NUTRITIONAL DISORDERS MAO Meng, MD Professor of Pediatrics School of Medicine, Sichuan University.

NUTRITIONAL DISORDERSNUTRITIONAL DISORDERS

MAO Meng, MD

Professor of Pediatrics

School of Medicine, Sichuan University

MARASMUS(Infantile Atrophy)

MALNUTRITION OBESITY

PROTEIN MALNUTRITION[PCM, Protein-Calorie (Energy) Malnutrition, Kwashiorkor]

NUTRITIONAL DISORDERS

MALNUTRITIONMALNUTRITION

Malnutrition, from a worldwide

perspective, is one of the

leading causes of morbidity

and mortality in childhood

MALNUTRITIONMALNUTRITION

improper and / or inadequate food intake

inadequate absorption of food

Deficient supply of food

poor dietary habitsfood faddism

emotional factors metabolic abnormalities

diseases

Diseases

Diarrhea or digestive system

diseases

Upper Respiratory Infection and

Pneumonia

Malformations

Mortality rate of diarrhea patients with malnutrition is fourfold of the diarrhea patients without malnutrition.

an accurate dietary history

evaluation of present deviations from

average height, weight, head

circumference, and past rates of growth

comparative measurements of midarm

circumference and skinfold thickness

chemical and other tests

INDICATORS INDICATORS FOR EVALUATION OF MALNUTRITIONFOR EVALUATION OF MALNUTRITION

CLINICAL INDICATORS CLINICAL INDICATORS FOR EVALUATION OF MALNUTRITIONFOR EVALUATION OF MALNUTRITION

weight-for-age (underweight): weight is lower

than -2SD of mean value of the reference

population of the same age and sex

height-for-age (stunting): height is lower than

-2SD of mean value of the reference population

of the same age and sex

weight-for-height (wasting): weight is lower

than -2SD of mean value of the reference

population of the same height and sex

About the Reference Population About the Reference Population in different countriesin different countries

The reference population from your own

country

NCHS-CDC-WHO Reference Population

(1976 and 2006)

Reference: De Onis M, Habicht JP. Anthropometric reference data for international use: recommendations from a World Health Organization Expert Committee [J]. The American Journal of Clinical Nutrition. 1996, 64(4):650-658

Protein----- serum albumin,

transferring, hemoglobin, prealbumin,

or retinol-binding protein

sodium, potassium, chloride

Immunologic insufficiency

Laboratory data

CLINICAL MANIFESTATIONS

Failure to gain weight or loss Failure to gain weight or loss of weight of weight

Thin, subcutaneous fat reduced or despaired

（（ orderly abdomen, buttocks, limb and finally faceorderly abdomen, buttocks, limb and finally face ））

Disturbulence of functions of organs Disturbulence of functions of organs

MARASMUSMARASMUS(Infantile Atrophy, energy-deficiency (Infantile Atrophy, energy-deficiency

or energy-protein deficiency)or energy-protein deficiency)

Inadequate caloric intake: insufficiency of diet, improper feeding habits

Metabolic abnormalities or congenital malformations

Severe impairment of any body system

may result in malnutrition

ETIOLOGYETIOLOGY

CLINICAL MANIFESTATIONSCLINICAL MANIFESTATIONS

Failure to gain weight followed by loss of weight until emaciation results

Loss of turgor in skin which becomes wrinkled and loose as subcutaneous fat disappears

Edema

Low temperature and slow pulse

Reduced basal metabolic rate

Fretful or listless

Diminished appetite and constipation

followed by the so-called starvation

type of diarrhea, with frequent, small

stools containing mucus

Emaciation Skin wrinkled Subcutaneous fat disappears from

abdomen first, then extremities, and finally face

PROTEIN MALNUTRITIONPROTEIN MALNUTRITION

(PCM or PEM, Protein-Calorie (Energy) Malnutrition, (PCM or PEM, Protein-Calorie (Energy) Malnutrition,

Kwashiorkor)Kwashiorkor)

deficient intake of protein of good biologic value

impaired absorption of protein, as in chronic diarrheal states

abnormal losses of protein in proteinuria Infection hemorrhage or burns failure of protein synthesis, as in chronic

liver diseases

ETIOLOGYETIOLOGY

a clinical syndrome resulted from a severe deficiency of protein & inadequate caloric intake

the most serious and prevalent form in industrially underdeveloped areas

“deposed child” may become evident from early infancy to 5 yr of age, usually after weaning

height and weight are accelerated with treatment but never equal those of consistently well-nourished children.

