PROTEIN ENERGY

MALNUTRITION
Severe childhood undernutrition
SCU

Soad Jaber 2009

objectives
Use the medical history and physical examination to
evaluate nutritional status.
Present an approach to recognizing and treating some
common nutritional problem of childhood.
Identify etiologic categories of malnutrition,1ry,2ry,
marasmus and kwashiorkor.
Display an understanding of the principles for managing
severe childhood under nutrition

Why more common in children?

High nutrient requirement/unit weight.

Dependence on adults for food

Water
Fat
Growth

- Higher body water> older children

- Rapid increase in the 1st 6 months
- Rapid from birth till six months
Growth rate increase at puberty.
More for boys than girls.

Developmental Milestones:
Neonates
12 weeks
20 weeks
28 weeks
7 months
9 months
10 months
12 months
15 months
18 months

Good swallowing + sucking.

Can-swallows food placed on anterior
tongue.
Can drink from held cup with biting
movements.
Teeth begin to erupt.
Feeds self biscuits., chewing movements.
Shuts mouth. Shakes head to refuse foods.
Fingers feeding
Drinks from cup.
Holds spoon unable to get food to mouth.
Control spoon + cups.
Plays with food.

How to assess nutritional

status?????
- Clinically
- Anthropometrically
- Bio-chemically
- Clinical "Signs"
Muscular, skeletal Tone. ,muscle wasting ,delayed
walking
Abdomen- Hepatomegally.. spleenomegally,
ascites..
CVS --Cardiomegally ,oedema
CNS--- Apathy, confusion, psychosis, depression.

Anthropometric
techniques

The trend overtime serial reading, NOT single

Weight for age reflect the combined effect of both recent

and longer term level of nutrition.
Height for age long term problem,comulative effect of
undernutrition during the life of the child.
Weight for height and age ,recent nutritional experiences.
Less<80-90% abnormally low
Skull circumference: Rapid growth in early infancy Genetic,
hormonal
Mid-upper arm circumference
Skin folds thickness:. Triceps sub-scapular % of body fat ..
They reflect severity and extent of the problem but not
specific for any particular disease

INTERPRETATION OF
WEIGHT AND HEIGHT FOR AGE
Weight> 80%
expected

Weight < 90%

expected

Height > 90%

Normal

Wasted

Height < 90%

Short

Stunted

PROTEIN ENERGY
MALNUTRITION
Definition : ( WHO)

* Marasmus Weight less than 60% of expected weight - no

oedema.
Kwashiorkor Weight between 60-80% of expected weight +
oedema
No oedema
Oedema

80% Under weight for age Kwashiorkor 80%

Marasmus 60%

60%MarasmicKwashiorkor

Wellcome Classification

Gomez Classification for

Malnutrition
1ry PEM is a spectrum ranging from:
* mild form
Decrease weight for length.
*severe form
Decrease length and weight for age.

Aetiology of (PEM)
Leading cause of death (less than 5 years of age)

1ry:. Protein + energy intakes below requirement for normal

growth
2ry:the need for growth is greater than can be supplied.
: decreased nutrient absorption

: increase nutrient losses

Linear growth ceases

Static weight
Weight loss
Wasting
Malnutrition and its signs

Kwashiorkor:

Ga language of West Africa = Supplanted one - Child

who recently have been weaned
(Pregnant mother) and emotional deprivation
History:
1933 Cecily
* Ghanaian children
* Weaned recently
* Oedema and hair changes
* Fatty liver
1967 Mc-Cane
* Anaemia
* Cardiac
* Skin changes
1971 Frood-Paskitt
* Biochemical

Pathogenesis:

Kwashiorkor:
Normal energy intake, Lack of protein
Edema:1970.decrease oncotic pressure,

Recent> Increase Renin activity,N a and fluid

retention.

Amino aciduria due to proximal tubular

dysfunction
Failure of adaptation
.Hepatomegaly due to fatty infiltration from
lipogenesis of excess CHO
- Biochemical and haematological changes

Pathogenesis:
Marasmus:
- Lack of all nutrients stimulate cortisone secretion
which result in muscle wasting, the released a. a will
synthesize albumin to prevent edema.
- Growth and energy expenditure limited, in response
to dietary stress
- Adaptation to reduce protein + energy
- Biochemical and haematological tests within normal
-Abdomin,flat due to ms wasting, OR distended due
to 2ry lactose intolerance.

