2Definitions of Malnutrition Kwashiorkor: protein deficiencyMarasmus: energy deficiencyMarasmic/ Kwashiorkor: combination of chronic energy deficiency and chronic or acute protein deficiencyFailure to thrive: marasmus in U. S. children under 3.
3Definitions of Malnutrition PEMPrimary: inadequate food intakeSecondary: result of diseaseFTTIn-organic: inadequate food intakeOrganic: result of disease
4History Marasmus well known for centuries Kwashiorkor: Cicely Williams Ga tribe in Ghana“the sickness the older child gets when the next baby is born”Starch edema, sugar babiesSimilar but different diseases
5How many? 36% of children in the world are underweight 43% stunted 9% wastedBetter nutrition, but more children in high risk areas, yields more children affected.
6Causes Social and Economic Poverty Ignorance Inadequate weaning practicesChild abuseCultural and social practicesVeganLow fat diets
8Age of child Infants and young children Marasmus < 1 year High nutritional needsEarly weaning or late weaningPoor hygieneMarasmus < 1 yearKwashiorkor >18 months with starchy weaning foods
9Pathophysiology Develops slowly, adapts to decreased intake MarasmusLess fragile metabolic equilibriumLess effective adaption or acute problemKwashiorkor, mixed
10Energy Decreased intake yields decreased activity Decreased play and physical activityMobilization of body fat, weight loss,Subcutaneous fatMuscle wastingMaintains visceral protein in marasmusNl albuminLarger protein deficit leads to faster visceral protein falls and edema.
11Biologic differences Marasmus Kwashiorkor Weight loss Nl or low proteinBoarderline hgb, hctNL AA profileNl blood glucoseNl enzymesNl transaminaseKwashiorkorNO weight lossHigh extracellular waterLow hgb, hctLow proteinElevated AA profileLow enzymesHigh transaminase
12Pathophysiology Cardiac Immune system Cytokines (glycoproteins) Output, heart rate and blood pressure decreasePostural hypotensionImmune systemT lymphocytes and complement decreasedSusceptible to bacterial infectionCytokines (glycoproteins)Poor immune responseTNF inc leading to anorexia, muscle wasting and lipid changes
13Pathophysiology Decreased total body potassium GI function Not electrolytes, but problem in rehabilitationGI functionPoor absorption of lipids, and sugarsDecreased enzyme and bile productionIncrease incidence of diarrhea, and bacterial overgrowth
14Pathophysiology CNS Parental adaptation Decreased brain growth and myelnationElectrical changes similar to dylexiaParental adaptationIncreased breastfeedingAltered expectations
15Diagnosis Anthropometry 4 groups Acute: Wasting: low weight for height Chronic: Stunted: low height for age4 groupsNormalWasted not stunted: acute PEMWasted and stunted: acute and chronic PEMStunted not wasted: past PEM, nutritional dwarfs
16Diagnosis Normal: ± 1 SD Mild: -1.1 to -2 SD Moderate -2.1 to -3 SD Severe greater than -3Less than 5th percentile in USBMI in adolescentsModerate <15 ages 11-13, <16.5 ages 14-17Severe <13 ages 11-13, <14.5 ages 14-17
17Diagnosis Mild to moderate Marasmus Weight loss if acute, decreased growth velocity of chronicDecreased activityMarasmusSkin and bones, thin hair, monkey faceHypoglycemia, hypothermia
18Diagnosis Kwashiorkor Soft pitting edema, starting in feet and legs Skin lesionsSkin dry, with hyperkeratosis and hyperpigmentationPreserved fat layer, small weight deficit, ht may be normalDry brittle hairAnorexia, with vomiting and diarrhea
19Diagnosis Mixed Edema, with or without skin lesions Muscle wasting and loss of subcutaneous fat
20Treatment Acute/ life threatening Fluid and electrolyte K and Mg shiftsOral rehydration, slowly ml/kgInfections: main cause of deathAggressive treatment, but disease alters metabolism of drugsOther deficienciesAnemia and heart failure, care with transfusions and no diurreticsVitamin A: immediate treatment
21Treatment Slow re-feeding Nutritional rehabilitation Small frequent feeding around the clockPatient encouragement of foodNutritional rehabilitationPlay and teachingcontrolinfections
22Recovery? At home Reach weight for height and replete muscle mass Normal is 25-75% weight for height and continue for one months afterTreat other deficienciesFamily problemsWho does this include here?Tube feeding.DisabilitiesFTT
23What does it mean? Poverty Brain development Correlation of income, wt, ht and hgb in USWhat is wealth?Importance of food choiceBrain developmentIron deficiency: neuro transmittersBrain waves:
24What does it mean? Learning: Difference in treatment by parents Duration of breastfeedingExpectationsLong term effectsINCAP two villages, one protein and one calorieAt 18 protein supplemented group had higher performance scores irrespective of educational exposure. They had taught themselves.
25What does it mean? Learning: Difference in treatment by parents Duration of breastfeedingExpectationsSlums of Kingston, JamaicaEducational intervention, early rise plateauNutritional intervention, late riseAdditive effectEducation lasts, not nutrition, but high IQ mom’s and nutrition group did as well as education.
26Implications Children learn by interacting with the environment Poverty: limited environmentMalnutrition: limited interactionAdditive effect!Loss to society of human potentialLead graph