Protein Energy Malnutrition


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Protein-energy malnutrition (PEM) is a potentially fatal body-depletion disorder.

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Protein Energy Malnutrition

  1. 1. Presented By : Qurrot Ulain Taher (B.Sc-IInd Yr)St. Ann’S College for Women.St.Anns Degree College for Women
  2. 2. Definitions  MALNUTRITION WHO defines Malnutrition as "the cellular imbalance between the supply of nutrients and energy and the bodys demand for them to ensure growth, maintenance, and specific functions.“ Malnutrition is the condition that develops when the body does not get the right amount of the vitamins, minerals, and other nutrients it needs to maintain healthy tissues and organ function. St.Anns Degree College for Women
  3. 3.  PROTEIN ENERGY MALNUTRITION It is a group of body depletion disorders which include kwashiorkor, marasmus and the intermediate stages MARASMUS Represents simple starvation . The body adapts to a chronic state of insufficient caloric intake KWASHIORKOR It is the body’s response to insufficient protein intake but usually sufficient calories for energy St.Anns Degree College for Women
  4. 4. DESCRIPTIONSt.Anns Degree College for Women
  5. 5. Protein-Energy Malnutrition PEM is also referred to as  protein-calorie malnutrition. It is considered as the primary nutritional problem in India. Also called the 1st National Nutritional Disorder. The term protein-energy malnutrition (PEM) applies to a group of related disorders that include marasmus, kwashiork or, and intermediate states of marasmus-kwashiorkor. PEM is due to “food gap” between the intake and requirement. St.Anns Degree College for Women
  6. 6. AETIOLOGYSt.Anns Degree College for Women
  7. 7. AETIOLOGY:Different combinations of many aetiologicalfactors can lead to PEM in children. They are:Social and Economic FactorsBiological factorsEnvironmental factorsRole of Free Radicals & AflatoxinAge of the Host St.Anns Degree College for Women
  8. 8.  Amongst the Social, Economic, Biological and Environmental Factors the common causes are:  Lack of breast feeding and giving diluted formula  Improper complementary feeding  Over crowding in family  Ignorance  Illiteracy  Lack of health education  Poverty  Infection  Familial disharmony St.Anns Degree College for Women
  9. 9.  Role of Free Radicals & Aflatoxin: Two new theories have been postulated recently to explain the pathogenesis of kwashiorkor. These include Free Radical Damage & Aflatoxin Poisoning . These may damage liver cells giving rise to kwashiorkor. Age Of Host : Frequent in Infants & young children whose rapid growth increases nutritional requirement. PEM in pregnant and lactating women can affect the growth, nutritional status & survival rates of their fetuses, new born and infants. Elderly can also suffer from PEM due to alteration of GI System St.Anns Degree College for Women
  10. 10. AETIOLOGY of PEM: Leading cause of death (less than 5 years of age) Primary PEM: Protein + energy intakes below requirement for normal growth. Secondary PEM:  the need for growth is greater than can be supplied.  decreased nutrient absorption  increase nutrient losses Linear growth ceases Static weight Weight loss Wasting Malnutrition and its signs St.Anns Degree College for Women
  11. 11. PREVALENCESt.Anns Degree College for Women
  12. 12. PREVALENCE:• Protein-energy malnutrition is a basic lack of food (from famine) and a major cause of infant mortality and morbidity worldwide.• Protein-energy malnutrition caused 0.46% of all deaths worldwide in 2002, an average of 42 deaths per million people per year. St.Anns Degree College for Women
  13. 13. Child Malnutrition in India 2005-2006 Urban 36.4 Rural 49.0 Malnutrition is the direct St.Anns Degree College for Women 50% of deaths in children. or indirect cause of more PEM is a silent killer in many children.
  14. 14. CLINICAL FEATURES St.Anns Degree College for Women
  15. 15. The clinical presentation depends upon the type, severity and duration of the dietary deficiencies. Thefive forms of PEM are : 1. Kwashiorkor 2. Marasmic-kwashiorkor 3. Marasmus 4. Nutritional dwarfing 5. Underweight child St.Anns Degree College for Women
  16. 16. Classification of PEM (FAO/WHO) Body weight as percentage  Oedema Deficit in weight for of standard heightKwashiorkor 60 – 80 + +Marasmic < 60 + ++kwashiorkorMarasmus < 60 0 ++Nutritional < 60 0 MinimaldwarfingUnderweight 60 – 80 0 +child Source: FAO / WHO 1971 Expert St.Anns Degree College for Women Committee on Nutrition 8th Report. WHO Technical Report Series 477
  17. 17. KWASHIORKOR  The term kwashiorkor is taken from the Ga language of Ghana and means "the sickness of the weaning”. Williams first used the term in 1933, and it refers to an inadequate protein intake with reasonable caloric (energy) intake. Kwashiorkor, also called wet protein-energy malnutrition, is a form of PEM characterized primarily by protein deficiency. This condition usually appears at the age of about 12 months when breastfeeding is discontinued, but it can develop at any time during a childs formative years. It causes fluid retention (edema); dry, peeling skin; and hair discoloration. St.Anns Degree College for Women
  18. 18.  Kwashiorkor was thought to be caused by insufficient protein consumption but with sufficient calorie intake, distinguishing it from marasmus. More recently, micronutrient and antioxidant deficiencies have come to be recognized as contributory. Victims of kwashiorkor fail to produce antibodies following vaccination against diseases, including diphtheria and typhoid. Generally, the disease can be treated by adding food energy and protein to the diet; however, it can have a long-term impact on a childs physical and mental development, and in severe cases may lead to death. St.Anns Degree College for Women
