human nutrition, assessment and PEM
Transcript of human nutrition, assessment and PEM
-
8/7/2019 human nutrition, assessment and PEM
1/49
PROTEIN ENERGY MALNUTRITION
Abdelaziz ElaminMD, PhD, FRCPCH
Professor of Child Health
College of Medicine
Sultan Qaboos UniversityMuscat, Oman
-
8/7/2019 human nutrition, assessment and PEM
2/49
HUMAN NUTRITION
Nutrients are substances that arecrucial for human life, growth & well-
being. Macronutrients (carbohydrates,
lipids, proteins & water) are neededfor energy and cell multiplication &
repair. Micronutrients are trace elements &
vitamins, which are essential for
metabolic processes.
-
8/7/2019 human nutrition, assessment and PEM
3/49
HUMAN NUTRITION/2
Obesity & under-nutrition are the 2ends of the spectrum of malnutrition.
A healthy diet provides a balancednutrients that satisfy the metabolicneeds of the body without excess or
shortage. Dietary requirements of children
vary according to age, sex &
development.
-
8/7/2019 human nutrition, assessment and PEM
4/49
Assessment of Nutr status
DirectClinical
Anthropometric
Dietary
Laboratory
IndirectHealth statistics
Ecological variables
-
8/7/2019 human nutrition, assessment and PEM
5/49
Clinical Assessment
Useful in severe forms of PEM
Based on thorough physicalexamination for features of PEM &vitamin deficiencies.
Focuses on skin, eye, hair, mouth &
bones.
Chronic illnesses & goiter to beexcluded
-
8/7/2019 human nutrition, assessment and PEM
6/49
Clinical Assessment/2
ADVANTAGES
Fast & Easy to perform
Inexpensive
Non-invasive
LIMITATIONSDid not detect early cases
Trained staff needed
-
8/7/2019 human nutrition, assessment and PEM
7/49
ANTHROPOMETRY
Objective with high specificity &sensitivity
Measuring Ht, Wt, MAC, HC, skin foldthickness, waist & hip ratio & BMI
Reading are numerical & gradable onstandard growth charts
Non-expensive & need minimaltraining
-
8/7/2019 human nutrition, assessment and PEM
8/49
ANTHROPOMETRY/2
LIMITATIONS
Inter-observers errors inmeasurement
Limited nutritional diagnosis
Problems with reference standardsArbitrary statistical cut-off levels
for abnormality
-
8/7/2019 human nutrition, assessment and PEM
9/49
LAB ASSESSMENT
Biochemical
Serum proteins,creatinine/hydroxyproline
Hematological
CBC, iron, vitamin levels
Microbiology
Parasites/infection
-
8/7/2019 human nutrition, assessment and PEM
10/49
DIETARY ASSESSMENT
Breast & complementary feedingdetails
24 hr dietary recall
Home visits
Calculation of protein & Caloriecontent of children foods.
Feeding technique & food habits
-
8/7/2019 human nutrition, assessment and PEM
11/49
-
8/7/2019 human nutrition, assessment and PEM
12/49
-
8/7/2019 human nutrition, assessment and PEM
13/49
CHILD MORTALITY
The major contributing factors are:
Diarrhea 20% ARI 20%
Perinatal causes 18%
Measles 07%
Malaria 05%
55% of the total have malnutrition
-
8/7/2019 human nutrition, assessment and PEM
14/49
-
8/7/2019 human nutrition, assessment and PEM
15/49
EPIDEMIOLOGY
The term protein energy malnutritionhas been adopted by WHO in 1976.
Highly prevalent in developingcountries among
-
8/7/2019 human nutrition, assessment and PEM
16/49
-
8/7/2019 human nutrition, assessment and PEM
17/49
PEM
In 2000 WHO estimated that 32% of
-
8/7/2019 human nutrition, assessment and PEM
18/49
-
8/7/2019 human nutrition, assessment and PEM
19/49
-
8/7/2019 human nutrition, assessment and PEM
20/49
-
8/7/2019 human nutrition, assessment and PEM
21/49
PEM in Sub-Saharan Africa
PEM in Africa is related to:
The high birth rate
Subsistence farming
Overused soil, draught & desertification
Pets & diseases destroy crops
Poverty Low protein diet
Political instability (war &displacement)
-
8/7/2019 human nutrition, assessment and PEM
22/49
PRECIPITATING FACTORS
y LACK OF FOOD (famine, poverty)
y
INADEQUATE BREAST FEEDING
y WRONG CONCEPTS ABOUT NUTRITION
y DIARRHOEA & MALABSORPTION
y INFECTIONS (worms, measles, T.B)
-
8/7/2019 human nutrition, assessment and PEM
23/49
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
-
8/7/2019 human nutrition, assessment and PEM
24/49
CLASSIFICATION (2)
B. COMMUNITY (GOMEZ)
Parameter: weight for age
Reference standard (50thpercentile) WHO chart
Grades:I (Mild) : 90-70
II (Moderate): 70-60
III (Severe) : < 60
-
8/7/2019 human nutrition, assessment and PEM
25/49
ADVANTAGES
y SIMPLICITY (no lab tests needed)
y REPRODUCIBILITY
y COMPARABILITY
y ANTHROPOMETRY+CLINICAL
SIGN USED FOR ASSESSMENT
-
8/7/2019 human nutrition, assessment and PEM
26/49
DISADVANTAGES
y AGE MAY NOT BE KNOWN
y
HEIGHT NOT CONSIDEREDy CROSS SECTIONAL
y CANT TELL ABOUT CHRONICITY
y WHO STANDARDS MAY NOTREPRESENT LOCAL COMMUNITYSTANDARD
-
8/7/2019 human nutrition, assessment and PEM
27/49
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 thesickness of weaning.
