2. DEFINITION
• Inadequate intake of protein and energy either because the
dietary intakes of these 2 nutrients are less than required
for normal growth or because the needs for growth are
greater than can be supplied by what otherwise would be
adequate intake (Nelson 18th edition)
• Range of pathological conditions arising from coincident
lack in varying proportions of protein and calories occurring
mostly in infants and young children and commonly
associated with infections ( WHO 1973)
• Severe childhood under nutrition: new terminology
• Primary malnutrition – reduced intake
• Secondary malnutrition – increased needs, decreased
absorption, increased losses
3. Epidemiology
The World Bank estimate : Rank 2 in the world in number
of malnourished children, second only to Bangladesh. (47%)
– 1998.
In 2010 – India is the world capital of malnutrition in terms
of numbers (43%) ; 4th in terms of percentage prevalence
2.1 million children die before reaching age of 5 every year
in India – from preventable diseases like diarrhea,
pneumonia, etc
9. What percentage of energy expenditure of a
child is contributed by each??
Item Energy expenditure
(%)
BMI 50
Activity 25
Growth 12
Fecal loss 8
Specific dynamic action 5
11. Patho-physiology -Theories
Gopalan’s theory of adaptation and maladaptation - 1967
Free radical injury theory – Golden’s
Viteri’s theory 1964 – acute Vs chronic
14. PEM - Assessment
Dietary assessment
• 24 hour recall method- accuracy increased by taking
average of 3 days recall during midweek
• Food frequency table – records frequency intake of
each food item after defining standard servings of
each
• Weighing uncooked and cooked food and assessing
nutritive value
• Breast feeding and bottle feeding practices, diet
during illness
16. PEM - Assessment
Clinical Features..
ORGAN SIGNS
eyes Pale conjunctiva
Bitot spots
Conjunctival /corneal xerosis
lips Angular stomatitis
Angular scars
Cheilosis
tongue Edema
Scarlet/ raw tongue
Bald tongue
Teeth Mottled enamel
Spongy, bleeding gums
Glands Thyroid and parotid swelling
nails Koilonychia,Platynychia,
Leuconychia
17. PEM - Assessment
Clinical Features..
ORGAN SIGNS
Subcutaneous Edema/ gross reduction
tissue
musculoskeleta Wasting
l Craniotabes
Frontoparietal bossing
Epiphyseal enlargement/
tenderness
Beading of ribs
Wide open AF
Knock knees / bow legs
Thoracospinal deformities
bleeds
GIT Fatty liver
Hepatomegaly
Lactose intolerance
18. PEM - Assessment
Clinical Features..
ORGAN SIGNS
Psychomotor changes
Confusion
Sensory loss
Motor weakness
neurological
Loss of position sense
Loss of ankle and knee jerks
Calf tenderness
Tremors
Cardiomegaly
CVS Tachycardia
Serous
cavities effusion
19. Differentiation
ITEM MARASMUS KWASHIORKAR
AGE infancy 1-5 years
FEEDING Poorly breast fed / diluted milk Early removal from
breast
PREVALENCE common rare
WEIGHT <60% 60-80%
GROWTH RETARDATION ++ +
EDEMA - +
APATHY - +
MOOD alert Lethargic
APPETITE good Poor
HAIR / SKIN CHANGES Mild Severe
FATTY LIVER Absent ++
SERUM ALB Low normal Very low
CATABOLISM ++ +
PROGNOSIS good poor
20. Assessment of PEM
Weight for Age (acute)
Height for Age (chronic)
Weight for Height (acute on chronic)
Head circumference
Chest circumference
23. Weight
Technique
No spring balance ; discourage bathroom scales
Clinical significance of weight
Formula for calculating weight:
Weight = Age x 2 + 8 (1-6 yrs)
Weight = (Age x 7 – 5)/2 (7-12 yrs)
Calculation of weight age
24. Weight for age
AGE WEIGHT In terms of birth wt
Birth 3 kg 1
5 months 6 kg 2
1 yr 9 kg 3
2 yrs 12 kg 4
3 yrs 15 kg 5
5 yrs 18 kg 6
7 yrs 21 kg 7
10 yrs 30 kg 10
25. Malnutrition
Based on weight for age : IAP classification 1972
Grade of Weight-for-age of Category
