1. Severe childhood undernutrition
PROTEIN ENERGY
MALNUTRITION
Severe childhood undernutrition
SCU
Soad Jaber 2009

3. objectives
Use the medical history and physical examination to evaluate nutritional status.
Present an approach to recognizing and treating some common nutritional problem of childhood.
Identify etiologic categories of malnutrition,1ry,2ry,
marasmus and kwashiorkor.
Display an understanding of the principles for managing severe childhood under nutritionز

4. Why more common in children?
High nutrient requirement/unit weight.
Dependence on adults for food
Water Higher body water> older children
Fat Rapid increase in the 1st 6 months
Growth Rapid from birth till six months
Growth rate increase at puberty.
More for boys than girls.

6. Developmental Milestones:
Neonates Good swallowing + sucking.
12 weeks Can-swallows food placed on anterior tongue.
20 weeks Can drink from held cup with biting movements.
28 weeks Teeth begin to erupt.
Feeds self biscuits., chewing movements.
7 months Shuts mouth. Shakes head to refuse foods.
9 months Fingers feeding
10 months Drinks from cup.
12 months Holds spoon unable to get food to mouth.
15 months Control spoon + cups.
18 months Plays with food.

7. How to assess nutritional status?????
- Clinically
- Anthropometrically
- Bio-chemically
- Clinical "Signs"
Muscular, skeletal …Tone. ,muscle wasting ,delayed walking
Abdomen- Hepatomegally.. spleenomegally, ascites…..
CVS --Cardiomegally ,oedema
CNS--- Apathy, confusion, psychosis, depression….

8. Anthropometric techniques
The trend overtime… serial reading, NOT single…
Weight for age reflect the combined effect of both recent and longer term level of nutrition.
Height for age long term problem,comulative effect of undernutrition during the life of the child.
Weight for height and age ,recent nutritional experiences. Less<80-90% abnormally low
Skull circumference: Rapid growth in early infancy… Genetic, hormonal
Mid-upper arm circumference
Skin folds thickness:. Triceps sub-scapular –% of body fat ..
They reflect severity and extent of the problem but not specific for any particular disease

10. WEIGHT AND HEIGHT FOR AGE
INTERPRETATION OF
WEIGHT AND HEIGHT FOR AGE
Weight < 90% expected
Weight> 80% expected
Wasted
Normal
Height > 90%
Stunted
Short
Height < 90%

11. PROTEIN ENERGY MALNUTRITION
Definition : ( WHO)
* Marasmus Weight less than 60% of expected weight - no oedema.
Kwashiorkor Weight between 60-80% of expected weight + oedema
No oedema Oedema
Kwashiorkor 80%
80% Under weight for age
60%Marasmic-Kwashiorkor
Marasmus 60%
Wellcome Classification

12. Gomez Classification for Malnutrition
1ry PEM is a spectrum ranging from:
* mild form
Decrease weight for length.
*severe form
Decrease length and weight for age.

13. Malnutrition and its signs
Aetiology of (PEM)
Leading cause of death (less than 5 years of age)
1ry:. Protein + energy intakes below requirement for normal growth
2ry:the need for growth is greater than can be supplied.
: decreased nutrient absorption
: increase nutrient losses
Linear growth ceases
Static weight
Weight loss
Wasting
Malnutrition and its signs

16. Kwashiorkor:
Ga language of West Africa = Supplanted one - Child who recently have been weaned
(Pregnant mother) and emotional deprivation
History:
1933 Cecily * Ghanaian children
* Weaned recently
* Oedema and hair changes * Fatty liver
1967 Mc-Cane * Anaemia
* Cardiac
* Skin changes
1971 Frood-Paskitt * Biochemical

17. Pathogenesis: Kwashiorkor: Normal energy intake, Lack of protein
Edema:1970.decrease oncotic pressure,
Recent> Increase Renin activity,N a and fluid retention.
Amino aciduria due to proximal tubular dysfunction
Failure of adaptation
.Hepatomegaly due to fatty infiltration from lipogenesis of excess CHO
- Biochemical and haematological changes

20. Pathogenesis: Marasmus:
- Lack of all nutrients stimulate cortisone secretion which result in muscle wasting, the released a. a will synthesize albumin to prevent edema.
- Growth and energy expenditure limited, in response to dietary stress
- Adaptation to reduce protein + energy
- Biochemical and haematological tests within normal
-Abdomin,flat due to ms wasting, OR distended due to 2ry lactose intolerance.

