Malnutrition

Protein / Energy

Compiled answers of Nica, Lesh and Harvey

GIVEN:

12 year old girl grade 3 brought to ER: difficulty breathing pneumonia second degree malnutrition third bout with acute respiratory infection this year

QUESTIONS:

By how much and in how long did she lose weight? Onset of respiratory infection/ pneumonia? Agent of respiratory infection? How certain it is second degree? Nutrition of patient? Lab exams? Weight, height and BMI of patient MAMC? Triceps skin fold? Serum albumin? Total ironbinding capacity?

DEFINITION OF TERMS:

Environmental diseases are conditions caused by exposure to chemical or physical agents in the ambient, workplace, and personal environments. The most common air pollutants are ozone, which in combination with oxides and particulate matter forms smog; sulfur dioxide; acid aerosols; and particles of less than 10 m in diameter. Carbon monoxide is an air pollutant and important cause of death from accidents and suicide; it binds hemoglobin with high affinity and causes systemic asphyxiation with CNS depression.

DEFINITION OF TERMS

Secondary Malnutrition: otherwise known as Conditional Malnutrition; supply of nutrients is adequate, but malnutrition may result from nutrient malabsorption, impaired nutrient use or storage, excess nutrient losses, or increased need for nutrients (Robbins) Second Degree Malnutrition: 60% decrease in body weight Street urchins are homeless children who roam the streets in urban areas. In Victorian England, they were called "street Arabs"; see the Baker Street Irregulars in the Sherlock Holmes stories

DEFINITION OF TERMS:

Like many infections, pneumonia usually produces fever, which in turn may cause sweating, chills, flushed skin and general discomfort. The child also may lose her appetite and seem less energetic than normal. If she's a baby or toddler, she may seem pale and limp and cry more than usual. Because pneumonia can cause breathing difficulties, you may notice the following more specific symptoms:

Cough Fast, labored breathing Increased activity of the breathing muscles below and between the ribs and above the collarbone Flaring (widening) of the nostrils Wheezing Bluish tint to the lips or nails, caused by decreased oxygen in the bloodstream

DEFINITION OF TERMS:
Differentials for Pneumonia: Asthma Bronchitis Smoke Inhalation Atelectasis Acute Respiratory Distress Syndrome

Definitions of Malnutrition

Kwashiorkor: protein deficiency Marasmus: energy deficiency Marasmic/ Kwashiorkor: combination of chronic energy deficiency and chronic or acute protein deficiency Failure to thrive: marasmus in U. S. children under 3.

Definitions of Malnutrition
PEM Primary: inadequate food intake Secondary: result of disease FTT In-organic: inadequate food intake Organic: result of disease

DIFFERENTIALS:

Asthma

Asthma is a condition characterized by paroxysmal narrowing of the bronchial airways due to inflammation of the bronchi and contraction of the bronchial smooth muscle. The inflammatory component is central to the pathogenesis of symptoms: dyspnea, cough, and wheezing.

Bronchitis

Acute bronchitis refers simply to inflammation of the tracheobronchial tree. The cause is usually infectious, but allergens and irritants can produce a similar clinical picture. Typically occurs in the setting of an upper respiratory illness; thus, it is observed more frequently in the winter months. Asthma can be mistakenly diagnosed as acute bronchitis if the patient has no prior history of asthma. In one study, one third of patients who had been determined to have recurrent bouts of acute bronchitis were eventually identified as having asthma.

Smoke Inhalation

Inhalation injury 3 Mechanisms:

Thermal damage Asphyxiation Pulmonary Irritation

Pulmonary injury due to smoke inhalation

Smoke Inhalation Pathophysiology

Inhalation injury occurs in 3 ways: (1) by cell injury and pulmonary parenchymal damage by irritants, (2) hypoxemia by interruption of oxygen delivery by asphyxiants, and (3) end organ damage by systemic absorption through the respiratory tract. Respiratory embarrassment can be broadly categorized as the result of thermal or chemical damage to the epithelial surfaces of the intrathoracic and extrathoracic airways.

