MALNUTRITION

PROTEIN ENERGY
MALNUTRITION
PEM
Definition :-
syndrome of clinical &
biochemical changes
caused by varying degrees
of protein caloric, vitamins
& minerals deficiencies
& affecting almost all
.body systems
 -:Etiology

.Lack of breast feeding-

.Lack of nutritional health-
.Unavailability of safe water supply-
.Chronic diarrhoeal diseases-
.Lack of immunization-
.Bottle feeding-
Bad housing (sanitation-
.&environmental)
 -:Etiology

.Short spacing &large family-

Mother ignorance (poor practicing-
.food taboos &believes)
.Preterm low birth wt& twines-
Poverty & inadequate-
.supplementation of food
.Metabolic diseases-
 Classification
-:Welcome classification \1

Clinical classification Depend on wt -

for age (+/-) edema

]2 *100%/)Actual wt +stander wt( [

edema marasmus- 60%< -
edema marasmic kwash+ 60% < -
edema kwashiorkor + %)80 – 60( -
edema Under wt - %)80 – 60( -
not accurate if related to(
) mortality & morbidity
 -:Gomes classification \2

For research &community survey

Wt for age
1st degree mild malnutrition 75%- 90
2ed degree moderate 60%-74%
malnutrition
3ed degree sever malnutrition 60%<
-: Waterloo classification \3

Wt/Ht & Ht for age

Acute & chronic malnutrition

Wt/Ht Severity Ht for age

Normal >95% 90%>
mild 95%-90% 81%-90%
80%-70 % moderate 89% 85%
sever < 85% % 70 <
WHO classification (Wt/Ht) \4

Acute & chronic

Z-scoring (Z normal 50 percentile)
Z 90% of median Wt/Ht 1
Z 80% of median Wt/Ht 2
Z 70% of median Wt/Ht 3
Z 60% of median Wt/Ht 4
Sever malnutrition below 3Z
 -:MUAC \5
)Midway b/w acromion& olecranon(
.For up to 5yrs only
.Ht > 68 cm
.cm normal 13 - 16 -
.cm mild malnutrition 5;13,5-12 -
.cm sever malnutrition 5;12< -
Good, rapid & reliable indicator
PATHOPHYSIOLOGY:

Energy provided by food to :-

1- Maintain the vital organ.
2-Maintain physical activity
3-Growth the child
4-Reserve in the muscles &fat
When the energy is insufficient
-Wt loss (using up the reserve of
energy to preserve the vital organs)
-Relative reduction of needs reported
to the body mass to reduce the
consumption of energy
-:Cellular function

Na pump activity & K

Cell membrane more leaky than
normal
intracellular Na & intracellular K
-:GIT
Intestine -
peristalsis
Loss of brush border (total or
sub total villous atrophy)
loss of enzymes loss of
digestion &absorption (Diarrhea)
Pancreas -
Exo :- loss of zymogene granules
Endo:-atrophy of B cells( glucose
intolerance)
Liver -
fatty infiltration (Kwash)
synthesis of protein
Biliary secretions
ability of liver to take up
metabolite & excrete toxins
limited capacity for
gluconeogenesis
Production of abnormal metabolites
&aa
-:Endocrine -
G.H Insulin &IGf
Epinephrine Somatomedene
glucocortecoids Thyroid .H
Aldosteron Gonadotrophin
Geneto -
urinary
GFR
Na excretion
Hyalinization & sclerosing of
glomeruli (It cannot deal
with water)
UTI is common
Cardio -
vascular
Cardiac out put &stroke volume
BP
HF ( Overload or sever anemia)
Metabolism & temper-
regulation

Limited internal heat production

Disturbed temperature regulation
(Body take tem of surrounding)
-: Immune system -
All aspects of immunity
Atrophy of LN thymus &tonsils
Inefficient killing function of
phagocytes
WBCs don't migrate to area of
damage
There may be not fever with
infection
Complement C6 C8 C9
CD4/CD ratio (vitA)
-:brain-
yrs Sever damage to 2<
interconnecting neurons below the
cortex affection of IQ
2yrs Just small cell damage no>
affection of IQ
-: Muscles-
Atrophy even to muscle spindle

-: Skin-
atrophy &hyperkeratosis (Niacin .
vitA deficiency)
-: Biochemical -
CHO Hypoglycemia
Proteins Hypoprotenemia
(Albumin)

Hypergamaglobulinemia
Urea, Ca, Mg ,K
CLINICAL FEATURES

Cardinal features : •
1- Muscle wasting or
.excoriation of the skin
.Total apathy or irritability -2 •
. Edema of both LL -3 •
Stunting growth -4 •
MARASMUS
(Sever wasting)
Many 2ry forms are ass with chronic
diseases (CF, Ca, Coeliac , AIDS, TB )
Associated with with chronic diarrhea

