Protein energy malnutrition overview: Difference between revisions
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==Overview== | ==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]]). Protein energy malnutrition is a nutritional deficiency resulting from either inadequate energy (caloric) or [[protein]] intake and manifesting in either [[marasmus]] or [[kwashiorkor]]. [[Marasmus]] is characterized by [[wasting]] of body tissues, particularly [[muscles]] and [[subcutaneous fat]], and is usually a result of severe restrictions in energy intake. [[Kwashiorkor]] affects mainly children, is characterized by [[edema]] (particularly ascites), and is usually the result of severe restrictions in [[protein]] intake. However, both types can be present simultaneously (marasmic kwashiokor) and mask [[malnutrition]] due to the presence of [[edema]]. The presence of severe of [[hypoproteinemia]], [[hypoalbuminemia]], [[electrolyte imbalance]] or an underlying [[HIV AIDS|HIV infection]] is associated with poorer prognosis among patients with protein energy malnutrition. | Protein energy malnutrition is defined by measurements that fall below 2 standard deviations under the normal [[weight]] for [[age]] ([[underweight]]), height for age ([[Stunted growth|stunting]]) and [[weight]] for [[height]] ([[wasting]]). Protein energy malnutrition is a nutritional deficiency resulting from either inadequate energy (caloric) or [[protein]] intake and manifesting in either [[marasmus]] or [[kwashiorkor]]. [[Marasmus]] is characterized by [[wasting]] of body tissues, particularly [[muscles]] and [[subcutaneous fat]], and is usually a result of severe restrictions in energy intake. [[Kwashiorkor]] affects mainly children, is characterized by [[edema]] (particularly ascites), and is usually the result of severe restrictions in [[protein]] intake. However, both types can be present simultaneously (marasmic kwashiokor) and mask [[malnutrition]] due to the presence of [[edema]]. The presence of severe of [[hypoproteinemia]], [[hypoalbuminemia]], [[electrolyte imbalance]] or an underlying [[HIV AIDS|HIV infection]] is associated with poorer prognosis among patients with protein energy malnutrition. | ||
==Historical Perspective== | ==Historical Perspective== | ||
The first clinical description of protein energy malnutrition was made in 1865 in Spanish which led to little dissemination of the information. In 1932, [[kwashiorkor]] was first described by Dr Cicely Williams, working with African children on the Gold Coast. The word [[kwashiorkor]] came from the Ga language of Accra, Ghana meaning the 'disease of the deposed baby when the next one is born'. The term [[marasmus]] is derived from the Greek word 'marasmos', which means [[Withering abalone syndrome|withering]] or [[wasting]]. | The first clinical description of protein energy malnutrition was made in 1865 in Spanish which led to little dissemination of the information. In 1932, [[kwashiorkor]] was first described by Dr. Cicely Williams, working with African children on the Gold Coast. The word [[kwashiorkor]] came from the Ga language of Accra, Ghana meaning the 'disease of the deposed baby when the next one is born'. The term [[marasmus]] is derived from the Greek word 'marasmos', which means [[Withering abalone syndrome|withering]] or [[wasting]]. | ||
==Classification== | ==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. | Protein energy malnutrition may be classified according to the 'Gomez classification' based on [[weight]] for [[age]], or the 'Water low classification' based on [[Stunted growth|stunting]] and [[wasting]] or the 'Welcome classification' based on the presence or absence of [[edema]]. | ||
==Pathophysiology== | ==Pathophysiology== | ||
Different pathophysiologic mechanisms are involved in the development of protein energy malnutrition as it comprises of two main diseases, kwashiorkor and marasmus. It is thought that kwashiorkor is produced by a deficiency in the adequate consumption of protein rich foods during the weaning process. However, the associated edema is not fully | Different pathophysiologic mechanisms are involved in the development of protein energy malnutrition as it comprises of two main [[diseases]], [[kwashiorkor]] and [[marasmus]]. It is thought that [[kwashiorkor]] is produced by a deficiency in the adequate consumption of [[Protein|protein-rich foods]] during the [[weaning]] process. However, the associated [[edema]] is not fully understood. Several theories have been put forward to explain this finding. [[Marasmus]] on the other hand is due to the total caloric deficiency leading to [[wasting]] in a child. [[Marasmus]] always results from a negative energy balance. | ||
==Causes== | ==Causes== | ||
Protein energy malnutrition may be caused by reduced breast feeding, poor weaning practices, limited availability of food and very little child care in cases of extreme poverty. This classically affects several poor people in regions of poor social and economic background. Other environmental causes such as infections, drought and earthquakes leading to decreased availability of food have also been identified. | Protein energy malnutrition may be caused by reduced [[breast feeding]], poor [[weaning]] practices, limited availability of food and very little child care in cases of extreme poverty. This classically affects several poor people in regions of poor social and economic background. Other environmental causes such as [[infections]], drought and [[Earthquake Valve|earthquakes]] leading to decreased availability of food have also been identified. | ||
