Clinical Marasmus
Transcript of Clinical Marasmus
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Protein Energy
Malnutrition:
Marasmus Group 12
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Marasmus
• Derived from the Greek word“marasmos” which means waste away .
• State in which virtually all available body
fat stores have been exhausted due tostarvation.
• Is the most common form of malnutrition.
•
Body weiht is !"# less than theex$ected weiht.
• %hin limbs and $rominent ribs are seen.
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&linical Database'
A 10 month old male child was examined during a
health screening program of an NG! "he mother
complained that her child was always hungry and crying
for food# and was ha$ing loose stools for the past 1month! "he stri%ing features noted was the
emancipated appearance, with gross wasting of all
muscle groups with the s%in hanging in loose folds and
lac% the normal shine and texture!
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"he child&s height was '0cm and weight was (%ilograms which were in the 10th and )elow the (th
percentile# respecti$ely of normal height and weight for
his age! "here was no edema! "he midarm
circumference * MA+, was 10 cm and the triceps s%infold thic%ness *"-", was (mm! "he mid.arm muscle
circumference *MAM+, was calculated to )e /!(! All
those anthropometric $alues when compared to standard
ta)le for age group and sex were )elow the (th percentile
and indicate wasting# low fat and protein reser$e!
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(aboratory %est )esults'
• asting lood Glucose: 0 mg3d4
• 2hr Post. Prandial lood Glucose: 1'5 mg3d4
• -erum Al)umin: 1!/ g3d4
• -erum Preal)umin: /mg3d4
• 6rine +reatine: 0! mmol3per day
• 7+: 8#(00 cells3 cu)ic mm
• ".cell count: low at 800 cells3cu)icmm
• -tool exam: a)undant fat glo)ules# pus cells and
9+!
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*. State the features of Marasmuswhich will di+erentiate it from
,washiorkorFEATURES MARASMUS KWASHIORKOR
Growth -ailure )/S/0% )/S/0%
Muscle wastin )/S/0% )/S/0%
/dema 1BS/0% )/S/0%2air chanes 1BS/0% )/S/0%
Mental chanes 1BS/0% )/S/0%
Dermatosis 1BS/0% )/S/0%
1$$etite )/S/0% 1BS/0%
1nemia )/S/0% )/S/0%3 S/4/)/
-at 1BS/0% )/S/0%3 )/D5&/D
-ace M60,/7 (I,/ /D/M1%65S
-atty in8ltration in (iver 1BS/0% )/S/0%
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"he li$er of a %washior%or child is yellow and fatty #due to reduced serum le$els of carrier proteins! "he
li$er of a marasmus child is normal )ut the lower
extremity show wasting !
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9. /x$lain the abnormal biochemical orlaboratory test seen in this $atient
• asting lood Glucose: 0 mg3d4 * '0.100 md3d4,
DECREASE
• 2hr Post. Prandial lood Glucose: 1'5 mg3d4 *120mg3d4,
INCREASE• -erum Al)umin: 1!/ g3d4 *8!(.(!( g3d4, DECREASE
• -erum Preal)umin: /mg3d4 * 1.0 mg3d4, DECREASE
• 6rine +reatine: 0! mmol3per day DECREASE
• 7+: 8#(00 cells3 cu)ic mm * #(00. 10#000 cells3mm,DECREASE
• ".cell count: low at 800 cells3cu)icmm DECREASE
• -tool exam: a)undant fat glo)ules# pus cells and 9+!
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:. /x$lain the hormonal chanes thatwill brin about muscle wastin seen
in this $atient(1) GH; asal G; le$els are high in children with
marasmus and they decrease to normal nutritional
reha)ilitation!"he cause for increased secretion of G;
• 4ow <G.1 which exert negati$e feed)ac% effect on the
hypothalamic.pituitary axis!
• 4ow serum tyrosine! its has )een demonstrated to correlate
significantly with )asal G; le$el in malnourished children
)efore and after reha)ilitation!
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(2) Glucocorticoids=• -erum cortisol le$els are high in the marasmus!
• "he response of cortisol to A+"; stimulation are
satisfactory in the marasmus!
•-erum cortisol le$els ha$e not correlated with either )loodglucose or serum al)umin in a large num)er of children with
PEM!
• "he stress of malnutrition and the presence of infections are
thought to )e the ma=or etiological factors in the ele$ation
of cortisol le$els.
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(3) Insulin nd Gluc!on=•
4ow )asal serum insulin le$els ha$e )een demonstrated inchildren with marasmus!
