PEM

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Prasad,Dr.Ramalingam,Dr.J.N.Naidu.

• ZINC AND COPPER LEVELS IN CHILDREN WITH PROTEIN
  ENERGY MALNUTRITION

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• INTRODUCTION
• World Health Organization ( WHO ) has defined ,
  Protein Energy Malnutrition ( PEM) as a range
  of pathological conditions arising from
  coincidental lack in varying proportion of
  proteins and calories , occurring most frequently
  in infants young children commonly associated
  with infection.
• most cases PEM is caused by a combination of
  inadequate dietary intake, lack of good care and
  the adverse effect of infection

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• WHO has described malnutrition as a global
  problem, having adverse effect on the survival,
  health performance progression of population
  group.
• In India 46 of all children under the age of
  three are too small for their age, 47 are
  underweight and 16 are wasted. Prevalence of
  severe malnutrition varies across the states with
  MP recording the highest rate (55) and Kerala,
  the lowest (27). In Andhra Pradesh it is 37.

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Zinc

• Zinc is required for muscle and bone formation.
• Zinc is essential for the immune system.
• It is required for tissue growth, development and
  regenaration.
• Zinc is involved in stabilization of Insulin
• It is involved in vit-A mobilization from the
  liver(dark adaptation)
• Over 200 zinc metalloenzymes have been isolated.
• They are LDH,MDH,CP, DNA and RNA polymerases
  ,thymidine kinase, ALP, Angiotensin converting
  enzyme, CA and SOD.

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• Zinc
• children who are zinc-deficient have more
  episodes of infection, particularly diarrhoea and
  respiratory disease.
• zinc deficiency causes increased losses of
  intestinal fluid during diarrhoea and delayed
  recovery from acute or persistent diarrhoea. If a
  two week course of a cheap syrup containing zinc
  acetate (2mgs of elemental zinc per kg/day) is
  given to
• these children
• _ recovery from diarrhoea is faster
• _ purging is less
• _ there are fewer episodes of diarrhoea in the
  following months.

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• zinc deficiency is common because the best
  sources of zinc are fish and meat, which are
  often too expensive for many families.
• the bioavailability in plant foods, such as
  cereals, is low. at present, the recommendation
  is to give zinc supplements during treatment of
  severely malnourished children particularly those
  with persistent diarrhoea and acute diarrhoea.
• zinc deficiency is an important cause of low
  birth weight in malnourished populations.
• supplementation of zinc-deficient women during
  pregnancy improves weight gain and birth weight
  but accurate detection of zinc deficiency is
  difficult.

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Copper

• Copper is required for the activity of enzymes
  involved in the Respiratory chain, Cross linking
  of collagen and elastin, blood cell formation,
  melanin formation, superoxides removal,
  neurotransmitter formation and neupeptidess.
• In most of the cases copper is a part of the
  enzyme molecule.
• Cuproenzymes are cytochrome oxidase,
  lysyloxidase, SOD, Ceruloplasmin, TK, Dopamine
  Beta-oxidase, amine oxidase and uricase.

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• Copper is necssary for iron incorporation of iron
  into hemoglobin.
• Copper is a co-factor for vitamin-C requiring
  hydroxylation.
• Copper increases HDL and so protects the heart

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Complications of P.E.M

• Hypoglycemia
• Hypothermia
• Hypokalemia
• Hyponatremia
• Heart failure
• Dehydration shock
• Infections (bacterial, viral thrush)

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CLASSIFICATION

• A. CLINICAL ( WELLCOME )
• Parameter weight for age oedema
• Reference tandard (50th percentile)
• Grades
• 80-60 without oedema is under weight
• 80-60 with oedema is Kwashiorkor
• lt 60 with oedema is Marasmus-Kwash
• lt 60 without oedema is Marasmus

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CLASSIFICATION (2)

• B. COMMUNITY (GOMEZ)
• Parameter weight for age
• Reference standard (50th percentile) WHO chart
• Grades
• I (Mild) 90-70
• II (Moderate) 70-60
• III (Severe) lt 60

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KWASHIORKOR

• Cecilly Williams, a British nurse, had introduced
  the word Kwashiorkor to the medical literature in
  1933. The word is taken from the Ga language in
  Ghana used to describe the sickness of weaning.

