ZINC AND COPPER LEVELS IN CHILDREN WITH PROTEIN ENERGY MALNUTRITION Prasad,Dr.Ramalingam,Dr.J.N.Naidu.
INTRODUCTION: • World Health Organization ( WHO ) has defined , “Protein Energy Malnutrition ( PEM) ” as a range of pathological conditions arising from coincidental lack in varying proportion of proteins and calories , occurring most frequently in infants & young children & commonly associated with infection. • most cases PEM is caused by a combination of inadequate dietary intake, lack of good care and the adverse effect of infection
WHO has described malnutrition as a “global problem”, having adverse effect on the survival, health performance & progression of population group. • In India 46 % of all children under the age of three are too small for their age, 47 % are underweight and 16 % are wasted. Prevalence of severe malnutrition varies across the states with MP recording the highest rate (55%) and Kerala, the lowest (27%). In Andhra Pradesh it is 37%.
Zinc: • Zinc is required for muscle and bone formation. • Zinc is essential for the immune system. • It is required for tissue growth, development and regenaration. • Zinc is involved in stabilization of Insulin • It is involved in vit-A mobilization from the liver(dark adaptation) • Over 200 zinc metalloenzymes have been isolated. • They are LDH,MDH,CP, DNA and RNA polymerases ,thymidinekinase, ALP, Angiotensin converting enzyme, CA and SOD.
Zinc • children who are zinc-deficient have more episodes of infection, particularly diarrhoea and respiratory disease. • zinc deficiency causes increased losses of intestinal fluid during diarrhoea and delayed recovery from acute or persistent diarrhoea. If a two week course of a cheap syrup containing zinc acetate (2mgs of elemental zinc per kg/day) is given to • these children: • _ recovery from diarrhoea is faster • _ purging is less • _ there are fewer episodes of diarrhoea in the following months.
zinc deficiency is common because the best sources of zinc are fish and meat, which are often too expensive for many families. • the bioavailability in plant foods, such as cereals, is low. at present, the recommendation is to give zinc supplements during treatment of severely malnourished children particularly those with persistent diarrhoea and acute diarrhoea. • zinc deficiency is an important cause of low birth weight in malnourished populations. • supplementation of zinc-deficient women during pregnancy improves weight gain and birth weight but accurate detection of zinc deficiency is difficult.
Copper: • Copper is required for the activity of enzymes involved in the Respiratory chain, Cross linking of collagen and elastin, blood cell formation, melanin formation, superoxides removal, neurotransmitter formation and neupeptidess. • In most of the cases copper is a part of the enzyme molecule. • Cuproenzymes are cytochromeoxidase, lysyloxidase, SOD, Ceruloplasmin, TK, Dopamine Beta-oxidase, amine oxidase and uricase.
Copper is necssary for iron incorporation of iron into hemoglobin. • Copper is a co-factor for vitamin-C requiring hydroxylation. • Copper increases HDL and so protects the heart
Complications of P.E.M • Hypoglycemia • Hypothermia • Hypokalemia • Hyponatremia • Heart failure • Dehydration & shock • Infections (bacterial, viral & thrush)
CLASSIFICATION • A. CLINICAL ( WELLCOME ) • Parameter: weight for age + oedema • Reference tandard (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
CLASSIFICATION (2) • B. COMMUNITY (GOMEZ) • Parameter: weight for age • Reference standard (50th percentile) WHO chart • Grades: • I (Mild) : 90-70 • II (Moderate): 70-60 • III (Severe) : < 60
KWASHIORKOR • 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.
CLINICAL PRESENTATION • Kwash is characterized by certain constant features in addition to a variable spectrum of symptoms and signs. • Clinical presentation is affected by: • The degree of deficiency • The duration of deficiency • The speed of onset • The age at onset • Presence of conditioning factors • Genetic factors
CONSTANT FEATURES OF KWASH • OEDEMA • PSYCHOMOTOR CHANGES • GROWTH RETARDATION • MUSCLE WASTING
USUALLY PRESENT SIGNS • MOON FACE • HAIR CHANGES • SKIN DEPIGMENTATION • ANAEMIA
OCCASIONALLY PRESENT SIGNS • HEPATOMEGALY • FLAKY PAINT DERMATITIS • CARDIOMYOPATHY & FAILURE • DEHYDRATION (Diarrh. & Vomiting) • SIGNS OF VITAMIN DEFICIENCIES • SIGNS OF INFECTIONS
MARASMUS • The 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 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 Marasmus • Severe wasting of muscle & s/c fats • Severe growth retardation • Child looks older than his age • No edema or hair changes • Alert but miserable • Hungry • Diarrhoea & Dehydration
EPIDEMIOLOGYand ETIOLOGY • The 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%. • All children with PEM have micronutrient deficiency. • Seen most commonly in the first year of life due to lack of breast feeding and the use of dilute animal milk. • Kwashiorkor can occur in infancy but its maximal incidence is in the 2nd yr of life following abrupt weaning.
Kwashiorkor is an example of lack of physiological adaptation to unbalanced deficiency where the body utilized proteins and conserve S/C fat. • One theory says Kwash is a result of liver insult with hypoproteinemia and oedema. Food toxins like aflatoxins have been suggested as precipitating factors. • Poverty or famine and diarrhoea are the usual precipitating factors • Ignorance & poor maternal nutrition are also contributory
AIMS AND OBJECTIVES • to evaluate copper and zinc levels in children with protein energy malnutrion.
MATERIALS AND METHODS • Serum zinc and copper were determined in thirty (30) malnourished pre-school-age children (age,0-60 months) and thirty (30) age-and sex-matched apparently healthy well nourished controls to evaluate the effect of protein-energy malnutrition on serum zinc and copper.
METHOD OF DETERMINATION OF COPPER AND ZINC • Serum zinc & Copper were estimated by the Atomoic Absorption Spectrophotometry • Serum total protein and albumin and globulin is estimated by autoanalyzer method
The data on personal history regarding the onset and duration of the symptoms in protein energy malnutrition and treatment history for PEM were collected through standard questionnaire. • Blood samples were collected in EDTA tubes. The blood was centrifuged and plasma was removed. The serum were carefully sampled from the bottom of the tubes to minimize contamination with sedimentation take fresh test tube to collecting. • Thirty healthy individuals working in Narayana Medical College & Hospital in the age group 01-05 were included in control group.
DISSCUTION: • This study shows that malnourished children have deficient serum zinc and copper. • For effective management of protein-energy malnutrition, zinc and copper supplementation should be part of treatment regimen, however, in order to prevent zinc and copper deficiency and its health implications in pre-school age children, food fortification should be promoted.
conclusion • Mean serum zinc and copper were significantly reduced (p<0.05) in malnourished than in well-nourished children. • in order to prevent zinc and copper deficiency and its health implications in pre-school age children, food fortification should be promoted.
REFERENCE: • 1. Alleyne GAO, Hay RW,et al . In: Protein Energy Malnutrition. London : The ELBS & Edward Arnold Ltd. 1981: Pg 1-3