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Revision as of 13:06, 7 August 2017
Protein energy malnutrition Microchapters |
Patient Information |
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Differentiating Protein energy malnutrition from other Diseases |
Diagnosis |
Treatment |
Case Studies |
Protein energy malnutrition overview On the Web |
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Risk calculators and risk factors for Protein energy malnutrition overview |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Omodamola Aje B.Sc, M.D. [2]
Overview
Protein energy malnutrition is defined by measurements that fall below 2 standard deviations under the normal weight for age (underweight), height for age (stunting) and weight for height (wasting). There are 2 major diseases in the spectrum known as kwashiorkor and marasmus and a variant known as marasmic kwashiorkor. Patients with kwashiorkor usually have swollen abdomen due to hepatomegaly, a round face and swollen extremities due to edema. Patients with marasmus on the other hand have monkey faces because of depletion of the subcutaneous fat in the cheek due to a total deficiency in caloric intake. This disease is prevalent in developing countries and typically affects children between the ages of 1 and 5 (post weaning period). Protein energy malnutrition can be fatal, but if addressed promptly and the nutritional status of the child is restored, it resolves completely without sequelae.
Historical Perspective
Classification
Protein energy malnutrition may be classified according to the Gomez classification based on weight for age, or the Water low classification based on stunting and wasting or the Welcome classification based on the presence or absence of edema.
Pathophysiology
Causes
There are various explanations for the development of kwashiorkor, and the topic remains controversial[1]. It is now accepted that protein deficiency, in combination with energy and micronutrient deficiency, is certainly important but may not be the key factor. The condition is likely to be due to deficiency of one of several type one nutrients (e.g. iron, folic acid, iodine, selenium, vitamin C), particularly those involved with anti-oxidant protection. Important anti-oxidants in the body that are reduced in children with kwashiorkor include glutathione, albumin, vitamin E and polyunsaturated fatty acids. Therefore, if a child with reduced type one nutrients or anti-oxidants is exposed to stress (e.g. an infection or toxin) he/she is more liable to develop kwashiorkor.
Ignorance of nutrition can be a cause. Dr. Latham, director of the Program in International Nutrition at Cornell University cited a case where parents who fed their child cassava failed to recognize malnutrition because of the edema caused by the syndrome and insisted the child was well-nourished despite the lack of dietary protein.
One important factor in the development of kwashiorkor is aflatoxin poisoning. Aflatoxins are produced by molds and ingested with moldy foods. They are toxified by the cytochrome P450 system in the liver, the resulting epoxides damage liver DNA. Since many serum proteins, in particular albumin, are produced in the liver, the symptoms of kwashiorkor are easily explained. It is noteworthy that kwashiorkor occurs mostly in warm humid climates that encourage mold growth, in dry climate marasmus is the more frequent disease associated with malnutrition. This has important consequences for treatment of the patients: Protein should be supplied only for anabolic purposes, the catabolic needs should be satisfied with carbohydrate and fat. Protein catabolism involves the urea cycle, which is located in the liver and can easily overwhelm the capacity of an already damaged organ. The resulting liver failure can be fatal.
Other malnutrition syndromes include marasmus and cachexia, although the latter is often caused by underlying illnesses.
Differentiating Kwashiorkor from other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Progonosis
Diagnosis
History and Symptoms
Symptoms of kwashiorkor
Symptoms of kwashiorkor include a swollen abdomen known as a pot belly, as well as reddish discoloration of the hair and depigmented skin. The swollen abdomen is generally attributed to two causes: First, the observation of ascites due to increased capillary permeability from the increased production of cysteinyl leukotrienes (LTC4 and LTE4) as a result of generalized intracellular deficiency of glutathione. It is also thought to be attributed to the effect of malnutrition on reducing plasma proteins (discussed below), resulting in a reduced oncotic pressure and therefore increased osmotic flux through the capillary wall. A second cause may be due to a grossly enlarged liver due to fatty liver. This fatty change occurs because of the lack of apolipoproteins which transport lipids from the liver to tissues throughout the body. Victims of kwashiorkor fail to produce antibodies following vaccination against diseases including diphtheria and typhoid.[3] Generally, the disease can be treated by adding food energy and protein to the diet; however, mortality can be as high as 60% and it can have a long-term impact on a child's physical growth and, in severe cases, affect mental development.
Physical Examination
Laboratory Findings
X ray
CT
MRI
Echocardiography or Ultrasound
Other Imaging Findings
Other Diagnostic Studies
Treatment
Medical Therapy
Surgery
Primary Prevention
Secondary Prevention
References
- ↑ Krawinkel M. (2003) Kwashiorkor is still not fully understood. Bull World Health Organ, vol.81, no.12, p.910-911.