definition of malnutrition, the definition of protein-energy malnutrition , the etiology 0f protein-energy malnutrition, the pathophysiology of malnutrition, features of marasmus, features of kwashiorkor, vitamins and micronutrient deficiencies, signs of micronutrients deficiency, diagnosis, management of malnutrition,prognosis of malnutrition ,prevention of malnutrition
2. Malnutrition
“The cellular imbalance between the
supply of nutrients and energy and the
body's demand for them to ensure growth,
maintenance, and specific functions."
https://www.who.int
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3. Pediatric
malnutrition[undernutrition]
“An imbalance between nutrient
requirement and intake, resulting in
cumulative deficits of energy, protein, or
micronutrients that may negatively affect
growth, development, and other relevant
outcomes."
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Mehta NM, Corkins MR, Lyman B, Malone A, Goday PS, Carney LN, et al. Defining pediatric malnutrition: a paradigm
shift toward etiology-related definitions. JPEN J Parenter Enteral Nutr. 2013 Jul. 37 (4):460-81
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to
of child-bearing age in Africa and south
Asia are underweight
contributes to the number of low
birth weight infants born annually
Blossner, Monika, de Onis, Mercedes. Malnutrition: quantifying the health impact atnational and
local levels. 2005. Available at http://whqlibdoc.who.int/publications/2005/9241591870.pdf.
5. Protein-Energy Malnutrition
(PEM)
A group of related disorders that include
marasmus, kwashiorkor, and intermediate
states of marasmus-kwashiorkor.
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https://emedicine.medscape.com/article/1104623-overview
6. Classification of malnutrition
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• Illness related
(secondary to another disease or injury)
• Non-illness related
(attributable to environmental / behavioral
causes)
• Combination of the two
Mehta NM, Corkins MR, Lyman B, Malone A, Goday PS, Carney LN, et al. Defining pediatric malnutrition: a paradigm shift toward
etiology-related definitions. JPEN J Parenter Enteral Nutr. 2013 Jul. 37 (4):460-81.
7. Malnutrition
can be also classified as:
acute versus chronic
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8. Acute malnutrition manifestations
Two major forms:
• Marasmus (the most common form)
• kwashiorkor
Some patients' condition may manifest
as a combination of both forms
(marasmic kwashiorkor)
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9. 07/09/2021
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Horta BL, Victora CG, de Mola CL, et al. Associations of linear growth and relative weight gain in early
life with human capital at 30 years of age. J Pediatr. 2017 Mar. 182:85-91.e3.
Features of chronic malnutrition
• Stunted growth
• Mental apathy
• Developmental delay
• Poor weight gain
10. Severe acute malnutrition
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Severe acute malnutrition is defined as the
presence of edema of both feet or severe
wasting
(*weight-for-height / length <-3SD
or
*mid upper arm circumference < 115 mm).
https://www.who.int/elena/titles/full_recommendations/sam_management/en/
13. The effects of changing environmental
conditions
• Poor environmental conditions may
increase insect and protozoal infections
• Environmental deficiencies in
micronutrients.
• Inadequate food intake or intake of foods
of poor nutritional quality.
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Mehta NM, Corkins MR, Lyman B, Malone A, Goday PS, Carney LN, et al. Defining pediatric malnutrition: a paradigm
shift toward etiology-related definitions. JPEN J Parenter Enteral Nutr. 2013 Jul. 37 (4):460-81
14. Etiology (Cont.)
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• Gastrointestinal infections because of
associated:
diarrhea
anorexia
vomiting
increased metabolic needs
decreased intestinal absorption
15. Etiology (Cont.)
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Diseases, such as:
• cystic fibrosis
• chronic renal failure
• childhood malignancies
• congenital heart disease
• neuromuscular diseases
(developed countries)
16. Etiology (Cont.)
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• Fad diets, inappropriate management of
food allergies, and psychiatric diseases
(eg, anorexia nervosa)
• Involuntary weight loss (IWL) is defined
as a loss of 4.5 kg or greater than 5% of
the usual body weight over a period of
6-12 months.
19. Pathophysiology
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kwashiorkor
Adequate carbohydrate
consumption and decreased
protein intake
Decreased synthesis of visceral proteins
Hypoalbuminemia
Extravascular fluid accumulation
Impaired synthesis of
B-lipoprotein
Fatty liver
20. Pathophysiology (Cont.)
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Protein-energy malnutrition also involves
• Inadequate intake of many essential
nutrients
• Impaired glucose clearance
(Dysfunction of pancreatic β cells)
• Immune response changes occur early
(significant malnutrition )
21. Hormonal adaptation to the stress of
malnutrition: The evolution of marasmus.