• "he insulin reser$e in response to arginine stimulation has
)een impaired in patients with marasmus!
• "he low insulin3glucagon ratios in patients with PEM produced the following:
. >ecrease glucose upta%e )y muscle and adipose tissue )ut
not )y the )rain and heart . <ncrease muscle protein cata)olism to supply the essential
amino acids necessary for gluconeogenesis and other
)iosynthetic purpose!
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• <ncrease lipolysis and supply of fatty acids to peripheral
tissues.
(") T#$roid Hor%on&=• "he free " le$els ha$e )een reported as normal or low in
marasmus!
• " le$els reported in this children patient with PEM could )e due to deficiency of thyroid )inding glo)ulin and
preal)umin!
•
"his suggest that decreased circulating "8 is not due todiminished hormone production )ut rather is an adaptation
of peripheral meta)olism of " directing the de.iodination
of " to "8 !
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. /numerate some tools for eneral nutritionassessment and ex$lain its sini8cance
• Medical history
•
-creening• Anthropometric measurements
• iochemical measurements
•+linical measurements
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Medical history
• >irected toward identifying underlying mechanism
that put patients at ris% for nutritional depletion or
excess! "hese mechanism include inade?uate inta%e#
impaired a)sorption# decreased utili@ation# increasedlosses# and increased re?uirements of nutrients!
-ource: ;arrison&s Principle of <nternal Medicine 1/th Edition
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Screenin
• <s the process of identifying patient characteristics
%nown to )e associated with nutritional pro)lems!
• <ts purpose it to ?uic%ly identify indi$iduals who are
malnourished or at nutritional ris% .
-ource: ;arrison&s Principle of <nternal Medicine 1/th Edition
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1nthro$ometric Measurements
• Pro$ide information on the )ody muscle mass and fat
reser$es! "he most practical and commonly used
measurements are )ody weight# height# triceps
s%infold and midarm circumference!
-ource: ;arrison&s Principle of <nternal Medicine 1/th Edition
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=eiht and heiht measurementsare essential to'
• <dentify malnourished infants and children!
• 4in% at.ris% children to medical and social ser$ices!
• E$aluate the o$erall health status of children!
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Mid 1rm &ircumference
• <s an excellent indicator of nutritional status and has
an important ad$antage of operational simplicity!
• <t is reduced su)stantially in the undernourished and
su)stantially increases in children who areo$erweight!
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M51& less than **"mm >**."cm?3 )/D &6(65)3 indicates Severe 1cuteMalnutrition .
M51& of between **"mm >**."cm? and *9@mm >*9.@cm?3 )/D&6(65) >:Acolour %a$e? or 6)10G/ &6(65) ><Acolour %a$e?3 indicates
Moderate 1cute Malnutrition >M1M?. %he child should be immediatelyreferred for su$$lementation. M51& of between *9@mm >*9.@cm? and *:@mm >*:.@cm?3 7/((6=&6(65)3 indicates that the child is at risk for acute malnutrition andshould be counseled and followedAu$ for Growth romotion and
Monitorin >GM?.
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%rice$s Skinfold %hickness
• A measure of
su)cutaneous fat
stores ta%en at the
midpoint of the posterior aspect of
the humerus
• +orrelates closely
with the percentageof )ody fat and
with total )ody fatC1'%% #<#$ c#ildr&n1 $&rs
*%% + indicti,& -o%od&rt& to s&,&r&
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Biochemical measurements
• many of the routine )lood and urine la)oratory test
found in patient&s chart are useful in pro$iding an
o)=ecti$e assessment of nutritional status!
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&linical 1ssessment
• <s the physical examination of an indi$idual for signs
and symptoms! "he examination is conducted )y the
physician on the anatomic changes that can )e
o)ser$ed!• "he use of stethoscope # )lood pressure and pulse rate
measurements# height and weight are standard
procedures in P!E! charting!
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@ ib l h i
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@. rescribe a eneral a$$roach inthe manaement of this case and
its rationale• A nutritious# well.)alanced diet with lots of fresh fruits and
$egeta)les# grains# and protein will reduce the ris% of
malnutrition and any related marasmus!
• "reatment of marasmus in$ol$es a special feeding andrehydration plan and close medical o)ser$ation to pre$ent
and manage complications of malnutrition! Pediatric
nutrition reha)ilitation centers ha$e )een esta)lished in
some countries and regions to coordinate treatment ofmalnourished children! <ntra$enous fluids# oral rehydration
solutions# and nasogastric feeding tu)es are forms of
treatment that may )e used!