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CLINICAL PRESENTATION

• Kwash is characterized by certain constant
  features in addition to a variable spectrum of
  symptoms and signs.
• Clinical presentation is affected by
• The degree of deficiency
• The duration of deficiency
• The speed of onset
• The age at onset
• Presence of conditioning factors
• Genetic factors

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CONSTANT FEATURES OF KWASH

• OEDEMA
• PSYCHOMOTOR CHANGES
• GROWTH RETARDATION
• MUSCLE WASTING

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USUALLY PRESENT SIGNS

• MOON FACE
• HAIR CHANGES
• SKIN DEPIGMENTATION
• ANAEMIA

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OCCASIONALLY PRESENT SIGNS

• HEPATOMEGALY
• FLAKY PAINT DERMATITIS
• CARDIOMYOPATHY FAILURE
• DEHYDRATION (Diarrh. Vomiting)
• SIGNS OF VITAMIN DEFICIENCIES
• SIGNS OF INFECTIONS

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MARASMUS

• The term marasmus is derived from the Greek
  marasmos, which means wasting.
• Marasmus involves inadequate intake of protein
  and calories and is characterized by emaciation.
• Marasmus represents the end result of starvation
  where both proteins and calories are deficient.
• Marasmus represents an adaptive response to
  starvation, whereas kwashiorkor represents a
  maladaptive response to starvation
• In Marasmus the body utilizes all fat stores
  before using muscles.

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Clinical Features of Marasmus

• Severe wasting of muscle s/c fats
• Severe growth retardation
• Child looks older than his age
• No edema or hair changes
• Alert but miserable
• Hungry
• Diarrhoea Dehydration

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EPIDEMIOLOGYand ETIOLOGY

• The term protein energy malnutrition has been
  adopted by WHO in 1976.
• Highly prevalent in developing countries among lt5
  children severe forms 1-10 underweight
  20-40.
• All children with PEM have micronutrient
  deficiency.
• Seen most commonly in the first year of life due
  to lack of breast feeding and the use of dilute
  animal milk.
• Kwashiorkor can occur in infancy but its maximal
  incidence is in the 2nd yr of life following
  abrupt weaning.

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• Kwashiorkor is an example of lack of
  physiological adaptation to unbalanced deficiency
  where the body utilized proteins and conserve S/C
  fat.
• One theory says Kwash is a result of liver insult
  with hypoproteinemia and oedema. Food toxins like
  aflatoxins have been suggested as precipitating
  factors.
• Poverty or famine and diarrhoea are the usual
  precipitating factors
• Ignorance poor maternal nutrition are also
  contributory

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AIMS AND OBJECTIVES

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• to evaluate copper and zinc levels in children
  with protein energy malnutrion.

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MATERIALS AND METHODS

• Serum zinc and copper were determined in thirty
  (30) malnourished pre-school-age children
  (age,0-60 months) and thirty (30) age-and
  sex-matched apparently healthy well nourished
  controls to evaluate the effect of protein-energy
  malnutrition on serum zinc and copper.

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• METHOD OF DETERMINATION OF COPPER AND ZINC
• Serum zinc Copper were estimated by the Atomoic
  Absorption Spectrophotometry
• Serum total protein and albumin and globulin is
  estimated by autoanalyzer method

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• The data on personal history regarding the onset
  and duration of the symptoms in protein energy
  malnutrition and treatment history for PEM were
  collected through standard questionnaire. 
• Blood samples were collected in EDTA tubes. The
  blood was centrifuged and plasma was removed.
  The serum were carefully sampled from the bottom
  of the tubes to minimize contamination with
  sedimentation take fresh test tube to
  collecting.
• Thirty healthy individuals working in Narayana
  Medical College Hospital in the age group 01-05
  were included in control group. 

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DISSCUTION

• This study shows that malnourished children have
  deficient serum zinc and copper.
• For effective management of protein-energy
  malnutrition, zinc and copper supplementation
  should be part of treatment regimen, however, in
  order to prevent zinc and copper deficiency and
  its health implications in pre-school age
  children, food fortification should be promoted.

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conclusion

• Mean serum zinc and copper were significantly
  reduced (plt0.05) in malnourished than in
  well-nourished children.
• in order to prevent zinc and copper deficiency
  and its health implications in pre-school age
  children, food fortification should be promoted.

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REFERENCE

• 1. Alleyne GAO, Hay RW,et al . In Protein Energy
  Malnutrition. London The ELBS Edward Arnold
  Ltd. 1981 Pg 1-3

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