PROTEIN ENERGY MALNUTRITION

Severe childhood undernutrition

SCU

Soad Jaber 2009

objectives
• Use the medical history and physical examination to evaluate nutritional status. • Present an approach to recognizing and treating some common nutritional problem of childhood. • Identify etiologic categories of malnutrition,1ry,2ry, • marasmus and kwashiorkor. • Display an understanding of the principles for managing severe childhood under nutrition‫ز‬

Why more common in children?
• High nutrient requirement/unit weight. • Dependence on adults for food

Water Fat Growth

- Higher body water> older children - Rapid increase in the 1st 6 months - Rapid from birth till six months Growth rate increase at puberty. More for boys than girls.

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Holds spoon unable to get food to mouth. Fingers feeding Drinks from cup. Teeth begin to erupt. Can drink from held cup with biting movements. Shuts mouth. chewing movements.Developmental Milestones: Neonates 12 weeks 20 weeks 28 weeks 7 months 9 months 10 months 12 months 15 months 18 months Good swallowing + sucking. . Plays with food. Control spoon + cups.. Feeds self biscuits. Can-swallows food placed on anterior tongue. Shakes head to refuse foods.

. • CVS --Cardiomegally .Anthropometrically .Clinically .Clinical "Signs" Muscular. . ascites….muscle wasting .. .oedema • CNS--. confusion.Hepatomegally. depression…. spleenomegally.How to assess nutritional status????? • • • • • .Bio-chemically . skeletal …Tone.delayed walking • Abdomen.Apathy. psychosis.

comulative effect of undernutrition during the life of the child. • They reflect severity and extent of the problem but not specific for any particular disease The trend overtime… serial reading. Less<80-90% abnormally low • Skull circumference: Rapid growth in early infancy… Genetic.recent nutritional experiences. NOT single… . hormonal • Mid-upper arm circumference • Skin folds thickness:. Triceps sub-scapular –% of body fat .Anthropometric techniques • • Weight for age reflect the combined effect of both recent and longer term level of nutrition. • Weight for height and age . • Height for age long term problem..

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INTERPRETATION OF WEIGHT AND HEIGHT FOR AGE Weight> 80% expected Weight < 90% expected Height > 90% Height < 90% Normal Short Wasted Stunted .

Kwashiorkor Weight between 60-80% of expected weight + oedema No oedema Oedema 80 %Under weight for age Kwashiorkor 80% Marasmus 60% 60%MarasmicKwashiorkor Wellcome Classification .no oedema.PROTEIN ENERGY MALNUTRITION • Definition : ( WHO) • • * Marasmus Weight less than 60% of expected weight .

. *severe form Decrease length and weight for age.Gomez Classification for Malnutrition 1ry PEM is a spectrum ranging from: * mild form Decrease weight for length.

Aetiology of (PEM) • Leading cause of death (less than 5 years of age) • 1ry:. Protein + energy intakes below requirement for normal growth • 2ry:the need for growth is greater than can be supplied. • : decreased nutrient absorption • : increase nutrient losses Linear growth ceases Static weight Weight loss Wasting Malnutrition and its signs .

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Child who recently have been weaned • (Pregnant mother) and emotional deprivation History: 1933 Cecily * Ghanaian children * Weaned recently * Oedema and hair changes * Fatty liver 1967 Mc-Cane * Anaemia * Cardiac * Skin changes 1971 Frood-Paskitt * Biochemical .Kwashiorkor: • Ga language of West Africa = Supplanted one .

.N a and fluid retention. • Amino aciduria due to proximal tubular dysfunction • Failure of adaptation • .Pathogenesis: Kwashiorkor: • Normal energy intake. Lack of protein • Edema:1970.Hepatomegaly due to fatty infiltration from lipogenesis of excess CHO • .decrease oncotic pressure.Biochemical and haematological changes – Recent> Increase Renin activity.

