaidiyamiezi12:200.000Units

• Iwapoanatatizolavidondamachonirudiadoziuliyompasikuyapilinatenabaadayawikimbili..

• IwapoinilimevimbamchomesindanoyaVitaminK1mg• Kilamtotoapatefolicacidkidongekimojakilaanapolazwakishaaendeleekupata

robokidongekwawikimbili.• KilamtotoapateMultivitamin(bilamadinichuma)kidongekimojax1/siku• KilasikumtotoapatePediatricZinc10mgx1/kwasiku• Ikihitajimtotoapate,Potassiumconcentrate15%,0.5ml/kgod2/52• MadiniyaPotassiumyanahusikasananamfumowautendajikaziwamoyonapia

utendajikaziwamfumowachakulanahasatumbolachakula.• Kuanziasikuyatatuanzakumpamtotovyakulavyakawaidakilabaadayamasaa

manne.PiampemaziwayaLactogen22ml/kwakilakiloyauzitox6/kwasiku.• Mtoto mwenye utapiamlo ana kiasi kikubwa cha madini ya Sodium kw hivyo

punguzakiasichasodiumkwenyechakula.• Mwishowamatibabuyaawaliunatambulikakwakurudikwahamuyakulapamoja

nakupunguwakwauvimbe. • Mtotoanayetibiwautapiamloapatiwakiasi chochotechachakulaambachoyupo

tayarikula.Lengokwasikunikipimocha130-200kcalkwakilakiloyauzitowake

kwa siku. Kwa mfano 100lcal zinapatikana katika mililita 100 za maziwa. Kwamaanahii nimuhimu apate na vyakula vingine. Sura inayofuata ya chapishohiliitaonyeshavyakulavinavyopatikanakatikamazingirayetupamojanakiasi chakekwakipimochacalories.

• Baada ya juma la kwanza lamatibabumpimemtotouzitowakemaramoja kwawiki.

• Givevitaminsandminerals• VitaminAstatdoseonadmission:

o agelessthan6months:50.000Unitso age6-12months:100.000Unitso over12months:200.000Units

• Ifsignsofceratomalaciaarepresentrepeatthesamedoseon2nddayandonceagainaftertwoweeks.

• IfliverisenlargedgiveVitaminK1mgim• Foreverychildfolicacid5mg(1tbl)onadmission.Thereafter¼tablet(1.25mg)od2/52• Multivitamin(withoutiron)x1/day• PediatricZink10mgx1/dayaslongasstationary• Ifneeded,Potassiumconcentrate15%,0.5ml/kgod2/52• (Potassiumaffectsnotonlythecontractibilityoftheheartbutalso• gastricemptying)• Fromdaythreeonwardstartoralfeedingfourhourly.GiveLactogen22ml/kgx6/day.• Malnourishedchildrenshouldreceivealowsodiumdietbecausetheyhaveparadoxically

hypernatremia• Theendoftheresuscitationphaseischaracterisedbyareturnofappetite,alongwithlossof

oedema.• Thechildshouldreceiveasmuchfoodasitiswillingtoeat.Theaimis130-200kcal/kg/day.

Forinstance100kcalare100mlofmilk,sootherfooditemsareneeded.Optimalfeedingonlocalfoodstakingcalorieintakeintoaccountwillbeshowninthenextchapter.

• Afterthefirstweekoftreatmentmeasuretheweightonceaweek.

2.3.3 VipimovyakufanyabaadayamtotokutokakatikahaliyahatariTestsafterthechildisstable

• Kiwangochadamu• Pichayakifua• KipimochamaambukiziyavirusivyaHIV• Protinikwenyemkojo• Kiwangochachembechembezadamu• Choonamkojo• KiwangochamadiniyaPotassium,Sodium,ManganesenaCalcium

• Hbifneeded• Chestx-ray

• TestingforHIV• Urineproteins(ifnecessarytodistinguishfromnephroticsyndrome)• FullbloodpictureandESR• Stoolandurineanalysis

• PotassiumandSodium,Magnesium,Calcium

2.3.4 NinichamuhimuchakukumbukaRulestoberemembered

• Kila mtoto anatakiwa kuwa na muuguzi wake kwa ajili ya kufuatilia lishe yakebaadayamatibabuyaawali

• Tengenezaratibamaalumkwaajiliyamudawakula• Pimauzitowamtotomarambilikwawikiyakwanzakishamaramojakilawiki• Kwamtotoaliyemalizamatibabuyaawalimpeujinamaziwa• Baadayayeyekuzoeampevyakulavyakawaida• Iwapomtotohuyoatalazwatenakwamatatizohayonimuhimukuangalia iwapo

kunamatatizoyakijamii.

