Malnutrition

1

• Malnutrition

2
Classification of PEM

• Mild (1st degree) 75-89
• Moderate (2nd degree) 60-74
• Severe (3rd degree) lt 60

3
Waterlow classification

• Observed wt
• Wt for Ht
  ? 100
• Reference Wt for pts Ht
• 90-110 Nl wasting
• 80-89 Mild
• 75-79 Moderate
• lt 75 Severe

4
Waterlow classification

• Observed Ht
• Ht for age
  ? 100
• Reference Ht for pts age
• 95 Nl
• 90-94 Mild
• 85-89 Moderate Stunting
• lt 85 Severe

5
Waterlow classification

• Normal
• Wasted not stunted
• Wasted and stunted
• Stunted not wasted

6
Clinical presentation

• Age
• Degree
• Duration
• Infection
• Vit, mineral and trace element deficiencies

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Spectrum of syndrome

• Simple growth failure
• Kwashiorkor
• Marasmus
• Marasmic kwashiorkor

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Mild protein energy malnutrition

• 1. Growth failure
• A slowing or ceasation in linear growth
• A decrease in mid-arm circumference
• A slowing or ceasation or loss of wt.
• Delayed Bone maturation
• Normal or ? weight to height ratio
• 2. Infection
• 3. Anemia
• 4. Diminished activity
• 5. Retardation of physical and mental development
  
• 6. Skin and hair changes

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Moderate to severe form of PEM

• 1. Kwashiorkor
• ? Presenting symptoms
• ? General appearance
• ? Growth failure ? Mucous membrane lesions
• ? Edema
• ? Muscle wasting ? Hair changes
• ? Skin fold thickness ? Eye changes
• ? Dermatosis ? Neurological-GI-Cardiovascular
  renal function

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• 2. Marasmus
• ? FTT. Apathy- chronic diarrhea
• ? Shrunken, wasted appearance is classic
  presentation
• ? Growth and musculoskeletal changes
• ? Other signs

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3. Marasmic kwashiorkor

• FTT
• Edema
• Dermatosis
• Wasted

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Welcome classification
Edema Edema _ Wt
Kwashiorkor Undernutrition 60-80
Marasmic kwashiorkor Marasmus lt60
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The clinical spectrum of PEM

1. Retardation growth
2. Poor socio-economic conditions
3. Frequent or persistent diarrhea
4. High morbidity and mortality from infections
5. Protein and/or energy deficient diet

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Pathology

• Total body protein
• Muscle
• Body fat
• Liver
• Pancreas
• GI

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Body composition

1. Total body water
2. ECF
3. Oedema
4. Potassium
5. Other minerals and trace elements

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• Carbohydrate absorption
• Protein absorption
• Fat absorption
• Pancreatic lipase ?
• Giardia infection
• Diarrhea
• Abnormalities of bile salt metabolism

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Endocrine system

• GH
• Thyroid hormone
• Adrenal glands
• Insulin

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Haemopoietic system

• 1) Anemia
• Protein deficiency
• Folate and iron deficiency
• Hemodynamic changes
• Hemolysis
• Infections
• 2) Leukocytes
• 3) Platelets coagulation (II, VII, X)

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Diagnosis of malnutrition

• History
• Physical examination
• Laboratory workup

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Physical examination

• Vital sign
• Ht. Wt. HC
• Muscle and fat mass
• Edema
• Skin lesions
• Sign of bone disease
• General P/E

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Lab work up

• CBC- WBC- Hb- ESR
• U/A (SG-WBC-PH), U/C
• Stool (OB-OP)
• BUN- Na- K- Ca- P-Alk.- FBS
• LFT
• TB test
• Stool fat
• D-xylose test
• Sweat test
• Antigliadine antibody
• Jujunal biopsy
• Bone age

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• Management of PEM

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Mild PEM

• Protein 2-3 g/kg/d
• Energy 150 kcal/kg/
• Vit A 1500 IU/d
• Vit D 400 IU/d

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Treatment of severe PEM

• Dehydration
• Electrolyte disturbances
• Hypoglycemia
• Infection

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Dehydration

• ORS 70-100 cc/kg 12-24 hours
• Breast feeding during dehydration
• Formula 6 hours after beginning dehydration

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IV Fluid

• Ringer lactate 20 cc/kg first hour
• Plasma 20 cc/kg in 1-2 hours
• D/VV 10 0.2 N saline 50 100 cc/kg/6 h
• D/W 10 0.2 N saline 100-150 cc/kg/d
• Kcl 40 meq/l

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Electrolyte

• K 4 meq/kg/d
• Ca 100-200 mg/kg/d
• Mg 50 solution 0.5-1.5 cc IM
• Zinc 2 mg/kg/d

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Infection

• Gram ve and gram ve
• Ampicillin
• Gentamicin
• Giardiasis
• Ascariasis

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Hypothermia

• (R lt 35oc)
• Hypoglycemia
• Septicemia
• ?Subcutaneous tissue
• ?Energy intake

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Hypoglycemia

• Blood sugar lt 40 mg/dl (10-50)
• Mild 20-40 mg/dl
• 25 D/W orally
• Severe lt 20 mg/dl
• Dextrose 50 2 cc/kg Iv stat
• Maintenance 10 dextrose

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Anemia

• Folic acid 5 mg/d X 10 days
• Ferrous sulphate 5 mg/kg/d
• Blood transfusion If Hb lt 6 g/dl
• Vit B12 is not indicated

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Vitamins

• Vit. A 100,000 iu im
• Vit. K 5mg iv or im
• Vit. D 400 iu/d
• Folic acid 5mg daily for 10 days
• Vit. B

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Dietary treatment

• Darrows solution or ORS 90 cc/kg/d Q 3h for 24
  hours
• Mike 60 cc/kg/d ? to 150 cc/kg/d

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Introduction of traditional foods

• When edema has disappeared
• Skin lesions are notably improved
• Patient becomes active
• Appetite is restored