SlideShare a Scribd company logo
1 of 69
PEM
Dr. BABU LAL MEENA
MD PEDIATRICS
PGIMER CHANDIGARH
DEFINITION
Undernutrition-
• Inadequate consumption, poor absorption
or excessive loss of nutrients.
Overnutrition-
• Overindulgence or excessive intake of
specific nutrients
Malnutrition-
• Refers to both undernutrition as well as
overnutrition.
DEFN CONT…
Protein energy malnutrition
Range of pathological conditions arising from
lack , in varying proportions , of protein and
calories.
 Marasmus: weight for age < 60% expected
 Kwashiorkor: weight for age < 80% + edema
 Marasmic kwashiorkor: wt/age <60% +
edema
EPIDEMIOLOGY
 Global burden- more prevalent in developing
countries. “Often starts in the womb and ends in
the tomb”
 PEM affects every 4th child world-wide
 More than 50% of deaths in 0-4 years are
associated with malnutrition
 Median case fatality rate is-23.5% in severe
malnutrition reaching 50% in edematous
malnutrition
INDIAN SCENARIO
 Childhood malnutrition underlying cause of
death in 35% of all deaths under 5.
 During 1st 6 months, when most babies are
breastfed, 20-30% are already
malnourished.
 By 18-23 months, during weaning, 30% are
severely stunted, 1/5th are underweight.
CHILD MORTALITY
The major contributing factors are:
• Diarrhea 20%
• ARI 20%
• Perinatal causes 18%
• Measles 07%
• Malaria 05%
55% of the total have malnutrition
INDICATORS
Indicator Interpretation Interpretation
Stunting Low height for age Chronic malnutrition
Prolonged food
deprival/disease
Wasting Low weight for height Acute malnutrition
Recent food
deficit/illness
Underweight Low weight for age Combined indicator to
reflect both acute on
chronic malnutrition.
CLASSIFICATION
 WEIGHT-FOR-AGE
 HEIGHT-FOR-AGE
 WEIGHT-FOR-HEIGHT
WEIGHT-FOR-AGE
GOMEZ CLASSIFICATION
• Only wt for age taken into account
• No comment about height
• All cases of edema in 3rd degree
ireespective of wt for age
Nutritional status Wt FOR AGE ( % of expected )
normal > 90
1st degree PEM 75-90
2nd degree PEM 60-75
3rd degree PEM < 60
JELLIFFE’S CASSIFICATION
Nutritional status WEIGHT FOR AGE
( % of expected )
normal 90
1st degree PEM 80-90
2nd degree PEM 70-80
3rd degree PEM 60-70
4TH degree PEM < 60
WELLCOME TRUST / INTERNATIONAL CLASSIFICATION
Based on wt-for-age and presence of edema.
Weight-for-
age(Boston)
(% of expected )
Oedema Clinical type of PEM
60-80 + Kwashiorkor
60-80 _ Underweight
< 60 _ Marasmus
< 60 + Marasmic
kwashiorkor
IAP CLASSIFICATION(1972)
Grade of malnutrition Weight for age of the
standard
(median) %
Normal >80
Grade I 71-80 (mild malnutrition)
Grade II 61-70 (moderate malnutrition)
Grade III 51-60 (severe malnutrition)
Grade IV <50 (very severe malnutrition)
CLASSIFICATIONS- WHO
Moderate
malnutrition
Severe
malnutrition
Symmetrical
oedema
No Yes
(oedematous
malnutrition)
Weight-for-height SD score
between
-2 to -3
SD score
< -3
Severe wasting
Height-for-age SD score
between
-2 to -3
SD score
< -3
Severe stunting
AGE INDEPENDENT INDICES
 Weight for height
 Mid arm circumference
 Body mass index
 Index ( Kanawati, Dughdale, Rao &
Singh’s )
 Skin fold thickness
SHAKIR TAPE
RATIOS
Name of index Calculation Normal value Value in
malnutrition
Kanawati and Mc
laren
MUAC(cm)/HC(c
m)
0.32-0.33 <0.25
Rao and Singh wt (kg)/Ht (cm)2
X 100
0.14 0.12-0.14
Dughdale wt (kg)/ht in cm
1.6 X100
0.88-0.97 <0.79
Quaker arm
circumference
MAC expected
for a given height
75-85%-
malnourished
<75%-severely
malnourished
Jellife’s ratio HC/CC <1 in a child
>1year:
malnourished
RISK FACTORS
 LBW
 Multiple birth
 Closely spaced birth
 Early stoppage of breast feeding
 Too early or late weaning
 Recurrent infections
 Illiteracy, poverty
 Secondary due to malabsorption
PATHOGENESIS
•Protein defficiency
•Gopalan theory
•Golden theory
MARASMUS
KWASHIORKOR
CLINICAL FEATURES
• Depends on the severity and duration
nutritional deprivation, the age, presence or
absence of associated infections.
KWASHIORKOR
• Essential Features
• Marked growth retardation
• Psychomotor changes
• Wasting of muscles
• Dependent pitting edema
• General appearance- fat sugar baby
appearance.
• Skin changes-
• Hyperpigmentation, desquamation and
dyspigmentation.
• Flaky paint dermatosis( confluent areas )
• Enamel spots( individual spots )
• Typically involving buttocks, perineum and
upper highs.
• Mucus membrane lesions
 Smooth tongue
 Cheilosis, angular stomatitis
 Herpes simplex stomatitis
• Edema
• Muscle wasting- weak, hypotonic and unable to
stand or walk.
Hair Changes
• Hypopigmented hair.
• Sparseness (alopecia)
• Change in texture (coarse / silky)
• Easy pluckbility
• Flag sign
Mental Changes :
• Lethargy
• Apathetic
• Poor appetite – difficult to feed
– GI Manifestations
• Diarrhoea
• Infections / Parasitic infestations
• Mucosal atrophy
• Enteraopathy sec. to anemia
• Liver enlargement
• Fatty liver
–Mineral & Vitamin deficiency
–Super added infections
• Tuberculosis, bronchopneumonia, measles,
enteritis..
MARASMUS
Essential Features
• Gross wasting of muscles – skin and bones.
• Emaciation- loss of buccal pad of fat-monkey facies, loose skin of
buttocks hanging down- baggy pants appearance
• Marked stunting
• No edema
Non -essential Features
•Mineral and vitamin deficiency
• Indolent ulcers and sores
• GI symptoms – hungry
• Liver is shrunk
• Psychomotor changes – irritable
CONT…
Grade 1 : Wasting starts in axilla & groin
Grade 2 : Wasting extended to thigh and
buttocks
Grade 3 : Chest and abdomen
Grade 4 : Wasting of buccal pad of fat also
SEVERE ACUTE
MALNUTRITION
 Weight-for-height of 70% (extreme wasting)
 Presence of bilateral pitting edema of
nutritional origin, “edematous malnutrition
 Mid-upper-arm circumference of less than
115 mm in children age 1-5 years old
COMPLICATIONS OF SAM
 ARI
 Diarrhea
 Gram negative septicemia
 Poor feeding
 Electrolyte abnormalities
CAUSES OF DEATH
Hypoglycemia
Hypothermia
Dehydration
Infection
Severe anemia
MANAGEMENT
Mild and moderate malnutrition
 Mainstay of treatment is to give adequate amounts of
protein and energy
 Atleast 150kCal/kg/day, protein intake of 3g/kg/day
 Best measure of efficacy of the treatment is weight gain
Locally produced RUTF
Hyderabad mix
120 g = 500 Kcal
(Wheat, black gram, groundnut flour)
Limited success in uncontrolled studies
INPATIENT TREATMENT OF SEVERE
ACUTE MALNUTRITION
WHO TEN STEPS to recovery in
Malnourished Children
In 2 phases
•Initial stabilisation – 2 to 7 days
•Rehabilitation – several weeks
TIME FRAME FOR TEN STEPS
STEP 1
PREVENT/TREAT HYPOGLYCEMIA
Blood glucose <54mg/dl
If cant be measured assume hypoglycemia
TREATMENT
Asymptomatic-
• 50ml of 10% glucose or sucrose solution
orally or NG f/b 1st feed
• Feed with starter F-75 q 2hrly
Symptomatic
 10% dextrose i.v 5ml/kg
 Follow with 50ml of 10% glucose or sucrose
solution NG
 Feed with starter F-75 q 2hrly
 Start appropriate antibiotics
Prevention
 Feed 2 hrly starting immediately
 Prevent hypothermia
STEP 2
PREVENT AND TREAT HYPOTHERMIA
Rectal temp <35.5 C/95.5 F or axillary <35
C/95 F
Treatment
 Clothe the child with warm clothes
 Provide heat
 Avoid rapid rewarming
 Feed the child
 Give appropriate antibiotics
STEP 3
TREAT/PREVENT DEHYDRATION
 Assume all SAM with watery diarrhoea to have
some dehydration.
 Hypovolemia can co exist with edema.
Treatment
 Use reduced osmolarity ORS with potassium
supplements for rehydration and maintenance.
 Initiate feeding within 2-3 hrs of starting
rehydration with F-75 formula on alt hrs with
reduced osmolarity ORS
 Be alert for signs of overhydration.
STEP 4
CORRECT ELECTROLYTE IMBALANCE
Supplemental potassium at 3-4meq/kg/d for
atleat 2 weeks
On day1, 50% MgSO4 i.m once (0.3 ml/kg,
max upto 2ml)
thereafter give extra Mg(0.8-1.2 meq/kg daily)
Excess body sodium exists even though
plasma sodium may be low.
Prepare food without adding salt.
STEP 5
TREAT/PREVENT INFECTION
 Multiple infections common
 Usual signs of infection such as fever often
absent
 Majority of blood stream infections due to
gram negative bacteria.
 Assume serious infections and treat.
 Hypoglycemia and hypothermia are markers
of severe infections.
Treatment
 Ampicillin iv for atleast 2 days f/b oral amoxycillin
 i.v. gentamicin or amikacin for 7 days.
If no imrovement within 48hrs,
 i.v. cefotaxime
 Ceftriaxone
Prevention
 Follow standard precautions like hand hygiene
 Give measles vaccine if >6 months and not
immunised or if the child is more than > 9 months.
STEP 6
CORRECT MIRONUTRIENT DEFICIENCIES
1. Use upto twice the RDA of various vitamins
and minerals
2. On day1, Vit A orally (if age>1yr 2lac IU, 6-
12 mon 1 lac IU, 0-5 mon 50,000 IU)
3. Folic acid 1mg/day ( 5mg on D1)
4. Copper 0.2-0.3 mg/kg/d
5. Iron 3mg/kg/d, once child starts gaining wt,
