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Nutrition (10) - Kwashiorkor and marasmus
Terms in this set (22)
Define severe malnutrition in Standar deviation wise
Severe wasting <70 percentile weight for height
<3 SD weight for height - marasmus
Marasmus has obvious pathology?
Kwashiorkor has pathology?
Kawashiorkor multiple pathologies
edema - may mask weight loss
Dermatosis - lighter hair color
Hypoalbuminaemia (fatty liver up to 50 percent wet weight)
K+ deficiency - apathy and anorexia
abnormal plasma amino acids (reduced EAAs)
Pitting edema on the dorsum of the foot
After applying pressure for a few seconds, a pit remains after the finger is removed
Pitting edema on legs + skin lesions of kwashiorkor - peeling skin and scaly skin.
Skin leisons are associated with higher risk of death, hypothermia and predispose to infections
What is clinical management of kwashiorkor that is currently often wrong and disastrous due to misconcieved ...
What are the WRONG guidelines for inpatient treatment of severely malnourished children?
etiology involving protein deficiency
1. Rehydration with intravenous fluids can increase mortality
2. Aggressive attempts to immediately promote rapid weight gain is DANGEROUS.
3. A high protein diet for children with kwashkoir can be fatal
4. Diurectics to get rid of edema can be fatal
5. Prescribing iron to treat anemia at the start of treatment increases deaths
The order in which problems are addresed is fundamental to effective care in malnutrition treatment ---- what are the order?
1. Severe malnutrition: medical emergency
2. Damaged cellular machinery - needs repair
3. Tissue deficits obvious, but, can only be repleted AFTER repair of cellular machinery
RESCUSTICATE (medical emergency) ----> REPAIR Cellular Machinery -----> Replete
Ten steps for routing treatment in two phase approach for malnutrition
Stablization phase and Rehablitation phase
1. Prevent and treat for
6. micronutrient deficiencies (no iron in week 1)
2. Provide special feeds for
7. initial stabilization
8. catch up growth
Provide: 9. Loving care and stimulation
Prepare for: 10. follow up after discharge1
Discuss stablization phase: week 1
1. Treat infection with broad spectrum antiboitic (deal with any hypoglycemia and hypothermia)
2. Deal with any dehydration with ReSoMal: Rehydration, Solution for malnutrition. Low blood volume can coexist with edema
Re= rehydration, So= solution, Mal= malnutrition
NB: Low blood volume can co-exist with edema
3. Correct vitamin and mineral deficiency with Vitamin A, multivitain daily supplements, folic acid, Zn Cu (without IRON)
4. Correct K+Mg deficiency with electrolyte supplemented low protein feed (4 to 6.5 % protein: energy) in maintenance -small- amounds
This would lead to edema treated - appetite returns
Discuss Rehablitation phase: week 2
1. Feed large amount of energy-dense milk based feed
(full cream milk + sugar + oil, 10 percent protein energy, 50 pecent fat energy with iron ---> this allows to catch up with growth
Inappropriate high protein tube feeding on admission is usually fatal for undernutrition? True or false?
What is kawashiorkor? What is marasmus (incorrect)
K - Protein deficiency
M - semi startvation
Usual outdated explanation of Sxs of kwashiorkor?
1. Edema - reduced albulin
2. fatty liver - reduce apo 100 synthesis,
3. skin and hair changes (zn,cu) deficiencies
Inadquate explanations because -
1. It is hypothesized that protein deficieny in children are rare
2. Sxms of Kwashiorkore is cured by low protein diet
3. loss of edema occurs before change in plasma albumin
4. Explanations do not link hypoalbumineamia and other sxms
protein deficieny in children are rare : explain
1. Protein: energy requirements ( 1 gram = 4 kcal)
Total = 5 to 6 percent for age 1-2 years old
Diet used for malnutrition in protein deficient
1. Initial - 5 to 6 percent protein calories
2. Catch up growth - 10 percent protein calories
5.6 percent ocassionaly - marginal (india south east asia)
2.1 to 3.5 - results in stunting (plantain, cassava) linkes with sweet potato, taro
Etiology of Marasmus
Development of stunting and wasting (marasmus)
- low protein diet --> growth stops ---> stunting
Very low protein diet(other nutrient deficiency) ---> anorexia --> weight loss---> wasting (marasmus)
Insufficient diet --> weight loss ---> wasting
Etilogy of kwashiorkor
Development of Kwashiorkor
Low protein diet --> growth stops ---(Noxious insult)--> stunting
Very low protein diet(other nutrient deficiency) ---> anorexia --> weight loss----noxious insult--> wasting (marasmus)
Insufficient diet --> weight loss ----noxious insult--> wasting
If the noxious insult is severe --- it would lead to kwashiorkor instead of stunting or wasting (marasmus)
What are the noxious insult in the kwashiorkar
Infection or bacterial translocation
Superoxide anion normally producted by T lmpocytes, NK ceells ---free radical production
Inadequate protein (antioxidants micronutrients)
Iron catalyzed chain reaction (superoxide anion converted to Hydroxyl radical)
Inadequate repair(deficiencies of EFA) ----> damage edema , fatty liver, skin lesions, bleached hair
What are the damage caused by oxidative stress?
Damage to membranes and proteins disrupting transport and ionic balance resulting in K+ loss
Kidney: sodium and water retention
Glycocalyx and intersititum - disruption giving edema
Liver: imparied protein synthesis, impaired albumin apob100 secretion, damaged mitochondrial function - i.e. decreased ATP generation and fatty infilitration
Skin: changes similar to subburn (Free radicals from ionising radiation in sunlight)
Hair: bleaching as with peroxide whiteners
Iron and kwashiorkor - what is the association?
Excess iron in the liver and bone arrow of kwashiorkor death (autopsy findings)
This usually occurs with chronic diseases such as anemia - growth inhibition and tissue wasting --> reduces blood volume with net loss of hemoglobin with iron entering stores
Low hemoglobin --- inhibits RBC synthesis
Free excess iron is extremely toxin since it increases the production of the very toxic hydroxyl free radical
Increased plasma ferritin is indicative of excess tissue iron stores and indicates a very bad prognosis
Plasma ferrintin levels are not INCREASED in the malnutrition children?
False, they are actually increased.
What is being done about severe childhood malnutrition?
These are two solutions to kwashiorkor involves:-
1. Improving micronutrient status (esepcially antioxidants_
2. improving water supply, sanitation, and hygiene
Money, dignity and quality of life
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