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MalnutritionMalnutrition
Dr. Ayesha Mohannad
MALNUTRITIONMALNUTRITION
A pathological state resulting from relative or absolute deficiency or excess of one or more of the essential nutrients
MALNUTRITUIONMALNUTRITUION Undernutrition: too little energy or too few nutrients, over an extended period of time causing weight loss or a nutrient deficiency disease
Over nutrition: too much energy or too much of a given nutrient over extended period of time, causing obesity, heart disease, or nutrient toxicity
MalnutritionMalnutritionImbalance: It is a pathological state
resulting from a disproportion among essential nutrients with or without the absolute deficiency of any nutrient
Specific: It is a pathological state resulting from a relative or absolute lack of an individual nutrient
Nutritional DeficienciesNutritional DeficienciesPrimary deficiency occurs when a person does not
consume enough of a nutrient, a direct consequence of inadequate intake
Nutritional DeficienciesNutritional Deficiencies
Secondary deficiency occurs when…
a person cannot absorb enough of a nutrient in his or her body
too much nutrient is excreted from the body
a nutrient is not utilized efficiently by the body
Deficiency SymptomsDeficiency Symptoms
Subclinical deficiency occurs in the early stages,
few or no symptoms are observed tests or other invasive procedures
to detect
Clinical deficiency Symptoms of nutrition deficiency that become obvious are referred to as overt
MALNUTRITIONMALNUTRITIONProtein-energy malnutrition
refers to a form of malnutrition where there is inadequate protein and calorie intake.
Types include:Kwashiorkor (protein malnutrition
predominant)Marasmus (deficiency in both
calorie and protein nutrition)Marasmic KwashiorkorMild to moderate PEM
EPIDEMIOLOGYEPIDEMIOLOGYThe term protein energy
malnutrition has been adopted by WHO in 1976.
Highly prevalent in developing countries among <5 children; severe forms 1-10% & underweight 20-40%. Malnutrition is implicated in >50% of deaths of <5 children (5 million/yr)
All children with PEM have micronutrient deficiency.
Etiology of Primary Etiology of Primary MalnutritionMalnutrition Lack of education Failure of Lactation. Poverty Food Taboos Lack of Family Planning 2 or more children under 5 years of age in same
household Incompetent/ Ignorant Mother. Improper Weaning Practices Death of Mother
Infections: Tuberculosis ( very common in Pakistan)
Infestations Lack of Immunization
Etiology of Secondary Etiology of Secondary MalnutritionMalnutrition Congenital Diseases: ASD, VSD,
cleft palate etc. Malabsorption: Celiac Disease,
Lactose intolerane, Giardiasis, Cystic Fibrosis
Metabolic: Inborn errors of Metabolism, CRF, Renal tubular Acidosis etc.
MARASMUSMARASMUSThe term marasmus is derived from the Greek marasmos, which means wasting.
Marasmus involves inadequate intake of protein and calories and is characterized by emaciation.
Marasmus represents the end result of starvation where both proteins and calories are deficient.
MARASMUS/2MARASMUS/2
Marasmus represents an adaptive response to starvation, whereas kwashiorkor represents a maladaptive response to starvation
In Marasmus the body utilizes all fat stores before using muscles.
Clinical Features of Clinical Features of MarasmusMarasmus
Severe wasting of muscle & s/c fats
Severe growth retardationChild looks older than his ageNo edema or hair changesHungryDiarrhoea & Dehydration
KWASHIORKORKWASHIORKOR
Cecilly Williams, a British
nurse, had introduced the
word Kwashiorkor to the
medical literature in 1933. The
word is taken from the Ga
language in Ghana & used to
describe the sickness of
weaning.
ETIOLOGYETIOLOGY
Kwashiorkor maximal
incidence is in the 2nd yr of
life following abrupt weaning.
Kwashiorkor is not only
dietary in origin. Infective,
psycho-socical, and cultural
factors are also operative.