after the stabilisation phase.
STEP 7
INITIATE RE-FEEDING
 Initiate feeding as soon as possible as frequent small
feeds
 If unable to take orally- NG feeds
 Total fluid recommended is 130ml/kg/d, reduce to
100ml/kg/d if there is severe, generalised edema
 Continue breast feeding ad libitum
 Start with F-75 starter feeds q 2 hrly
 F-75 contains 75kCal/100ml with 1g protein/100ml
 If persistent diarrhea, cereal based low lactose F-75 diet
as starter diet
 If diarrhea continues on low lactose diets give F-75
lactose free diets
STEP 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/d
• Continue breast feeding on demand
• Make a gardual 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
STEP 9
PROVIDE SENSORY STIMULATION AND
EMOTIONAL SUPPORT
 A cheerful, stimluating environment
 Age appropriate structured play therapy for
atleast 15-30 mins/day
 Age appropriate physical activity as soon as
the child is well enough
 Tender loving care
STEP 10
PREPARE FOR FOLLOW UP AFTER
RECOVERY
Said to have rcovered when wt for ht is 90% of NCHS
median and has no edema
Primary failure to respond if
• Failure to gain appetite by D4
• Failure to start losing edema by D4
• Presence of edema on D10
• Failure to gain atleast 5g/kg/d by D10
Secondary failure to respond if
• Failure to gain at least 5g/kg/d for consecutive days
during the rehabilitation phase
Complication during rehabilitation
Nutritional Recovery Syndrome
Treated with very high proteins
Abdominal distension (hepatomegaly, ascites,
splenomegaly), prominent veins, hypertrichosis,
parotid swelling, gynaecomastia, eosinophilia,
hyper-Ig
Incresed estrogen and recovering pituitary
Kwashi shake/encephalitis states (too much of
proteins)
Pseudotumor cerebri
Refeeding syndrome
REFEEDING SYNDROME
Definition
Refeeding syndrome (RFS) is a term that describes
the metabolic and clinical changes that occur on
aggressive nutritional rehabilitation of a malnourished
patient.
- Exact incidence in pediatric patients not known.
- 30% to 38% in adults on TPN with phosphorus.
- 100% in adults on TPN without phosphorus.
- 25% of adults with cancer.
RISK FACTORS
PATHOPHYSIOLOGY
Starvation
- Increased catabolism
- Increased glycogen depletion
- Breakdown of proteins to aminoacids for
gluconeogenesis
- Production of ketone bodies from fatty acids
ON REFEEDING
• Altered membrane
potenial – Cardiac
arrythmias
• Neuromuscular
dysfunction
• Sodium retention
• Fluid overload
• Fatty liver
• Hypokalemia
• Increased
corticosteroids.
• Ketoacidosis
• Altered menbrane
potential
• Impaired Na+K+ ATPase
activity
• Co-factor for enzymes
in oxidative
phosphorylation and
ATP production
• Decreased ventricular
mass
• Decreased sarcomere
contractility
• Decreased production of
ATP
• Rhabdomyolysis
Hypo PO4
2-
(onset <72 hrs,
nadir 7 days)
Hypomagnesemia
(Onset <72 hrs)
HypokalemiaHyperinsulinemia
and
Hyperglycemia
CLINICAL FEATURES
< 2 weeks
- Increased weight gain, tachypnoea, features of cardiac failure,
dilutional hyponatermia – s/o fluid overload.
- Neuromuscular symptoms like weakness, paresthesias,
cramps, respiratory muscle weakness – altered membrane
potential due to electrolyte imbalance.
- Cardiac failure, rhabdomyolysis, altered mental status,
confusion, coma, hemolysis, thrombocytopenia and leukocyte
dysfunction – hypophosphatemia.
- Abdominal distention, increasing hepatomegaly, ascites,–
Fatty liver.
 2 weeks
- Prominient thoraco-abdominal venous network
- Hypertrichosis (after 60 days)
- Parotid swelling
- Gynaecomastia
- Eosinophilia (after 60 days)
- Spleenomegaly
Cause: Not clear. Probably due to excessive intake of high quality
protein during rehabilitation, leading to increase in various trophic
hormones produced by the recovering pituitary gland.
Gomez et al, Pediatrics 1952; 10:513-526
DIAGNOSIS AND EARLY RECOGNITION IS
THE KEY
- There is no defined diagnostic criteria for refeeding syndrome in
children.
- Monitoring of biochemical parameters for hypophosphatemia,
hypomagnesemia, hyperglycemia, hypoalbuminemia.
- Daily weight monitoring for the initial 7 days.
- Goal of weight gain should not be more than 1 Kg/week.
- Fluid status (intake/output) should be moniitored.
- Cardiorespiratory monitoring during the initial.
- Assess frequently for neuromuscular weakness and mental status.
MANAGEMENT
- Stop all sources of calorie and protein until the electrolyte
imbalances are corrected.
- Start with 50% of the caloric intake at which the patient
developed symptoms.
- Supplement with multivitamins (including thiamine)
- Watch for recurrence of refeeding syndrome by monitoring
clinical and biochemical parameters daily.
- Limit sodium and fluid intake.
- Gradually increase the caloric requirement every 3 days.
“Start low and go slow”.
- Protein restriction is not recommended, 1.5 g/Kg/day rich in
essential aminoacids is required for anabolism to occur.
PREVENTION
A) MONITORING
Before initiating refeeding through any route and during initial 3 –
5 days,
- Hydration and fluid assessment. Early weight gain may be
secondary to weight gain.
- Daily electrolytes: Initial glucose and albumin. Daily sodium,
potassium, calcium, phosphorus, magnesium, urea and
creatinine.
- Cardiac status. (ECG ± ECHO)
B) ORAL FEEDING REGIMEN
1. Initial volume and calories
• In more severe cases an initial starting volume of 75% of total daily
requirements has been used
- < 7 years old - 80–100 kcal/kg/day
- 7–10 years - 75 kcal/kg/day
- 11–14 years - 60 kcal/kg/day
- 15–18 years - 50 kcal/kg/day
• If the initial food challenge is tolerated, this may be increased over 3–
5 days (Target 150 kcal/kg/day – Rehabilitation phase).
• Each requirement should be tailored to an individual’s need and the
above values may need to be adjusted by as much as 30%.
• Frequent small feeds (every 2 hrly) are recommended initially. Slowly
increase the volume per feed, max of 22 ml/kg/feed (130 ml/kg/day)
• Feeds should provide minimum of 1 kcal/ ml (F-100) to minimize
volume overload.
2. PROTEIN
• If a milk-based feed induces diarrhoea with positive faecal
reducing substances, a hydrolysate may be used.
• An initial regimen for malnourished children suggests 0.6–1
g/kg/day
• The feed should be rich in essential amino acids and gradually
increased as an intake of 1.2–1.5 g/kg/ day is needed for
anabolism to occur.
• Slowly increase proteins to 4 – 6 g/kg/day during the catch up
phase (Rehabilitation phase after 2 weeks).
3. SUPPLEMENTS
• Twice the recommended daily allowance for vitamins and
minerals (Na, K, Ca, PO).
• Supplement with Zinc, copper, folic acid, Vit B12.
• Oral Vit A on day 1.
TAKE HOME MESSAGES
- Refeeding syndrome is due to the metabolic and hormonal
changes that occur due to aggressive nutritional
rehabilitation.
- START LOW AND GO SLOW.
- IDENTIFICATION of patients at risk and monitoring
patients during nutritional rehabilitation is the key to
prevention.
- AWARENESS of the potential complications involved in
reintroducing feeds to an undernourished patient is
crucial
CRITERIA FOR DISCHARGE FROM
NON-RESIDENTIAL CARE
 Weight-for-height has reached -1 SD (90%) of NCHS/WHO median
reference values
 Eating an adequate amount of a nutritious diet that the mother can
prepare at home
 Gaining weight at a normal or increased rate
 All vitamin and mineral deficiencies have been treated
 All infections and other conditions have been or are being treated,
including anaemia, diarrhoea, intestinal parasitic infections, malaria,
tuberculosis and otitis media
 Full immunization programme started
FOLLOW UP
 Child should be seen after 1week, 2 weeks, 1
month, 3 months and 6 months. More frequently if
any problem found.
 After 6 months, visits should be twice yearly until the
child is at least 3 years old.
 The child should be examined, weighed and
measured, and the results recorded.
 Any needed vaccine, vit A should be given.
 Training of the mother should focus on areas that
need to be strengthened, especially feeding
practices, and mental and physical stimulation of the
child.
PREVENTION
At national level
1. Nutrition supplementation- Fortification, iodination
2. Nutritional surveillance- define the character and
magnitude of nutritional problems and strategies to
tackle.
3. Nutritional planning- formulation of nutrition policy,
improve food production and supplies, ensure
distribution.
PREVENTION
At community level-
• Health and nutritional education
• Promotion of education and literacy in the
community
• Growth monitoring
• Integrated health package
• Vigorous promotion of family planning programs
PREVENTION
At family level
 Exclusive breast feeding
 Complementary feeds at 6 months
 Vaccination
 Spacing between pregnancies
THANK YOU

