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PROTEIN ENERGYPROTEIN ENERGY

MALNUTRITIONMALNUTRITION

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PROTEIN ENERGY

MALNUTRITION Definition : ( WHO) * Marasmus Weight less than 60% of expected weight - no

oedema.

Kwashiorkor Weight between 60-80% of expected weight +oedemaNo oedema Oedema

Kwashiorkor 80%80 %Underweightfor age

60%Marasmic-Kwashiorkor

Marasmus60%

Wellcome Classification

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Gomez Classification for

Malnutrition1ry PEM is a spectrum ranging from:

* mild formDecrease weight for length.

*severe formDecrease length and weight for age.

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Aetiology of (PEM)

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

1ry:. Protein + energy intakes below requirement for normalgrowth

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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Kwashiorkor: Ga language of West Africa = Supplanted one - Childwho recently have been weaned

(Pregnant mother) and emotional deprivationHistory:

1933 Cecily * Ghanaian children* Weaned recently* Oedema and hair changes* Fatty liver

1967 Mc-Cane * Anaemia

* Cardiac* Skin changes

1971 Frood-Paskitt * Biochemical

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Pathogenesis:Kwashiorkor: Normal energy intake, Lack of protein Edema:1970.decrease oncotic pressure,

Recent> Increase Renin activity,N a and fluid

retention. Amino aciduria due to proximal tubulardysfunction

Failure of adaptation .Hepatomegaly due to fatty infiltration from

lipogenesis of excess CHO - Biochemical and haematological changes

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Pathogenesis:

Marasmus: - Lack of all nutrients stimulate cortisone

secretion which result in muscle wasting, the

released a. a will synthesize albumin to preventedema. - Growth and energy expenditure limited, in

response to dietary stress - Adaptation to reduce protein + energy

- Biochemical and haematological tests withinnormal -Abdomin,flat due to ms wasting, OR distended

due to 2ry lactose intolerance.

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Causes:

Social.ecomomic.poverity.ignorance.maternal

malnutrtion.enviromental.Kwashiorkor:

Insufficient intake of protein of good biological value.

Impaired absorption of protein e.g. chronic diarrhoea.

Abnormal losses of protein e.g.severe nephrosis . Severe or prolonged infection

Failure of protein synthesis e.g.

chronic liver diseases.

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Marasmus:

Inadequate caloric intake due to insufficient diet . Improper feeding habits .

Emotional deprivation.

Metabolic abnormalities

Congenital malformation Severe impairment of any body system

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Management:

- Accurate history of social and economic factors.

poverety,ignorance. environmental factors .diet history: maternal malnutrition, breast milk and other feedinghabits .food allergies ,food taboos.chronic illness ,burns .HIV. cystic fibrosis .malignancies .inbornerror of metabolism ,

- Evaluation of growth parameters: weight, height, headcircumference

- Evaluation of the degree of illness and dehydration:skin fold thickness - Biochemical evaluation

* mild * moderate * severe

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1) Mild - moderate with no complication

- Home management

food increase calories + energy

Multivitamin 1st week

Iron replacement 2nd week.

antibiotics for infection

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2) Severe marasmic or severe kwashiorkorComplicated cases or marasmic kwashiorkorHospital management

INITIAL PHASE1st day: History --- clinical exam -- rehydrationPrevent heat lossNGT feeding ORS, IVF (glucose and electrolytes)Treatment of infection,bacterial and parasitic.

2nd -7th day:a) Continue rehydration by NGT,

b) start diet by NGT .calories 80-100/kg/day ,Protein 3-4 g/kg/d. small volumes2hourly then 4hourly to6 hourly. and increase calories gradually, c) multivitamin. Vit A, folic acid. Without IRON for the 1st week.

d) Correct anaemia ( packed RBC carefully)

If diarrhea starts or fails to resolve may be lactose intolerance lactose free milk or cow milkprotein intolerance start soy protein hydrolysate formula.

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Rehabilitation phase week2-6a) Start oral feedingb) Continue antibioticsc) Start iron

Oedema disappear ,, appetite improvement .the child ismore interested in the surrounding

Follow up phase

Discharge..Supervising the mother in cooking

parental education to prevent an additional episodes

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Follow-up:1st sign of improvement:

-Awareness in the child-Appetite (kw)-Weight loss (kw)

Weight gain

rapid Marasmus

Slow (10th day) Kwashiorkor

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Failureof improvement:

1) Combined marasmic -kwashiorkor

2) Infection TB ,,,parasite

3) drowsiness -Severehypokalemia-Hepatic failure

-Proteinintolerance

4) Rapid gainofweight - Cardiac failure- Grossly disturbed metabolism- Unabletotoleratetherateofrefeeding (oedema)

5) Profusediarrhea - GITinfection- Food intolerance(discharidase)- Othernutrients deficiency

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Complications:1) Infection:

1. Immunological defect- Cell mediated> humoral- Measles> fatal disease

2. Subtle infection- Lack of fever- Hypothermia

- No increase in WBC- Inability to localize infection

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Complications (cotn)

2) Hypoglycaemia apnoea

3) Hypothermia bradycardia

4) Heart failure death

5) Vit deficiencies Vit A blindness

6) Permanent growth stunting

7) Prolonged illness developmental delay

cognitive functionslow intellectualachievement

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Prevention:Improve nutritional status Improve water supplyWithout change in food supply Proper sanitation

Health educationSocial worker visits,

Reduce infection rate ImmunizationSupervision of feeding

Good weaning practice

Long term communityhealth measures

Effective for

one generation

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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 failureof adaptation

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