2. INTRODUCTION
Malnutrition- Refers to both under nutrition as well as
over nutrition
Under nutrition- Inadequate consumption, poor absorption
or excessive loss of nutrients.
Over nutrition- Overindulgence or excessive intake of
specific nutrients.
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3. PROTEIN ENERGY MALNUTRITION
Definition – Acc to WHO it is a range of pathological
conditions arising from coincidental lack in varying
proportions of protein and calories occurring most
frequently in infants and young children and
commonly associated with infection.
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4. CLASSIFICATION
I. Clinical classification
Marasmus: weight for age < 60% expected + without edema
Kwashiorkor: weight for age < 80% + edema
Marasmic kwashiorkor: wt for age <60% + edema
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5. II. Gomez classification
Based on weight for age
Grade I 90-75 % of expected weight
Grade II 75 – 60 % of expected weight
Grade III <60 % of expected weight
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6. III. IAP classification
Based on weight for age
Weight of a child is compared with weight of normal expected
for that age
If the child is having edema letter ‘k’ is placed in front of the
grade
Grade I 80-71 % of expected weight
Grade II 70 – 61 % of expected weight
Grade III 60 - 51 % of expected weight
Grade IV < 50 % of expected weight
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7. IV. Jelliffee’s classification
Similar to IAP classification but normal goes upto 90% and grade IV
is < 60%
If the child is having edema letter ‘k’ is placed in front of the grade
Grade I 80-90 % of expected weight
Grade II 70 – 79 % of expected weight
Grade III 60 - 69 % of expected weight
Grade IV < 60 % of expected weight
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8. V. Wellcome classification
VI. WHO classification
Wt. for age Edema No edema
60-80% Kwashiorkor Underweight
<60% Marasmic –
kwashiorkor
Marasmus
Moderate
malnutrition
Severe
malnutrition
Edema No Yes
Wt for height 70-79% <70%
Height for age 85-89% < 85%
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9. VII. Waterlow classification
Normal Wasted Stunted
Weight for age Normal Less Less
Weight for
height
Normal Less Normal
Height for age Normal Normal Less
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10. MAC Nutritional status
>13.5 cm Green Normal
12.5-13.5 Yellow Mild and moderate
PEM
< 12.5 cm Red Severe PEM
VIII. Arnold’s classification based on Mid arm
circumference
Used for below 5 years of age
<13.5 cm : Malnutrition
Shakir tape is used to measure MAC
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11. ETIOLOGY OF PEM
PEM results from many inter related factors :
1. Sociodemographic factors
2. Environmental factors
3. Nutritional factors
1. Sociodemographic factors
Large family size
Lack of child spacing
Neglect of girl child
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12. 2. Environmental factors
Low socio economic status
Poverty and ignorance
Illiteracy
Poor sanitation and low standard of living
Parental attitudes and rearing practices
Cultural practices
Natural or man made disasters
Chronic diseases
Inadequate medical facilities
3.Nutritional factors
Early weaning from breast or late weaning
Diet during illness-increased intestinal loss, anorexia
Maternal malnutrition
Low birth weight
Recurrent infections and infestations, diarrhea, worm infestations
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13. Marasmus
Also known as athrepsia
Marasmus is a form of severe PEM which occur as result
from energy deficiency that may occur at any age,
particularly in early infancy and is characterized by:
Severe wasting (body weight is less than 60% of the expected), the
body utilizes all fat stores before using muscles.
Loss of subcutaneous fat.
Gross muscle wasting.
Absence of edema.
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14. Causes
Inadequate diet
Faulty eating habits
Anomalies such as cleft lip and cleft palate which prevents
intake of food
Conditions such as anorexia, vomiting and diarrhea
Allergy to certain foods
Disturbed mother and child relationships
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15. Kwashiorkor
Insufficient protein consumption.
The word kwashiorkor describes the malnourished
child, the result of the ill-health which develops
when an infant is weaned from breast-feeding when
a sibling is born and monopolizes breast feeding.
