Protein-energy Malnutrition (PEM) The Third Affiliated Hospital of Zhengzhou University Wangdiao
Definition PEM is a kind of malnutrition caused by inadequate dietary intake or some diseases, occurs commonly in children under 3 years of age. Kwashiorkor
Marasmus
Etiology The Primary PEM Inadequate food intake Inadequate food absorption
The Secondary causes Increased nutrient needs Disorder in nutrient absorption Increased body metabolism Certain metabolic abnormality
Pathophysiology Metabolic disorder
Protein metabolism anabolism & catabolism ; hypoalbuminemia
Fat metabolism mobilized fat store, acetone body ; metabolic acidosis; fatty liver
Carbohydrate: low hepatin, hypoglycemia
Fluid & electrolyte disorders hypernatremia; edema; potassium disorder; acid-base disturbances
Pathophysiology Disorders of Organ & Tissue function
Failure to thrive
Lower digested function ： diarrhea
Central nerve system: apathy or irritability
Cardiovascular system ： pulse slow, Low BP
Low renal function: urine amount decrease
Low immunologic function: easy to be infected
Clinical Manifestations
• • • • • • • •
Marasmus
Failure to gain weight Weight loss and listlessness skin become wrinkled and loose Subcutaneous fat disappear (sequence :abdomen→trunk → buttocks → extremities →face) Muscle: atrophy, hypotonia Constipation, a starvation diarrhea Pulse slow Irritability
Clinical Manifestations Edematous PEM (Kwashiorkor) • Lethargy, apathy, or irritability •
Inadequate growth
•
Increased susceptibility to infection
•
Vomiting, diarrhea, anorexia
•
Flabby subcutaneous tissue
•
Edema
•
Liver enlargement
•
Dermatitis
•
Hair sparse and thin
Complications of Malnutrition • • • • •
Nutritional deficiency anemia Deficiencies of vitamins and minerals Infections Infantile diarrhea Hypotonic dehydration
Physical Measurement WHO Zscore chronic or acute malnutrition system X － 3SD≤W/A<X － 2SD moderate W/A<X － 3SD severe
underweight
stunting long-term chronic malnutrition X － 3SD≤H/A<X － 2SD moderate H/A<X － 3SD severe
wasting recent acute malnutrition X － 3SD≤W/H<X － 2SD moderate W/H<X － 3SD severe
Laboratory Examination Serum albumin concentration Normal: >35g/L; Diagnose:< 25g/L
Serum Pre-albumin concentration Normal: 150 ～ 296mg/L; Mild deficiency: 100 ～ 150mg/L; Moderate:50 ～ 100mg/L;
Severe:<50mg/L
Urine hydroxy-proling concentration
Diagnosis History Clinical manifestations Anthropometric indicators Laboratory examination
Principles of Treatment To treat the primary disease To provide adequate nutrients intakes
To supply energy and protein
To keep the Fluid & electrolyte balance
To supply multi-vitamins
To provide the accelerant for protein synthesize
Supporting therapy
Management of malnutrition • Provision of Optimum Nutrition and Energy The mild : 60~80kcal/kg/day→--→ The moderate to severe : 45~60kcal/kg/day→ -- →-- →140kcal/kg/day
• Supplement of Vitamin and Minerals • Establish Appropriate Diet Habit
Prevention promoting the skills for breast-feeding
and the introduction of supplementary Food Nutrition education Growth monitoring Prevention and treatment of infectious diseases