Abstract Celiac disease is a gluten sensitive enteropathy of small bowel characterized by villous atrophy that leads to malabsorption steatorrhea and weight loss. Broad spectrum of disorders specially auto immune is associated with celiac disease ranging from primary biliary cirrhosis, Sjogren’s syndrome to dermatitis herpetiformis. Celiac disease also shows variety of neurological manifestation including ataxia, epilepsy, neuropathy and myelopathy. The cause of tis association is still not cleared. Celiac crisis is a life-threatening presentation associated with celiac disease leading to electrolyte imbalance. Neurological manifestation of celiac crisis with residual encephalopathy is rare presentation of celiac crisis with apparently no published local data. We are going to document 2.5 years old give case presented to emergency department with status epilepticus and encephalopathy. Patient was in usual state of health prior to illness at home with history of abdominal distension, intermittent diarrhea and failure to thrive. Patient presented to tertiary care at Bahawalpur in emergency with status epilepticus and encephalopathy with probable diagnosis of TBM. And then referred to the Children Hospital and the Institute of Child Health Multan for status epilepticus at emergency department. In the context of this case, it is suggested that celiac crises should be considered in the differentials of seizures and encephalopathy. Key words: Attention deficient hyperactive disorder, Celiac disease, Celiac crises, Encephalopathy Glasgow coma scale, Intracranial pressure, Pakistan Pediatric Association, Signs of meningial irritation, Status epilepticus, Tuberculosis meningitis, The children hospital and institute of children health

Objective: To compare the feeding of sugar based F75, Cooked rice based F75 and Enhanced cooked rice based modified F75 during stabilization phase for the management of children with SAM (Severe Acute Malnutrition) aged 6-60 months presented with diarrhea. Study Design: An open-label randomized controlled trial. Place and Duration: Stabilization center, Children’s Hospital and Institute of Child Health Multan from 1st January 2018 to 30th November 2019. Methodology: The total 270 children, (who were under 5 years of age and admitted to the stabilization center for complicated Severe Acute Malnutrition (SAM) during study duration) were divided into three groups of 90 patients each. Group A was given Standard sugar-based F75, Group B was given Cooked Rice based F75 and Group C was given Enhanced cooked rice based modified F75. Clinical and biochemical parameters of patients were analyzed at day 1, day 3 and day 7 after admission. Results: The age of our patients was 16.7 ± 12.2 months with male to female ratio of 1.2:1. The mid upper arm circumference (MUAC) of cases was 10.07±0.86 cm. More than half of the children had diarrhea at admission. During the initial stabilization phase (day 1 to day 7), number of patients with complains of diarrhea increased from 57.78% to 65.54% in group A while it reduced from 52.22% to 15.54% in group B and from 62.16% to 7.77% in group C. Conclusion: Modified rice base therapeutic feeding is more effective for treatment of SAM with diarrhea as compared to standard sugar based F75 formula. Keywords: Children, Diarrhoea, Severe Acute Malnutrition, Stabilization Phase, Carbohydrate Malabsorption, Diarrhea, F75 Rice Based Therapeutic Feed How to Cite This: Khan S, Iqbal I, Ali I, Batool N, Abbas A, Arshad R. Comparison of Therapeutic feed (different recipes) during Stabilization Phase for the management of Children with Severe Acute Malnutrition (SAM). Isra Med J. 2022; 14(3): 108-112. DOI: https://doi.org/10.55282/imj.oa1140

