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Recognition and Management of Malnutrition

4. Clinical Features of Malnutrition

Objectives

  • Identify through physical examination the main clinical findings of protein-energy malnutrition and those indicating severe malnutrition.
  • Recognize the particular features and the clinical and pathophysiologic differences between marasmus and kwashiorkor.
  • Describe the pathophysiology of the refeeding syndrome.

Healthy, well-nourished persons have some protection from acute malnutrition, because they have adequate stores of glycogen, protein reserves, and calories stored as fat. During the first 3 days without food, glycogen stores in the liver and muscle are depleted, and the liver attempts to maintain blood sugar levels by converting mobilized amino acids into glucose (gluconeogenesis). At the same time, the breakdown of fat (lipolysis) leads to the formation of an alternate fuel source, ketone bodies, allowing for short-term survival. However, individuals who are malnourished at the onset of a disaster are incapable of activating these protective mechanisms and thus face greater risk of acute nutritional decompensation.

The pathophysiology of severe protein-energy malnutrition is very complex, affecting the cellular function of many organ systems, including heart and bowel. In the heart, redistribution of muscle proteins increases the risk for cardiovascular collapse, and damage to the intestinal villi leads to malabsorption.

Marasmus is the most common form of PEM and is caused by deprivation of both energy/calories and protein that leads to weight loss of more that 20% of initial body weight. It is characterized by profound wasting, fatigue, apathy, and irritability.