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ment if the child begins to show signs of Noma Ulcer, even in the absence of recent measles. If you see a mouth ulcer, swelling and redness of
Courtesy of Noma Children’s Hospital
cheek, foul breath, pain and fever in a malnourished child, especially between 6-72 months, give the Vitamin A,
and begin oral metronidazole, at a dose appropriate to the child’s age. The child should be treated at
the health center as soon as possible also, but start
the treatment while arranging for that care. The child may need Other antibiotics even by injection to control the mouth infection and prevent an inva-sive gangrene that could permanently disfigure the child’s face or result in death. Vitamin A will
quickly improve the tissues in the lining of the mouth, and will restore good immune function, but
once the infection has begun, antibiotics, surgical
debridement, and possibly later reconstruction may
Questions and Answers
Q: What is Vitamin A?
Vitamin A is a natural substance that the body needs for a healthy immune system (to fight infec-
tions), and for normal healing and growth. Children need it more than adults, and can get it by eating
animal products such as eggs, milk and meat, or eating richly colored fruits, greens and vegetables.
Oil must be added to the diet to allow the child to absorb Vitamin A and for brain growth. When the
diet is lacking in Vitamin A, or it is being depleted by illness, Vitamin A mega-dose capsules can help
keep children healthy, and save their lives and eyes. Q: What other nutrients should a malnourished child receive to help them to recover, grow well and
Proteins - mixed grains, soy, eggs, milk, meat; Minerals - Zinc, Iodine & Iron - often require sup-
plements, and fortification. (Eg: Iodized salt); Vitamins C and Folate from fruits and vegetables &
Vitamin D from sunshine, for healthy bones
Q: What else can be done to protect children from mouth infections that lead to Noma?
Keep children clean - especially their hands, faces and mouths! Use a new, clean chewing stick
every morning before breakfast, and every evening before bed. Brush the child’s teeth and gums
carefully for 5 minutes. Use Tooth Cleansing Powder (Sodium Bicarbonate, Iodized salt with Zinc
Oxide) and a chewing stick, to help with cleaning and to promote healing.
Q: What is Metronidazole, and why does it help fight Noma Ulcer if given in time?
Metronidazole is an antibiotic that kills “anaerobic” bacteria, the kind that cause the foul odor of a
mouth infection. (The germs often come from the family livestock.) When a child is weak from mal-
nutrition, especially after measles, even normal mouth bacteria can invade a small mouth ulcer and
Severe Vitamin A deficiency is a wide-spread problem in Nigeria, especially in the
Northwest, and is one of the reasons that children suffer so many infections.
Noma Ulcer and Nutritional Blindness
Vitamin A Mega-dose Capsules
For Anaerobic Infection
(200,000 International Units)
Tablets 250 mg
Treatment and Prevention Doses
(7.5mg per kg per dose 4x a day)
With or without food
*Take with food if GI Upset
Malnutrition in children, especially Vitamin A deficiency
¾ Recent measles, malaria or other infections that deplete the child’s
Age or Weight: Instruc-
Vitamin A stores and affect the eyes, nose and mouth
¾ Extreme poverty
¾ Water and food contamination from animal wa
Or < 2kg
1 week to 2
Community-wide Vitamin A mega-dose (200,000 International Units)
capsule distribution every 4-6 months (See chart for age-specific
¾ Measles vaccination
¾ Twice daily tooth brushing with disposable chewing stick
Improved diet for pregnant and nursing mothers and children
¾ Clean food and water
¾ Separation of livestock from family living space
Not safe for
First sign of Nutritional Blindness is loss of night vision; later signs
include dry, red and sore eyes. Progresses rapidly to softening of the
cornea, ulceration, rupture and blindness. This is EMERGENCY!
First sign of Noma Ulcer is a small mouth ulcer or inflamed gums.
In a malnourished child with poor immunity to infection and weak
Give to new
tissues, bacteria can quickly invade and cause infection with signs
12 years to adult
including: cheek swelling, foul breath odor, fever and pain. espe-
cially after measles, malaria or other serious illness. If untreated,
gangrene can rapidly destroy the structures of the face. This is
Vitamin A Mega-Dose Capsules for community-wide mass distribution:
Give 1 Vitamin A capsule every 4-6 months. (Under 1 year or possibly pregnant: See chart)
¾ Vitamin A mega-dose (200,000 International Units) capsules – given
immediately – 1 today, followed by 1 tomorrow and 1 in two weeks.
Vitamin A Three Dose Treatment for Malnourished Children with Severe Infections:
(See dosage adjustments for infants and women) Don’t allow Noma
In addition to other appropriate treatments, use the emergency 3 dose regimen for life-threatening infections such as severe measles, diarrhea, pneumonia, TB, malaria or meningitis
Ulcer or irreversible Blindness. Treat early and seek consultation.
¾ For mouth infection, begin oral Metronidazol tablets 2-4 times daily.
Vitamin A One Extra Dose Treatment for Malnourished Children with Moderate Infections:
In addition to other appropriate treatments, when a malnourished child presents with a serious, but
See chart. Treat early and seek consultation. Continue for 2 weeks.
not acutely life-threatening condition such as ear infection, diarrhea, tonsillitis, respiratory infection, parasites, or worsening malnutrition, give an extra dose. See chart.
The Influence of Shagya Blood in Warmblood Breeding Submitted by Terry Hey Although rare and relatively little known in America, Shagyas have had a profound influence on European warmblood breeding programs. Studs in Trakehner, Hannover, Holstein, Holland, Sweden, Switzerland, Denmark, Westphalia and many others have been using the Shagya for years to bring refinement to warmblood breeds.
Falls and Fall Prevention: A Clinical Perspective Elizabeth A. Phelan, MD, MS Associate Professor Medicine / Gerontology and Geriatric Medicine July 10, 2009 Objectives Know and understand: – How often falls occur – Consequences of falls – Why falls occur – How falls may be prevented Definition: coming to rest inadvertently on the ground or lowe