Objective: To evaluate the serum phosphate level of children with severe acute malnutrition and effect of therapeutic feeds (F75 and F100) on serum phosphate levels. Study Design: Prospective Observational Study. Place and Duration of Study : The study was conducted at Stabilization center of Children's Hospital and Institute of Child Health Multan from 1 March 2018 to 30 March 2019. Materials and Methods: The total 270 children with severe acute malnutrition, who were under 5 years of age and admitted to the stabilization center for complicated SAM during study duration were included in the study. Initial management of the patients were started by following WHO protocols for Severe Acute Malnutrition management and the baseline labs along with serum phosphate levels were sent for evaluation. Patients were admitted at Stabilization Centre for the management plan as per guidelines. Once the patients were stabilized in one week approximately the transition towards rehabilitation phase of severe acute management started. Serum phosphate levels were assessed at admission, at stabilization (day 7 of admission) and at the time of discharge. Data was analyzed using SPSS version 21. Results: The mean age of our patients was 22 ± 2 months. The male to female ratio were 1:2. Hypophosphatemia was documented in 180 (66%) patients with mean 0.96 ± 0.40 mmol/ltr < (1.45 –1.78mmol/ltr) serum phosphate levels at the time of admission. During transition phase the phosphate levels were 1.1± 0.45 mmol/l and after rehabilitation phase 1.45 ± 0.45 mmol/l on average of 15 days of management. After using F75 and F100 therapeutic feeds in stabilization, transition, and rehabilitation phase 178 (98.9%) children were treated and had normal serum phosphate level at the time of discharge. Conclusion: Hypophosphatemia is commonly present in SAM children. Introduction of therapeutic feeds F75 and F-100 during stabilization phase and rehabilitation phase significantly improves phosphate levels in SAM children with low phosphate levels.

OBJECTIVE:To identify echocardiography-based myocardial changes in children with severe acute malnutrition. Methods:The prospective study was conducted from January to November 2020 at a territory care paediatric hospital in Multan, Pakistan, and comprised severe acute malnutrition patients of either gender aged 1-60 months and an equal number of matching healthy controls. Malnutrition was categorised using the World Health Organisation criteria. Echocardiographic evaluation was done by expert cardiologists. Values for ejection fraction shortening, left ventricular mass, E/A wave ratio as well as mitral and tricuspid annular plane systolic excursions were noted. Data was analysed using SPSS 21. RESULTS:Of the 150 subjects, 75(50%) each were cases and controls. Age and gender were not significantly different between the groups (p>0.05). Left ventricular mass and left ventricular mass index with body surface area were significantly reduced in the cases compared to the controls, and the same was the case with left ventricular ejection fractional shortening (p<0.05). There was no significant difference between the groups in terms of E/A wave ratio as well as mitral and tricuspid annular plane systolic excursions (p>0.05). Among the cases, cardiac evaluation showed 26(34.6%) were kwashiorkor and 49(65.3%) were marasmic patients. CONCLUSIONS:Left ventricular parameters in malnourished children were found to be reduced. As such, the assessment of these parameters may appear to be a significant indicator for timely identification of cardiac malfunction in severe acute malnutrition cases.

Objective: The main purpose of the study was to assess the nutritional status of lactating mothers. Study Design: Cross Sectional study. Setting: Fatima Jinnah Hospital, Chowk Ghantaghar, Multan. Period: March 2019 to November 2019. Material & Methods: The study comprised of 250 lactating mothers aged 18-40 years. The data for this study was collected by trained nutritionist when lactating mothers came for checkup and SPSS software was used for data analysis. Results: This study showed that mother status mostly effected due to iron deficiency. Only 20% women were having normal Hemoglobin level. 80% women were anemic and 61.6% women were underweight and 4.8% women were overweight during lactation period. Their serum ferritin level was significantly low due to iron deficient diet/ low iron supplementation. In this conducted study 34.4% women were uneducated and 70.8% women were from rural areas of Multan. 42.4% women were poor socioeconomic status. Conclusion: Nutritional status of lactating mother is mostly affected by iron deficiency. Iron deficient diet or lack of iron supplementation due to poor socioeconomic status/ lack of education about nutrients affect the lactating status of mother.

