Rittu Chandel1

PROTEIN ENERGY MALNUTRITION

Dr.Rittu Chandel

Second year resident

Grant Government Medical College

02 -01-2013

Rittu Chandel2

The World Health Organization (WHO) defines malnutrition as "the cellular imbalance between the supply of nutrients and energy and the body's demand for them to ensure growth, maintenance, and specific functions.”

WHO defines PEM as range of pathological conditions arising from coincidental lack in varying proportions of proteins and calories, occuring most frequently in infants, young children

Protein-energy malnutrition - weight loss of greater than 10% of normal body weight

Rittu Chandel3

Marasmus

•Greek word marasmos, which means withering or wasting. •Chronic state of insufficient calorie intake•characterized by emaciation

kwashiorkar

•the Ga language of Ghana and means "the sickness of the weaning."•Insufficient protein intake• characteristic is edema

Rittu Chandel4

A global problem First national nutritional disorder

‘Protein gap’ replaced by ‘food gap’

Childhood mortality and morbidityPhysical impairment

Retardation of mental growth

Rittu Chandel5

CAUSES Worldwide, the most common cause of is inadequate food

intake ineffective weaning poor hygiene, economic factors, and cultural factors Gastrointestinal infections

malnutrition infection

Rittu Chandel6

Early detection

First indicator – underweight for age

Method – maintenance of growth charts

Rittu Chandel7

CAUSES by decreased absorption or abnormal metabolism Burns cystic fibrosis chronic renal failure childhood malignancies congenital heart disease neuromuscular diseases psychiatric diseases, such as anorexia nervosa

Rittu Chandel8

Rittu Chandel9

MARASMUS insufficient energy intake to match the

body's requirements

Duration : months to years Emaciation loss of subcutaneous fat muscle wasting an adaptive response to starvation skin is xerotic, wrinkled, and loose Monkey facies fine, brittle hair; alopecia; impaired growth; and fissuring of the nails Good appetite Listless Temperature - subnormal

Rittu Chandel10

KWASHIORKAR adequate carbohydrate consumption decreased protein intake Duration : weeks edema, moon facies a swollen abdomen (potbelly) Poor appetite Irritable, moaning cry

Rittu Chandel11

Rittu Chandel12

Hypoalbuminemia

-Impaired synthesis of B-lipoprotein

produces a fatty liver

- Atrophy of pancreas,salivary gland

and intestine

hair-pull analysis

Flaky paint dermatosis

Pavement dermatosis

Rittu Chandel13

elderly persons indicative sign of malnutrition is delayed healing decubitus ulcers increased likelihood of calciphylaxis, a small vessel

vasculopathy involving mural calcification with intimal proliferation, fibrosis, and thrombosis. As a result, ischemia and necrosis of skin occurs. Other tissues affected include subcutaneous fat, visceral organs, and skeletal muscle

Noma

Rittu Chandel14

Marasmic Kwashiorkar Initially marasmic-------then oedema develops

Rittu Chandel15

Laboratory Studies

The WHO recommends the following laboratory tests: Blood glucose Examination of blood smears Hemoglobin Urine examination and culture Stool examination by microscopy for ova and parasites Serum albumin HIV test Electrolytes

16

Cellular reactions to protein deficiency

Decrease cellular RNA

Decreased protein catabolism

Decreased DNA

synthesis

Decreased formation of new

cells

CNS –delayed mental developmentImmunologically competent cells – deficient immune response

Decreased myeloid, monocytes – susceptibility to infectionDecreased erythrocytes – anemia

Endochondral bone growth - growth retardationHair follicle – atrophy

Stomach and small intestine - malabsorption

Rittu Chandel

Cellular reactions to protein calorie deficiency

Decrease cellular RNA

Decreased protein catabolism

Decreased DNA

synthesis

Fall in tissue and cellular proteins and

enzymes

Anatomical changes – Fatty liver

Atrophy of pancreas, salivary glands

Delayed mental

development

Rittu Chandel18

Kwashiorkar Proteins - decreases

hypoalbuminemia (< 2.8 g/dl)

Hypoglobulinemia• Amino acids

essential amino acids ( branched ones) – decreases

Non essential - tyrosine, arginine, citrulline, ᵧ - amino butyric acid - decreases

Ratio – branched essential amino acids glycine, glutamic acid, serine Incomplete metabolism of histidine, phenylalanine, tryptophan

Rittu Chandel19

KWASHIORKARtransferrin (<150 mg/dl)

Iron binding capacity < 200 mcg/dl

hypoglycemia

lymphopenia growth hormone levels are high insulin secretion and insulin like growth factor levels are

decreased. percentage of body water and extracellular water is increased potassium and magnesium depleted iron deficiency anemia lactase, amylase, lipase - reduced

Rittu Chandel20

MARASMUS Urinary excretion of hydroxyproline diminished, reflecting

impaired growth and wound healing Increased urinary 3-methylhistidine is a reflection of muscle

breakdown Creatinine – height index –low (< 60%)

Rittu Chandel21

PREVENTIVE MEASURES From WHO expert committee on nutrition

Health Promotion

1.Measures directed to pregnant and lactating women

2.Promotion of breast feeding

3.Meal given at frequent intervals

4.Improve family diet

5.Promotion of correct feeding practices

6.Family planning and spacing of births

Rittu Chandel22

Specific Protection

1.Immunization

2.Food fortification

3.Diet must contain protein and energy rich foods – milk, egg, fresh fruit

Early Diagnosis and treatment

1.Early diagnosis of any lag of growth

2. Early diagnosis and treatment of infections and diarrhea

3.Rehydration

4.deworming

Rittu Chandel23

treatment

PHASE STABILISATION REHABILITATION

Day 1-2 Day 2-7+ Week 2-6

1. Hypoglycaemia2. Hypothermia3. Dehydration4. Electrolytes5. Infection6. Micronutrients7. Cautious feeding8. Rebuild tissues9. Sensory stimulation10. Prepare for follow-up

no iron with iron

Rittu Chandel24

Bibliography

Harrisons internal Medicine 17th edition Nelsons Pediatrics IAP pediatrics Parks Preventive Social and Medicine Talwar

THANK YOU