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