قراءة
عرض

MALNUTRITION

ا.م.د.رائد كريم العكيلي
7/1/2020
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MALNUTRITION

Cellular imbalance between supply of nutrient and energy and body's demand for them to ensure growth , maintenance and specific functions.
Kwashiorkor: protein deficiency
Marasmus: energy deficiency
Marasmic/ Kwashiorkor: combination of chronic energy deficiency and chronic or acute protein deficiency.
Kwashiorkor and Marasmus are major 2 form of PEM, and odema is the major distinguished sign.

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Most important risk factor for illness and death globally (>1/2 of death in children world wide).
Protein-energy malnutrition (PEM) is manifested primarily by inadequate dietary intakes of protein and energy, either because the dietary intakes of these 2 nutrients are less than required for normal growth or because the needs for growth are greater than can be supplied by what otherwise would be adequate intakes.
Chronic malnutrition usually involve deficit of more than a single nutrient.
PEM is almost always accompanied by deficiencies of other nutrients.
Marasmus include (caloric and protein deficiency), while kwashiorkor have inadequate protein intake.


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Pathophysiology

All organs can be affected
Dietary protein is needed to provide amino acid to form body protein.
Micronutrients are essential in many metabolic functions in body as component and co factors in enzymatic processes.
Decrease brain growth and brain weight , cerebral cortex becomes thin also decrease No. of neurons and insufficient myelinization.
Chronic Malnourished child exhibit behavioral changes
( irritability, apathy . and decrease social responsiveness, anxiety and attention deficit)
Liver & heart---- Fatty degeneration .

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GIT atrophy of small bowel and decrease intravascular volume leading to secondary hyperaldosteronism.

In addition to physical and mental retardation , immune system can be effected early in the diseases:
Loss of delayed hypersensitivity , impaired phagocytosis secondary to complement deficiency.
Immune deficiency is common in PEM and demonstrated by total WBCs <1,500/mm.
Decrease secretary IgA.


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CLINICAL FEATURES

History : clinical S&S of PEM include
poor weight gain
slowing of linear growth
behavioral changes , irritability apathy.
Malnourished children show developmental delay and permanent cognitive deficit ( degree of delay and deficit depend on severity and duration of nutritional compromise and age at which malnutrition occurred).
Clinical sign and symptom of micronutrient deficiencies include the following :
Iron fatigue , anemia , and decrease cognitive function glositis and nail changes
Iodine goiter and mental retardation

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Vit. D poor growth and rickets and hypocalcemia

Vit. A night blindness , xerophthalmia . poor growth & hair changes
Folate glossitis and megaloplastic anemia
Zinc anemia , dwarfism ,hyper-
pigmentation , hypogonadism , acrodermatitis enteropatheca , Poor wound healing


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Physical finding

1- decrease subcutaneous tissues ( legs , arms ,buttock,& face )
2- eodema :- distal extremities and generalized( anasarca)
3-oral changes --- chelosis(lip) angular stomatitis, papillar atrophy
4-abdominal finding Distended secondary to poor musculature
Hepatospenomegaly secondary to fatty infiltration
5- skin changes Dry ,peeling skin with raw exposed area
Hyper pigmented plaques over area of trauma .
6- nail changes fissured or ridged
7- hair changes thin , sparse , brittle , easily pulled out turn

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CAUSES OF MALNUTRITION

1- inadequate food (in developing countries )
a - Insufficient or inadequate food supply
b- early weaning
c- inadequate sanitation lead to infection then nutrient loss
2- in developed countries ( chronic illnesse) a) -chronic illness → anorexia
b)- increase inflammatory burden increase metabolic demand so increase caloric need
c-impaired digestive and absorptive function ( liver & small bowel disease )


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3-chronic illness (developed and developing) that commonly associated with nutritional deficiency
a -cystic fibrosis b-neuromuscular disease
c - CRF d -malignancy e- CHD
4- hildren with multiple food allergies ( sever ` dietary restriction)
5- miscellaneous
-Prematurity
-developmental delay
- in utero toxin exposure (fetal alcohol exposure)

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LAB. STUDIES

1- hematological
CBC
Blood film (iron ,folate and B12 )
S albumin and pre albumin
Transferin
S. creatinin and blood urea level
2- serum electrolytes , urine analysis and culture , stool examination
3- thyroid function test , sweat chloride test if hight velocity abnormal
4- zinc level in chronic diarrhea


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5-celiac serology

6-essential aminoacid level ( decrease)
7-increase amino acid urea
8-sever hypophosphetemia <0.32 mmol/l
9-low serum cholesterol
10-low alkaline phosphatase

DDX

1-chronic infection
2-protein losing enteropathy

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Marasmus :(infantile atrophy)

Loss of calories
Age usually 9m -2 years
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Malnutrition





Malnutrition

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Clinical features

-Weight /length <70% of 50th percentile weight /lenght.
-Failure to gain weight then loss of weight, then failure to gain height .

-Loss of skin turger and skin became wrinkled

Loss of body fat, and muscle strength ( hand and temporal area).

