BSC NURSING nutrition 1st year

1. Program: B.Sc Nursing, Second Year
BNSG-201 Nutrition & Biochemistry
Topic- pem (sign and symptoms, treatment)
Dr. Sudharani B Banappagoudar
Professor, SONS/OBG
1
BNSG 201

2. topic : pem (sign and symptoms,
treatment)
Subject: Community Nutrition

3. Protein energy malnutrition
• Protein Energy Malnutrition (PEM) is the deficiency of macronutrients or energy
and protein in the diet.
• It is a nutritional disorder, which affects all the segments of population like children,
women and adult males particularly from the backward and downtrodden
communities.
Clinical forms
o Kwashiorkor
o Marasmus
o Marasmic kwashiorkor
Sub-clinical forms
Underweight
Wasting
Stunting
Different Types of PEM

4. Kwashiorkor
• Kwashiorkor is an African word, meaning a "disease of the displaced child",
who is deprived of adequate nutrition.
• Mostly in children between the ages of 1 and 3 years, when they are
completely weaned (taken off the breast).
• The three essential manifestations or signs of kwashiorkor are:
1. Oedema (swelling of feet)
2. Growth failure, and
3. Mental changes.

5. clinical signs of kwashiorkor in detail
Oedema: accumulation of fluid in the tissues.
• Usually begins with a slight swelling in feet gradually spreading up the legs. Later,
hands and face may also have oedema.
Poor growth: Growth retardation is the earliest manifestation.
• The child will be lighter and shorter than its normal peers of same age and weigh
about 80% or less of their normal peers.
• Sometimes, in cases of gross swelling, the body weight may be relatively higher.
The child will also be wasted (thinner). The child's arms and legs will appear thin
as a result of wasting.
Mental changes: kwashiorkor child has no interest in the surrounding.
• The child will also be irritable and prefers to stay at one place and in one position.

6. Other signs which may be present are
Hair changes: In kwashiorkor, the hair loses its healthy sheen and becomes silkier and thinner.
It takes coppery red colour (referred to as 'discoloured hairy).
• You could easily pluck small tufts of hair without causing any pain (referred to as easy pluck
ability) just by passing your hands through the hair.
Skin changes: In many cases, dermatosis (changes in skin) is seen.
• Such changes are common in areas of friction.
Moon face: The cheeks may seem swollen with fluid or fatty tissue and often be slightly
sagging.
Micronutrient deficiencies: Almost all the children manifest anaemia (due to iron deficiency) of
some degree.
• Eye signs of vitamin A' deficiency are also common.
• Manifestations of vitamin B complex deficiency are also noted in many cases.

8. Marasmus
• Marasmus is common in children below the age of 2 years.
• The marasmic children are so weak that they may not have even energy
to cry, which most often is barely audible.
• The child is extremely wasted with very little subcutaneous fat with the
skin hanging loosely particularly over the buttocks.
• Oedema is absent and there are no skin and hair changes.
• However, frequent diarrhoeal episodes leading to dehydration and
micronutrient deficiencies of vitamin A, iron and B-complex are
common.

9. • Signs and Symptoms of
Marasmus
• Extreme muscle wasting - "skin
and bones"
• Loose and hanging skin folds
• Old man's or monkey faces
• Absolute weakness

10. Marasmic Kwashiorkor
• Sometimes, in areas where PEM is common, malnourished children exhibit
the features of both kwashiorkor and marasmus. Such changes could occur
during the transition from one form of severe PEM to another.
• These children will have extreme wasting of different degrees (representing
marasmus) and also oedema (a sign of kwashiorkor).
• They may also man
• Signs and symptoms of Marasmic Kwashiorkor
• Extreme muscle wasting - "skin and bones"
• Loose and hanging skin folds
• Old man's or monkey's face
• Absolute weakness
• Oedema

11. Biochemical signs specific to PEM
Biochemical Changes Marasmus Kwashiorkor
Serum albumin Normal or slightly decreased low
Urinary urea per g of
the creatinine
Normal or decreased low
Urinary Hydroxyproline Index low low
Serum free amino acid ratio Normal Elevated
Anaemia May be observed Common iron and folate
deficiency may be associated
Pancreatic secretions Reduced enzymatic activity Reduced enzymatic activity

12. Treatment
Diet
• Treatment of cases of kwashiorkor or marasmus involves mainly providing
appropriate nutrition support. The child should receive a diet that provides
adequate amounts of energy and protein. Both of these are required in larger
quantities than normal.
The child should be given the following concentrations:
• Energy : 170 - 200 kcal per kg of body weight
• Protein : 3 - 4 g/kg of body weight
Vitamin and mineral supplements
• All cases of severe PEM require multivitamin preparation to meet the increased
demands during recovery.
• Iron (60 mg) and folic acid (100 mg) may be given daily to correct anaemia.

