Malnutrition Protein / Energy Definitions of Malnutrition
Kwashiorkor: protein deficiency Marasmus: energy deficiency
Marasmic/ Kwashiorkor: combination of chronic energy deficiency and
chronic or acute protein deficiency Failure to thrive:marasmus in
U. S. children under 3. Definitions of Malnutrition
PEM Primary: inadequate food intake Secondary: result of disease
FTT In-organic: inadequate food intake Organic: result of disease
MARASMUS Marasmus is the term used for severe PEM and wasting (low
wt/ht). Many secondary forms of marasmic PEM are associatedw ith
chronic diseases( cysricfibrosis, tuberculosis,cancer, acquired
immunodeficiency virus, celiac disease). The principal clinical
manifestarion in a child wirh severe malnutririon is emaciation
with a body weight less than 50%o f the median (50th percentile)
for age or less than70%o f the ideal weight For height and depleted
body fat stores Loss of muscle mass and subcutaneous fat stores are
confirmed by inspection or palpation and quantified by
anthropometric measurements. the head may appearlarge but generally
is proportional to the body length. Edema usually is absent. The
skin is dry and thin, and the hair may be thin, sparse, and easily
pulled out. Marasmic children may be apathetic and weak Bradycardia
and hypothermia signify severe and lifethreatening
malnutririon.
Atrophy of the filiform papillae of the tongue is common) and
monilial stomatitis is frequent. Inappropriate or inadequate
weaning practices and chronic diarrhea are common findings in
developing countries. Stunting (impaired linear growth (Table 30-1)
results from a combination of malnutrition, especially
micronutrients, and recurrent infections. Stunting is more
prevalent than wasting KOWASHIORKOR Kwashiorkor is hypoalbuminemic,
edematous malnutrition and presents with pitting edema that srarts
in the lower extremities and ascends with increasing severity. It
is classically described as being caused by inadequate protein
intake in the presence of fat to good caloric intake. Other
factors, such as acute infection, toxins, and possibly specific
micronutrient or aminoacid imbalances,are likely to contribute to
the etiology The major clinical manifestation of kwashiorkor is
that the body weight of the child ranges from 60%to 80% of the
expected weight for age weight alone may not accurately reflect the
nutritional status because of edema Physical examination reveals a
relative maintenance of subcutaneous adipose tissue and a marked
atrophy of muscle mass. Edema varies from a minor pitting of the
dorsum of the foot to generalized edema with involvement of the
eyelids andscrotum. The hair is sparse; is easily plucked; and
appears dull brown, red, or yellow-white. Nutritional repletion
restores hair color, leaving a band of hair with altered
pigmentation followed by a band with normal pigmentation(flag sign)
Skin changes are common and range from hyperpigmented
hyperkeratosis to an erythematous macular rash (pellagroid) on the
trunk and extremities. In the most severe form of kwashiorkor, a
superficial desquamation occurs over pressure surfaces ("flaky
paint" rash). Angular cheilosis, atrophy of the filiform papillae
of the tongue, and monilial stomatitis are common. Enlarged parotid
glands and facial edema result in moon apathy and disinterest in
eating are typical of kwashiorkor. Examination of the abdomen may
reveal an enlarged, soft liver with an indefinite edge.
Lymphatic tissue commonly is atrophic. Chest examination may reveal
basilar rales. The abdomen is distended, and bowel sounds tend to
be hypoactive History Marasmus well known for centuries
Kwashiorkor: Cicely Williams
Ga tribe in Ghana the sickness the older child gets when the next
baby is born Starch edema, sugar babies Similar but different
diseases How many? 36% of children in the world are underweight 43%
stunted
9% wasted Better nutrition, but more children in high risk areas,
yields more children affected. Causes Social and Economic Poverty
Ignorance
Inadequate weaning practices Child abuse Cultural and social
practices Vegan Low fat diets Biologic factors Maternal
malnutrition, prematurity Infectious disease
Start life with poor stores Infectious disease Diarrhea, Aids, TB,
measles Environmental Unsanitary living, poor quality water
Agricultural/culturalpatterns Droughts, floods, wars, forced
migrations Age of child Infants and young children Marasmus < 1
year
High nutritional needs Early weaning or late weaning Poor hygiene
Marasmus < 1 year Kwashiorkor >18 months with starchy weaning
foods Pathophysiology Develops slowly, adapts to decreased
intake
Marasmus Less fragile metabolic equilibrium Less effective adaption
or acute problem Kwashiorkor, mixed Energy Decreased intake yields
decreased activity
Decreased play and physical activity Mobilization of body fat,
weight loss, Subcutaneous fat Muscle wasting Maintains visceral
protein in marasmus Nl albumin Larger protein deficit leads to
faster visceral protein falls and edema. Biologic differences
Marasmus Kwashiorkor Weight loss
Nl or low protein Boarderline hgb, hct NL AA profile Nl blood
glucose Nl enzymes Nl transaminase Kwashiorkor NO weight loss High
extracellular water Low hgb, hct Low protein Elevated AA profile
Low enzymes High transaminase Pathophysiology Cardiac Immune system
Cytokines (glycoproteins)
Output, heart rate and blood pressure decrease Postural hypotension
Immune system T lymphocytes and complement decreased Susceptible to
bacterial infection Cytokines (glycoproteins) Poor immune response
TNF inc leading to anorexia, muscle wasting and lipid changes
Pathophysiology Decreased total body potassium GI function
Not electrolytes, but problem in rehabilitation GI function Poor
absorption of lipids, and sugars Decreased enzyme and bile
production Increase incidence of diarrhea, and bacterial overgrowth
Pathophysiology CNS Parental adaptation
Decreased brain growth and myelnation Electrical changes similar to
dylexia Parental adaptation Increased breastfeeding Altered
expectations Diagnosis Anthropometry 4 groups Acute: Wasting: low
weight for height
Chronic: Stunted: low height for age 4 groups Normal Wasted not
stunted: acute PEM Wasted and stunted: acute and chronic PEM
Stunted not wasted: past PEM, nutritional dwarfs Diagnosis Normal:
1 SD Mild: -1.1 to -2 SD Moderate -2.1 to -3 SD
Severe greater than -3 Less than 5th percentile in US BMI in
adolescents Moderate
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