PROTEIN ENERGY MALNUTRITION AMONG

CHILDREN

Mrs. Sushma Oommen

RN,RM,MN

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 metabolic processes.

Protein: deficit in amino acids needed for cell structure, function

Energy: calories (or joules) derived from macronutrients: protein, carbohydrate and fat

Micronutrients: vitamin A, B-complex, iron, zinc, calcium, others

MALNUTRION

Obesity under-nutrition

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)•Xenobiotics(aflatoxins)

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% & underweight 20-40%.

All children with PEM have micronutrient deficiency.

CLASSIFICATION

A. CLINICAL ( WELLCOME ) Parameter: weight for age + oedema Reference tandard (50th percentile) Grades:

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)

WHO chart Grades:

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

KWASHIORKOR

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

weaning.

Dietary Factors

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. Theory says it is a result of liver insult with hypoproteinemia and oedema.

Food toxins like aflatoxins have been suggested as precipitating factors.

Kwashiorkor

CONSTANT FEATURES Edema Mental changes Growth retardation wasting

USUALLY PRESENT SIGNS Moon face Hair Changes Skin

depigmentation Anemia

l OCCASIONALLY PRESENT SIGNS HEPATOMEGALY FLAKY PAINT DERMATITIS CARDIOMYOPATHY & FAILURE DEHYDRATION (Diarrhea & Vomiting) SIGNS OF VITAMIN DEFICIENCIES SIGNS OF INFECTIONS

Marasmus

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 muscles

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 also contributory

Too little breast milk or complementary foods •< 2 yrs of age

Marasmus

Severely wasted (emaciated) & stunted Very low WAZ “Balanced”starvation “Old Man”face, wrinkled appearance, sparse hair No edema, fatty liver, skin changes Alert bur Miserable Hungry Diarrhea and dehydration

CLINICAL FEATURES

Diagnostic evaluation History- including detailed dietary history. physical exam Anthropometric measurements.

Weight •Length/height •Mid upper arm circumference MUAC) •Chest circumference •Head circumference •Skinfoldmeasurements: Tricipitaland Subscapular Anthropometric Measurements of Nutritional Status

Laboratory test Full blood counts Blood glucose profile Septic screening Stool & urine for parasites & germs Electrolytes, Ca, Ph & ALP, serum proteins Mantoux test HIV testing & malabsorption

Complications of P.E.M

Hypoglycemia Hypothermia Hypokalemia Hyponatremia Heart failure Dehydration & shock Infections (bacterial, viral & thrush)

MANAGEMENT OF P.E.M. S- Correction of Sugar deficiency H-Prevention of Hypothermia I-Treatment of Infections (bacterial, viral & thrush) Correction of water &

electrolyte imbalance EL- Correction of electrolyte imbalance De- Correction of Dehydration D- To treat Deficiency conditions (eg, anemia, xerophthalmia)

OTHER

Dietary support: 3-4 g protein & 200 Cal /kg body wt/day + vitamins & minerals

Counsel parents & plan future care including immunization & diet supplements

Dietary support 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

Breast milk; 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

•Micronutrient supplements: •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 2nd day-6-8 3rd day onwards-7

What’s BEST

B-BEGIN FEEDING

E-ENERGY DENSE FEEDING

S-STIMULATION OF EMOTIONAL ,SENSORIMOTOR DEVELOPMENT

T-TRANSFER TO HOME BASED DIET

•NURSING CARE

Nursing Assessment 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 age.

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 child.

If possible, observe the parent feeding the child. Assess child's overall tone, sucking pattern, oral sensitivity (gag reflex), lip and tongue function, and swallowing ability.

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

Nursing Diagnoses

Imbalanced Nutrition: Less Than Body Requirements related to inadequate intake

Delayed Growth and Development related to malnutrition

Impaired Parenting related to inability to meet the needs of the malnourished child

Nursing Interventions

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 manner.

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.

Nursing Interventions 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 and Development

Obtain accurate weight at every visit or every day if hospitalized. Assess child's growth by using age- and gender-appropriate

growth charts. 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 experiences.

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 Considerations

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 structure.

Make referrals to social work and occupational or physical therapy as needed.

Expected Outcomes

Increases weight steadily Attains developmental milestones at

appropriate age Parents participating in child's care, using

appropriate feeding technique

Family Education and Health Maintenance

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 for growth. 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 immunizations.

Take care of me,,,,,,,,,,,,,,,,,,,,,,,,,

THANK YOU