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Mr.

Vishwas jog K

Definitions
MALNUTRITION WHO defines Malnutrition as "the cellular imbalance between the supply of nutrients and energy and the body's demand for them to ensure growth, maintenance, and specific functions.
Malnutrition is the condition that develops when the body does not get the right amount of the vitamins, minerals, and other nutrients it needs to maintain healthy tissues and organ function.

PROTEIN ENERGY MALNUTRITION It is a group of body depletion disorders which include kwashiorkor, marasmus and the intermediate stages MARASMUS Represents simple starvation . The body adapts to a chronic state of insufficient caloric intake KWASHIORKOR It is the bodys response to insufficient protein intake but usually sufficient calories for energy

DESCRIPTION

Protein-Energy Malnutrition
PEM is also referred to as protein-calorie malnutrition. It is considered as the primary nutritional problem in India. Also called the 1st National Nutritional Disorder. The term protein-energy malnutrition (PEM) applies to a group of related disorders that include marasmus, kwashiorkor, and intermediate states of marasmus-kwashiorkor. PEM is due to food gap between the intake and requirement.

AETIOLOGY

AETIOLOGY: Different combinations of many aetiological factors can lead to PEM in children. They are: Social and Economic Factors Biological factors Environmental factors Role of Free Radicals & Aflatoxin Age of the Host

Amongst the Social, Economic, Biological and Environmental Factors the common causes are:
Lack of breast feeding and giving diluted formula Improper complementary feeding Over crowding in family Ignorance Illiteracy Lack of health education Poverty Infection Familial disharmony

Role of Free Radicals & Aflatoxin: Two new theories have been postulated recently to explain the pathogenesis of kwashiorkor. These include Free Radical Damage & Aflatoxin Poisoning . These may damage liver cells giving rise to kwashiorkor. Age Of Host : Frequent in Infants & young children whose rapid growth increases nutritional requirement. PEM in pregnant and lactating women can affect the growth, nutritional status & survival rates of their fetuses, new born and infants. Elderly can also suffer from PEM due to alteration of GI System

AETIOLOGY of PEM:

Leading cause of death (less than 5 years of age)


Protein + energy intakes below requirement for normal growth.

Primary PEM:

the need for growth is greater than can be supplied. decreased nutrient absorption increase nutrient losses Linear growth ceases

Secondary PEM:

Static weight
Weight loss Wasting Malnutrition and its signs

PREVALENCE

PREVALENCE:
Protein-energy malnutrition is a basic lack of food (from famine) and a major cause of infant mortality and morbidity worldwide.

Protein-energy malnutrition caused 0.46% of all deaths worldwide in 2002, an average of 42 deaths per million people per year.

Child Malnutrition in India 2005-2006

Urban

36.4

Malnutrition is the direct or indirect cause of more 50% of deaths Rural in 49.0 children. PEM is a silent killer in many children.

CLINICAL FEATURES

The clinical presentation depends upon the type , severity and duration of the dietary deficiencies. The five forms of PEM are :
1. 2. 3. 4. 5. Kwashiorkor Marasmic-kwashiorkor Marasmus Nutritional dwarfing Underweight child

Classification of PEM (FAO/WHO)


Body weight as percentage of standard Kwashiorkor Marasmic kwashiorkor Marasmus Nutritional dwarfing Underweight child 60 80 < 60 < 60 < 60 60 80

Oedema

Deficit in weight for height + ++ ++ Minimal +


Source: FAO / WHO 1971 Expert Committee on Nutrition 8th Report. WHO Technical Report Series 477

+ + 0 0 0

The term kwashiorkor is taken from the Ga language of Ghana and means "the sickness of the weaning. Williams first used the term in 1933, and it refers to an inadequate protein intake with reasonable caloric (energy) intake. Kwashiorkor, also called wet protein-energy malnutrition, is a form of PEM characterized primarily by protein deficiency. This condition usually appears at the age of about 12 months when breastfeeding is discontinued, but it can develop at any time during a child's formative years. It causes fluid retention (edema); dry, peeling skin; and hair discoloration.

KWASHIORKOR

Kwashiorkor was thought to be caused by insufficient protein consumption but with sufficient calorie intake, distinguishing it from marasmus. More recently, micronutrient and antioxidant deficiencies have come to be recognized as contributory. Victims of kwashiorkor fail to produce antibodies following vaccination against diseases, including diphtheria and typhoid. Generally, the disease can be treated by adding food energy and protein to the diet; however, it can have a long-term impact on a child's physical and mental development, and in severe cases may lead to death.