More Related Content

What's hot

Iron deficiency anemia in children
Iron deficiency anemia in childrenIron deficiency anemia in children
Iron deficiency anemia in childrenAzad Haleem
 
Vitamin A and its deficiency
Vitamin A and its deficiencyVitamin A and its deficiency
Vitamin A and its deficiencyReshma Ann Mathew
 
Anaemia mukt bharat
Anaemia mukt bharatAnaemia mukt bharat
Anaemia mukt bharatSeema Verma
 
Diarrhoeal control programme
Diarrhoeal control programmeDiarrhoeal control programme
Diarrhoeal control programmeNikhil Gupta
 
Protein energy malnutrition
Protein energy malnutritionProtein energy malnutrition
Protein energy malnutritionArifa T N
 
Malnutrition in pediatrics
Malnutrition in pediatricsMalnutrition in pediatrics
Malnutrition in pediatricsADRIEN MUGIMBAHO
 
Moderate acute malnutrition
Moderate acute malnutritionModerate acute malnutrition
Moderate acute malnutritionDrhunny88
 
Nutritional anemia
Nutritional  anemiaNutritional  anemia
Nutritional anemiaMoumita Pal
 
malnutrition classification and severe malnutrition management
malnutrition classification and severe malnutrition managementmalnutrition classification and severe malnutrition management
malnutrition classification and severe malnutrition managementMuhammad Jawad
 
integrated management of neonatal and childhood illness(IMNCI)
integrated management of neonatal and childhood illness(IMNCI)integrated management of neonatal and childhood illness(IMNCI)
integrated management of neonatal and childhood illness(IMNCI)Shubhanshu Gupta
 
Vitamin A prophylaxis programme
Vitamin A prophylaxis programmeVitamin A prophylaxis programme
Vitamin A prophylaxis programmesaheli chakraborty
 
