PROTEIN ENERGY MALNUTRITION

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. 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 12 hr - prealbumin 1,9 d - transferrin 8 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 90-100 %= 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

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)