PROTEIN ENERGY MALNUTRITION Abdelaziz Elamin MD, PhD, FRCPCH Professor of Child Health College of Medicine Sultan Qaboos University Muscat, Oman

HUMAN NUTRITION zNutrients are substances that are crucial for human life, growth & well- being. zMacronutrients (carbohydrates, lipids, proteins & water) are needed for energy and cell multiplication & repair. zMicronutrients are trace elements & vitamins, which are essential for metabolic processes.

HUMAN NUTRITION/2 zObesity & under-nutrition are the 2 ends of the spectrum of malnutrition. zA healthy diet provides a balanced nutrients that satisfy the metabolic needs of the body without excess or shortage. zDietary requirements of children vary according to age, sex & development.

Assessment of Nutr status zDirect yClinical yAnthropometric yDietary yLaboratory zIndirect yHealth statistics yEcological variables

Clinical Assessment zUseful in severe forms of PEM zBased on thorough physical examination for features of PEM & vitamin deficiencies. zFocuses on skin, eye, hair, mouth & bones. zChronic illnesses & goiter to be excluded

Clinical Assessment/2 zADVANTAGES yFast & Easy to perform yInexpensive yNon-invasive zLIMITATIONS yDid not detect early cases yTrained staff needed

ANTHROPOMETRY zObjective with high specificity & sensitivity zMeasuring Ht, Wt, MAC, HC, skin fold thickness, waist & hip ratio & BMI zReading are numerical & gradable on standard growth charts zNon-expensive & need minimal training

ANTHROPOMETRY/2 zLIMITATIONS yInter-observers’ errors in measurement yLimited nutritional diagnosis yProblems with reference standards yArbitrary statistical cut-off levels for abnormality

LAB ASSESSMENT zBiochemical ySerum proteins, creatinine/hydroxyproline zHematological yCBC, iron, vitamin levels zMicrobiology yParasites/infection

DIETARY ASSESSMENT zBreast & complementary feeding details z24 hr dietary recall zHome visits zCalculation of protein & Calorie content of children foods. zFeeding technique & food habits

OVERVIEW OF PEM zThe majority of world’s children live in developing countries zLack of food & clean water, poor sanitation, infection & social unrest lead to LBW & PEM zMalnutrition is implicated in >50% of deaths of <5 children (5 million/yr)

CHILD MORTALITY zThe major contributing factors are: yDiarrhea 20% yARI 20% yPerinatal causes18% yMeasles 07% yMalaria 05% 55% of the total have malnutrition

EPIDEMIOLOGY zThe term protein energy malnutrition has been adopted by WHO in zHighly prevalent in developing countries among <5 children; severe forms 1-10% & underweight %. zAll children with PEM have micronutrient deficiency.

PEM zIn 2000 WHO estimated that 32% of <5 children in developing countries are underweight (182 million). z78% of these children live in South- east Asia & 15% in Sub-Saharan Africa. zThe reciprocal interaction between PEM & infection is the major cause of death & morbidity in young children.

PEM in Sub-Saharan Africa zPEM in Africa is related to: yThe high birth rate ySubsistence farming yOverused soil, draught & desertification yPets & diseases destroy crops yPoverty yLow protein diet yPolitical instability (war & displacement)

PRECIPITATING FACTORS  LACK OF FOOD (famine, poverty)  INADEQUATE BREAST FEEDING  WRONG CONCEPTS ABOUT NUTRITION  DIARRHOEA & MALABSORPTION  INFECTIONS (worms, measles, T.B)

CLASSIFICATION yA. CLINICAL ( WELLCOME ) yParameter: weight for age + oedema yReference tandard (50th percentile) yGrades: x80-60 % without oedema is under weight x80-60% with oedema is Kwashiorkor x< 60 % with oedema is Marasmus-Kwash x< 60 % without oedema is Marasmus

CLASSIFICATION (2) yB. COMMUNITY (GOMEZ) yParameter: weight for age yReference standard (50th percentile) WHO chart yGrades: xI(Mild):90-70 xII(Moderate):70-60 xIII(Severe):< 60

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

DISADVANTAGES  AGE MAY NOT BE KNOWN  HEIGHT NOT CONSIDERED  CROSS SECTIONAL  CAN’T TELL ABOUT CHRONICITY  WHO STANDARDS MAY NOT REPRESENT LOCAL COMMUNITY STANDARD

KWASHIORKOR zCecilly Williams, a British nurse, had introduced the word Kwashiorkor to the medical literature in The word is taken from the Ga language in Ghana & used to describe the sickness of weaning.