Anemia in Pregnancy
Anemia in PregnancyAnemia in Pregnancy
Anemia in Pregnancyobgymgmcri
 
Dehydration in children
Dehydration in childrenDehydration in children
Dehydration in childrenNaz Mayi
 

What's hot (20)

Iron deficiency anemia in children
Iron deficiency anemia in childrenIron deficiency anemia in children
Iron deficiency anemia in children
 
Failure to thrive
Failure to thriveFailure to thrive
Failure to thrive
 
Who growth chart
Who growth chartWho growth chart
Who growth chart
 
Vitamin A and its deficiency
Vitamin A and its deficiencyVitamin A and its deficiency
Vitamin A and its deficiency
 
Anaemia mukt bharat
Anaemia mukt bharatAnaemia mukt bharat
Anaemia mukt bharat
 
Kwashiorkor
KwashiorkorKwashiorkor
Kwashiorkor
 
Vitamin a prophylaxis
Vitamin a prophylaxisVitamin a prophylaxis
Vitamin a prophylaxis
 
IMNCI
IMNCIIMNCI
IMNCI
 
Diarrhoeal control programme
Diarrhoeal control programmeDiarrhoeal control programme
Diarrhoeal control programme
 
Protein energy malnutrition
Protein energy malnutritionProtein energy malnutrition
Protein energy malnutrition
 
PROTEIN ENERGY MALNUTRITION
PROTEIN ENERGY MALNUTRITIONPROTEIN ENERGY MALNUTRITION
PROTEIN ENERGY MALNUTRITION
 
Malnutrition in pediatrics
Malnutrition in pediatricsMalnutrition in pediatrics
Malnutrition in pediatrics
 
Moderate acute malnutrition
Moderate acute malnutritionModerate acute malnutrition
Moderate acute malnutrition
 
Nutritional anemia
Nutritional  anemiaNutritional  anemia
Nutritional anemia
 
malnutrition classification and severe malnutrition management
malnutrition classification and severe malnutrition managementmalnutrition classification and severe malnutrition management
malnutrition classification and severe malnutrition management
 
BFHI- update
BFHI- updateBFHI- update
BFHI- update
 
integrated management of neonatal and childhood illness(IMNCI)
integrated management of neonatal and childhood illness(IMNCI)integrated management of neonatal and childhood illness(IMNCI)
integrated management of neonatal and childhood illness(IMNCI)
 
Vitamin A prophylaxis programme
Vitamin A prophylaxis programmeVitamin A prophylaxis programme
Vitamin A prophylaxis programme
 
Anemia in Pregnancy
Anemia in PregnancyAnemia in Pregnancy
Anemia in Pregnancy
 
Dehydration in children
Dehydration in childrenDehydration in children
Dehydration in children
 

Similar to Protein energy malnutrition

Similar to Protein energy malnutrition (20)

Malnutrition.pptx
Malnutrition.pptxMalnutrition.pptx
Malnutrition.pptx
 
1.Acute Malnutrition.pptx
1.Acute Malnutrition.pptx1.Acute Malnutrition.pptx
1.Acute Malnutrition.pptx
 
child_malnutrition_final_FINAL.pptx
child_malnutrition_final_FINAL.pptxchild_malnutrition_final_FINAL.pptx
child_malnutrition_final_FINAL.pptx
 
PEM
PEMPEM
PEM
 
Protein Energy Malnutrition
Protein Energy MalnutritionProtein Energy Malnutrition
Protein Energy Malnutrition
 
Severe Acute Malnutrition - Copy.ppt
Severe Acute Malnutrition - Copy.pptSevere Acute Malnutrition - Copy.ppt
Severe Acute Malnutrition - Copy.ppt
 
1.malnutrition
1.malnutrition1.malnutrition
1.malnutrition
 
6.Nutrition and ENERGY detailed FINAL.pptx
6.Nutrition and ENERGY detailed FINAL.pptx6.Nutrition and ENERGY detailed FINAL.pptx
6.Nutrition and ENERGY detailed FINAL.pptx
 
Protein Energy Malnutrition
Protein Energy MalnutritionProtein Energy Malnutrition
Protein Energy Malnutrition
 
Nutritional problems 2
Nutritional problems 2Nutritional problems 2
Nutritional problems 2
 
malnutrition.pptx
malnutrition.pptxmalnutrition.pptx
malnutrition.pptx
 
Nutritional deficiency disorders.pptx
Nutritional deficiency disorders.pptxNutritional deficiency disorders.pptx
Nutritional deficiency disorders.pptx
 
protein-energy-malnutrition.pptx
protein-energy-malnutrition.pptxprotein-energy-malnutrition.pptx
protein-energy-malnutrition.pptx
 
Nutritional_Deficiency_Disorder rashi.pptx
Nutritional_Deficiency_Disorder rashi.pptxNutritional_Deficiency_Disorder rashi.pptx
Nutritional_Deficiency_Disorder rashi.pptx
 
SAM
SAMSAM
SAM
 
malnutrition
malnutritionmalnutrition
malnutrition
 
SAM latest guideline
SAM latest guidelineSAM latest guideline
SAM latest guideline
 
Malnutrition.pptx
Malnutrition.pptxMalnutrition.pptx
Malnutrition.pptx
 
Malnutrition in children
Malnutrition in childrenMalnutrition in children
Malnutrition in children
 
Malnutrition by dr.Azad Al.Kurdi 2015
Malnutrition by dr.Azad Al.Kurdi 2015Malnutrition by dr.Azad Al.Kurdi 2015
Malnutrition by dr.Azad Al.Kurdi 2015
 

Recently uploaded

Compare home pulse pressure components collected directly from home
Compare home pulse pressure components collected directly from homeCompare home pulse pressure components collected directly from home
Compare home pulse pressure components collected directly from homeCatherine Liao
 
TUBERCULINUM-2.BHMS.MATERIA MEDICA.HOMOEOPATHY
TUBERCULINUM-2.BHMS.MATERIA MEDICA.HOMOEOPATHYTUBERCULINUM-2.BHMS.MATERIA MEDICA.HOMOEOPATHY
TUBERCULINUM-2.BHMS.MATERIA MEDICA.HOMOEOPATHYDRPREETHIJAMESP
 
THORACOTOMY . SURGICAL PERSPECTIVES VOL 1
THORACOTOMY . SURGICAL PERSPECTIVES VOL 1THORACOTOMY . SURGICAL PERSPECTIVES VOL 1
THORACOTOMY . SURGICAL PERSPECTIVES VOL 1DR SETH JOTHAM
 
linearity concept of significance, standard deviation, chi square test, stude...
linearity concept of significance, standard deviation, chi square test, stude...linearity concept of significance, standard deviation, chi square test, stude...
linearity concept of significance, standard deviation, chi square test, stude...KavyasriPuttamreddy
 
Denture base resins materials and its mechanism of action
Denture base resins materials and its mechanism of actionDenture base resins materials and its mechanism of action
Denture base resins materials and its mechanism of actionDr.shiva sai vemula
 
Anuman- An inference for helpful in diagnosis and treatment
Anuman- An inference for helpful in diagnosis and treatmentAnuman- An inference for helpful in diagnosis and treatment
Anuman- An inference for helpful in diagnosis and treatmentabdeli bhadarva
 
