Protein energy malnutrition



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PROTEIN ENERGY MALNUTRITION

  • Abdelaziz Elamin
  • MD, PhD, FRCPCH
  • Professor of Child Health
  • College of Medicine
  • Sultan Qaboos University
  • Muscat, Oman
  • azizmin@hotmail.com

HUMAN NUTRITION

  • Nutrients are substances that are crucial for human life, growth & well-being.
  • Macronutrients (carbohydrates, lipids, proteins & water) are needed for energy and cell multiplication & repair.
  • Micronutrients are trace elements & vitamins, which are essential for metabolic processes.

HUMAN NUTRITION/2

  • Obesity & under-nutrition are the 2 ends of the spectrum of malnutrition.
  • A healthy diet provides a balanced nutrients that satisfy the metabolic needs of the body without excess or shortage.
  • Dietary requirements of children vary according to age, sex & development.

Assessment of Nutr status

  • Direct
    • Clinical
    • Anthropometric
    • Dietary
    • Laboratory
  • Indirect
    • Health statistics
    • Ecological variables

Clinical Assessment

  • Useful in severe forms of PEM
  • Based on thorough physical examination for features of PEM & vitamin deficiencies.
  • Focuses on skin, eye, hair, mouth & bones.
  • Chronic illnesses & goiter to be excluded

Clinical Assessment/2

  • ADVANTAGES
    • Fast & Easy to perform
    • Inexpensive
    • Non-invasive
  • LIMITATIONS
    • Did not detect early cases
    • Trained staff needed

ANTHROPOMETRY

  • Objective with high specificity & sensitivity
  • Measuring Ht, Wt, MAC, HC, skin fold thickness, waist & hip ratio & BMI
  • Reading are numerical & gradable on standard growth charts
  • Non-expensive & need minimal training

ANTHROPOMETRY/2

  • LIMITATIONS
    • Inter-observers’ errors in measurement
    • Limited nutritional diagnosis
    • Problems with reference standards
    • Arbitrary statistical cut-off levels for abnormality

LAB ASSESSMENT

  • Biochemical
    • Serum proteins, creatinine/hydroxyproline
  • Hematological
    • CBC, iron, vitamin levels
  • Microbiology
    • Parasites/infection

DIETARY ASSESSMENT

  • Breast & complementary feeding details
  • 24 hr dietary recall
  • Home visits
  • Calculation of protein & Calorie content of children foods.
  • Feeding technique & food habits

OVERVIEW OF PEM

  • The majority of world’s children live in developing countries
  • Lack of food & clean water, poor sanitation, infection & social unrest lead to LBW & PEM
  • Malnutrition is implicated in >50% of deaths of <5 children (5 million/yr)

CHILD MORTALITY

  • The major contributing factors are:
    • Diarrhea 20%
    • ARI 20%
    • Perinatal causes 18%
    • Measles 07%
    • Malaria 05%
    • 55% of the total have malnutrition

EPIDEMIOLOGY

  • The term protein energy malnutrition has been adopted by WHO in 1976.
  • Highly prevalent in developing countries among <5 children; severe forms 1-10% & underweight 20-40%.
  • All children with PEM have micronutrient deficiency.

PEM

  • In 2000 WHO estimated that 32% of <5 children in developing countries are underweight (182 million).
  • 78% of these children live in South-east Asia & 15% in Sub-Saharan Africa.
  • The reciprocal interaction between PEM & infection is the major cause of death & morbidity in young children.

PEM in Sub-Saharan Africa

  • PEM in Africa is related to:
    • The high birth rate
    • Subsistence farming
    • Overused soil, draught & desertification
    • Pets & diseases destroy crops
    • Poverty
    • Low protein diet
    • Political instability (war & displacement)

PRECIPITATING FACTORS

    • LACK OF FOOD (famine, poverty)
    • INADEQUATE BREAST FEEDING
    • WRONG CONCEPTS ABOUT NUTRITION
    • DIARRHOEA & MALABSORPTION
    • INFECTIONS (worms, measles, T.B)

CLASSIFICATION

    • A. CLINICAL ( WELLCOME )
    • Parameter: weight for age + oedema
    • Reference tandard (50th percentile)
    • Grades:

CLASSIFICATION (2)

    • B. COMMUNITY (GOMEZ)
    • Parameter: weight for age
    • Reference standard (50th percentile) WHO chart
    • Grades:
      • I (Mild) : 90-70
      • II (Moderate): 70-60
      • III (Severe) : < 60

ADVANTAGES

    • SIMPLICITY (no lab tests needed)
    • REPRODUCIBILITY
    • COMPARABILITY
    • ANTHROPOMETRY+CLINICAL SIGN USED FOR ASSESSMENT

DISADVANTAGES

    • AGE MAY NOT BE KNOWN
    • HEIGHT NOT CONSIDERED
    • CROSS SECTIONAL
    • CAN’T TELL ABOUT CHRONICITY
    • WHO STANDARDS MAY NOT REPRESENT LOCAL COMMUNITY STANDARD

KWASHIORKOR

  • Cecilly Williams, a British nurse, had introduced the word Kwashiorkor to the medical literature in 1933. The word is taken from the Ga language in Ghana & used to describe the sickness of weaning.