Objective: To determine the percentage of Hypothyroidism in children with severe acute malnutrition. Study Design: Cross Sectional study. Setting: Nutrition Rehabilitation Center, Children’s Hospital and Institute of Child Health Multan. Period: January 2019 to December 2019. Material & Methods: A total of 255 malnourished patients (as per inclusion criteria) were included in current study. A written Performa was designed to collect history, anthropometric measurements and systemic examination. Taking aseptic measures venous blood was sent for baseline tests as well as for T3, T4 and TSH, total serum protein albumin and total ferritin levels to hospital laboratory. Correlation between serum thyroid concentrations and total protein, albumin, hemoglobin and serum ferritin were estimated by using t-test and p-vlaue less than 0.05 was considered as significant. Total collected data was entered and analyzed in SPSS version 21.0. Results: A total of 255 malnourished children were included in this study. Majority of studied subjects were male (52.5%) with 83.92%, 3-5 years of age. Amongst the 255 children mean values of T3 in MAM and SAM patients were 105.4 ng/dl and 89.7 ng/dl respectively. There was a statistically significant (p <0.001) association between decreased T3 and type of malnutrition. Similarly, mean values of T4 in MAM and SAM patients were 6.3 ug/dl and 5.7 ug/dl respectively that was statistically significant (p <0.05). Lower values of T4 were higher among SAM children in 1 to 3 years age group compared to respective MAM children with p value .0.05 and high T4 value in 3-5 years age group of MAM children were both statistically insignificant. Higher mean Values of TSH was found in SAM compared to MAM children both age groups. Conclusion: Severe acute malnutrition (SAM) is associated with reduction in T3 and T4 levels and higher levels of TSH in SAM children as compared to MAM. The altered thyroid hormone status in children with PEM is perhaps a protective phenomenon to limit protein catabolism and lower energy requirements.

Objectives: Pakistan is facing double burden of malnutrition. The purpose of current study was to access the nutritional status by different anthropometric methods and common barriers that affect the nutritional status of children. Study Design: Cross Sectional study. Setting: Children Hospital & Institute of Child Health Multan, Pakistan. Period: From 1st March 2019 to 1ST January 2020. Material & Methods: The study contained of 405 children with 216 boys and 187 girls. The data was collected by trained nutritionist in OPD of Children Hospital & Institute of Child Health and data was analyzed by using SPSS version 21.0. Results: The study showed that malnutrition is caused by poor socioeconomic status and low education level of care giver. The data showed that 318 (78.51%) participants involved in this study were malnourished. Nutritional status mostly affected during first birthday (36.79%). In this study 50.12% participants belonged to poor nutritional status and 47.65% mother were uneducated. Conclusion: The mother education and good socioeconomic status can prevent children from malnutrition. Feeding practices and weaning starting time also play role in defining nutritional status of children. Children under five year of age are at very sensitive of age and more prone to diseases so well balance diet and mother feeding upto-2 years of age can prevent children from chronic diseases and improve nutritional status.

Objectives: To determine the average weight gain after lactation counseling therapy in infants up to six months of age having severe acute malnutrition. Study Design: Quasi experimental trial. Setting: Stabilization Center Unit, the Children’s Hospital & the Institute of Child Health, Multan. Period: 1st October 2015 to 1st October 2016. Material & Methods: A total of 205 children with SAM were included in this study using non-probability consecutive sampling technique. Mothers of these children were motivated for more than 8 feeds/day, positioning and attachment at breast feeding was advised, demonstrated and monitored. All the data obtained was entered and analyzed by SPSS version 20. Results: Of these 205 study cases, 142 (69.3%) were boys and 63 (30.75) were girls. Mean age of our study cases was 3.75 ± 1.39 months (with minimum age of our study cases was 2 months while maximum age was 6 months). Of these 205 study cases, 101 (49.3 %) were from rural areas while 104 (50.7%) were from urban areas. Mothers of 117 (57.1%) study cases were literate while 88 (42.9%) were illiterate. Majority of our study cases i.e. 129 (62.9%) were from middle income background and 76 (37.1%) were from poor social background. Partial breast feeding was positive in 145 (70.7%) of our study cases and no breast feeding was noted in 60 (29.3%). Mean baseline weight was 2737.07± 585.60 grams. Mean weight at discharge was 2995.37 ± 621.97 grams and mean weight gain was 800.0 ± 258. 29 grams. Average daily weight gain was noted to be 11.27 ± 4.73 g/kg/day. Conclusion: Our study results have shown that lactation counseling therapy significantly improves weight gain in children under 6 months of age with severe acute malnutrition. Mothers of infants presenting with malnutrition must be counselled to breast feed to improve their clinical outcomes. Mean weight gain was significantly associated with maternal education and socioeconomic status. Further studies are suggested from different parts of the country to generate our local data at national level which may be incorporated for national health policy guidelines.

