SEVERE ACUTE MALNUTRITION by Dr Deepankar shriwas .pptx

discussion of pathophysiology of severe acute malnutrition

1. SEVERE ACUTE MALNUTRITION PRESENTED BY – Dr . DEEPANKAR SHRIWAS Department of pathology IPGMER AND SSKM HOSPITAL , KOLKATA MODERATOR – Dr . URVEE SARKAR Assistant professor, Department of pathology IPGMER AND SSKM HOSPITAL, KOLKATA

2. A healthy diet provides :- (1) Sufficient energy, in the form of carbohydrates, fats, and proteins, for the body’s daily metabolic needs. (2) Essential as well as nonessential amino acids and fatty acids, used as building blocks for synthesis of structural and functional proteins and lipids’ (3) Vitamins and minerals, which function as coenzymes or hormones in vital metabolic pathways or as in the case of calcium and phosphate, as important structural components.

3. What is malnutrition ? As per WHO - Malnutrition refers to deficiencies, excesses or imbalances in a person’s intake of energy and/or nutrients. The term malnutrition covers 2 broad groups of conditions. One is ‘undernutrition’—which includes stunting (low height for age), wasting (low weight for height), underweight (low weight for age) and micronutrient deficiencies or insufficiencies (a lack of important vitamins and minerals). The other is overweight, obesity and diet-related noncommunicable diseases (such as heart disease, stroke, diabetes, and cancer).

4. Malnutrition Primary malnutrition:- O ne or all of healthy diet components are missing from the diet. Secondary or conditional malnutrition:- The dietary intake of nutrients is adequate but malnutrition results from nutrient malabsorption, impaired use or storage, excess losses, or increased requirements.

5. Severe acute malnutrition :- The WHO defines severe acute malnutrition (SAM) as a state characterized by a greatly reduced weight for height ratio that is below 3 standard deviation of WHO standards. Epidemiology:- Worldwide about 16 million children under the age of 5 years are affected by it. It is more common in poor countries.

6. SAM previously called protein energy malnutrition (PEM) manifests as a range of clinical syndromes, all resulting from a dietary intake of protein and calories that is inadequate to meet the body’s needs. The two ends of the spectrum of SAM are known as marasmus and kwashiorkor. There are two protein compartments in the body:-

7. MARASMUS :- Marasmus develops when the diet is severely lacking in calories . Growth retardation and loss of muscle mass as a result of catabolism and depletion of the somatic protein compartment . The visceral protein compartment is depleted only marginally so serum albumin levels are either normal or only slightly reduced . Leptin production is low, which may stimulate the hypothalamic-pituitary-adrenal axis to produce the high levels of cortisol that contribute to lipolysis.

8. With such losses of muscle and subcutaneous fat, the extremities are emaciated, by comparison, the head appears too large for the body. Anemia and manifestations of multivitamin deficiencies are present, and there is evidence of immune deficiency, particularly of T-cell–mediated immunity.

9. Kwashiorkor:- Kwashiorkor occurs when protein deprivation is relatively greater than the reduction in total calories. This is the most common form of SAM seen in African children and also high in poor countries of Southeast Asia who have been weaned too early and subsequently fed, almost a carbohydrate diet. Less severe forms may occur worldwide in persons with chronic diarrheal states, in which protein is not absorbed or in those with chronic protein loss (e.g., protein-losing enteropathies, the nephrotic syndrome, or in extensive burns)

10. Marked protein deprivation is associated with severe loss of the visceral protein compartment and the resultant hypoalbuminemia gives rise to generalized or dependent edema. The weight of children with severe kwashiorkor typically is 60% to 80% of normal. The true loss of weight is masked by the increased fluid retention (edema).

11. Characteristics of kwashiorkor

12. Changes in different organs Organs Kwashiorkor Marasmus Liver Enlarged and fatty and superimposed cirrhosis is rare Normal Small bowel mitotic index in the crypts of the glands, mucosal atrophy and loss of villi and microvilli and concurrent loss of small intestinal enzymes occurs, most often manifested as disaccharidase deficiency that causes lactate intolerant initially and may not respond well to full-strength, milk-based diets. Rare Bone marrow Hypoplastic marrow , dyserythropoiesis mostly due to iron deficiency and concurrent deficiency of folate may lead to a mixed microcytic-macrocytic anemia. Same Thymic and lymphoid atrophy Markedly present Present Deficiencies of other required nutrients such as iodin and vitamins Present Present

13. Brain :- Infants who are born to malnourished mothers and who suffer from SAM during the first 1 or 2 years of life has been reported by some investigators to show cerebral atrophy, a reduced number of neurons, and impaired myelination of white matter.

14. Reference :-