-
8/7/2019 human nutrition, assessment and PEM
28/49
ETIOLOGY
Kwashiorkor can occur in infancy but
its maximal incidence is in the 2nd yrof life following abrupt weaning.
Kwashiorkor is not only dietary in
origin. Infective, psycho-socical, and
cultural factors are also operative.
-
8/7/2019 human nutrition, assessment and PEM
29/49
ETIOLOGY (2)
Kwashiorkor is an example of lack ofphysiological adaptation to
unbalanced deficiency where the bodyutilized proteins and conserve S/C fat.
One theory says Kwash is a result of
liver insult with hypoproteinemia andoedema. Food toxins like aflatoxinshave been suggested as precipitatingfactors.
-
8/7/2019 human nutrition, assessment and PEM
30/49
CLINICAL PRESENTATION
Kwash is characterized by certainconstant features in addition to avariable spectrum of symptoms and
signs. Clinical presentation is affected by:
The degree of deficiencyThe duration of deficiencyyThe speed of onsetyThe age at onsetyPresence of conditioning factors
yGenetic factors
-
8/7/2019 human nutrition, assessment and PEM
31/49
CONSTANT FEATURES OF KWASH
OEDEMA
PSYCHOMOTOR CHANGES
GROWTH RETARDATION
MUSCLE WASTING
-
8/7/2019 human nutrition, assessment and PEM
32/49
USUALLY PRESENT SIGNS
MOON FACE
HAIR CHANGES
SKIN DEPIGMENTATION
ANAEMIA
-
8/7/2019 human nutrition, assessment and PEM
33/49
OCCASIONALLY PRESENT SIGNS
HEPATOMEGALY
FLAKY PAINT DERMATITISCARDIOMYOPATHY & FAILURE
DEHYDRATION (Diarrh. & Vomiting)
SIGNS OF VITAMIN DEFICIENCIES
SIGNS OF INFECTIONS
-
8/7/2019 human nutrition, assessment and PEM
34/49
DD of Kwash Dermatitis
Acrodermatitis Entropathica
Scurvy
Pellagra
Dermatitis Herpitiformis
-
8/7/2019 human nutrition, assessment and PEM
35/49
-
8/7/2019 human nutrition, assessment and PEM
36/49
MARASMUS
The term marasmus is derived fromthe Greek marasmos, which means
wasting. Marasmus involves inadequate
intake of protein and calories and ischaracterized by emaciation.
Marasmus represents the end result
of starvation where both proteins
and calories are deficient.
-
8/7/2019 human nutrition, assessment and PEM
37/49
MARASMUS/2
Marasmus represents an adaptive
response to starvation, whereaskwashiorkor represents a
maladaptive response to starvation
In Marasmus the body utilizes all fatstores before using muscles.
-
8/7/2019 human nutrition, assessment and PEM
38/49
EPIDEMIOLOGY & ETIOLOGY
Seen most commonly in the first yearof life due to lack of breast feedingand the use of dilute animal milk.
Poverty or famine and diarrhoea arethe usual precipitating factors
Ignorance & poor maternal nutritionare also contributory
-
8/7/2019 human nutrition, assessment and PEM
39/49
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
-
8/7/2019 human nutrition, assessment and PEM
40/49
-
8/7/2019 human nutrition, assessment and PEM
41/49
-
8/7/2019 human nutrition, assessment and PEM
42/49
CLINICAL ASSESSMENT
Interrogation & physical examincluding detailed dietary history.
Anthropometric measurements
Team approach with involvement ofdieticians, social workers &community support groups.
-
8/7/2019 human nutrition, assessment and PEM
43/49
Investigations for PEM
Full blood counts
Blood glucose profile
Septic screening
Stool & urine for parasites & germs
Electrolytes, Ca, Ph & ALP, serumproteins
CXR & Mantoux test
Exclude HIV & malabsorption
-
8/7/2019 human nutrition, assessment and PEM
44/49
NON-ROUTINE TESTS
Hair analysis
Skin biopsy
Urinary creatinine over proline ratio
Measurement of trace elements
levels, iron, zinc & iodine
-
8/7/2019 human nutrition, assessment and PEM
45/49
Complications of P.E.M
Hypoglycemia
Hypothermia
Hypokalemia
Hyponatremia
Heart failure
Dehydration & shock
Infections (bacterial, viral & thrush)
-
8/7/2019 human nutrition, assessment and PEM
46/49
TREATMENT
Correction of water & electrolyteimbalance
Treat infection & worm infestations Dietary support: 3-4 g protein & 200 Cal
/kg body wt/day + vitamins & minerals
Prevention of hypothermia Counsel parents & plan future care
including immunization & diet
supplements
-
8/7/2019 human nutrition, assessment and PEM
47/49
KEY POINT FEEDING
Continue breast feeding
Add frequent small feeds Use liquid diet
Give vitamin A & folic acid on
admission With diarrhea use lactose-free or
soya bean formula
-
8/7/2019 human nutrition, assessment and PEM
48/49
PROGNOSIS
Kwash & Marasmus-Kwash havegreater risk of morbidity & mortality
compared to Marasmus and underweight
Early detection & adequate treatment
are associated with good outcome Late ill-effects on IQ, behavior &
cognitive functions are doubtful and
not proven
-
8/7/2019 human nutrition, assessment and PEM
49/49
THANKS YOU