malnutrition the median %
Normal >80
Grade I 71-80 mild
Grade II 61-70 moderate
Grade III 51-60 severe
Grade IV <50 Very severe
Reference : 50th centile of Harvard standards
26. Malnutrition
Wellcome trust 1970
Weight for age No edema Edema
60 – 80 % underweight kwashiorkor
< 60 % marasmus Marasmic
kwashiorkor
Reference : 50 th centile of Boston standards
27. Malnutrition
Gomez classification 1956
WEIGHT FOR AGE
STATUS % of expected
HARVARD
NORMAL >90
1ST DEGREE PEM 75 – 90
2ND DEGREE PEM 60 – 75
3RD DEGREE PEM <60
28. Malnutrition
Jeliffe classification 1965
WEIGHT FOR AGE
STATUS % of expected
HARVARD
NORMAL >90
1ST DEGREE PEM 80 – 90
2ND DEGREE PEM 70 – 80
3RD DEGREE PEM 70 – 60
4th DEGREE PEM < 60
29. Length
• Equipment-Infant Length
Board (Infanto-meter)
• It is a calibrated length board with
fixed headpiece and movable foot
piece
• Two trained people are needed
• Infant should be placed on its
back. FHH parallel to the head
piece. Both legs should be fully
extended at knees
• Measure length to 0.1 cm
30. Standing height
> 2 yrs age
Heels/ buttocks/ back – in contact with vertical board
Frankfurt plane parallel to floor
Bi-auricular plane – horizontal
STADIOMETER
Fixed
Mobile
31. Height variation with age
Age Length / Height
Birth 50 cm
3 months 60 cm
9 months 70 cm
1 yr 75 cm
2 yrs 90 cm
4.5 yrs 100 cm
Height = 77 + (age x 6) [3-12 yrs age group]
32. Clinical significance of Height
Indicator of Long term malnutrition
Concept of MID-PARENTAL height
ESTIMATED TARGET HEIGHT and TARGET RANGE.
LOW Height for age STUNTING
33. Stunting – based on Height for
age
Percentage of the ideal height Grade of stunting
expected for the age
>95 % No stunting
90 – 95% I
85 – 89% II
<85% III
34. Concept of
‘WEIGHT for HEIGHT’
The concept of Wasting
7 yr boy with Ht 104 cm and wt 12 kg. COMMENT
What is the height age?
What is the ideal wt for that age?
What percentage of his ideal wt is his present wt?
Wt for Ht as % of expected Grade of Wasting
>110 overweight Waterlow
classification
91- 110 Normal
81 – 90 I
71 – 80 II
<70 III
36. Protein Energy Malnutrition
WHO classification of Under-nutrition in Under-five children
Moderate Severe Undernutrition
Undernutrition
Symmetrical edema No Yes (Kwarshiorkar &
marasmic kwarshiorkar)
Edematous malnutrition
Weight for height 70 – 79% expected < 70% expected
WASTING SEVERE WASTING
-2 to -3 SD < -3 SD
Height for age 85 -89% expected < 85% expected
STUNTING SEVERE STUNTING
-2 to -3 SD < -3SD
37. Head
circumference
Use a flexible, non-stretchable tape
Measure to nearest 0.1 cm
Position the tape just above the eyebrow, above the ears and
around the biggest part on the back of the head
Indicator of Brain growth
HC < 2 SD small head ; HC <3 SD microcephaly
Microcephaly – usually late stages of malnutrition due to “BRAIN
sparing effect”
38. Chest Circumference
At the level of nipples Vs xiphoid process
Tape parallel to the ground ; between insp and exp
At birth, 3 cm < HC ; HC=CC by 1 yr, thereafter CC>HC
Significance of CC in comparison to HC
Not reliable in case of chest wall deformities
40. Mid Arm Circumference
For children 1 – 5 yrs
Determine midpoint on arm – midway between acromion
and olecranon
Left arm loosely held by side of the child
Crossed tape method
No skin indentation
Shakir’s tape
42. Mid arm circumference
Interpretation
MAC Interpretation
Kanawati & Mc Laren’s index
MAC/ OFC >13.5 Normal
>0.31 Normal 12.5 – 13.5 Moderate
0.31 – 0.28 Mild PEM malnutrition
0.28 – 0.25 Moderate PEM <12.5 Severe
malnutrition
<0.25 Severe PEM
<11.5 SEVERE
wasting
43. • QUAC stick
Quaker arm circumference measuring stick - A stick used to measure height
which also shows the 80th and 85th centiles of expected MUAC.