==Differentiating Kwashiorkor from other Diseases== | ==Differentiating Kwashiorkor from other Diseases== | ||
Protein energy malnutrition must be differentiated from other diseases that cause | Protein energy malnutrition must be differentiated from other [[diseases]] that cause [[failure to thrive]], [[edema]], [[wasting]] [[Infections|recurrent infections]], [[skin]] and [[hair]] changes. It is important to also differentiate [[kwashiorkor]] from [[marasmus]] as the two [[diseases]] belong to the protein energy malnutrition. | ||
==Epidemiology and Demographics== | ==Epidemiology and Demographics== | ||
The prevalence of protein energy malnutrition in children under 5 is estimated to be 150 million cases annually. In Nigeria, the prevalence is as high as 41,600 per 100,000 children. Protein energy malnutrition is majorly a diseases of the developing countries. There is no racial or sexual predisposition. | The [[prevalence]] of protein energy malnutrition in children under 5 is estimated to be 150 million cases annually. In Nigeria, the [[prevalence]] is as high as 41,600 per 100,000 children. Protein energy malnutrition is majorly a [[Disease|diseases]] of the developing countries. There is no racial or sexual predisposition. | ||
==Risk Factors== | ==Risk Factors== | ||
Common risk factors in the development of protein energy malnutrition may be classified as maternal and environmental. | Common risk factors in the development of protein energy malnutrition may be classified as [[maternal]] and [[Environmental epidemiology|environmental]]. | ||
==Screening== | ==Screening== | ||
There is insufficient evidence to recommend routine screening for protein energy malnutrition. | There is insufficient evidence to recommend routine [[Screening (medicine)|screening]] for protein energy malnutrition. | ||
==Natural History, Complications and Prognosis== | ==Natural History, Complications and Prognosis== | ||
If left untreated, all children with protein energy malnutrition will progress to develop | If left untreated, all children with protein energy malnutrition will progress to develop permanent [[Stunted growth|stunting]] (height for age), poorly developed [[immune system]] which causes overwhelming [[bacteremia]] and [[sepsis]] which is responsible for the cause of death. | ||
==Diagnosis== | ==Diagnosis== | ||
===History and Symptoms=== | ===History and Symptoms=== | ||
The history of protein energy malnutrition includes a failure to thrive in children under 1 year of age especially after they have just been weaned of breast milk. Some common signs and symptoms include failure to thrive, fatigue, irritability, changes in skin and hair pigment, decreased muscle mass, diarrhea, increased and more severe infections due to damaged immune system, edema and hepatomegaly. | The history of protein energy malnutrition includes a [[failure to thrive]] in children under 1 year of age especially after they have just been [[Weaning|weaned]] of [[breast milk]]. Some common signs and symptoms include [[failure to thrive]], [[fatigue]], [[irritability]], changes in [[Skin changes|skin]] and [[Hair analysis|hair pigment]], [[Wasting|decreased muscle mass]], [[diarrhea]], increased and more severe [[infections]] due to damaged [[immune system]], [[edema]] and [[hepatomegaly]]. | ||
===Physical Examination=== | ===Physical Examination=== | ||
Physical examination of patients with kwashiorkor is usually remarkable for rounded prominence of the cheeks known as the moon face, and distended abdomen due to an enlarged liver, hyperkeratosis and hyperpigmentation of the skin, generalized edema especially on the dependent areas of the body like the feet. On the other hand, patients with marasmus usually look listless, emaciated and hungry looking with monkey like faces due to absence of subcutaneous fat pad in the cheeks. The skin looks atrophic and dry. | Physical examination of patients with kwashiorkor is usually remarkable for rounded prominence of the cheeks known as the moon face, and distended abdomen due to an enlarged liver, hyperkeratosis and hyperpigmentation of the skin, generalized edema especially on the dependent areas of the body like the feet. On the other hand, patients with marasmus usually look listless, emaciated and hungry looking with monkey like faces due to absence of subcutaneous fat pad in the cheeks. The skin looks atrophic and dry. | ||
Revision as of 10:39, 8 August 2017
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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). Protein energy malnutrition is a nutritional deficiency resulting from either inadequate energy (caloric) or protein intake and manifesting in either marasmus or kwashiorkor. Marasmus is characterized by wasting of body tissues, particularly muscles and subcutaneous fat, and is usually a result of severe restrictions in energy intake. Kwashiorkor affects mainly children, is characterized by edema (particularly ascites), and is usually the result of severe restrictions in protein intake. However, both types can be present simultaneously (marasmic kwashiokor) and mask malnutrition due to the presence of edema. The presence of severe of hypoproteinemia, hypoalbuminemia, electrolyte imbalance or an underlying HIV infection is associated with poorer prognosis among patients with protein energy malnutrition.
