Kwashiorkor and marasmus, classification of PEM, Its management in ten steps, Complications of PEM.

1. PEM
Nutritional deficiency disorders
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Anju George, SGCON, Parumala

2. INTRODUCTION
 Malnutrition- Refers to both under nutrition as well as
over nutrition
 Under nutrition- Inadequate consumption, poor absorption
or excessive loss of nutrients.
 Over nutrition- Overindulgence or excessive intake of
specific nutrients.
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3. PROTEIN ENERGY MALNUTRITION
 Definition – Acc to WHO it is a range of pathological
conditions arising from coincidental lack in varying
proportions of protein and calories occurring most
frequently in infants and young children and
commonly associated with infection.
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4. CLASSIFICATION
I. Clinical classification
 Marasmus: weight for age < 60% expected + without edema
 Kwashiorkor: weight for age < 80% + edema
 Marasmic kwashiorkor: wt for age <60% + edema
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5. II. Gomez classification
 Based on weight for age
 Grade I  90-75 % of expected weight
 Grade II 75 – 60 % of expected weight
 Grade III  <60 % of expected weight
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6. III. IAP classification
 Based on weight for age
 Weight of a child is compared with weight of normal expected
for that age
 If the child is having edema letter ‘k’ is placed in front of the
grade
 Grade I  80-71 % of expected weight
 Grade II 70 – 61 % of expected weight
 Grade III 60 - 51 % of expected weight
 Grade IV  < 50 % of expected weight
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7. IV. Jelliffee’s classification
 Similar to IAP classification but normal goes upto 90% and grade IV
is < 60%
 If the child is having edema letter ‘k’ is placed in front of the grade
 Grade I  80-90 % of expected weight
 Grade II 70 – 79 % of expected weight
 Grade III 60 - 69 % of expected weight
 Grade IV  < 60 % of expected weight
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8. V. Wellcome classification
VI. WHO classification
Wt. for age Edema No edema
60-80% Kwashiorkor Underweight
<60% Marasmic –
kwashiorkor
Marasmus
Moderate
malnutrition
Severe
malnutrition
Edema No Yes
Wt for height 70-79% <70%
Height for age 85-89% < 85%
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9.  VII. Waterlow classification
Normal Wasted Stunted
Weight for age Normal Less Less
Weight for
height
Normal Less Normal
Height for age Normal Normal Less
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10. MAC Nutritional status
>13.5 cm Green Normal
12.5-13.5 Yellow Mild and moderate
PEM
< 12.5 cm Red Severe PEM
VIII. Arnold’s classification based on Mid arm
circumference
 Used for below 5 years of age
 <13.5 cm : Malnutrition
 Shakir tape is used to measure MAC
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11. ETIOLOGY OF PEM
 PEM results from many inter related factors :
1. Sociodemographic factors
2. Environmental factors
3. Nutritional factors
1. Sociodemographic factors
 Large family size
 Lack of child spacing
 Neglect of girl child
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12. 2. Environmental factors
 Low socio economic status
 Poverty and ignorance
 Illiteracy
 Poor sanitation and low standard of living
 Parental attitudes and rearing practices
 Cultural practices
 Natural or man made disasters
 Chronic diseases
 Inadequate medical facilities
3.Nutritional factors
 Early weaning from breast or late weaning
 Diet during illness-increased intestinal loss, anorexia
 Maternal malnutrition
 Low birth weight
 Recurrent infections and infestations, diarrhea, worm infestations
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13. Marasmus
 Also known as athrepsia
 Marasmus is a form of severe PEM which occur as result
from energy deficiency that may occur at any age,
particularly in early infancy and is characterized by:
 Severe wasting (body weight is less than 60% of the expected), the
body utilizes all fat stores before using muscles.
 Loss of subcutaneous fat.
 Gross muscle wasting.
 Absence of edema.
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14. Causes
 Inadequate diet
 Faulty eating habits
 Anomalies such as cleft lip and cleft palate which prevents
intake of food
 Conditions such as anorexia, vomiting and diarrhea
 Allergy to certain foods
 Disturbed mother and child relationships
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15. Kwashiorkor
 Insufficient protein consumption.
 The word kwashiorkor describes the malnourished
child, the result of the ill-health which develops
when an infant is weaned from breast-feeding when
a sibling is born and monopolizes breast feeding.
