PROTEIN ENERGY MALNUTRITION

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PROTEIN ENERGY MALNUTRITION

• SEVERE CHILDHOOD UNDERNUTRITION

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PEM(SCU)

• Most important nutritional disease in developing
  countries.
• Leading cause of morbidity and mortality.
• MALNUTRITION 1) inproper or inadequate food
  intake
• 2) inadequate absorbtion of food

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1 MARASMUS

• Primarily energy deficient
• take

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2 KWASHIORKOR

• Primarily protein deficient take

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3 MARASMIK-KWASHIORKOR

• Has features of both disorders-wasting and edema

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• ETIOLOGY 1)Primary-Main
• -insufficient food
• - inadequate knowledge of feeding tecniques
• - poor hygiene
• - infections
• - socioeconomic status

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• 2) Secondary-Precipitating factors -
  prematurity, SGA
• - metabolic abnormalities (DM, hypotiroidism
  etc..)
• - congenital abnormalities of digestive system
  (cleft palate etc...)
• - severe inpairment of any body system (CVS,
  GUS, CNS etc...)
• - constitutional defects (celiac , CF etc..)

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CLINIC MANIFESTATIONS

• MARASMUS - failure to gain weight
• - severe wasting
• - linear growth stunting
• - generalized muscular wasting and absence of
  subcutaneous fat gt loss of turgor.
• - atrophy of muscle gt hypotonia
• - skin is dry, appears loose
• - face resembles an elderly person ? loss of
  temporal and buccal fat pads (last subcutane
  adipose depots to be mobilized in starvation)

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CLINIC MANIFESTATIONS 2

• - hair is thin.
• - hypothermia, slow pulse rate, hypotension.
• - abdomen distended or flat
• - intestinal pattern may be readily visible.
• - basal metabolic rate tends to be reduced.

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KWASHIORKOR

• Disease of the deposed baby when the next is born
  (Africans dialect)
• Insufficient intake of protein (often associated
  with deficient energy intake)
• Evident from early infancy to about 5 yr. of age
  (during the weaning or postweaning phase) (18
  mounts-3 years most common)
• Produce a fat appearing childgt sugar baby

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KWASHIORKOR 2

• Soft painless edema (espacially feet and
  legsgtface and upper extremities)? failure the
  gain weight may be masked
• dermatosehyperkeratosis,dyspigmentation,
  desqumation.
• Thin hair, color changes red to yellowish gray
• Height may be normal/stunted

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KWASHIORKOR 3

• Abdomen is frequently protruding
• Lethargy, apathy or irritability
• Loss of muscular tissue
• Liver may enlarge early/late ? fatty
  infiltration(lipogenesis from the excess ch
  intake)
• Renal plasma flow, GFR, renal tubular functions
  are decrased
• Increased susceptiblity to infections
• -acute or chronic (HIV,TBC,NOMA-necrotizing
  ulceration of gingiva and the cheeks)

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MARASMIK-KWASHIORKOR

• Clinical features of both types malnutrition
• Main features
• - edema of Kwashiorkor
• - cachexia of Marasmus

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DIAGNOSIS - dietary history - evaluation of
present deviations from avarage

• Height
• Weight FOR AGE
• HC
• WEIGHT- FOR HEIGHT
• Mid arm circumference (1-5 yrsgtstable)
• Skinfold thickness ? PEM
• ? obesity

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• Muscle massgt arm circumference- skinfold
  measurement
• BMI w/h²
• Deficiencies of some nutrientsgt low blood levels
  and their metabolities
• Protein reserves serum albumin ? halflife
• rapid turnover pr- transthyretin
  12 hr
• - prealbumin
  1,9 d
• - transferrin
  8 d

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• Excretion of hydroxyproline is decreased
  hydroxyproline/creatinine ? 2 gt nutritional
  deficiency
• Low plasma methionine,a dietary precursor of
  cysteine,needed for major antioxidant glutathione
• - Free radical damage
• Cellular immunologic insufficiency (total
  lymphocyte count, anergy to skin test Ags
  streptokinase, streptodornase, candida, mumps,
  tuberculin

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• Plasma IgG ?
• Ketonuria in early stage
• Increased aminoaciduria
• K, Mg, cholesterol ?
• BUN ?, insufficient protein intake
• Amylase, transaminases, lipase ,AP ?
• Anemia
• Bone growth delayed

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CLASSIFICATION OF SEVERITY

• GOMEZ, WELLCOME, WATERLAW
• GOMEZ w weight h height
• w for age()w of patient/w of healty
  child with same age X 100
• 90-100 NORMAL
• 75-891º malnutrition (mild)
• 60-742º malnutrition (moderate)
• lt60 3º malnutrition (severe)

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WELLCOME

• W for age - 60-80
• - lt60
• EDEMA () Kwashiorkor, Marasmic- Kwashiorkor
• (-)Underweight, Marasmus

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WATERLAW

• H for age h of patient/h of healty child with
  same age X 100
• 95 ?gt chronic malnutrition stunting
• W for h w of the patient/ w of healty child with
  with the same h X100
• 90 ?gt acute malnutrition wasting

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TREATMENT

• 1st Phase Resusitation phase 2-4 days
• Treatment of dehydration, hypothermi,
  hypoglicemia, vitamine def, anemia, infections,
  anorexia
• Sufficient quantities of the appopriate liquid
  preparation for mild-moderate dehydrationgt
  orally/NG tube
• Breastfed infant should be nursed as often as
  he/she wants.
• IV fluids are necessary for treatment of severe
  dehydration

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TREATMENT 2

• 2nd Phase First renutrition phase provide for
  catch-up growth and designed to provide calories
  and proteins to reconstitute normal height and
  weight over a period of 1 week or more

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day Protein(g/kg/day) Eng(kcal/kg/day)
0-1 0,7 70 ORT (12)
2-3 1,0 100 Milk ½
4-5 2,0 120 Whole milk
6-7 3,0 150 High energy milk
8-12 4,0 150 High energy milk
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TREATMENT 3

• 3rd Phase Rehabilitation phase 2-6w continued
  on the phase 2 refer with additional caloric
  suplementationgt normal diet
• K 2 Weeks
• Mg 1-2 Weeks
• Zn 2 Weeks
• Fe , Folic acid 3 months for correction of
  anemia
• Vit A

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OUTCOME

• Mortality rate in severe cases 10-20
• Adverse prognostic factors mental
  depression,hypothermia, hypoglicemia, petechies
• CAUSE of DEATH electrolite imbalance, severe
  dehidratation, cardiac insufficiency, infections,
  broncopneumonia, sepsis (Gr- microorganisms)

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