Historical Perspective
The first clinical description of protein energy malnutrition was made in 1865 in Spanish which led to little dissemination of the information. In 1932, kwashiorkor was first described by Dr. Cicely Williams, working with African children on the Gold Coast. The word kwashiorkor came from the Ga language of Accra, Ghana meaning the 'disease of the deposed baby when the next one is born'. The term marasmus is derived from the Greek word 'marasmos', which means withering or wasting.
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
Different pathophysiologic mechanisms are involved in the development of protein energy malnutrition as it comprises of two main diseases, kwashiorkor and marasmus. It is thought that kwashiorkor is produced by a deficiency in the adequate consumption of protein-rich foods during the weaning process. However, the associated edema is not fully understood. Several theories have been put forward to explain this finding. Marasmus on the other hand is due to the total caloric deficiency leading to wasting in a child. Marasmus always results from a negative energy balance.
Causes
Protein energy malnutrition may be caused by reduced breast feeding, poor weaning practices, limited availability of food and very little child care in cases of extreme poverty. This classically affects several poor people in regions of poor social and economic background. Other environmental causes such as infections, drought and earthquakes leading to decreased availability of food have also been identified.
Differentiating Kwashiorkor from other Diseases
Protein energy malnutrition must be differentiated from other diseases that cause failure to thrive, edema, wasting recurrent infections, skin and hair changes. It is important to also differentiate kwashiorkor from marasmus as the two diseases belong to the protein energy malnutrition.
Epidemiology and Demographics
The prevalence of protein energy malnutrition in children under 5 is estimated to be 150 million cases annually. In Nigeria, the prevalence is as high as 41,600 per 100,000 children. Protein energy malnutrition is majorly a diseases of the developing countries. There is no racial or sexual predisposition.
Risk Factors
Common risk factors in the development of protein energy malnutrition may be classified as maternal and environmental.
Screening
There is insufficient evidence to recommend routine screening for protein energy malnutrition.
Natural History, Complications and Prognosis
If left untreated, all children with protein energy malnutrition will progress to develop permanent stunting (height for age), poorly developed immune system which causes overwhelming bacteremia and sepsis which is responsible for the cause of death.
Diagnosis
History and Symptoms
The history of protein energy malnutrition includes a failure to thrive in children under 1 year of age especially after they have just been weaned of breast milk. Some common signs and symptoms include failure to thrive, fatigue, irritability, changes in skin and hair pigment, decreased muscle mass, diarrhea, increased and more severe infections due to damaged immune system, edema and hepatomegaly.
Physical Examination
Physical examination of patients with kwashiorkor is usually remarkable for rounded prominence of the cheeks known as the moon face, and distended abdomen due to an enlarged liver, hyperkeratosis and hyperpigmentation of the skin, generalized edema especially on the dependent areas of the body like the feet. On the other hand, patients with marasmus usually look listless, emaciated and hungry looking with monkey like faces due to absence of subcutaneous fat pad in the cheeks. The skin looks atrophic and dry.
Laboratory Findings
Laboratory findings consistent with the diagnosis of protein energy malnutrition include abnormally low blood glucose, hypoalbuminemia (10-25 g/L), hypoproteinemia (transferrin, essential amino acids, lipoprotein)and hypoglycemia.
X ray
There are no chest X ray findings associated with protein energy malnutrition.
CT
There are no CT findings associated with protein energy malnutrition.
MRI
There are no MRI findings associated with protein energy malnutrition. However, a MRI may be helpful in the diagnosis of complications of protein energy malnutrition which include cerebral atrophy and ventricular dilatation.
Echocardiography or Ultrasound
Echocardiography findings may be helpful in the diagnosis of protein energy malnutrition. Findings on an echocardiography suggestive of protein energy malnutrition include decrease of R wave and QTc interval, decreased cardiac index which improved significantly after rehabilitation.
Other Imaging Findings
There are no other imaging findings associated with protein energy malnutrition.
Other Diagnostic Studies
There are several parameters that can be used in the assessment of a child with protein energy malnutrition. Malnutrition can be assessed according to the WHO based on Mid upper arm circumference into moderate and severe malnutrition. Other parameters include the Z-score which assesses linear growth and weight for length.
Treatment
Medical Therapy
In some cases, protein energy malnutrition may be complicated by dehydration and specific infections, such as pneumonia and septicemia. In such cases, protein energy malnutrition is a is a medical emergency and requires prompt treatment with antibiotics.
Surgery
Surgical intervention is not recommended for the management of protein energy malnutrition.