• Haveapersonalnurseforeverymalnourishedchildtocontrolfeedingalsoaftertheacutephase

• Makeadetailedscheduleoffeedingtimes• Controlweightduringthefirstweektwice/weekandthereafteronce/week• Startstabilizationwithlactogenandporridge• Addsolidfoodslateron• Ifthesamechildisreadmittedafterrecoveryagainforthesameproblemconsidersocial

measures

3 KUZUIAUTAPIAMLOPREVENTINGMALNUTRITIONLengo la juhudi zote katika huduma za afya barani Africa ni kuanzisha vituo vya afyavinavyotoa huduma na ambavyo vatoa huduma wa afya wanachukua jukumu lakusuluhishamatatizoyakiafya.Nilazimakuwaondoataratibuwatoahudumawanchizakigeni ili kuhakikisha kuwa huduma zinakuwa endelevu na kuweza kuwategemeawataalamu wazawa. Zoezi la kuzuia utapiamlo litawezekana tu endapo elimu kuhusuchakulaborakwawatotoitaeneavijijiikupitia watoahudumawaafyanawataalamwalishe.

TheaimofeveryeffortinmedicalhealthcareinAfricamustbetheestablishmentoffunctional,localfacilitieswherelocalhealthcareprofessionalstakeresponsibilitytofightmedicalhazards.Thewithdrawalofforeignprofessionalstheniscompulsorytoensureself-sufficiencyandcontinuity.Thepreventionofmalnutritionisonlythensuccessfuliftheknowledgeofabalanceddietforchildrenisspreadingintotheremotevillagesbyteachingandcontrolthroughlocalhealthcareworkersandnutritionists.

Katika kupunguzautapiamlo vyakula vinavyopatikanakatikamazingira yaasili ambavyovina kiasi kikubwa cha protini ni lazima vitambulike na jamii kuelekezwa. Pia taarifapotofu kuhusu unyonyeshaji lazima zisasihishwe na akinamamawahimizwe kuendeleakunyonyeshawatotowao iwapowanashikaujauzitomapema.Pianimuhimukufahamuutunzajimzuriwanafaka kuzunguauotajiwa fungus zenye sumuwakatiwamsimuwamvua.

Inthepreventionofmalnutritionlocalfooditemswithahighproteinvaluehavetobeidentifiedandpresentedtothepublic.Wrongknowledge,especiallyaboutbreastfeedingmustbeclearedoutandmothersmustbeencouragedtocontinuebreastfeedingdespiteaprobablenewpregnancy.EspeciallypreventionofKwashiorkordemandsthedrystorageofgraintopreventtheformationofmouldsduringtherainyseason.

Jedwali(Table)1vyaVyakulaasilivinavyowezakutumikakuzuiautapiamlo.Dailyallowancesforproteinandenergyintoddlers.

Weightinkg

Needforenergy≈95kcal/kg*

Needforproteing/day(intotal)

Needforproteinofbiologicalvalueg/day

6 570 7 4

9 855 10 6

12 1140 13,5 8

15 1425 16,5 10

*Alternativelytheneedforenergycanbeevaluatedusingtheequation:98kcal/kg–(agex3)kcal

Katika swala la utapiamlo nimuhimu kuzingatia umuhimuwa uwiano kati ya vyakulavinavyoliwanauwezowakewakuletanguvumwilini.VyakulavyenyekaisikikubwachanguvunakiasikidogochaprotinikwamfanomihogoikitumikakwakiasikikubwahuwezakusababishaMarasmusauKwashiokor.Kwahivyonimuhimupiakuwekauwianokatiyavyakulavyaprotininavyakulavyawanga,pamojanakiasichautoshachavitamin,madininamafuta.

