2. PROTEIN-ENERGY MALNUTRITION (PEM)
• PEM results when the body's needs for protein
and energy fuels are not satisfied by the diet.
• It is accompanied by deficiency of several
micronutrients
• Severity ranges from milder forms weight loss or
growth retardation to distinct clinical features
marasmus, kwashiorkor or marasmic
kwashiorkor.
3. Primary PEM- due to inadequate food intake
Secondary PEM- other disease lead to
low food ingestion,
inadequate nutrient absorption or
utilization, increased
nutritional requirements, increased nutrient
losses
causes
4. Epidemiology and etiology
According to the Ethiopian Demographic and
Health Survey (EDHS) preliminary report of 2011
for under five children showed
The percentage of children who are stunted is 44%; of
which 21% are severely stunted
The percentage of children who are wasted is 10%
And those of underweight is 29%, and 9% of children
are severely underweight
5. Etiology
• Social and Economic Factors
-Poverty
-Ignorance
-Social and cultural problems
• Biological factors
-Maternal malnutrition -
Infection -
Dietary factor bulky foods with low nutritional
value
6. Environmental factors -
Overcrowded and/or unsanitary living
conditions
Agricultural patterns, droughts, floods, wars, and
forced
Age of the host -
more frequent among infants and young
children
7. PATHOPHYSIOLOGY AND ADAPTIVE
RESPONSES
Infants prematurely weaned from breast milk,
exposed to diluted and dirty formula =>repeated
GI infection=>develop marasmus before age 1yr
Children with prolonged breast feeding, starchy
gruel, family diet & devoid of proteins => acute
infections => edema (kwashiorkor) more
frequently after age 18months.
8. Free radical theory
Increased production of free radicals by
infection, toxins, iron, trauma sunlight exposure
and decreased scavenger mechanism that
removes free radicals (vit A, C,E, zinc, selinium)
& glutathione
=>Accumulation of free radicals
=>Damage to cell membrane and vessels
=>Alteration seen in kwashiorkor- fatty liver,
dermatosis,edema
9. Decreased energy intake
↓
Decreased energy expenditure
↓
Fat mobilization and wt loss
↓
Subcutaneous fat markedly reduced and
muscle wasting due to protein catabolism
Visceral protein in spared in marasmus
longer but early involved in kwashiorkor
10. Endocrine
maintenance of energy homeostasis through
increased glycolysis and lipolysis, increased
amino acid mobilization, preservation of visceral
proteins through increased breakdown of muscle
proteins, decreased storage of glycogen, fats,
and proteins, and decreased energy metabolism
11. Hematology reduction in Hgb
CVS and renal
◦ reduction in CO,HR & BP
◦ reduction in renal blood flow & glomerular filtration rate
Electrolytes
◦ decreased total body potassium and magnesium
◦ increased intracellular sodium
Metabolism hypoglycemia
decreased basal metabolic rate
12. Gastrointestinal
decrease in gastric, pancreatic, and bile production
and decrease in absorption
villi atrophy , bacterial overgrowth
CNS
severe PEM at an early age may result decreased
brain growth, nerve myelination, neurotransmitter
production, and velocity of nervous conduction
13. Immune system
reduction of T lymphocytes
decreased production of complement system
Phagocytosis, chemotaxis, and intracellular killing are
also impaired
B cell and Ig are relatively normal but there may br
defect in antibody production such as secretory
immunoglobulin A
14. Classification of PEM
Welcome system uses weight for age measured
by Harvard curve
Weight for
age
Edema- Edema +
60-80% Underweight Kwashaikor
<60% Marasmic Marasmickwash
15. Water low classification asses severity of
wasting and stunting using the NCHS curve
Grade of
malnutrition
Wt/ht
(Wasting )
Ht /age
(Stunting )
Normal > or=90% > or=95%
Mild 80-89% 90-94%
Moderate 70-79% 85-89%
severe <70% <85%
16. Clinical manifestations
Marasmus = Greek term means to waste
It is an adaptive process
Generalized muscle wasting and absence of
subcutaneous fat “bone and skin appearance” or
old man’s face
Hair sparse, thin, dry & easily pulled out
Skin is dry, thin with little elasticity, and wrinkles
easily
17. Patients are apathetic but usually aware and
have a look of anxiety on their face
Some are anorexic, whereas others are
ravenously hungry
Diarrhea, vomiting, abdominal distension
Heart rate, blood pressure, and body
temperature may be low
Hypoglycemia
18. Kwashiorkor:
Edema
◦ bilateral pitting ,painless of the feet and legs in severe
cases may involve the upper extremities and face
Skin lesions are usually present
◦ include Hyperpigmentation, hypopigmentation
desquamation and ulceration (flaky paint dermatosis)
◦ affected site areas of edema, continuous pressure
( buttocks and back), or frequent irritation (perineum
and thighs).