Smoke Inhalation Pathophysiology

Secondary insult with bacterial pneumonia may occur days after inhalation, causing further cytotoxic damage. Ciliary function is impaired, leading to accumulation of airway debris. The inflammatory cascade initiates neutrophil infiltration. Macrophages within the alveoli are destroyed, allowing bacteria to proliferate. Lack of an intact epithelial barrier further facilitates the development of pneumonia.

Atelectasis

Complete or partial lung collapse Caused by a blockage of the air passages (bronchus or bronchioles) or by pressure on the lung. Risk factors for atelectasis include anesthesia, prolonged bed rest with few changes in position, shallow breathing, and underlying lung diseases. Mucus that plugs the airway, foreign objects (common in children) in the airway, and tumors that obstruct the airway Symptoms: breathing difficulty, chest pain, cough

ARDS

Acute respiratory distress syndrome (ARDS) is characterized by the development of sudden breathlessness within hours to days of an inciting event. Inciting events include:

trauma, sepsis (microorganisms growing in a person's blood), drug overdose, massive transfusion of blood products, acute pancreatitis, or aspiration (fluid entering the lungs, especially stomach contents).

SUPPORTING STUDIES:
Acquired cell-mediated immunodeficiency is the most common kind of immunodeficiency. It can develop in association with protein-calorie malnutrition Pulmonary Infections in Immunocompromised Hosts: The Importance of Correlating the Conventional Radiologic Appearance with the Clinical Setting1 Yu Whan Oh, MD, Eric L. Effmann, MD and J. David Godwin, MD

SUPPORTING STUDIES:
Protein-energy malnutrition (PEM) is a major public health problem in the tropical and subtropical regions of the world and often arises during protein and / or energy deficit due to nutritional inadequacy, infections and poor socio-economic and environmental conditions. It is the most common nutritional disorder affecting children in developing countries and the third most common disease of childhood in such countries. PEM has a lasting effect on immune functions, growth and development of children, learning ability, social adjustment, work efficiency and productivity of labour. It seems that many deaths from PEM occur as a result of outdated clinical practices and that improving these practices reduces the rate of morbidity and mortality.http://www.surgical-pathology.com/protein_calorie_malnutrition.htm

SUPPORTING STUDIES:

Association of resident, facility, and geographic characteristics with chronic undernutrition in a nationally represented sample of older residents in U.S. nursing homes.J Nutr Health Aging. 2007 Mar-Apr;11(2):179-84. CONCLUSION: This study found a high percentage of chronic undernutrition in this nationally representative sample of U.S. nursing home residents. Furthermore, resident, facility, and geographic characteristics were associated with chronic undernutrition. Strategies need to be developed and documented that ensure nutritional health to residents with a variety of health problems.

SUPPORTING STUDIES:

Diarrheal disease as a cause of malnutrition.Am J Trop Med Hyg. 1992 Jul;47(1 Pt 2):16-27. Although long associated with infectious diseases, malnutrition is recognized as a major effect of specific infections, especially those of the gastrointestinal tract. Synergistic exacerbation of infections and nutritional deficiency commonly begin with weaning, where the impact of repeated infections and possible monocyte mediator release may have an even greater effect on malnutrition of young children than that of deficient diets in many areas. Reviewed here are the detailed host alterations seen with specific enteric infections that lead to malnutrition. These include mucosal dysfunction, systemic metabolic responses, impaired intake, digestion and absorption, nutrient losses, altered immune responses, and ultimately, impaired growth, development, and nutrition. The tremendous health impact of diarrhea on both morbidity and mortality in many developing areas must be recognized and controlled along with correction of food shortages in order to improve the nutrition, growth, and survival of impoverished children.

ETIOLOGY AND PATHOPHYSIOLOGY:

Malnutrition and Pneumonia

History: Malnutrition

Marasmus well known for centuries Kwashiorkor: Cicely Williams

Ga tribe in Ghana the sickness the older child gets when the next baby is born Starch edema, sugar babies

Similar but different diseases

How many?

36% of children in the world are underweight 43% stunted 9% wasted Better nutrition, but more children in high risk areas, yields more children affected.

