Group 7

Salas Salayog Salazar Salazar Salazar Sales Salvador

MARASMUS & KWASHIORKOR

OBJECTIVES
1. 2. 3. To differentiate Marasmus and Mwashiorkor Discuss the cause and molecular perspective of both diseases To determine the patient nutritional status using a) Gomez Classification b) Waterlow Classification

4. To give the mechanism behind the following manifestations in the patient: Flaky skin Hair that is brittle, dry and depigmented Distended abdomen Enlarged liver Edema of the lower extremities Dry conjunctiva Low hemoglobin, hypoproteinemia and hypoalbuminemia

5. To give the factors that contributed to the development of malnutrition in this patient. 6. To discuss the management of the case as well as the preventive measures that can be advised to the mother so that the other children will not develop malnutrition.

General Data
Male 2 years old Quezon City 4 siblings

- youngest: 6 months old; breastfed

 Livelihood
father is a tricycle driver

Main diet
starchy gruel occassionally mixed with diluted condensed milk

Past Medical History

10 months old
(+) Intermittent diarrhea (+) Respiratory Infection

2 months prior to consult

(+) Measles

Physical Examination
Weight: 8 kgs Height: 81 cm Hair: brittle dry, depigmented Conjunctiva: dry with Bitots spot formation Skin: pale, flaky Abdomen: distended Liver: (+) moderate enlargement Lower extremities: (+) edema

irritable apathetic (+) poor appetite

Laboratory Findings
Hemoglobin
6.0g/dl

Normal
(13-15) (6-8)

Total serum protein

4.4g/dl

Albumin
2.0g/dl (3.5-5.5)

Protein-Energy Malnutrition (PEM)

refers to a range of clinical syndromes characterized by an inadequate dietary intake of protein and calories to meet the body's needs. Two protein compartments in the body: a) Somatic protein compartment represented by the skeletal muscles the somatic compartment is affected more severely in marasmus (calorie deficiency) If the somatic protein compartment is catabolized, the resultant reduction in muscle mass is reflected by reduced circumference ofthe midarm.

..Cont.. (PEM)
b) Visceral protein compartment represented by protein stores in the visceral organs, primarily the liver. This compartment is depleted more severely in kwashiorkor (protein deficiency) Measurement of serum proteins (albumin, transferrin, and others) provides a measure of the adequacy of the visceral protein compartment.

 Differentiate Marasmus and Kwashiorkor

Marasmus
From the Greek word withering

one component of protein-energy

malnutrition(PEM) severe form of malnutrition caused by inadequate intake of protein and calories More common in the first year of life

Kwashiorkor
The disease of the displaced child Protein malnutrition/Nutritional Edema Syndrome Macronutrient deficiency

Marasmus
Deficiency in both calorie and protein nutrition Marasmus is caused by a severe deficiency of nearly all nutrients, especially protein and carbohydrates. Old Man Face

Kwashiorkor
Protein malnutrition predominant Deficiency of one of several types of nutrients (e.g., iron, iodine, selenium, vitamin C), particularly those involved with anti-oxidant protection. Important anti-oxidants in the body that are reduced in children with kwashiorkor. Moon Face Onset is later, after the breastfeeding is stopped Not very pronounced Edema is present Blood protein concentration is reduced very much

The onset is earlier, usually in the first year of life Growth failure is more pronounced There is no edema Blood protein concentration is reduced less markedly

Skin changes are seen less frequently

Flaky skin, brittle, dry and de-pigmented skin and Red boils and patches are classic symptoms
Fatty liver is seen

Liver is not infiltrated with fat

Recovery is much longer

Recovery period is short.

Marasmus or Cachexia

Kwashiorkor or Protein-Calorie Malnutri-tion Protein intake during stress state Weeks Well-nourished appearance Easy hair pluckability Edema

Marasmus and Kwashiorkor

Clinical setting Time course to develop Clinical features

Energy intake Months or years Starved appearance Weight <80% standard for height Triceps skinfold <3 mm Midarm muscle circumference <15 cm Creatinine-height index <60% standard

Laboratory findings

Reasonably preserved responsiveness to short-term stress Clinical course Low unless related to underlying disease Triceps skinfold <3 mm Midarm muscle circumference <15 cm

Serum albumin <2.8 g/dL Total iron-binding capacity <200 g/dL Lymphocytes <1500/ L Anergy Infections Poor wound healing, decubitus ulcers, skin break-down High

Mortality

Diagnostic criteria

Serum albu-min <2.8 g/dL At least one of the following: Poor wound healing, decubitus ulcers, or skin breakdown Easy hair pluckability Edema

DIAGNOSIS :

Kwashiorkor

NUTRITIONAL STATUS

 Determine the patients nutritional status

Determination of Ideal Body Weight

Use standard height and weight tables Thanhausser Method based on height in centimeters Fernandos Method

Gibsons Method
(Age x 2) + 8 (2y/o x 2) + 8 =12

IDEAL BODY WEIGHT:

AGE <6 months 6 months-1 year old 1-6 years old FORMULA Age in months X 600 X birth weight Age in months X 500 + birth weight Weight X 2 + 8

>7 years old

Weight X (5-7/2)

Nutritional Status
Gomez Classification (Actual body weight/Ideal body weight) x 100 (8 kgs / 12 kgs) x 100
=

66.67

Interpretation
Weight for Age
90-100% 75-89% 60-74% <60%

Status
Normal First Degree Malnutrition
Second Degree Malnutrition

Third Degree Malnutrition

101-120%
>120%

Overweight
Obese

Nutritional Status
Waterlow Classification
(Combination of weight for height and height for age)

