INTRODUCTION

ETIOPATHOPHYSIOLOGY

CLASSIFICATION

INDICATORS

TREATMENT

OVER VIEW

DEFINITION :

A range of pathological conditions arising from coincident lack of protein and calories in varying proportion, occuring most frequently in infants ,young children and usually associated with infections.

Cecilly Williams, a British nurse, introduced the word

Kwashiorkor (1933) - the sickness of weaning

marasmos-wasting.

The term protein energy malnutrition has been adopted by WHO in 1976

Dietic hypothesis

Adaptation hypothesis by Gopalan

VITERIS time scale theory

GOLDEN free radical injury theory

PATHOPHYSIOLOGY

ADAPTATION THEORY

Inadequate energy

HPA axis

Increased cortisol levels

Musle wasting – EAA production

Synthesis of albumin & beta lipoprotein

NO OEDEMA NO FATTY LIVER

catabolism

DSYSADAPTATION THEORY

Protein depletion

Protein intake Cortisol elevationNot sustained

IncreasedGH

DecreasedInsulin&sometomedins

hypoproteinemia

Decreased AA pool

lipolysis

Increased fatty acidflux

Decreased lipogenesisDecreased protein syn.

OEDEMA FATTY LIVER OEDEMA

HORMONES MARASMUS KWASHIORKAR

Growth hormone Very high Low

Cortisol Very high High (not sustained)

Insulin & IGF Normal Low

Glucagon Normal/variable Normal/variable

Thyroxine Normal/variable Normal/variable

Somatomedins Low Very low

ETIOLOGY

Socioeconomic, environmental and cultural factors

Medical factors

Decreased absorption and increased losses

Increased demands

ASSESSMENT OF NUTRITIONAL STATUS

DIRECT METHODS

Clinical signs

Anthropometry

Biochemical tests

Biophysical methods

INDIRECT METHODS

Dietary survey

Health statistics

Ecological factors

Affected by:

degree of deficiency

duration of deficiency

speed of onset

age at onset

Presence of conditioning factors

Genetic factors

CLINICAL PRESENTATION

KWASHIORKAR

Essential features :Growth failureOedemaMuscle wastingPsychomotor changes

Non essential features :Skin & hair changesAnemiaGIT changesVitamin deficienciestremors

MARASMUS

Growth retardation

Irritable

Muscle wasting

Other changes

ANTHROPOMETRIC MEASUREMENTS

Weight

Height

Mid arm circumference

Head circumference

Chest circumference

Head and chest growth ratios

Upper segment/lower segment ratio

Arm span

Mid arm circumference

Kanawati index

MAC to height ratio

Rao & singh’s (quetlet index)

Dugdale’s index

HC / CC

MAMC

BMI

AGE DEPENDENT AGE INDEPENDENT

BIOPHYSICAL INDICATORS

NORMAL MODERATE PEM

SEVERE

PEM

Mean bulb diameter

>0.11mm 0.06-0.11mm <0.06mm

Hair bulb atrophy

0-25% 26-50% >50%

No. of anagens >50% 30-50% <30%

No. of telogens <20% 20-45% >45%

Buccal mucosa changes :Normal – 5-10% mutilatedSevere - 70% mutilated

RADIOLOGICAL INDICATORS

BIOCHEMICAL INDICATORS :

Plasma albumin concentration

Serum amino acid pattern

Other serum proteins

Urinary urea/urinary creatinine

Urinary hydroxyproline/creatinine

3 methyl histidine excretion

GOMEZ’S CLASSIFICATION

NUTRITIONAL STATUS

WEIGHT FOR AGE

( % OF EXPECTED)

Normal > 90%

First degree PEM 75-90%

Second degree PEM 60-75%

Third degree PEM <60%

JELLIFFE’ CLASSIFICATION

NUTRITIONAL STATUS

WEIGHT FOR AGE

Normal >90 %

First degree PEM 80-90%

Second degree PEM 70-80%

Third degree PEM 60-70%

Fourth degree PEM <60%

WEIGHT FOR AGE

OEDEMA CLINICAL TYPE OF PEM

60-80% + KWASHIORKAR

60-80% - UNDERWEIGHT

<60% - MARASMUS

< + MARASMIC KWASHIORKAR

WELLCOME TRUST CLASSIFICATION

NUTRITIONAL STATUS

WEIGHT FOR AGE

Normal >80%

Grade 1 PEM 71-80%

Grade 2 PEM 61-70%

Grade 3 PEM 51-60%

Grade 4 PEM <50%

IAP CLASSIFICATION

Height for age

Waterlow’s mcLaren’s Visweshwara

Normal >95% >93% >90%

First degree stunting

90-95% 80-93% 80-90%

Second degree stunting

85-90% - -

Third degree stunting

<85% <80% <80%

WEIGHT FOR HEIGHT

Waterlow’s McLaren’s

Normal >90% >90%

First degree wasting

80-90% 85-90%

Second degree wasting

70-80% 75-85%

Third degree wasting

<70% <75%

Z score SD/Z Score = measured individual value – reference median /SD of the reference mean