Vaccines: A Powerful and Cost-Effective Tool Protecting Americans Against Dis...
Vaccines: A Powerful and Cost-Effective Tool Protecting Americans Against Dis...Vaccines: A Powerful and Cost-Effective Tool Protecting Americans Against Dis...
Vaccines: A Powerful and Cost-Effective Tool Protecting Americans Against Dis...PhRMA
 
Video capsule endoscopy (VCE ) in children
Video capsule endoscopy (VCE ) in childrenVideo capsule endoscopy (VCE ) in children
Video capsule endoscopy (VCE ) in childrenRaju678948
 
180-hour Power Capsules For Men In Ghana
180-hour Power Capsules For Men In Ghana180-hour Power Capsules For Men In Ghana
180-hour Power Capsules For Men In Ghanahealthwatchghana
 
Scientificity and feasibility study of non-invasive central arterial pressure...
Scientificity and feasibility study of non-invasive central arterial pressure...Scientificity and feasibility study of non-invasive central arterial pressure...
Scientificity and feasibility study of non-invasive central arterial pressure...Catherine Liao
 
Cardiovascular Physiology - Regulation of Cardiac Pumping
Cardiovascular Physiology - Regulation of Cardiac PumpingCardiovascular Physiology - Regulation of Cardiac Pumping
Cardiovascular Physiology - Regulation of Cardiac PumpingMedicoseAcademics
 
Hemodialysis: Chapter 2, Extracorporeal Blood Circuit - Dr.Gawad
Hemodialysis: Chapter 2, Extracorporeal Blood Circuit - Dr.GawadHemodialysis: Chapter 2, Extracorporeal Blood Circuit - Dr.Gawad
Hemodialysis: Chapter 2, Extracorporeal Blood Circuit - Dr.GawadNephroTube - Dr.Gawad
 
DIGITAL RADIOGRAPHY-SABBU KHATOON .pptx
DIGITAL RADIOGRAPHY-SABBU KHATOON  .pptxDIGITAL RADIOGRAPHY-SABBU KHATOON  .pptx
DIGITAL RADIOGRAPHY-SABBU KHATOON .pptxSabbu Khatoon
 
Factors Affecting child behavior in Pediatric Dentistry
Factors Affecting child behavior in Pediatric DentistryFactors Affecting child behavior in Pediatric Dentistry
Factors Affecting child behavior in Pediatric DentistryDr Simran Deepak Vangani
 
Multiple sclerosis diet.230524.ppt3.pptx
Multiple sclerosis diet.230524.ppt3.pptxMultiple sclerosis diet.230524.ppt3.pptx
Multiple sclerosis diet.230524.ppt3.pptxMeenakshiGursamy
 
BMK Glycidic Acid (sodium salt) CAS 5449-12-7 Pharmaceutical intermediates
BMK Glycidic Acid (sodium salt)  CAS 5449-12-7 Pharmaceutical intermediatesBMK Glycidic Acid (sodium salt)  CAS 5449-12-7 Pharmaceutical intermediates
BMK Glycidic Acid (sodium salt) CAS 5449-12-7 Pharmaceutical intermediatesdorademei
 
DECIPHERING COMMON ECG FINDINGS IN ED.pptx
DECIPHERING COMMON ECG FINDINGS IN ED.pptxDECIPHERING COMMON ECG FINDINGS IN ED.pptx
DECIPHERING COMMON ECG FINDINGS IN ED.pptxdrwaque
 
In-service education (Nursing Mangement)
In-service education (Nursing Mangement)In-service education (Nursing Mangement)
In-service education (Nursing Mangement)Monika Kanwar
 
Impact of cancers therapies on the loss in cardiac function, myocardial fffic...
Impact of cancers therapies on the loss in cardiac function, myocardial fffic...Impact of cancers therapies on the loss in cardiac function, myocardial fffic...
Impact of cancers therapies on the loss in cardiac function, myocardial fffic...Catherine Liao
 
รายการตํารับยาแผนไทยแห่งชาติ ฉบับ พ.ศ. 2564.pdf
รายการตํารับยาแผนไทยแห่งชาติ ฉบับ พ.ศ. 2564.pdfรายการตํารับยาแผนไทยแห่งชาติ ฉบับ พ.ศ. 2564.pdf
รายการตํารับยาแผนไทยแห่งชาติ ฉบับ พ.ศ. 2564.pdfVorawut Wongumpornpinit
 

Recently uploaded (20)

Compare home pulse pressure components collected directly from home
Compare home pulse pressure components collected directly from homeCompare home pulse pressure components collected directly from home
Compare home pulse pressure components collected directly from home
 
TUBERCULINUM-2.BHMS.MATERIA MEDICA.HOMOEOPATHY
TUBERCULINUM-2.BHMS.MATERIA MEDICA.HOMOEOPATHYTUBERCULINUM-2.BHMS.MATERIA MEDICA.HOMOEOPATHY
TUBERCULINUM-2.BHMS.MATERIA MEDICA.HOMOEOPATHY
 
THORACOTOMY . SURGICAL PERSPECTIVES VOL 1
THORACOTOMY . SURGICAL PERSPECTIVES VOL 1THORACOTOMY . SURGICAL PERSPECTIVES VOL 1
THORACOTOMY . SURGICAL PERSPECTIVES VOL 1
 
linearity concept of significance, standard deviation, chi square test, stude...
linearity concept of significance, standard deviation, chi square test, stude...linearity concept of significance, standard deviation, chi square test, stude...
linearity concept of significance, standard deviation, chi square test, stude...
 
Denture base resins materials and its mechanism of action
Denture base resins materials and its mechanism of actionDenture base resins materials and its mechanism of action
Denture base resins materials and its mechanism of action
 
Anuman- An inference for helpful in diagnosis and treatment
Anuman- An inference for helpful in diagnosis and treatmentAnuman- An inference for helpful in diagnosis and treatment
Anuman- An inference for helpful in diagnosis and treatment
 
Vaccines: A Powerful and Cost-Effective Tool Protecting Americans Against Dis...
Vaccines: A Powerful and Cost-Effective Tool Protecting Americans Against Dis...Vaccines: A Powerful and Cost-Effective Tool Protecting Americans Against Dis...
Vaccines: A Powerful and Cost-Effective Tool Protecting Americans Against Dis...
 
Video capsule endoscopy (VCE ) in children
Video capsule endoscopy (VCE ) in childrenVideo capsule endoscopy (VCE ) in children
Video capsule endoscopy (VCE ) in children
 
180-hour Power Capsules For Men In Ghana
180-hour Power Capsules For Men In Ghana180-hour Power Capsules For Men In Ghana
180-hour Power Capsules For Men In Ghana
 
Scientificity and feasibility study of non-invasive central arterial pressure...
Scientificity and feasibility study of non-invasive central arterial pressure...Scientificity and feasibility study of non-invasive central arterial pressure...
Scientificity and feasibility study of non-invasive central arterial pressure...
 