Objective: To assess the nutritional status of mothers of severely malnourished children, and to evaluate the factors associated with inadequate caloric intake of children with severe acute malnutrition versus sufficient caloric intake by mothers. Methods: The cross-sectional descriptive study was conducted from January to June 2016 at Children Hospital and Institute of Child Health, Multan, Pakistan, and comprised mothers of severely malnourished children admitted for treatment. Data was collected using a questionnaire administered through interviews. Elements noted included body mass index, 24-hour recall, dietary restriction during pregnancy, lactation and complimentary feeding patterns of the children. The mothers were also examined for clinical signs of iron deficiency anaemia. Results: Of the 100 women, 20(20%) were malnourished, 42(42%) were of normal weight, and 38(38%) were either overweight, pre-obese or obese. The caloric intake of 26(26%) mothers was less than 1500 kcal per day, while 42(42%) were taking between 2000- 2500 kcal per day and 32(32%) were taking >2500 kcal daily. Also, 67(67%) women were suffering from anaemia and 80(80%) women had some myths related with dietary restrictions during pregnancy, lactation and complimentary feeding of children. Overall, 23(23%) women breastfed their babies.

Background Stunting is a major public health issue in most of developing countries. Although, its worldwide prevalence is decreasing slowly but the number of stunted children is still rising in Pakistan. Stunting is highly associated with several long-term consequences, including higher rate of mortality and morbidity, deficient cognitive growth, school performance, learning capacity, work capacity and work productivity. To prevent stunting, we proposed Stunting Diagnostic and Education app. This app includes detailed knowledge of stunting and it’s all forms, symptoms, causes, video tutorials and guidelines by the Pediatricians and Nutritionists. Methods A cross-sectional study has been conducted in schools of Multan District, Pakistan for the period of January 2019 to June 2019. Sample data of 1420 children, aged 4 to 18 years using three age groups, were analyzed by using SPSS version 21.0 to assess the prevalence of stunting and to analyze the risk factors associated with it in children under and over 5 age. Chi square test was applied in comparison with rural and urban participants and p -value < 0.05 was considered as significant. This study includes distribution of sociodemographic characteristics, parental education, working status of mothers, dietary patterns of school going children and prevalence of stunting in school going children. After getting study results, Stunting Diagnostic and Education app was developed according to the instructions of child experts and nutritionists. Results 354 (24.93%) participants were stunted out of 1420, 11.9% children were obese and 63.17% children were normal. Out of 354 stunted children, higher ratio of stunting was found in the age group of 8–11 years children with 51.98 percentage. 37.85% stunted children were found in the age group of 4–7 years and 10.17% stunting was found in the age group of 12–18 years children. It was observed in the study that male children were highly stunted than female with 57.91 and 42.09% respectively. Children living in rural areas were more stunted affected as compared to the children living in urban society with percentage 58.76 and 41.24 respectively. Conclusions Our study concluded that 24.93% children were stunted, out of which, age group of 8–11 years children were highly stunted. The study showed that the literacy of mother or caregiver had high impact on children’s health. Therefore, Stunting Diagnostic and Education app was developed to educate mothers to diagnose stunting and to teach about the prevention of stunting.

Breast feeding is the most natural way of feeding the infants and help to reduce child mortality and morbidity and millions of deaths could be prevented each year if mothers were aware of benefits of exclusive breast feeding for 4 -6 months and early initiation of breast feeding. In current study, awareness regarding breast feeding and complementary feeding in mothers of severely malnourished children was evaluated. The results showed that 99% mothers considered breast milk safe and effective but practically only 23% babies were breast fed while 77% were bottle fed. According to 58% mothers, there should be a early initiation of breast feeding, while 57% were un aware of the facts that clostrum should be given while 43% (43/100) of then considered it unhealthy and non effective. The current awareness reveals that most of the mothers prefer to give commercially available foods for their infants instead of breast feeding. This situation is alarming regarding child health and there is need to educate the mothers especially about the beneficial and health curing effects of breast feeding.

