Soad Jaber 2008Soad Jaber 2008
PROTEIN ENERGYPROTEIN ENERGY
Severe childhood undernutrition
• Use the medical history and physical examination to
evaluate nutritional status.
• Present an approach to recognizing and treating some
common nutritional problem of childhood.
• Identify etiologic categories of malnutrition,1ry,2ry,
• marasmus and kwashiorkor.
• Display an understanding of the principles for managing
severe childhood under nutritionز
Why more common in children?
• High nutrient requirement/unit weight.
• Dependence on adults for food
Water - Higher body water> older children
Fat - Rapid increase in the 1st
Growth - Rapid from birth till six months
Growth rate increase at puberty.
More for boys than girls.
Neonates Good swallowing + sucking.
12 weeks Can-swallows food placed on anterior
20 weeks Can drink from held cup with biting
28 weeks Teeth begin to erupt.
Feeds self biscuits., chewing movements.
7 months Shuts mouth. Shakes head to refuse foods.
9 months Fingers feeding
10 months Drinks from cup.
12 months Holds spoon unable to get food to mouth.
15 months Control spoon + cups.
18 months Plays with food.
• The trend overtime… serial reading, NOT single…
• Weight for age reflect the combined effect of both recent
and longer term level of nutrition.
• Height for age long term problem,comulative effect of
undernutrition during the life of the child.
• Weight for height and age ,recent nutritional experiences.
Less<80-90% abnormally low
• Skull circumference: Rapid growth in early infancy…
• Mid-upper arm circumference
• Skin folds thickness:. Triceps sub-scapular –% of body fat ..
• They reflect severity and extent of the problem but not
specific for any particular disease
Weight < 90%
Height > 90% Normal Wasted
Height < 90% Short Stunted
INTERPRETATION OFINTERPRETATION OF
WEIGHT AND HEIGHT FOR AGEWEIGHT AND HEIGHT FOR AGE
• Definition : ( WHO)
• * Marasmus Weight less than 60% of expected weight - no
• Kwashiorkor Weight between 60-80% of expected weight +
No oedema Oedema
80% Under weight for age Kwashiorkor 80%
Marasmus 60% 60%Marasmic-
Gomez Classification for
1ry PEM is a spectrum ranging from:
* mild form
Decrease weight for length.
Decrease length and weight for age.
Aetiology of (PEM)
• Leading cause of death (less than 5 years of age)
• 1ry:. Protein + energy intakes below requirement for normal
• 2ry:the need for growth is greater than can be supplied.
• : decreased nutrient absorption
• : increase nutrient losses
Linear growth ceases
Malnutrition and its signs
• Ga language of West Africa = Supplanted one - Child
who recently have been weaned
• (Pregnant mother) and emotional deprivation
1933 Cecily * Ghanaian children
* Weaned recently
* Oedema and hair changes
* Fatty liver
1967 Mc-Cane * Anaemia
* Skin changes
1971 Frood-Paskitt * Biochemical
• Normal energy intake, Lack of protein
• Edema:1970.decrease oncotic pressure,
– Recent> Increase Renin activity,N a and fluid
• Amino aciduria due to proximal tubular
• Failure of adaptation
• .Hepatomegaly due to fatty infiltration from
lipogenesis of excess CHO
• - Biochemical and haematological changes
• - Lack of all nutrients stimulate cortisone
secretion which result in muscle wasting, the
released a. a will synthesize albumin to prevent
• - Growth and energy expenditure limited, in
response to dietary stress
• - Adaptation to reduce protein + energy
• - Biochemical and haematological tests within
• -Abdomin,flat due to ms wasting, OR distended
due to 2ry lactose intolerance.
• Insufficient intake of protein of good biological value.
• Impaired absorption of protein e.g. chronic diarrhoea.
• Abnormal losses of protein e.g.
severe nephrosis . Severe or prolonged infection
• Failure of protein synthesis e.g.
chronic liver diseases.
Inadequate caloric intake due to insufficient diet .
• Improper feeding habits .
• Emotional deprivation.
• Metabolic abnormalities
• Congenital malformation
• Severe impairment of any body system
- Accurate history of social and economic factors.
poverety,ignorance. environmental factors .
diet history: maternal malnutrition, breast milk and other feeding
habits .food allergies ,food taboos.
chronic illness ,burns .HIV. cystic fibrosis .malignancies .inborn
error of metabolism ,
- Evaluation of growth parameters: weight, height, head
- Evaluation of the degree of illness and dehydration:
skin fold thickness - Biochemical evaluation
* mild * moderate * severe
1) Mild - moderate with no complication
• - Home management
• food increase calories + energy
• Multivitamin 1st
• Iron replacement 2nd
• ± antibiotics for infection
2) Severe marasmic or severe kwashiorkor
Complicated cases or marasmic kwashiorkor
day: History --- clinical exam -- rehydration
Prevent heat loss
NGT feeding ORS, IVF (glucose and electrolytes)
Treatment of infection,bacterial and parasitic.
a) Continue rehydration by NGT,
b) start diet by NGT .calories 80-100/kg/day ,Protein 3-4 g/kg/d. small volumes
2hourly then 4hourly to6 hourly. and increase calories gradually
, c) multivitamin. Vit A, folic acid. Without IRON for the 1st
d) Correct anaemia ( packed RBC carefully)
If diarrhea starts or fails to resolve may be lactose intolerance lactose free milk or cow milk
protein intolerance start soy protein hydrolysate formula.
Rehabilitation phase week2-6
a) Start oral feeding
b) Continue antibiotics
c) Start iron
Oedema disappear ,, appetite improvement .the child is
more interested in the surrounding
Follow up phase
Supervising the mother in cooking
parental education to prevent an additional episodes
sign of improvement:
-Awareness in the child
-Weight loss (kw)
Failure of improvement:
1) Combined marasmic -kwashiorkor
2) Infection TB ,,,parasite
3) drowsiness -Severe hypokalemia
4) Rapid gain of weight - Cardiac failure
- Grossly disturbed metabolism
- Unable to tolerate the rate of re feeding (oedema)
5) Profuse diarrhea
- GIT infection
- Food intolerance (discharidase)
- Other nutrients deficiency
1. Immunological defect
- Cell mediated> humoral
- Measles> fatal disease
2. Subtle infection
- Lack of fever
- No increase in WBC
- Inability to localize infection
2) Hypoglycaemia apnoea
3) Hypothermia bradycardia
4) Heart failure death
5) Vit deficiencies Vit A blindness
6) Permanent growth stunting
7) Prolonged illness developmental delay
Improve nutritional status Improve water supply
Without change in food supply Proper sanitation
Social worker visits,
Reduce infection rate Immunization
Supervision of feeding
Good weaning practice
Long term community
health measuresEffective for
Marasmus due to under feeding good
Kwashiorkor MR 10-25%
Marasmus I Kwashiorkor worse progress
End point of nutritional