Mrs. Sushma Oommen
Let’s Review nutrition
Nutrients are substances that are crucial
for human life, growth & well-being.
Macronutrients (carbohydrates, lipids,
proteins & water) are needed for energy
and cell multiplication & repair.
Micronutrients are trace elements &
vitamins, which are essential for
Protein: deficit in amino acids needed for
cell structure, function
Energy: calories (or joules) derived from
macronutrients: protein, carbohydrate
Micronutrients: vitamin A, B-complex,
iron, zinc, calcium, others
2 ends of the spectrum of malnutrition
•Chronic, severely low energy and protein intake
•Exclusive breast feeding for too long
•Dilution of formula
•Unclean/non-nutritious, complementary foods of
low energy and micronutrient density
•Infection (eg, measles, diarrhea, others)
Causes of Severe Childhood PEM
PROTEIN ENERGY MALNUTRITION
The term protein energy malnutrition has
been adopted by WHO in 1976.
Highly prevalent in developing countries
among <5 children; severe forms 1-10% &
All children with PEM have micronutrient
A. CLINICAL ( WELLCOME )
Parameter: weight for age + oedema
Reference tandard (50th percentile)
80-60 % without oedema is under weight
80-60% with oedema is Kwashiorkor
< 60 % with oedema is Marasmic-Kwashshiorkar
< 60 % without oedema is Marasmus
B. GOMEZ CLASSIFICATION
Parameter: weight for age
Reference standard (50th percentile)
I (Mild) : 90-70
II (Moderate): 70-60
III (Severe) : < 60
•Kwashiorkor: disease when child is displaced from
breast (Cicely Williams, 1935, Gold Coast, W Africa)
•Marasmus: Extreme wasting
•Marasmic-Kwashiorkor: Kwashiorkor Marasmus
Different manifestations of similar nutritional deficits of
energy, protein, micronutrients; unique causal roles for
aflatoxins& oxidative stress in Kwashiorkor
Severe Childhood PEM-
•Underweight :Weight for age < -2SD of the median age-sex
specific weight of the NCHS/WHO reference
•Stunting: Height for age < -2SD of the median age-sex specific
height of the NCHS/WHO reference
•Wasting: Weight for height <-2SD of the median weight at a
given height of the NCHS/WHO reference
Cecilly Williams, a British nurse, had
introduced the word Kwashiorkor to the
medical literature in 1933. The word is
taken from the Ga language in Ghana &
used to describe the sickness of weaning.
CAUSES OF KWASHIORKAR
maximal incidence is in the 2nd yr of life following abrupt
Contributing factors - Infective, psycho-socical, and cultural
factors are also operative.
lack of physiological adaptation to unbalanced deficiency
where the body utilized proteins and conserve S/C fat.
it is a result of liver insult with hypoproteinemia and oedema.
Food toxins like aflatoxins have been suggested as
USUALLY PRESENT SIGNS
l OCCASIONALLY PRESENT SIGNS
FLAKY PAINT DERMATITIS
CARDIOMYOPATHY & FAILURE
DEHYDRATION (Diarrhea &
SIGNS OF VITAMIN DEFICIENCIES
SIGNS OF INFECTIONS
The term marasmus is derived from the Greek
marasmos, which means wasting.
Caused due to inadequate intake of protein and calories
and is characterized by emaciation.
Marasmus is the end result of starvation where both
proteins and calories are deficient,
an adaptive response to starvation, whereas kwashiorkor
represents a maladaptive response to starvation
In Marasmus the body utilizes all fat stores before using
CAUSES OF MARASMUS
Seen most commonly in the first year of
life due to lack of breast feeding and the
use of dilute animal milk.
Poverty or famine and diarrhoea are the
usual precipitating factors
Ignorance & poor maternal nutrition are
Too little breast milk or complementary
foods •< 2 yrs of age
MANAGEMENT OF P.E.M.
S- Correction of Sugar deficiency
H-Prevention of Hypothermia
I-Treatment of Infections (bacterial, viral & thrush) Correction of water &
EL- Correction of electrolyte imbalance
De- Correction of Dehydration
D- To treat Deficiency conditions (eg, anemia, xerophthalmia)
Dietary support: 3-4 g protein & 200 Cal /kg body wt/day + vitamins &
Counsel parents & plan future care including immunization & diet
Energy Dense Feeding-Establish a daily, graduated intake of
•4-5 g protein per kg (actual) body wt
•200 kcal of energy per kg body wt
Liquid feeds of skimmed milk, oil, sugar; soft
Cereal gruels with milk, oil, sugar soft
Soft ripe fruit, cooked vegetables
*Fortify with Oil, Ghee to make it energy dense
•To treat clinical conditions (eg, anemia, xerophthalmia)
•To prevent further deficiencies
Route-Oral or nasogastric in small amount, More frequent small feeds better
than large meals
Quantum-according to stomach volume,3% of child’s body weight
No, of Feed-Ist day-12
E-ENERGY DENSE FEEDING
S-STIMULATION OF EMOTIONAL
T-TRANSFER TO HOME BASED DIET
Obtain accurate anthropometric measurements.
