nursing management of child with protein energy malnutrition kwashiorkor marasmus malnutrition

1. Protein Energy
Malnutrition
By: Mr. Arvind Joshi
Lecturer
Grow More Institute Of Nursing

2. Definition
 Malnutrition refers to both undernutrition &
overnutrition.
 Undernutrition – a condition in which there is
inadequate consumption, poor absorption or
excessive loss of nutrients.
 Overnutrition – caused by over indulgence or
excessive intake of specific nutrients.

3. Protein-Energy-Malnutrition
Protein-Energy-Malnutrition is a
clinical syndrome present in infants
and children as a result of deficient
intake and/or utilization of food.

4. Indicators Of Malnutrition
 Stunting – low height for age.
 Wasting – low weight for height.
 Under weight – low weight for age.

5. Epidemiology
 Childhood malnutrition is an underlying cause
in an estimated 35% of all deaths under 5
children.
 Max. levels of underweight children –
Chattisgarh, Bihar, Jharkhand M.P.

6. Etiology
•Poverty: cannot purchase adequate amount and
quality of food for meeting nutritional requirements.
•LBW: Malnourished mothers high incidence of LBW
and growth retarded babies


7. Etiology (Cont.)
•Infections : Diarrhea, pneumonia, malaria,
measles, whooping cough and tuberculosis
acute malnutrition. (Appetite is impaired.
Metabolic demands during infection are higher.
Immune status vulnerable to infection)
•Population growth : Increase in birth rate is
disproportionate to increase in food production.
Large families and higher birth order result in
higher incidence of malnutrition. Rapid
succession of pregnancy affects nutritional
status of mother.

8. Etiology (Cont.)
•Feeding habits: lack of exclusive breast feeding
•High pressure advertising of baby food: early
discontinuation of breast feeding
•Social factors: Repeated pregnancies, inadequate
child spacing, separation child from parents

9. Risk Factors
•LBW
•Female child
•Multiple birth
•Closely spaced birth
•Early stoppage of breast feeding
•Too early or late weaning

10. Risk Factors (Cont.)
•Many children in family
•Recurrent infections: diarrhea, pneumonia,
T.B, measles, malaria, parasitic infestation
•Illiteracy, poverty
•Secondary malnutrition due to intestinal
malabsorption, celiac disease, cystic
fibrosis, DM, galactosemia

13. Calculation
 Percent weight for height = [(weight of
patient) / (weight of a normal child of the
same height)] * 100
 Percent height for age = [(height of patient)
/ (height of a normal child of the same
age)] * 100

14. Classification Of PEM
Gomez Classification
Wellcome Trust Classification
WHO Classification (Waterlow)
IAP Classification

15. Gomez Classification
Weight for age %
90-100 Normal
75-89 Grade I, Mild malnutrition
60-74 Grade II, Moderate malnutrition
<60 Grade III, Severe malnutrition

16. Wellcome Classification
Weight
For Age
With Edema Without
Edema
60-80% Kwashiorkor Undernutrition
Less than
60%
Marasmic
Kwashiorkor
Marasmus

17. Waterlow Classification
Mild 80%–90% WFH
Moderate 70%–80% WFH
Severe <70% WFH

18. IAP Classification
Grade I (71-80%)
Grade II (61-70%)
Grade III (51-60%)
Grade IV (< = 50%)

19. Classification Of Malnutrition
Mid upper arm circumference :
Rapidly increases in the 1st year ( 11-16
cm)
Then stable between 1 – 5 yrs ( 16 – 17
cm)
Any value below 13.5 = malnutrition
< 11.5 = severe malnutrition

20. Shakir’s Tape

21. Bangle Test
A bangle with an internal diameter of 4 cm is
passed above the elbow.
- Severe malnutrition ,it is passable above the
elbow.

