Protein-energy malnutrition

Question 1

Marasmus - overview (3)

Answer 1

1. Def = wasting of muscle mass and depletion of body fat stores, with BMI > 3SD below mean
2. Wasted, wizened appearance; edema not present
3. Most common form of PEM; caused by inadequate energy intake (total calories)

Question 2

Marasmus - clinical presentation

Answer 2

Symptoms

1. Severe constipation
2. Ravenously hungry once refeeding in progress

Signs

3. Diminished weight and height for age; shrunken arms, thighs and buttocks with redundant skin folds caused by loss of subcutaneous fat
   * *Mid-arm circumference markedly reduced
4. Bradycardia, hypotension and hypothermia. Withdrawn and irritable affect
5. Thin, dry skin and thin, sparse hair that is easily plucked

Question 3

Kwashiokor - background (3)

Answer 3

1. PEM + edema = marked muscle atrophy + normal or increased body fat + presence of peripheral edema (anascara)
2. **Edema = defining characteristic for establishing the dx
3. Due to inadequate protein intake. Pathogenesis is not fully understood

Question 4

Kwashiokor - clinical features

Answer 4

Symptoms
1. Anorexia - almost universal

Signs

2. Normal or nearly normal weight for age (bc of edema) + anascara (severe generalised edema), pitting edema in lower extremities, presacral area, genitalia and periorbitally
   * *Note: children with oedema should be considered malnourished, regardless of of mid upper arm circumference
3. ‘Flaky-paint’ skin rash with hyperkeratosis (thickened skin) and desquamation. Hair which is sparse and depigmented
4. Angular stomatitis. Distended abdomen and enlarged liver (usually due to fatty infiltration)
5. Diarrhoea, hypothermia, bradycardia and hypotension

Question 5

PEM - ix

Answer 5

1. FBE (reduced Hb)
2. UEC + Ca + Mg + phosphate
3. Albumin (reduced)
4. BGL (reduced)
5. Stool MCS for ova, cysts and parasites

Question 6

PEM - mx

Answer 6

1. Admit to hospital if no appetite or medical complications; otherwise, care can be community based
2. Correct dehydration and electrolyte imbalance (IV if required). Correct hypoglycameia
3. Tx underlying infection +/- parasitic infections. Tx concurrent/causative disease
4. Tx specific nutritional deficiencies
5. Orally refeed slowly - watch out for refeeding syndrome (potentially fatal respiratory and cardiac failure induced by electrolyte disturbance following overzealous nutritional therapy in severe malnutrition)