Concerningmalnutrition,thebalanceofenergy-andcaloricintakeiscritical.Fooditemswithahighcaloricvaluebutlowinproteincontentasforinstancecassavalead,whenusedasthemainfoodsupply,toproteindeficiencyandeventuallycausethedevelopmentofMarasmusorKwashiorkor.Inadditiontotheneedofabalanceinprotein-andcaloricintake,ahealthyandbalanceddietincludeasufficientandbalancedcontentofvitamins,mineralsandfat.

Fooditem Energyinkcal Proteiningrams Energyinkcal Proteiningrams per100g per100g perportion/piece perportion/piece_______________________________________________________________________________Egg 130 12.5 70(1piece) 6.5Milk(fat4.4%) 70 3.0 70(1dl) 3.0Formula 65 1.3 65(1dl) 1.3Potato 75 1.9 45(1piece*) 1.1Sweetpotato 80 1.6 45(60g) 1.1Riceporridge 45 1.0 45(1dl) 1.0Maizeporridge 35 0.9 35(1dl) 0.9Beans(cooked)115 8.5 45(½dl) 3.5Cashewnuts 570 20 100(2tblsps) 3.5Avocado 195 2.6 95(½piece) 1.3Mango 55 1.1 30(1/4piece) 0.6Banana 85 1.1 50(½piece) 0.6Papaija 55 1.1 30(1/4piece) 0.6Grashopper 55-75%ofbodyweightSilvercyprinid(dagaa/mukene) 53-58.8%ofbodyweight ---------------------------------------------------------------------------------------------------------------------------------*about60gramsandsizeofanegg

Jedwali(Table)2

1½TABLESPOONFULOFWELLCOOKEDMEATOR100MLOFMILK

HALFANEGGOR100-150MLOFBEANS

150MLOFBROWNRICEOR300-400MLOFRICEORMAIZEPORRIDGE

2½TABLESPOONFULOFPEANUTSOR7GOFDRIEDSILVERCYPRINID(DAGAA)

Jedwali(Table)3Examplesoffooditemswiththecontentof3-4gramsofproteinsufficientforthedailyallowancesinachildwith6kgofweight

4 LISHEBORABALANCEDDIETPamoja na kuwepo na uhitaji wa kiasi kinachotosha cha protini na vyakula vya wangakunaumuhimuwauwepowamadini, vitaminna vyakula vyamafuta.Wizara yaAfya ,Maendeleo ya Jamii, Jinsia,Wazee naWatoto imechapisha mwongozo wa vyakula namatunzokwawatuwanaoishinaVVU(NationalGuidelinesforNutritionCareandSupportforPLHIV-February2009)naMwongozowaUlishajiwaWatoto,(NationalGuidelinesforInfantandyoungchildfeeding2013).Machapishohayayanatoamaelekezokuhusuainambalimbalizavyakulanaswalazimalalishebora.

Inaddition toasufficientandbalanceddiet in termsofenergyandproteincontent,minerals,vitaminsandessentialfattyacidsareneeded.TheMinistryofHealthandSocialWelfareoftheUnitedRepublicofTanzaniahaspublishedNationalGuidelines,promotingnutritionalcareandsupport for people living with HIV (National Guidelines for Nutrition Care and Support forPLHIV-February 2009) and National Guidelines for infant and young child feeding (NationalGuidelines for Infant and young child feeding 2013). The booklets depict different groups offooditems,whichcovertheoveralldiversityofabalanceddiet.

Makundiyavyakulavinavyojumuishwakwenyelisheborani:

1 Nafakanamizizi;2 Jamiiyamaharagenakaranga;3 Maziwanavyakulavinavyotokananamaziwa;4 Nyama,samaki,kukunandegenabidhaazake;5 Mayai;6 MatundanambogazamajanizenyeVitaminA;7 Matundanambogazamajani.

Thefoodsgroupsusedtoensureabalanceddietare:

1. Grains,rootsandtubers;2. Legumesandnuts;3. Dairyproducts(milk,yogurt,cheese);4. Fleshfoods(meat,fish,poultryandliver/organmeats);5. Eggs;6. Vitamin-Arichfruitsandvegetables;7. Otherfruitsandvegetables.