Percentage of median =Measured individual value × 100 / reference median

Moderate malnutrition

Severe malnutrition

Symmetrical oedema No Yes

Weight for height -3SD<SD score<-2SD (70-79%)

SD score<-3SD (<70%)

Height for age -3SD<SD score<-2SD(85-89%)

SD score<3 SD (<85%)

MARASMUS KWASHIORKAR

APPEARANCE Old man app.,generalized wasting

Moon face, dependent oedema ,upper limb wasted

AGE GROUP Infants 1-5 yrs

PREVALENCE Common Rare

WEIGHT < 60% >60%

GROWTH RETARDATION

++ +

OEDEMA Nil ++

APATHY Mild ++

MOOD Usually alert irritable

Cont……

MARASMUS KWASHIORKOR

APPETITE Good Very poor

HAIR CHANGES Nil /mild +

SKIN CHANGES Nil/mild +

FATTY LIVER Absent/ mild ++

INFECTIONS + ++

LIFE THREATENING MEDICAL EMERGENCIES

+ ++

S.PROTEIN &ALBUMIN

low normal very low

CARRIER PROTEINS low normal Very low

ANABOLISM + very low

CATABOLISM ++ +

RESPONSE TO TREATMENT

Good poor

TREATMENT

Criteria for admission :

Weight for age <60% of expected with any of the following

age less than 1 year oedema severe dehydration shock hypothermia severe diarrhea systemic infection Bleeding from any site persistent loss of appetite jaundice

The guidelines are divided in five sections:

A. General principles for routine care (the’10 steps’)

B. Emergency treatment of shock and severe anaemia

C. Treatment of associated conditions

D. Failure to respond to treatment

E. Discharge before recovery is complete

1.Treat/prevent hypoglycaemia

2.Treat/prevent hypothermia

3.Treat/prevent dehydration

4.Correct electrolyte imbalance

5.Treat/prevent infection

6.Correct micronutrient deficiencies

7.Start cautious feeding

8.Achieve catch-up growth

9.Provide sensory stimulation and emotional support

10. Prepare for follow-up after recovery

GENERAL PRINCIPLES FOR ROUTINE CARE (the ‘10 Steps’)

Step 1. Treat/prevent hypoglycaemia

Hypoglycaemia and hypothermia together

signs of infection.

Hypothermia (axillary<35.0oC; rectal<35.5oC)

Treatment

CHILD CONSCIOUS and BSL<3mmol/l or 54mg/dl give:

50 ml bolus of 10% glucose or 10% sucrose solution (1 roundedteaspoon of sugar in 3.5 tablespoons water), orally or (NG) tube. starter F-75 every 30 min. for two hours

antibiotics

two-hourly feeds, day and night

Monitor:blood glucose

rectal temperature: if this falls to <35.5oC

level of consciousness: deteriorates

Prevention:feed two-hourly, start straightaway or if necessary

rehydrate first

feeds throughout the night

CHILD UNCONSCIOUS, lethargic or convulsing give:

IV sterile 10% glucose (5ml/kg), followed by 50ml of 10% glucose or sucrose by Ng tube. starter F-75, antibiotics & feed

Step 2. Treat/prevent hypothermia

axillary temperature <35.0oC rectal temperature <35.5oC

Treatment:

feed straightaway (or start rehydration if needed)

rewarm the child

antibiotics

Monitor:• body temperature

• blood glucose level

Prevention

Step 3. Treat/prevent dehydration

special Rehydration Solution for Malnutrition (ReSoMal)

assume all children with watery diarrhoea may have dehydration :ReSoMal 5 ml/kg every 30 min. for two hours, orally or by nasogastrictube, then5-10 ml/kg/h for next 4-10 hours

Observe half-hourly for two hours, then hourly for the next 6-12 hours

Continuing rapid breathing and pulse during rehydration suggest coexisting infection or overhydration

Prevention :

component ReSoMal(mMol/L)

