Malnutrition & Undernutrition

A powerpoint presentation on the clinical presentation and management of childhood malnutrition

1. MALNUTRITION AND UNDERNUTRION Presented by Paul N. TOLEFAC, MD Intern, FMBS/UY1 Supervised by Innocent Takougang , MD Associate Professor, FMBS Tolefac@2105 1

2. Objectives At the end of the presentation we should understand: Understand the difference between malnutrition and undernutrition Classification of malnutrition The 3 phase approach in the management of severe acute malnutrition Tolefac@2105 2

3. Outline Definitions epidemiology Pathophysiology Clinical features management Tolefac@2105 3

4. Definitions Malnutrition : An abnormal physiological condition caused by inadequate, unbalanced or excessive consumption of macronutrients and/or micronutrients. It includes undernutrition and over-nutrition and obesity. Undernutrition : it is a subset of malnutrition that results from undernourishment, and/or poor absorption. It includes: Underweight: a child has low weight for age. Composite measure includes chronic and acute malnutrition. Stunting : child short for their age as a result of chronic under nutrition during the most critical periods of growth and development in early life (< -2 SD HFA). Wasting : child ’ s weight is too low for their height as a result of acute under nutrition (< -2SD WFH). Tolefac@2105 4

5. Definitions H unger : A state, lasting for at least one year, of inability to acquire enough food, defined as a level of food intake insuffiecient to meet dietary energy requirements. Famine is the state in which significant proportion (at least 20%) of a defined population lacks access to food in sufficient quantity and quality, such that epidemics of infectious disease become more frequent, acute malnutrition rates in children under 5 are above 30% and death rates rise. Starvation occurs when the individual’ nutrient intake drops below the minimum needed to maintain body mass leading to consumption of muscles and lean body tissue for energy production. Tolefac@2105 5

6. Definitions Protein – Energy Malnutrition (PEM): This is the manifestation of inadequate dietary intakes of protein and or energy. Most common forms are marasmus and kwashiorkor. Primary malnutrition: Malnutrition resulting from an inadequate food intake such as in starvation and famine. Secondary malnutrition: Malnutrition resulting from increased nutrient needs, decreased nutrient absorption, and/or increased nutrient losses Tolefac@2105 6

7. Epidemiology In 2000, 26.7% of preschoolers in the developing world were estimated to be underweight, as reflected by a low weight for age, and 32.5% were estimated to be stunted based on a low height for age. Tolefac@2105 7

8. Epidemiology: World & Africa Tolefac@2105 8

9. Epidemiology: world Tolefac@2105 9

10. Epidemiology: Stunting worldwide Globally, about 1 in 5 (26% in 2011) children are stunted of whom 80% live in 40 countries . Tolefac@2105 10

11. Epidemiology: World and Africa Tolefac@2105 11

12. Epidemiology: Cameroon Author , Year Journal Objective Results Jesson J et al, 2015 BMC infectious diseases Prevalence of malnutrition amongst HIV infected children in central & west Africa Prevalence was 42% (n = 1350) with acute chronic and mixed malnutrition 9%, 7% and 26%. Georges Nguefack-Tsague et al , 2014 Pan African Medical journal Using underweight to predict wasting Wasting in 5.5% and underweight in 12,9% Sobze SM et al, 2014 Pan African Medical journal assess the nutritional status of infants from mothers tested positive to HIV in the Dschang HD SD was noticed in height-for-age z-score of girls between 1 to 2 years compared to 1-year old girls as well as to boys of all ages, defining them as stunted. Sumbele IU et al, 2015 BMC public health examines the prevalence, severity and predictors of malnutrition on malaria parasitaemia . The overall prevalence of malnutrition was 22.8 %, with stunting being the most common form (17.1 %), followed by underweight (8.2 %) and wasting (5.5 % Mbuh JV et al, 2013 Journal of helminthology The prevalence of intestinal helminth infection was 47.2% (n = 265) The prevalence of malnutrition was 30.2% Tolefac@2105 12

13. Causes of malnutrition Primary: Starvation, famine aand hunger resulting from food scarcity, poverty and unemployment and natural disasters Secondary: GI disorders Malabsorption syndromes Hyper-catabolic state such as hyperthyroidism Tolefac@2105 13

14. Pathophysiology Tolefac@2105 14

15. Clinical Features Oedema Loss of muscle & fat often masked by the oedema Anorexia Abdominal distention Hair losing color Apatic /irritable, miserable Skin cracks/fragile, prone to infections Acutely sick Tolefac@2105 15

16. Clinical features Severe Wasting, very thin Loss of Muscle Bulk, No subcutaneous Fat Loose skin folds, floppy buttocks Often reasonable appetite when no med complication Miserable, restless Apathy Tolefac@2105 16

17. Classification of Malnutrition Classification Definition classes Class definition Gomez Weight below % median WFA Mild 75%-90% WFA Moderate 60%–74% WFA Severe <60% WFA waterlow z score below median WFH Mild 80%–90% WFH Moderate 70%-80% WFH Severe <70% WFH WHO (wasting) z score below median WFH Moderate -3%</= z-score < -2 Severe z-score < -3 WHO (wasting) z score below median HFA   -3%</= z-score < -2   z-score < -3 Kanawati MUAC/OFC Mild <0.31 Moderate <0.28 Severe <0.25 cole z score of BMI for age Grade 1 BMI for age z-score < -1 Grade 2 BMI for age z-score < -2 Grade 3 BMI for age z-score < -3 Tolefac@2105 17

18. Classification of malnutrition Classification Mild Moderate Severe Albumin (g/ dL ) 2.8-3.4 2.1-2.7 < 2.1 Transferrin (mg/ dL ) 150 - 200 100 - 149 < 100 Total Lymphocyte Count (per µL) 1200 - 2000 800 - 1199 < 800 Wellcamb Classification Weight for Age (Gomez) With Edema Without Edema 60-80% kwashiorkor undernutrition < 60% marasmic-kwashiorkor marasmus Tolefac@2105 18

19. Management SAM Severe acute malnutrition is defined as the presence of oedema of both feet or severe wasting (WFH <-3SD or MUAC < 11.5 cm). The patient should be evaluated clinically for the presence of other conditions. Criteria for admission in children 6-59 months include: MUAC < 11.5cm Z score < -3SD Presence of oedema Lack of appetite Tolefac@2105 19

20. Management: 3 Phases Tolefac@2105 20

21. management ReSoMal 2 litres water WHO ORS 1 sachet Sugar 50g KCl 40ml Others Vitamin A: Give vitamin A orally on days 1, 2 and 14 (age < 6 months, 50 000 IU; age 6–12 months, 100 000 IU; older children, 200 000 IU ). Severe Anaemia : Blood transfusion should be given in the first 24 h only if : Hb is < 4 g/dl or Hb is 4–6 g/dl and the child has respiratory distress. Tolefac@2105 21

22. Management Tolefac@2105 22

23. Conclusion Back to objectives Understand the difference between malnutrition and undernutrition Classification of malnutrition The 3 phase approach in the management of severe acute malnutrion Tolefac@2105 23

24. The hidden truth about success Tolefac@2105 24