Lisheborakwawatotowaumriwamiezi6-23itapatikanaendapomtotohuyuatapokeavyakulakutokaaangalumakundimannekatikahayoyaliyotajwa,kwamantikihiyo,kwasehemu nyingi kuna kuwa na uwezekanomkubwa zaidi wamtot kupata aina moja yachakulachaasiliyawanyamanatundaaumbogamajanipamojanavyakulavyanafaka.

Dietarydiversityfora6-23montholdchildisestablishedifthechildreceivesfooditemsfromatleast4foodgroupsonthepreviousday,whichwouldmeanthatinmostpopulationsthechildhadahighlikelihoodofconsumingatleastoneanimal-sourcefoodandatleastonefruitorvegetablethatday,inadditiontoastaplefood(grain,rootortuber).

5 THAMANIYAKUNYONYESHAVALUEOFBREASTFEEDINGKunyonyesha ndio njia bora ya kumpamtotomchanga virutubisho anavyo hitaji katikaukuaji wake. Pia kunyonyesha ndio njia rahisi, safi na yenye gharama nafuu katikakumlisha mtoto. Akina mama wote wana uwezo wa kunyonyesha. Cha muhimu nikwamba wapate taarifa sahihi kuhusu kunyonyesha na pia msaada kutoka kwa watoahudumazaafya.

Breastfeedingisthebestwaytoprovideyounginfantswiththenutrientstheyneedforhealthygrowthanddevelopment.Itisalsotheeasiest,mosthygienicandcost-effectivewaytofeedachild.Allmotherscanbreastfeed,theyjusthavetobeprovidedwithaccurateinformation,andsupportofthehealthcaresystem.

Inapendekezwakumnyonyeshamtotobilakumpachakulakinginechochotehadiafikapomiezi sita ya umri na kisha baada ya hapo kumnyonyesha pamoja na kumpa vyakulavinginehadiafikapoumriwamiakamiwili.Inapaswakuanzakumnyonyeshamtotondaniyasaamojabaadayamamakujifungua.

Exclusivebreastfeedingisrecommendedupto6monthsofage.Afterthatitispossibletobecontinueduptotwoyearsofageorbeyondalongwithappropriate,complementary,solidfoods.Inaddition,breastfeedingshouldbestartedimmediatelyafterthechildisborn(withinthefirsthourofbirth).

Kunyonyesha pia kuna faida kwa mama. Kunyonyesha humsaidia mama aliyejifunguakurudikatikahaliyaafyabaadayakujifunguaSambambanakupunguzahatariyakupatasaratani ya maziwa na mayai ya kike, kisukari na msongo wa mawazo baada yakujifungua.

Breastfeedingalsobenefitsthemotherherself.Ithelpstorecoverfromthechildbirthanditreducesrisksofbreastandovariancancer,typeIIdiabetesandpostpartumdepression.

5.1 MaziwayamamaBreastmilk

Kunaainatatuzamaziwayamama

1. Maziwayamwanzo:Yanapatikanakatiyasikuya1hadiya7.Hayayanampamtotokingakutokakwamamanavirutubishovyakumkuuzamtotonapiakumlindadhidiyamaambukizinakifo.

2. Maziwayampito:Hayayanatokakaiyasiku8hadi20nanikipindichampitokatiyamaziwayamwanzonamaziwayaliyokomaa.

3. Maziwa yaliyokomaa: Haya ni kuanzia siku 20 na kuendelea kwa kipindi choteambachomamaatamnyonyeshamtoto.Nayoyanampamtotoulinzinavirutubishovingine.

Therearethreetypesofbreastmilk:

1. Colostrum,theinitialmilk(1-7days),constitutesthebaby’sfirstimmunizationbytransferringvitalantibodiesandgrowthfactorsfromthemothertothechild,preventingearlydeathandprotectingthenew-bornsfrominfections.

2. Transitionalmilkisthetransitionfromcolostrumtomaturemilk,wherelactationisestablishedandproductionofmilkbeginsinthebreasttissue.Transitionalmilkisproducedfromapproximatelyday8–20.