Standard ORS

Glucose 125 111

Sodium 45 90

Potassium 40 20

Chloride 70 80

Citrate 7 10

Magnesium 3 -

Zinc 0.3 -

Copper 0.045 -

Osmolarity 300 311

Composition of ReSoMal

Step 4. Correct electrolyte imbalance

Hypernatremia

Hypokalemia

Hypomagnesemia

extra potassium 3-4 mmol/kg/d

extra magnesium 0.4-0.6 mmol/kg/d

when rehydrating, low sodium rehydration fluid (e.g. ReSoMal)

prepare food without salt

No diuretics for oedema

Step 5. Treat/prevent infection

usual signs of infection absent

broad-spectrum antibiotic(s)

measles vaccine if child is > 6m and not immunised

specific infections are identified to be identified

No complications Cotrimoxazole (25mg SMZ +5TMP/kg) BD X 5 days

Complications

+ gentamycin IV/IM(7.5 mg/kg) OD

X 7 days

+ ampicillin IV/IM(50mg/kg) QID

X 2 days

Amoxicillin oral (15mg/kg) TDS

X 5 days

Fails to improve in 48 hrs +

Chloramphenicol IV/IM (25mg/kg)TDS X 5 days

Step 6. Correct micronutrient deficiencies

Vitamin A orally on day 1

daily for at least 2 weeks:

Multivitamin supplement

Folic acid 1 mg/d (give 5 mg on Day 1)

Zinc 2 mg/kg/d

Copper 0.3 mg/kg/d

Iron

Step 7. Start cautious feeding

feeding in the stabilisation phase are: small, frequent feeds of low osmolarity and low lactose oral or nasogastric (NG) feeds

100 kcal/kg/d 1-1.5 g protein/kg/d130 ml/kg/d of fluid (100 ml/kg/d if severe oedema) encourage breastfeeding

Days Frequency Vol/kg/feed Vol/kg/d1-2 2-hourly 11 ml 130ml

3-5 3-hourly 16 ml 130ml

6-7+ 4-hourly 22 ml 130ml

Step 8. Achieve catch-up growth

high intakes and rapid weight gain of >10 g gain/kg/d

To change from starter to catch-up formula: replace starter F-75 with the same amount of catch-up formula F-100 for 48 hours then, increase each successive feed by 10 ml…..200ml/kg/dayMonitor during the transition for signs of heart failure

Monitor progress after the transition by assessing the rate of weight gain:• weigh each morning • each weekIf weight gain is:• poor (<5 g/kg/d) • moderate (5-10 g/kg/d)• good (>10 g/kg/d)

Step 9. Provide sensory stimulation and emotional support

Step 10. Prepare for follow-up after recovery

90% weight-for-length

bring child back for regular follow-up checks

ensure booster immunizations are given

ensure vitamin A is given every six months

B. EMERGENCY TREATMENT OF SHOCK & SEVERE ANAEMIA

oxygensterile 10% glucose (5 ml/kg) by IVIV fluid at 15 ml/kg over 1 hourmeasure and record pulse and respiration rates every 10 minutesAntibiotics

If signs of improvement :repeat IV 15 ml/kg over 1 hour; thenswitch to oral or nasogastric rehydration with ReSoMal, 10 ml/kg/hfor up to 10 hoursReSoMal in alternate hours continue feeding

If fails to improve after the first hour of treatment -septic shock:maintenance IV fluids (4 ml/kg/h)fresh whole blood at 10 ml/kg slowly over 3 hoursbegin feeding

A blood transfusion required :• Hb is less than 4 g/dl• or if there is respiratory distress and Hb is between 4 and 6 g/dl

whole blood 10 ml/kg body weight slowly over 3 hoursfurosemide 1 mg/kg IV

If severely anaemic & signs of cardiac failure, transfuse packed cells (5-7 ml/kg)

2) Severe anemia

C. TREATMENT OF ASSOCIATED CONDITIONS

1. Vitamin A deficiencyany eye signs of deficiency vitamin A on days 1, 2 and 14corneal clouding or ulceration, • chloramphenicol or tetracycline eye drops • atropine eye drops (1%)• eye pads

2. Dermatosis

3. Parasitic worms

4. Continuing diarrhoea :Mucosal damage and giardiasisLactose intoleranceOsmotic diarrhoea5. Tuberculosis

D. FAILURE TO RESPOND TO TREATMENT

Failure to regain appetite Day 4Failure to start to lose oedema Day 4Oedema still present Day 10Failure to gain at least 5 g/kg of body weight per day Day 10

Secondary failure to respond:Failure to gain at least 5 g/kg of body weight per day During rehabilitationfor 3 successive days

1)Inadequate feeding2)Inadequate treatment of nutrient deficiencies3)Untreated infection4)HIV/AIDS5)Psychosocial problems

E. DISCHARGE BEFORE RECOVERY IS COMPLETE

aged >12 months

completed antibiotic treatment

good appetite and good weight gain

taken potassium/magnesium/mineral/vitamin supplement for 2 weeks (or possible at home)

COMPLICATIONS ARISING DURING TREATMENT

Pseudotumor cerebri

Gomez syndrome

Kahn’s protein encephalopathy

Congestive heart failure

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