1. PROTEIN ENERGY MALNUTRITION
SEVERE CHİLDHOOD UNDERNUTRITION

2. 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

3. 1 MARASMUS
Primarily energy deficient
take

4. 2 KWASHIORKOR
Primarily protein deficient take

5. 3 MARASMIK-KWASHIORKOR
Has features of both disorders-wasting and edema

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

7. 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..)

8. 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)

9. 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.

10. 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

11. 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

12. 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)

13. 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.

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

15. 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

16. 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 hr
- prealbumin ,9 d
- transferrin d

17. 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

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

19. 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
%= NORMAL
75-89%=1º malnutrition (mild)
60-74%=2º malnutrition (moderate)
<60% = 3º malnutrition (severe)

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

21. 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

23. 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

24. 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

25. 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

26. 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

27. _________________________ _____________
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

28. 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)