Protein Energy Malnutrition   Saptharishi L G                              
DEFINITION• Inadequate intake of protein and energy either because the  dietary intakes of these 2 nutrients are less than...
Epidemiology The World Bank estimate : Rank 2 in the world in number  of malnourished children, second only to Bangladesh...
Worldwide prevalence of PEM
Distribution of PEM population
UNICEF DataNFHS-3 (2005-06) : for under 3 yrs  Underweight - 40%  Stunted      - 45%  Wasted        - 23 %
PEM and Hunger – distribution among states
Significance of PEM
What percentage of energy expenditure of achild is contributed by each??        Item              Energy expenditure      ...
DETERMINANTSDeterminantsPhysical environmentBiological environmentPsycho socio cultural environmentFeeding PracticesMicroe...
Patho-physiology -Theories Gopalan’s theory of adaptation and maladaptation - 1967 Free radical injury theory – Golden’s...
PEM - Assessment• Dietary factors• Clinical features• Anthropometry• Biochemical parameters• Morphological parameters• Rad...
PEM - Assessment                  Dietary assessment• 24 hour recall method- accuracy increased by taking  average of 3 da...
PEM - AssessmentClinical Features..       ORGAN           SIGNS                  Hypochromotrichia       Hair       Easily...
PEM - AssessmentClinical Features..       ORGAN            SIGNS       eyes       Pale conjunctiva                  Bitot ...
PEM - AssessmentClinical Features..           ORGAN            SIGNS    Subcutaneous      Edema/ gross reduction    tissue...
PEM - AssessmentClinical Features..          ORGAN           SIGNS                    Psychomotor changes                 ...
DifferentiationITEM                  MARASMUS                           KWASHIORKARAGE                   infancy          ...
Assessment of PEMWeight for Age        (acute)Height for Age        (chronic)Weight for Height     (acute on chronic)Head ...
Age dependent indices         of       PEM                        
Weight Technique No spring balance ; discourage bathroom scales Clinical significance of weight Formula for calculatin...
Weight for ageAGE          WEIGHT    In terms of birth wtBirth        3 kg      15 months     6 kg      21 yr         9 kg...
Malnutrition Based on weight for age : IAP classification 1972       Grade of            Weight-for-age of Category      ...
Malnutrition Wellcome trust 1970       Weight for age   No edema        Edema       60 – 80 %        underweight     kwas...
Malnutrition Gomez classification 1956                              WEIGHT FOR AGE               STATUS           % of ex...
Malnutrition Jeliffe classification 1965                                WEIGHT FOR AGE                 STATUS           %...
Length•   Equipment-Infant Length    Board (Infanto-meter)•   It is a calibrated length board with    fixed headpiece and ...
Standing height > 2 yrs age Heels/ buttocks/ back – in contact with vertical board Frankfurt plane parallel to floor B...
Height variation with ageAge                                  Length / HeightBirth                                50 cm3 m...
Clinical significance of Height Indicator of Long term malnutrition Concept of MID-PARENTAL height   ESTIMATED TARGET H...
Stunting – based on Height for             agePercentage of the ideal height   Grade of stuntingexpected for the age>95 % ...
Concept of         ‘WEIGHT for HEIGHT’ The concept of Wasting 7 yr boy with Ht 104 cm and wt 12 kg. COMMENT      What i...
MALNUTRITION WATERLOW 1972
Protein Energy MalnutritionWHO classification of Under-nutrition in Under-five children                           Moderate...
Head    circumference   Use a flexible, non-stretchable tape   Measure to nearest 0.1 cm   Position the tape just above...
Chest Circumference At the level of nipples Vs xiphoid process Tape parallel to the ground ; between insp and exp At bi...
Age independent Indices          of         PEM                          
Mid Arm Circumference For children 1 – 5 yrs Determine midpoint on arm – midway between acromion  and olecranon Left ar...
PEM - AssessmentUNICEF armcircumferencetape
Mid arm circumference               Interpretation                                   MAC           Interpretation Kanawat...
•   QUAC stick    Quaker arm circumference measuring stick - A stick used to measure height    which also shows the 80th a...
Skin-fold Thickness Techniques of measurement (NHANES III)     General gudelines       Hold 2 cm above measurement site...
Skin fold thickness Harpenden’s callipers         > 10 mm – normal         6 – 10 mm – mild malnourishment        < 6 ...
Skin-fold Thickness
Other IndicesName of Index     Formula                  Normal         Malnutrition                                       ...
