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

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

Start life with poor stores

Infectious

disease

Diarrhea, Aids, TB, measles

Environmental

Unsanitary living, poor quality water

Agricultural/cultural patterns
Droughts, floods, wars, forced migrations

Age of child
Infants

and young children

High nutritional needs

Early weaning or late weaning
Poor hygiene

Marasmus

< 1 year
Kwashiorkor >18 months with starchy
weaning foods

Pathophysiology
Develops

Marasmus
Less fragile metabolic equilibrium

Less

slowly, adapts to decreased intake

effective adaption or acute problem

Kwashiorkor, mixed

Energy

Decreased intake yields decreased activity

Mobilization of body fat, weight loss,

Subcutaneous fat
Muscle wasting

Maintains visceral protein in marasmus

Decreased play and physical activity

Nl albumin

Larger protein deficit leads to faster visceral protein

falls and edema.

Biologic differences

Marasmus

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

Output, heart rate and blood pressure decrease

Postural hypotension
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

GI

total body potassium

Not electrolytes, but problem in rehabilitation

function
Poor absorption of lipids, and sugars
Decreased enzyme and bile production
Increase incidence of diarrhea, and bacterial
overgrowth

Pathophysiology
CNS

Decreased brain growth and myelnation

Electrical changes similar to dylexia

Parental adaptation

Increased breastfeeding
Altered expectations

Diagnosis
Anthropometry

Acute: Wasting: low weight for height

Chronic: Stunted: low height for age

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 <15 ages 11-13, <16.5 ages 14-17

Severe <13 ages 11-13, <14.5 ages 14-17

Diagnosis
Mild

to moderate

Weight loss if acute, decreased growth velocity of

chronic
Decreased activity

Marasmus

Skin and bones, thin hair, monkey face

Hypoglycemia, hypothermia

Diagnosis
Kwashiorkor

Soft pitting edema, starting in feet and legs

Skin lesions
Skin dry, with hyperkeratosis and
hyperpigmentation
Preserved fat layer, small weight deficit, ht may
be normal
Dry brittle hair
Anorexia, with vomiting and diarrhea

Diagnosis
Mixed

Edema, with or without skin lesions

Muscle wasting and loss of subcutaneous fat

Treatment

Acute/ life threatening

Fluid and electrolyte

K and Mg shifts
Oral rehydration, slowly 70-100 ml/kg

Infections: main cause of death

Aggressive treatment, but disease alters metabolism of drugs

Other deficiencies
Anemia and heart failure, care with transfusions and no
diurretics
Vitamin A: immediate treatment

Treatment
Slow

re-feeding

Small frequent feeding around the clock

Patient encouragement of food

Nutritional

rehabilitation

Play and teaching

controlinfections

Recovery?

At home
Reach weight for height and replete muscle mass

Normal is 25-75% weight for height and continue for one

months after

Treat other deficiencies

Family problems
Who does this include here?

Tube feeding.
Disabilities
FTT

What does it mean?

Poverty

Correlation of income, wt, ht and hgb in US

What is wealth?
Importance of food choice

Brain

development

Iron deficiency: neuro transmitters

Brain waves:

What does it mean?

Learning:

Difference in treatment by parents

Duration

of breastfeeding
Expectations

Long term effects

INCAP

two villages, one protein and one calorie

At 18 protein supplemented group had higher
performance scores irrespective of educational
exposure. They had taught themselves.

What does it mean?

Learning:

Difference in treatment by parents

Duration

of breastfeeding
Expectations

Slums of Kingston, Jamaica

Educational

intervention, early rise plateau

Nutritional intervention, late rise
Additive effect
Education lasts, not nutrition, but high IQ moms and
nutrition group did as well as education.

Implications
Children

learn by interacting with the

environment

Poverty: limited environment

Malnutrition: limited interaction
Additive effect!

Loss

to society of human potential

Lead graph