3. Maturemilkisproducedfromday20afterbirthandonwards,aslongasthemotherwillbreastfeed.Itcontinuestoprovideimmunefactorsandotherimportantnon-nutritionalcomponentstotheinfant.

Maziwayamamayanavirutubishovyoteambavyomtotoanahitajikwaajiliyakukua:

• Maji• Protini:asilimia75yamaziwa• Mafuta• Wanga• Madininavitamini

Breastmilkcontainsallthenutrientstheinfantneedsforpropergrowthanddevelopment:

• Freewater• Proteins–Proteinaccountsfor75%ofthenitrogen-containingcompoundsandthenon-

proteinnitrogensubstancesincludeurea,nucleotides,peptides,freeaminoacidsandDNA.• Fats–Essentialfattyacidsandlong-chainpolyunsaturatedfattyacids• Carbohydrates–Theprincipalcarbohydrateofhumanmilkislactose.

• Minerals,vitamins,andtraceelements.

Kirutubisho

Component

Kiasikatikamaziwayaliyokomaa(kwa100ml)

Meanvalueformaturebreastmilk(per100ml)

Energy(kcal) 67

Protein(g) 1.4

Fat(g) 4.2

Carbohydrate(g) 7.0

Sodium(mg) 15

Calcium(mg) 35

Phosphorus(mg) 15

Iron(mcg) 76

VitaminA(mcg) 60

VitaminC(mcg) 3.8

VitaminD(mcg) 0.01

Jedwali(Table)4VirutubishomuhimuvipatikanavyokwenyemaziwayamamaCompositionofsomeofthekeynutrientsfoundinbreastmilk

Maziwa ya mama yana viungo ambavyo sio virutubisho kwa mfano vichochezi vyakusaidiammeng’enyowachakula,vichochzivyakusaidiakatikaukuajiwamtoto,nakingadhidiyamaambukizimbalimbali.

Breastmilkalsocontainsimportantnon-nutritionalcomponents,suchasantimicrobialfactors,digestiveenzymes,hormonesandgrowthfactorsthatareimportantforpassiveprotectionagainstinfectionsandimmune-mediateddiseasesandmodulateimmunologicaldevelopment.

5.2 JinsiyaKunyonyeshaHowtobreastfeed

Mtotoanapaswakunyonyeshwamarakwamara(kilabaadayasaa1-masaa3)kutokanana uhitaji wa mtoto. Mtoto anatakiwa kunyonya maziwa yote mawili. Kipindi chakunyonyakinawezakudumudakika15–20auzaidikwakilaziwa.Mamaatafahamupaleambapomtotoametosheka.

Thechildshouldbebreastfedoftenenough(every1-3hours)orasoftenasthechilddemandsit,andfrombothbreasts.Feedingsmaybe15to20minutesorlongerperbreast,thereisnosettime.Thebabywillletthemotherknowwhenheorshehasfinished.

Tumbo la mtoto mchanga ni dogo na hasa katika siku za mwanzo baada ya kuzaliwa.Baadayakuanzakunyonyawatotowanaonyonyamaziwayamamabilavyakulavinginekatiyaumriwamwezi1hadimiezi6huwawananyonyagramu300hadi900kwasiku.

Anew-born’sstomachisverysmall,especiallyshortlyafterbirth.Oncebreastfeedingisestablished,exclusivelybreastfedbabiesfromage1to6monthsdrinkbetween300and900gramsperday.

Vipindivyaukuajiwakasivinawezakumsababishamtotokunyonyamaranyinginakwamudamrefuzaidi.Vipindihivivyaukuajihuwavinatokeamtotoanapokuwakatikaumriwawikimbilihaditatu,wikisitanamiezimitatunahatakatikaumrimwinginewowote.Akina mama wanapaswa kujuwa kuwa maziwa ya mama yanatosha kabisa kukidhimahitaji ya mtoto. Kadri ambavyomama ananyonyesha zaidi ndivyo ambavyomaziwayanatokakwawingizaidi.Kumbuka:Kunyonyeshwazaidikunatoamaziwazaidi.