Wasting
Actual body weight/Weight for height x 100 (8kg/ 10.6) x 100 = 75.47 Moderate

- Stunting
Actual height/ Height for age x 100
(81cm/ 87.8) x 100 = 92.25 Mild

Interpretation
Standard Normal Stunting >95% Wasting >90%

Mild
Moderate

87.5-95%
80-87.4%

80-90%
70-79%

Severe

<80%

<70%

 Give the mechanism behind the following manifestations in the patient:

Flaky skin Hair: brittle, dry, pigmented Distended abdomen Enlarged liver Edema of the lower extremities Dry conjunctiva Low hemoglobin, hypoproteinemia, hypoalbumenemia

Mechanisms

Flaky Skin

Mechanisms

Hair: Brittle, Dry, Pigmented

Mechanisms

Distended Abdomen

Mechanisms

Enlarged Liver

Mechanisms

Edema of Lower Extremities

Dry Conjunctiva

MANIFESTATION MECHANISM

PROTEIN DEFICIENT FUNCTION PROTEIN AFFECTED COMPONENT

Mechanical support Collagen

Flaky Skin

Hair that is brittle, dry and depigmented

Subcutaneous fat disappears Skin loses turgor and becomes wrinkled and loose Skin lesions, with alternating zones of hyperpigmentation, areas of desquamation, and hypopigmentation, giving a flaky paint appearance. Overall loss of color or alternating bands of pale and darker hair. Sparse and thin and, in dark-haired children, may become streaky red or gray.

Mechanical support

Keratin

MANIFESTATION

MECHANISM

PROTEIN DEFICIENT FUNCTION PROTEIN AFFECTED COMPONENT

Oncotic Pressure Glycine Albumin

Low hemoglobin, hypoproteinemia and hypoalbuminemia

Synthesis of albumin decreases relatively early in conditions of protein malnutrition Albumin 75-80% oncotic pressure albumin = edema Fatty infiltrations of the liver Decreased Protein carriers Leptin cortisol = lipolysis Liver enlargement and abnormal accumulation of fluid(ascites) Ascites as a result of decreased oncotic pressure.

Enlarged liver

Enzymatic catalysis Hormones

Lipoprotein Leptin

Distended abdomen

Oncotic Pressure

Lipoprotein Albumin

MANIFESTAT MECHANISM ION

PROTEIN FUNCTION AFFECTED

Oncotic Pressure

DEFICIENT PROTEIN COMPONENT

Lipoprotein Albumin

Edema of the Diminished colloid oncotic lower extremities pressure Resultant hypoalbuminemia generalized or dependent edema Severe hypoalbuminemia and the consequent reduced colloid osmotic pressure, the NaCl and H2O that are retained cannot be restrained within the vascular compartment, and total and effective arterial blood volumes decline Develops early Dry conjunctivae Tears

Lubricant function

Lactofferin and other proteins

Factors that contributed to the

development of malnutrition in this patient.

MALNUTRITION
A broad term refers to undernutrition or overnutrition. Condition caused by an unbalanced diet with certain foods being deficient, in excess, or in the wrong proportions.

There are four forms:

Undernutrition - Inadequate nutrition resulting from lack of food or failure of the body to absorb or assimilate nutrients properly. Specific Nutrient deficiency (e.g. vitamin defiency or iron) Overnutrition eating too much, eating too many of the wrong foods. Nutrient imbalance

COMMON NUTRITIONAL DISORDERS

Nutritional Deficiency- occur s when a person's nutrient intake consistently falls below the recommended requirement. I. Etiology

Low income Ignorance and erroneous food habits and beliefs Scarcity of food supply Overpopulation Birth Spacing

II. Classification of Nutritional deficiencies Primary dietary inadequacy in amount or in kind Secondary pathologic condition preventing adequate ingestion of food or proper metabolism of nutrients

Management and preventives measures to avoid malnutrition

Management and preventives measures to avoid malnutrition

Health Education Emphasis on the adequacy of protein intake Effective nutrition education will be required to see that the mother actually gives this protein to the young child. Need for better feeding practices (good hygiene)

 Teaching the mother the importance of milk and meat products in childs growth and development.
General measures designed to improve environmental sanitation and decrease diarrheal disease and intestinal parasitism will be helpful in reducing the incidence of clinical kwashiorkor, but are not a substitute for improved nutrition.

 Monitor your child growth and development Regular checkups with the health care provider helps in monitoring childs height and weight on growth charts. Measure height and weight Children with edema must be assessed carefully for actual nutritional status because edema may mask the severity of malnutrition. Parents must proactively prevent childhood obesity by recognizing weight imbalances. (in case of overnutrition). Follow up check up in minimal interval (7 days) to assess the nutritional status of the patient and any change in parameters.

Treatment:
High calorie and protein diet (If treated early the patient will reach full height and growth) If the patient has been starving for a long time food must be reintroduced gradually) Carbohydrates are given first to provide energy followed by protein. The food stuffs that are allowed for a high protein diet are milk and milk products, bread made of wheat or rice, butter, sugar, fruits, ghee, wheat flour, bananas and vegetable protein mixture. Vitamin and mineral supplements.

Treatment:
Malnourished children may develop lactose intolerance; lactase supplements may be given for the patient to tolerate milk. For severe cases, wherein the patient is in shock, the priority intervention is to restore blood volume and maintain blood pressure.

Prevention:
Provision of balanced diet, adequate housing, accessible potable water and proper sanitation. Advise parents/caretaker make sure the diet has enough carbohydrates, fat (at least 10 percent of total calories), and protein (12 percent of total calories).

 GOAL for HEALTH : Varied Diet with Physical Activity

THANK YOU!