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• 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
• Types of malnutrition


  • Protein energy malnutrition (PEM)
  • Primary PEM due to inadequate food intake
  • Secondary PEM - other disease lead to low food ingestion, inadequate nutrient absorption or utilization, increased nutritional requirements, increased nutrient losses

  
• The greatest risk of under nutrition occurs in the first 1000 days, from conception to 24 mo of age
• Early damage to growth and development, adverse consequences on health, intellectual ability, school achievement, work productivity, and earnings
• Categories of acute malnutrition


  • Marasmus
  • Kwashiorkor

  
• Causes of malnutrition


  • Social and Economic Factors: Poverty, Ignorance, Social and cultural problems
  • Biological factors: Maternal malnutrition, Infection
  • Dietary factor: bulky foods with low nutritional value
  • Environmental factors: Overcrowded and/or unsanitary living conditions, Agricultural patterns, droughts, floods, wars
  • Age of the host: More frequent among infants and young children

  
• Immediate causes of malnutrition

  • Inadequate dietary intake including poor quality and quantity of food in the diet
  • Infection and disease such as malaria, diarrheal diseases, acute respiratory infections, worm infestations, HIV, and tuberculosis (TB)

  
• Underlying causes of malnutrition

  • Contribute to the immediate causes and must be dealt with to improve the overall nutrition situation
  • Why some people are at higher risk for illness or are unable to consume an adequate diet

  
• Reductive adaptation


  Important abnormal physiologic changes that occur in severe acute malnutrition

  
• Main alterations in each of the body systems in severe acute malnutrition

  • Cardiovascular system
  • Gastro-intestinal system
  • Liver function
  • Genitourinary system
  • Electrolytes and fluid
  • Immune system
  • Circulatory system
  • Endocrine system
  • Central nervous system
• Marasmus


  Generalized muscle wasting and absence of subcutaneous fat, "bone and skin appearance" or old man's face
• Kwashiorkor


  Edema, skin lesions, hair changes, mental status changes, gastrointestinal symptoms
• Electrolyte and mineral deficiencies in severe acute malnutrition

  • Potassium
  • Magnesium
  • Zinc
  • Copper
  • Selenium
• Edema


  Caused by severe fatty infiltration
• Abdomen


  • Protruding because of distended stomach and intestinal loops
• Kwashiorkor


  Edematous severe acute malnutrition (SAM)

  
• Kwashiorkor


  • Rapid onset, inadequate protein intake
  • 18 months to 2 years of age
  • Edema and fatty liver
  • Apathy, irritability, sadness
  • Loss of appetite
  • Infections linger, more common
  • Some muscle wasting
  • Anthropometric indicator showing acute malnutrition
  • Loss of hair and skin pigments
  • Skin scaly, cracked
• Marasmus


  Non-edematous severe acute malnutrition (SAM)

  
• Marasmus


  • 6 to 18 months of age
  • Diet inadequate to meet needs for calories, protein, essential FA
  • Develop slowly
  • Severe weight loss and muscle wasting
  • Anxiety and apathy
  • Cold, no energy
  • Hair and skin problems as in Kwashiorkor
  • No edema or fatty liver
• Electrolyte / Mineral Deficiencies

  • Potassium
  • Magnesium
  • Zinc
  • Copper
  • Selenium
  • Sodium
• Potassium


  Potassium supplements help reduce edema<|>Muscle weakness / apathy<|>Reduced cardiac output
• Magnesium


  Convulsions / arrhythmias
• Zinc


  Diarrhea/ skin disease
• Copper


  Anemia
• Selenium


  Heart failure
• Sodium


  Total body sodium is often increased<|>Expansion of extracellular fluid volume<|>Leakage of sodium into cells
• Bilateral Pitting edema


  Grade 0: Absent, no edema<|>Grade +: Mild, both feet/ankles<|>Grade ++: Moderate, both feet, plus lower legs, hands, or lower arms<|>Grade +++: Severe, generalized bilateral pitting edema, including both feet, legs, arms, and face
• Neurobehavioral changes in Kwashiorkor

  • Mucocutaneous and hair changes
  • Edema (ascites uncommon), ulcer, pallor
  • Cloudy cornea
  • Bitot's spot
  • Corneal opacity
  • Multifactor anemia
• Skeletal abnormalities may be noted
• Laboratory studies


  • Blood glucose
  • Stool exam and culture
  • Urinalysis and culture
  • Total protein and serum albumin and pro albumin
  • Blood film
  • CBC and RBC indices
  • CXR
  • PITC (HIV Testing)
  • Sputum/gastric aspirate AFB and gene xpert
  • CSF examination and culture when needed
  • LFT and RFT
  • Serum electrolytes
  • Blood culture
  • Blood group and RH and cross match when needed
  • Viral markers, VDRL
• Serum concentrations of total proteins, especially albumin

  Markedly reduced in edematous PEM, normal or moderately low in marasmus
• Electrolytes


  Intracellular concentrations of potassium and magnesium decrease, and that of sodium increases
• Ratio of nonessential to essential amino acids in plasma

  Elevated in edematous malnutrition
• Serum free fatty acids

  Elevated particularly in edematous malnutrition
• Urinary creatinine excretions


  Markedly reduced particularly in edematous malnutrition
• Assessment of nutritional status and criteria for admission

  • Weight-for-height (or length)
  • Height (or length)-for-age
  • Edema
  • MUAC
  • BMI-for-age
• Classification of severe malnutrition

  Edematous<|>Severely wasted - non-edematous<|>Severely stunted

  
• Anthropometric measurements


  • Weight
  • Height
  • MUAC
  • Head circumference
  • BMI
• Anthropometric indices


  • Weight-for-age
  • Height-for-age
  • Weight-for-height
  • BMI-for-age
  • MUAC
• Classification of nutritional status using Z-scores for infants 0-6 months

  • Complicated severe acute malnutrition
  • Uncomplicated severe acute malnutrition
  • Moderate acute malnutrition
  • No acute malnutrition