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Growth and energy expenditure limited. in response to dietary stress • .flat due to ms wasting.Lack of all nutrients stimulate cortisone secretion which result in muscle wasting.Adaptation to reduce protein + energy • .Pathogenesis: Marasmus: • . the released a. • . . a will synthesize albumin to prevent edema. OR distended due to 2ry lactose intolerance.Biochemical and haematological tests within normal • -Abdomin.

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. • Impaired absorption of protein e. chronic liver diseases.poverity.ecomomic. Kwashiorkor: • Insufficient intake of protein of good biological value.enviromental.Causes: Social. chronic diarrhoea.ignorance. severe nephrosis .g. • Abnormal losses of protein e.g.maternal malnutrtion.g. Severe or prolonged infection • Failure of protein synthesis e.

• Emotional deprivation.Marasmus: Inadequate caloric intake due to insufficient diet . • Metabolic abnormalities • Congenital malformation • Severe impairment of any body system . • Improper feeding habits .

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head circumference .Evaluation of the degree of illness and dehydration: skin fold thickness . poverety.HIV.Management: - diet history: maternal malnutrition.food taboos.inborn error of metabolism .Evaluation of growth parameters: weight. chronic illness .Biochemical evaluation * mild * moderate * severe Accurate history of social and economic factors.malignancies . . environmental factors . height.burns . breast milk and other feeding habits .food allergies .ignorance. . cystic fibrosis .

Home management • food increase calories + energy • Multivitamin 1st week • Iron replacement 2nd week.1) Mild .moderate with no complication • . • ± antibiotics for infection .

2) Severe marasmic or severe kwashiorkor Complicated cases or marasmic kwashiorkor Hospital management INITIAL PHASE 1st day: History --. folic acid.Protein 3-4 g/kg/d. d) Correct anaemia ( packed RBC carefully) volumes If diarrhea starts or fails to resolve may be lactose intolerance lactose free milk or cow milk protein intolerance start soy protein hydrolysate formula. Without IRON for the 1st week. . c) multivitamin. 2nd -7th day: a) Continue rehydration by NGT.bacterial and parasitic. IVF (glucose and electrolytes) Treatment of infection. small 2hourly then 4hourly to6 hourly. and increase calories gradually .rehydration Prevent heat loss NGT feeding ORS.clinical exam -. Vit A. b) start diet by NGT .calories 80-100/kg/day .

Rehabilitation phase week2-6 a) Start oral feeding b) Continue antibiotics c) Start iron Oedema disappear .. appetite improvement .. Supervising the mother in cooking parental education to prevent an additional episodes .the child is more interested in the surrounding Follow up phase Discharge.

Follow-up: 1st sign of improvement: -Awareness in the child -Appetite (kw) -Weight loss (kw) Weight gain rapid  Marasmus Slow (10th day) Kwashiorkor .

Cardiac failure .Other nutrients deficiency 4) Rapid gain of weight 5) Profuse diarrhea .Unable to tolerate the rate of re feeding (oedema) .parasite -Severe hypokalemia -Hepatic failure -Protein intolerance .GIT infection .Failure of improvement: 1) Combined marasmic -kwashiorkor 2) Infection 3) drowsiness TB .Grossly disturbed metabolism ..Food intolerance (discharidase) ..

Immunological defect .Inability to localize infection .Lack of fever .Hypothermia . Subtle infection .Cell mediated> humoral .Complications: 1) Infection: 1.Measles> fatal disease 2.No increase in WBC .

Complications (cot’n) 2) 3) 4) 5) 6) 7) Hypoglycaemia apnoea Hypothermia bradycardia Heart failure death Vit deficiencies Vit A  blindness Permanent growth stunting Prolonged illness developmental delay cognitive function slow intellectual achievement .

Prevention: Improve nutritional status Improve water supply Without change in food supply Proper sanitation Health education Social worker visits. Reduce infection rate Immunization Supervision of feeding Good weaning practice Effective for one generation Long term community health measures .

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Prognosis: Marasmus due to under feeding  good Kwashiorkor MR 10-25% Marasmus I Kwashiorkor  worse progress End point of nutritional stress failure of adaptation .