Background: Breast feeding is the most natural way of feeding the infants and help to reduce child mortality and morbidity and millions of deaths could be prevented each year if mothers were aware of benefits of exclusive breast feeding for 4 -6 months and early initiation of breast feeding. Objective:To evaluate the awareness regarding breast feeding and complementary feeding in mothers of severely malnourished children. Study Design: This is a descriptive /cross sectional study. Place and duration of study: This study was conducted at the department of preventive pediatrics Children hospital and institute of child health, Multan from March 2013 to September 2013. Materials and Methods:This study included a total of 100 females that were the mothers of malnourished children visiting the follow up room of department of preventive pediatrics Children hospital and institute of child health, Multan. A questionnaire was designed and others were interviewed in detail after taking proper consent. Results:In this study, the mean age of the sample was25years +/_3 years. 70 % females (70/100) were from urban areas while 30 %(30/100) were from rural areas. Of the 100 respondents 54%( 54/100) of mothers were illiterate and this study showed that 99% (99/100) considered breast milk safe and effective than other feeds but practically only 23%(23/100) babies were breast fed while 77%(77/100) were bottle fed. Pre-lacteal feed was given by 82% (82/100). According to 58% (58/100) mothers there should be a early initiation of breast feeding, while 57% (57/100) were un aware of the facts that clostrum should be given while 43 %(43/100)of then considered it unhealthy and non effective,82%(82/100) considered 4 months a period of exclusive breast feeding,61% (61/100) were counseled by doctors regarding the benefits of breast feeding,50%(50/100) were aware of the use of exclusive breast feeding as a contraceptive tool and 34 % (34/100) were aware of its importance for the prevention of breast cancer. Conclusion:The findings of the study indicated the various important policy implications for the intervention of breastfeedig. Strategies to encourage mothers to follow breastfeeding recommendations should concentrate on improving their knowledge.

Background: Breast feeding is the most natural way of feeding the infants and help to reduce child mortality and morbidity and millions of deaths could be prevented each year if mothers were aware of benefits of exclusive breast feeding for 4 -6 months and early initiation of breast feeding. Objective:To evaluate the awareness regarding breast feeding and complementary feeding in mothers of severely malnourished children. Study Design: This is a descriptive /cross sectional study. Place and duration of study: This study was conducted at the department of preventive pediatrics Children hospital and institute of child health, Multan from March 2013 to September 2013. Materials and Methods:This study included a total of 100 females that were the mothers of malnourished children visiting the follow up room of department of preventive pediatrics Children hospital and institute of child health, Multan. A questionnaire was designed and others were interviewed in detail after taking proper consent. Results:In this study, the mean age of the sample was25years +/_3 years. 70 % females (70/100) were from urban areas while 30 %(30/100) were from rural areas. Of the 100 respondents 54%( 54/100) of mothers were illiterate and this study showed that 99% (99/100) considered breast milk safe and effective than other feeds but practically only 23%(23/100) babies were breast fed while 77%(77/100) were bottle fed. Pre-lacteal feed was given by 82% (82/100). According to 58% (58/100) mothers there should be a early initiation of breast feeding, while 57% (57/100) were un aware of the facts that clostrum should be given while 43 %(43/100)of then considered it unhealthy and non effective,82%(82/100) considered 4 months a period of exclusive breast feeding,61% (61/100) were counseled by doctors regarding the benefits of breast feeding,50%(50/100) were aware of the use of exclusive breast feeding as a contraceptive tool and 34 % (34/100) were aware of its importance for the prevention of breast cancer. Conclusion:The findings of the study indicated the various important policy implications for the intervention of breastfeedig. Strategies to encourage mothers to follow breastfeeding recommendations should concentrate on improving their knowledge.