human nutrition, assessment and PEM

8/7/2019 human nutrition, assessment and PEM

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PROTEIN ENERGY MALNUTRITION

Abdelaziz ElaminMD, PhD, FRCPCH

Professor of Child Health

College of Medicine

Sultan Qaboos UniversityMuscat, Oman

[email protected]


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HUMAN NUTRITION

Nutrients are substances that arecrucial for human life, growth & well-

being. Macronutrients (carbohydrates,

lipids, proteins & water) are neededfor energy and cell multiplication &

repair. Micronutrients are trace elements &

vitamins, which are essential for

metabolic processes.


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HUMAN NUTRITION/2

Obesity & under-nutrition are the 2ends of the spectrum of malnutrition.

A healthy diet provides a balancednutrients that satisfy the metabolicneeds of the body without excess or

shortage. Dietary requirements of children

vary according to age, sex &

development.


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Assessment of Nutr status

DirectClinical

Anthropometric

Dietary

Laboratory

IndirectHealth statistics

Ecological variables


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Clinical Assessment

Useful in severe forms of PEM

Based on thorough physicalexamination for features of PEM &vitamin deficiencies.

Focuses on skin, eye, hair, mouth &

bones.

Chronic illnesses & goiter to beexcluded


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Clinical Assessment/2

ADVANTAGES

Fast & Easy to perform

Inexpensive

Non-invasive

LIMITATIONSDid not detect early cases

Trained staff needed


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ANTHROPOMETRY

Objective with high specificity &sensitivity

Measuring Ht, Wt, MAC, HC, skin foldthickness, waist & hip ratio & BMI

Reading are numerical & gradable onstandard growth charts

Non-expensive & need minimaltraining


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ANTHROPOMETRY/2

LIMITATIONS

Inter-observers errors inmeasurement

Limited nutritional diagnosis

Problems with reference standardsArbitrary statistical cut-off levels

for abnormality


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LAB ASSESSMENT

Biochemical

Serum proteins,creatinine/hydroxyproline

Hematological

CBC, iron, vitamin levels

Microbiology

Parasites/infection


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DIETARY ASSESSMENT

Breast & complementary feedingdetails

24 hr dietary recall

Home visits

Calculation of protein & Caloriecontent of children foods.

Feeding technique & food habits


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CHILD MORTALITY

The major contributing factors are:

Diarrhea 20% ARI 20%

Perinatal causes 18%

Measles 07%

Malaria 05%

55% of the total have malnutrition


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EPIDEMIOLOGY

The term protein energy malnutritionhas been adopted by WHO in 1976.

Highly prevalent in developingcountries among


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PEM

In 2000 WHO estimated that 32% of


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PEM in Sub-Saharan Africa

PEM in Africa is related to:

The high birth rate

Subsistence farming

Overused soil, draught & desertification

Pets & diseases destroy crops

Poverty Low protein diet

Political instability (war &displacement)


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PRECIPITATING FACTORS

y LACK OF FOOD (famine, poverty)

y

INADEQUATE BREAST FEEDING

y WRONG CONCEPTS ABOUT NUTRITION

y DIARRHOEA & MALABSORPTION

y INFECTIONS (worms, measles, T.B)


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CLASSIFICATION

A. CLINICAL ( WELLCOME )

Parameter: weight for age + oedema

Reference tandard (50th percentile)

Grades:

80-60 % without oedema is under weight

80-60% with oedema is Kwashiorkor < 60 % with oedema is Marasmus-Kwash

< 60 % without oedema is Marasmus


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CLASSIFICATION (2)

B. COMMUNITY (GOMEZ)

Parameter: weight for age

Reference standard (50thpercentile) WHO chart

Grades:I (Mild) : 90-70

II (Moderate): 70-60

III (Severe) : < 60


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ADVANTAGES

y SIMPLICITY (no lab tests needed)

y REPRODUCIBILITY

y COMPARABILITY

y ANTHROPOMETRY+CLINICAL

SIGN USED FOR ASSESSMENT


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DISADVANTAGES

y AGE MAY NOT BE KNOWN

y

HEIGHT NOT CONSIDEREDy CROSS SECTIONAL

y CANT TELL ABOUT CHRONICITY

y WHO STANDARDS MAY NOTREPRESENT LOCAL COMMUNITYSTANDARD


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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 thesickness of weaning.