ETIOLOGY zKwashiorkor can occur in infancy but its maximal incidence is in the 2nd yr of life following abrupt weaning. zKwashiorkor is not only dietary in origin. Infective, psycho-socical, and cultural factors are also operative.

ETIOLOGY (2) zKwashiorkor is an example of lack of physiological adaptation to unbalanced deficiency where the body utilized proteins and conserve S/C fat.  One theory says Kwash is a result of liver insult with hypoproteinemia and oedema. Food toxins like aflatoxins have been suggested as precipitating factors.

CLINICAL PRESENTATION zKwash is characterized by certain constant features in addition to a variable spectrum of symptoms and signs. zClinical presentation is affected by: The degree of deficiency The duration of deficiency  The speed of onset  The age at onset  Presence of conditioning factors  Genetic factors

CONSTANT FEATURES OF KWASH xOEDEMA xPSYCHOMOTOR CHANGES xGROWTH RETARDATION xMUSCLE WASTING

USUALLY PRESENT SIGNS zMOON FACE zHAIR CHANGES zSKIN DEPIGMENTATION zANAEMIA

OCCASIONALLY PRESENT SIGNS xHEPATOMEGALY xFLAKY PAINT DERMATITIS xCARDIOMYOPATHY & FAILURE xDEHYDRATION (Diarrh. & Vomiting) xSIGNS OF VITAMIN DEFICIENCIES x SIGNS OF INFECTIONS

DD of Kwash Dermatitis zAcrodermatitis Entropathica zScurvy zPellagra zDermatitis Herpitiformis

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

MARASMUS/2 zMarasmus represents an adaptive response to starvation, whereas kwashiorkor represents a maladaptive response to starvation zIn Marasmus the body utilizes all fat stores before using muscles.

EPIDEMIOLOGY & ETIOLOGY zSeen most commonly in the first year of life due to lack of breast feeding and the use of dilute animal milk. zPoverty or famine and diarrhoea are the usual precipitating factors zIgnorance & poor maternal nutrition are also contributory

Clinical Features of Marasmus zSevere wasting of muscle & s/c fats zSevere growth retardation zChild looks older than his age zNo edema or hair changes zAlert but miserable zHungry zDiarrhoea & Dehydration

CLINICAL ASSESSMENT zInterrogation & physical exam including detailed dietary history. zAnthropometric measurements zTeam approach with involvement of dieticians, social workers & community support groups.

Investigations for PEM zFull blood counts zBlood glucose profile zSeptic screening zStool & urine for parasites & germs zElectrolytes, Ca, Ph & ALP, serum proteins zCXR & Mantoux test zExclude HIV & malabsorption

NON-ROUTINE TESTS zHair analysis zSkin biopsy zUrinary creatinine over proline ratio zMeasurement of trace elements levels, iron, zinc & iodine

Complications of P.E.M zHypoglycemia zHypothermia zHypokalemia zHyponatremia zHeart failure zDehydration & shock zInfections (bacterial, viral & thrush)

TREATMENT zCorrection of water & electrolyte imbalance zTreat infection & worm infestations zDietary support: 3-4 g protein & 200 Cal /kg body wt/day + vitamins & minerals zPrevention of hypothermia zCounsel parents & plan future care including immunization & diet supplements

KEY POINT FEEDING zContinue breast feeding zAdd frequent small feeds zUse liquid diet zGive vitamin A & folic acid on admission zWith diarrhea use lactose-free or soya bean formula

PROGNOSIS zKwash & Marasmus-Kwash have greater risk of morbidity & mortality compared to Marasmus and under weight zEarly detection & adequate treatment are associated with good outcome zLate ill-effects on IQ, behavior & cognitive functions are doubtful and not proven

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