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SERUM FREE TRI IODOTHYRONINE AND

THYROID STIMULAT ING HORMONE LEVEL IN

SEVERE PROTEIN ENERGY MALNOURISHED

CHILDRENSHAHJADI S1, KHAN AS2, AKHTER QS3, AKTER N4, HASAN SMMMA5, RAHMAN T6

AbstractContext: A cross sectional study was carried out to observe the serum levels of FT 3and TSH in severe Protein Energy Malnourished (PEM) children.

Methods:Total 70 subjects were selected, of whom 50 were severe PEM children(case group,B) and 20 were normal healthy children (control group,A). The casegroup B also subdivided into B1 (marasmus group) and B2 (Kwashiorkorgroup).The subjects were taken from Dhaka Medical College Hospital, ShishuHospital, GonoShastho Medical College Hospital

Result: In this study the meant (SD) of serum FT 3 level of case were significantly

lower (p

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.

1. Dr. Shorifa Shahjadi, Assistant Professor, Department of Physiology, MARKS MedicalCollege, Dhaka.2. Dr. Arif Salam Khan, Resident surgeon, Dhaka Medical College, Dhaka3. Dr. Qazi Shamima Akhter, Head of the Department, Physiology, Dhaka Medical College, Dhaka4. Dr. Nurjahan Akter, M Phil, Physiology

5. Dr. S.M.Md Mahid-Al-Hasan, M Phil, Pharmacology6. Dr. Tahmina Rahman, Assistant Professor, Department of Physiology, Samorita Medical College,Dhaka. Correspondence : Dr. Shorifa Shahjadi, Assistant Professor, Department of Physiology,MARKS Medical College, Dhaka.

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Serum Free Triiodothyronine and ThyroidStimulating Hormone Level Shahjadi S et al

PEM can arise from primary orsecondary causes. Primary PEMresults from inadequate or poorquality food intake. Secondary PEM

occurs from diseases that alter foodintake or nutrient requirements,metabolism, or absorption. Infant andyoung children who lose 20% or morebody weight is generally classified assevere PEM. People with this conditioncannot eat normal quantity of meals.

They have slow heart rates and lowblood pressure and bodytemperatures1.

Secondary PEM symptoms range frommild to severe, and can alter the form orfunction of almost every organ in thebody. The type and intensity ofsymptoms depend on the patient's priornutritional status and on the nature ofthe underlying disease . Othersymptoms of severe secondary PEMinclude baggy, wrinkled skin;constipation; dry, thin, brittle hair ;lethargy; pressure sores and other skinlesions.

Marasmus and kwashiorkor are the two

main types of PEM. People who havekwashiorkor often have extremely thinarms and legs, but liver enlargementand ascites (abnormal accumulation offluid) can distend the abdomen and hideweight loss. Hair may turn red or yellow.Anaemia, diarrhoea, and electrolytedisorders are common. The body'simmune system is weakened, behavioraldevelopment is slow, and mentalretardation may occur. Children maygrow to normal height but are

abnormally thin.

Kwashiorkor- like secondary PEM usuallydevelops in patients who have beensuffering from tissue- destroyinginfection or any other life- threateningillness. The onset is so sudden that bodyfat and muscle mass of the childrenhaving normal weight may not change.Severe marasmus is accompanied

profound weakness. Since the bodybreaks down its own fats and muscles tobe used as calories, children with thiscondition lose all their body fat andmuscle strength. They acquire a skeletalappearance most noticeable in the

hands and in the temporal muscle infront of and above each ear. Childrenwith marasmus are small

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for their age. Since their immunesystems are weakened, they suffer fromfrequent infections. Other symptomsinclude loss of appetite, diarrhoea, skinthat is dry and baggy, sparse hair that isdull brown or reddish yellow, mental and

behavioral retardation, low bodytemperature (hypothermia), and slowpulse and breathing rate5.175

Severe PEM affects physiology of thethyroid hormone, especially peripheralhormone metabolism6.

In short term Protein energymalnutrition, thyroid abnormalities areconfined to the thyroid hormonaltransport system. Long-term PEM

induced hypothyroidism places childrenat risk for possible brain damage7 .