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ETIOLOGY

Kwashiorkor can occur in infancy but

its maximal incidence is in the 2nd yrof life following abrupt weaning.

Kwashiorkor is not only dietary in

origin. Infective, psycho-socical, and

cultural factors are also operative.


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ETIOLOGY (2)

Kwashiorkor is an example of lack ofphysiological adaptation to

unbalanced deficiency where the bodyutilized proteins and conserve S/C fat.

One theory says Kwash is a result of

liver insult with hypoproteinemia andoedema. Food toxins like aflatoxinshave been suggested as precipitatingfactors.


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CLINICAL PRESENTATION

Kwash is characterized by certainconstant features in addition to avariable spectrum of symptoms and

signs. Clinical presentation is affected by:

The degree of deficiencyThe duration of deficiencyyThe speed of onsetyThe age at onsetyPresence of conditioning factors

yGenetic factors


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CONSTANT FEATURES OF KWASH

OEDEMA

PSYCHOMOTOR CHANGES

GROWTH RETARDATION

MUSCLE WASTING


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USUALLY PRESENT SIGNS

MOON FACE

HAIR CHANGES

SKIN DEPIGMENTATION

ANAEMIA


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OCCASIONALLY PRESENT SIGNS

HEPATOMEGALY

FLAKY PAINT DERMATITISCARDIOMYOPATHY & FAILURE

DEHYDRATION (Diarrh. & Vomiting)

SIGNS OF VITAMIN DEFICIENCIES

SIGNS OF INFECTIONS


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DD of Kwash Dermatitis

Acrodermatitis Entropathica

Scurvy

Pellagra

Dermatitis Herpitiformis


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MARASMUS

The term marasmus is derived fromthe Greek marasmos, which means

wasting. Marasmus involves inadequate

intake of protein and calories and ischaracterized by emaciation.

Marasmus represents the end result

of starvation where both proteins

and calories are deficient.


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MARASMUS/2

Marasmus represents an adaptive

response to starvation, whereaskwashiorkor represents a

maladaptive response to starvation

In Marasmus the body utilizes all fatstores before using muscles.


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EPIDEMIOLOGY & ETIOLOGY

Seen most commonly in the first yearof life due to lack of breast feedingand the use of dilute animal milk.

Poverty or famine and diarrhoea arethe usual precipitating factors

Ignorance & poor maternal nutritionare also contributory


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Clinical Features of Marasmus

Severe wasting of muscle & s/c fats

Severe growth retardation

Child looks older than his age

No edema or hair changes

Alert but miserable

Hungry

Diarrhoea & Dehydration


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CLINICAL ASSESSMENT

Interrogation & physical examincluding detailed dietary history.

Anthropometric measurements

Team approach with involvement ofdieticians, social workers &community support groups.


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Investigations for PEM

Full blood counts

Blood glucose profile

Septic screening

Stool & urine for parasites & germs

Electrolytes, Ca, Ph & ALP, serumproteins

CXR & Mantoux test

Exclude HIV & malabsorption


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NON-ROUTINE TESTS

Hair analysis

Skin biopsy

Urinary creatinine over proline ratio

Measurement of trace elements

levels, iron, zinc & iodine


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Complications of P.E.M

Hypoglycemia

Hypothermia

Hypokalemia

Hyponatremia

Heart failure

Dehydration & shock

Infections (bacterial, viral & thrush)


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TREATMENT

Correction of water & electrolyteimbalance

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


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KEY POINT FEEDING

Continue breast feeding

Add frequent small feeds Use liquid diet

Give vitamin A & folic acid on

admission With diarrhea use lactose-free or

soya bean formula


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PROGNOSIS

Kwash & Marasmus-Kwash havegreater risk of morbidity & mortality

compared to Marasmus and underweight

Early detection & adequate treatment

are associated with good outcome Late ill-effects on IQ, behavior &

cognitive functions are doubtful and

not proven


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THANKS YOU

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human nutrition, assessment and PEM