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Malnutrition

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Title: Malnutrition


1
  • Malnutrition

2
Classification of PEM
  • Mild (1st degree) 75-89
  • Moderate (2nd degree) 60-74
  • Severe (3rd degree) lt 60

3
Waterlow classification
  • Observed wt
  • Wt for Ht
    ? 100
  • Reference Wt for pts Ht
  • 90-110 Nl wasting
  • 80-89 Mild
  • 75-79 Moderate
  • lt 75 Severe

4
Waterlow classification
  • Observed Ht
  • Ht for age
    ? 100
  • Reference Ht for pts age
  • 95 Nl
  • 90-94 Mild
  • 85-89 Moderate Stunting
  • lt 85 Severe

5
Waterlow classification
  • Normal
  • Wasted not stunted
  • Wasted and stunted
  • Stunted not wasted

6
Clinical presentation
  • Age
  • Degree
  • Duration
  • Infection
  • Vit, mineral and trace element deficiencies

7
Spectrum of syndrome
  • Simple growth failure
  • Kwashiorkor
  • Marasmus
  • Marasmic kwashiorkor

8
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24
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25
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26
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27
Mild protein energy malnutrition
  • 1. Growth failure
  • A slowing or ceasation in linear growth
  • A decrease in mid-arm circumference
  • A slowing or ceasation or loss of wt.
  • Delayed Bone maturation
  • Normal or ? weight to height ratio
  • 2. Infection
  • 3. Anemia
  • 4. Diminished activity
  • 5. Retardation of physical and mental development
  • 6. Skin and hair changes

28
Moderate to severe form of PEM
  • 1. Kwashiorkor
  • ? Presenting symptoms
  • ? General appearance
  • ? Growth failure ? Mucous membrane lesions
  • ? Edema
  • ? Muscle wasting ? Hair changes
  • ? Skin fold thickness ? Eye changes
  • ? Dermatosis ? Neurological-GI-Cardiovascular
    renal function

29
  • 2. Marasmus
  • ? FTT. Apathy- chronic diarrhea
  • ? Shrunken, wasted appearance is classic
    presentation
  • ? Growth and musculoskeletal changes
  • ? Other signs

30
3. Marasmic kwashiorkor
  • FTT
  • Edema
  • Dermatosis
  • Wasted

31
Welcome classification
Edema Edema _ Wt
Kwashiorkor Undernutrition 60-80
Marasmic kwashiorkor Marasmus lt60
32
The clinical spectrum of PEM
  1. Retardation growth
  2. Poor socio-economic conditions
  3. Frequent or persistent diarrhea
  4. High morbidity and mortality from infections
  5. Protein and/or energy deficient diet

33
Pathology
  • Total body protein
  • Muscle
  • Body fat
  • Liver
  • Pancreas
  • GI

34
Body composition
  1. Total body water
  2. ECF
  3. Oedema
  4. Potassium
  5. Other minerals and trace elements

35
  • Carbohydrate absorption
  • Protein absorption
  • Fat absorption
  • Pancreatic lipase ?
  • Giardia infection
  • Diarrhea
  • Abnormalities of bile salt metabolism

36
Endocrine system
  • GH
  • Thyroid hormone
  • Adrenal glands
  • Insulin

37
Haemopoietic system
  • 1) Anemia
  • Protein deficiency
  • Folate and iron deficiency
  • Hemodynamic changes
  • Hemolysis
  • Infections
  • 2) Leukocytes
  • 3) Platelets coagulation (II, VII, X)

38
Diagnosis of malnutrition
  • History
  • Physical examination
  • Laboratory workup

39
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40
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44
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45
Physical examination
  • Vital sign
  • Ht. Wt. HC
  • Muscle and fat mass
  • Edema
  • Skin lesions
  • Sign of bone disease
  • General P/E

46
Lab work up
  • CBC- WBC- Hb- ESR
  • U/A (SG-WBC-PH), U/C
  • Stool (OB-OP)
  • BUN- Na- K- Ca- P-Alk.- FBS
  • LFT
  • TB test
  • Stool fat
  • D-xylose test
  • Sweat test
  • Antigliadine antibody
  • Jujunal biopsy
  • Bone age

47
  • Management of PEM

48
Mild PEM
  • Protein 2-3 g/kg/d
  • Energy 150 kcal/kg/
  • Vit A 1500 IU/d
  • Vit D 400 IU/d

49
Treatment of severe PEM
  • Dehydration
  • Electrolyte disturbances
  • Hypoglycemia
  • Infection

50
Dehydration
  • ORS 70-100 cc/kg 12-24 hours
  • Breast feeding during dehydration
  • Formula 6 hours after beginning dehydration

51
IV Fluid
  • Ringer lactate 20 cc/kg first hour
  • Plasma 20 cc/kg in 1-2 hours
  • D/VV 10 0.2 N saline 50 100 cc/kg/6 h
  • D/W 10 0.2 N saline 100-150 cc/kg/d
  • Kcl 40 meq/l

52
Electrolyte
  • K 4 meq/kg/d
  • Ca 100-200 mg/kg/d
  • Mg 50 solution 0.5-1.5 cc IM
  • Zinc 2 mg/kg/d

53
Infection
  • Gram ve and gram ve
  • Ampicillin
  • Gentamicin
  • Giardiasis
  • Ascariasis

54
Hypothermia
  • (R lt 35oc)
  • Hypoglycemia
  • Septicemia
  • ?Subcutaneous tissue
  • ?Energy intake

55
Hypoglycemia
  • Blood sugar lt 40 mg/dl (10-50)
  • Mild 20-40 mg/dl
  • 25 D/W orally
  • Severe lt 20 mg/dl
  • Dextrose 50 2 cc/kg Iv stat
  • Maintenance 10 dextrose

56
Anemia
  • Folic acid 5 mg/d X 10 days
  • Ferrous sulphate 5 mg/kg/d
  • Blood transfusion If Hb lt 6 g/dl
  • Vit B12 is not indicated

57
Vitamins
  • Vit. A 100,000 iu im
  • Vit. K 5mg iv or im
  • Vit. D 400 iu/d
  • Folic acid 5mg daily for 10 days
  • Vit. B

58
Dietary treatment
  • Darrows solution or ORS 90 cc/kg/d Q 3h for 24
    hours
  • Mike 60 cc/kg/d ? to 150 cc/kg/d

59
Introduction of traditional foods
  • When edema has disappeared
  • Skin lesions are notably improved
  • Patient becomes active
  • Appetite is restored
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