1、Protein-Energy Malnutrition,Department of Pediatrics Zhejiang University School of Medicine JIE SHAO,Introduction,There is more than one-third of the worlds under-five population is malnourished. In China:serious PEM is rare,but mild or moderate PEM are still common,Nutritional status of children un
2、der 6 years,Definition,A state of deficiency resulting from inadequate intake of protein and/or energy relative to physiological needs leading to progressive changes in body composition and functionThe child with PEM usually has growth failure which manifests shorter in height or lighter in weight t
3、han expected for a child of his age, or may be thinner than expected for height,Definition,PEM, a macronutrient deficiency, not a micronutrient deficiency Mainly occur in the children 3 years old,Classification,MarasmusSevere inadequacy of energy and nutrients， characterized by severe wasting,Classi
4、fication,Edema (Kwashiorkor) hypoalbuminemic, edematous malnutrition and presents with pitting edema that starts in the lower extremities and ascends with increasing severity.,Classification,Marasmus-edema Intermediate forms,Etiology,Primary: Long-term inadequate food intake,1.Insufficient food supp
5、ly ：poverty-stricken2.Improper feeding inappropriate weaning practicesstaple diets that are often of low energy densityinsufficient artificial feeding 3. social and behavioral factorsmonophagiaPicky EatingAnorexia Nervosa,Etiology,Secondary:Disease factor,Inadequate digestion & absorption of foodAbn
6、ormality of alimentary canalMalabsorption syndrome Infection TuberculosisParasitosis Chronic wasting diseaseDiabetes Hyperthyroidism,Etiology,Congenital deficiency,Prematurity Low birth weight infant Intrauterine malnourishment（IUM ） Congenital metabolic diseases,Pathophysiology,1. Protein metabolis
7、m disorderhypoalbuminemic2. Glucose metabolism disorderhypoglycemia,Metabolism abnormality,Pathophysiology,Metabolism abnormality 3. Fat metabolism disorder,Serum cholesterol,Adipose infiltration in liver,Fat consume too much,Pathophysiology,4. Water-electrolyte metabolism disorder,Hypokalemia,Patho
8、physiology,Body systems dysfunction1. Gastrointestinal SystemBowel movement , quantity and activity of enzyme Dysbacteriosis、Infection、Diarrhea etc2. Circulation SystemSystole weaken、blood pressure drop down、pulse extenuate etc,3. Urinary SystemKidney concentrate function Urinary volume Urine specif
9、ic gravity4. Nervous SystemDecrease of DNA and RNA in the brainDelay of motor/language/cognition/social-emotional development,Impaired immunityReduce of nonspecific immunity ( deficit of anatomic-mucociliary barrier ) Impaired adaptive immune responses(involve antigen-specific T lymphocytes and B ly
10、mphocytes)Patients are likely to be stricken by various kinds of infection。,Clinical manifestations,Poor growth Growth failure always occursThe child will be found to be shorter /lighter than normal,Clinical manifestations,Wasting Weight (anthropometric measurements)Loss of muscle mass and subcutane
11、ous fat stores Abdomen trunk hips limbs face The muscles are always extremely wasted (marked atrophy)The ribs are prominentThe limbs are very emaciatedThe face has a characteristic simian (monkey-like) appearanceThere is little if any subcutaneous fat leftThe skin hangs in wrinkles, especially aroun
12、d the buttocks and thighs,Clinical manifestations,Temperature (hypothermia ) Skin and Hair changes : dry and thin, sparse Circulation System (bradycardia) Gastrointestinal System bowel sounds tend to be hypoactive diarrhea Urinary System Nervous System apathetic and weak, weak muscle tone,Clinical m
13、anifestations,KwashiorkorOcuurs in children aged 1-3yr It is classically described as being caused by inadequate protein intake (fed on relatively high starch diet . Clinical manifestationWasting, edema, sparse hair and pigmented skin, monilial stomatitis and hepatomegaly.,Clinical manifestations,Co
14、mplications,Nutritional anemia ( IDA) Trace nutritional element deficiencyVitamin A and zinc deficiencies Infection Spontaneous hypoglycemia,Diagnosis,HistoryInsufficient food supply Improper feedingChronic wasting disease Symptoms & Signs Gross loss of weightGrowth retardationWasting of subcutaneou
15、s fat and muscle,Diagnosis,laboratory examination The level of plasma-albumin diagnostic changeIGF-1 sensitive Necessary Amino AcidsCholesterin potassium/ magnesium Calcium,phosphate and Vit D levels,Classification Guidelines for Pediatric Undernutrition,Nutrition status,Underweight Insufficient wei
16、ght gain relative to age/gender weight Moderate: mean-3SD = weight mean-2SD Severe: weight mean-3SD Implies slow/acute malnutrition,Typing and graduation,Stunting Insufficient height gain relative to age/sex height Moderate: mean-3SD = Heightmean-2SD Severe: Heightmean-3SD Implies long-term malnutri
17、tion,Wasting Insufficient weight gain relative to hight/sex weight Moderate: mean-3SD = weight mean-2SD Severe: weight mean-3SD Implies recent/acute malnutrition.,Typing and graduation,Treatment,Etiology therapyprimary disease Diet therapy1. The gastrointestinal tract may not tolerate a rapid increa
18、se in intake. 2. Nutritional rehabilitation should be initiated and advanced slowly to minimize the complications,Treatment,Calories are given in the form of carbohydrates, sugars, and fatsCaloric intake can be increased 10% to 20% per dayMild: 250344kJ(6080kcal) /kg/dMid-Severe: from 167251kJ(4060k
19、cal) /kg/dto 628.0711kJ(150170kcal)/kg/dProtein: from 1.52.0g/kg to 3.04.5g/kg,Treatment,Supply vitamin and mineral supplements are essential( VitA 5000IU, iron 13mg, Zinc 1mg) Drug therapy Pepsin, Pancreatin&Vitamin B Nandrolone Phenpropionate promote the synthesize of protein Insulin Zinc suppleme
20、ntation Chinese traditional medicine,Complication therapy restore and maintain fluid and electrolyte balance prevent and treat spontaneous hypoglycemia blood infusion(10ml/kg) if severe anaemia,Intensive care Enough sleep Proper exercise Good diet habit,Treatment,Before therapy,After therapy,Prevention,Proper feeding encourage breast milk Prevent and cure disease Congenital diseases, chronic infection disease etc Social /behavioral intervention sleep and diet Take exercise,Email: ,Thank you！,What are the clinical features of Kwashiorkor? How do you manage a child with severe PEM?,
