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  1. 1. The Department of Pediatrics V.N. Karazin Kharkiv National University
  3. 3. 1. 2. 3. 4. 5. 6. 7. 8. 9. The plan of the lecture: Definition of Malnutrition and Dystrophy Types of chronic disorders of nutrition Etiology of Malnutrition (Hypotrophy) Pathophysiology of Malnutrition (Hypotrophy) Classification of protein-energy malnutrition (PEM) Marasmus and Kwashiorkor Clinical manifestations of PEM Laboratory tests Treatment and Prevention of PEM
  4. 4. • The World Health Organization (WHO) defines malnutrition as "the cellular imbalance between supply of nutrients and energy and the body's demand for them to ensure growth, maintenance, and specific functions."
  6. 6. • However, the term ‘malnutrition ’ is frequently used to denote either the lack of adequate nutrition or inadequate supply/amount of calories, as the synonym of ‘undernutrition’ !!!
  7. 7. • In Russian-speaking medical literature the term “ dystrophy” is usually used to mean children’s chronic disorders of nutrition. It corresponds to the English term ‘ malnutrition ’. • Dystrophy (from Greek dis – frustration, trophy – a nutrition) is a group of diseases which are accompanied by polyorganic insufficiency, endogen intoxication, disorders of the weight, growth and development. It is diagnosed more often for children of first three years of life.
  9. 9. • Hypotrophy (=undernutrition, malnutrition) is the chronic disturbance of nutrition and digestion, characterized by lag of growth and weight and accompanied by disorders of metabolic and trophic processes, decrease of immunity and development of micronutrient deficiency.
  10. 10. • Hypostature is the dystrophy which is characterized by approximately uniform reduction of body weight and growth of the child beside satisfactory state of nourishment and turgor of tissue.
  11. 11. • Failure to thrive is a term typically used to describe infants and young children whose weight is persistently below the third percentile for age on an appropriate standardized growth chart, or less than 80% of ideal weight for age.
  12. 12. Paratrophy, and obesity are the conditions which are characterized by the superfluous body weight of the child. Paratrophy is specified to breastfed and early age children with the superfluous body weight which is no more then 1020% of norm and characterized by increased hydrolability of tissue. The term obesity is used for elder children.
  13. 13. Lack of calories and protein too many calories Hypotrophy   (protein-energy malnutrition) Hypostature Failure to thrive Paratrophy Obesity
  14. 14. • Malnutrition =undernutrition • Hypotrophy =undernutrition • Hypotrophy = Malnutrition • Failure to thrive = Hypostature • Severe Malnutrition = protein-energy malnutrition (PEM) ( marasmus, kwashiorkor)
  15. 15. Malnutrition • is a major health problem, especially in developing countries.
  16. 16.  925 million undernourished people is 13.6 % of the world population (FAO, 2010) Year 1990 Undernourished people 843 in the world (millions) 1995 2005 2008 788 848 923
  17. 17. • With 95 % of all malnourished peoples living in the sub-tropics and tropics.
  18. 18. • More than 70% of children with PEM live in Asia and 26% in Africa, and 4% in Latin America and the Caribbean (WHO 2000).
  19. 19. Percentage undernutrition’s children under the age of 5.
  20. 20. • Malnutrition is by far the biggest contributor to child mortality:  • 49% of the 10.4 million deaths occurring in children younger than 5 years in developing countries are associated with PEM. • 6 million children die of hunger every year. WHO
  21. 21. • Even mild degrees of malnutrition double the risk of mortality for respiratory and diarrheal disease mortality and malaria. 
  22. 22. • Children who are undernourishe d are more likely to be short in adulthood, have lower educational achievement and economic
  23. 23. Etiology PEM PEM Prenatal or congential hypotrophy (malnutrition) or intrauterine growth retardation Postnatal hypotrophy (malnutrition)
  24. 24. • A defective nutrition of • • • • • pregnant women Acute and chronic diseases of pregnant women In utero toxin exposure (professional factors, unfavorable factors of surroundings, bad habits – smoking, alcohol andor drugs abuse) Intra-uterine infections of fetus (TORCH) Chromosomal aberrations of fetus Prematurity Prenatal factors:
  25. 25. Etiology PEM PEM Primary (non organic) Insufficiency of food, Inadequate or unbalanced diet Secondary (organic) Problems with digestion or absorption , Chronic illnesses
  26. 26. Causes of Primary (non organic) Malnutrition Parents are not giving their child enough food because: • they can’t afford to (they are poor, unemployed); • they don’t want to (in cases when parents abuse or neglect their children ); • they don’t know (they are too young or uneducated).
