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Causative conditions
Loss of appetite
Alteration of normal metabolism
during infection/fever
HIV/AIDS
Prevention of nutrient absorption
Diarrheal infection causing changes in GI epithelium
Diversion of nutrients to parasitic agents themselves
Hookworms, tapeworms, schistosome worm
Malaria
Children with Intestinal
Parasites
(courtesy of WHO)
Prevention of nutrient diversion
Sanitary waste disposal and clean water important
in reducing secondary malnutrition
Prevention of transmission of parasites and diarrheal
diseases
Hookworm acquired by walking barefoot over
contaminated soil
Other roundworm infections use oral-fecal route
Soap an important factor in nutritional status
Education of women extremely important in this regard
Micronutrient Malnutrition
Dietary Deficiencies of
Vitamin A
Iodine
Iron
Others: Zinc, vitamins D, C, and Bs
Protein Calorie Malnutrition
More food needed for normal growth,
health and activity
Rarely have protein deficiency without
caloric deficiency due to the nature of the
food supplies
exception seen with cassava and plantain as
staples
Role of calories
Involuntary use: breathing, blood
circulation, digestion, maintaining muscle
tone and body temperature
Physical activity
Mental activity
Fighting disease
Growth
Role of protein
For building cells that make up muscles,
membranes, cartilage and hair
Carrying oxygen
Nutrient transport
Antibodies
Enzymes needed for most chemical reactions
in the body
What happens to people when they
have inadequate amounts of food
and nutrients?
Metabolic changes
Physiologic changes
Psychological changes
Metabolic Response to Starvation
Hunger subsides after 2-3 days
Defecation ceases after 3-4 days
Urine output drops after 1 week in the majority of
people to 100-700 ml/day
Blood glucose levels drop to 35-65 mg/dL without
clinical signs of hypoglycemia
Nausea occurs in about 1/3 from ketone
production from body fat breakdown
Serum electrolytes do not change
Renal conservation occurs promptly
Rarely see low potassium in prolonged fast
Metabolic Response to Starvation
Negative nitrogen balance - 1st 5-7 days
12-15 grams of nitrogen per day is excreted in
the urine (based on 1800 kcal daily needs)
Skeletal muscle is catabolized to produce
glucose (gluconeogenesis), using about 75
grams per day of protein
This is equal to lb of wet tissue per day
About 160 gm/day of body fat is also used
Metabolic Response to Starvation
Negative nitrogen balance
Gradually slows so that at about 1 month
2-4 grams of nitrogen is loss per day
Skeletal muscle catabolism decrease
significantly
Only for cells that have to have glucose
Central nervous system
Red blood cells
White blood cells
Metabolic Response to Starvation
Gradual shift in metabolic fuels
First glucose is produced from protein
breakdown to provide energy
Then fat breakdown and metabolism provides
ketones for all tissues except CNS, RBC and
WBC
Brain will eventually use ketones but red blood cells
have no mitochondria, so must use glucose
Serum fatty acid levels increase
Serum albumin is normal until late in starvation
Production of Ketones
Metabolism
Metabolic Response to Starvation
Hormonal changes
Plasma insulin decreases
Plasma cortisol and growth hormone stay the
same and glucagon increases
These changes are responsible for the
mobilization and oxidation of fat stores
Changes in sympathetic nervous system and
metabolism of thyroid hormone lowers basal
metabolic rate
Metabolic Response to Starvation
Weight loss
1st week 0.7-1.3 kg/day, much of which is salt
& water loss
After 1st week 0.3-0.5 kg/day
Basal Metabolic Rate & Total Energy
Expenditure in prolonged starvation
See activity, sleep
body temperature
Protein Energy Malnutrition
Primary:
nutrition intake <<
OUTPUT:
Infection
Chronic diarrhea/
Malabsorption
Hypermetabolism
etc.
Protein Energy Malnutrition
T Nutr.status = spectrum :
Wt/Ht
DIAGNOSIS :
1. Anamnesis
2. Physical examination
3. others : - laboratory
- anthropometry
- dietary analysis
PEM.
Checklist : anamnesis
Usual diet before current episode of
illness
Breastfeeding history
Food & fluids taken in past few days
Recent sunken eyes
Duration & freq. of vomiting / diarrhoea,
appearance of vomit / diarrhoeal stools
PEM.
Checklist : anamnesis
Time when urine was last passed
Any deaths of siblings
Birth weight?
Milestones reached (sitting up, standing,etc)
Contact with people with measles or
tuberculosis
Immunizations
PEM.
Puffy
Oedema
Severe PEM : Kwashiorkor
Hepatomegaly
Crazy pavement oedema
dermatosis
Severe PEM : Marasmus
face
hair
Muscles atrophy
SC fat <<
Ribs
Severe PEM : Marasmus + KP
lymphadenopathy
Severe PEM : Marasmus + KP
Caverne
Laboratory tests:
Tests that may be useful :
Blood glucose : < 54 mg/dl = hypoglycaemia
Blood smear : parasit malaria
Hb or Ht : < 4 g/dl / < 12% = severe anaemia
Urine exam/culture: bacteria (+) / > 10 lekosit/HPF
infection
Faeces : blood (+) disentri
Giardia (+) / parasit lain infeksi
X-ray : - thorax : l Pneumonia
l Heart failure
MANAGEMENT :
l Mild-moderate PEM :
- no specific clinical signs : thin, hypotrophic
- not necessary to hospitalize
- looking for the probable causes
- nutrition education & supplementation
Other criteria :
Very low BW:
W/H < 70%
W/A < 60%
W/A > 60% + edema
+ clinical signs & symptoms :
edema (M-K)
severe dehydration
persistent diarrhea & / vomiting
severe pallor, hypothermia, shock
signs of systemic / local infection, URI
severe anemia ( Hb < 5 g/dl)
jaundice
anorexia
< 1 yr of age
PEM.
