protein energy malnutrition
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Rittu Chandel1
PROTEIN ENERGY MALNUTRITION
Dr.Rittu Chandel
Second year resident
Grant Government Medical College
02 -01-2013
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The World Health Organization (WHO) defines malnutrition as "the cellular imbalance between the supply of nutrients and energy and the body's demand for them to ensure growth, maintenance, and specific functions.”
WHO defines PEM as range of pathological conditions arising from coincidental lack in varying proportions of proteins and calories, occuring most frequently in infants, young children
Protein-energy malnutrition - weight loss of greater than 10% of normal body weight
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Marasmus
•Greek word marasmos, which means withering or wasting. •Chronic state of insufficient calorie intake•characterized by emaciation
kwashiorkar
•the Ga language of Ghana and means "the sickness of the weaning."•Insufficient protein intake• characteristic is edema
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A global problem First national nutritional disorder
‘Protein gap’ replaced by ‘food gap’
Childhood mortality and morbidityPhysical impairment
Retardation of mental growth
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CAUSES Worldwide, the most common cause of is inadequate food
intake ineffective weaning poor hygiene, economic factors, and cultural factors Gastrointestinal infections
malnutrition infection
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Early detection
First indicator – underweight for age
Method – maintenance of growth charts
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CAUSES by decreased absorption or abnormal metabolism Burns cystic fibrosis chronic renal failure childhood malignancies congenital heart disease neuromuscular diseases psychiatric diseases, such as anorexia nervosa
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MARASMUS insufficient energy intake to match the
body's requirements
Duration : months to years Emaciation loss of subcutaneous fat muscle wasting an adaptive response to starvation skin is xerotic, wrinkled, and loose Monkey facies fine, brittle hair; alopecia; impaired growth; and fissuring of the nails Good appetite Listless Temperature - subnormal
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KWASHIORKAR adequate carbohydrate consumption decreased protein intake Duration : weeks edema, moon facies a swollen abdomen (potbelly) Poor appetite Irritable, moaning cry
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Hypoalbuminemia
-Impaired synthesis of B-lipoprotein
produces a fatty liver
- Atrophy of pancreas,salivary gland
and intestine
hair-pull analysis
Flaky paint dermatosis
Pavement dermatosis
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elderly persons indicative sign of malnutrition is delayed healing decubitus ulcers increased likelihood of calciphylaxis, a small vessel
vasculopathy involving mural calcification with intimal proliferation, fibrosis, and thrombosis. As a result, ischemia and necrosis of skin occurs. Other tissues affected include subcutaneous fat, visceral organs, and skeletal muscle
Noma
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Marasmic Kwashiorkar Initially marasmic-------then oedema develops
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Laboratory Studies
The WHO recommends the following laboratory tests: Blood glucose Examination of blood smears Hemoglobin Urine examination and culture Stool examination by microscopy for ova and parasites Serum albumin HIV test Electrolytes
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Cellular reactions to protein deficiency
Decrease cellular RNA
Decreased protein catabolism
Decreased DNA
synthesis
Decreased formation of new
cells
CNS –delayed mental developmentImmunologically competent cells – deficient immune response
Decreased myeloid, monocytes – susceptibility to infectionDecreased erythrocytes – anemia
Endochondral bone growth - growth retardationHair follicle – atrophy
Stomach and small intestine - malabsorption
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Cellular reactions to protein calorie deficiency
Decrease cellular RNA
Decreased protein catabolism
Decreased DNA
synthesis
Fall in tissue and cellular proteins and
enzymes
Anatomical changes – Fatty liver
Atrophy of pancreas, salivary glands
Delayed mental
development
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Kwashiorkar Proteins - decreases
hypoalbuminemia (< 2.8 g/dl)
Hypoglobulinemia• Amino acids
essential amino acids ( branched ones) – decreases
Non essential - tyrosine, arginine, citrulline, ᵧ - amino butyric acid - decreases
Ratio – branched essential amino acids glycine, glutamic acid, serine Incomplete metabolism of histidine, phenylalanine, tryptophan
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KWASHIORKARtransferrin (<150 mg/dl)
Iron binding capacity < 200 mcg/dl
hypoglycemia
lymphopenia growth hormone levels are high insulin secretion and insulin like growth factor levels are
decreased. percentage of body water and extracellular water is increased potassium and magnesium depleted iron deficiency anemia lactase, amylase, lipase - reduced
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MARASMUS Urinary excretion of hydroxyproline diminished, reflecting
impaired growth and wound healing Increased urinary 3-methylhistidine is a reflection of muscle
breakdown Creatinine – height index –low (< 60%)
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PREVENTIVE MEASURES From WHO expert committee on nutrition
Health Promotion
1.Measures directed to pregnant and lactating women
2.Promotion of breast feeding
3.Meal given at frequent intervals
4.Improve family diet
5.Promotion of correct feeding practices
6.Family planning and spacing of births
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Specific Protection
1.Immunization
2.Food fortification
3.Diet must contain protein and energy rich foods – milk, egg, fresh fruit
Early Diagnosis and treatment
1.Early diagnosis of any lag of growth
2. Early diagnosis and treatment of infections and diarrhea
3.Rehydration
4.deworming
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treatment
PHASE STABILISATION REHABILITATION
Day 1-2 Day 2-7+ Week 2-6
1. Hypoglycaemia2. Hypothermia3. Dehydration4. Electrolytes5. Infection6. Micronutrients7. Cautious feeding8. Rebuild tissues9. Sensory stimulation10. Prepare for follow-up
no iron with iron
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Bibliography
Harrisons internal Medicine 17th edition Nelsons Pediatrics IAP pediatrics Parks Preventive Social and Medicine Talwar
THANK YOU