pem

PROTEIN ENERGY MALNUTRITION

Assessment , Clinical features, Adaptation & Management

Dr Bedangshu SaikiaRegistrar, Pediatrics and Neonatology

St Stephens Hospital, New Delhi

11/22/14 1Bedangshu

DEFINITION

A range of pathological conditions arising from

coincident lack in varying proportions of protein and calories occurring most frequently in infants and

young children and commonly associated with infections.

WHO 197311/22/14 2Bedangshu

THE MAGNITUDE OF PROBLEM

In India, nearly 65% i.e. nearly 80 million children under five years of age suffer from varying degrees of malnutrition

Nearly 30% of humanity is suffering from some form of malnaurishment

The World Health Organization estimates that by the year 2015, the prevalence of malnutrition will have decreased to 17.6% globally, with 113.4 million children younger than 5 years affected as measured by low weight for age. The overwhelming majority of these children, 112.8 million, will live in developing countries with 70% of these children in Asia, particularly the south central region, and 26% in Africa. An additional 165 million (29.0%) children will have

stunted length/height secondary to poor nutrition.

___________________________________________________________________________

Distribution of under 5 deaths in developing nations -1995

Assessment Dietary factors C/F of malnutrition Anthropometric measurements Biochemical parameters Morphological parameters Radiological parameters Epidemiological data 11/22/14 8Bedangshu

Anthropometric assessment Weight [WHO Growth Charts] Height/ Length [WHO Growth Charts] Wt for ht: Act Wt/Expected wt for ht × 100 Ht for age: Act Ht/Exp ht for actual age ×100 Midarm circumference (MAC) Head circumference Chest circumference Skin Fold Thickness- Herpenden Calipers Midparental height Upper segment-lower segment ratio11/22/14 9Bedangshu

Anthropometry :Age independent indicators Bangle test- inner diameter of 4 cms Shakir’s tape- green, yellow & red zones Quacker arm circumference stick- 2 sets of

markings- for Ht & MAC Modified Quac Stick Nabarrow’s thinness chart: graphic

representation of W f H – Save the Children Fund MAC/HC (Kanawati’s) -

Mild - 0.28 - 0.314 Moderate - 0.25-0.279 Severe - <0.249

11/22/14 10Bedangshu

Anthropometry:Age independent indicators HC/CC : >1-normal in >9mths age Rao’s W(kg)/H2(cm) :Normal - >0.0015

Severe - <0.0013 Ponderal index [W/H³]: Normal - >2.5

Severe PEM - <2 Dughdale W/H 1.6: Normal – >0.79

Malnutr it ion - <0.79 BMI (kg/m2):Normal 18.5-25

Overweight >25 Obese >30 Underweight <13

Quetlet Index: W(kg)/ H(cm)2 X 100 : Normal >0.15 Mid arm muscle circumference: MAC-(3.14xSFT) cms


Classification:

Gomez’s (wt/age) Wellcome Trust (wt/age)

Nut Status % of exp (Harvard)

Normal >90

1st deg PEM 75-90

2nd deg PEM 60-75

3rd deg PEM <60

% of exp (Boston)

Edema

Type of PEM

60-80 + Kwasi

60-80 - Underwt

<60 - Maras

<60 + MarasKwasi


Classification:

Ht for age (% of exp)

Waterlow’s McLaren’s

Normal >95 >93

1st deg stunting/ short

90-95 80-93

2nd deg stunting 85-90

3rd deg stunting/ dwarf

<85 <80


Classification:

Wt for Ht (% of exp)

Waterlow’s McLaren’s

Normal >90 >90

1st deg wasting 80-90 85-90

2nd deg wasting 70-80 75-85

3rd deg wasting <70 <75


Classification: IAP Classification:

Nutrit ional Status Wt for Age (% of exp)Normal >80Gr I PEM 71-80Gr II PEM 61-70Gr III PEM 51-60Gr IV PEM <50

Alphabet K is post fixed in presence of edema11/22/14 15Bedangshu

WHO Classification

Moderate undernutrition

Severe undernutrition

Symmetrical edema

No Yes

Weight for height(measure of wasting

70-79% of expected wasting

<70% of expected severe wasting

Height for age (measure of stunting)

85-89% of expected stunting

<85% of expected severe stunting


Clinical Features:Organ Signs1. Hair Lustureless, thin, sparse, straight, depigmented,