- Loss of fat from the sucking pads of the cheeks often occurs late in the course of the disease.

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Abdomen flat or distended and intestinal pattern may be visible .

-Muscles atrophy lead to hypotonia .
Subnormal temperature and slow pulse rate and respiratory rate .
Infant initially fretful then listless
Decrease appetite
Usually constipation (starvation diarrhea ) {frequent small stool contain mucus}
Mental and behavioral retardation.
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KWASHIORKOR:
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Malnutrition

Clinical features of kwashiorkor:-

- Weight /length normal or slightly retarded
-Lethargy , apathy and irritability
-Lack of stamina
-Edema ( early in face and limbs )
-Infection ( secondary immune deficiency )
-Anorexia - Flabbiness of subcutaneous tissues
- Decrease GFR and renal plasma flow
- Small heart early then cardiomegaly
- Dermatitis
- Skin . dark ,dyspigmented in irritated area ( not sun exposed area……pellagra )
- Distended abdomen and hepatomegally
- Hair brittle . discolored ,dry and easily pluck able

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case fatality rate about 30-40 % Treatment
Hospitalization indicated in :
Difficult chewing and swallowing
Pain
Nausea
Decrease appetite.

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The initial phase (1-7 days)

is a stabilization phase. dehydration, if present, is corrected, oral rehydration therapy is preferred. If intravenous therapy(e.g. ringer lactate) is necessary, estimates of dehydration should be reconsidered frequently, particularly during the first 24 hr of therapy.
Antibiotic therapy (Routine administration of AB such as co- trimoxazole advocated for 5-10 days) is initiated to control bacterial or parasitic infection.
Oral feedings are also started with specialized high-calorie formula. The initial phase of oral treatment is with the F75 diet (75kcal) Feedings are initiated with higher frequency and smaller volumes; over time, the frequency is reduced from 12 to 8 and then to 6 feedings per 24 hr. The initial caloric intake is estimated at 80-100 kcal/kg/day.

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If diarrhea starts or fails to resolve and lactose intolerance is suspected, a non–lactose-containing formula should be substituted.
If milk protein intolerance is suspected, a soy protein or hydrolyzed formula may be used.
Another approach is the use of ready to use therapeutic foods (RUTFs). F100 is water based and subject to bacterial contamination, whereas RUTF is an oil-based paste that has little water content and a similar nutrient profile but a higher calorie density and is equally palatable to F100. RUTF is a mixture of powdered milk, peanuts, sugar, vitamins, and minerals.


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The second rehabilitation phase (wk 2-6)

May include continued antibiotic therapy with appropriate changes, if the initial combination was not effective, and introduction of the F100 or RUTF diet with a goal of at least 100 kcal/kg/day.
At any time, if the infant is unable to take the feedings from a cup, syringe, or dropper, administration by a nasogastric tube rather than by the parenteral route is preferred.

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Iron therapy usually is not started until this phase of treatment; iron can interfere with the protein's host defense mechanisms.
There also is concern that free iron during the early phase of treatment might exacerbate oxidant damage, precipitating infections (malaria), clinical kwashiorkor, or marasmic kwashiorkor in a child with clinical marasmus.
Some recommend treatment with antioxidants.
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Final follow-up phase:-

which consists of feeding to cover catch-up growth as well as providing emotional and sensory stimulation.
In developing countries, this final phase is often carried out at home. In all phases, parental education is crucial for continued effective treatment as well as preventing additional episodes.
Zinc, iron ,Iodine, Manganese , Copper, Multivitamins, Selenium


Treat diarrhea ,anorexia and hypothermia
Oral small frequent feed if dehydration corrected .

Yogurt for lactose intolerant child should made with 50 gm of sugar/L.

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Refeeding syndrome can complicate the acute nutritional rehabilitation of children who are undernourished from any cause.
The hallmark of refeeding syndrome is the development of severe hypophosphatemia after the cellular uptake of phosphate during the 1st week of starting to refeed.
Serum phosphate levels of ≤0.5 mmol/L can produce weakness, rhabdomyolysis, neutrophil dysfunction, cardiorespiratory failure, arrhythmias, seizures, altered level of consciousness, or sudden death.
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Phosphate levels should be monitored during refeeding, and if they are low, phosphate should be administered during refeeding to treat severe hypophosphatemia.
Patient may lose weight for few weeks after treatment due to disappearance of edema.
Rapid administration of calories and fluid lead to enlarged liver , distended abdomen and slow improvement.

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Prevention
Prenatal nutrition and good antenatal care.
Encourage breast feeding.
Improvement in hygiene practice and sanitation.
Fortification of milk with micronutrient (e,g iodine ,vit.D3 ).

Prognosis:- Chronic malnutrition (IUGR )and those with early age , do not achieve their full growth potential or regain cognitive deficit

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THANK YOU

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رفعت المحاضرة من قبل: Mubark Wilkins
المشاهدات: لقد قام 10 أعضاء و 187 زائراً بقراءة هذه المحاضرة








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