pem lecture revised
TRANSCRIPT
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PROTEIN ENERGY MALNUTRITION
Dr.Yulchair R,SpA
SMF Anak RSI Pd Kopi
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PE
Nutrition Problems in Indonesia
t Protein Energy Malnutrition (PEM)
t Iron Deficiency Anaemiat Iodine Deficiency (=GAKI)t Zinc Deficiencyt Vitamin A Deficiencyt Obesity
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Theoretical framework of Nutrition Problems.
Nutrition problems
Food intake Infect Disease directcauses
Food availability Mother & child Health indirectin household caring service causes
POOR FAMILY & EDUCATION, main
FOOD STUFF & JOB OPPORTUNITY problem
ECONOMIC & POLITIC CRISIS core
problem
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Three level of determinants lead to nutrition status
Underlying :- Household food security
- Access to PHC
- Community of awareness
& care for children & women
Basic :- Socio-economic conditions
(poverty & crisis)
- Political factors
- Traditional practices (infant
feeding)
- Environment & sanitation
Intervention programs
Supply side :- access : health care facilities
- supplementation of food &
micronutrients.
- immunization
- quality: provider skill- information system: coverage
of supplement., fortification,
surveillance, etc.
Demand side:- empowerment
- family awareness of nutrition
- subsidies / health insurance
Health &
Nutrition
Status ofChildren
Immediate :Inadequacy of dietary intake
manifested:
- PEM
- Micronutr.deficiency
- Diarrhea & worm disease
- ARI
Supply & coverage immuniz
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PE
The problems of PEM :
tthe main health problemt primadonna of nutritional diseases
t influencing morbidity & mortality amongunderfives
t early detection and proper management are verimportant
t severe malnutrition should be hospitalized
t poor quality of life
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Protein Energy Malnutrition
tdisease / clinical conditions caused by energy
& protein deficiency, usually accompanied by
deficiency of other nutrients.
tPrimary : - nutr.intake
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OUTPUT:Infection
Chronic diarrhea/MalabsorptionHypermetabolismetc.
INPUT:
InfectionPovertyOrganic dis.etc.
Energy balance: negative
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Protein Energy Malnutrition
T Nutr.status = spectrum :
Wt/Ht
undernutrition normal overnutrition70 80 90 110 120 %
-3SD -2SD +2SD +3SD
PEM severemoderatemild overweightobese
-Kwashiorkor mild-Marasmus moderate-M-K severe
super
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PEM.
Classification :
1. GOMEZ (195..) : W/A
2. MacLarren (196..) : Clinical + laboratory
3. The Wellcome : Clinica+anthropometricTrust Party (1970) (W/A)
4. Waterlow (1973) : W/H5. WHO (1999) : Clinical+anthropometric
(Z-score)
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MEP.
Classification (WHO,1999) :Moderate PEM Severe PEM
Symmetrical oedema -- +(oedematousmalnutrition)
W/H -3< Z-score
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PEM.
DIAGNOSIS :
1. Anamnesis
2. Physical examination
3. others : - laboratory
- anthropometry- dietary analysis
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PEM.
Checklist : anamnesis Usual diet before current episode of
illness
Breastfeeding history Food & fluids taken in past few days
Recent sunken eyes
Duration & freq. of vomiting / diarrhoea,
appearance of vomit / diarrhoeal stools
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PEM.
Checklist : anamnesis Time when urine was last passed Any deaths of siblings
Birth weight?
Milestones reached (sitting up, standing,etc)
Contact with people with measles or
tuberculosis Immunizations
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PEM.
Checklist: Physical examination
Weight, Length/Height
Signs of circulatory collapse : cold hands &feet, weak pulse, consciousness
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Anaemia
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PEM.
Checklist: physical examination
Thirst, dryness of lips & mouth
ENT : evidence of infection?
Abdominal distension, bowel sounds? Enlargement or tenderness of liver, jaundice
Skin : infection, purpura, fat tissue?
Oedema, muscles atrophy Apperance of faeces
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Severe PEM : Kwashiorkorhair
face
Oedema
Puffy
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Severe PEM : Kwashiorkor
Crazy pavementdermatosis
oedemaHepatomegaly
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Severe PEM : Marasmus
face
hair
Ribs
Muscles atrophySC fat
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Severe PEM : Marasmus + KP
lymphadenopathy
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Severe PEM : Marasmus + KP
Caverne
6 weeks after th/Destroyed lung
PEM
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PEM.
Laboratory tests: Teststhat may be useful:k Blood glucose : < 54 mg/dl = hypoglycaemia
k Blood smear : parasit malaria
k Hb or Ht : < 4 g/dl or < 12% = severe anaemia
kUrine exam/culture: bacteria + or > 10 lekosit/HPF
infectionkFaeces : blood + disentri
Giardia + / parasit lain infeksi
kX-ray : - thorax : l Pneumonial Heart failure
- bone : rickets, fracture
k Tes tuberkulin : often negative
Tests that are little ot no value: serum protein, HIV,electrol tes
PEM
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PEM.
MANAGEMENT :
l Mild-moderate PEM :- no specific clinical signs : thin, hypotrophic
- not necessary to hospitalize- looking for the probable causes
- nutr. education & supplementation
l Severe PEM : should be hospitalized
PEM
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PEM.
