NUTRITIONAL DISORDERS MAO Meng, MD Professor of Pediatrics School of Medicine, Sichuan University P

NUTRITIONAL DISORDERS OBESITY MALNUTRITION PROTEIN MALNUTRITION [PCM, Protein-Calorie (Energy) Malnutrition, Kwashiorkor] MARASMUS (Infantile Atrophy)

MALNUTRITION Malnutrition, from a worldwide perspective, is one of the leading causes of morbidity and mortality in childhood

improper and / or inadequate food intake inadequate absorption of food poor dietary habits food faddism MALNUTRITION diseases Deficient supply of food metabolic abnormalities emotional factors

Diseases  Diarrhea or digestive system diseases  Upper Respiratory Infection and Pneumonia  Malformations

Mortality rate of diarrhea patients with malnutrition is fourfold of the diarrhea patients without malnutrition.

FOR EVALUATION OF MALNUTRITION INDICATORS FOR EVALUATION OF MALNUTRITION  an accurate dietary history  evaluation of present deviations from average height, weight, head circumference, and past rates of growth  comparative measurements of midarm circumference and skinfold thickness  chemical and other tests

FOR EVALUATION OF MALNUTRITION CLINICAL INDICATORS FOR EVALUATION OF MALNUTRITION  weight-for-age (underweight): weight is lower than -2SD of mean value of the reference population of the same age and sex  height-for-age (stunting): height is lower than -2SD of mean value of the reference population of the same age and sex  weight-for-height (wasting): weight is lower than -2SD of mean value of the reference population of the same height and sex

About the Reference Population in different countries  The reference population from your own country  NCHS-CDC-WHO Reference Population (1976 and 2006)  Reference: De Onis M, Habicht JP. Anthropometric reference data for international use: recommendations from a World Health Organization Expert Committee [J]. The American Journal of Clinical Nutrition. 1996, 64(4):650-658

Laboratory data  Protein----- serum albumin, transferring, hemoglobin, prealbumin, or retinol-binding protein  sodium, potassium, chloride  Immunologic insufficiency

CLINICAL MANIFESTATIONS Failure to gain weight or loss of weight Thin, subcutaneous fat reduced or despaired （orderly abdomen, buttocks, limb and finally face） Disturbulence of functions of organs

MARASMUS (Infantile Atrophy, energy-deficiency or energy-protein deficiency)

ETIOLOGY  Inadequate caloric intake: insufficiency of diet, improper feeding habits  Metabolic abnormalities or congenital malformations Severe impairment of any body system may result in malnutrition

CLINICAL MANIFESTATIONS

 Failure to gain weight followed by loss of weight until emaciation results  Loss of turgor in skin which becomes wrinkled and loose as subcutaneous fat disappears  Edema

 Low temperature and slow pulse  Reduced basal metabolic rate  Fretful or listless  Diminished appetite and constipation followed by the so-called starvation type of diarrhea, with frequent, small stools containing mucus

 Emaciation  Skin wrinkled  Subcutaneous fat disappears from abdomen first, then extremities, and finally face

PROTEIN MALNUTRITION (PCM or PEM, Protein-Calorie (Energy) Malnutrition, Kwashiorkor)

ETIOLOGY  deficient intake of protein of good biologic value  impaired absorption of protein, as in chronic diarrheal states  abnormal losses of protein in proteinuria  Infection  hemorrhage or burns  failure of protein synthesis, as in chronic liver diseases

KWASHIORKOR  a clinical syndrome resulted from a severe deficiency of protein & inadequate caloric intake  the most serious and prevalent form in industrially underdeveloped areas  “deposed child” may become evident from early infancy to 5 yr of age, usually after weaning  height and weight are accelerated with treatment but never equal those of consistently well-nourished children.

CLINICAL MANIFESTATIONS  Early clinical evidence----vague, including lethargy, apathy, and irritability  Inadequate growth, lack of stamina, loss of muscular tissue, increased susceptibility to infections, and edema  Dermatitis and dyspigmentation  Secondary immunodeficiency  Anorexia, flabbiness of subcutaneous tissues, and loss of muscle tone

 Lethargy, apathy  Inadequate growth, loss of muscular tissue  Infections, and edema and dermatitis  Flabbiness of subcutaneous tissues, and loss of muscle tone

 Liver enlargement early or late  Fatty infiltration  Edema usually develops early (failure to gain weight may be masked by edema, which is often present in internal organs before it can be recognized in the face and limbs)  Renal plasma flow, glomerular filtration rate, and renal tubular function are decreased  The heart may be small in the early stages and enlarged later

LABORATORY DATA  Concentration of serum albumin decreased  Aminoaciduria  Ketonuria in the early stage  Low blood glucose values  Potassium and magnesium deficiencies  Amylase, esterase, transaminase, lipase, alkaline phosphatase, pancreatic enzymes decreased  normocytic, microcytic, or macrocytic Anemia  Bone growth delayed and GH increased

Diagnosis  The feeding history  Low body weight, loss of muscular tissue and disturbances of system functions Laboratory data Excluding other diseases

Comparing with children in the same age group (or height) and sex:  Underweight: weight for age is lower than -2SD  Stunting: height for age is lower than -2SD  Wasting: weight for height is lower than -2SD One or two or three may present to one child. Having any one of the three, the child can be diagnosed malnutrition.

DIFFERENTIAL DIAGNOSIS  Protein deprivation: chronic infections, diseases in which there is an excessive loss of protein through urine or stool  The diseases of metabolic inability to synthesize protein

PREVENTION  Diet containing an adequate quantity of protein of good biologic quality  Adequate dietary instruction and food distribution  Treatment of diseases

TREATMENT Immediate management of any acute problems such as those of severe diarrhea, renal failure, and shock and, ultimately, the replacement of missing nutrients are essential.

DEHYDRATION  For mild to moderate dehydration, feedings are administered orally or by nasogastric tube, when culturally appropriate, to prevent aspiration. A breasted infant should be nursed as often as he of she wants.  For severe dehydration, intravenous (IV) fluids are necessary

MILK  When dehydration is corrected, oral or nasogastric feeding starts with small, frequent feeds of dilute milk (66 kcal and 1.0g protein/100 ml at ~120/ml/kg/24 hr) with nutrient supplementation;

 Strength and volume are gradually increased and frequency decreased over the next 5-7 days;  By day 6-8, the child should receive 150 ml/kg/24 hr in ~6 feeds of high-energy milk (114 kcal and 4.1 g protein /100 ml). Cow’s milk, or yogurt for the lactose-intolerant child, should be made with 50 g of sugar/L.

ANTIBIOTICS The routine administration of antibiotics such as co-trimoxazole has also been advocated. Other antimicrobials are used only to treat overt infection because of concerns about emergence of microbial resistance.

Vitamins and minerals, especially vitamin A, potassium, and magnesium, are necessary from the outset of treatment. Iron and folic acid usually correct the anemia.

CHILD MANUTRITION —— Multiple choices What are the factors contributing to malnutrition? Deficient supply of food Poor dietary habits Food faddism and emotional factors Certain metabolic abnormalities The indicators for evaluation of nutritional status are: Weight for age Height for age Weight for height 24hr creatinine excretion

CHILD MANUTRITION —— Multiple choices The lower weight for height indicates: The child has acute malnutrition The child is stunted The child is wasted The child is normal   Protein reserves in malnourished child are assessed from: Serum albumin Transferring Hemoglobin Prealbumin High density lipid protein