Developed by a Quaker Service Team in Nigeria in the 1960s as a rapid and simple
tool for assessment of nutritional status.
• SHAKIRS TAPE
green- adequate
yellow- borderline
red – frank malnourishment
44. Skin-fold Thickness
Techniques of measurement (NHANES III)
General gudelines
Hold 2 cm above measurement site
Wait for 3 seconds
Sub-scapular site
Fold pointing towards ipsilateral elbow
Supra-iliac site
Fold pointing towards groin
45. Skin fold thickness
Harpenden’s callipers
> 10 mm – normal
6 – 10 mm – mild malnourishment
< 6 mm – severe malnourishment
• Age – sex specific charts used ideally to interpret
47. Other Indices
Name of Index Formula Normal Malnutrition
Value
Kanawati & MAC/ OFC 0. 32 - 0.33 < 0.25 severe
McLaren’s malnourishment
Rao & Singh’s Wt (kg)/ Ht2(cm) x 100 0.14 0.12 -0.14
Dugdale’s Wt (kg)/ Ht1.6 (cm) 0.88 -0.97 < 0.79
Quaker Arm MAC expected for a Ht QUAC stick 75 – 85% :mal
Circumeference < 75% : sev.
mal
Jeliffe’s ratio HC / CC >1 in an >1 in a >1 yr child
infant
49. NUTRITIONAL PARAMETERS
ITEM REMARKS
Proteins Reversal of alb/glob ratio
Increased NE/E AA
Carbohydrate Low glycogen, hypoglycemia
Lipids Increased NE/EFA ratio
Electrolytes Normal/ high Na, low K
Water Increased TBW,
High ECF/ICF ratio
minerals Low Ca, P, Mg, K
50. Other Indicators
MORPHOLOGICAL INDICATORS
mutilation of cells in buccal smear
(normally < 10%)
hair texture, shaft size
EPIDEMIOLOGICAL INDICATORS
vital statistics, under 5 mortality is used to
rank nations based on child health and
nutritional status
51. PEM Management
Criteria for Admission:
• Severe wasting
• Symmetrical edema involving at least the feet
• Wt/age <60% with
diarrhea
shock
hypothermia
systemic infection
jaundice
bleeding
age<1 year
persistent loss of appetite
52. PEM Management
Basic Principles
• Careful initial evaluation
• Anticipation of problems
• Prevention of problems
• Early detection &treatment of problems
• Avoid intravenous infusions except when essential
• Promotion of food intake by all available means
54. PEM Management
• Routine treatment
The 10 Steps
• Emergency treatment 1. Treat/prevent hypoglycemia S
2. Treat/prevent hypothermia
• Associated Conditions
3. Treat/prevent infection
• Treatment failure 4. Correct electrolyte imbalance
5. Treat/prevent dehydration
• Preparing Follow-up
6. Correct micronutrient deficiencies
7. Begin cautious feeding
8. Achieve catch-up growth E
9. Sensory Stimulation and emotional support
10. Prepare for follow-up T
BEST
55. Weight gain during the rehabilitation
phase
Poor: <5g/kg/d
Moderate: 5-10g/kg/d
Good: >10 g/kg/d
56. Criteria for discharge
Absence of infection.
The child is eating at least 120-130 cal/kg/day and receiving
adequate micronutrients
There is consistent weight gain (of at least 5 g/kg/day for 3
consecutive days) on exclusive oral feeding
WFH is 90% of NCHS median; The child is still likely to have a
low weight-for-age because of stunting.
Absence of edema.
Completed immunization appropriate for age.
Caretakers are sensitized to home care.