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16.  Causes
 Social and Economic
 Poverty
 Ignorance
 Inadequate weaning practices
 Child abuse
 Cultural and social practices
 Vegetarian diet
 Low fat diet
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17. Clinical Features
 Kwashiorkor – meaning red haired boy
 Classical features – Lethargy, Edema, Growth failure
 The main clinical features are
 Skin changes, hair changes, facies, associated vitamin deficiency,
anemia
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18. I. Skin changes
1. Dry scaly skin: mosaic pattern appearing on trunk and limbs
2. Thin, shiny, stretched over edematous limbs.
3. Skin changes more commonly seen in extremities.
4. Starts with erythematous rashes –> hyper pigmentation ->
desquamate -> hyper pigmented patches.
5. This alternative hypo/hyper pigmented patches gives an
appearance of flaky paint dermatosis
6. On the pressure sites, jet black patches appear which then
exfoliate leaving the sub adjacent zone leading to crazy
pavement dermatosis
Contn..9/25/202018Anju George, SGCON, Parumala

19. 9/25/202019Anju George, SGCON, Parumala

20. 7. Deep fissures are seen on elbows, knees ,groin and behind the
ears
8. Multiple punctuate pinkish areas develop over extremities due to
perifollicular hemorrhage
9. Angular stomatitis due to potassium and riboflavin deficiency
10. Gangrenous dermatitis
11. Scabies and pyoderma
12. Skin lesions
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21. II. Hair changes
1. Thin, scanty, easily pluckable, lusterless, commonly
brownish/less black
2. Dyschromotrichia – light color of hair
3. Flag sign – Alternate band of hyper pigmented and hypo
pigmented hair
4. Hair loss can also affect eyelashes and eyebrows
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22. III. Facies
1. Cheeks look full due to hydration of cells of buccal fat and
surrounding tissues
2. Moon face appearance
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23. IV. Associated Vitamin deficiency
1. Angular stomatitis due to riboflavin deficiency
2. Rickets (Vitamin D)
3. Scurvy (Vitamin C)
V. Anemia
1. Normochromic normocytic anemia
2. Can be hypochromic macrocytic anemia due to iron
deficiency
3. Hepatosplenomegaly
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24.  Marasmus –
 The characteristic feature is loss of subcutaneous fat
 Grade I – loss of fat in axilla and groin
 Grade II – loss of fat in axilla, groin, abdomen and gluteal region
 Grade III – loss of fat in axilla, groin, abdomen, gluteal region,
chest and spine
 Grade IV – loss of fat in axilla, groin, abdomen, gluteal region,
chest, spine, buccal pads.
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25.  Old man appearance
 Cheeks and temples are hollow
 Skin is loose and wrinkled, loss of elasticity
 Marasmic purpura in terminal cases
 Distended abdomen, scaphoid with visible peristalsis
 Later when infection sets in
 Apathetic and less active
 Constipation
 Severe electrolyte imbalance  convulsions and various
neurological signs
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27. EVALUATION OF CHILD WITH PEM
 Assessment should include:-
 Socioeconomic status and sociocultural factors
 Severity
 Classify malnutrition
 Associated mineral and vitamin deficiency
 Complication
 Assess etiology
 Check development
 Ensure immunization
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28.  Lab investigations such as :-
 Hb and peripheral smear
 Sr. protein and albumin
 Blood sugar and electrolytes
 Other investigations to check evidence for infections – blood
counts, blood culture and sensitivity, urine and stool
examination, chest x-ray, mantoux test.