CONSTANT FEATURES OF KWASHCONSTANT FEATURES OF KWASH
OEDEMA
PSYCHOMOTOR CHANGES
GROWTH RETARDATION
MUSCLE WASTING
OCCASIONALLY PRESENT OCCASIONALLY PRESENT SSIGNSIGNS
HEPATOMEGALY FLAKY PAINT DERMATITIS CARDIOMYOPATHY & FAILURE DEHYDRATION (Diarrh. & Vomiting) SIGNS OF VITAMIN DEFICIENCIES SIGNS OF INFECTIONS
USUALLY PRESENT USUALLY PRESENT SIGNSSIGNS
MOON FACE
HAIR CHANGES
SKIN DEPIGMENTATION
ANAEMIA
DD of Kwash DermatitisDD of Kwash Dermatitis
Acrodermatitis Entropathica ScurvyPellagraDermatitis Herpitiformis
ANTHROPOMETRYANTHROPOMETRY
Objective with high specificity & sensitivity
Measuring Ht, Wt, MAC, HC, skin fold thickness, waist & hip ratio & BMI
Reading are numerical & gradable on standard growth charts
Non-expensive & need minimal training
Detection Of PEMDetection Of PEM
Height for ageWeight for age Weight for height Arm circumferenceSkin fold thicknessHead and chest circumference
MALNUTRITIONMALNUTRITION
Interpretation of Interpretation of IndicatorsIndicatorsWaterlow’s Classification Defines two groups for PEMMalnutrition with low weight for a
normal height(wasting or acute malnutrition)
Malnutrition with low height for age(stunting or chronic malnutrition)
Wt/ht%= Wt of the child
x100 Wt of the child of same Ht
Ht/age%= Ht of the child x100 Ht of the child of same age
Interpretation of Interpretation of IndicatorsIndicators
Nutritional status Stunting(% of height/age)
Wasting(% of weight/ height)
Normal >95 >90
Mild 87.5-95 80-90
Moderate 80-87.5 70-80
severe <80 <70
CLASSIFICATIONCLASSIFICATION
◦A. CLINICAL ( WELLCOME )◦Parameter: weight for age +
oedema◦Reference standard (50th percentile)◦Grades:
80-60 % without oedema is under weight 80-60% with oedema is Kwashiorkor < 60 % with oedema is Marasmus-Kwash < 60 % without oedema is Marasmus
MalnutritionMalnutritionGomez’ ClassificationIt is based on weight retardationWt for age(%) = Wt of the child x 100 Wt of the normal child of same
ageBetween 90-110% =normal 75- 89% =mild malnutrition 60-74% =moderate Under 60%=severe
ADVANTAGESADVANTAGES
SIMPLICITY (no lab tests needed)
REPRODUCIBILITYCOMPARABILITYANTHROPOMETRY+CLINICAL SIGN USED FOR ASSESSMENT
DISADVANTAGESDISADVANTAGES
AGE MAY NOT BE KNOWNHEIGHT NOT CONSIDEREDCROSS SECTIONALCAN’T TELL ABOUT CHRONICITYWHO STANDARDS MAY NOT REPRESENT LOCAL COMMUNITY STANDARD
CLINICAL ASSESSMENTCLINICAL ASSESSMENT
Interrogation & physical exam including detailed dietary history.
Anthropometric measurementsTeam approach with involvement of dieticians, social workers & community support groups.
Investigations for PEMInvestigations for PEMFull blood countsBlood glucose profileSeptic screeningStool & urine for parasites & germs
Electrolytes, Ca, Ph & ALP, serum proteins
CXR & Mantoux testExclude HIV & malabsorption
NON-ROUTINE TESTSNON-ROUTINE TESTS
Hair analysisSkin biopsyUrinary creatinine over proline ratio
Measurement of trace elements levels, iron, zinc & iodine
Complications of P.E.MComplications of P.E.MHypoglycemiaHypothermiaHypokalemiaHyponatremiaHeart failureDehydration & shockInfections (bacterial, viral & thrush)
Primary PreventionPrimary Prevention
Health Promotion Promotion of breast feeding Development of low cost weaning
foods rich in protein and energy Measures to improve family diet Promotion of correct feeding
practicesFamily planning and improving
family environment
Primary PreventionPrimary Prevention
ImmunizationPromotion of early use of ORS in
diarrhoeaDeworming
Secondary PreventionSecondary PreventionMass screening of high risk
population by simple tools like weight for age or MUAC
Early diagnosis and treatment Good nutritional careSupplementary feeding150
mg/kg body weight through oral or NG feed
Counselling of the mothers
Tertiary PreventionTertiary Prevention
Rehabilitation
Follow up care