A Broad overview for management of PEM. Very important topic for MBBS Students. Seminars ,Lectures and exam preparation can be done using my presentaion. Helpful for CMC Vellore Seminars

1. PEM MANAGEMENT
By – Uzagare Joshua John

2. Complications
• SHIELDED
 S- Sugar def i.e., Hypoglycemia
 H- Hypothermia
 I- Infection and septic shock
 EL - Electrolyte imbalance (hypokalemia)
 D - Def of Fe, Vitamins and other micronutrients

3. The ten steps for routine care
1. Hypoglycaemia
2. Hypothermia
3. Dehydration
4. Electrolysis
5. Infection
6. Micronutrients
7. Cautious feeding
8. Catch-up growth
9. Sensory stimulation
10. Prepare for follow-up
Stabilization Rehabilitation
Days 1-2 Days 3-7 Weeks 2-6
No iron With iron

5. Criteria for admission
• Children weighing less than 60% for age with:
 Edema
 Severe dehydration
 Diarrhea
 Hypothermia
 Shock
 Systemic infection
 Jaundice
 Bleeding
 Persistent loss of appetite
 Severe wasting or edematous nutrition

7. STEP 1 PREVENT/TREAT HYPOGLYCEMIA
• Blood glucose <54mg/dl
• If cant be measured assume hypoglycemia
• Hypoglycemia, hypothermia and infections generally occour as
a triad
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

8. STEP 2 PREVENTAND TREAT HYPOTHERMIA
Rectal temp <35.5 C/95.5 F or axillary <35 C/95 F
Treatment
• Avoid Rapid Rewarming
• Clothe with warm cloths
• Ensure head is also covered well with a scarf or a cap
• Provide heat with overhead warmer, incandescent lamp or radiant
warmer, warm water bottles, warm pads, etc.
• Give appropriate antibiotics
• Feed 2 hrly starting immediately after admission
• Always keep child covered, Place bed away from doors and
windows
• Minimize exposure after bathing or clinical exam.
• Let child sleep in close contact with mother
• Kangaroo mother care

9. 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.

10. ReSoMal
• Severely malnourished children have low potassium and
abnormally high sodium
• ORS should contain less sodium and more potassium
than the standard WHO-recommended solution.
• Magnesium, zinc and copper should also be given to
correct deficiencies of these minerals.
• ReSoMal Can be prepared by:
 Diluting 1 pack of standard ORS in 2 litres of water
(instead of 1L) and adding 50g sucrose and 40 ml of
mineral mix solution

11. - NO DEHYRATION : ReSoMal with each loose stool
<2yrs 50-100 ml/loose stool
>2yrs 100-200 ml/ loose stool Till Diarrhoea Stops
-MILD TO MOD :
SEVERE : 100ml/kg of NS/RL in 3-6 hrs, add dextrose
to this, also add potassium
 K + supplement – 2-4meq/kg/day,, if acidosis, give sodium
bicarbonate 2ml/kg
70-100 ml/Kg 2 Hours 10 Hours
Give By Oral Or
NG route
5 ml/Kg every 30
Min.
5-10 ml/Kg per
hour

12. STEP 4 CORRECT ELECTROLYTE IMBALANCE
• Supplemental potassium at 3-4meq/kg/d for at least 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.

13. 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 50mg/kg/dose q6h iv for atleast 2 days f/b oral amoxycillin
15mg/kg q8h * 5 days and gentamycin 7.5mg/kg or amikacin 15-20mg/kg
i.m. or i.v. OD * 7 days
• If no imrovement within 48hrs, i.v. cefotaxime 100-150mg/kg/day q6h or
Ceftriaxone 50-75mg/kg/day q12h
• If other specific infections are identified give appropriate antibiotics
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.

14. 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.
 ANEMIA –
•-Severe anemia , give 5-10ml/kg of packed cell transfusion
with lasix,
•-mild to moderate anemia, give 2-6mg/kg elemental iron after
patient has been stabilised and dewormed.
 Iron is not given early because unbound iron in gut may
lead to over growth of E.coli

15. 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

16. 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

17. STEP 9 PROVIDE SENSORY STIMULATIONAND
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

18. STEP 10 PREPARE FOR FOLLOW UPAFTER RECOVERY
• Said to have recovered when wt for ht is 90% of NCHS
median and has no edema