Radiological assessmentRADIOLOGICAL INDICATORS Bone Age Rickets Scurvy Osteoporosis
NUTRITIONAL PARAMETERS           ITEM                           REMARKSProteins             Reversal of alb/glob ratio    ...
Other IndicatorsMORPHOLOGICAL INDICATORS mutilation of cells in buccal smear (normally < 10%) hair texture, shaft sizeEPID...
PEM ManagementCriteria for Admission:• Severe wasting• Symmetrical edema involving at least the feet• Wt/age <60% with    ...
PEM ManagementBasic Principles• Careful initial evaluation• Anticipation of problems• Prevention of problems• Early detect...
PEM Management• Routine treatment                                  The 10 Steps• Emergency treatment     1. Treat/prevent ...
Weight gain during the rehabilitationphasePoor:    <5g/kg/dModerate: 5-10g/kg/dGood:   >10 g/kg/d
Criteria for discharge   Absence of infection.   The child is eating at least 120-130 cal/kg/day and receiving    adequa...
PREVENTIONDeterminantsPhysical environmentBiological environmentPsycho socio cultural environmentFeeding PracticesMicroenv...
Prevention of Malnutrition NATIONAL LEVEL    Nutrition supplementation    Nutritional surveillance    Nutritional plan...
Prevention of malnutrition FAMILY LEVEL    EBF    Appropriate weaning    Vaccination    Discourage iatrogenic food re...
National Nutrition Policy Integrated Child development services Program (ICDS)   Mid-day meals programme – 2007       1...
item             amt             kcal    protroti             1(30gm)         100     3.6daliya           1(30gm)         ...
Protein Energy malnutrition
Protein Energy malnutrition
Protein Energy malnutrition
Protein Energy malnutrition
Protein Energy malnutrition
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Protein Energy malnutrition

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Protein Energy malnutrition

  1. 1. Protein Energy Malnutrition Saptharishi L G 
  2. 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. 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
  4. 4. Worldwide prevalence of PEM
  5. 5. Distribution of PEM population
  6. 6. UNICEF DataNFHS-3 (2005-06) : for under 3 yrs Underweight - 40% Stunted - 45% Wasted - 23 %
  7. 7. PEM and Hunger – distribution among states
  8. 8. Significance of PEM
  9. 9. What percentage of energy expenditure of achild is contributed by each?? Item Energy expenditure (%) BMI 50 Activity 25 Growth 12 Fecal loss 8Specific dynamic action 5
  10. 10. DETERMINANTSDeterminantsPhysical environmentBiological environmentPsycho socio cultural environmentFeeding PracticesMicroenvironment
  11. 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
  12. 12. PEM - Assessment• Dietary factors• Clinical features• Anthropometry• Biochemical parameters• Morphological parameters• Radiological parameters• Epidemiological data
  13. 13. 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
  14. 14. PEM - AssessmentClinical Features.. ORGAN SIGNS Hypochromotrichia Hair Easily pluckable Flag sign Straightening Altered texture Flaky paint dermatosis Skin Crazy pavement dermatosis Secondary infections Cutaneous diphtheria Xerosis Follicular hyperkeratosis Pellagra Depigmentation face Noma Moon facies
  15. 15. PEM - AssessmentClinical 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
  16. 16. PEM - AssessmentClinical 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
  17. 17. PEM - AssessmentClinical 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
  18. 18. DifferentiationITEM MARASMUS KWASHIORKARAGE infancy 1-5 yearsFEEDING Poorly breast fed / diluted milk Early removal from breastPREVALENCE common rareWEIGHT <60% 60-80%GROWTH RETARDATION ++ +EDEMA - +APATHY - +MOOD alert LethargicAPPETITE good PoorHAIR / SKIN CHANGES Mild SevereFATTY LIVER Absent ++SERUM ALB Low normal Very lowCATABOLISM ++ +PROGNOSIS good poor
  19. 19. Assessment of PEMWeight for Age (acute)Height for Age (chronic)Weight for Height (acute on chronic)Head circumferenceChest circumference 
  20. 20. Age dependent indices of PEM 
  21. 21. 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
  22. 22. Weight for ageAGE WEIGHT In terms of birth wtBirth 3 kg 15 months 6 kg 21 yr 9 kg 32 yrs 12 kg 43 yrs 15 kg 55 yrs 18 kg 67 yrs 21 kg 710 yrs 30 kg 10
  23. 23. 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
  24. 24. 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
