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Malnutrition
Protein / Energy
Definitions of Malnutrition
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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
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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
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Similar but different diseases
How many?
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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
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Social and Economic
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Poverty
Ignorance
Inadequate weaning practices
Child abuse
Cultural and social practices
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Vegan
Low fat diets
Biologic factors
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Maternal malnutrition, prematurity
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Infectious disease
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Start life with poor stores
Diarrhea, Aids, TB, measles
Environmental
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Unsanitary living, poor quality water
Agricultural/cultural patterns
Droughts, floods, wars, forced migrations
Age of child
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Infants and young children
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High nutritional needs
Early weaning or late weaning
Poor hygiene
Marasmus < 1 year
Kwashiorkor >18 months with starchy
weaning foods
Pathophysiology
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Develops slowly, adapts to decreased intake
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Marasmus
Less fragile metabolic equilibrium
Less effective adaption or acute problem
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Kwashiorkor, mixed
Energy
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Decreased intake yields decreased activity
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Mobilization of body fat, weight loss,
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Subcutaneous fat
Muscle wasting
Maintains visceral protein in marasmus
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Decreased play and physical activity
Nl albumin
Larger protein deficit leads to faster visceral protein
falls and edema.
Biologic differences
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Marasmus
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Weight loss
Nl or low protein
Boarderline hgb, hct
NL AA profile
Nl blood glucose
Nl enzymes
Nl transaminase
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Kwashiorkor
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NO weight loss
High extracellular water
Low hgb, hct
Low protein
Elevated AA profile
Low enzymes
High transaminase
Pathophysiology
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Cardiac
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Immune system
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Output, heart rate and blood pressure decrease
Postural hypotension
T lymphocytes and complement decreased
Susceptible to bacterial infection
Cytokines (glycoproteins)
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Poor immune response
TNF inc leading to anorexia, muscle wasting and lipid
changes
Pathophysiology
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Decreased total body potassium
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Not electrolytes, but problem in rehabilitation
GI function
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Poor absorption of lipids, and sugars
Decreased enzyme and bile production
Increase incidence of diarrhea, and bacterial
overgrowth
Pathophysiology
CNS
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Decreased brain growth and myelnation
Electrical changes similar to dylexia
Parental adaptation
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Increased breastfeeding
Altered expectations
Diagnosis
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Anthropometry
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Acute: Wasting: low weight for height
Chronic: Stunted: low height for age
4 groups
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Normal
Wasted not stunted: acute PEM
Wasted and stunted: acute and chronic PEM
Stunted not wasted: past PEM, nutritional dwarfs
Diagnosis
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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
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Moderate <15 ages 11-13, <16.5 ages 14-17
Severe <13 ages 11-13, <14.5 ages 14-17
Diagnosis
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Mild to moderate
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Weight loss if acute, decreased growth velocity of
chronic
Decreased activity
Marasmus
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Skin and bones, thin hair, monkey face
Hypoglycemia, hypothermia
Diagnosis
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Kwashiorkor
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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
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Mixed
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Edema, with or without skin lesions
Muscle wasting and loss of subcutaneous fat
Treatment
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Acute/ life threatening
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Fluid and electrolyte
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Infections: main cause of death
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K and Mg shifts
Oral rehydration, slowly 70-100 ml/kg
Aggressive treatment, but disease alters metabolism of drugs
Other deficiencies
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Anemia and heart failure, care with transfusions and no
diurretics
Vitamin A: immediate treatment
Treatment
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Slow re-feeding
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Small frequent feeding around the clock
Patient encouragement of food
Nutritional rehabilitation
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Play and teaching
controlinfections
Recovery?
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At home
Reach weight for height and replete muscle mass
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Normal is 25-75% weight for height and continue for one
months after
Treat other deficiencies
Family problems
Who does this include here?
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Tube feeding.
Disabilities
FTT
What does it mean?
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Poverty
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Correlation of income, wt, ht and hgb in US
What is wealth?
Importance of food choice
Brain development
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Iron deficiency: neuro transmitters
Brain waves:
What does it mean?
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Learning:
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Difference in treatment by parents
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Duration of breastfeeding
Expectations
Long term effects
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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?
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Learning:
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Difference in treatment by parents
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Duration of breastfeeding
Expectations
Slums of Kingston, Jamaica
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Educational intervention, early rise plateau
Nutritional intervention, late rise
Additive effect
Education lasts, not nutrition, but high IQ mom’s and
nutrition group did as well as education.
Implications
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Children learn by interacting with the
environment
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Poverty: limited environment
Malnutrition: limited interaction
Additive effect!
Loss to society of human potential
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Lead graph