22. Clinical Manifestations
Kwashiorkor
Essential Features
 Marked growth
retardation
 Psychomotor
changes
 Wasting of muscles
 Dependent pitting
edema

24. Clinical Manifestations
(Cont.)
Mental Changes :
 Lethargy
 Apathetic
 Resent examination
 Poor appetite – difficult to feed

25. Clinical Manifestations
(Cont.)
Edema :
 Pitting
 Increased capillary permeability – infection
Hair Changes:
 Hypochromotrichia
 Sparseness (alopecia)
 Change in texture (coarse / silky)
 Easy pluckbility
 Flag sign

26. Clinical Manifestations
(Cont.)
Skin Changes:
 Hypopigmented
 Mosaic dermatoses (pellagra like)
 Flaky paint dermatoses (Crazy pavement
dermatoses)
 Pyoderma, Indolent ulcers

27. Clinical Manifestations
(Cont.)

28. Clinical Manifestations
(Cont.)
G - I Manifestations
– Diarrhoea
 Infections / Parasitic infestations
 Mucosal atrophy
Mineral & Vitamin deficiency
Liver enlargement
 Fatty liver
Super added infections
 Tuberculosis, bronchopneumonia, measles,
enteritis

29. MARASMUS
 Results from
prolonged starvation
 Main sign is –
severe wasting of
shoulders, arms,
buttocks & thighs
 Loss of buccal fat
creates aged /
wrinkled
appearance.

30. Classification Of Marasmus
Grade Characteristics
I Loss of fat in groin & axilla
II Gr. I + Loss of fat around
abdomen
III Gr. II + Loss of fat around the
chest
IV Gr. III + Loss of buccal fat

31. Clinical Manifestations
(Cont.)
 Essential Features
• Gross wasting of muscles
• Emaciation
• Marked stunting
• No edema

32. Clinical Manifestations
(Cont.)
 Non -essential Features
• Mineral and vitamin deficiency
• Indolent ulcers and sores
• GI symptoms – hungry
• Liver is shrunk
• Psychomotor changes – irritable
• Clubbing may be present

34. Marasmus vs Kwashiorkor
MARASMUS KWASHIORKOR
a) Age 0-3 years 1-3 years
Features
Edema
Wasting
Growth
retardation
Mental
Changes
Absent
Gross
Obvious
Alert
Always (dependent)
Present (hidden)
Hidden
Irritable, Apathetic

35. Marasmus vs Kwashiorkor
(Cont.)
MARASMUS KWASHIORKOR
Variable Features
Appetite
Diarrhoea
Skin changes
Hair changes
Usually good
Often
Seldom
Seldom
Poor appetite
Often
Often
Often

36. Marasmus vs Kwashiorkor
(Cont.)
MARASMUS KWASHIORKOR
Biochemical
Serum albumin
Urine Urea
Urinary
hydroxy proline
/
S. Creatinine
Normal / Low
Normal / Low
Low
Low
Low
Low

37. The WHO recommends the following laboratory
tests:
Blood glucose
Examination of blood smears by microscopy or
direct detection testing
Hemoglobin
Urine examination and culture
Stool examination by microscopy for ova and
parasites
Serum albumin
HIV test
Laboratory Studies

38. Management
 History Taking
•Recent intake of food and fluids
•Usual diet (before the current illness)
•Breastfeeding
•Duration and frequency of diarrhea and
vomiting
•Type of diarrhea (watery/bloody)

39. •Loss of appetite
•Family circumstances (to understand the
child’s social background)
•Chronic cough contact with tuberculosis
•Recent contact with measles
•Known or suspected HIV infection.

40. Management (Cont.)
 On Examination LOOK FOR
 •Signs of dehydration
 •Shock (cold hands slow capillary refill, weak and rapid
pulse).
 •Severe palmar pallor.
 •Localizing signs of infection, including ear and throat
infections, skin infection or pneumonia.
 •Fever (temperature ≥37.5 °C or ≥99.5 ° F) or
hypothermia (rectal temperature <35.5 °C or <95.9 °F).