  19. 19. SYMPTOMS Changes in skin pigment. Decreased muscle mass Diarrhea Failure to gain weight and  grow Fatigue Hair changes (change in color or texture) Increased and more severe infections due to damaged immune system Irritability Large belly that sticks out (protrudes) Lethargy or apathy Loss of muscle mass Rash (dermatitis) Shock (late stage) Swelling (edema) St.Anns Degree College for Women
  20. 20. St.Anns Degree College for Women
  21. 21. MARASMUS  The term marasmus is derived from the Greek word marasmos, which means withering or wasting. Marasmus is a form of severe protein-energy malnutrition characterized by energy deficiency and emaciation. Primarily caused by energy deficiency, marasmus is characterized by stunted growth and wasting of muscle and tissue. Marasmus usually develops between the ages of six months and one year in children who have been weaned from breast milk or who suffer from weakening conditions like chronic diarrhea. St.Anns Degree College for Women
  22. 22. SYMPTOMS Severe growth retardation Loss of subcutaneous fat Severe muscle wasting The child looks appallingly thin and limbs appear as skin and bone Shriveled body  Wrinkled skin Bony prominence Associated vitamin deficiencies Failure to thrive Irritability, fretfulness and apathy Frequent watery diarrhoea and acid stools Mostly hungry but some are anoretic Dehydration Temperature is subnormal Muscles are weak Oedema and fatty infiltration are absent St.Anns Degree College for Women
  24. 24. St.Anns Degree College for Women
  25. 25. DIFFERENCE IN CLINICAL FEATURES BETWEEN MARASMUS AND KWASHIORKOR CLINICAL MARASMUS KWASHIORKOR FEATURES -MUSCLE WASTING Obvious Sometimes hidden by edema and fat -FAT WASTING Severe loss of Fat often retained but subcutaneous fat not firm -EDEMA None Present in lower legs, and usually in face and lower arms May be masked by -WEIGHT FOR Very low edema HEIGHT Irritable, moaning, -MENTAL Sometimes quite and apathetic CHANGES apathetic St.Anns Degree College for Women
  26. 26. DIFFERENCE IN CLINICAL FEATURES BETWEEN MARASMUS AND KWASHIORKOR CLINICAL MARASMUS KWASHIORKOR FEATURES -APPETITE Usually good Poor -DIARRHOEA Often Often -SKIN CHANGES Usually none Diffuse pigmentation, sometimes „flaky paint dermatitis‟ -HAIR CHANGES Seldom Sparse, silky, easily pulled out -HEPATIC None Sometimes due to ENLARGEMENT accumulation of fat St.Anns Degree College for Women
  27. 27. MARASMIC-KWASHIORKORA severely malnourished childwith features of bothmarasmus and Kwashiorkor. The features of Kwashiorkor are severe oedema of feet and legs and also hands, lower arms, abdomen and face. Also there is pale skin and hair, and the child is unhappy. There are also signs of marasmus, wasting of the muscles of the upper arms, shoulders and chest so that you can see the ribs. St.Anns Degree College for Women
  28. 28. NUTRITIONAL DWARFING OR STUNTING Some children adapt to prolonged insufficiency of food-energy and protein by a marked retardation of growth. Weight and height are both reduced and in the same proportion, so they appear superficially normal. St.Anns Degree College for Women
  29. 29. UNDERWEIGHT CHILD Children with sub- clinical PEM can be detected by their weight for age or weight for height, which are significantly below normal. They may have reduced plasma albumin. They are at risk for respiratory and gastric infections St.Anns Degree College for Women
  30. 30. BIOCHEMICAL & METABOLIC CHANGES St.Anns Degree College for Women
  31. 31. BIOCHEMICAL & METABOLIC CHANGES Significant findings in kwashiorkor include hypoalbuminemia (10-25 g/L), hypoproteinemia (transferrin, essential amino acids, lipoprotein), and hypoglycemia. Plasma cortisol and growth hormone levels are high, but insulin secretion and insulinlike growth factor levels are decreased. The percentage of body water and extracellular water is increased. Electrolytes, especially potassium and magnesium, are depleted. Levels of some enzymes (including lactase) are decreased, and circulating lipid levels (especially cholesterol) are low. Ketonuria occurs, and protein-energy malnutrition may cause a decrease in the urinary excretion of urea because of decreased protein intake. In both kwashiorkor and marasmus, iron deficiency anemia and metabolic acidosis are present. Urinary excretion of hydroxyproline is diminished, reflecting impaired growth and wound healing. St.Anns Degree College for Women
  32. 32. St.Anns Degree College for Women
  33. 33. TREATMENTSt.Anns Degree College for Women
  34. 34. TREATMENT Treatment strategy can be divided into three stages. Resolving life threatening conditions Restoring nutritional status Ensuring nutritional rehabilitation.There are three stages of treatment.1. Hospital TreatmentThe following conditions should be corrected.Hypothermia, hypoglycemia, infection, dehydration, electrolyteimbalance, anaemia and other vitamin and mineral deficiencies.2. Dietary ManagementThe diet should be from locally available staple foods - inexpensive, easilydigestible, evenly distributed throughout the day and increased number offeedings to increase the quantity of food.3. RehabilitationThe concept of nutritional rehabilitation is based on practical nutritional trainingfor mothers in which they learn by feeding their children back to health undersupervision and using local foods. St.Anns Degree College for Women
  35. 35. PREVENTIONSt.Anns Degree College for Women
  36. 36. PREVENTION Promotion of breast feeding Development of low cost weaning Nutrition education and promotion of correct feeding practices Family planning and spacing of births Immunization Food fortification Early diagnosis and treatment St.Anns Degree College for Women
  37. 37. THANK YOUSt.Anns Degree College for Women