Causes:
Social.ecomomic.poverity.ignorance.maternal
malnutrtion.enviromental.
Kwashiorkor:
Insufficient intake of protein of good biological value.
Impaired absorption of protein e.g. chronic diarrhoea.
Abnormal losses of protein e.g.
severe nephrosis . Severe or prolonged infection
Failure of protein synthesis e.g.
chronic liver diseases.

Marasmus:
Inadequate caloric intake due to insufficient diet .
Improper feeding habits .
Emotional deprivation.
Metabolic abnormalities
Congenital malformation
Severe impairment of any body system

Management:
-

Accurate history of social and economic factors.

poverety,ignorance. environmental factors .

diet history: maternal malnutrition, breast milk and other feeding

habits .food allergies ,food taboos.
chronic illness ,burns .HIV. cystic fibrosis .malignancies .inborn error
of metabolism ,
- Evaluation of growth parameters: weight, height, head circumference
- Evaluation of the degree of illness and dehydration:
skin fold thickness - Biochemical evaluation
* mild * moderate
* severe

1) Mild - moderate with no complication

- Home management
calories + energy
food increase
Multivitamin 1st week
Iron replacement 2nd week.
antibiotics for infection

2) Severe marasmic or severe kwashiorkor

Complicated cases or marasmic kwashiorkor
Hospital management
INITIAL PHASE

1st day: History --- clinical exam -- rehydration

Prevent heat loss

NGT feeding ORS, IVF (glucose and electrolytes)
Treatment of infection,bacterial and parasitic.

2nd -7th day:

a) Continue rehydration by NGT,

b) start diet by NGT .calories 80-100/kg/day ,Protein 3-4 g/kg/d. small
2hourly then 4hourly to6 hourly. and increase calories gradually
, c) multivitamin. Vit A, folic acid. Without IRON for the 1 st week.
d) Correct anaemia ( packed RBC carefully)

volumes

If diarrhea starts or fails to resolve may be lactose intolerance lactose free milk or cow milk
protein intolerance start soy protein hydrolysate formula.

Rehabilitation phase week2-6

a) Start oral feeding
b) Continue antibiotics
c) Start iron
Oedema disappear ,, appetite improvement .the child is
more interested in the surrounding
Follow up phase

Discharge..

Supervising the mother in cooking

parental education to prevent an additional episodes

Follow-up:
1st sign of improvement:
-Awareness in the child
-Appetite (kw)
-Weight loss (kw)
Weight gain

rapid Marasmus
Slow (10th day) Kwashiorkor

Failure of improvement:
1) Combined marasmic -kwashiorkor
2) Infection

TB ,,,parasite

3) drowsiness
-Severe hypokalemia
-Hepatic failure
-Protein intolerance
4) Rapid gain of weight - Cardiac failure
- Grossly disturbed metabolism
- Unable to tolerate the rate of re feeding (oedema)
5) Profuse diarrhea
- GIT infection
- Food intolerance (discharidase)
- Other nutrients deficiency

Complications:
1) Infection:
1. Immunological defect
- Cell mediated> humoral
- Measles> fatal disease

2. Subtle infection

- Inability to

Lack of fever
Hypothermia
No increase in WBC
localize infection

Complications (cotn)
2)
3)
4)
5)
6)
7)

Hypoglycaemia
apnoea
Hypothermia bradycardia
Heart failure
death
Vit deficiencies
Vit A blindness
Permanent growth stunting
Prolonged illness developmental delay
cognitive function
slow intellectual
achievement

Prevention:

Improve nutritional status

Improve water supply
Without change in food supply Proper sanitation
Health education
Social worker visits,
Reduce infection rate
Immunization
Supervision of feeding
Good weaning practice

Effective for
one generation

Long term community

health measures

Prognosis:
Marasmus due to under feeding good
Kwashiorkor MR 10-25%
Marasmus I Kwashiorkor worse progress
End point of nutritional
stress failure
of adaptation