KWASHIORKORKWASHIORKOR

Early clinical evidence----vague, including lethargy, apathy, and irritability

Inadequate growth, lack of stamina, loss of muscular tissue, increased susceptibility to infections, and edema

Dermatitis and dyspigmentation

Secondary immunodeficiency

Anorexia, flabbiness of subcutaneous tissues, and loss of muscle tone

CLINICAL MANIFESTATIONSCLINICAL MANIFESTATIONS

Lethargy, apathy Inadequate growth, loss of muscular tissue Infections, and edema and dermatitis

Flabbiness of subcutaneous tissues, and loss of muscle tone

Liver enlargement early or late

Fatty infiltration

Edema usually develops early (failure to gain weight may be masked by edema, which is often present in internal organs before it can be recognized in the face and limbs)

Renal plasma flow, glomerular filtration rate, and renal tubular function are decreased

The heart may be small in the early stages and enlarged later

Concentration of serum albumin decreased Aminoaciduria Ketonuria in the early stage Low blood glucose values Potassium and magnesium deficiencies Amylase, esterase, transaminase, lipase,

alkaline phosphatase, pancreatic enzymes decreased

normocytic, microcytic, or macrocytic Anemia Bone growth delayed and GH increased

LABORATORY DATALABORATORY DATA

DiagnosisDiagnosis

The feeding history

Low body weight, loss of muscular

tissue and disturbances of system

functions Laboratory data Excluding other diseases

Underweight: weight for age is lower than -2SD

Stunting: height for age is lower than -2SD

Wasting: weight for height is lower than -2SD

Comparing with children in the same Comparing with children in the same age group (or height) and sex:age group (or height) and sex:

One or two or three may present to one child. Having any one of the three,

the child can be diagnosed malnutrition.

Protein deprivation: chronic infections, diseases in which there is an excessive loss of protein through urine or stool

The diseases of metabolic inability to synthesize protein

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS

Diet containing an adequate

quantity of protein of good biologic

quality

Adequate dietary instruction and

food distribution

Treatment of diseases

PREVENTIONPREVENTION

Immediate management of any acute

problems such as those of severe

diarrhea, renal failure, and shock and,

ultimately, the replacement of missing

nutrients are essential.

TREATMENTTREATMENT

For mild to moderate dehydration, feedings are administered orally or by nasogastric tube, when culturally appropriate, to prevent aspiration. A breasted infant should be nursed as often as he of she wants.

For severe dehydration, intravenous (IV) fluids are necessary

DEHYDRATIONDEHYDRATION

When dehydration is corrected, oral or nasogastric feeding starts with small, frequent feeds of dilute milk (66 kcal and 1.0g protein/100 ml at ~120/ml/kg/24 hr) with nutrient supplementation;

MILKMILK

Strength and volume are gradually increased and frequency decreased over the next 5-7 days;

By day 6-8, the child should receive 150 ml/kg/24 hr in ~6 feeds of high-energy milk (114 kcal and 4.1 g protein /100 ml). Cow’s milk, or yogurt for the lactose-intolerant child, should be made with 50 g of sugar/L.

The routine administration of antibiotics

such as co-trimoxazole has also been

advocated. Other antimicrobials are used

only to treat overt infection because of

concerns about emergence of microbial

resistance.

ANTIBIOTICSANTIBIOTICS

Vitamins and minerals, especially vitamin A, potassium, and magnesium, are necessary from the outset of treatment. Iron and folic acid usually correct the anemia.

CHILD MANUTRITION —— Multiple choices

What are the factors contributing to malnutrition?Deficient supply of foodPoor dietary habitsFood faddism and emotional factors Certain metabolic abnormalities

The indicators for evaluation of nutritional status are:Weight for age Height for ageWeight for height24hr creatinine excretion

CHILD MANUTRITION —— Multiple choices

The lower weight for height indicates:The child has acute malnutritionThe child is stuntedThe child is wastedThe child is normal

  Protein reserves in malnourished child are assessed from:

Serum albuminTransferringHemoglobinPrealbuminHigh density lipid protein