Childhood protein energy malnutrition

Childhood Protein-
Energy Malnutrition
Prof . Dr. Saad S Al Ani
Prof. of Pediatric
Senior {Pediatric Consultant
Saad’s Kids Clinic
saadssalani@gmail.com

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
07/09/2021
Childhood Protein-Energy Malnutrition
Prof. Dr. Saad S Al Ani
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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.

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

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.

Malnutrition
can be also classified as:
acute versus chronic
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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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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

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/

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Children who are <-3SD
weight-for-age may be
stunted (short stature) but
not severely wasted.

Etiology
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• Inadequate food intake (most common
cause )
• Ineffective weaning (significant)
secondary to:
ignorance economic factors
poor hygiene cultural factors

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

Etiology (Cont.)
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• Gastrointestinal infections because of
associated:
diarrhea
anorexia
vomiting
increased metabolic needs
decreased intestinal absorption

Etiology (Cont.)
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Diseases, such as:
• cystic fibrosis
• chronic renal failure
• childhood malignancies
• congenital heart disease
• neuromuscular diseases
(developed countries)

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.

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Protein-energy malnutrition
occurs when weight loss of
greater than 10% of normal
body weight occurs.

Pathophysiology
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Marasmus
Insufficient energy
intake
The body draws on its own stores
emaciation

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

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 )

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

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The most common and clinically
significant micronutrient deficiencies in
children and childbearing women
• Iron
• Iodine
• Zinc
• Vitamin A

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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Physical findings that are
associated with PEM include the
following:
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1.Decreased subcutaneous tissue
Areas that are most affected are :
• The legs
• The arms
• The buttocks
• The face
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2.Edema
Areas that are most affected are :
• The distal extremities
• Anasarca (generalized edema)

3.Oral changes
• Cheilosis
• Angular stomatitis
• Papillar atrophy
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4.Abdominal findings
• Abdominal distention secondary to poor
abdominal musculature
• Hepatomegaly secondary to fatty infiltration
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5.Skin changes
• Dry, peeling skin with raw, exposed areas
• Hyperpigmented plaques over areas of
trauma
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6.Nail changes
• Fissured or ridged nails
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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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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

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Kwashiorkor features
• Peripheral pitting edema
• “Moon facies,"
• Hepatomegaly
• Pursed mouth

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https://www.toppr.com/ask/content/story/amp/malnutrition-46106/

The most common and clinically
significant micronutrient
deficiencies and their consequences
include the following:
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Iron deficiency
• Fatigue • Headache
• Anemia • Glossitis
• Decreased
cognitive function
• Nail changes
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Iodine deficiency
• Goiter
• Developmental delay
• Mental retardation
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Vitamin D deficiency
• Poor growth
• Rickets
• Hypocalcemia
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Vitamin A deficiency
• Night blindness • Poor growth
• Xerophthalmia • Hair changes
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Folate deficiency
• Glossitis
• Anemia (megaloblastic)
• neural tube defects
(in fetuses of women without folate supplementation)
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Zinc deficiency
• Anemia • Acrodermatitis
enteropathica
• Dwarfism • Diminished immune
response
• Hepato-
splenomegaly
• Poor wound healing
• Hyperpigmentation and hypogonadism
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Initial diagnostic laboratory
studies include the following:
• Complete blood count
• Sedimentation rate
• Serum electrolytes
• Urinalysis
• Culture
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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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The most helpful laboratory
tests for assessing malnutrition
in a child are:
- Hematologic studies
- Protein status studies
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Hematologic studies should
include a complete blood count
with red blood cell indices and
a peripheral smear.
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Measures of protein
nutritional status :
Serum albumin Transferrin
Retinol-binding
protein:
Creatinine
Prealbumin Blood urea
nitrogen
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Other studies may focus on
thyroid functions or sweat
chloride tests, particularly if
height velocity is abnormal.
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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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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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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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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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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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The requirement for increased
protein is met typically by
increasing the food intake
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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

Refeeding syndrome
is a potentially life
threatening condition that
occurs with administration
of high calorie feeds in
severely malnourished
children
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Refeeding syndrome (Cont.)
• This potentially fatal
condition is associated with
electrolyte disturbances
including:
- hypokalemia
- hypophosphatemia
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Moderate to severe malnutrition
In moderate to severe cases
of malnutrition, enteral
supplementation via tube
feedings may be necessary
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Moderate to severe malnutrition
In moderate to severe cases
of malnutrition, enteral
supplementation via tube
feedings may be necessary
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1.Starts with an emphasis
on prenatal nutrition and
good prenatal care
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2. Promotion of
breastfeeding is particularly
crucial in developing
countries
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3.The appropriate
introduction of nutritious
supplemental foods.
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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

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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Simply
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Marasmus represents an
adaptive response to starvation
kwashiorkor represents a
maladaptive response to starvation

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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