Pem Finally 1

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OVER VIEWINTRODUCTION

ETIOPATHOPHYSIOLOGY

CLASSIFICATION

INDICATORS

TREATMENT

DEFINITION : A range of pathological conditions arising from coincident lack of protein and calories in varying proportion, occuring most frequently in infants ,young children and usually associated with infections. Cecilly Williams, a British nurse, introduced the word

Kwashiorkor (1933) - the sickness of weaning marasmos-wasting. The term protein energy malnutrition has been adopted by WHO in 1976

PATHOPHYSIOLOGY

Dietic hypothesis

Adaptation hypothesis by Gopalan

VITERIS time scale theory

GOLDEN free radical injury theory

ADAPTATION THEORY Inadequate energy HPA axis Increased cortisol levels catabolism Musle wasting EAA production Synthesis of albumin & beta lipoprotein

NO OEDEMA

NO FATTY LIVER

DSYSADAPTATION THEORY Protein depletion

Protein intake Cortisol elevation Increased GH Not sustained hypoproteinemia lipolysis Decreased AA pool

Decreased Insulin& sometomedins

Decreased lipogenesis Increased fatty acid Decreased protein syn. flux FATTY LIVER OEDEMA

OEDEMA

HORMONES Growth hormone Cortisol Insulin & IGF Glucagon Thyroxine Somatomedins

MARASMUS Very high Very high Normal Normal/variable Normal/variable Low

KWASHIORKAR Low High (not sustained) Low Normal/variable Normal/variable Very low

ETIOLOGYSocioeconomic, environmental and cultural factors

Medical factors

Decreased absorption and increased losses

Increased demands

ASSESSMENT OF NUTRITIONAL STATUSDIRECT METHODSClinical signs Anthropometry Biochemical tests Biophysical methods

INDIRECT METHODS

Dietary survey Health statistics Ecological factors

CLINICAL PRESENTATION Affected by:

degree of deficiency duration of deficiency speed of onset age at onset Presence of conditioning factors Genetic factors

KWASHIORKAR Essential features : Growth failure Oedema Muscle wasting Psychomotor changes

Non essential features : Skin & hair changes Anemia GIT changes Vitamin deficiencies tremors

MARASMUSGrowth retardation Irritable Muscle wasting Other changes

ANTHROPOMETRIC MEASUREMENTS AGE DEPENDENTWeight Height Mid arm circumference Head circumference Chest circumference Head and chest growth ratios Upper segment/lower segment ratio Arm span

AGE INDEPENDENTMid arm circumference Kanawati index MAC to height ratio Rao & singhs (quetlet index) Dugdales index HC / CC MAMC BMI

BIOPHYSICAL INDICATORSNORMAL Mean bulb diameter Hair bulb atrophy No. of anagens No. of telogens >0.11mm 0-25% >50% 90% 75-90% 60-75% 90 % 80-90% 70-80% 60-70% 93%

>90%

First degree stunting Second degree stunting

90-95%

80-93%

80-90%

85-90%

-

-

Third degree