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Protein-EnergyMalnutrition
DepartmentofPediatricsZhejiangUniversitySchoolofMedicine
JIESHAOIntroduction
Thereismorethanone-thirdoftheworld'sunder-fivepopulationismalnourished.InChina:seriousPEMisrare,butmildormoderate
PEMarestillcommonNutritionalstatusofchildrenunder6years
Normal(eutrophy)Overweight/Obese
Protein-EnergyMalnutritionDefinitionPEM,amacronutrientdeficiency,notamicronutrientdeficiencyMainlyoccurinthechildren≦3yearsoldClassificationMarasmus
Severeinadequacyofenergyandnutrients，characterizedbyseverewastingClassificationEdema
(Kwashiorkor)hypoalbuminemic,edematousmalnutritionandpresentswithpittingedemathatstartsinthelowerextremitiesandascendswithincreasingseverity.ClassificationMarasmus-edemaIntermediateformsEtiologySecondary:DiseasefactorInadequatedigestion&absorptionoffood
AbnormalityofalimentarycanalMalabsorptionsyndromeInfection
TuberculosisParasitosisChronicwastingdisease
DiabetesHyperthyroidismPathophysiology1.Proteinmetabolismdisorderhypoalbuminemic2.GlucosemetabolismdisorderhypoglycemiaMetabolismabnormality
Pathophysiology
4.Water-electrolytemetabolismdisordersodiumpump’sfunctionaldisturbanceATPdecreaseextracellularfluidhypotensionHypotonicdehydrationMetabolicacidosisHypocalcemiaHypokalemiaPathophysiologyBodysystems’dysfunction
1.GastrointestinalSystem
Bowelmovement,quantityandactivityofenzymeDysbacteriosis、Infection、Diarrheaetc
2.CirculationSystem
Systoleweaken、bloodpressuredropdown、pulseextenuateetc
3.UrinarySystem
KidneyconcentratefunctionUrinaryvolumeUrinespecificgravity
4.NervousSystem
DecreaseofDNAandRNAinthebrainDelayofmotor/language/cognition/social-emotionaldevelopment
Impairedimmunity
Reduceof
nonspecificimmunity(deficitofanatomic-mucociliarybarrier)Impairedadaptiveimmuneresponses(involveantigen-specificTlymphocytesandBlymphocytes)Patientsarelikelytobestrickenbyvariouskindsofinfection。ClinicalmanifestationsPoorgrowth
GrowthfailurealwaysoccursThechildwillbefoundtobeshorter/lighterthannormalClinicalmanifestations
Temperature(hypothermia)SkinandHairchanges:dryandthin,sparseCirculationSystem
(bradycardia)GastrointestinalSystem
bowelsoundstendtobehypoactivediarrheaUrinarySystemNervousSystem
apatheticandweak,weakmuscletone
ClinicalmanifestationsKwashiorkor
Ocuursinchildrenaged1-3yr
Itisclassicallydescribedasbeingcausedbyinadequateproteinintake(fedonrelativelyhighstarchdiet.ClinicalmanifestationWasting,edema,sparsehairandpigmentedskin,monilialstomatitisandhepatomegaly.ComplicationsNutritionalanemia(IDA)Tracenutritionalelementdeficiency
VitaminAandzincdeficienciesInfectionSpontaneoushypoglycemia
DiagnosisHistory
InsufficientfoodsupplyImproperfeedingChronicwastingdisease
Symptoms&Signs
GrosslossofweightGrowthretardationWastingofsubcutaneousfatandmuscleClassificationGuidelinesforPediatricUndernutritionNutritionStatusWeight/AgeHeight/AgeWeight/Height%IBWWastingNormalorlowNormal<5thpercentile<85-90%Stunting<5thpercentile<5thpercentileNormalNormalMildmalnutritionNormalorlowNormal<5thpercentile81-90%ModeratemalnutritionNormalorlowNormal<5thpercentile70-80%KwashiorkorNormalorlowNormalorlowNormal(edema)NormalMarasmus(severewasting)LowNormalorlow<5thpercentile<70%Nutritionstatus
Underweight①Insufficientweightgainrelativetoage/genderweight②Moderate:
mean-3SD=weight<mean-2SD
Severe:
weight<mean-3SD③
Impliesslow/acute
malnutrition<TypingandgraduationStunting①Insufficientheightgainrelativetoage/sexheight②Moderate:
mean-3SD=Height<mean-2SD
Severe:
Height<mean-3SD③Implieslong-termmalnutrition<TreatmentEtiologytherapy
primarydiseaseDiettherapy1.Thegastrointestinaltractmaynottoleratearapidincreaseinintake.2.NutritionalrehabilitationshouldbeinitiatedandadvancedslowlytominimizethecomplicationsTreatment
Caloriesaregivenintheformofcarbohydrates,sugars,andfatsCaloricintakecanbeincreased10%to20%perdayMild:250~344kJ(60~80kcal)
/kg/d
Mid-Severe:from167~251kJ(40~60kcal)
/kg/d
to
628.0~711kJ(150~170kcal)/kg/dProtein:from1.5~2.0g/kgto3.0~4.5g/kgTreatmentSupplyvitaminandmineralsupplementsareessential(VitA5000IU,iron1~3mg,Zinc1mg)DrugtherapyPepsin,Pancreatin&VitaminBNandrolonePhenpropionatepromotethesynthesizeofproteinInsulinZincsupplementationChinesetraditionalmedicineComplicationtherapyrestoreandmaintainfluidandelectrolytebalancepreventandtreatspontaneoushypoglycemiabloodinfusion(<10ml/kg)ifsevereanaemiaIntensivecareEnoughsleepProperexerciseGooddiethabitTreatmentBeforetherapyAftertherapyPreventionProperfeedingencourage
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