  27. 27. Defective assimilation (problems with digestion or absorption): 1 . Malabsorption • infections; • celiac disease; • chronic diarrhea for whatever reason (from allergies, immune deficiencies to chronic diseases)
  28. 28. Defective assimilation (problems with digestion or absorption): • Hereditary anomalies of metabolism • • (galactosemia, leycinosis, fructosemia, fenilketonuria, and others), Malformations of gastrointestinal tract (pylorostenosis, etc.) Syndrome of “short bowel” after extensive intestinal resections
  29. 29. Chronic illnesses : – – – – – Cystic fibrosis; Chronic renal failure; Chronic heart or lung disease Childhood malignancies; Chronic inflammatory bowel diseases (Crohn disease and ulcerative colitis); – Hereditary primary immunodeficiencies – Endocrine disease (adrenogenital syndrome, diabetes mellitus , etc)
  30. 30. Pathophysiological changes nutritional and energy deficits body composition changes metabolic changes anatomic changes
  31. 31. Metabolic Changes • Protein metabolism: Total plasma proteins, albumin gamma globulins Carbohydrate metabolism: The glucose level glycogen stores Fat metabolism: Blood lipid levels
  32. 32. Practical nutritional assessment 1. Complete history, including a detailed dietary history 2. Growth measurements, (weight and length/height). 3. Complete physical examination
  33. 33. Main Diagnostic Criteria • Poor weight gain and deficit of weight • Slowing of linear growth and lag of length/height
  34. 34. • Expression of the clinical signs depends on degree of malnutrition (hypotrophy).
  35. 35. Classification of Hypotrophy– the • I degree (mild) • • deficiency of 10-20% of the body weight, II degree (moderate) – the deficiency of 2030% of the body weight, III degree (severe) – the deficiency more than 30% of the body weight.
  36. 36. Classification of Malnutrition (WHO) Moderate Malnutrition Weight for Between -2 height or and -3 SD or length 70th to 79th percentile Mid-upper Arm Less than Circumference 12.5 cm Edema N ot Severe Malnutrition Less than -3 SD or below the 70 th percentile Less than 11 cm Bilateral
  37. 37. • The World Health Organization defines severe malnutrition as "a very low weight for height, by visible severe wasting, or by the presence of nutritional oedema."
  38. 38. 2 forms of Severe Malnutrition MARASMUS “ waste away” wastin g wastin g no no edema edema KWASHIORKOR “ displaced child” wastin g wastin g edem a edem a
  39. 39. MARASMUS • The term is derived from the Greek • word marasmos, which means withering or wasting (“to waste away”). Marasmus results from the inadequate intake of protein and calories. However, to avoid confusion, the term severe wasting is preferred. 
  40. 40. KWASHIORKOR • The term is taken from the Ga language of Ghana and means “the sickness of the weaning”, “reddish boy”, or from the West African word for “displaced child”. Kwashiorkor is a nutritional deficiency disease caused when very young children are weaned from their mother's milk and placed on a diet high in calories and carbohydrates, but low in protein.
  41. 41. MAIN SYNDROMES OF MALNUTRITION Syndrome of trophic disorders Syndrome of gastrointestinal disorders Syndrome of CNS dysfunctions Syndrome of immunological disorders
  42. 42. Syndrome of trophic disorders: Decreased subcutaneous tissue . Subcutaneous fatty layer is thinned on the abdomen in the mild malnutrition, it is decreased from the body and the extremities in the moderate malnutrition, and subcutaneous fat is absent in the severe PEM, buccal fat pads (clots of Bichaut) may be preserved only. Decreases of tissue’s turgor, muscles are wasting, flabby, thinned. Sings of deficiencies of micronutrients (polyhypovitaminoses).
  43. 43. • In marasmus, the child appears emaciated. Monkey fac e s are characteristic to this disorder because of loss of buccal fat pads.
  44. 44. • A child with marasmus has the appearance of an old person trapped in a young person's body.
  45. 45. Edema • Kwashiorkor typically presents edema, moon faces
  46. 46. Edema most of all the distal extremities are affected, but anasarca (generalized edema) can be met too
  47. 47. Skin changes: • skin is pale, flabby; in severe PEM it is xerotic, wrinkled, and loose.
  48. 48. • Kwashiorkor typically • presents with dry peeling skin with raw exposed areas, hyperpigmented plaques. This feature is called the classic "mosaic skin" and "flaky paint" dermatosis.
  49. 49. Hair changes: • Hair is dry, lusterless, thin, sparse, brittle. It easily pulls out, sometimes may result in alopecia.
  50. 50. Syndrome of gastrointestinal disorders • Anorexia • Usually loss of appetite, but in marasmus may be voracious appetite. • Instability of stool with tendency to constipation, often the diarrhea.
  51. 51. • All severely Angular stomatitis malnourished children have vitamin and mineral deficiencies (Fe, Zn, Co, I, Vitamins A, B1, B2, B12, C, D )
  52. 52. Syndrome of CNS dysfunctions • Behavioral changes: - domination of negative emotions (irritability, anxiety), – small activity, apathy, lethargy – Developmental delay and psychomotor retardations, delayed mental development, and may have permanent cognitive deficits. • Disorders of thermoregulation (tendency
  53. 53. Abdominal findings: • abdominal distension secondary to poor abdominal musculature . • enlarged liver ( hepatomegaly )
  54. 54. Kwashiorkor Swollen abdomen (potbelly)
  55. 55. Syndrome of immunological disorders • Frequent severe and chronic infections, recurrent episodes of respiratory and skin infections, diarrhea and other. • Tendency to asymptomatic and atypical course of frequent infections diseases.