Growthspurtsmayincreasetheaswellfrequencyasthetimeababywant´stobenursed.Thesegrowthspurtsmayoccurattwotothreeweeks,sixweeks,andthreemonthsofage.Theymayalsooccuratanyothertime.Themothershouldbeinformedhowever,thathermilksupplyisnottoolowtosatisfyherbaby.Themothershouldfollowherbaby´sneeds–nursingmoreandmoreoftenwillhelptoincreasetheproductionofbreastmilk.Remember:Morebreastfeedingproducesmoremilk!

5.2.1 KumwekamtotokwenyeziwaBringingthebabytothebreast

Ni muhimu sana mtoto kukamata ziwa vizuri ili aweze kunyonya vizuri na mamakunyonyeshakwaStarehe

• Mtekenyemtotokwenyeshavukumfanyaafunguemdomo• Msogezemtotoilitayalalitanguliekusogeakwenyeziwa• Sogeza ziwa ndani mdomoni kuwezesha mtoto kupata sehemu kubwa

iwezekanavyoyaziwa.

Agoodlatchisveryimportantforthebabytobreastfeedeffectivelyandformotherscomfort!

• Ticklethebaby’slipstoencouragehimorhertoopenwide.• Pullthebabyclosesothatthechinandlowerjawmovesintothebreastfirst.• Watchthelowerlipandaimitasfarfromthebaseofthenippleaspossible,sothebaby

takesalargemouthfulofbreast.

5.2.2 PichazakuonyeshaunyonyeshajiboranaunyonyeshajiusioboraAgoodexampleofproperandimproperlatches

A, B: Mtoto amekamata chuchuvizuri na anawezesha maziwakufikamdomonivizuri

Youcanseethatthebaby'slipsareopenandtakinginmostoftheareolawhichhelpsthenippletogetbackfarenoughtoletthetonguemassagethemilkintothemouth.

C, D: Mtoto hajakamata chuchuvizurikwahivyomaziwahayafikivizurimdomoni

Youcanseethatthebaby'slipsarepursedandbarelyanyofthenippleorareolaareinthemouth,whichcancausepaininthenippleandmakesithardforthebabytogainanymilk.

5.3 UnyonyeshajikatikaujauzitoBreastfeedingduringpregnancy

Kunyonyesha katika kipindi cha ujauzito wa mtoto anayefuata sio hatari kwa mama,mtotomdogoanayenyonyawalamtotoanayetarajiakuzaliwa.

Ni jambolamuhimukuendeleakunyonyeshaiwapomamaatashikaujauzitoakiwabadoana mtoto mdogo anayenyonya. Iwapo mama atawacha kunyonyesha kwa kuwaameshikaujauzitokunahatariyamtotoanayekatizwakunyonyakupatautapiamlo.

Breastfeedingduringanoncomingpregnancybearsnorisksforthemother,thebreastfeedingtoddlerorthedevelopingfoetus.

It’sveryimportanttocontinuebreastfeedingaftercomingpregnantagain.Ifthemotherstopsbreastfeedingbecauseofanewpregnancy,it’smorelikelythattheformerlybreastfedchildwillgetmalnourished.

5.4 HIVnaUnyonyeshajiHIVandbreastfeeding

Unyonyeshaji nahasaunyonyeshajimaziwa tu yamamabilamchanganyikowavyakulavingine ni moja ya njia muhimu sana ya kupunguza vifo vya watoto wachanga. Hii nimojawapo ya sababu muhimu kwa mama anayeishi na VVU kumnyonyesha mwanae.Kunyonyeshakunampamtotohuyukingadhidiyamagonjwamenginemengi.

MtotoanawwezakupatauambukiziwaVVUkatikakipindichaujauzitowamama,wakatiwauchunguhadikujifungua,napiakupitiamaziwayamamawakatiwakunyonya.TafitizinaonyeshakuwamamaanayeishinaVVUakitumiadawazakufubazaVVUkwanjiailiyosahihiuwezekanowakumuambukizamtotokupitiaunyoneshajiunapunguasana.ShirikalaAfyaDunianilinapendekezakuwaakinamamawotewanaoishinaVVUwakiwakatikakipindichaujauzitonakujifunguawatumiedawazakufubazaVVUkwamaishayakeyote.