SYMPTOMS
Changes in skin pigment. Decreased muscle mass Diarrhea Failure to gain weight and grow Fatigue Hair changes (change in color or texture) Increased and more severe infections due to damaged immune system Irritability Large belly that sticks out (protrudes) Lethargy or apathy Loss of muscle mass Rash (dermatitis) Shock (late stage) Swelling (edema)

St.Ann's Degree College for Women

The term marasmus is derived from the Greek word marasmos, which means withering or wasting. Marasmus is a form of severe protein-energy malnutrition characterized by energy deficiency and emaciation. Primarily caused by energy deficiency, marasmus is characterized by stunted growth and wasting of muscle and tissue. Marasmus usually develops between the ages of six months and one year in children who have been weaned from breast milk or who suffer from weakening conditions like chronic diarrhea.

MARASMUS

SYMPTOMS
Severe growth retardation Loss of subcutaneous fat Severe muscle wasting The child looks appallingly thin and limbs appear as skin and bone Shriveled body Wrinkled skin Bony prominence Associated vitamin deficiencies Failure to thrive Irritability, fretfulness and apathy Frequent watery diarrhoea and acid stools Mostly hungry but some are anoretic Dehydration Temperature is subnormal Muscles are weak Oedema and fatty infiltration are absent

DIFFERENCE IN CLINICAL FEATURES BETWEEN MARASMUS AND KWASHIORKOR

DIFFERENCE IN CLINICAL FEATURES BETWEEN MARASMUS AND KWASHIORKOR

CLINICAL FEATURES -MUSCLE WASTING

MARASMUS
Obvious

KWASHIORKOR
Sometimes hidden by edema and fat Fat often retained but not firm Present in lower legs, and usually in face and lower arms May be masked by edema Irritable, moaning, apathetic

-FAT WASTING

Severe loss of subcutaneous fat None

-EDEMA

-WEIGHT FOR HEIGHT

Very low

-MENTAL CHANGES Sometimes quite and apathetic

DIFFERENCE IN CLINICAL FEATURES BETWEEN MARASMUS AND KWASHIORKOR

CLINICAL FEATURES -APPETITE -DIARRHOEA -SKIN CHANGES

MARASMUS Usually good Often Usually none

KWASHIORKOR Poor Often Diffuse pigmentation, sometimes flaky paint dermatitis Sparse, silky, easily pulled out

-HAIR CHANGES

Seldom

-HEPATIC ENLARGEMENT

None

Sometimes due to accumulation of fat

MARASMIC-KWASHIORKOR
A severely malnourished child with features of both marasmus and Kwashiorkor. The features of Kwashiorkor are severe oedema of feet and legs and also hands, lower arms, abdomen and face. Also there is pale skin and hair, and the child is unhappy. There are also signs of marasmus, wasting of the muscles of the upper arms, shoulders and chest so that you can see the ribs.

NUTRITIONAL DWARFING OR STUNTING


Some children adapt to prolonged insufficiency of food-energy and protein by a marked retardation of growth. Weight and height are both reduced and in the same proportion, so they appear superficially normal.

UNDERWEIGHT CHILD
Children with subclinical PEM can be detected by their weight for age or weight for height, which are significantly below normal. They may have reduced plasma albumin. They are at risk for respiratory and gastric infections

BIOCHEMICAL & METABOLIC CHANGES

BIOCHEMICAL & METABOLIC CHANGES


Significant findings in kwashiorkor include hypoalbuminemia (10-25 g/L), hypoproteinemia (transferrin, essential amino acids, lipoprotein), and hypoglycemia. Plasma cortisol and growth hormone levels are high, but insulin secretion and insulinlike growth factor levels are decreased. The percentage of body water and extracellular water is increased. Electrolytes, especially potassium and magnesium, are depleted. Levels of some enzymes (including lactase) are decreased, and circulating lipid levels (especially cholesterol) are low. Ketonuria occurs, and protein-energy malnutrition may cause a decrease in the urinary excretion of urea because of decreased protein intake. In both kwashiorkor and marasmus, iron deficiency anemia and metabolic acidosis are present. Urinary excretion of hydroxyproline is diminished, reflecting impaired growth and wound healing.

TREATMENT

Treatment strategy can be divided into three stages. Resolving life threatening conditions Restoring nutritional status Ensuring nutritional rehabilitation. There are three stages of treatment.

TREATMENT

1. Hospital Treatment The following conditions should be corrected. Hypothermia, hypoglycemia, infection, dehydration, electrolyte imbalance, anaemia and other vitamin and mineral deficiencies. 2. Dietary Management The diet should be from locally available staple foods - inexpensive, easily digestible, evenly distributed throughout the day and increased number of feedings to increase the quantity of food. 3. Rehabilitation The concept of nutritional rehabilitation is based on practical nutritional training for mothers in which they learn by feeding their children back to health under supervision and using local foods.

PREVENTION

PREVENTION
Promotion of breast feeding Development of low cost weaning Nutrition education and promotion of correct feeding practices Family planning and spacing of births Immunization Food fortification Early diagnosis and treatment