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29. Diagnosis
 Nutritional assessment – wt, ht, MAC, Head
circumference and chest circumference
 Skinfold thickness
 Biochemical measurements
 Serum albumin :<3g/100ml in kwashiorkor : normal or
slightly decreased in marasmus
 Hydroxyprolene/creatinine ratio is ess
 Plasma/amino acid ratio is low
 Elevated growth hormone and plasma cortisol levels
 Insulin levels are reduced
 Elevated TSH
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30. S = Sugar deficiency (Hypoglycemia)
H = Hypothermia
I = Infections
D = Deficiency of micronutrients
E
ELectrolyte abnormality
L
D
Dehydration
E
COMPLICATIONS
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31. MANAGEMENT
 Falls under 3 phases and is a ten step process
1. Acute/initial phase (1-7 days)
 It includes
 Assessment
 Management of life threatening complications step 1-5
 Nutritional management step 6-8
2.Recovery/Rehabilitation phase (2-6 weeks)
o It includes
 Nutritional management step 6-8
 Physical and emotional stimulation step 9
 Family education step 10
3. Follow up phase (6 weeks- 6 months)
o It includes
 Nutritional rehabilitation and continual care at home step 10
 Monitoring and home visits step 10
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32. A. General Principles of Routine Care
STEPS PHASE
Stabilization Rehabilitation
Days 1-2 Days 3-7 Weeks 2 – 6
1 Treat / Prevent Hypoglycemia
2 Treat / Prevent Hypothermia
3 Treat / Prevent Dehydration
4 Correct Electrolyte Imbalance
5 Treat / Prevent Infection
6 Correct micro-nutrient deficiencies
Iron supplementation
7 Start Cautious Feeding
8 Achieve Catch-up Growth
9 Provide Sensory Stimulation
and Emotional Support
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33. 1.Prevent & correct hypoglycaemia
Hypoglycemia - Is due to reduced glycogen stores
and increased utilization.
 Blood glucose < 54 mg/dl
 Child is able to take oral feeds – 50ml bolus of 10%
glucose solution orally.
 Child is unable to take oral feeds –treat with IV 2ml/kg of
25% D or 5 ml/kg of 10% D followed by 50 ml of 10%D as
IV infusion.
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34. 2.Prevent and correct hypothermia
 Hypothermia – is due to decreased heat
production, decreased BMR and increased heat loss
due to large surface area and loss of subcutaneous
fat.
 Axillary temperature < 35°C
 Clothe the child including extremities and head especially at
night
 Place a heater/ lamp nearby (avoid hot water bags )
 Provide woollen clothing
 Encourage kangaroo mother care
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35. 3. Treat / prevent dehydration
 As these children are more prone to fluid overload,
sodium restriction and fluid restriction to be done while
rehydrating.
 ReSoMal (Rehydrating Solution for Malnutrition) is given
 70-100 ml/kg over 8-12 hrs.
 5ml/kg every 30mts for first 2 hrs then 5-10ml/kg/hr for next 4-10 hrs.
 If there is diarrhoea, 50-100ml of ReSoMal for each
stool
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36. 4. Correct electrolyte imbalance
 Hypokalemia is a problem in both marasmus and
kwashiorkor which leads to respiratory muscle paralysis.
 If potassium <2 – administer 40meq/l of K⁺
 If potassium is between 2-2.5 – administer 30meq/l of K ⁺
 Hypomagnesaemia is another problem that can lead to
muscle weakness. The treatment is 50% MgSO4 at a dose of
0.3ml/kg x 7 days
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37. 5. Treat infections
 Infections caused by Gram negative organisms
are septicaemia, respiratory diseases, otitis
media, diarrheal diseases.
 Skin disorders are caused by gram positive
organism.
 IM/IV Ampicillin 50 mg/kg + gentamycin 7.5
mg/kg
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38. 6. Correct micronutrient deficiencies
 Provide multivitamin supplements
 Administer vitamin A single dose, orally if its not given in the last month
(dosage :- if age>1 year 2lac IU, 6- 12 months 1 lac IU, 0-5 months 50,000
IU)
 Folic acid - 1mg/day
 Zinc - 2mg/kg/day
 Copper - 0.3 mg/kg/day
 Iron - 3mg/kg/day
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39. 7. Start cautious feeding
 Initiate feeding as soon as possible as frequent small feeds (upto
12 meals/day)
 If unable to take orally- NG feeds
 The goal is to provide 80-100 kcal/kg/day
 Total fluid recommended is 130ml/kg/d, reduce to 100ml/kg/d if
there is severe, generalized edema
 Continue breast feeding
 Start with F-75 starter feeds every 2 hrly
 F-75 contains 75kCal/100ml with 1g protein/100ml
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40. 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/day
 Continue breast feeding on demand
 Make a gradual 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
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41. 9. Tender loving care & sensory stimulation
 A cheerful, stimulating environment
 Age appropriate structured play therapy for at least 15-
30 mins/day
 Age appropriate physical activity as soon as the child is
well enough
 Tender loving care
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42. 10. Prepare for follow up after recovery
 Total duration for recovery 6-8 wks
 Criteria for recovery- weight for length 90%
 Weekly follow ups for the first 2 months
 Once a month for the next two months
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