WT loss(<60%)-1
Loss of muscle mass & subcutaneous -2
fat (Wasting )
large head appearances (proportionate -3
to Ht)
Oldman face appearances-4
Apathic & weak-5
 MARASMUS
(Sever wasting )
Dry &thin skin -6
Bradycardia &hypothermia -7
Hair thin ,spared & easily bulled-8
out
Smooth tongue due to atrophy of -9
papillae
Kwashiorkor
(Edematous malnutrition)
Due to inadequate pro intake in the presence
of fair caloric intake Ass e Acute infec
,toxins &specific micronutrients &aa
imbalance
Wt loss (60%-80%)-1
Edema started in the feet &ascending-2
with the severity
Hair:spared ,easily bulled appears dull-3
brown ,red or yellow white (Flag sign)
Hepatomegaly -4
Kwashiorkor
(Edematous malnutrition)
Skin changes: Hyper pigmentation -5
(Keratosis) to erythematouse
maculae (Bellagroid)
Flaky paint rash (superficial-6
.desquamations) in the pressure areas
Anguler chelosis ,atrophy of the-7
papillae ,monelial thrush
Enlaged parotid & facials edema (moon-8
face)
Apathy &disinterest in eating-9
Sites for muscle wasting
Arm bit (Biceps ,Triceps, Deltoid) -1
Buttocks -2
inner part of the thigh -3
Bellow the scapulae -4
Shoulders -5
Intercostals ribs -6
Lateral aspects of pectoralies -7
major
Abd muscles -8
BAD PROGNOSTIC SIGNs
.Hypothermia (<35,5c) -1
Hypoglycemia (<53mg/dl or -2
.3mmol)
.Hepatomegaly (>5cm) -3
. Ascites -4
. Jaundice -5
.Bleeding tendency -6
-:Causes of diarrhea -
Infectious diarrhea-1
Malabsorption diarrhea-2
Osmotic diarrhea (Reducing -3
substances)
Chemical (Lactose &Lactic acid)-4
Causes of recurrent GE -
Rota virus Shegella
Salmonellas
E.Coli Campylobacter Guardia
INVESTIGATIONS
BBFM-1 •
FBC (Hb% ,TWBC&deff, PCV,MCV MCH-2 •
MCHC )
UG &for C/S (WBCs >10hpf)-3 •
Stool infective diarr &reducing-4 •
substance
RBG(<3mmol)-5 •
BUN &electrolytes (esp in pt e-6 •
dehydration Na premature, Salecylate
poisoning)
INVESTIGATIONS
LFT total serum protein not useful in mmt, but -7
may guide prognosis
8- Sputum for gram stain ZN C/S
CXR-9
-:Mataux test-10
5mm Negative -----0
mm Doubtful 9 -----5
10mm or > positive
-: False –ve
Severely ill pts
Immuno compromised Pts
Viral infections
Pts under steroids
INVESTIGATIONS
-:DignosticBCG (Koch phenomena)-11
BCG indurations Nodules
Vesicles Pustules
Breakdown BCG ulcer
Scare (6/52)
Accelerated response over (1/52)
Serum triglycerides -12
Endoscopy for total &subtotal atrophy-13
HIV screening-14
-: principles