Other criteria :
Very low BW :- W/H < 70%- W/A < 60%(- W/A > 60% + oedema)
+ clinical signs & symptoms :- oedema (M-K)- severe dehydration- persistent diarrhoea and / or vomiting- severe pallor, hypothermia, shock
- signs of systemic/local infection, URI- severe anaemia ( Hb < 5 g/dl)- jaundice- anorexia
- < 1 yr of age
PEM
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PEM.
Signs & symptoms of dehydration :
- history of diarrhoea or no/diminished intake
- weak, apathetic unconscious
- weak to absent radial pulse- thirst, dry mouth and absent of tears
- sunken eyes and fontanel
- hypothermia- cold hands and feet
- Urine flow
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Dehydration
Sunken eyes
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Dehydration
Turgor :
PEM
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PEM.
5 ASPECTS in the MANAGEMENT of Severe PEM :
A. 10 main steps
B. Treatment of underlying diseases
C. Failure to respond to treatment
D. Discharge before recover
E. Emergency
PEM
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PEM.
A : 10 main steps
No Interven- StabilizationTransition Rehabilitation Follow-up
tion d.1-2 d.3-7 wk-2 wk 3-6 wk 7-261. Treat/preventhypoglycaemia
2. Treat/preventhypothermia
3. Treat/preventdehydration4. Correct electr.
imbalance5. Treat infection6. Correct micro- without Fe + Fe
nutrients defic.7. Begin feeding8. Increase feeding9. Stimulation10. Prepare for
discharge
PEM
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PEM.
B. Treatment of underlying diseases / infection :
Bacterial infection :- no apparent signs of infection/no complication:
cotrimoxazole ( 5 mg TMP/kg, 2x/d, 5 days )
- signs of infection / complications / sepsis :- ampicilline 50 mg/kg/6 hrs, IM/IV,
for 2 days oral (ampi / amoxy)
- gentamycin 7.5 mg/kg, IM/IV, 7 days- KP + anti-TB drugs
Viral infection :no specific th/
- all PEM should receive measles vaccine
PEM
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PEM.
C. Failure to respond to treatment :
Frequent causes of failure to respond :
a. Problems with the treatment facility :
- poor environment for malnourished children
- insufficient or inadequately trained staff
- inaccurate weighing machine- food prepared or given incorrectly
PEM
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PEM.
C. Failure to respond to treatment :
Frequent causes of failure to respond :
b. Problems of individual children :
- insufficient food given- vitamin-mineral deficiency
- malabsorption of nutrients
- rumination- infections
- serious underlying disease
PEM
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PEM.
C. Failure to respond to treatment :
Criteria Time of admissionPrimary failure to respond:
- failure to regain appetite Day 4
- Failure to start to lose oedema Day 4- Oedema still present Day 10
- Failure to gain at least 5 g/kg/d Day 10
Secondary failure to respond :
- failure to gain at least 5 g/kg/d During rehabilitation
for 3 consecutive days
PEM
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PEM.
C. Failure to respond to treatment :
1. Death= within first 24 hrs :
- hypoglicaemia- hypothermia- dehydration- sepsis
= within 24 72 hrs :- volume of formula >>- caloric density >>
PEM
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PEM.
C. Failure to respond to treatment :
2. Inadequate gaining weight :- infection- diet
- psychologic
Weight gain :
= satisfactory: > 10 g/kg/d good == sufficient : 5-10 g/kg/d > 50 g/kg/wk
= poor : < 5 g/kg/d or < 50 g/kg/wk
PEM
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PEM.
D. Discharge before fully recover:
= Dietary advice :- high protein and calorie
- frequent feeding ( 5x/d )- finish all meals given- vit-min supplementation & electrolytes- continue BF
= frequent controle ( 1x/wk )
= Immunization
5 Em n :
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5. Emergency :
5.1. Shock :
N2 or RLG5%15 ml/kg, 1 hr
Repeat 1 hr more
Resomal 10 ml/kg, 10 hrs
Special formula
sepsis
Maintenance, 4 ml/kg/hrFresh blood, 10 ml/kg
Improvement+
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5 E
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5. Emergency :
5.2. Severe anaemia.
Hb ?
Hb < 4 g/dl Hb 4-6 g/dl
Resp.distress/heart failure?
Fresh blood 10 ml/kg*PRC 10 ml/kg* Observation
* : give furosemid 1 mg/kg, iv, before transfusion
+
_
PEM
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PEM.
Prepare for discharge :
- W/H : - 1 SD or severe PEM moderate/mild
- Education for mother :- hygiene & sanitation- healthy foods- immunization- stimulation
- regular controle
- to continue the th/ of chronic diseases
- to completing immunization
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On admission :Sh, girl, 2 yrs,W : 3.875 g
H : 67 cmW/H : < -4SD
2 weeks later :W : 4.750 gH : 67.4 cm
W/H : < -3 SD
4 weeks later :W : 5.310 g
H : 67.7 cmW/H : + -3 SD
5 weeks later :W : 6.280 g
H : 67.8 cmW/H : - 2 SD
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7 yrs,10 kg
Recovery : 16 kg