Protein energy malnutrition in children 2021 Classification, epidemiology and etiology

1. Protein Energy Malnutrition
in Children
Classification, Epidemiology and Etiology
Prof. Imran Iqbal
Prof of Paediatrics (2003-2018)
Prof of Pediatrics Emeritus, CHICH
Prof of Pediatrics, CIMS
Multan, Pakistan

3. AL – QURAN (76:8-9)
Surah Al-Insan (ayat 8 - 9)
And, because of the love of Allah; they give food to the
needy, the orphan, and the prisoner.
(they say) We feed you only for the sake of Allah, we do
not want any reward or thanks from you.

4. What is Malnutrition ?

5. NUTRITIONAL STATUS
is the result of a balance between
intake and expenditure of any nutrient
NUTRITIONAL INTAKE NUTRITIONAL EXPENDITURE
NUTRITIONAL STATUS

6. NUTRITIONAL INTAKE
Low Intake
NUTRITIONAL EXPENDITURE
Diseases
NUTRITIONAL STATUS
MALNUTRITION
is a pathological state resulting from an absolute or
relative deficiency of one or more essential nutrients

7. What is Malnutrition ?
• Malnutrition is a Pathological State resulting from Deficiency of One
or More Essential Nutrients
• Protein – Calorie Malnutrition (PCM / PEM)
• Severe Acute Malnutrition (SAM)
• Specific Micronutrient deficiency
- Vit A deficiency immunodeficiency
- Vit D deficiency Rickets
- Iron deficiency anemia
- Iodine deficiency goitre

8. Protein – Calorie Malnutrition (PCM / PEM)
A pathological state resulting from
lack of protein and calories in diet
often associated with infection

9. Clinical Presentations
and
Classification
of
Protein – Calorie Malnutrition (PCM / PEM)

10. Clinical Presentations of Malnutrition
o Underweight child (weight less than expected)
o Stunted Child (remains small)
o Wasted Child (remains thin)
SEVERE CLINICAL PICTURES
o Marasmus (calorie malnutrition)
o Kwashiorkor (protein and calorie malnutrition)

11. Stunting and Wasting

12. Marasmus

13. Kwashiorkor

15. Clinical Types of Malnutrition
Current terminology
(clinical picture)
• Marasmus
• Kwashiorkor
• Marasmic Kwashiorkor
New terminology (measurements)
(Weight, Height, MUAC )
• Low weight (Weight for age)
• Stunting (Length for age)
• Wasting (Weight for Length/Height)
• Acute Malnutrition
• MAM (moderate acute malnutrition)
• SAM (severe acute malnutrition)

16. Normal Anthropometric Measurements
• Weight for age – more than – 2 z-score
(> 70 % of mean or expected for age)
• Length / Height for age – more than – 2 z-score
(> 85 % of mean or expected for age)
• Weight for Length / Height – more than – 2 z-score
(> 80 % of mean or expected for height)
• Mid arm circumference (MUAC) – 125 mm to 160 mm
(at 6 months to 5 years of age)

17. Clinical types of Malnutrition
• Underweight child – low Weight for Age (overall malnutrition)
• Stunting – Low Height for Age (indicates chronic malnutrition)
• Wasting – Low Weight for Height (indicates acute malnutrition)

18. Stunting and Wasting

19. Low Weight (Weight for age)
Indicates overall nutritional status
• Underweight child – Weight for Age less than – 2 z-score
(< 70 % of mean or expected for age)
• Moderate low weight - < – 2 z-score but > - 3 z-score
• Severe low weight - < – 3 z-score

20. Stunting (Height for age)
Indicates chronic malnutrition
• Stunted child – Weight for Height less than – 2 z-score
(< 85 % of mean or expected for age)
• Moderate stunting - < – 2 z-score but > - 3 z-score
• Severe stunting - < – 3 z-score

21. Wasting (Weight for Length / Height)
Indicates acute malnutrition
• Correlates with risk of mortality
• Wasted child – Weight for Length / Height less than – 2 z-score
(< 80 % of mean or expected for length / height)
• Moderate wasting (MAM) - < – 2 z-score but > - 3 z-score
• Severe wasting (SAM) - < – 3 z-score

22. Stunting and Wasting

23. Moderate Acute Malnutrition (MAM)
(Presence of any of the following)
• Weight for Height < -2 z-score (< 80 %)
• MUAC < 125 mm

24. Severe Acute Malnutrition (SAM)
(Presence of any of the following)
• Weight for Height < -3 z-score (< 70 %)
• MUAC < 115 mm
• Edema

25. Severe Acute Malnutrition
• Age = 11 months
• Length = 70 cm
• Weight = 5.5 kg ( - 4 SD)

26. Severe Acute Malnutrition (SAM)
• SAM (Severe Acute Malnutrition) is the name given to
malnourished child when he is wasted or having nutritional
edema.
• Patients having SAM include patients clinically diagnosed as
having marasmus or Kwashiorkor .
• These children are at increased risk of death
• They need specific management with therapeutic foods and
micronutrients.