19. Restoration
• Calories and protein: goal is
• -150-200 kcal / kg,
• -3-4 g protein / kg and
• -100-165 ml fluid / kg
 Calorie requirement is calculated based on actual weight
irrespective of edema
 Total calorie calculated is to be divided into 6-8 feeds and
may be given orally or using a feeding tube
 Coconut oil as fat supplement as it is rich in MCTs
 Oil supplementation can be up to 10 – 15 % of calculated
calories
 50% of calories
from CHOs
 15% from
proteins
 35% from fat

20. • Feeding methods – if breast fed, continue it, add on MCT
• If > 4 months add on cereals, legumes, milk, oil, fruits
etc
• MVT, micronutrients should be started early

21. READY RECKONER FOR TAKING DIET HISTORY
MILK EXCHANGE
Each milk exchange contains
*prt. 3g *CHO 4g, Fat 4g, K. Cals 65
Cow’s milk - 100ml ( ½ cup)
Buffalo’s milk - 50ml ( ½ cup)
Curds - 100ml ( ½ cup)
Skimmed milk - 200ml ( 1 cup)
Skimmed milk powder 18g 5tsp
Whole milk powder 13g (3tsp)
Fat negligible
CEREAL EXCHANGE
Each cereal exchange contains
*prt. 1-3g *CHO 18-21g Fat negligible, K Cals 85
Rice - 25g (2 Tbsp)
Cooked Rice - ½ cup
Wheat Ravai - 25g (2 Tbsp)
Broken Rice - 25g (2 Tbsp)
Sooji - 25g (2 Tbsp)
Oats - 25g (3 ½ Tbsp)
Vermicelli - 25g (2 ½ Tbsp)
Flakes - 25g (5 Tbsp)
Wheat flour - 25g (3 ½ Tbsp)
Ragi flour - 25g (3 ½ Tbsp)
Rice flour - 25g (3 Tbsp)
Arrow root - 25g (2 Tbsp)
Sago - 25g (3 Tbsp)
Iddli - 1 medium size
Dosai - 1 medium size
Chappathi - 1 medium size
Uppuma - ½ cup
Noodles/spaghetti - ½ cup
Potato - 100 g
Yam - 75g
Colccasia - 100g
Sweet potato - 75g
Tapioca - 50g
Bread - 2 half inch slices
Protein negligible
MEAT EXCHANGE
Each meat exchange contains
*prt. 75g *CHO nil, Fat 6g, K. Cals 85
Beef - 75g
Chicken - 75g
Liver - 75g
Pork muscle - 75g
Egg - 1 medium
Meat - 50 g
Fish - 75-100g
Fish and liver contain small amounts of CHO.
There is wide variation
between items in this exchange

22. DHAL EXCHANGE
Each exchange contains
CHO 15g, Prt. 6g, K.Cals 85, Fat negligible
Pulses - 25g ( ½ cup cooked)
Legumes - 25g ( ½ cup cooked)
FAT EXCHANGE
Each Fat exchange contains
Fat 10g K. Cals 90 * Prt & CHO, nil
Oil (any variety) - 10g (3 tps)
Ghee - 10g (2 tps)
Butter - 12g (2 ½ tps)
Vanaspathi - 10g (2 tps)
Margarine - 10g
FRUIT EXCHANGE
Each fruit exchange contains
CHO 10g, K. Cal 40, Prt. & Fat negligible
Amla - 4.5
Apple - 1 small
Apricots - 2 fresh
Banana - ½ small
Custard apple - 1 small
Dates - 2
Grapes - 20
Grape fruit - ½ small
Guava - 1 medium
Jack fruit - 3 pieces
Jambu - 10 small
Mango - 1 small
Melon - 1 slice
Orange - 1 average
Papaya - 2” x 3” slice
Peach - 1 medium
Pear - 1 small
Pineapple - 1 slice
Plums - 2
Sapota - 1 small
Straw berries - 1 cup
Sweet lime - 1 medium size
Water melon - 1 slice (200 g)

23.  A weight gain of 0.5kg/week in children and
70g/kg/week in infants is the target. 150-200g/week is
expected in newborns and young infants
 Restoration of wt for ht may take about 8- 12 weeks
 Oedema clears and social smile returns in 1-2 weeks

24. Rehabilitation phase
 Frequent feeding.
 Treating concurrent deficiencies
 Routine advice for easily available , cheap,culturally acceptable
food.
• PEM can be improved by
 Overall socioeconomic development.
 Better standard of living.
 Improved sanitary conditions.
 Exclusive breast feeding during first 6 months.
 Optimum weaning practices.
 Supplementary feeding.
 Micronutrient supplementation.
 Universal immunisation.
 Nutrition & health education.
 Nutrition & health of girl child.