Weights on children younger than age 3 should be done
unclothed in a supine position using a calibrated beam
scale. Children older than age 3 should be done standing
on a standard scale wearing same clothing each time.
Effort should be made to use the same scale each time.
Heights should be recumbent up to age 2. All children
should be measured without shoes
Head circumference is measured each visit until age 2 with a nonstretchable
tape placed firmly from maximal occipital prominence to just above the eyebrow.
All measurements need to be corrected for prematurity up to the second
birthday by subtracting the number of weeks premature from the chronological
Measurements should be plotted on growth chart using a straight edge or plot
grid. Birth measurements should be obtained and entered for comparison.
Obtain nutritional history regarding eating patterns;.
Observe parent-child interactions, such as sensitivity to child's needs, eye-to-
eye contact, if and how the infant is held, and how the parent speaks to the
If possible, observe the parent feeding the child. Assess child's overall tone,
sucking pattern, oral sensitivity (gag reflex), lip and tongue function, and
Assess neurologic and cardiovascular status for alertness, attentiveness,
developmental delays, cardiac arrhythmias or murmurs.
Assess skin, hair, and musculoskeletal system
Assess developmental status using a Denver II Developmental tool as indicated
Imbalanced Nutrition: Less Than Body
Requirements related to inadequate intake
Delayed Growth and Development related to
Impaired Parenting related to inability to meet
the needs of the malnourished child
Promoting Adequate Nutrition
If hospitalized, provide a primary core of staff to feed the child.
Ask the parents to do so when present, in a nonthreatening
Develop individualized teaching plan to instruct parents of child's
dietary needs. Specify type of diet, essential nutrients, serving
sizes, and method of preparation.
Provide a quiet, nonstimulating environment for eating.
Demonstrate proper feeding techniques including details on how
to hold and how long to feed the child.
Administer multivitamin supplements as prescribed.
Encourage nutritious, high-calorie, and fortified fluids to increase
nutrient density. For infants, use 24 to 30 cal/oz rather than 20
cal/oz. For older children, suggest fruit smoothies using whole
milk and ice cream.
Refeed the malnourished child with caution, monitoring
electrolytes, calcium, magnesium, and phosphorous daily or
more frequently if abnormal.
Gradually increase nutrients, and use small, frequent feedings
with adequate fluids to ensure hydration.
Monitor intake and output.
Maintain high-nutrient diet until weight is appropriate for height
(usually age 4 to 9 months).
Advise family that some nutritional intervention will be continued
until appropriate height for age is reached.
Promoting Adequate Growth
Obtain accurate weight at every visit or every day if hospitalized.
Assess child's growth by using age- and gender-appropriate
Assess child's development using developmental screening
tests, such as the Denver II
Observe interactions between parents and child and among
family members, including eye contact, communications
patterns, coping ability.
Provide the infant with visual and auditory stimulation by
exposing to bright colors, shapes, and music. Provide the older
child with age-appropriate stimulation, such as books, games,
and toys. Place the infant prone, while awake, on the floor to
encourage trunk control.
Encourage periods of scheduled rest and sleep.
Promoting Effective Parenting
Teach the parents (especially the mother) normal parenting skills by
demonstrating proper holding, stroking, feeding, and communication
using age-appropriate words and gestures.
If hospitalized, encourage and facilitate the parents to spend as much
time as possible with the child.
Educate the parents to recognize and respond to the child's distress
and hunger calls.
Help the parents to develop organizational skills ”write down daily
schedule with meal times, time for shopping, and so forth.
Refer for counseling, if necessary, to help parents overcome feelings of
mistrust or neglect resulting from adverse personal childhood
Refer to social services to help resolve any social and financial
difficulties that might interfere with providing a nurturing environment.
Monitor parents' progress and provide positive reinforcement.
Community and Home Care
Make regular home visits to:
Observe for continued parent-child interaction.
Encourage continued developmentally appropriate play.
Monitor feeding status and assess intake amount.
Determine frequency of voiding and stooling.
Assess child's weight, height, and head circumference.
Monitor vital signs, and watch for signs of dehydration.
Auscultate bowel sounds.
Assess muscle tone and vigor of activity.
Assess family dynamics and use of support systems.
Inform parents of community resources,
Make sure that daycare providers can meet child's special needs in
terms of diet, feeding, and developmentally appropriate play. Daycare
may be beneficial in the presence of family dysfunction by providing
Make referrals to social work and occupational or physical therapy as
Increases weight steadily
Attains developmental milestones at
Parents participating in child's care, using
appropriate feeding technique
Family Education and Health
Reinforce the need for a quiet, nonthreatening, nurturing environment.
Encourage the parents to be consistent with feedings. Although forced
feeding is avoided, strict adherence to appropriate feeding is essential
Advise the parents to introduce new foods slowly and follow the child's
rhythm of feeding.
Review the importance of providing a routine rest schedule in an
environment that is conducive to sleep.
Review development, stressing need for visual, auditory, and tactile
stimulation and age-appropriate toys for continued development.
Reinforce the need for follow-up care, well-child visits, and
Take care of me,,,,,,,,,,,,,,,,,,,,,,,,,