Severe Childhood malnurition

Question 1

Marasmus

Answer 1

severe wasting ( no obvious pathology

Question 2

Kwashiorkor cause

Answer 2

severe wasting ( with the presence of EDEMA -> multiple pathologies, often fatal

Question 3

Kwashiorkor clinical presentation

Answer 3

edema (may mask weight loss), dermatosis (lighter hair color), hypoalbuminemia (fatty liver up to 50% wet weight), abnormal plasma amino acids (reduced EAAs), K+ deficiency (apathy and anorexia), infection

Question 4

Clinical management of Kwashiorkor

Answer 4

high protein diets tube-fed on admission are fatal -> this happens now in many centers throughout the world with very high mortality

Question 5

Severe malnutrition

Answer 5

medical emergency -> damaged cellular machinery needs repair -> tissue deficits are obvious but only can be repleted AFTER repair of cellular machinery -> RESCUSITATE, REPAIR, REPLETE

Question 6

Ten steps for routine treatment of severe malnutrition

Answer 6

prevent and treat hypoglycemia, hypothermia, dehydration in first 1-2 days; electrolytes (through entire period), infection (for first week), micronutrients (IRON ONLY IN FINAL PHASES) -> cautious feeding (in first week -> stabilization), catch up growth (in rehabilitation phase after first week), sensory stimulation (throughout treatment), prepare for follow up (after first week)

Question 7

Initial stabilization (week 1 of treatment of severe nutrition)

Answer 7

treat infection with broad spectrum antibiotics (and deal with any associated hypoglycemia and hypothermia), deal with any dehydration with rehydration solution for malnutrition (low blood volume can exist with edema) -> correct vitamin and mineral deficiencies (NO IRON), correct K and Mg deficiencies with electrolyte supplemented low protein feed (4-6.5% protein: energy) in maintenance (small) amounts -> edema cured, appetite returns

Question 8

Rehabilitation (weeks 2-6 of treatment of severe nutrition)

Answer 8

feed large amounts of energy dense milk-based feed (full cream milk + sugar + oil, 10% protein energy, 50% fat energy WITH iron (allows for catch up growth) -> muscle size catches up to bone length -> eventually amino acids will turn off appetite mechanism once weight for height ratio is achieved

Question 9

Kwashiorkor -> usual explanation of symptoms

Answer 9

edema due to hypoalbuminemia, fatty liver due to reduced hepatic ApoE synthesis, skin and hair changes due to various nutritional deficiencies (Zn, Cu)

Question 10

Hypoalbuminemia -> typical explanations

Answer 10

failure to adapt to protein deficient diet, cortisol inadequacy and adrenal dysfunction, Aflatoxins in food (stored in damp conditions), protein losing enteropathies

Question 11

Why typical Kwashiorkor explanations are inadequate

Answer 11

protein deficiency is rare and symptoms cured by low protein diet (lower than the original diet they were on), loss of edema occurs before any change in plasma albumin, explanations do not link hypoalbuminemia and other symptoms

Question 12

Protein

Answer 12

Requirements for children is low -> children 1-2 years need 5-6% calories -> initial diet for PEM treatment needs to be 5-6%, 10% for catch up growth -> even most developing countries get at least 5.7% of their calories -> plantain, cassava (toxic), sweet potato, taro are all very poor sources of protein

Question 13

Simple malnutrition

Answer 13

leads to stunting and wasting but not kwashiorkor

Question 14

Kwashiorkor

Answer 14

simple malnutrition with additional noxious insult

Question 15

Marasmus-kwashiorkor

Answer 15

severe malnutrition with additional noxious insult (3SD below weight for height + edema)

Question 16

Noxious insult (infection)

Answer 16

increases free radical production (SO- produced by NK cells) -> inadequate protection (deficiencies of antioxidant nutrients in these children) -> iron catalyzed chain reactions (apparent iron overload -> SO- converted to destructive OH-) -> inadequate repair (deficiencies of Essential FA -> damage, edema, fatty liver, skin lesions, bleached hair)

Question 17

Kwashiorkor damage caused by oxidative stress

Answer 17

damages membranes and proteins disrupting transport and ionic balance resulting in K loss -> kidney has impaired function (edema), liver has impaired protein synthesis, impaired albumin, ApoE secretion, damaged mitochondrial function (decreased ATP generation and fatty infiltration), skin has changes similar to sunburn (free radicals), hair has bleaching (like peroxide whiteners)

Question 18

Iron in kwashiorkor

Answer 18

free form is extremely toxic since it increases production of the very toxic hydroxyl free radical -> increased plasma ferritin is indicative of excess tissue stores and indicates a VERY bad prognosis -> excess in the liver and bone marrow as occurs with anemia of chronic diseases (growth inhibition and wasting reduces blood volume with net loss of hemoglobin and so this enters storage -> low hemoglobin reflects inhibition of RBC synthesis due to inflammatory cytokines

Question 19

Plasma ferritin levels in malnourished children

Answer 19

increases in marasmus -> kwashiorkor -> death

Question 20

Solution to kwashiorkor

Answer 20

improved micronutrient status and abundant clean water