Protein energy malnutrition

Protein energy malnutrition

1. Spurthi B.S Pharm D Mallige college of pharmacy

2.  MALNUTRITION 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.“ Malnutrition is the condition that develops when the body does not get the right amount of the vitamins, minerals, and other nutrients it needs to maintain healthy tissues and organ function. Definitions 

3.  PROTEIN ENERGY MALNUTRITION It is a group of body depletion disorders which include kwashiorkor, marasmus and the intermediate stages  MARASMUS Represents simple starvation . The body adapts to a chronic state of insufficient caloric intake  KWASHIORKOR It is the body’s response to insufficient protein intake but usually sufficient calories for energy

4.  Protein-Energy Malnutrition  PEM is also referred to as protein-calorie malnutrition .  It is considered as the primary nutritional problem in India. Also called the 1 st National Nutritional Disorder.  The term protein-energy malnutrition (PEM) applies to a group of related disorders that include marasmus, kwashiork or, and intermediate states of marasmus-kwashiorkor .  PEM is due to “food gap” between the intake and requirement.

5. AETIOLOGY: Different combinations of many aetiological factors can lead to PEM in children. They are:  Social and Economic Factors  Biological factors  Environmental factors  Role of Free Radicals & Aflatoxin  Age of the Host

6.  Amongst the Social, Economic, Biological and Environmental Factors the common causes are: Lack of breast feeding and giving diluted formula Improper complementary feeding Over crowding in family Ignorance Illiteracy Lack of health education Poverty Infection Familial disharmony

7.  Role of Free Radicals & Aflatoxin : Two new theories have been postulated recently to explain the pathogenesis of kwashiorkor. These include Free Radical Damage & Aflatoxin Poisoning . These may damage liver cells giving rise to kwashiorkor.  Age Of Host : Frequent in Infants & young children whose rapid growth increases nutritional requirement. PEM in pregnant and lactating women can affect the growth, nutritional status & survival rates of their fetuses, new born and infants. Elderly can also suffer from PEM due to alteration of GI System

8. Leading cause of death (less than 5 years of age) Primary PEM : Protein + energy intakes below requirement for normal growth . Secondary PEM: 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 Etiopathogenesis of PEM:

9. The clinical presentation depends upon the type , severity and duration of the dietary deficiencies. The five forms of PEM are :

10. KWASHIORKOR   The term kwashiorkor is taken from the Ga language of Ghana and means " the sickness of the weaning ”.  Williams first used the term in 1933, and it refers to an inadequate protein intake with reasonable caloric (energy) intake.  Kwashiorkor, also called wet protein-energy malnutrition, is a form of PEM characterized primarily by protein deficiency .  This condition usually appears at the age of about 12 months when breastfeeding is discontinued, but it can develop at any time during a child's formative years.  It causes fluid retention (edema); dry, peeling skin; and hair discoloration.

11.  Kwashiorkor was thought to be caused by insufficient protein consumption but with sufficient calorie intake, distinguishing it from marasmus.  More recently, micronutrient and antioxidant deficiencies have come to be recognized as contributory.  Victims of kwashiorkor fail to produce antibodies following vaccination against diseases, including diphtheria and typhoid.  Generally, the disease can be treated by adding food energy and protein to the diet; however, it can have a long-term impact on a child's physical and mental development , and in severe cases may lead to death.

12.  SYMPTOMS  Changes in skin pigment.  Decreased muscle mass  Diarr hea  Failure to gain weight and grow  Fatigue  Hair changes (change in color or texture)  Increased and more severe infections due to damaged immune system  Irritability  Large belly that sticks out (protrudes)  Lethargy or apathy  Loss of muscle mass  Rash (dermatitis)  Shock (late stage)  Swelling (edema)

13. MARASMUS   The term marasmus is derived from the Greek word marasmos, which means withering or wasting.  Marasmus is a form of severe protein-energy malnutrition characterized by energy deficiency and emaciation.  Primarily caused by energy deficiency, marasmus is characterized by stunted growth and wasting of muscle and tissue.  Marasmus usually develops between the ages of six months and one year in children who have been weaned from breast milk or who suffer from weakening conditions like chronic diarrhea.

14.  SYMPTOMS  Severe growth retardation  Loss of subcutaneous fat  Severe muscle wasting  The child looks appallingly thin and lim bs appear as skin and bone  Shriveled body  Wrinkled skin  Bony prominence  Associated vitamin deficiencies  Failure to thrive  Irritability, fretfulness and apathy  Frequent watery diarrhoea and acid stools  Mostly hungry but some are anoretic  Dehydration  Temperature is subnormal  Muscles are weak  Oedema and fatty infiltration are absent

15. DIFFERENCE IN CLINICAL FEATURES BETWEEN MARASMUS AND KWASHIORKOR

16. St.Ann's Degree College for Women

17. CLINICAL MARASMUS KWASHIORKOR FEATURES - MUSCLE WASTING Obvious Sometimes hidden by edema and fat - FAT WASTING Severe loss of Fat often retained but subcutaneous fat not firm - EDEMA None Present in lower legs, and usually in face and lower arms May be masked by - WEIGHT FOR Very low edema HEIGHT Irritable, moaning, - MENTAL Sometimes quite and apathetic CHANGES apathetic DIFFERENCE IN CLINICAL FEATURES BETWEEN MARASMUS AND KWASHIORKOR

18. CLINICAL FEAT U RES MARASMUS KWASHIORKOR -APPETITE Usually good Poor -DIARRHOEA Often Often -SKIN CHANGES Usually none Diffuse pigmentation, sometimes „flaky paint dermatitis‟ -HAIR CHANGES Seldom Sparse, silky, easily pulled out -HEPATIC ENLARGEMENT None Sometimes due to accumulation of fat DIFFERENCE IN CLINICAL FEATURES BETWEEN MARASMUS AND KWASHIORKOR

19. BIOCHEMICAL & METABOLIC CHANGES

20.  Significant findings in kwashiorkor include hypoalbuminemia (10-25 g/L), hypoproteinemia (transferrin, essential amino acids, lipoprotein), and hypoglycemia.  Plasma cortisol and growth hormone levels are high, but insulin secretion and insulinlike growth factor levels are decreased.  The percentage of body water and extracellular water is increased.  Electrolytes, especially potassium and magnesium, are depleted.  Levels of some enzymes (including lactase) are decreased, and circulating lipid levels (especially cholesterol) are low.  Ketonuria occurs, and protein-energy malnutrition may cause a decrease in the urinary excretion of urea because of decreased protein intake.  In both kwashiorkor and marasmus, iron deficiency anemia and metabolic acidosis are present.  Urinary excretion of hydroxyproline is diminished, reflecting impaired growth and wound healing. BIOCHEMICAL & METABOLIC CHANGES

21.  Promotion of breast feeding  Development of low cost weaning  Nutrition education and promotion of correct feeding practices  Family planning and spacing of births  Immunization  Food fortification  Early diagnosis and treatment PREVENTION