Causes: Malnutrition

Social and Economic

Poverty Ignorance Inadequate weaning practices Child abuse Cultural and social practices

Vegan Low fat diets

Causes: Malnutrition

Inadequate food intake is the most common cause of malnutrition worldwide. In developing countries, inadequate food intake is secondary to insufficient or inappropriate food supplies or early cessation of breastfeeding. In some areas, cultural and religious food customs may play a role. Inadequate sanitation further endangers children by increasing the risk of infectious diseases that increase nutritional losses and alters metabolic demands. In developed countries, inadequate food intake is a less common cause of malnutrition. Instead, diseases and, in particular, chronic illnesses play an important role in the etiology of malnutrition. Children with chronic illness are at risk for nutritional problems for several reasons, including the following:

Children with chronic illnesses frequently have anorexia, which leads to inadequate food intake. Increased inflammatory burden and increased metabolic demands can increase caloric need. Any chronic illness that involves the liver or small bowel affects nutrition adversely by impairing digestive and absorptive functions.

Causes: Malnutrition

Chronic illnesses that commonly are associated with nutritional deficiencies include the following:

Cystic fibrosis Chronic renal failure Childhood malignancies Congenital heart disease Neuromuscular diseases Chronic inflammatory bowel diseases

In addition, the following conditions place children at significant risk for the development of nutritional deficiencies:

Prematurity Developmental delay In utero toxin exposure (ie, fetal alcohol exposure)

Children with multiple food allergies present a special nutritional challenge because of severe dietary restrictions. Patients with active allergic symptoms may have increased calorie and protein needs.

Biologic factors: Malnutrition

Maternal malnutrition, prematurity

Start life with poor stores Diarrhea, Aids, TB, measles Unsanitary living, poor quality water Agricultural/cultural patterns Droughts, floods, wars, forced migrations

Infectious disease

Environmental

Age of child

Infants and young children

High nutritional needs Early weaning or late weaning Poor hygiene

Marasmus < 1 year Kwashiorkor >18 months with starchy weaning foods

Pathophysiology: Malnutrition

Develops slowly, adapts to decreased intake

Marasmus Less fragile metabolic equilibrium Kwashiorkor, mixed

Less effective adaption or acute problem

Pathophysiology: Malnutrition

Malnutrition affects virtually every organ system. Dietary protein is needed to provide amino acids for synthesis of body proteins and other compounds that have a variety of functional roles. Energy is essential for all biochemical and physiologic functions in the body. Furthermore, micronutrients are essential in many metabolic functions in the body as components and cofactors in enzymatic processes. In addition to the impairment of physical growth and of cognitive and other physiologic functions, immune response changes occur early in the course of significant malnutrition in a child. These immune response changes correlate with poor outcomes and mimic the changes observed in children with acquired immune deficiency syndrome (AIDS). Loss of delayed hypersensitivity, fewer T lymphocytes, impaired lymphocyte response, impaired phagocytosis secondary to decreased complement and certain cytokines, and decreased secretory immunoglobulin A (IgA) are some changes that may occur.

Pathophysiology: Malnutrition

These immune changes predispose children to severe and chronic infections, most commonly, infectious diarrhea, which further compromises nutrition causing anorexia, decreased nutrient absorption, increased metabolic needs, and direct nutrient losses. Early studies of malnourished children showed changes in the developing brain, including, a slowed rate of growth of the brain, lower brain weight, thinner cerebral cortex, decreased number of neurons, insufficient myelinization, and changes in the dendritic spines. More recently, neuroimaging studies have found severe alterations in the dendritic spine apparatus of cortical neurons in infants with severe protein-calorie malnutrition. These changes are similar to those described in patients with mental retardation of different causes. There have not been definite studies to show that these changes are causal rather than coincidental. Other pathologic changes include fatty degeneration of the liver and heart, atrophy of the small bowel, and decreased intravascular volume leading to secondary hyperaldosteronism.

Energy : Malnutrition

Decreased intake yields decreased activity

Decreased play and physical activity

Mobilization of body fat, weight loss,

Subcutaneous fat Muscle wasting

Nl albumin

Maintains visceral protein in marasmus

Larger protein deficit leads to faster visceral protein falls and edema.