ETIOLOGY

  • Kwashiorkor can occur in infancy but its maximal incidence is in the 2nd yr of life following abrupt weaning.
  • Kwashiorkor is not only dietary in origin. Infective, psycho-socical, and cultural factors are also operative.

ETIOLOGY (2)

  • Kwashiorkor is an example of lack of physiological adaptation to unbalanced deficiency where the body utilized proteins and conserve S/C fat.
  • One theory says Kwash is a result of liver insult with hypoproteinemia and oedema. Food toxins like aflatoxins have been suggested as precipitating factors.

CLINICAL PRESENTATION

  • Kwash is characterized by certain constant features in addition to a variable spectrum of symptoms and signs.
  • Clinical presentation is affected by:
      • The degree of deficiency
      • The duration of deficiency
      • The speed of onset
      • The age at onset
      • Presence of conditioning factors
      • Genetic factors

CONSTANT FEATURES OF KWASH

      • OEDEMA
      • PSYCHOMOTOR CHANGES
      • GROWTH RETARDATION
      • MUSCLE WASTING

USUALLY PRESENT SIGNS

  • MOON FACE
  • HAIR CHANGES
  • SKIN DEPIGMENTATION
  • ANAEMIA

OCCASIONALLY PRESENT SIGNS

      • HEPATOMEGALY
      • FLAKY PAINT DERMATITIS
      • CARDIOMYOPATHY & FAILURE
      • DEHYDRATION (Diarrh. & Vomiting)
      • SIGNS OF VITAMIN DEFICIENCIES
      • SIGNS OF INFECTIONS

DD of Kwash Dermatitis

  • Acrodermatitis Entropathica
  • Scurvy
  • Pellagra
  • Dermatitis Herpitiformis

MARASMUS

  • The term marasmus is derived from the Greek marasmos, which means wasting.
  • Marasmus involves inadequate intake of protein and calories and is characterized by emaciation.
  • Marasmus represents the end result of starvation where both proteins and calories are deficient.

MARASMUS/2

  • Marasmus represents an adaptive response to starvation, whereas kwashiorkor represents a maladaptive response to starvation
  • In Marasmus the body utilizes all fat stores before using muscles.

EPIDEMIOLOGY & ETIOLOGY

  • Seen most commonly in the first year of life due to lack of breast feeding and the use of dilute animal milk.
  • Poverty or famine and diarrhoea are the usual precipitating factors
  • Ignorance & poor maternal nutrition are also contributory

Clinical Features of Marasmus

  • Severe wasting of muscle & s/c fats
  • Severe growth retardation
  • Child looks older than his age
  • No edema or hair changes
  • Alert but miserable
  • Hungry
  • Diarrhoea & Dehydration

CLINICAL ASSESSMENT

  • Interrogation & physical exam including detailed dietary history.
  • Anthropometric measurements
  • Team approach with involvement of dieticians, social workers & community support groups.

Investigations for PEM

  • Full blood counts
  • Blood glucose profile
  • Septic screening
  • Stool & urine for parasites & germs
  • Electrolytes, Ca, Ph & ALP, serum proteins
  • CXR & Mantoux test
  • Exclude HIV & malabsorption

NON-ROUTINE TESTS

  • Hair analysis
  • Skin biopsy
  • Urinary creatinine over proline ratio
  • Measurement of trace elements levels, iron, zinc & iodine

Complications of P.E.M

  • Hypoglycemia
  • Hypothermia
  • Hypokalemia
  • Hyponatremia
  • Heart failure
  • Dehydration & shock
  • Infections (bacterial, viral & thrush)

TREATMENT

  • Correction of water & electrolyte imbalance
  • Treat infection & worm infestations
  • Dietary support: 3-4 g protein & 200 Cal /kg body wt/day + vitamins & minerals
  • Prevention of hypothermia
  • Counsel parents & plan future care including immunization & diet supplements

KEY POINT FEEDING

  • Continue breast feeding
  • Add frequent small feeds
  • Use liquid diet
  • Give vitamin A & folic acid on admission
  • With diarrhea use lactose-free or soya bean formula

PROGNOSIS

  • Kwash & Marasmus-Kwash have greater risk of morbidity & mortality compared to Marasmus and under weight
  • Early detection & adequate treatment are associated with good outcome
  • Late ill-effects on IQ, behavior & cognitive functions are doubtful and not proven

THANKS YOU



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