Cardiovascular Physiology - Regulation of Cardiac Pumping
Cardiovascular Physiology - Regulation of Cardiac PumpingCardiovascular Physiology - Regulation of Cardiac Pumping
Cardiovascular Physiology - Regulation of Cardiac Pumping
 
Hemodialysis: Chapter 2, Extracorporeal Blood Circuit - Dr.Gawad
Hemodialysis: Chapter 2, Extracorporeal Blood Circuit - Dr.GawadHemodialysis: Chapter 2, Extracorporeal Blood Circuit - Dr.Gawad
Hemodialysis: Chapter 2, Extracorporeal Blood Circuit - Dr.Gawad
 
DIGITAL RADIOGRAPHY-SABBU KHATOON .pptx
DIGITAL RADIOGRAPHY-SABBU KHATOON  .pptxDIGITAL RADIOGRAPHY-SABBU KHATOON  .pptx
DIGITAL RADIOGRAPHY-SABBU KHATOON .pptx
 
Factors Affecting child behavior in Pediatric Dentistry
Factors Affecting child behavior in Pediatric DentistryFactors Affecting child behavior in Pediatric Dentistry
Factors Affecting child behavior in Pediatric Dentistry
 
Multiple sclerosis diet.230524.ppt3.pptx
Multiple sclerosis diet.230524.ppt3.pptxMultiple sclerosis diet.230524.ppt3.pptx
Multiple sclerosis diet.230524.ppt3.pptx
 
BMK Glycidic Acid (sodium salt) CAS 5449-12-7 Pharmaceutical intermediates
BMK Glycidic Acid (sodium salt)  CAS 5449-12-7 Pharmaceutical intermediatesBMK Glycidic Acid (sodium salt)  CAS 5449-12-7 Pharmaceutical intermediates
BMK Glycidic Acid (sodium salt) CAS 5449-12-7 Pharmaceutical intermediates
 
DECIPHERING COMMON ECG FINDINGS IN ED.pptx
DECIPHERING COMMON ECG FINDINGS IN ED.pptxDECIPHERING COMMON ECG FINDINGS IN ED.pptx
DECIPHERING COMMON ECG FINDINGS IN ED.pptx
 
In-service education (Nursing Mangement)
In-service education (Nursing Mangement)In-service education (Nursing Mangement)
In-service education (Nursing Mangement)
 
Impact of cancers therapies on the loss in cardiac function, myocardial fffic...
Impact of cancers therapies on the loss in cardiac function, myocardial fffic...Impact of cancers therapies on the loss in cardiac function, myocardial fffic...
Impact of cancers therapies on the loss in cardiac function, myocardial fffic...
 
รายการตํารับยาแผนไทยแห่งชาติ ฉบับ พ.ศ. 2564.pdf
รายการตํารับยาแผนไทยแห่งชาติ ฉบับ พ.ศ. 2564.pdfรายการตํารับยาแผนไทยแห่งชาติ ฉบับ พ.ศ. 2564.pdf
รายการตํารับยาแผนไทยแห่งชาติ ฉบับ พ.ศ. 2564.pdf
 

