Malnutrition

Dr. Ayesha Mohannad

MALNUTRITION
y

A pathological state resulting from relative or absolute deficiency or excess of one or more of the essential nutrients

MALNUTRITUION
y

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

Malnutrition
y

Imbalance: 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 Deficiencies
y

Primary deficiency occurs when a person does not consume enough of a nutrient, a direct consequence of inadequate intake

Nutritional Deficiencies
Secondary deficiency occurs when y a person cannot absorb enough of a nutrient in his or her body y too much nutrient is excreted from the body y a nutrient is not utilized efficiently by the body

Deficiency Symptoms
y

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

MALNUTRITION
y

y y y y y

Protein-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 Kwashiorkor Mild to moderate PEM

EPIDEMIOLOGY
The term protein energy malnutrition has been adopted by WHO in 1976. y 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) y All children with PEM have micronutrient deficiency.
y

Etiology of Primary Malnutrition

y y y y y y y

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) y Infestations y Lack of Immunization

y

Etiology of Secondary Malnutrition

Congenital Diseases: ASD, VSD, cleft palate etc. y Malabsorption: Celiac Disease, Lactose intolerane, Giardiasis, Cystic Fibrosis y Metabolic: Inborn errors of Metabolism, CRF, Renal tubular Acidosis etc.
y

MARASMUS
The term marasmus is derived from the Greek marasmos, which means wasting. y Marasmus involves inadequate intake of protein and calories and is characterized by emaciation. y Marasmus represents the end result of starvation where both proteins and calories are deficient.
y

MARASMUS/2
y

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 y Severe growth retardation y Child looks older than his age y No edema or hair changes y Hungry y Diarrhoea & Dehydration
y

KWASHIORKOR
y

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.

ETIOLOGY
y

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 KWASH

x OEDEMA x PSYCHOMOTOR CHANGES x GROWTH RETARDATION x MUSCLE WASTING

OCCASIONALLY PRESENT SIGNS SIGNS

x HEPATOMEGALY x FLAKY PAINT DERMATITIS x CARDIOMYOPATHY & FAILURE x DEHYDRATION (Diarrh. & Vomiting) x SIGNS OF VITAMIN DEFICIENCIES x SIGNS OF INFECTIONS

USUALLY PRESENT SIGNS

y MOON y HAIR y SKIN

FACE

CHANGES DEPIGMENTATION

y ANAEMIA

DD of Kwash Dermatitis
y Acrodermatitis y Scurvy y Pellagra y Dermatitis

Entropathica

Herpitiformis

ANTHROPOMETRY
Objective with high specificity & sensitivity y Measuring Ht, Wt, MAC, HC, skin fold thickness, waist & hip ratio & BMI y Reading are numerical & gradable on standard growth charts y Non-expensive & need minimal training
y

Detection Of PEM
Height for age y Weight for age y Weight for height y Arm circumference y Skin fold thickness y Head and chest circumference
y

MALNUTRITION

Interpretation of Indicators
y

Waterlows Classification Defines two groups for PEM Malnutrition with low weight for a normal height(wasting or acute malnutrition) Malnutrition with low height for age(stunting or chronic malnutrition)

Wt/ht%= y Wt of the child x100 y Wt of the child of same Ht

y

Ht/age%= y Ht of the child x100 y Ht of the child of same age

y y

Interpretation of Indicators

Nutritional status Normal Mild Moderate severe

Stunting(% of height/age) >95 87.5-95 80-87.5 <80

Wasting(% of weight/ height) >90 80-90 70-80 <70

CLASSIFICATION
A. CLINICAL ( WELLCOME )
Parameter: weight for age + oedema Reference standard (50th percentile) Grades:
x x x x 80-60 % without oedema is under weight 80-60% with oedema is Kwashiorkor < 60 % with oedema is Marasmus-Kwash < 60 % without oedema is Marasmus

Malnutrition
y y y

Gomez Classification It is based on weight retardation Wt for age(%) = Wt of the child x 100 Wt of the normal child of same age Between 90-110% =normal 75- 89% =mild malnutrition 60-74% =moderate Under 60%=severe

ADVANTAGES
y SIMPLICITY (no lab tests needed) y REPRODUCIBILITY y COMPARABILITY y ANTHROPOMETRY+CLINICAL SIGN USED FOR ASSESSMENT

DISADVANTAGES
y AGE MAY NOT BE KNOWN y HEIGHT NOT CONSIDERED y CROSS SECTIONAL y CANT TELL ABOUT CHRONICITY y WHO STANDARDS MAY NOT REPRESENT LOCAL COMMUNITY STANDARD

CLINICAL ASSESSMENT
Interrogation & physical exam including detailed dietary history. y Anthropometric measurements y Team approach with involvement of dieticians, social workers & community support groups.
y

Investigations for PEM

Full blood counts y Blood glucose profile y Septic screening y Stool & urine for parasites & germs y Electrolytes, Ca, Ph & ALP, serum proteins y CXR & Mantoux test y Exclude HIV & malabsorption
y

NONNON-ROUTINE TESTS
Hair analysis y Skin biopsy y Urinary creatinine over proline ratio y Measurement of trace elements levels, iron, zinc & iodine
y

Complications of P.E.M
Hypoglycemia y Hypothermia y Hypokalemia y Hyponatremia y Heart failure y Dehydration & shock y Infections (bacterial, viral & thrush)
y

Primary Prevention
Health Promotion y Promotion of breast feeding y Development of low cost weaning foods rich in protein and energy y Measures to improve family diet y Promotion of correct feeding practices y Family planning and improving family environment

Primary Prevention
Immunization y Promotion of early use of ORS in diarrhoea y Deworming
y

Secondary Prevention
Mass screening of high risk population by simple tools like weight for age or MUAC y Early diagnosis and treatment y Good nutritional care y Supplementary feeding150 mg/kg body weight through oral or NG feed y Counselling of the mothers
y

Tertiary Prevention
y

Rehabilitation Follow up care