protein energy malnutrition in children

1. PEM
- Dr Jyoti Saroj

2. Definition
 WHO (1973) defined PEM as a range of pathological conditions arising
from coincident lack, in varying proportions of protein and calories,
occurying most frequently in infants and young children and commonly
associated with infections.

3. Spectrum of PEM
Severe mild
Kwashiorkor Prekwashiorkor
Marasmus Nutritional dwarfing
Marasmic kwashiorkor underweight
Invisible PEM
Early lactation failure (ELF)syndrome
MAM and SAM

4. Kwashiorkor
Prof Cicely Williams
Kwa-ni-oshi korkor- pretend not to mind the second one/ the disease of
first child/ red boy/ deposed child
Grade I- pedal edema
Grade II- I+ facial edema
Grade III- II + paraspinal & chest edema
Grade IV- III + ascites
Triad- Growth retardation + edema+ mental changes

5. Marasmus
 “ Wasting ”
Grade I – Axilla & groin
Grade II- I+ thigh and buttocks
Grade III- II + chest and abdomen
Grade IV- III + buccal pad of fat

6. Other forms
 Marasmic kwashiorkor- Marasmus + edema
 Prekwashiorkor- Poor nutritional status + hair changes+ moon face+
hepatomegaly BUT NO EDEMA
 Nutritional dwarfing- Bonsai children/ pocket editions
Stunting but no wasting (micronutrient deficiency), prolonged PEM, early in
life
 Underweight – WFA 60-80%, no other features
 Invisible – Toddlers with breast addiction , too small for age, less
resistance, receive only 60% of caloric requirement, within road to health
but flat/ downward curve
 ELF syndrome – Dilute starch based diet, protein def- skin changes, apathy,
hypoalbuminemia, anemia, edema, micronutrient def

7. Magnitude of problem
 150 million affected
 120 million in India
 75 million visible PEM
 Kerala – highest normal nutrition status

8. Assessment of environment
1) Physical
2) Biological
3) Psychosocial
4) Microenvironment- immediate home environment
5) Assessment tools – Kuppuswami scale
6) Ten commandments in environmental health- safe drinking water,
disposal of excreta, proper disposal of all wastes, control and prevention
of air pollution, noise reduction and control, proper housing standards,
proper ventilation and lighting, prevention of radiation exposure, control
of biological hazards (microbes, animals, man), legal measures for above

9. Assessment of nutritional status
 Anthropometric assessment / Auxology
 Biochemical indicators of malnutrition
 Clinical assessment
 Dietary assessment
 Epidemiology/ Ecological evaluation
 Functional evaluation

10. Anthropometric assessment/ Auxology
Gold standard
1) Weight for age (WFA)- Salter scale
2) Height for age (HFA)- Infantometer, Frankfurt plane
3) Weight for height (WFH)
4) Mid upper arm circumference (<12.5cm severe PEM, 12.5- 13.5 cm
moderate PEM, >13.5cm normal
5) Head circumference
6) Chest circumference
7) Skinfold thickness (SFT)- Harpenden calipers

12. 8) Somatic quotient (SQ)
9) Upper segment- lower segment ratio
10) Mid parental height (MPH) & Target Height
11) Reference stds
12) Age independent anthropometric indicators- bangle test, Shakir’s tape,
Quac stick, modified Quac stick, Nabarrow’s thinness chart, Kanawati
index, HC/ CC , MAC/H, Rao & Singh wt/ht2, ponderal index of wt/ht3,
Dughadale wt of wt /ht 1.6 , BMI, Quetlet index, MAC

13. Classification of malnutrition
1) Wt for age
2) Ht for age
3) Wt for ht
4) Who cut offs & Z score

14. WEIGHT FOR AGE
1) Gomez’s
2) Jelliffe’s
3) Wellcome trust/ International
4) IAP

18. HEIGHT FOR AGE

19. WEIGHT FOR HEIGHT

20. Who cut offs

21. Z score

22. Biochemical indicators
 Low serum protein
 Urinary creat – Indirect evidence of muscle mass
 Alpha 1 globulin (APR) & Gamma globulin ( antibodies) – RAISED
 Alpha 2 & Beta globulins (carrier proteins) – LOW

