Malnutrition Protein / Energy Definitions of Malnutrition
Kwashiorkor: protein deficiency Marasmus: energy deficiency Marasmic/ Kwashiorkor: combination of chronic energy deficiency and chronic or acute protein deficiency Failure to thrive:marasmus in U. S. children under 3. Definitions of Malnutrition
PEM Primary: inadequate food intake Secondary: result of disease FTT In-organic: inadequate food intake Organic: result of disease MARASMUS Marasmus is the term used for severe PEM and wasting (low wt/ht). Many secondary forms of marasmic PEM are associatedw ith chronic diseases( cysricfibrosis, tuberculosis,cancer, acquired immunodeficiency virus, celiac disease). The principal clinical manifestarion in a child wirh severe malnutririon is emaciation with a body weight less than 50%o f the median (50th percentile) for age or less than70%o f the ideal weight For height and depleted body fat stores Loss of muscle mass and subcutaneous fat stores are confirmed by inspection or palpation and quantified by anthropometric measurements. the head may appearlarge but generally is proportional to the body length. Edema usually is absent. The skin is dry and thin, and the hair may be thin, sparse, and easily pulled out. Marasmic children may be apathetic and weak Bradycardia and hypothermia signify severe and lifethreatening malnutririon.
Atrophy of the filiform papillae of the tongue is common) and monilial stomatitis is frequent. Inappropriate or inadequate weaning practices and chronic diarrhea are common findings in developing countries. Stunting (impaired linear growth (Table 30-1) results from a combination of malnutrition, especially micronutrients, and recurrent infections. Stunting is more prevalent than wasting KOWASHIORKOR Kwashiorkor is hypoalbuminemic, edematous malnutrition and presents with pitting edema that srarts in the lower extremities and ascends with increasing severity. It is classically described as being caused by inadequate protein intake in the presence of fat to good caloric intake. Other factors, such as acute infection, toxins, and possibly specific micronutrient or aminoacid imbalances,are likely to contribute to the etiology The major clinical manifestation of kwashiorkor is that the body weight of the child ranges from 60%to 80% of the expected weight for age weight alone may not accurately reflect the nutritional status because of edema Physical examination reveals a relative maintenance of subcutaneous adipose tissue and a marked atrophy of muscle mass. Edema varies from a minor pitting of the dorsum of the foot to generalized edema with involvement of the eyelids andscrotum. The hair is sparse; is easily plucked; and appears dull brown, red, or yellow-white. Nutritional repletion restores hair color, leaving a band of hair with altered pigmentation followed by a band with normal pigmentation(flag sign) Skin changes are common and range from hyperpigmented hyperkeratosis to an erythematous macular rash (pellagroid) on the trunk and extremities. In the most severe form of kwashiorkor, a superficial desquamation occurs over pressure surfaces ("flaky paint" rash). Angular cheilosis, atrophy of the filiform papillae of the tongue, and monilial stomatitis are common. Enlarged parotid glands and facial edema result in moon apathy and disinterest in eating are typical of kwashiorkor. Examination of the abdomen may reveal an enlarged, soft liver with an indefinite edge.
Lymphatic tissue commonly is atrophic. Chest examination may reveal basilar rales. The abdomen is distended, and bowel sounds tend to be hypoactive History Marasmus well known for centuries Kwashiorkor: Cicely Williams
Ga tribe in Ghana the sickness the older child gets when the next baby is born Starch edema, sugar babies Similar but different diseases How many? 36% of children in the world are underweight 43% stunted
9% wasted Better nutrition, but more children in high risk areas, yields more children affected. Causes Social and Economic Poverty Ignorance
Inadequate weaning practices Child abuse Cultural and social practices Vegan Low fat diets Biologic factors Maternal malnutrition, prematurity Infectious disease
Start life with poor stores Infectious disease Diarrhea, Aids, TB, measles Environmental Unsanitary living, poor quality water Agricultural/culturalpatterns Droughts, floods, wars, forced migrations Age of child Infants and young children Marasmus < 1 year
High nutritional needs Early weaning or late weaning Poor hygiene Marasmus < 1 year Kwashiorkor >18 months with starchy weaning foods Pathophysiology Develops slowly, adapts to decreased intake
Marasmus Less fragile metabolic equilibrium Less effective adaption or acute problem Kwashiorkor, mixed Energy Decreased intake yields decreased activity
Decreased play and physical activity Mobilization of body fat, weight loss, Subcutaneous fat Muscle wasting Maintains visceral protein in marasmus Nl albumin Larger protein deficit leads to faster visceral protein falls and edema. Biologic differences Marasmus Kwashiorkor Weight loss
Nl or low protein Boarderline hgb, hct NL AA profile Nl blood glucose Nl enzymes Nl transaminase Kwashiorkor NO weight loss High extracellular water Low hgb, hct Low protein Elevated AA profile Low enzymes High transaminase Pathophysiology Cardiac Immune system Cytokines (glycoproteins)
Output, heart rate and blood pressure decrease Postural hypotension Immune system T lymphocytes and complement decreased Susceptible to bacterial infection Cytokines (glycoproteins) Poor immune response TNF inc leading to anorexia, muscle wasting and lipid changes Pathophysiology Decreased total body potassium GI function
Not electrolytes, but problem in rehabilitation GI function Poor absorption of lipids, and sugars Decreased enzyme and bile production Increase incidence of diarrhea, and bacterial overgrowth Pathophysiology CNS Parental adaptation
Decreased brain growth and myelnation Electrical changes similar to dylexia Parental adaptation Increased breastfeeding Altered expectations Diagnosis Anthropometry 4 groups Acute: Wasting: low weight for height
Chronic: Stunted: low height for age 4 groups Normal Wasted not stunted: acute PEM Wasted and stunted: acute and chronic PEM Stunted not wasted: past PEM, nutritional dwarfs Diagnosis Normal: 1 SD Mild: -1.1 to -2 SD Moderate -2.1 to -3 SD
Severe greater than -3 Less than 5th percentile in US BMI in adolescents Moderate