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Immune response changes in PEM
• Loss of delayed hypersensitivity
• Fewer T lymphocytes
• Impaired lymphocyte response
• Impaired phagocytosis secondary to
decreased complement and certain
cytokines
• Decreased secretory immunoglobulin
A (IgA)
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The sequelae of immune response changes
• Predispose children to severe and chronic
infections, most commonly, infectious
diarrhea
• Compromises nutrition causing :
i. anorexia
ii. decreased nutrient absorption
iii. increased metabolic needs
iv. direct nutrient losses
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Changes in the developing brain of
malnourished children
• slowed rate of growth of the brain
• lower brain weight
• thinner cerebral cortex
• decreased number of neurons
• insufficient myelinization
• changes in the dendritic spines
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Other pathologic changes seen in
malnourished children
• fatty degeneration of the liver and heart
• atrophy of the small bowel
• decreased intravascular volume leading
to secondary hyperaldosteronism
27. Practical nutritional assessment
includes the following:
• Complete history, including a
detailed dietary history
• Growth measurements,
including weight and
length/height; head
circumference in children
younger than 3 years
• Complete physical examination
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28. Physical findings that are
associated with PEM include the
following:
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29. 1.Decreased subcutaneous tissue
Areas that are most affected are :
• The legs
• The arms
• The buttocks
• The face
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31. 3.Oral changes
• Cheilosis
• Angular stomatitis
• Papillar atrophy
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32. 4.Abdominal findings
• Abdominal distention secondary to poor
abdominal musculature
• Hepatomegaly secondary to fatty infiltration
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33. 5.Skin changes
• Dry, peeling skin with raw, exposed areas
• Hyperpigmented plaques over areas of
trauma
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34. 6.Nail changes
• Fissured or ridged nails
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35. 7.Hair changes
• Thin, sparse, brittle hair that is easily pulled
out
• Hair turns to a dull brown or reddish color
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36. 8.Developmental defect
• delayed achievement of motor skills
• delayed mental development
• may have permanent cognitive deficits
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Marasmic child features
• Low weight-for-height
• Reduced mid-upper arm
circumference
• large head relative to the rest
of their body
• Other findings include:
- dry skin
- thin hair
- irritability
40. The most common and clinically
significant micronutrient
deficiencies and their consequences
include the following:
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41. Iron deficiency
• Fatigue • Headache
• Anemia • Glossitis
• Decreased
cognitive function
• Nail changes
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42. Iodine deficiency
• Goiter
• Developmental delay
• Mental retardation
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43. Vitamin D deficiency
• Poor growth
• Rickets
• Hypocalcemia
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44. Vitamin A deficiency
• Night blindness • Poor growth
• Xerophthalmia • Hair changes
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45. Folate deficiency
• Glossitis
• Anemia (megaloblastic)
• neural tube defects
(in fetuses of women without folate supplementation)
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46. Zinc deficiency
• Anemia • Acrodermatitis
enteropathica
• Dwarfism • Diminished immune
response
• Hepato-
splenomegaly
• Poor wound healing
• Hyperpigmentation and hypogonadism
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47. Initial diagnostic laboratory
studies include the following:
• Complete blood count
• Sedimentation rate
• Serum electrolytes
• Urinalysis
• Culture
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48. Stool specimens should be
obtained if :
- the child has a history of
abnormal stools or stooling
patterns
or
- the family uses an unreliable
or
- questionable source of water.
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49. The most helpful laboratory
tests for assessing malnutrition
in a child are:
- Hematologic studies
- Protein status studies
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50. Hematologic studies should
include a complete blood count
with red blood cell indices and
a peripheral smear.
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51. Measures of protein
nutritional status :
Serum albumin Transferrin
Retinol-binding
protein:
Creatinine
Prealbumin Blood urea
nitrogen
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52. Other studies may focus on
thyroid functions or sweat
chloride tests, particularly if
height velocity is abnormal.
