PROTEIN ENERGY MALNUTRITION SEVERE CHİLDHOOD UNDERNUTRITION

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

1 MARASMUS Primarily energy deficient take

2 KWASHIORKOR Primarily protein deficient take

3 MARASMIK-KWASHIORKOR Has features of both disorders-wasting and edema

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

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..)

CLINIC MANIFESTATIONS MARASMUS: - failure to gain weight - severe wasting - linear growth stunting - generalized muscular wasting and absence of subcutaneous fat ==> loss of turgor. - atrophy of muscle ==> 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)

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.

KWASHIORKOR Disease of the deposed baby when the next is born (African’s 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 child==> sugar baby

KWASHIORKOR 2 Soft painless edema (espacially feet and legs=>face and upper extremities) failure the gain weight may be masked dermatose=hyperkeratosis,dyspigmentation, desqumation. Thin hair, color changes; red to yellowish gray Height may be normal/stunted

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)

Kwashiorkor Marasmus Onset is later, after the breast-feeding is stopped. The onset is earlier, usually in the first year of life Not very Pronounced. Growth failure is more pronounced. Edema is present. There is no edema Blood protein concentration is reduced very much. Blood protein concentration is reduced less markedly. Red boils and patches are classic symptoms. Skin changes are seen less frequently. Fatty liver is seen. Liver is not infiltrated with fat Recovery period is short. Recovery is much longer.

MARASMIK-KWASHIORKOR Clinical features of both types malnutrition Main features : - edema of Kwashiorkor - cachexia of Marasmus

Mid arm circumference (1-5 yrs=>stable) Skinfold thickness: ↓ PEM DIAGNOSIS= - dietary history - evaluation of present deviations from avarage Height } Weight } FOR AGE HC } WEIGHT- FOR HEIGHT Mid arm circumference (1-5 yrs=>stable) Skinfold thickness: ↓ PEM : ↑ obesity

Muscle mass=> arm circumference- skinfold measurement BMI= w/h² Deficiencies of some nutrients=> low blood levels and their metabolities Protein reserves – serum albumin ↓ halflife rapid turnover pr- transthyretin 12 hr - prealbumin 1,9 d - transferrin 8 d

Excretion of hydroxyproline is decreased hydroxyproline/creatinine = ↓ 2 => 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

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

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 75-89%=1º malnutrition (mild) 60-74%=2º malnutrition (moderate) <60% = 3º malnutrition (severe)

WELLCOME W for age - 60-80% - <60% EDEMA (+) Kwashiorkor, Marasmic- Kwashiorkor (-)Underweight, Marasmus

WATERLAW H for age= h of patient/h of healty child with same age X 100 95% ↓=> chronic malnutrition= stunting W for h= w of the patient/ w of healty child with with the same h X100 90% ↓=> acute malnutrition= wasting

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 dehydration=> orally/NG tube Breastfed infant should be nursed as often as he/she wants. IV fluids are necessary for treatment of severe dehydration

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

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

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

_________________________ _____________ Stabilization Rehabilitation   _________________________ _____________ Days 1-2 Days 3-7 Weeks 2-6 1. Hypoglycaemia 2. Hypothermia 3. Dehydration 4. Electrolytes 5. Infection 6. Micronutrients no iron with iron 7. Initiate feeding 8. Catch-up growth 9. Sensory stimulation 10. Prepare for follow-up  

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)