Flag Sign, easily pluckable2. Face Pigmentation, moon facies

3. Eyes Pallor, bitot’s spot, conjunctival & corneal xerosis, keratomalacia

4. Lips Angular stomatitis, cheilosis

5. Tongue Oedema, scarlet raw tongue, atrophic papillae

6. Teeth & gums Mottled enamel, spongy & bleeding gums

7. Glands Thyroid & parotid enlargment


Clinical Features:Organ Signs8. Skin Xerosis, hypo/ hyperpigmentation, petechiae, Flaky

paint dermatosis, scrotal & vulval dermatosis9. Nails Koilonychia

10. Subcutaneous Tissue Edeme, reduced subcut tissue

11. Musculoskeletal System

Mm wasting, craniotabes, frontal bossing, epiphyseal enlargement, beading of ribs, wide open AF, knock knee/bow legs, local/diffuse skeletal deformities, musculoskeletal haemorrhages

12. GIT Hepatomegaly

13. Nervous System Psychomotor changes, confusion, sensory loss, motor weakness, loss of jerks, tremors

14. CVS Cardiomegaly/ Microcardia18

SPECTRUM OF PEM Invisible PEM: Toddlers frequent desire to

breast feed; monitor nutritional status; use growth chart

Underweight: 60-80% weight for age expected

Nutrit ional dwarfing: prolonged PEM with evidence of stunting, no wasting-bonsai

Prekwashiorkor: no edema; features of kwashiorkor

Marasmic kwashiorkor11/22/14 22Bedangshu

MARASMUS Gross wasting of muscles and subcutaneous

tissues resulting in emaciation and old man appearance

Marked stunting No edema Alert with voracious appetite Grades: as per progression of wasting

Gr I: axilla & groin Gr II: Gr I + thighs & buttocks Gr III: Gr II + chest & abdomen Gr IV: Gr III + buccal pad of fat


KWASHIORKOR 1st recognized by Prof Cicely Williams in

1933 denotes “deposed child” Apathetic,miserable,stunted,oedema,hepato

megaly, anemia, hair and skin changesGrd I- Pedal edemaGrd II- I + Facial edemaGrd III- II + paraspinal & chest edemaGrd IV- III + ascitis


Item Marasmus KwashiorkorAppearance Old man like, gen wasting Moon facies, oedema, wasted ULAge Infants 1-5 yrsPrevalence Common RareWt <60% 60-80%GR ++ +Edema Nil ++Apathy Nil/ mild ++Mood Usually alert IrritableAppetite Good Very poorHair changes Nil/ mild +Skin changes Nil/ mild +Fatty liver Absent/ mild ++Infections + ++Life threat + ++S/ protein, albumin Low Very lowCarrier protein Low Very lowAnabolism + Very lowCatabolism ++ +Response to Rx Good poor

Adaptation Chemical and hormonal mechanisms :

CortisolInsulinGrowth hormoneSomatomedinGlucagonThyroxin


Cortisol

27

Insulin


Growth hormone


Dysadaptation in kwashiorkor


↓insulin in kwashiorkor


Pathogenesis of edema


Laboratory tests CBC with peripheral blood smear RBS to r/o hypoglycemia Routine & culture of urine Stool examination CXR Mantoux test Serum protein, albumin Serum electrolytes LFT,RFT,CSF,HIV Test whenever indicated


Management: 10 steps Treat/Prevent

Hypoglycemia Treat/Prevent

Hypothermia Treat/Prevent

Dehydration Correct Electrolyte

Imbalance Treat/Prevent

Infection

Correct Micronutrient Defeciencies

Start Cautious Feeding Achieve Catch-up

Growth Provide Sensory

Stimulation & Emotional Support

Prepare for FU after Recovary


Day 1-2

Rx of complications

Day 3-7

Initiatefeeding

2-6 wks

Catch upGrowth &Rehab

6-8 wks

Discharge

8-36 wks

FU

Sugar defHypothermiaInfectionELectrolyteDEhydrationDef of micro nutrn

Begin feeding

Energy dense feeding

Stimulation

Transfer to home diet

Restore wt for ht

Prevent relapse

Sequential Approach for Mgmt of Severe PEM


Management: Hypoglycemia:

BS- <54mg/dL, in severe malnutrition Symptomatic or asymptomatic Triad of Hypothermia, Hypoglycemia &

Infection Conscious Child- 50 ml of 10% glc or sucrose soln

orally or NGT Symptomatic Child- 10% dex IV @ 5ml/kg or NGT Start Early Feeding with Starter F 75 Start Abt Monitor every 30 mins till BS becomes normal11/22/14 37Bedangshu

Management: Hypothermia:

All severely malnourished are at risk Rectal <35.5°C or Axillary <35°C Feed immediately/ Clothe/ Overhead warmer/ KMC/