19.
20. The extent of dermatosis can be described in the
following way:
+ mild: discoloration or a few rough patches of skin
+ + moderate: multiple patches on arms and/or
legs
+ + + severe: flaking skin, raw skin, fissures
(openings in the skin)
21.
22.
23. Hair
dry, fine, straight, without its normal sheen, and can
be pulled out easily
Color usually changes to brown, red, or even yellowish
white
“Flag sign” Alternating periods of poor and relatively
good protein intake can produce alternating bands of
depigmented and normal hair
25. Mental status
apathetic and irritable, cry easily, and expression of
misery and sadness
Gastrointestinal
Anorexia, postprandial vomiting, and diarrhea
Hepatomegaly with a soft, round edge caused by
severe fatty infiltration
abdomen protruding because of distended stomach
and intestinal loops
26. Marasmic- kwashiorkor
combines clinical characteristics of kwashiorkor and
marasmus
edema of kwashiorkor, with or without its skin lesions,
and the muscle wasting and decreased
subcutaneous fat of marasmus
29. Serum concentrations of total proteins specially
albumin
are markedly reduced in edematous PEM, and they
are normal or moderately low in marasmus
Electrolytes
intracellular concentrations of potassium and
magnesium decrease, and that of sodium increases
30. The ratio of nonessential to essential amino
acids in plasma is elevated in kwashiorkor
Serum free fatty acids are elevated particularly
in kwashiorkor
Urinary creatinine excretions markedly reduced
particularly in kwashiorkor
32. Admission to in patient
SAM plus
Medical complication or
Failed appetite test or
Edema +++ or
Wt/ht< 70% with edema or
33. Medical complications
Unable to breast feed drink or feed or vomiting
everything
Convulsions
Very Weak, Lethargic or unconscious
Pneumonia
Hypothermia or Fever >39 0C
Shock, Severe DHN, Hypoglycaemia
Severe anemia, Jaundice, Bleeding Tendencies
Dermatosis +++
Dysentery, Persistent diarrhoea
34. Treatment at a outpatient treating program
WFL/H < 70% of median or
MUAC <11cm or
Edema of both feet (+, ++)
AND
No medical complication AND pass appetite test
35. SAM for Infants less than 6 months
WFL < 70% of median or
OR
Visible severe wasting,
OR
Edema of both feet
Admit for inpatient treatment
36. Phase 1 nutritional management
Principles of phase 1 treatment
Feed the patient F- 75
Routine medications
Monitor the patient
Prevent, diagnose and treat complications
37. 1. F75 =75 kcal per 100ml
Has less Na, proteins, fats, lower
osmolarity and renal solute load
Less energy dense
75kcal/100ml and 0.9gprotein /
100ml
Is given 8 times per day
38. Use NG tube when
Taking less than 75% of prescribed diet per 24 hours
in Phase 1
Pneumonia with a rapid respiration rate
Painful lesions of the mouth
Cleft palate or other physical deformity
Disturbances of consciousness
39. 2. Routine medicines
Vitamin A for all children except those with
edema or those who received vitamin A in the
past 6 months
On the day of admission and on the day of
discharge
6-11months 100,000IU
>12months 200,000IU
40. Folic acid single dose of folic acid 5mg to
children with clinical signs of anaemia
Antibiotics:
First line : amoxicillin
Second line :chloramphenicol or gentamycin
Measles vaccine: all children > 9 months
without a vaccination card on admission and
discharge after Phase 2
41. 3. Surveillance (monitoring)
Weight each day
degree of edema each day
Body temperature twice per day
stool, vomiting, dehydration, cough, respiration
and liver size assessed each day
MUAC is taken each week
Length or Height is taken after 21 days
42. 4. Complications
Dehydration
-All signs of dehydration in normal child are
present in severe malnourished children with no
dehydration
-History of significant recent fluid loss and history
of a recent change in the child’s appearance
- Rx resomal -5ml/kg every 30 minute for the
first 2hrs then 5-10 ml /kg/hr for the next 4-10
hrs.