25. Failure to respond
• PRIMARY FAILURE
1. Failure to regain appetite by day 4
2. Failure to lose edema by day 4
3. Failure of disappearance of edema by day 10
4. Failure to gain wt atleast 5g/kg/day by day 10
• SECONDARY FAILURE
• Child does not gain >5g/kg/d body wt for 3
consecutive days

26. Frequent causes of failure to respond
Problems with the treatment facility:
• Poor environment for malnourished children
• Insufficient or inadequately trained staff
• Inaccurate weighing machines
• Food prepared or given incorrectly
Problems of individual children:
• Insufficient food given
• Vitamin or mineral deficiency
• Malabsorption of nutrients
• Rumination
• Infections, especially diarrhoea, dysentery, otitis media,
pneumonia, tuberculosis,
urinary tract infection, malaria, intestinal helminthiasis and
HIV/AIDS
• Serious underlying disease

27. Poor prognostic factors
 Depressed sensorium
 Marasmic Kwashiorkor
 Hypothermia
 Hypoglycemia
 Albumin < 1.5 gm
 Gram negative sepsis
 Purpura
 Severe dermatosis
 Xerophthalmia
 Elevated bilirubin and liver enzymes
 Marked hepatomegaly
 Electrolyte and fluid imbalances

28. Nutrition Recovery Syndrome
• Definition: Apparent worsening of a child with PEM
while on nutritional rehabilitation
• Clinical features:
• Increasing hepatomegaly
• hypertrichosis
• parotid swelling
• ascites
• splenomegaly
• eosinophilia
• gynecomastia
• Tremors
-it is a self limiting condition.
Treatment: observation; continue nutritional rehabilitation.
-occurs due to excess of hormones(estrogen) produced nutritional rehab

29. • Pseudotumor cerebri
• Over energetic nutritional correction in malnourished infants may
be accompanied by transient rise in ICT
• Benign and self limiting
• Encephalitis like syndromes
• Upto 1/5th of children with kwashiorkor may become drowsy within
3-4 days after initiation of diatery therapy
• Self limiting
• Occasionaly accompanied by progressive unconsciousness with
fatal outcome
• Rarely with a transient phenomena marked by coarse tremors,
parkinsonian rigidity, bradykinesia and myoclonus may appear
several days after starting the dietary rehabilitation
• Encephalitis like states result of too much protein in the diet

30. DISCHARGE criteria for PEM
Child should have atleast 90% of his ideal Weight for
his height.
 Weight gain should be 70gm/kg/week.
 All infections, vitamin& mineral deficiencies should
have been treated,
 Serum Albumin--> 3 gm/dl.
 Immunization should have been initiated.
 Mother should have been educated regarding domiciliary
care

31. 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.

32. Prevention
 Antenatal care should be emphasised and strengthened.
 Health and nutritional status of the adolescent girls should be
improved
• At national level
• Nutrition supplementation- Fortification, iodination
• Nutritional surveillance- define the character and magnitude of nutritional problems and strategies
to tackle.
• Nutritional planning- formulation of nutrition policy, improve food production and supplies, ensure
distribution.
• 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
• At family level
• Exclusive breast feeding
• Complementary feeds at 6 months
• Vaccination
• Spacing between pregnancies

33. NIMFES
 N – nutrition and growth monitoring
 I – immunisation
 M – medical checkup and medical care during illness
 F – family welfare(timing, limiting and spacing of
births)
 E – education
 S – stimulation, developmental surveillance
and TLC

34. In Short…
• RESUSCITATION (Goal:
treatment of medical
emergencies)
• RESTORATION (Goal: wt
for height )
• REHABILITATION (Goal:
wt for age)
• PREVENTION
- Hypoglycemia,
hypothermia, infections,
dehydration, CCF
-Nutritional therapy,
deworming, MVT
-Food supplementation
-NIMFES

35. Sources
• Fundamentals of pediatrics by Dr. K.E. Elizabeth
• Ghai Essential Pediatrics 7th edition
• Management of severe malnutrition: a manual for
physicians and other senior health workers By World
Health Organization, Geneva
• Scott’s Pedia Tricks

36. Thank You