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16. Causes
Social and Economic
Poverty
Ignorance
Inadequate weaning practices
Child abuse
Cultural and social practices
Vegetarian diet
Low fat diet
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17. Clinical Features
Kwashiorkor – meaning red haired boy
Classical features – Lethargy, Edema, Growth failure
The main clinical features are
Skin changes, hair changes, facies, associated vitamin deficiency,
anemia
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18. I. Skin changes
1. Dry scaly skin: mosaic pattern appearing on trunk and limbs
2. Thin, shiny, stretched over edematous limbs.
3. Skin changes more commonly seen in extremities.
4. Starts with erythematous rashes –> hyper pigmentation ->
desquamate -> hyper pigmented patches.
5. This alternative hypo/hyper pigmented patches gives an
appearance of flaky paint dermatosis
6. On the pressure sites, jet black patches appear which then
exfoliate leaving the sub adjacent zone leading to crazy
pavement dermatosis
Contn..9/25/202018Anju George, SGCON, Parumala
20. 7. Deep fissures are seen on elbows, knees ,groin and behind the
ears
8. Multiple punctuate pinkish areas develop over extremities due to
perifollicular hemorrhage
9. Angular stomatitis due to potassium and riboflavin deficiency
10. Gangrenous dermatitis
11. Scabies and pyoderma
12. Skin lesions
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21. II. Hair changes
1. Thin, scanty, easily pluckable, lusterless, commonly
brownish/less black
2. Dyschromotrichia – light color of hair
3. Flag sign – Alternate band of hyper pigmented and hypo
pigmented hair
4. Hair loss can also affect eyelashes and eyebrows
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22. III. Facies
1. Cheeks look full due to hydration of cells of buccal fat and
surrounding tissues
2. Moon face appearance
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23. IV. Associated Vitamin deficiency
1. Angular stomatitis due to riboflavin deficiency
2. Rickets (Vitamin D)
3. Scurvy (Vitamin C)
V. Anemia
1. Normochromic normocytic anemia
2. Can be hypochromic macrocytic anemia due to iron
deficiency
3. Hepatosplenomegaly
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24. Marasmus –
The characteristic feature is loss of subcutaneous fat
Grade I – loss of fat in axilla and groin
Grade II – loss of fat in axilla, groin, abdomen and gluteal region
Grade III – loss of fat in axilla, groin, abdomen, gluteal region,
chest and spine
Grade IV – loss of fat in axilla, groin, abdomen, gluteal region,
chest, spine, buccal pads.
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25. Old man appearance
Cheeks and temples are hollow
Skin is loose and wrinkled, loss of elasticity
Marasmic purpura in terminal cases
Distended abdomen, scaphoid with visible peristalsis
Later when infection sets in
Apathetic and less active
Constipation
Severe electrolyte imbalance convulsions and various
neurological signs
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27. EVALUATION OF CHILD WITH PEM
Assessment should include:-
Socioeconomic status and sociocultural factors
Severity
Classify malnutrition
Associated mineral and vitamin deficiency
Complication
Assess etiology
Check development
Ensure immunization
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28. Lab investigations such as :-
Hb and peripheral smear
Sr. protein and albumin
Blood sugar and electrolytes
Other investigations to check evidence for infections – blood
counts, blood culture and sensitivity, urine and stool
examination, chest x-ray, mantoux test.
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29. Diagnosis
Nutritional assessment – wt, ht, MAC, Head
circumference and chest circumference
Skinfold thickness
Biochemical measurements
Serum albumin :<3g/100ml in kwashiorkor : normal or
slightly decreased in marasmus
Hydroxyprolene/creatinine ratio is ess
Plasma/amino acid ratio is low
Elevated growth hormone and plasma cortisol levels
Insulin levels are reduced
Elevated TSH
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30. S = Sugar deficiency (Hypoglycemia)
H = Hypothermia
I = Infections
D = Deficiency of micronutrients
E
ELectrolyte abnormality
L
D
Dehydration
E
COMPLICATIONS
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31. MANAGEMENT
Falls under 3 phases and is a ten step process
1. Acute/initial phase (1-7 days)
It includes
Assessment
Management of life threatening complications step 1-5
Nutritional management step 6-8
2.Recovery/Rehabilitation phase (2-6 weeks)
o It includes
Nutritional management step 6-8
Physical and emotional stimulation step 9
Family education step 10
3. Follow up phase (6 weeks- 6 months)
o It includes
Nutritional rehabilitation and continual care at home step 10
Monitoring and home visits step 10
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32. A. General Principles of Routine Care
STEPS PHASE
Stabilization Rehabilitation
Days 1-2 Days 3-7 Weeks 2 – 6
1 Treat / Prevent Hypoglycemia
2 Treat / Prevent Hypothermia
3 Treat / Prevent Dehydration
4 Correct Electrolyte Imbalance
5 Treat / Prevent Infection
6 Correct micro-nutrient deficiencies
Iron supplementation
7 Start Cautious Feeding
8 Achieve Catch-up Growth
9 Provide Sensory Stimulation
and Emotional Support
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33. 1.Prevent & correct hypoglycaemia
Hypoglycemia - Is due to reduced glycogen stores
and increased utilization.
