Problems of postnatal growth and developmentMacronutrient deficiencies (Protein Energy Malnutrition)Dr. IKG Suandi, SpADepartment of Pediatrics, School of Medicine, Udayana University/Sanglah Hospital Denpasar

ObjectivesTo understand the sign & symptom of patient with protein energy malnutrition (PEM)

To built diagnosis of patient with protein energy malnutrition (PEM)

To understand the treatment and prevention of the patient with protein energy malnutrition (PEM)

Introduction Protein Energy Malnutrition (PEM) is a leading cause of death among children < 5 yrs of age

Primary PEM caused by social or economic factors that result of lack of food (protein & calorie deficiencies).

Secondary PEM occurs in children with various conditions associated with increased caloric requirements1 (infection, trauma, & cancer), increased caloric loss2 (malabsorption, & cystic fibrosis), reduced caloric intake3 (anorexia, cancer, oral intake restriction, & social factors), or combination4 of these three variables

Pathophysiology of macronutrient deficienciesPEM presents a complex relationship between: reduced protein and calorie intake1, secondary immune dysfunction2, continued exposure to infectious disease3, morbidity / mortality4.

I. Marasmus Marasmus is the most common form of primary PEM, is caused by severe caloric depletion (inappropriate weaning practice)

Secondary forms of marasmic PEM are associated with such diseases as cystic fibrosis, tbc, cancer, celiac disease, or acquired immunodeficiency syndrome (AIDS), chronic diarrhea

Clinical manifestation: Body weight for age below 60%, or below 70% of the ideal weight for height Depleted body-fat stores; growth stunting; loss of muscle mass and subcutaneous fat stores Skin is dry and thin, the hair may be thin, sparse, and easily pulled outGenerally apathetic and weak; bradycardia and hypothermiaAtrophy of the filiform papillae of the tongue and monilial stomatitis is frequent

Old man face & Piano ribs

Wasting: loss of muscle mass and subcutaneous fat stores

Role of chronic diarrheaAs a result of the effects of malnutrition on the GI tract:mucosal atrophy and secondary malabsorption

increased of susceptibility to viral, bacterial, protozoal, and parasitic infections related to a secondary T- and B-cell immunodeficiency state

diarrhea and formula intolerance:transient lactose intolerancemonosaccharide malabsorption milk protein intolerance

II. Kwashiorkor Presenting with pitting edema that starts in the lower extremities and ascends with increasing severity

Is caused by inadequate protein intake in the presence of fair to good caloric intake

pitting edemaPressure

Kwashiorkor may be a complication of critical illness (when inadequate amounts of protein are provided for a prolonged time):burns / canceracute and chronic infectionmulti-organ system failureinflammatory bowel diseaseanorexia nervosaand postoperative surgery

Kwashiorkor.Clinical manifestation:the body weight: 60-80% of the expected weight for agerevealed a relative maintenance of subcutaneous adipose tissuea marked atrophy of muscle massa minor pitting edema the hair is sparse, easily pluckable, and appears dull brown, red, or yellow-white

generalized edema with involvement of the eyelids, abdomen, scrotum and lower extremities

15Flag sign: the hair may be thin, sparse, and easily pulled out appears dull brown, red, or yellow-white

Flag sign: the hair may be thin, sparse, and easily pulled out appears dull brown, red, or yellow-white

Kwashiorkor.Skin changes: from hyperpigmented hyperkeratosis to an erythematous macular rash, a superficial desquamation

Angular cheilosis and atrophy of filiform papillae of tongue; monilial stomatitis

Crazy pavement dermatosis:hyperpigmented hyperkeratosis, erythematous macular rash on extremities

A large, soft liver with indefinite edge, lymphatic tissue is atrophic

Chest examination may revealed basilar rales, abdomen distended, bowel sounds tend to be hypoactive

Complication of malnutritionInfection1, sepsis, pneumonia, gastroenteritis Hypoglycemia2Hypothermia3, bradycardia4 Vitamin A deficiencies5 altered immune response and increased morbidity (infection and blindness) and mortality (from measles)

abdomen distended

Treatment of malnutritionNutrient provided increasing metabolic rate stimulating anabolism & thus increasing nutrient requirementsGI tract may not tolerate a rapid increase in intake nutritional rehabilitation should be initiated advanced slowly to minimize these complications Fluid and solute load must be monitored to avoid stressing the compromised myocardial function

Calories can be safely started at 20% above the childs recent intake (50-75% of the normal energy requirement is safe) can be increased 10-20%/day may require 150% or more of the recommended calories

Monitoring: electrolyte imbalances, poor cardiac function, edema, or feeding intolerance

Summary of selected hormonal changes and their main metabolic effects usually seen in severe Protein Energy Malnutrition