Protein energy malnutrition

  • 1. PEM Dr. BABU LAL MEENA MD PEDIATRICS PGIMER CHANDIGARH
  • 2. DEFINITION Undernutrition- • Inadequate consumption, poor absorption or excessive loss of nutrients. Overnutrition- • Overindulgence or excessive intake of specific nutrients Malnutrition- • Refers to both undernutrition as well as overnutrition.
  • 3. DEFN CONT… Protein energy malnutrition Range of pathological conditions arising from lack , in varying proportions , of protein and calories.  Marasmus: weight for age < 60% expected  Kwashiorkor: weight for age < 80% + edema  Marasmic kwashiorkor: wt/age <60% + edema
  • 4. EPIDEMIOLOGY  Global burden- more prevalent in developing countries. “Often starts in the womb and ends in the tomb”  PEM affects every 4th child world-wide  More than 50% of deaths in 0-4 years are associated with malnutrition  Median case fatality rate is-23.5% in severe malnutrition reaching 50% in edematous malnutrition
  • 5. INDIAN SCENARIO  Childhood malnutrition underlying cause of death in 35% of all deaths under 5.  During 1st 6 months, when most babies are breastfed, 20-30% are already malnourished.  By 18-23 months, during weaning, 30% are severely stunted, 1/5th are underweight.
  • 6. CHILD MORTALITY The major contributing factors are: • Diarrhea 20% • ARI 20% • Perinatal causes 18% • Measles 07% • Malaria 05% 55% of the total have malnutrition
  • 7. INDICATORS Indicator Interpretation Interpretation Stunting Low height for age Chronic malnutrition Prolonged food deprival/disease Wasting Low weight for height Acute malnutrition Recent food deficit/illness Underweight Low weight for age Combined indicator to reflect both acute on chronic malnutrition.
  • 10. GOMEZ CLASSIFICATION • Only wt for age taken into account • No comment about height • All cases of edema in 3rd degree ireespective of wt for age Nutritional status Wt FOR AGE ( % of expected ) normal > 90 1st degree PEM 75-90 2nd degree PEM 60-75 3rd degree PEM < 60
  • 11. JELLIFFE’S CASSIFICATION Nutritional status WEIGHT FOR AGE ( % of expected ) normal 90 1st degree PEM 80-90 2nd degree PEM 70-80 3rd degree PEM 60-70 4TH degree PEM < 60
  • 12. WELLCOME TRUST / INTERNATIONAL CLASSIFICATION Based on wt-for-age and presence of edema. Weight-for- age(Boston) (% of expected ) Oedema Clinical type of PEM 60-80 + Kwashiorkor 60-80 _ Underweight < 60 _ Marasmus < 60 + Marasmic kwashiorkor
  • 13. IAP CLASSIFICATION(1972) Grade of malnutrition Weight for age of the standard (median) % Normal >80 Grade I 71-80 (mild malnutrition) Grade II 61-70 (moderate malnutrition) Grade III 51-60 (severe malnutrition) Grade IV <50 (very severe malnutrition)
  • 14. CLASSIFICATIONS- WHO Moderate malnutrition Severe malnutrition Symmetrical oedema No Yes (oedematous malnutrition) Weight-for-height SD score between -2 to -3 SD score < -3 Severe wasting Height-for-age SD score between -2 to -3 SD score < -3 Severe stunting
  • 15. AGE INDEPENDENT INDICES  Weight for height  Mid arm circumference  Body mass index  Index ( Kanawati, Dughdale, Rao & Singh’s )  Skin fold thickness
  • 17. RATIOS Name of index Calculation Normal value Value in malnutrition Kanawati and Mc laren MUAC(cm)/HC(c m) 0.32-0.33 <0.25 Rao and Singh wt (kg)/Ht (cm)2 X 100 0.14 0.12-0.14 Dughdale wt (kg)/ht in cm 1.6 X100 0.88-0.97 <0.79 Quaker arm circumference MAC expected for a given height 75-85%- malnourished <75%-severely malnourished Jellife’s ratio HC/CC <1 in a child >1year: malnourished
  • 18. RISK FACTORS  LBW  Multiple birth  Closely spaced birth  Early stoppage of breast feeding  Too early or late weaning  Recurrent infections  Illiteracy, poverty  Secondary due to malabsorption
  • 22. CLINICAL FEATURES • Depends on the severity and duration nutritional deprivation, the age, presence or absence of associated infections.
  • 23. KWASHIORKOR • Essential Features • Marked growth retardation • Psychomotor changes • Wasting of muscles • Dependent pitting edema
  • 24. • General appearance- fat sugar baby appearance. • Skin changes- • Hyperpigmentation, desquamation and dyspigmentation. • Flaky paint dermatosis( confluent areas ) • Enamel spots( individual spots ) • Typically involving buttocks, perineum and upper highs.
  • 25. • Mucus membrane lesions  Smooth tongue  Cheilosis, angular stomatitis  Herpes simplex stomatitis • Edema • Muscle wasting- weak, hypotonic and unable to stand or walk.
  • 26. Hair Changes • Hypopigmented hair. • Sparseness (alopecia) • Change in texture (coarse / silky) • Easy pluckbility • Flag sign Mental Changes : • Lethargy • Apathetic • Poor appetite – difficult to feed
  • 27. – GI Manifestations • Diarrhoea • Infections / Parasitic infestations • Mucosal atrophy • Enteraopathy sec. to anemia • Liver enlargement • Fatty liver –Mineral & Vitamin deficiency –Super added infections • Tuberculosis, bronchopneumonia, measles, enteritis..
  • 28. MARASMUS Essential Features • Gross wasting of muscles – skin and bones. • Emaciation- loss of buccal pad of fat-monkey facies, loose skin of buttocks hanging down- baggy pants appearance • Marked stunting • No edema Non -essential Features •Mineral and vitamin deficiency • Indolent ulcers and sores • GI symptoms – hungry • Liver is shrunk • Psychomotor changes – irritable
  • 29. CONT… Grade 1 : Wasting starts in axilla & groin Grade 2 : Wasting extended to thigh and buttocks Grade 3 : Chest and abdomen Grade 4 : Wasting of buccal pad of fat also
  • 30. SEVERE ACUTE MALNUTRITION  Weight-for-height of 70% (extreme wasting)  Presence of bilateral pitting edema of nutritional origin, “edematous malnutrition  Mid-upper-arm circumference of less than 115 mm in children age 1-5 years old
  • 31. COMPLICATIONS OF SAM  ARI  Diarrhea  Gram negative septicemia  Poor feeding  Electrolyte abnormalities
  • 33. MANAGEMENT Mild and moderate malnutrition  Mainstay of treatment is to give adequate amounts of protein and energy  Atleast 150kCal/kg/day, protein intake of 3g/kg/day  Best measure of efficacy of the treatment is weight gain
  • 34. Locally produced RUTF Hyderabad mix 120 g = 500 Kcal (Wheat, black gram, groundnut flour) Limited success in uncontrolled studies
  • 35. INPATIENT TREATMENT OF SEVERE ACUTE MALNUTRITION WHO TEN STEPS to recovery in Malnourished Children In 2 phases •Initial stabilisation – 2 to 7 days •Rehabilitation – several weeks
  • 36. TIME FRAME FOR TEN STEPS
  • 37. STEP 1 PREVENT/TREAT HYPOGLYCEMIA Blood glucose <54mg/dl If cant be measured assume hypoglycemia TREATMENT Asymptomatic- • 50ml of 10% glucose or sucrose solution orally or NG f/b 1st feed • Feed with starter F-75 q 2hrly
  • 38. Symptomatic  10% dextrose i.v 5ml/kg  Follow with 50ml of 10% glucose or sucrose solution NG  Feed with starter F-75 q 2hrly  Start appropriate antibiotics Prevention  Feed 2 hrly starting immediately  Prevent hypothermia
  • 39. STEP 2 PREVENT AND TREAT HYPOTHERMIA Rectal temp <35.5 C/95.5 F or axillary <35 C/95 F Treatment  Clothe the child with warm clothes  Provide heat  Avoid rapid rewarming  Feed the child  Give appropriate antibiotics
  • 40. STEP 3 TREAT/PREVENT DEHYDRATION  Assume all SAM with watery diarrhoea to have some dehydration.  Hypovolemia can co exist with edema. Treatment  Use reduced osmolarity ORS with potassium supplements for rehydration and maintenance.  Initiate feeding within 2-3 hrs of starting rehydration with F-75 formula on alt hrs with reduced osmolarity ORS  Be alert for signs of overhydration.
  • 41. STEP 4 CORRECT ELECTROLYTE IMBALANCE Supplemental potassium at 3-4meq/kg/d for atleat 2 weeks On day1, 50% MgSO4 i.m once (0.3 ml/kg, max upto 2ml) thereafter give extra Mg(0.8-1.2 meq/kg daily) Excess body sodium exists even though plasma sodium may be low. Prepare food without adding salt.
  • 42. STEP 5 TREAT/PREVENT INFECTION  Multiple infections common  Usual signs of infection such as fever often absent  Majority of blood stream infections due to gram negative bacteria.  Assume serious infections and treat.  Hypoglycemia and hypothermia are markers of severe infections.
  • 43. Treatment  Ampicillin iv for atleast 2 days f/b oral amoxycillin  i.v. gentamicin or amikacin for 7 days. If no imrovement within 48hrs,  i.v. cefotaxime  Ceftriaxone Prevention  Follow standard precautions like hand hygiene  Give measles vaccine if >6 months and not immunised or if the child is more than > 9 months.
  • 44. STEP 6 CORRECT MIRONUTRIENT DEFICIENCIES 1. Use upto twice the RDA of various vitamins and minerals 2. On day1, Vit A orally (if age>1yr 2lac IU, 6- 12 mon 1 lac IU, 0-5 mon 50,000 IU) 3. Folic acid 1mg/day ( 5mg on D1) 4. Copper 0.2-0.3 mg/kg/d 5. Iron 3mg/kg/d, once child starts gaining wt, after the stabilisation phase.
