Malnutrition Malnutrition

Dr K N Prasad

Community Medicine

“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

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)

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

UnderweightPrevalence 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)

CHILD MORTALITY

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.

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.

"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.

PEM in Sub-Saharan Africa

PEM in Africa is related to:The high birth rateSubsistence farmingOverused soil, draught & desertificationPets & diseases destroy cropsPovertyLow protein dietPolitical instability (war & displacement)

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)

PRECIPITATING FACTORS

LACK OF FOOD (famine, poverty)

INADEQUATE BREAST FEEDING

WRONG CONCEPTS ABOUT

NUTRITION

DIARRHOEA & MALABSORPTION

INFECTIONS (worms, measles, T.B)

Anthropometric Measurements of Nutritional Status

Weight Length/height Mid upper arm circumference MUAC)Chest circumferenceHead circumferenceSkin fold measurements: Triceps and

Subscapular region

CLASSIFICATION

A. CLINICAL ( WELLCOME )Parameter: weight for age + oedemaReference 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

CLASSIFICATION (2)

B. COMMUNITY (GOMEZ)Parameter: weight for ageReference standard (50th percentile)

WHO chart Grades:

• I (Mild) : 90-70

• II (Moderate): 70-60

• III (Severe) : < 60

Starvation at Auschwitz Concentration Camp WWII

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.

Kwashiorkor

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

MARASMUS (PEM)

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

Prevention of PEMMaintain nutritional status of infants

and children at highest possible level.Reducing risk and effects of infectionNutritional health education: education

of the mothers in the ante-natal care during pregnancy and after birth about the sound feeding and meaning during infancy.

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

KEY POINT FEEDING

Continue breast feeding Add frequent small feedsUse liquid dietGive vitamin A & folic acid on

admissionWith diarrhea use lactose-free or

soya bean formula

Thought for the day

An investment in knowledge always pay the best

interest.

Thank you