Breastfeeding,andespeciallyearlyandexclusivebreastfeeding,isoneofthemostsignificantwaystoimproveinfantsurvivalrates.ThatiswhyalsoaHIV-positivemothercanandshouldbreastfeed.Breastfeedingprotectsthebabyfromawholerangeofinfections.

HIVcanpassfromamothertoherchildduringpregnancy,labourordelivery,andalsothroughbreast-milk.Thereisevidencethatantiretroviraltreatment(ART),giventoanursingmotherbeingHIVpositive,significantlyreducestheriskoftransmissiontothechild.ThatwhytheWHOrecommendsallpregnantwomenandlactatingmotherslivingwithHIV,totakeARTforlifeimmediatelyafterbeingdiagnosedforHIV.

6 AFYAYAMIFUPABONEHEALTHKinabinadamuwanahitajimifupamiimara.Kwaukuajiwamifupanilazimakutumiayao.Watotonaulemavuwanachelewakuendeleakujifunzakusimama,kutembeanakuruka.Watotonaulemavukalihawawezakutumiamiguunamgongovizuridaimanamifupayaohajabeba uzito. Sababu nyingine ni tatizo la kula chakula bora vizuri, kunamatatizo yakutafunanakumeza.Wazaziwanawalishekwachakulalainitu,watotohawapatamadinicalsiumnaphosphoruskutosha.SababunyinginenitabiakukaadnanibilajuakuwakanakuwapavitaminiDkupitiangozi.VitaminiDnilazimakwamwilikuwezakutengamifupa.Mifupayawalemavunimyembambanahajakuwanacalsiumnafosforuskutosha.Mifupayaoyanaharibikarahisi.

Ugongwamwingine wamifupa ni matega (aumatege?).Matega ni aina ya utapiamlo.Watoto na matega wana miguu yalipindwa na viungo vyo vinavimba. Misuli yao nihypotonicnawanaliamarakwamarakwasababuwanamauvivu,nawanachelewakukuanakuendeleavizuri.SababuyamateganiupungufuwachakulanacalsiumnaphosporusnavitaminiDkutosha.

Ni lazima kuwalishe watoto wote kwa calcium na phosphorus. Maziwa ya mama aubaadayeyang´ombenitajirinamadini,mchicha,karanga,maharagwesoya(?)matundanasamakiwanamadinipia.WatotowotewanahitajikuchezaasubuhinaalasirinjejuuyajuakwadakikaishirinimiguunamikonowazikwakutumiashatindogonakapturafupitukupatavitaminiDkutokajua.

Allpeopleneedstrongbones.Forgrowthandstrengtheningofbonesitisnecessarytousethem.Disabledchildrenaredelayedinlearningtogetupstanding,towalkandtojump.Severelydisabledchildrenneverlearntousetheirlegsandbackwellandtheirbonesdon´tbeartheirownbody-weight.Anotherreasonistheirproblemtoeatwell,theyhaveproblemstochewandtoswallow.Parentsfeedthembysoftdietsonlyandthesechildrendontgetenoughmineralslikecalciumandphosphorus.Anotherproblemis,thatdisabledchildrensitmostlyinsideandarerarelyexposedtosunlighttogetvitaminDthroughtheirskin.VitaminDisnecessaryforthebodytobuildupbones.Bonesofdisabledchildrenarethinanddontcontainenoughcalciumandphosphorus.Theirbonesbreakeasily.

Anotherdiseaseofbonesisrickets.Ricketsisonetypeofmalnutrition.Bonesofchildrenwithricketsbendandtheirjointsswell.Musclesarehypotonic,theylookmiserablebecauseofpainandtheyaredelayedingrowthanddevelopment.ThereasonofricketsislackofthemineralscalciumandphosphorusandvitaminD.

Itisnecessarytofeedchildrenwithmineralscalciumandphosphorus.Breastmilkorlatercow´smilkisrichofminerals,alsovegetables,peanuts,soyabeans,fruitsandfishcontaintheseminerals.AllchildrenneedtoplayoutsideinthemorningsandafternoonsforatleasttwentyminutestobeexposedtosunlightbywearingonlyasmallshirtandshortstogetvitaminDthroughsunlightexposure.