13. Oral rehydration
• Since diarrhoea is very common in severe PEM, correction of dehydration is
the first step in the treatment.
• Home made (salt-sugar mixture) or commercial oral rehydration solution
(ORS) can be administered to correct dehydration.
• Intravenous fluids are required only in severe dehydration.
Control of infections and infestations
• Appropriate antibiotics should be started immediately since infections are
the immediate cause of death in many children.
• Children with intestinal infestations Like giardiasis and ascariasis should be
treated.
"prevention is better than cure". So it becomes extremely
important that we make sincere efforts to prevent and control PEM

14. supplementary feeding programmes
• Food supplementation programmes have a very important role to play to combat
malnutrition.
• The aim of these supplementary feeding programmes is to improve the nutritional
status of vulnerable groups through distribution of food supplements.
Following supplementary feeding programmes :
1. National Programme of Nutritional Support to Primary Education (Mid Day Meal Programme)
2. Special Nutrition Programme
3. Pradhan Mantri's Gramodaya Yojana (PMGY)
4. Balwadi Feeding Programme
5. Composite Nutrition Programme, and
6. Applied nutrition programme

15. Mid Day Meal Programme
• The National Programme of Nutritional Support to Primary Education
commonly known as Mid Day Meals Scheme was launched in August, 1995
• The mid day meal programme is one of the most important ongoing feeding
programmes
• organized by the Department of Education not only to improve nutritional
status of school children but also to attract poor children to school.
Objectives
• The programme is intended to give a boost to universalization of primary
education by increasing enrolment, retention and attendance and
simultaneously impacting upon nutritional status of students in primary
classes.

16. Special Nutrition Programme
• The Special Nutrition Programme was launched by the Central Social
Welfare Board (CSWD) in 1970-71.
• The aim of the programme was to provide supplementary nutrition to
children, pregnant women and nursing mothers belonging to the
weaker sections of the society.
• The main component of the programme was food supplementation.
• The supplement consisted of 300 Kcal and 10 g protein for children and
500 Kcal and 25 g protein for Pregnant- lactating women. Feeding of the
beneficiaries was undertaken for 300 days a year.
• In addition to supplementary feeding, the scheme also included
periodic health check ups for the beneficiaries.

17. Pradhan Mantri's Gramodaya Yojana (PMGY)
• In order to achieve the objective of sustainable human development at
the village level, a new initiative in the form of Pradhan Mantri's
Gramodaya Yojana (PMGY) has been introduced in the Annual Plan
2000-01.
• Schemes related to health, nutrition, education, drinking water, housing
and rural roads are undertaken within this programme
• The PMGY has two components: Prograrmmes for rural connectivity
with 50 percent allocation, and other programmes of primary health,
primary education, rural shelter, rural drinking water and nutrition with
the remaining 50 percent allocation.

18. Balwadi Feeding Programme
• Like the Special Nutrition Programme , the Balwadi Feeding Programme was
also launched in 1970-71.
• Although the Special Nutrition Programme is no longer in operation, the
Balwadi Feeding Programme remains one of the ongoing programmes -
implemented through the voluntary organizations.
• The beneficiaries of the programme include preschool children attending the
Balwadi. The services provided under the programme are supplementary
feeding, regular health check-ups, immunization, habit formation and
socialization through games and recreation.
• The nutrition programme also has an educative value as it brings together
several children of the same age and is expected to inculcate good habits and
help children develop taste for different types of foods.

19. Composite Nutrition Programme
• The Composite Nutrition Programme was a feeding programme launched by
the Department of Community Development, with the main objective of
providing nutrition education to the masses.
• The core of the programme was nutrition education and its particular
application through demonstration feeding.
• The programme had five components:
1. Nutrition education through mahila mandals
2. Encouragement of economic activities of mahila mandals ,
3. Strengthening 'the supervisory machinery for women's programme
4. Training of associate women workers, and
5. Demonstration feeding

20. Applied Nutrition Programme
• The Applied Nutrition Programme was one of the first national nutrition
programmes launched in 1963 through the Community Development Department,
• Aimed at improving the nutrition of lactating and pregnant women and children.
• The programme was developed 'to educate rural people about how they can
increase and improve their food supply through their own efforts'.
The main objectives of the programme were:
1. To encourage production of body-building foods (such as eggs, fish, milk etc.) and
protective foods (such as vegetables, fruits), and
2. To provide nutrition education, so as to promote consumption of the body-
building
protective foods by mothers and children.

21. THE END