1. Malnutrition Dr K N Prasad Community Medicine

2. “PEM”: Invariably reflects combined deficiencies in… Protein: deficit in amino acids needed for cell structure, function Energy: calories (or joules) derived from macronutrients: protein, carbohydrate and fat Micronutrients: vitamin A, B-complex, iron, zinc, calcium, others

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

4. What is Malnutrition? Both protein-energy malnutrition (underweight etc.) and micronutrient deficiencies Retards physical and cognitive growth; increases susceptibility to infections Cause of half of all child deaths, and more than half of deaths due to major diseases (malaria, diarrhea, pneumonia, measles) Cause of 22% of disease burden of country

5. Underweight Prevalence of underweight children is highest in the world, double of sub- Saharan Africa, more than a third of undernourished kids of the world live in India. Most retardation occurs by age 2 (30% low birth weight)

6. CHILD MORTALITY

11. EPIDEMIOLOGY The term protein energy malnutrition has been adopted by WHO in 1976. Highly prevalent in developing countries among <5 children; severe forms 1-10% underweight 20-40%. All children with PEM have micronutrient deficiency.

12. PEM In 2006 WHO estimated that 32% of <5 children in developing countries are underweight (182 million). 78% of these children live in South- east Asia & 15% in Sub-Saharan Africa. The reciprocal interaction between PEM & infection is the major cause of death & morbidity in young children.

13. "South Asian Enigma" South Asian countries have worse incidence of malnutrition than Africa. Characteristics of south Asia: low birth weight, less powerful women, poor sanitation.

14. 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)

16. Causes for severe Malnutrition Chronic, severely low energy and protein intake Exclusive breast feeding for too long Dilution of formula Unclean/non-nutritious, complementary foods of low energy and micronutrient density Infection (eg, measles, diarrhea, others) Xenobiotics (aflatoxins)

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

18. Anthropometric Measurements of Nutritional Status Weight Length/height Mid upper arm circumference MUAC) Chest circumference Head circumference Skin fold measurements: Triceps and Subscapular region

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

20. CLASSIFICATION (2) B. COMMUNITY (GOMEZ) Parameter: weight for age Reference standard (50th percentile) WHO chart Grades: I(Mild):90-70 II(Moderate):70-60 III(Severe):< 60

21. Starvation at Auschwitz Concentration Camp WWII

22. 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 the sickness of weaning.

23. Kwashiorkor

24. Edema Mental changes Hair changes Fatty liver Dermatosis (skin lesions) Infection Moderate wasting High case fatality Low prevalence 1 st to 3 rd years of life

25. MARASMUS (PEM)

26. Marasmus Severely wasted (emaciated) & stunted Very much wasting “Balanced” starvation “Old Man” face, wrinkled appearance, sparse hair No edema, fatty liver, skin changes Too little breast milk or complementary foods < 2 yrs of age

27. Prevention of PEM Maintain nutritional status of infants and children at highest possible level. Reducing risk and effects of infection Nutritional health education: education of the mothers in the ante-natal care during pregnancy and after birth about the sound feeding and meaning during infancy.

28. TREATMENT Correction of water & electrolyte imbalance 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

29. 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

30. Thought for the day An investment in knowledge always pay the best interest.

31. Thank you