.treat\prevent hypoglycemia \1 •
.treat\prevent hypothermia\2 •
.treat\prevent dehydration\3 •
.corect electrolyte imbalance\4 •
.treat\prevent infection\5 •
correct micronutrient\6 •
.deficiencies
.start feeding\7
.achieve catch-up growth\8
.provide emotional suport\9
.flow-up after recovery\10
treat\prevent\1
-:hypoglycemia
hypoglycemia RBS<3mmol\l or( •
) 54mg\dl
:if conscious -1 •
50ml glucose 10%orally or by- •
NG tube then feed by F-75 every
.30min for 2hr
.antibiotics- •
.two hourly feeds- •
if unconscious ,lethargic or-2 •
: convulsing
iv sterile 10% glucose (5ml\kg)- •
followed by 50ml by NG tube then
.start F75 as above
.antibiotic- •
.two hourly feed- •
Monitor (RBS , rectal •
temperature , level of
consciousness)
-:Prevention •
.feed two hourly- •
.always feeds throw out night- •
Treat\prevent \2
:hypothermia
.feed straightaway- •
.rewarm the child- •
.give antibiotic- •
:Monitor •
.body temperature- •
ensure the child is covered at all- •
.time
.Feel for warmth •
.RBG- •
:Prevention •
.feed 2 hourly- •
.feed throughout the day- •
.keep covered- •
.keep dry- •
.avoid exposure- •
.let the child sleep with mother- •
Treat\prevent \3
:dehydration
: Note •
Don’t use IV route except in •
.case of shock
RESOMAL (REhydration •
SOlution for Malnutrition)
It is difficult to estimate •
dehydration using clinical signs
.alone
:Treatment •
resomal 5ml\kg every 30 min for 2hr-
.orally
.ml\kg\hr for next 4-10 hr 5-10-
.continue F75-
:Monitor
.pulse-
.respiratory rate-
.urine , stool , vomiting-
:Prevention •
.Keep feeding with F75- •
.replace losses- •
if the child is breastfed enourge- •
.to continue
Correct electrolyte \4
:imbalance
give extra potassium 3-4- •
.mmol\kg
give extra magnesium 0,4 – 0,6- •
.mmol\kg
when rehydrating give low- •
sodium rehydration fluid
.(resomal)
.prepare food without salt- •
Treat\prevent \5
:infection
if the child have no complication -1 •
give co- trimoxazol 5ml orally twice
.daily for 5days
if the child is severely ill give -2 •
ampicillin 50mg\kg 8 hourly for 5
days
And gentamicin 7,5 mg\kg IM or IV •
.once daily for 7 days
if the child not improve within 48hr-3 •
add chloramphenicol 25mg\kg 8hrly
.for 5days
Correct micronutrient \6
:deficiencies
Give •
.vit A orally- •
.multivitamin supplement daily- •
.folic acid 1mg\d- •
.zinc 2mg\kg\d- •
.copper 0,3 mg\kg\d- •
iron 3mg\kg\d but only when gaining- •
.wt (2nd week)
:Start cautious feeding \7
In the stabilization phase the •
:essential feature of feeding are
small frequent feeds of low- •
.osmolarity and low lactose
.oral or NG feed- •
.100kcal\kg\d- •
.g protein\kg\d 0,5 - 1- •
.130ml\kg\d of fluid- •
if breast feed encourage to- •
.continue
F-75 containing 75kcal\100 ml •
.and 0,9 g protein\100ml
:Monitor and note •
.amount offered and left over- •
.vomiting- •
.frequency of watery stool- •
.daily body weight- •
Achieve catch-up \8
:growth
In rehabilitation phase use F-100 •
contains 100kcal and 2,9 g protein \
.100ml
To change from starter to catch-up •
:formula
replace F-75 with the same amount- •
of catch-up formula F-100 for 48 hr
then
increase each feed by 10 ml until- •
.some food remains
Provide emotional \9
:support
:Provide •
.tender loving care- •
acheerful , stimulating- •
.environment
structured play therapy 15-30- •
.min\d
.physical activity- •
.maternal involvement- •
Follow-up after \10
:recovery
: Advice parent to •
.bring child for regular follow up- •
ensure booster immunization- •
.are given
ensure vit A is given every 6- •
.month
Treatment of shock and
:sever anaemia
: shock \1 •
.give oxygen- •
.glucose (5ml\kg) by IV 10%- •
give IV fluid at 15ml\kg over 1hr (use- •
ringer lactatet with 5% dextrose or half-
NS with 5% dextrose or drrows sollution
.with dextrose or ringer lactate)
measure and record pulse and respiratory- •
.rate
.give antibiotics- •
: If improve •
repeat IV 15ml\kg over 1hr. Then- •
.switch to oral- •
.continue with F-75- •
:If not improve •
give maintenance IV fluids- •
.(4ml\kg\hr)
transfuse fresh whole blood- •
.(10ml\kg)
.continue with F-75- •
:sever anemia \2 •
Transfusion require if (Hb less •
than 4g\dl or respiratory
distress and Hb between 4-
.6g\dl
Give •
.whole blood.10ml\kg- •
.lasix 1mg\kg at the start- •
:Monitor •
.fever- •
.itchy rash- •
.dark red urine- •
.cofusion- •
.shock- •
Treat associated
:condition
:vit A deficiency \1 •
vit A on day 1 , 2 and 14- •
)for age >12month give 200,000 IU( •
)for age 6-12 month give 100,000 IU( •
)for age 0-5 month give50,000 IU( •
If there is corneal clouding or •
ulceration give chloramphenicol or
tetracycline drops and atropine eye
. drops
:dermatosis \2 •
:Signs •
.hypo-or hyper pigmentation- •
.desquamation- •
.ulceration- •
.exudative lesions- •
Treatment : (omit nappies so that the •
perineum can dry and apply barrier
.cream eg zinc and caster oil)
:parasitic worm \3 •
.Give mebendazole 100mg oraly •
:continuing diarrhea \4 •
mucosal damage and giardiasis are- •
common so examine the stool
microscopically and give
.metronidazole 7,5 mg\kg 8hrly
lactose intolerance so substitute- •
milk with yoghurt or lactose free
.formula
osmotic diarrhea so use isotonic F-- •
.75 and introduce F-100 gradually
:tuberculosis \5 •
. perform mantoux test- •
.chest x – ray- •
Treat according to national TB •
.guidelinse
Failure to respond to
treatment
:Indicated by •
.high mortality -1 •
low wt gain during the -2 •
.rehabilitation phase
poor <5g\kg\d moderate5- ( •
.) 10g\kg\d good >10g\kg\d
:Causes of poor wt gain •
.inadequate feeding - •
.specific nutrient deficiencies- •
.untreated infection- •
.HIV- •
.psychological problems- •