43. Replace ongoing loss with 30 ml of ReSoMal per
watery stool for oedematous children and with
50-100 ml for non-oedematous children under 2
years
If the child has already received IV fluids for
shock and is switching to ReSoMal, omit the first
2-hour treatment and start with the amount for
the next period of up to 10 hours.
44. Congestive heart failure
C/F weight gain, tachycardia, tachypenia, engorged
neck veins, gallop rhythm, increase in lived size and
tender, creptation
Stop all fluids and feeds, small sugar in water solution
orally
Furosemide 1mg/kg
Digoxin in small doses 5microgram/kg
Even if severely anemic don’t transfuse manage heart
failure first
45. Anemia
Hgb <4g/dl or HCT <12% during the first 48hrs of
admission
Give 10ml/kg of whole blood or packed RBC over 3 hr
46. HypoglycemiaIn severely malnourished children,
the level considered low is less than
<54 mg/dl
Clinical signs that occur in normal
person doesn’t occur in malnourished
children
Eye lead retraction is one important
sign
47. If conscious -50 ml of 10%sugar in water
or F75 diet by mouth
If loosing consciousness -give 50 ml of
10% sugar- water by naso-gastric tube
If unconscious - 5ml/kg of 10% glucose
solution IV, followed by 50 ml of 10%
sugar by NG tube
48. Hypothermia
Rectal temperature below 35.5oC or under arm
temperature below 35oC
Commonest cause is due to environmental or lack of
cover
-Use the “kangaroo technique” for children with a
caretaker
-Put a hat on the child and wrap mother and child
together
49. -The room should be kept warm, especially at night
thermo-neutral temperature range for malnourished
patients is 28oC to 32oC
-Treat for hypoglycemia and give second-line
antibiotic treatment
50. Transition phase
The criteria to progress from Phase 1 to
Transition Phase are :
- Return of appetite and
-Beginning of loss of edema and
-No IV line, no NGT
F100(100kcal/100ml) is given same amount as
phase 1, 8times per day
Expected wt gain is 6g/Kg/day
51. Criteria to move back from Transition phase to
Phase 1
Rapid weight gain greater than 10g/kg/d
Edema increasing or development of
edema
Rapid increase in the size of the liver
Any signs of fluid overload develop
Tense abdominal distension
53. Criteria to progress from Transition phase to Phase
2
Good appetite
Complete loss of edema
No other medical problems
54. Phase 2
F100 (100ml = 100 kcal): five feeds per day or
Ready to use therapeutic feeding(RUTF)
One porridge may be given for patients who are
more than 8kg
Phase 2 management can be done as out patient at
home or in therapeutic feeding center
Wt gain 8g/kg/day
55. Routine medications during phase 2
Iron: is added to the F100 in Phase 2
De-worming: Albendazole or
Mebendazole is given at the start of the
Phase 2
57. Causes of treatment failure
Problems with the treatment facility
Poor environment for malnourished children
Poorly trained staff
Inaccurate weighing machines
Food prepared or given incorrectly
58. Problems of individual children
Insufficient food given
Malabsorption
Infection, especially: Diarrhoea, dysentery,
pneumonia, tuberculosis, urinary infection
Other serious underlying disease: congenital
abnormalities (e.g. Down’s syndrome)
59. Discharge criteria
W/L>=85% or W/H>=85% =(Two days for in-
patients, two weeks for out-patients)
and
No edema for 10 days (In-patient)
Vaccination updated
Education to the mother is given
60. Follow-up after discharge
The patients should be enrolled in a Supplementary
Feeding Program and given nutritional
support for another 4 months
61. Poor prognostic factors for PEM
Age <6 mon
Signs of circulatory collapse
Altered mental status
Infections
Bleeding tendencies
Dehydration and electrolyte disturbances
62. Congestive heart failure
Total serum proteins <30 g/L
Severe anemia
Clinical jaundice or elevated serum bilirubin
Extensive exudative or exfoliative
cutaneous lesions or deep decubitus
ulcerations
Hypoglycemia or Hypothermia
63. References
Nelson text book of pediatric 19th
edition
Modern malnutrition in health and disease
Protocol for management of severe malnutrition
Ethiopia Federal Ministry of health 2011
(MODFIED FROM DR MAHLET’S PPT)