In PEM carbohydrate and vitamindeficiency inhibit the liver microsomalenzyme for conversion of T4 to T3. Thisreduction in T3level can be explained byimpaired liver function in PEM children.Cortisol which is found to be elevated inthe acute stages of PEM also prevents T3generation from T4 by inhibiting the 5-deiodinase system. That is why lower T3

level is found among PEM children2.Serum TSH level increased due todecrease serum FT3 level. Thyroidhormones deficiency affects in all stagesof life. Its deficiency causes physical andmental handicap and poor educability ofchildren. Thyroid disorders is a publichealth problem not only in Bangladeshbut also in many developing countries.

MethodsThis cross sectional study was carried

out in the Department of Physiology,Dhaka Medical College, Dhaka. For thispurpose total 70 subjects were selected,of whom 50 were severe PEM children(case group, B) and 20 were normalhealthy children (control group, A). Thecase group B also subdivided into B1(marasmus group) and ) B2 (Kwashiorkorgroup).The subjects were taken fromDhaka Medical College Hospital, ShishuHospital , GonoShastho Medical College

Hospital. Mid -upper arm circumference,weight-for-height median (WHM),weight-for-height z -score (WHZ), bipedaloedema (kwashiorkor), HB%, were thecriteria for selection of severe

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J Dhaka Med Coll. Vol. 20, No. 2. October, 2011

malnourished children Common anthro-pometric indicators of child malnutritionare combinations of body measurementsand age, because the short-termresponse of a child's body to inadequate

food intake is to slow down growth. Thisresults in low height-for-age (stunting)and low weight-for-height (wasting). Theindicators recommended forinternational use are: stunting, wastingand underweight (a measure of bothstunting and wasting). To assess thelevel of malnutrition, a child's height andweight are compared with theNCHS/WHO reference curves of height-for-age, weight-for-age and weight-for-height. Child malnutrition must be

stratified by level of severity (i.e. mild,moderate, severe) .Different degrees ofmalnutrition have different associatedrisks. According to Z score, severe,moderate and mild are classified as-children who fall below -3 SD, and in theintervals -3 SD to < -2 SD, and -2 SD to< -1 SD from the median of the weight-for-age distribution for the childpopulation. Permission was taken fromthe concerned departments&authorities. Informed written consentwas taken from all the study subjectsafter full explanation of nature andpurpose of the study. All the subjectswere explained about the aims andobjectives of the study. The testprocedure were briefed anddemonstrated and written consent weretaken before performing the test. Withall aseptic precautions 5ml venous bloodwas drawn from the antecubital vein in adisposable syringe and then blood was

immediately transferred to a dry cleantest tube and allowed to clot. After clotformation, serum was separated bycentrifuging the blood at 3000 rpm for 5minutes. Serum was kept in microcentrifuge tube after labeling and waspreserved at -200 C until analysis.Estimation of serum FT3 levels of studysubjects were done by RIA and TSHlevels were done by IRMA at Center forNuclear Medicine & Ultrasound, DMCH

campus, Dhaka. After the collection ofdata these were checked, verified,edited for consistency to reduce error.Analysis of data were done with the helpcomputer by SPSS program version of12.0 software facilities. Significance test

were done by Student's unpaired "t"test.

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Results176Results were expressed as mean SD( Standard deviation ). The statisticalsignificance of difference between thegroups were evaluated by using

Student's unpaired `t' test in case andcontrol groups and by ANOVA test incase of subgroups (case).

Table-IMeanSD of serum FT3 and TSH level in

study and control group

Group Number of Serum free T3 SerumTSH

A

B1

B2

20

25

6.44

.76(5.14-7.62)3.16.30

2.97.

21(2.50-3.23)4.98.32

Statisti analys

GroupF

t & p

Serum FT3

t & p

Serum TSH

`A vs B1

A vs B2

B1 vs B2

43

4.04 .001(***)

4.20 .***

5.29 .001(***)

5.73 .001(***)

.10 NS

The results were expressed as MeanSD. Unpaired Student's `t' test isperformed to compare between groups.

The test of significance was done and pvalues

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Serum Free Triiodothyronine and ThyroidStimulating Hormone Level Shahjadi S et al

liver microsomal enzyme for conversionof T4 to T3.Cortisol which is found to beelevated in the acute stages of PEM alsoprevents T3 generation from T4 by

inhibiting the 5 deiodinase system2

Decreased in serum FT3 concentrationwere due to low intake of amino acidsby severe PEM children6.

The mean t SD serum TSH levels were2.97 t 0.21 mIu/L 4.98 t 0.32 mIu /L, 5.02t 0.29 mIu/L in group A, B1 8v B2respectively. The mean t SD of serum

TSH levels in group B1 8v B2 weresignificantly higher (p

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