Module Two: Diseases Of Poverty

     

Malnutrition: Protein-Calorie

Background

Protein-calorie malnutrition (PCM) is present when sufficient energy and/or protein is not available to meet metabolic demands, leading to impairment in normal physiologic processes. Infants and younger children are more susceptible to PCM, though PCM may occur at any age. PCM is more likely in the presence of infection, malaria, trauma, burns, malabsorptive states, diabetes mellitus, pregnancy, and lactation.

Classification

• Kwashiorkor is a condition that develops in the presence of gross protein deficiency, though non-protein calorie intake may be adequate.
  
  
• Marasmus occurs with deficiency of both protein and calories.
  
  
• PCM is classified according to the degree of severity and by calculating actual weight as a percentage of the expected weight for height.
  
  
• 1st Degree PCM: 85% to 90% of expected weight, characterized by growth failure in children and wasting in adults
  
  
• 2nd Degree PCM: 75% to 85% of expected weight, characterized by additional biochemical changes
  
  
• 3rd Degree PCM: less than 75% of expected weight

• Stunted growth and reduction in subcutaneous fat in adults
  
  
• Stunted growth, wasted body habitus, delayed puberty, and retarded cognitive and psychosocial development in children
  
  
• Decreased handgrip strength
  
  
• Risk of intrauterine growth retardation in pregnant women
  
  
• Reduced volume of breast milk with low fat content

• Muscle wasting in the extremities
  
  
• Loss of subcutaneous fat
  
  
• Atrophy of temporalis and interosseus hand muscles
  
  
• Decreased skin elasticity
  
  
• Delayed wound healing
  
  
• Decubitus ulcers
  
  
• Dry, reddish-brown, sparse hair
  
  
• Lethargy, early satiety, vomiting, and constipation
  
  
• Heart rate, blood pressure, and core body temperature may be subnormal
  
  
• Marasmic infants show gross weight loss, growth retardation, and wasting of subcutaneous fat and muscle
  
  
• Kwashiorkor is characterized by generalized edema, flaky painful dermatoses, sparse hair with pigment changes, enlarged and fatty liver, and petulant apathy.

• Inadequate dietary intake
  
  
• Poor quality dietary protein
  
  
• Increased metabolic demands
  
  
• Increased nutritional losses

• Differential diagnosis includes pellagra, nephrosis, cardiac failure, cystic fibrosis, malabsorption, congenital defects, and deprivation.
  
  
• Laboratory findings include reduced plasma albumin, decreased lymphocyte count, decreased blood urea nitrogen (BUN), decreased plasma transferrin, and hypoglycemia.
  
  
• Abnormal triceps skinfold thickness
  
  
• Abnormal mid-arm muscle area (MAMA) measurement
  
  
• Marasmus is characterized by muscle wasting and reduction in muscle mass due to glyconeogenesis. Mummified appearance, no edema, fat deposits reduced, and loss of subcutaneous fat.
  
  
• Kwashiorkor is characterized by impaired protein synthesis and hypoalbuminemia, which causes dependent edema. Impaired beta lipoprotein synthesis causes fatty liver.

• Inpatient care is needed for severe anemia, dehydration, electrolyte imbalance, and superimposed infections. Outpatient care is appropriate for stabilized patients.
  
  
• Death in the first few days of treatment is usually due to electrolyte imbalance, infection, hypothermia, or circulatory failure. Jaundice, petechiae, low serum sodium, and stupor are ominous signs.
  
  
• Recovery is generally more rapid in kwashiorkor than in marasmus.
  
  
• Diarrhea due to other causes should be identified and treated.
  
  
• Supplementary vitamins and micronutrients can be given.
  
  
• Mild anemia usually responds to oral protein, iron, and folic acid supplements.

• For infants and children, adequate calories should be supplied by adding sugar and cereal to a mild diet.
  
  
• Small, frequent feedings around the clock are better tolerated in the early stages of treatment.
  
  
• Gradually supplement diet with high-energy foods, such as candies, cakes, puddings, meats, eggs, and fruit juices.

• Emphasize nutritional education and continuous nutritional care.
  
  
• Routinely record height and weight.
  
  
• Seek early recognition of increased nutritional needs during stress and infection.

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