Biologic differences: Malnutrition

Marasmus

Kwashiorkor

Weight loss Nl or low protein Boarderline hgb, hct NL AA profile Nl blood glucose Nl enzymes Nl transaminase

NO weight loss High extracellular water Low hgb, hct Low protein Elevated AA profile Low enzymes High transaminase

Pathophysiology: Malnutrition

Cardiac

Output, heart rate and blood pressure decrease Postural hypotension T lymphocytes and complement decreased Susceptible to bacterial infection

Immune system

Cytokines (glycoproteins)

Poor immune response TNF inc leading to anorexia, muscle wasting and lipid changes

Pathophysiology: Malnutrition

Decreased total body potassium

Not electrolytes, but problem in rehabilitation Poor absorption of lipids, and sugars Decreased enzyme and bile production Increase incidence of diarrhea, and bacterial overgrowth

GI function

Pathophysiology: Malnutrition
CNS

Decreased brain growth and myelnation Electrical changes similar to dylexia

Parental adaptation

Increased breastfeeding Altered expectations

Etiology: Pneumonia naman

Most pneumoniae follow a viral upperrespiratory-tract infection. Typically, the viruses that cause these infections (respiratory syncytial virus [RSV], influenza, parainfluenza, adenovirus) spread to the chest and produce pneumonia there.

Etiology

Other viruses, such as those related to:

measles, chickenpox, herpes, infectious mononucleosis and rubella, may travel from various parts of the body to the lungs, where they also can cause pneumonia.

Pathophysiology

Pneumonia is an inflammatory pulmonary process that may originate in the lung or be a focal complication of a systemic process. Abnormalities of airway patency as well as alveolar ventilation and perfusion frequently ensue due to various mechanisms.

Epidemiology: Malnutrition
In 2005, in all developing countries 32% of children under 5 years of age (178 million children) were estimated to be stunted (that is, their height fell 2 standard deviations below the median height-for-age of the reference population). In that year, more than 40% of stunting was found in the WHO regions of Africa and South-East Asia, around 25% in the Eastern Mediterranean Region and 1015% in the regions of the Americas and the Western Paci c. Of the 39 countries with a prevalence of stunting of 40% and higher, 22 are in the African Region, 7 in South-East Asia, 4 in the Eastern Mediterranean, 4 in the Western Paci c, and 1 each in Europeand in the Americas. Of the 35 countries with a stunting prevalence lower than 20%, 13 are in the Region of the Americas, 11 in Europe, 6 in the Eastern Mediterranean, 3 in the Western Paci c and 2 in South-East Asia.Wasting (de ned as being 2 standard deviations below the median of weightfor-height) is a sign of acute mal-nutrition and is a strong predictor of mortality among children. The global estimate of wasting occurring among children under 5 years of age based on WHOs new standards is 10% (or 55 million). The highest number of affected children 29 million is estimated to live in southcentral Asia. The same regional pattern is found for severe wasting (dened as being 3 standard deviations below the median), with an estimated total preva-lence of 4% or 19 million children affected. Many of these children are likely to die before reaching the age of 5 years. In general, compared with estimates based on the previous international reference, stunting rates are higher for all age groups when the new WHO standards are used. Additionally, the prevalences of wast-ing and severe wasting are higher during the rst half of infancy with the new WHO standards; and thereafter severe wasting rates continue to be 1.5 to 2.5 times higher than those of the previous reference.

Epidemiology: pneumonia

Epidemiology: Pneumonia

Epidemiology: correlation WHO

Incidence and Epidemiology

(PDI, 7/5/08) 4M Malnourished Filipino Children. Four million Filipino children are malnourished and the number is expected to grow as record-high inflation force households to cut down on food, officials of the Food and Nutrition Research Institute (FNRI) said. Capanzana said Filipino children are not eating enough vegetable. Their diet, he said, consists mostly of foods high in salt and sugar and low in nutrition.

Incidence and Epidemiology

Our estimate is that there are 3.7 million schoolchildren who are malnourished, he said. Most of the schoolchildren, Capanzana said, are undernourished or have low protein, energy, and vitamin intake. About 1.6 million kids are over-nourished, meaning they are either overweight or obese, he said. On the other hand, the number of overweight or obese children, he said, is rising because of their consumption of fatty foods.