Start Abt Check every 2 hrly till temp is 36.5°C, splly at

nightime Early feeding prevents hypothermia


Management: Dehydration:

Over diagnosed & overestimated in severely malnourished

IVF not to be used except in cases of shock ORS + 2L of water + 45ml of KCl soln + 50 gm of

sucrose (WHO) Low Osmolar ORS without further dilution can be

used safely ( IAP Task Force) 5 ml/kg every 30 mins for 1st 2 hrs →5-10 ml/kg/hr

for next 4-10 hrs Amt of fluid needed depends upon how much the

child wants, vol of stool loss, vomiting 11/22/14 39Bedangshu

Management: Dehydration:

Feeding with F 75 starter within 2-3 hrs of starting rehydration on alternate hrs with ORS

Monitor for progress of rehydration Be alert for overhydration Stop rehydration with ORS if 4 signs of hydration

are present ( less thirst, urine passing, tears, moist oral mucosa, eyes less sunken, faster skin pinch)

Continue feeding


Management: Severe dehydration with Shock:

H/o profuse watery diarrhoea & rapid improvement on IVF → shock due to severe dehydration

Severe malnutrition + severe dehydration without watery diarrhoea → septic shock

IV/ IO fluid challenge @ 15ml/kg/hr with RL-5%PD/ ½NS/ RL

If improvement after 1hr→ dehydration with shock→ Rpt RL @ 15ml/kg over 1 hr→ ORS @ 5-10ml/ kg/ hr, orally or NGT

If no improvement/ worsening→ septic shock→ ABT & others


Management: Electrolyte Imbalance:

Excess body Na, low K & Mg in severely malnourished

Supplemental K at 3-4 mmol/kg for 2 wks (Syp Potklor) K<2 mmol/L or <3.5mmol/L with ECG change → 0.3-

0.5mmol/kg/hr of KCl in IVF with monitoring Arrhythmia due to hypokalemia → 1mmol/kg/hr of KCl

in IVF till normal rhythm On day 1, give IM Inj of 50% MgSO4 (0.3ml/kg upto a

max of 2ml) →thereafter 0.4-0.6mmol/kg daily No added salt in diet11/22/14 42Bedangshu

Management: Infection:

Multiple infections are common S/S are few, often nonspecific Mostly Gram (-)ve bacteria (E.coli – predominant) LRTI, UTI- most common All severely malnourished children should be

assumed to have a serious infection on their arrival in hospital & treated with BSA (WHO)

Hypoglycemia, hypothermia- markers of severe infection


Management: Infection: choice of BSA

Ampicillin for 2 days followed by Amoxycillin for 5 daysand

Gentamicin or Amikacin for 7 days

If child fails to improve within 48hrs, Cefotaxim/ Ceftriaxone

Appropriate Abt/ Drugs for specific infections.Role of Metronidazole- doubtful/ depends upon clinician


Management: Infection:

Look for response If no improvement/ deterioration, search for

resistant bacterial pathogen, TB, HIV, unusual enteric pathogens

Prevent Hospital Acquired Infections Measles vaccination:

in >6 months & not immunized >9 months & vaccinated before 9 months of age


Management: Micronutrient Deficiencies:

All severely malnourished have vitamin & mineral deficiencies

Up to twice the RDA Vit. A on Day 1, Day 2 & Day 14/28 Daily

Multivitamin ( Vit A, C, D, E, B1, B2, B6, B12) Folic Acid- 5mg on Day 1, then 1mg/ day Zinc- 2 mg/kg/day Copper- 0.2-0.3mg/kg/day Iron- 3mg/kg/day, once child starts gaining wt, by wk 211/22/14 46Bedangshu

Management: Initiate re-feeding:

Diet should have, Osmolarity <350mosm/L Lactose not >2-3gm/kg/day Initial calories from protein- 5% Adequate bioavailability of micronutrients Low viscosity, easy to prepare, socially

acceptable Adequate storage, cooking, refrigeration


Management: Start cautious feeding Initially, Energy recommended-

100kcal/kg/day Protein recommended, 1-1.5gm/kg/day Fluid recommended, 130ml/kg/day Continue breast feeding


Management: Starter DietsContent (per 100ml)

F-75 Starter F-75 Starter (cereal based)

F-75 Starter (low lactose-cereal based)

Cows milk (ml) 30 (1/3rd katori)

30 (1/3rd katori)

25 (¼th katori)

Sugar (gm) 9 (1½ tsf) 6 (1 tsf) 3 (½ tsf)Cereal: (gm) powdered rice

- - - 2.5 (¾ tsf) 6 (2 tsf)