41. Management (Cont.)
•Mouth ulcers
•Skin changes of kwashiorkor:
-hypo- or hyperpigmentation, desquamation
-ulceration (spreading over limbs, thighs, genitalia,
groin, and behind the ears).
-exudative lesions (resembling severe burns) often
with secondary infection (including Candida).

42. Treatment
 B – beginning of feeding
 E – energy dense feeding
 S – stimulation of sensory &
emotional development
 T – transfer to home based diets,
before discharge

44. Beginning Of Feeding
1) Routine feeding
2) Quantum of feeds – by stomach
volume
It is estimated to be 3% of the child's
body weight
Eg. Wt 5 kg = 167 ml.
6-8 feeds / day

45. Beginning Of Feeding
3) Type of feeds – milk based diets
Sugar & oil should be added.
4) Diet content- maintenance requirement –
E – 80 kcal/kg/d
P - 0.79/kg/d
Therapeutic diets – E = 150 – 220 kcal / kg/d
P= 4 – 5 gm/kg/d

46. SAMPLE HOME BASED DIET
Food Stuff Calories
Morning Breakfast
1cup milk+ 1 tsf sugar
1 bread + 2.5 g butter
2 biscuits
155 (135+20)
80 ( 62 + 18 )
64

47. SAMPLE HOME BASED DIET
(Cont.)
Food Stuff Calories
Lunch
1 chapati
1 katori dal ( cooked in 2.5 g
oil)
½ katori green vegetable
(cooked in 1g oil)
85
107 ( 85+22)
29 (20+9)
Evening Snack
1 banana
½ katori curd
84
30

48. SAMPLE HOME BASED DIET
(Cont.)
Food Stuff Calories
Dinner
1 bowel khichudi (20g rice +5g
oil + 20 g dal)
1 katori vegetable+ 2.5g oil
181 (68+68+45)
82 (60+22)
Night
1 cup milk+ 1 tsp sugar 155(135+20)

49. Energy Dense Feeding
 •Increase the amount of calories by giving energy dense foods
once the child is free of complications, shows signs of recovery
and appetite returns after initiation dietary therapy.
•For catch up growth energy ( 150-220 kcal/kg/day) and protein
(4-5 g/kg/d).
•Rate of weight gain should be 10-20 g/kg/d
•Hypochromic anemia is Rx with oral ferrous sulphate 3 mg/kg/d.
•Vitamin B 12 100 pg/day if PS shows macrocytes
•Vitamin B complex, C and E. potassium, magnesium, zinc,
copper and selenium.

50. Stimulation:
 Human contact and emotional support
including TLC are important during this stage.

51. Transfer to home based diets –
 Foods to be :
 Easily affordable
 Easily cooked at home
 Does not perish easily
 Culturally acceptable
 Easily available
in a week’s time-
E = 150 kcal /kg/d
P = 2 – 3 g/kg/d
fluids = 100- 125 ml/kg/d

52. Criteria For Discharge
 Appetite to return normal.
 Child constantly gaining weight.
 All infections, vitamin, mineral deficiencies to
be treated.
 Immunization to be explained.
 Mother explained regarding domiciliary care.

53. Follow Up
•After 1 week, 2 week, 1 month, 3 month, and 6
months after discharge
•Progress is satisfactory if the weight for height
continues to be maintained at 90% of
expected.
•The aim is to prevent relapse and assure
physical, mental and emotional development.

54. Immediate Complications
Dehydration
Electrolyte disturbances
Hypothermia
Hypoglycemia
Infections
Severe anemia
Vitamins deficiency

55. Problems Associated With
PEM
•Pneumonia
•Gastroenteritis
•Dyselectrolytemia
•TB
•Xeropthalmia
•Pyoderma
•Intestinal parasitic disease
•Infection by gram negative organism.

56. Prevention
•Growth monitoring: weight is taken and plotted
on growth.
•Oral rehydration therapy
•Breast feeding
•Immunization
•Female education
•Food supplementation
•Family spacing
•Family planning
•De-worming