Prasad,Dr.

Ramalingam,
Dr.J.N.Naidu.
ZINC AND COPPER LEVELS IN
CHILDREN WITH PROTEIN ENERGY
MALNUTRITION

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

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%.



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.

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.

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.


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.
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
Complications of P.E.M
Hypoglycemia
Hypothermia
Hypokalemia
Hyponatremia
Heart failure
Dehydration & shock
Infections (bacterial, viral & thrush)
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
< 60 % with oedema is Marasmus-Kwash
< 60 % without oedema is Marasmus

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) : < 60
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.
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
CONSTANT FEATURES OF KWASH
OEDEMA
PSYCHOMOTOR CHANGES
GROWTH RETARDATION
MUSCLE WASTING
USUALLY PRESENT SIGNS
MOON FACE
HAIR CHANGES
SKIN DEPIGMENTATION
ANAEMIA
OCCASIONALLY PRESENT SIGNS
HEPATOMEGALY
FLAKY PAINT DERMATITIS
CARDIOMYOPATHY & FAILURE
DEHYDRATION (Diarrh. & Vomiting)
SIGNS OF VITAMIN DEFICIENCIES
SIGNS OF INFECTIONS
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.

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

EPIDEMIOLOGYand ETIOLOGY
The term protein energy malnutrition has been
adopted by WHO in 1976.
Highly prevalent in developing countries among
<5 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.

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

AIMS AND OBJECTIVES

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

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.

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

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.

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.
conclusion
Mean serum zinc and copper were
significantly reduced (p<0.05) 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.

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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