Incidence and Epidemiology

According to Capanzana, an average Filipino childs diet is low in fruits and vegetables and consists mostly of convenient and junk foods that are high in salt, sugar, and fat. A recent study by the National Nutrition Council revealed that children below 5 years old are eating an average of only 23 grams of vegetables per day, 50 percent less of the recommended intake that their growing bodies need. Furthermore, vegetables are not in FNRIs list of 10 food items commonly consumed by children five years old and below. Among those commonly consumed by children are rice, comprising over 80 percent, coconut oil, refined white sugar, powdered filled milk, brown sugar, egg, pan de sal, chocolate drinks, and instant noodles.

Management: Pharmacologic and Nonpharmacologic

Pneumonia and Malnutrition

Management: Pharmacological

Ordinarily, no medication is necessary.Because it is often difficult to tell whether the pneumonia is caused by a virus or by bacteria, your pediatrician may prescribe an antibiotic. All antibiotics should be taken for the full prescribed course and at the specific dosage recommended. You may be tempted to discontinue them early because your child will feel better after just a few days, but if you do this, some bacteria may remain and the infection might return.

Management: Non-pharmacological

When pneumonia is caused by a virus, there is no specific treatment other than rest and the usual measures for fever. Cough suppressants containing codeine or dextromethorphan should not be used because coughing is necessary to clear the excessive secretions caused by the infection. Viral pneumonia usually disappears after a few days, though the cough may linger up to several weeks.

Management: Non-pharmacological

Your child should be checked by your pediatrician as soon as you suspect pneumonia. You should check back with the doctor if your youngster shows any of the following warning signs that the infection is worsening or spreading: Fever lasting more than two or three days despite the use of antibiotics Breathing difficulties Evidence of infection elsewhere in the body: red, swollen joints, bone pain, neck stiffness, vomiting

Treatment: for Malnutrition

Acute/ life threatening

Fluid and electrolyte

K and Mg shifts Oral rehydration, slowly 70-100 ml/kg Aggressive treatment, but disease alters metabolism of drugs Anemia and heart failure, care with transfusions and no diurretics Vitamin A: immediate treatment

Infections: main cause of death

Other deficiencies

Treatment: for Malnutrition

Slow re-feeding

Small frequent feeding around the clock Patient encouragement of food Play and teaching controlinfections

Nutritional rehabilitation

Recovery?: Malnutrition

At home Reach weight for height and replete muscle mass

Normal is 25-75% weight for height and continue for one months after

Treat other deficiencies Family problems Who does this include here?

Tube feeding. Disabilities FTT

NOTE from Nica:

See Chapter in Pharma on Toxicology. Remedies enumerated for Environmental toxins (in this case kasi were unsure of the patients exposure so enumerate ninyo na lang)

What does it mean?

Poverty

Correlation of income, wt, ht and hgb in US What is wealth? Importance of food choice Iron deficiency: neuro transmitters Brain waves:

Brain development

What does it mean?

Learning:

Difference in treatment by parents

Duration of breastfeeding Expectations INCAP two villages, one protein and one calorie At 18 protein supplemented group had higher performance scores irrespective of educational exposure. They had taught themselves.

Long term effects

What does it mean?

Learning:

Difference in treatment by parents

Duration of breastfeeding Expectations Educational intervention, early rise plateau Nutritional intervention, late rise Additive effect Education lasts, not nutrition, but high IQ moms and nutrition group did as well as education.

Slums of Kingston, Jamaica

Implications

Children learn by interacting with the environment

Poverty: limited environment Malnutrition: limited interaction Additive effect! Lead graph

Loss to society of human potential

Management Inputs

Make sure that the children eat vegetables at a young age. Parents should also try to be creative in preparing vegetables. Capanzana said the FNRI have developed food items that are fortified with vegetables. They have manufactured pan de sal using Vitamin A-rich squash flour and noodles using pureed saluyot, Capanzana explained.

PH:
1. 2. 3.

4.
5. 6. 7. 8. 9.

Accessibility Availability Economic Information Dissemination Sustainable development Empowerment Overpopulation Sanitation/ Environment Acceptability

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