Blood glucose < 54 mg/dl
Child is able to take oral feeds – 50ml bolus of 10%
glucose solution orally.
Child is unable to take oral feeds –treat with IV 2ml/kg of
25% D or 5 ml/kg of 10% D followed by 50 ml of 10%D as
IV infusion.
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34. 2.Prevent and correct hypothermia
Hypothermia – is due to decreased heat
production, decreased BMR and increased heat loss
due to large surface area and loss of subcutaneous
fat.
Axillary temperature < 35°C
Clothe the child including extremities and head especially at
night
Place a heater/ lamp nearby (avoid hot water bags )
Provide woollen clothing
Encourage kangaroo mother care
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35. 3. Treat / prevent dehydration
As these children are more prone to fluid overload,
sodium restriction and fluid restriction to be done while
rehydrating.
ReSoMal (Rehydrating Solution for Malnutrition) is given
70-100 ml/kg over 8-12 hrs.
5ml/kg every 30mts for first 2 hrs then 5-10ml/kg/hr for next 4-10 hrs.
If there is diarrhoea, 50-100ml of ReSoMal for each
stool
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36. 4. Correct electrolyte imbalance
Hypokalemia is a problem in both marasmus and
kwashiorkor which leads to respiratory muscle paralysis.
If potassium <2 – administer 40meq/l of K⁺
If potassium is between 2-2.5 – administer 30meq/l of K ⁺
Hypomagnesaemia is another problem that can lead to
muscle weakness. The treatment is 50% MgSO4 at a dose of
0.3ml/kg x 7 days
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38. 6. Correct micronutrient deficiencies
Provide multivitamin supplements
Administer vitamin A single dose, orally if its not given in the last month
(dosage :- if age>1 year 2lac IU, 6- 12 months 1 lac IU, 0-5 months 50,000
IU)
Folic acid - 1mg/day
Zinc - 2mg/kg/day
Copper - 0.3 mg/kg/day
Iron - 3mg/kg/day
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39. 7. Start cautious feeding
Initiate feeding as soon as possible as frequent small feeds (upto
12 meals/day)
If unable to take orally- NG feeds
The goal is to provide 80-100 kcal/kg/day
Total fluid recommended is 130ml/kg/d, reduce to 100ml/kg/d if
there is severe, generalized edema
Continue breast feeding
Start with F-75 starter feeds every 2 hrly
F-75 contains 75kCal/100ml with 1g protein/100ml
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40. 8. Achieve catch up growth
Once appetite returns in 2-3 days, encourage higher feeds
Increase volume offered in each feed and decrease the
frequency of feeds to 6 feeds/day
Continue breast feeding on demand
Make a gradual transition from F-75 to F-100 diet
F-100 contains 100kCal/100ml with 2.5-3g protein/100ml
Increase calories to 150-200 kCal/kg/d and proteins to 4-
6g/kg/d
Add complementary foods as soon as possible to prepare
the child for home foods at discharge
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41. 9. Tender loving care & sensory stimulation
A cheerful, stimulating environment
Age appropriate structured play therapy for at least 15-
30 mins/day
Age appropriate physical activity as soon as the child is
well enough
Tender loving care
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42. 10. Prepare for follow up after recovery
Total duration for recovery 6-8 wks
Criteria for recovery- weight for length 90%
Weekly follow ups for the first 2 months
Once a month for the next two months
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