  25. 25. 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
  26. 26. 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
  27. 27. 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
  28. 28. 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
  29. 29. Height variation with ageAge Length / HeightBirth 50 cm3 months 60 cm9 months 70 cm1 yr 75 cm2 yrs 90 cm4.5 yrs 100 cm Height = 77 + (age x 6) [3-12 yrs age group]
  30. 30. 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
  31. 31. Stunting – based on Height for agePercentage of the ideal height Grade of stuntingexpected for the age>95 % No stunting90 – 95% I85 – 89% II<85% III
  32. 32. 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
  33. 33. MALNUTRITION WATERLOW 1972
  34. 34. Protein Energy MalnutritionWHO classification of Under-nutrition in Under-five children Moderate Severe Undernutrition UndernutritionSymmetrical edema No Yes (Kwarshiorkar & marasmic kwarshiorkar) Edematous malnutritionWeight for height 70 – 79% expected < 70% expected WASTING SEVERE WASTING -2 to -3 SD < -3 SDHeight for age 85 -89% expected < 85% expected STUNTING SEVERE STUNTING -2 to -3 SD < -3SD
  35. 35. 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”
  36. 36. 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
  37. 37. Age independent Indices of PEM 
  38. 38. 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
  39. 39. PEM - AssessmentUNICEF armcircumferencetape
  40. 40. 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
  41. 41. • 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
  42. 42. 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
  43. 43. 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
  44. 44. Skin-fold Thickness
  45. 45. Other IndicesName of Index Formula Normal Malnutrition ValueKanawati & MAC/ OFC 0. 32 - 0.33 < 0.25 severeMcLaren’s malnourishmentRao & Singh’s Wt (kg)/ Ht2(cm) x 100 0.14 0.12 -0.14Dugdale’s Wt (kg)/ Ht1.6 (cm) 0.88 -0.97 < 0.79Quaker Arm MAC expected for a Ht QUAC stick 75 – 85% :malCircumeference < 75% : sev. malJeliffe’s ratio HC / CC >1 in an >1 in a >1 yr child infant
  46. 46. Radiological assessmentRADIOLOGICAL INDICATORS Bone Age Rickets Scurvy Osteoporosis
  47. 47. NUTRITIONAL PARAMETERS ITEM REMARKSProteins Reversal of alb/glob ratio Increased NE/E AACarbohydrate Low glycogen, hypoglycemiaLipids Increased NE/EFA ratioElectrolytes Normal/ high Na, low KWater Increased TBW, High ECF/ICF ratiominerals Low Ca, P, Mg, K
  48. 48. Other IndicatorsMORPHOLOGICAL INDICATORS mutilation of cells in buccal smear (normally < 10%) hair texture, shaft sizeEPIDEMIOLOGICAL INDICATORS vital statistics, under 5 mortality is used to rank nations based on child health and nutritional status
  49. 49. PEM ManagementCriteria 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
  50. 50. PEM ManagementBasic 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
  51. 51. 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
  52. 52. Weight gain during the rehabilitationphasePoor: <5g/kg/dModerate: 5-10g/kg/dGood: >10 g/kg/d
  53. 53. 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.
  54. 54. PREVENTIONDeterminantsPhysical environmentBiological environmentPsycho socio cultural environmentFeeding PracticesMicroenvironment
  55. 55. Prevention of Malnutrition NATIONAL LEVEL  Nutrition supplementation  Nutritional surveillance  Nutritional planning COMMUNITY LEVEL  Health & nutrition education  Promotion of education & literacy  Growth monitoring  Integrated health package  Family planning programs
  56. 56. Prevention of malnutrition FAMILY LEVEL  EBF  Appropriate weaning  Vaccination  Discourage iatrogenic food restriction during illnesses  Adequate spacing
  57. 57. National Nutrition Policy Integrated Child development services Program (ICDS) Mid-day meals programme – 2007  15th aug 1995  450 kcal + 12 g protein  700 kcal + 20g protein National nutritional anemia prophylaxis programme – 1970  100 mg Iron + 0.5 mg folic acid  20 mg Iron + 0.1 mg folic acid x 100 days (1-5 yrs)
  58. 58. item amt kcal protroti 1(30gm) 100 3.6daliya 1(30gm) 100 3.6Suji 1(30 gm) 100 3.0dal 1(30gm) 100 6.8khichdi 1 bowl(20+20) 140 6.0Veg.(gr.Leafy) ½ cup 30-40 - (others) 1/2 cup 50-60 -bread 2(40gm) 100 3.0egg 1 80 6.6paneer 25 60 4.6

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