Veg oil (gm) 2 (½ tsf) 2.5 (½+ tsf) 3 (¾ tsf)Water (ml) 100 100 100Energy (kcal) 75 75 75Protein (gm) 0.9 1.1 1.2Lactose (gm) 1.2 1.2 1.011/22/14 49Bedangshu

Management: Starter Diets

Lactose free diets rarely needed

If there is lactose intolerance

Content (per 100 ml)

F 75 Starter ( lactose free)

Egg white (gm) 5 (2tsf)Glucose (gm) 3.5 (¾+ tsf)Powdered rice (gm)

7 (2+ tsf)

Veg oil (gm) 4 (1 tsf)Water (ml) 100Energy (kcal) 75Protein (gm) 1lactose 0


Management: Achieve Catch up growth:

Appetite returns in 2-3 days Decrease frequency, increase volume Each successive feed increased by 10 ml until

some is left uneaten Starter F 75 should be replaced with F 100 in

equal amount in 2 days Calorie intake, ↑ to 150-200 kcal/kg/day Protein intake, ↑ to 4-6 gm/kg/day Complementary foods should be added as soon

as possible 11/22/14 51Bedangshu

Management:Catch up GrowthContent (per 100ml)

F 100 F 100 (cereal based)

F 100 (low lactose)

F 100 (no lactose)

Milk (ml) 95 75 25Egg white (gm)

12 (2+ tsf) 20 (2+ tsf)

Sugar (gm) 5 (1 tsf) 2.5 (½ tsf) 4 (1tsf)Powdered rice (gm)

7 (2 tsf) 12 (~4 tsf) 12 (~4 tsf)

Veg oil (gm) 2 (½ tsf) 2 (½ tsf) 4 (1 tsf) 4 (1 tsf)Water (ml) 100 100 100 100Energy (kcal) 101 100 100 100Protein (gm) 2.9 2.9 2.9 3Lactose (g) 3.8 3 1 011/22/14 52Bedangshu

Management: Feeding pattern in Initial Days:

Days Frequency Vol/kg/feed Vol/kg/day

1-2 2 hrly 11 ml 130 ml

3-5 3 hrly 16 ml 130 ml

6- 4 hrly 22 ml 130 ml


Management: Provide sensory stimulation & emotional

support: Cheerful, stimulating environment Age appropriate Structured play therapy for

at least 15-30 mins a day Age appropriate Physical activity Tender loving care


Management: Prepare for FU after recovery:

Primary failure: Failure to regain appetite by day 4 Failure to start losing edema by day 4 Presence of edema on day 10 Failure to gain at least 5gm/kg/day by day 10

Secondry failure: Failure to gain at least 5gm/kg/day for 3

consecutive days


Management:

Good wt gain is >10gm/kg/day Indicates good response, CST

Moderate wt gain is 5-10gm/kg/day Check food intake, screen for infection

Poor wt gain is <5gm/kg/day Screen for inadequate feeding, sp nutrient

deficiencies, untreated infection, TB, HIV/AIDS, psychological problems 11/22/14 56Bedangshu

Management Criteria for discharge:

Absence of infection Eating at least 120-130cal/kg/day with adequate

micronutrients WFH is 90% of NCHS median Absence of edema Completed immunization appropriate for age Caretakers are sensitized to home care

Advice to caregiver: regular FU, booster immunizations, Vit A 6 monthly, frequent feeding with energy & nutrient dense food, structured play therapy11/22/14 57Bedangshu

ManagementDischarge Criteria Before Complete Recovery:

Child, *>12months *completed Abt *good appetite *good wt gain *completed 2 wks of

nutritional supplement

Mother/ Caregiver, *not employed *trained for feeding,play

therapy *has financial resources *easy reach of hosp *follow advice, visits

regularly

Follow up after: 1wk,2wk,1mth,3mth,6mthAim : To prevent relapse and assure continued physical, mental and emotional development


Causes of death Dehydration Dyselectrolytemia Hypothermia Hypoglycemia Anemia in CHF


Bad prognostic signs Hypoglycemia Hypothermia Dehydration Infection CHF

Hepatic failure Seizure Altered sensorium Severe dermatosis Bleeding diathesis


Undesirable phenomenon during rehabilitation CHF Nutritional recovery syndrome Neurological syndromes Pseudotumour cerebri Rickets Anemia


Malnutrition is often found to start in the womb and end in

the tomb


THANK YOU


pem

Health & Medicine

deg wasting70

years of age

deg pem60

deg wastingclassification

deg pemclassification

deg stunting85

actual age

young children