  56. 56. • In severe malnutrition the usual signs of infection, such as fever, are often absent !!!
  57. 57. Laboratory tests: • • • • • • • • • • CBC (complete blood count) Urine examination Urine culture Stool examination by microscopy Blood glucose Serum protein and albumin HIV test Serum electrolytes A sweat test Chest radiograph
  58. 58. Treatment 1. Detection of causes and their 2. 3. 4. 5. elimination Diet therapy Rational regimen, care, hygienic educations Detection and treatment of infections, complications and accompanying diseases Ferment-therapy, vitamin-therapy and symptomatic therapy
  59. 59. • Therapeutic nutrition of infants with malnutrition (hypotrophy) includes 3 stages: • I stage – period of food tolerance estimating (discharging and minimal nutrition); • II stage – increasing nutritional loading (the transition period); • III stage – optimal nutrition.
  60. 60. Stage I • volume of feeding is 2/3-1/2 of the full volume, • the rest of volume is given to the patient with liquids (orally or in a parenteral way). • Number of feedings on this stage is usual or plus 1-2 feedings (in severe malnutrition – 10-12 time/day). • Duration of stage I is from 1-2 to 8-10 days.
  61. 61. Stage II • Increasing of the feeding volume and • decreasing of frequency Breast milk is optimal base food. If there is lack of breast milk, special hydrolyzed formulas or easily digestible formulas with high quantities of protein and calories can be used.
  62. 62. Treatment • If any organic illness is identified, • treatment specific for that disorder should be undertaken. Malnutrition is considered a medical emergency in infants or toddlers who weigh less than 70% of the predicted weight for length.
  63. 63. The Treatment of Severe Malnutrition initially stabilization phase 1 week Cautiou s Cautiou s Correct ion Correct ion feeding feeding of acute of acute Correct ion Correct ion medica ll medica of  of  conditi ons micronu trient conditi ons micronu trient deficien cies deficien cies rehabilitation phase 2-6 weeks Feedi ng Feedi ng Emoti onal Emoti onal and and physi cal physi cal stimul ation stimul ation
  64. 64. Medical care Keep the malnourished child: • Dry (change wet nappies, clothes and bedding) • Warm (cover and take away from draughts. Avoid exposure (e.g. bathing, prolonged medical examinations). Let the child sleep with the mother for warmth at night, use a kangaroo position if possible at day.
  65. 65. Monitor • The axillaries (rectal) temperature, • If hypothermia is found, check blood glucose • Weight gain • Each week calculate and record weight gain as g/kg/d. • Control pulse rate, respiratory rate, urine frequency and stool/vomit frequency, especially if patient has rehydration therapy.
  66. 66. Essential features of feeding in the initially phase: • small, frequent feeds of low osmolarity and low lactose • • • • • (2-hourly feeds, day and night) oral or NG feeds (never parenteral preparations) 100 kcal/kg/d 1-1.5 g protein/kg/d 130 ml/kg/d of fluid (100 ml/kg/d if the child has severe oedema) if the child is breastfed, continue to breastfeed but make sure the prescribed amounts of starter formula are given (except in case of shock or coma).
  67. 67. The WHO had recommended • For enteral hydration use special Re hydration So lution for Mal nutrition (ReSoMal) • For feeding use the liquid products, such as the starter milk-based formulas F- 75 containing 75 kcal/100ml and 0.9 g protein/100ml
  68. 68. Correct of micronutrient deficiencies • Vit A orally on Day 1 (if aged >1 year give 200,000 iu; age 6-12m give 100,000iu; age 0-5m give 50,000 iu) Give daily for at least 2 weeks:• Multivitamin supplement • Folic acid 1mg/d (give 5mg on Day 1) • Zinc 2mg/kg/d • Copper 0.3mg/kg/d • Iron 3mg/kg/d but only when gaining weight.
  69. 69. Essential features of feeding in the rehabilitation phase: • frequent feeds (at least 4-hourly) of • • • • • • unlimited amounts of a catch-up formula 150-220 kcal/kg/d 4-6 g protein/kg/d to encourage the child to eat as much as possible to restart breastfeeding as soon as possible to stimulate the emotional and physical development to actively prepare the child and mother to return to home and prevent recurrence
  70. 70. • The recommended milk-based F• 100 contains 100 kcal and 2.9 g protein/100 ml rapid weight gain of >10 g gain/kg/d .
  71. 71. Further Inpatient Care • Child – Appropriate weight for height (-1 standard deviation [SD]) – Eating well and gaining weight – Infections properly treated – Immunization started
  72. 72. Further Inpatient Care • Mother – Able to look after the child – Able to prepare appropriate food – Able to provide home treatment for diarrhea – Able to recognize the signs that mean she must seek medical assistance
  73. 73. A child who is 90% weight-forlength (equivalent to -1 SD) can be considered to have recovered.
  74. 74. Prevention • careful assessment and monitoring of all families • monitoring of growth of the child • parents education
  75. 75. Thanks