Class 6- Protein Malnutrition

Protein Energy Malnutrition (PEM)

  • Definition: WHO defines PEM as an imbalance between the supply of protein and energy, and the body's demand for them, ensuring optimal growth and function.

  • Types of Imbalance:

    • Inadequate energy intake leading to malnutrition (wasting, stunting, underweight).

    • Excessive energy intake resulting in overweight and obesity.

Precipitating Factors of Malnutrition

  • Malnutrition in children is influenced by several factors:

    • Poor food quality.

    • Inadequate breastfeeding.

    • Insufficient food intake.

    • Severe infectious diseases.

  • These conditions are linked to living standards and access to basic needs such as food, housing, and healthcare.

Growth Indicators for Nutritional Status Assessment

  • WHO recommends the following anthropometric indicators:

    • Low weight-for-height (Wasting):

      • Indicates recent and severe weight loss; associated with acute starvation or severe illness.

    • Low height-for-age (Stunting):

      • Reflects failure to reach linear growth potential; commonly linked to poor socioeconomic status and adverse health conditions.

    • Low weight-for-age (Underweight):

      • Reflects body mass relative to chronological age; influenced by height and weight, indicating long-term health and nutrition.

Specific Conditions: Wasting, Stunting, and Underweight

Wasting

  • Definition: Characterized by low weight-for-height.

  • Statistics: 52 million children under 5 were wasted globally (8% in 2011).

Stunting

  • Definition: Characterized by low height-for-age; indicates failure to achieve growth potential.

  • Statistics: 165 million children under 5 were stunted globally (26% in 2011).

Underweight

  • Definition: Reflects body mass relative to age, influenced by height and weight; indicates long-term health/nutrition issues.

  • Statistics: 101 million children under 5 were underweight globally (16% in 2011).

Classification of Malnutrition

  • Z-Score Classification System: Used to assess growth indicators.

    • Weight-for-age, length/height-for-age, and BMI-for-age.

    • Ranges define obesity, overweight, possible risk of overweight, stunting, and underweight conditions.

Mid-Upper Arm Circumference (MUAC)

  • Important screening tool for acute malnutrition, used for children aged 12-59 months.

Protein Energy Malnutrition Disorders

  • Includes:

    • Kwashiorkor: Characterized by inadequate protein with sufficient caloric intake; usually follows breast-feeding.

    • Marasmus: Severe PEM due to inadequate intake of protein and calories.

    • Marasmic-Kwashiorkor: Presence of both marasmus and kwashiorkor clinical signs.

Pathophysiology of Kwashiorkor

  • Dietary Inadequacy:

    • Transition from balanced breastmilk diet to inadequate carbohydrate-rich diet leads to protein deficiency.

    • Results in poor tissue development, decreased enzyme synthesis, and malabsorption.

  • Clinical Effects:

    • Diarrhea causing loss of fluid and electrolytes.

    • Edema due to decreased plasma proteins.

    • Hepatomegaly from altered fat metabolism.

Clinical Presentation of Kwashiorkor

  • Growth Metrics:

    • Weight-for-age: 60-80%; weight-for-height normal or decreased.

  • Symptoms:

    • Puffiness and edema, moon-shaped face, muscle wasting, psychomotor changes (apathy).

    • Gastrointestinal issues including diarrhea, reduced appetite, and malabsorption.

    • Skin lesions (dermatosis), hair changes, and signs of micronutrient deficiencies.

Pathophysiology of Marasmus

  • Occurs due to inadequate protein and caloric intake leading to negative energy balance.

  • Results in:

    • Reduced metabolic activity, growth suppression, significant body fat and muscle loss.

    • Increased susceptibility to infections and hypothermia.

Clinical Presentation of Marasmus

  • Growth Metrics:

    • Weight-for-age < 60%; presents with stunting and reduced body metrics.

  • Symptoms:

    • Profound muscle wasting, increased hunger, good appetite despite extreme body wasting.

    • Differentiated from kwashiorkor by absence of edema, dermatosis, and hair changes.

Management of PEM

  • Includes calculations of Z scores and assessments of weight-for-length standards.

  • WHO guidelines for management of Severe Acute Malnutrition (SAM) involve rehabilitation stages focusing on hypoglycemia, dehydration, and appropriate feeding strategies.

Refeeding Syndrome Concerns

  • During refeeding, monitor for:

    • Electrolyte imbalances (hypokalemia, hypomagnesemia, hypophosphatemia).

    • Nutritional needs and risk of salt/water retention.

References

  • WHO guidelines, UNICEF resources, and various scientific publications addressing childhood malnutrition.