23. Causes:
Social.ecomomic.poverity.ignorance.maternal malnutrtion.enviromental.
Kwashiorkor:
Insufficient intake of protein of good biological value.
Impaired absorption of protein e.g. chronic diarrhoea.
Abnormal losses of protein e.g.
severe nephrosis . Severe or prolonged infection
Failure of protein synthesis e.g.
chronic liver diseases.

24. Marasmus:
Inadequate caloric intake due to insufficient diet .
Improper feeding habits .
Emotional deprivation.
Metabolic abnormalities
Congenital malformation
Severe impairment of any body system

33. Management:
- Accurate history of social and economic factors. poverety,ignorance. environmental factors .
diet history: maternal malnutrition, breast milk and other feeding habits .food allergies ,food taboos.
chronic illness ,burns .HIV. cystic fibrosis .malignancies .inborn error of metabolism ,
- Evaluation of growth parameters: weight, height, head circumference
- Evaluation of the degree of illness and dehydration:
skin fold thickness - Biochemical evaluation
* mild * moderate * severe

34. 1) Mild - moderate with no complication
- Home management
food increase calories + energy
Multivitamin 1st week
Iron replacement 2nd week.
± antibiotics for infection

35. 2) Severe marasmic or severe kwashiorkor
Complicated cases or marasmic kwashiorkor
Hospital management
INITIAL PHASE
1st day: History --- clinical exam -- rehydration
Prevent heat loss
NGT feeding ORS, IVF (glucose and electrolytes)
Treatment of infection,bacterial and parasitic.
2nd -7th day:
a) Continue rehydration by NGT,
b) start diet by NGT .calories /kg/day ,Protein 3-4 g/kg/d. small volumes 2hourly then 4hourly to6 hourly. and increase calories gradually
, c) multivitamin. Vit A, folic acid. Without IRON for the 1st week.
d) Correct anaemia ( packed RBC carefully)
If diarrhea starts or fails to resolve may be lactose intolerance lactose free milk or cow milk protein intolerance start soy protein hydrolysate formula.

36. Discharge.. Rehabilitation phase week2-6 a) Start oral feeding
b) Continue antibiotics
c) Start iron
Oedema disappear ,, appetite improvement .the child is more interested in the surrounding
Follow up phase
Discharge..
Supervising the mother in cooking
parental education to prevent an additional episodes

37. 1st sign of improvement: -Awareness in the child -Appetite (kw)
Follow-up:
1st sign of improvement:
-Awareness in the child
-Appetite (kw)
-Weight loss (kw)
Weight gain
rapid  Marasmus
Slow (10th day) Kwashiorkor

38. Failure of improvement:
1) Combined marasmic -kwashiorkor
2) Infection TB ,,,parasite
3) drowsiness -Severe hypokalemia
-Hepatic failure
-Protein intolerance
4) Rapid gain of weight - Cardiac failure
- Grossly disturbed metabolism
- Unable to tolerate the rate of re feeding (oedema)
5) Profuse diarrhea
- GIT infection
- Food intolerance (discharidase)
- Other nutrients deficiency

39. Complications: 1) Infection: 1. Immunological defect
- Cell mediated> humoral
- Measles> fatal disease
2. Subtle infection
Lack of fever
Hypothermia
No increase in WBC
- Inability to localize infection

40. Complications (cot’n)
2) Hypoglycaemia apnoea
3) Hypothermia bradycardia
4) Heart failure death
5) Vit deficiencies Vit A  blindness
6) Permanent growth stunting
7) Prolonged illness developmental delay
cognitive function
slow intellectual achievement

41. Prevention: Improve nutritional status Improve water supply
Without change in food supply Proper sanitation
Health education
Social worker visits,
Reduce infection rate Immunization
Supervision of feeding
Good weaning practice
Long term community health measures
Effective for
one generation

43. Marasmus due to under feeding  good Kwashiorkor MR 10-25%
Prognosis:
Marasmus due to under feeding  good
Kwashiorkor MR 10-25%
Marasmus I Kwashiorkor  worse progress
End point of nutritional
stress failure
of adaptation