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NUTRITIONAL DISORDERSNUTRITIONAL DISORDERS
MAO Meng, MD
Professor of Pediatrics
School of Medicine, Sichuan University
MARASMUS(Infantile Atrophy)
MALNUTRITION OBESITY
PROTEIN MALNUTRITION[PCM, Protein-Calorie (Energy) Malnutrition, Kwashiorkor]
NUTRITIONAL DISORDERS
MALNUTRITIONMALNUTRITION
Malnutrition, from a worldwide
perspective, is one of the
leading causes of morbidity
and mortality in childhood
MALNUTRITIONMALNUTRITION
improper and / or inadequate food intake
inadequate absorption of food
Deficient supply of food
poor dietary habitsfood faddism
emotional factors metabolic abnormalities
diseases
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.
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
INDICATORS INDICATORS FOR EVALUATION OF MALNUTRITIONFOR EVALUATION OF MALNUTRITION
CLINICAL INDICATORS CLINICAL INDICATORS FOR EVALUATION OF MALNUTRITIONFOR 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 About the Reference Population in different countriesin 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
Protein----- serum albumin,
transferring, hemoglobin, prealbumin,
or retinol-binding protein
sodium, potassium, chloride
Immunologic insufficiency
Laboratory data
CLINICAL MANIFESTATIONS
Failure to gain weight or loss Failure to gain weight or loss of weight of weight
Thin, subcutaneous fat reduced or despaired
(( orderly abdomen, buttocks, limb and finally faceorderly abdomen, buttocks, limb and finally face ))
Disturbulence of functions of organs Disturbulence of functions of organs
MARASMUSMARASMUS(Infantile Atrophy, energy-deficiency (Infantile Atrophy, energy-deficiency
or energy-protein deficiency)or energy-protein deficiency)
Inadequate caloric intake: insufficiency of diet, improper feeding habits
Metabolic abnormalities or congenital malformations
Severe impairment of any body system
may result in malnutrition
ETIOLOGYETIOLOGY
CLINICAL MANIFESTATIONSCLINICAL 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 MALNUTRITIONPROTEIN MALNUTRITION
(PCM or PEM, Protein-Calorie (Energy) Malnutrition, (PCM or PEM, Protein-Calorie (Energy) Malnutrition,
Kwashiorkor)Kwashiorkor)
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
ETIOLOGYETIOLOGY
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.
KWASHIORKORKWASHIORKOR
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
CLINICAL MANIFESTATIONSCLINICAL MANIFESTATIONS
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
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
LABORATORY DATALABORATORY DATA
DiagnosisDiagnosis
The feeding history
Low body weight, loss of muscular
tissue and disturbances of system
functions Laboratory data Excluding other diseases
Underweight: weight for age is lower than -2SD
Stunting: height for age is lower than -2SD
Wasting: weight for height is lower than -2SD
Comparing with children in the same Comparing with children in the same age group (or height) and sex:age group (or height) and sex:
One or two or three may present to one child. Having any one of the three,
the child can be diagnosed malnutrition.
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
DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS
Diet containing an adequate
quantity of protein of good biologic
quality
Adequate dietary instruction and
food distribution
Treatment of diseases
PREVENTIONPREVENTION
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.
TREATMENTTREATMENT
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
DEHYDRATIONDEHYDRATION
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;
MILKMILK
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.
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.
ANTIBIOTICSANTIBIOTICS
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 foodPoor dietary habitsFood faddism and emotional factors Certain metabolic abnormalities
The indicators for evaluation of nutritional status are:Weight for age Height for ageWeight for height24hr creatinine excretion
CHILD MANUTRITION —— Multiple choices
The lower weight for height indicates:The child has acute malnutritionThe child is stuntedThe child is wastedThe child is normal
Protein reserves in malnourished child are assessed from:
Serum albuminTransferringHemoglobinPrealbuminHigh density lipid protein