Signs & symptoms of dehydration :
history of diarrhea or no/diminished intake
weak, apathetic unconscious
weak to absent of radial pulse
thirst, dry mouth & absent of tears
sunken eyes & fontanel
hypothermia
cold hands & feet
urine flow << / -
Dehydration
Sunken eyes
Dehydration
Turgor :
PEM.
A. 10 main steps
E. Emergency
PEM.
A : 10 main steps
No Interven- Stabilization Transition Rehabilitation Follow-up
tion d.1-2 d.3-7 wk-2 wk 3-6 wk 7-26
1. Treat/prevent
hypoglycaemia
2. Treat/prevent
hypothermia
3. Treat/prevent
dehydration
4. Correct electr.
imbalance
5. Treat infection
6. Correct micro- without Fe + Fe
nutrients defic.
7. Begin feeding
8. Increase feeding
9. Stimulation
10. Prepare for
discharge
PEM.
Bacterial infection :
- no apparent signs of infection/no complication:
cotrimoxazole ( 5 mg TMP/kg, 2x/d, 5 days )
1. Death
= within first 24 hrs :
- hypoglycemia
- hypothermia
- dehydration
- sepsis
= within 24 72 hrs :
- volume of formula >>
- caloric density >>
PEM.
Weight gain :
= satisfactory: > 10 g/kg/d good =
= sufficient : 5-10 g/kg/d > 50 g/kg/wk
= poor : < 5 g/kg/d or < 50 g/kg/wk
PEM.
= Dietary advice :
- high protein and calorie
- frequent feeding ( 5x/d )
- finish all meals given
- vit-min supplementation & electrolytes
- continue BF
= frequent controle ( 1x/wk )
= Immunization
5. Emergency :
5.1. Shock :
N2 or RLG5%
15 ml/kg, 1 hr
Improvement
_
+
Special formula
5. Emergency :
Hb ?
Resp.distress/heart failure?
Fresh blood 10 ml/kg* _
+
Recovery : 16 kg
Protein energy malnutrition
1- Marasmus
Definition:
A clinical syndrome & a form of under nutrition
characterized by failure to gain weight due
to inadequate caloric intake.
Incidence:
Commonly in infants between the age of 6mo -
2years (Infantile atrophy).
Etiology
1. Dietary errors
2. Infection: (acute / chronic) TB, Otitis media, Pyelonephritis
3. Gastroenteritis: acute / chronic
4. Parasitic infestations: Ascaris, Ankylostoma, Giardia
5. Congenital anomalies: Cardiac (PDA, VSD, F4), Renal (renal
agenesis, obstructive uropathy), GIT (Pyloric stenosis, Cleft lip or
palate)
6. Metabolic diseases: Galactosemia, Fructose intolerance, Idiopathic
hypocalcaemia
7. Prematurity
8. Some cases of mental retardation
9. Low socio-economic status
10. Endocrine causes (DM, Hyperthyroidism)
Assessment of Marasmic
Child/Infant
Failure to thrive, loss of weight (weight < 60% of expected)
Loss of subcutaneous fat: (measured at many parts of the
body according to the degrees)
o 1 st degree: abd. wall
o 2 nd degree: abd. wall & limbs
o 3 rd degree: abd. Wall, limbs & face
Assessment of Marasmic
Child/Infant (Cont.)
Muscle wasting (thin muscles & prominence of
bony surfaces)
GIT disturbances: anorexia in advanced cases,
hungry, constipation / diarrhea / starvation diarrhea
Liability to infection
Hypovolemia
Weak feeble pulse, subnormal temp, pulse rate
Senile face & pallor
Complications of Marasmus
1. Intercurrent infection:
Bronchopneumonia is the cause of death
2. Gastroenteritis
3. Hemorrhagic tendency, purpura
4. Hypothermia
5. Hypoglycemia
6. Edema (marasmic kwashiorkor)
Investigations for Marasmic
Infant
1. Blood analysis: WBC, Electrolytes,
Glucose, Ketones, Plasma proteins
2. Urine analysis: Culture, Glucose,
Ketones, Ca, Phosphate, Protein
3. Stool analysis: parasites
4. X-ray: chest
5. Tuberculin test: TB
6. ENT examination: Otitis media
Treatment
1. Prevention:
Balanced nutritional diet
Encourage breast feeding up to weaning
Proper weaning
Vaccination (measles, TB, whooping cough)
Education regarding the cheap sources of balanced
diet, family planning.
Proper follow up of the growth rate
Early treatment of defects or associated diseases
Treatment (Cont.)
2 Curative treatment:
A. Proper dietary management:
Adequate balanced feeding; teaching: nutritional needs, preparation
of diet, technique of administration of food
If there is vomiting or anorexia, give IV fluids / naso gastric tube
feeding.
Gradual increase the amount and concentration of formula (total
calories is 120-200 cal/kg/d)
B. Treatment of the cause
C. Emergency treatment for complications
D. Blood transfusion
E. Vitamins and minerals supplementation
2-Kwashiorkor
Definition
A clinical syndrome & a form of malnutrition
characterized by slow rate of growth due to
deficient of protein intake, high CHO diet
and vitamins & minerals deficiency
(adequate supply of calories).
Incidence
Commonly in toddlers between the age 1-
3years, following or with weaning
Etiology