  • 45. STEP 7 INITIATE RE-FEEDING  Initiate feeding as soon as possible as frequent small feeds  If unable to take orally- NG feeds  Total fluid recommended is 130ml/kg/d, reduce to 100ml/kg/d if there is severe, generalised edema  Continue breast feeding ad libitum  Start with F-75 starter feeds q 2 hrly  F-75 contains 75kCal/100ml with 1g protein/100ml  If persistent diarrhea, cereal based low lactose F-75 diet as starter diet  If diarrhea continues on low lactose diets give F-75 lactose free diets
  • 46. STEP 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/d • Continue breast feeding on demand • Make a gardual 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
  • 47. STEP 9 PROVIDE SENSORY STIMULATION AND EMOTIONAL SUPPORT  A cheerful, stimluating environment  Age appropriate structured play therapy for atleast 15-30 mins/day  Age appropriate physical activity as soon as the child is well enough  Tender loving care
  • 48. STEP 10 PREPARE FOR FOLLOW UP AFTER RECOVERY Said to have rcovered when wt for ht is 90% of NCHS median and has no edema Primary failure to respond if • Failure to gain appetite by D4 • Failure to start losing edema by D4 • Presence of edema on D10 • Failure to gain atleast 5g/kg/d by D10 Secondary failure to respond if • Failure to gain at least 5g/kg/d for consecutive days during the rehabilitation phase
  • 49. Complication during rehabilitation Nutritional Recovery Syndrome Treated with very high proteins Abdominal distension (hepatomegaly, ascites, splenomegaly), prominent veins, hypertrichosis, parotid swelling, gynaecomastia, eosinophilia, hyper-Ig Incresed estrogen and recovering pituitary Kwashi shake/encephalitis states (too much of proteins) Pseudotumor cerebri Refeeding syndrome
  • 50. REFEEDING SYNDROME Definition Refeeding syndrome (RFS) is a term that describes the metabolic and clinical changes that occur on aggressive nutritional rehabilitation of a malnourished patient. - Exact incidence in pediatric patients not known. - 30% to 38% in adults on TPN with phosphorus. - 100% in adults on TPN without phosphorus. - 25% of adults with cancer.
  • 53. Starvation - Increased catabolism - Increased glycogen depletion - Breakdown of proteins to aminoacids for gluconeogenesis - Production of ketone bodies from fatty acids
  • 55. • Altered membrane potenial – Cardiac arrythmias • Neuromuscular dysfunction • Sodium retention • Fluid overload • Fatty liver • Hypokalemia • Increased corticosteroids. • Ketoacidosis • Altered menbrane potential • Impaired Na+K+ ATPase activity • Co-factor for enzymes in oxidative phosphorylation and ATP production • Decreased ventricular mass • Decreased sarcomere contractility • Decreased production of ATP • Rhabdomyolysis Hypo PO4 2- (onset <72 hrs, nadir 7 days) Hypomagnesemia (Onset <72 hrs) HypokalemiaHyperinsulinemia and Hyperglycemia
  • 56. CLINICAL FEATURES < 2 weeks - Increased weight gain, tachypnoea, features of cardiac failure, dilutional hyponatermia – s/o fluid overload. - Neuromuscular symptoms like weakness, paresthesias, cramps, respiratory muscle weakness – altered membrane potential due to electrolyte imbalance. - Cardiac failure, rhabdomyolysis, altered mental status, confusion, coma, hemolysis, thrombocytopenia and leukocyte dysfunction – hypophosphatemia. - Abdominal distention, increasing hepatomegaly, ascites,– Fatty liver.
  • 57.  2 weeks - Prominient thoraco-abdominal venous network - Hypertrichosis (after 60 days) - Parotid swelling - Gynaecomastia - Eosinophilia (after 60 days) - Spleenomegaly Cause: Not clear. Probably due to excessive intake of high quality protein during rehabilitation, leading to increase in various trophic hormones produced by the recovering pituitary gland. Gomez et al, Pediatrics 1952; 10:513-526
  • 58. DIAGNOSIS AND EARLY RECOGNITION IS THE KEY - There is no defined diagnostic criteria for refeeding syndrome in children. - Monitoring of biochemical parameters for hypophosphatemia, hypomagnesemia, hyperglycemia, hypoalbuminemia. - Daily weight monitoring for the initial 7 days. - Goal of weight gain should not be more than 1 Kg/week. - Fluid status (intake/output) should be moniitored. - Cardiorespiratory monitoring during the initial. - Assess frequently for neuromuscular weakness and mental status.
  • 59. MANAGEMENT - Stop all sources of calorie and protein until the electrolyte imbalances are corrected. - Start with 50% of the caloric intake at which the patient developed symptoms. - Supplement with multivitamins (including thiamine) - Watch for recurrence of refeeding syndrome by monitoring clinical and biochemical parameters daily. - Limit sodium and fluid intake. - Gradually increase the caloric requirement every 3 days. “Start low and go slow”. - Protein restriction is not recommended, 1.5 g/Kg/day rich in essential aminoacids is required for anabolism to occur.
  • 60. PREVENTION A) MONITORING Before initiating refeeding through any route and during initial 3 – 5 days, - Hydration and fluid assessment. Early weight gain may be secondary to weight gain. - Daily electrolytes: Initial glucose and albumin. Daily sodium, potassium, calcium, phosphorus, magnesium, urea and creatinine. - Cardiac status. (ECG ± ECHO)
  • 61. B) ORAL FEEDING REGIMEN 1. Initial volume and calories • In more severe cases an initial starting volume of 75% of total daily requirements has been used - < 7 years old - 80–100 kcal/kg/day - 7–10 years - 75 kcal/kg/day - 11–14 years - 60 kcal/kg/day - 15–18 years - 50 kcal/kg/day • If the initial food challenge is tolerated, this may be increased over 3– 5 days (Target 150 kcal/kg/day – Rehabilitation phase). • Each requirement should be tailored to an individual’s need and the above values may need to be adjusted by as much as 30%. • Frequent small feeds (every 2 hrly) are recommended initially. Slowly increase the volume per feed, max of 22 ml/kg/feed (130 ml/kg/day) • Feeds should provide minimum of 1 kcal/ ml (F-100) to minimize volume overload.
  • 62. 2. PROTEIN • If a milk-based feed induces diarrhoea with positive faecal reducing substances, a hydrolysate may be used. • An initial regimen for malnourished children suggests 0.6–1 g/kg/day • The feed should be rich in essential amino acids and gradually increased as an intake of 1.2–1.5 g/kg/ day is needed for anabolism to occur. • Slowly increase proteins to 4 – 6 g/kg/day during the catch up phase (Rehabilitation phase after 2 weeks). 3. SUPPLEMENTS • Twice the recommended daily allowance for vitamins and minerals (Na, K, Ca, PO). • Supplement with Zinc, copper, folic acid, Vit B12. • Oral Vit A on day 1.
  • 63. TAKE HOME MESSAGES - Refeeding syndrome is due to the metabolic and hormonal changes that occur due to aggressive nutritional rehabilitation. - START LOW AND GO SLOW. - IDENTIFICATION of patients at risk and monitoring patients during nutritional rehabilitation is the key to prevention. - AWARENESS of the potential complications involved in reintroducing feeds to an undernourished patient is crucial
  • 64. CRITERIA FOR DISCHARGE FROM NON-RESIDENTIAL CARE  Weight-for-height has reached -1 SD (90%) of NCHS/WHO median reference values  Eating an adequate amount of a nutritious diet that the mother can prepare at home  Gaining weight at a normal or increased rate  All vitamin and mineral deficiencies have been treated  All infections and other conditions have been or are being treated, including anaemia, diarrhoea, intestinal parasitic infections, malaria, tuberculosis and otitis media  Full immunization programme started
  • 65. FOLLOW UP  Child should be seen after 1week, 2 weeks, 1 month, 3 months and 6 months. More frequently if any problem found.  After 6 months, visits should be twice yearly until the child is at least 3 years old.  The child should be examined, weighed and measured, and the results recorded.  Any needed vaccine, vit A should be given.  Training of the mother should focus on areas that need to be strengthened, especially feeding practices, and mental and physical stimulation of the child.
  • 66. PREVENTION At national level 1. Nutrition supplementation- Fortification, iodination 2. Nutritional surveillance- define the character and magnitude of nutritional problems and strategies to tackle. 3. Nutritional planning- formulation of nutrition policy, improve food production and supplies, ensure distribution.
  • 67. PREVENTION At community level- • Health and nutritional education • Promotion of education and literacy in the community • Growth monitoring • Integrated health package • Vigorous promotion of family planning programs
  • 68. PREVENTION At family level  Exclusive breast feeding  Complementary feeds at 6 months  Vaccination  Spacing between pregnancies