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53. Complications of protein-energy
malnutrition
1.Hypothermia 4.Diarrhea
2.Hypoglycemia 5.Heart failure
3.Encephalopathy 6.Infection
7.Micronutrient defiencies
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54. Predictors of poor prognosis
• The extent of growth failure
• The severity of:
- hypoproteinemia
- hypoalbuminemia
- electrolyte imbalances
• Underlying human
immunodeficiency virus (HIV)
infection
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55. Morbidity of chronic malnutrition
1. Behavioral changes, including :
*irritability
*apathy
*decreased social responsiveness
*anxiety
*attention deficits
2. Dose-dependent relationships between
impaired growth and:
* poor school performance
* decreased intellectual achievement
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56. Chronic malnutrition
Children with chronic
malnutrition may require
caloric intakes of more than
120-150 kcal/kg/day to
achieve appropriate weight
gain
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57. Mild malnutrition
Most children with mild
malnutrition respond to
increased oral caloric intake
and supplementation with
vitamins, iron, and folate
supplements
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58. The requirement for increased
protein is met typically by
increasing the food intake
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59. Management must
be carried out in
specialised centers
by physicians
familiar with
nutritional
disorders as
nutritional recovery
syndrome may
occur
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Nutritional
recovery
syndrome
excessive
sweating
Hepatomegaly
60. Refeeding syndrome
is a potentially life
threatening condition that
occurs with administration
of high calorie feeds in
severely malnourished
children
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61. Refeeding syndrome (Cont.)
• This potentially fatal
condition is associated with
electrolyte disturbances
including:
- hypokalemia
- hypophosphatemia
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62. Moderate to severe malnutrition
In moderate to severe cases
of malnutrition, enteral
supplementation via tube
feedings may be necessary
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63. Moderate to severe malnutrition
In moderate to severe cases
of malnutrition, enteral
supplementation via tube
feedings may be necessary
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64. 1.Starts with an emphasis
on prenatal nutrition and
good prenatal care
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65. 2. Promotion of
breastfeeding is particularly
crucial in developing
countries
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66. 3.The appropriate
introduction of nutritious
supplemental foods.
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68. Kwashiorkor vs. Marasmus
Children with kwashiorkor have
nutritional edema and metabolic
disturbances, ( including
hypoalbuminemia and hepatic
steatosis)
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Whereas marasmus is
characterized by severe wasting
69. Kwashiorkor marasmus
Edema Present Absent
Protein intake Inadequate Inadequate
Calorie intake fair-to-normal Inadequate
Representation
to starvation
Dysadaptation
to starvation
Adaptation
to starvation
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71. References
• Di Giovanni V, Bourdon C, Wang DX, et al. Metabolomic changes in serum of children with different
clinical diagnoses of malnutrition. J Nutr. 2016 Dec. 146 (12):2436-44.
• Di Giovanni V, Bourdon C, Wang DX, et al. Metabolomic changes in serum of children with
different clinical diagnoses of malnutrition. J Nutr. 2016 Dec. 146 (12):2436-44.
• Spoelstra MN, Mari A, Mendel M, et al. Kwashiorkor and marasmus are both associated with
impaired glucose clearance related to pancreatic beta-cell dysfunction. Metabolism. 2012 Mar 2.
• Velly H, Britton RA, Preidis GA. Mechanisms of cross-talk between the diet, the intestinal
microbiome, and the undernourished host. Gut Microbes. 2017 Mar 4. 8 (2):98-112
• McCarthy A, Delvin E, Marcil V, et al. Prevalence of malnutrition in pediatric hospitals in developed
and in-transition countries: the impact of hospital practices. Nutrients. 2019 Jan 22. 11 (2)
• World Health Organization. Malnutrition fact sheet. Available at https://www.who.int/news-
room/fact-sheets/detail/malnutrition. February 16, 2018
• Rosenberger C, Rechsteiner M, Dietsche R, Breidert M. Energy and protein intake in 330 geriatric
orthopaedic patients: Are the current nutrition guidelines applicable?. Clin Nutr ESPEN. 2019 Feb.
29:86-91.
• Bekele A, Janakiraman B. Physical therapy guideline for children with malnutrition in low income
countries: clinical commentary. J Exerc Rehabil. 2016 Aug. 12 (4):266-75
• Williams PCM, Berkley JA. Guidelines for the treatment of severe acute malnutrition: a systematic
review of the evidence for antimicrobial therapy. Paediatr Int Child Health. 2018 Nov. 38
(sup1):S32-S49
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