23. Clinical assessment

25. Dietary assessment
Breastfeeding and complementary feeding
Growth monitoring
Ort
BF
Immunization
Food supplementation
Female education
Family planning
24 hr recall method

26. Pathogenesis
Time
Acute
Kwashiorkor
Chronic
Marasmus

28. Physiochemical & hormonal mech in
adaptation & dysadaptation

36. Management
 Assess
 Investigate
 Manage
1. General principles for routine care (The 10 steps)
2. Emergency treatment of shock & severe anemia
3. Treatment of associated conditions
4. Appetite test & RUTF
5. Failure to respond to treatment
6. Discharge before recovery is complete
7. SAM < 6 months old

37. WHO guidelines
 Diagnosis of SAM ( Any one of below):
1) WFH<70% of expected or <-3 Z score
2) Visible wasting with MUAC<11.5cm
3) Oedema -bilateral pitting
4) MUAC<11.5cm in 6-60 months old
5) MUAC < 11cm if length < 66cm

45. Antibiotics
Associated conditions Antibiotics
Complications  IV Ampicillin 50mg/kg/dose q6 hrly +
IV Gentamicin 2.5mg/kg/dose q8hrly
 Staph- IV Cloxacillin 100mg/kg/day
q6hrly
 Revise therapy based on CS report
Septic shock/ worsening in initial 48 hrs IV Cefotaxime 100mg/kg/day q8hrly
Meningitis  IV Cefotaxime 200mg/kg/day q6hrly +
IV Amikacin 15mg/kg/day q8hrly
OR
 IV Ceftriaxone 100m/kg/day IV q12
hrs
Dysentery  Ciprofloxacin 30mg/kg/day BD
 IV Ceftriaxone 50mg/kg/day OD /BD

52. Appetite test & RUTF
1) Separate place
2) Explain purpose
3) Wash hands
4) Comfortable position
5) Short time to 1 hour
6) Not to force
7) Plenty of water
BW(kg) Wt (gms)
<4kg 15 gms or more
>4 kg 25 gms or more

53. Phase I
• No appetite
+/-
complications
Transition phase
• For IPD pts-
appetite
improves &
edema
decreases
Phase II
• Good appetite
, no
complications
Criteria to progress
from phase I to phase II

54. Transition
1. Wt gain > 10gm/kg/day
2. Increasing edema
3. Develops edema
4. Rapid increase in size of liver
5. Signs of fluid overload
6. Tense abdominal distension
7. Significant refeeding diarrhea with wt loss
8. IV infusion needed
9. NG tube needed
Phase I

55. Surveillance criteria
1. Weight daily
2. Degree of edema daily
3. Daily feed intake
4. Temp daily
5. Stool, vomiting,dehydration, cough, respiration, liver size daily
6. MUAC weekly
7. Wt gain <5g/kg/day = poor= Requires full reassessment
8. 5-10 gm/kg/day =moderate= check intake targets/ infection overlooked
9. > 10gm/kg/day = good= continue & encourage

56. Discharge criteria

57. Failure to respond to treatment
1. Poor wt gain
2. Inadequate feeding
3. Untreated infection
4. Specific nutrient def
5. TB in HIV/ AIDS
6. Psychological problems

58. Discharge

59. Discharge before recovery

60. SAM < 6months

61. Management
 Supplemental suckling technique (SST)
1. BF every 3 hrs for atleast 20 mins (more often)
2. 1 ½ hr in between give diluted F100 : 130 ml/kg/day (100kcal/kg/day),
divided in 8 meals (F75 only if child has edema)
3. Breastfeeding corner
 Routine medicine
1. Vitamin A :50,000 IU at admission
2. Folic acid: 2.5mg (1 tab) in one single dose
3. Ferrous sulphate : when good sucking with wt gain
4. Antibiotics : Amox (from 2 kg) : 30mg/kg/dose 2 times a day + gentamicin

62. Discharge criteria

63. Care for the mothers
1. 2500 kcal/ day
2. Infant < 2 months -200,000 IU
3. Infant >2 months 25,000 IU once a week
4. Micronutrients

72. Prevention

73. Thank you