27. SAM
• SAM (Severe Acute Malnutrition) is present when any of
the following signs are present:
• Weight for length/ height is less than -3 SD (less than 70% of
expected Ht/length)
• Mid-arm Circumference (MUAC) < 115mm (less than 11.5
cm)
• Nutritional edema of both feet

28. Contribution of Malnutrition in Child Deaths

29. Epidemiology

30. Prevalence of Malnutrition under 5 years of age
National Nutrition Survey – 2018

31. National Nutrition Survey – 2018

32. National Nutrition Survey – 2018
Stunting and Wasting
• Stunting = 40.2 %
• Severe Stunting = 19.6 %
• Wasting = 17.7 %
• Severe Wasting = 8.0 %

33. National Nutrition Survey – 2018

34. National Nutrition Survey – 2018
Micronutrient Deficiencies
• Anemia = 53.7 %
• Iron deficiency = 28.6 %
• Zinc deficiency = 18.6 %
• Vitamin A deficiency = 51.5 %
• Vitamin D deficiency = 62.7 %

35. Causes of
Malnutrition in Pakistan

36. National Nutrition Survey – 2018
Inadequate Milk Feeding
• Exclusive Breast Feeding = 48 %
• Early initiation of Breast Feeding = 46 %
• Breast Feeding at 1 year age = 68 %
• Complementary feeding at 6-8 months = 36 %

37. National Nutrition Survey – 2018
Inadequate Semisolid Feeds
• Adequate diet at 6-24 months = 14 %
• Adequate meals at 6-24 months = 18 %
• Acceptable diet at 6-24 months = 3 %

38. National Nutrition Survey – 2018
Contaminated Environment
• Contaminated drinking water = 56 %
• Milk quality = ?
• Food Contamination = ?
• Atmospheric pollution = ?

39. Nutrition Causal Framework
Adapted from Unicef
Outcome Under-Nutrition
Immediate
Causes
Inadequate
Dietary Intake
Disease
Underlying
Health /
Nutrition
Causes
Inadequate
Care for Mothers
and Children
Insufficient
Access to Food
Lack of health services &
unhealthy environment

40. INDEQUATE DIET /DISEASE CYCLE
INFECTIONS
LOW
IMMUNITY
MALNUTRITION
INADEQUATE
DIETARY
INTAKE

41. Causes of Malnutrition in Pakistan
LOW FOOD INTAKE (underfeeding)
+
RECURRENT INFECTIONS

42. WHY MALNUTRITION ?
PREDISPOSING FACTORS
(Background causes)
 Poverty
 Lack of education
 Inadequate health facilities

43. Mothers in Pakistan

44. Anemia in Mothers

45. Vitamin D deficiency in Mothers

46. Nutritional Status and Mother Education

47. Determinants of Malnutrition
• Poor maternal health
• Lactation failure
• Unequal distribution of food in home
• Unhealthy feeding habits (diluted milk, delayed weaning)
• Restriction of food during illness
• Unhygienic environment
• Repeated infections
• Poor literacy rate
• Poverty (Household Food Insecurity = 37%)

48. Patho-physiology of
Malnutrition

49. Reductive adaptation
• Smaller size
• Thinness
• Smaller organs
• Reduced immunity

50. Pathological Effects of Malnutrition
• Cardiovascular - ↓ cardiac output, ↓ blood pressure
• GI - mucosal atrophy, ↓ enzymes, malabsorption
• Renal - ↓ glomerular filtration, ↓ waste excretion
• Immune - ↓ immunoglobulins, ↓ cell-mediated immunity,
↓ phagocytosis, ↓ inflammatory response
• Liver - ↓ glycogen, Hypoglycemia
• Endocrine - ↓ insulin levels, ↓ IGF-1 levels
• Cellular function - ↑ permeability of cell membranes
• Temperature regulation - ↓ BMR, Hypothermia
• Skin, muscles, glands – atrophy, muscle fatigue

51. MALNUTRITION and INFECTION
- Immunoglobulins ↓
- T-CELL FUNCTION ↓
- POLYs FUNCTION ↓
- Complement levels ↓
- Transferrin levels ↓
- Macrophage function ↓
- Intestinal commensel flora-altered
↓
INFECTIONS

52. Complications of Malnutrition

53. Acute Complications
• Hypoglycemia
• Hypothermia
• Diarrhea, Dehydration, Shock
• Fluid overload, Congestive Heart Failure
• Electrolyte imbalance – K+ deficiency
• Acute infections – Diarrhea, pneumonia,
• Eyes – keratitis, keratomalacia
• Dermatosis
• Anemia
• Purpura

54. Chronic Complications
• Chronic infection e.g T.B
• Malabsorption / Chronic diarrhea
• Anemia
• Vitamin Deficiencies
• Growth retardation
• Learning disorders ( low IQ)

55. Management of
Malnutrition

56. Principles in Management of Malnutrition
• Treat Acute complications - hypothermia, hypoglycemia,
dehydration, diarrhea, infection
• Adequate diet which the child can digest (150 – 200 calories /
kg / day)
• Micronutrients ( Vitamin A )
• Growth monitoring (assess weight daily or weekly)
• Follow-up (monthly to prevent relapse)

57. Time frame for the management of
a child with severe malnutrition
Stabilization Rehabilitation
Days 1-2 Days 3-7 Weeks 2-6
1. Hypoglycaemia
2. Hypothermia
3. Dehydration
4. Electrolytes
5. Infection
6. Micronutrients no iron with iron
7. Initiate feeding
8. Catch up growth
9. Sensory stimulation
10. Prepare for follow-up
Source: WHO

58. PCM (Classification, Epidemiology and Etiology)
• Malnutrition is seen in about half of children under five in Pakistan
• Protein – Calorie Malnutrition can present as Low weight, Stunting
(short child, chronic malnutrition) or Wasting (thin child, acute
malnutrition)
• Severe Acute Malnutrition includes recognised clinical pictures of
marasmus and kwashiorkor
• Children with Severe Acute Malnutrition have increased risk of death
• Low food intake (underfeeding) and recurrent infections are the
main immediate causes of malnutrition in children
• Poverty, low levels of education, contaminated environment and
inadequate health care are the major background factors

59. Thank you