| ID | 372 |
|---|---|
| Name | PROTEIN-ENERGY MALNUTRITION |
| Cause | Starvation. It is the disease that develops when protein intake or energy intake, or both, chronically fail to meet the body's requirements for these nutrients |
| Signs Symptoms | Weight loss or poor weight gain, slowing of linear growth, fatigue, apathy at rest, and irritability when disturbed |
| Diagnosis | The principal differentiating features of PEM17 Marasmus Kwashiorkor A. Usual age 0-3 years 1-3 years B. Essential features 1. Edema None Lower legs (symmetrical), sometimes face or generalized.* 2. General wasting Gross loss of Sometimes hidden, subcutaneous fat, sometimes fat blubbery ‘skin & bone’ appearance* 3. Muscle wasting Obvious Sometimes hidden 4. Growth retardation Obvious Sometimes hidden 5. Mental changes Usually apathetic, Usually irritable, quiet moaning, also apathetic. C. Variable features 1. Appetite Usually good Usually poor 2. Diarrhea Often Often (past or present) (past or present) 3. Skin changes Seldom Often-diffuse depigmentation, occasional flaky paint dermatosis 4. Hair changes Seldom Often sparse, straight silky dyspigmentation grey or reddish D. Biochemistry/ Endocrine changes 1 . Serum albumin Usually normal Low* or low 2. Urinary- urea & Usually normal Low* creatinine or low 3. Anemia Uncommon Common* 4. Liver biopsy Normal or atrophic* Fatty changes* 5. Serum cortisol Markedly elevated Elevated S. growth hormone Normal Elevated Serum insulin Normal Low / normal T3, T4, TSH Decreased Decreased ‘These are the most characteristic or useful distinguishing features. Distribution of PEM According to Gomez: 1. Marasmus- 60% 2. Kwashiorkor- 10% 3. Marasmic Kwashiorkor- 30% |
| Investigations | Measurement of height, weight, and body mass index (BMI). Blood tests will typically show anaemia, low serum protein and albumin levels, and often liver function abnormalities |
| Management | Management of PEMr’s. Hn Treatment of mild to moderate PEM:17 1. Mild to moderate cases can be managed at their homes or in a local health centre. 2. Nutritional education should be given to the family and the community. 3. Locally available and affordable nutritious balanced diet should be given to the patient. 4. Treatment at home should be supervised and monitored- weekly visits to a nearby nutrition rehabilitation centre or OPD of a hospital should be advised. 5. Weight should be measured and plotted on growth chart. Weight gain is the yardstick of response to the nuritional rehabilitation. 6. In most cases of PEM infection or any other underlying cause may be present, which should be properly investigated and treated. Treatment of severe PEM:13-14-17 Indications of hospitalization: Children weighing less than 60 percent for age with any of the following conditions, such as- i. edema, ii. severe dehydration, iii. severe diarrhea, iv. hypothermia, v. shock, vi. systemic infection, vii. jaundice, viii. bleeding, should be admitted and treated in the hospital. Children with severe wasting or edematous under nutrition should also be admitted; those with severe stunting alone may be managed in the community. Framework for treatment of severe PEM:11 Activity Initial treatment Rehabilitation Follow-up days- 1-2 days 3-7 weeks 2-6 weeks 7-26 Treat or prevent hypoglycemia ——— > hypothermia ——— > dehydration ——— > Correct celtrolyte imbalance —————————————— > Treat infection ——————— > Correct micronutrient -without iron -with iron deficiencies ——— > Begin feeding ——— > Increase feeding to recover lost weight ——— > (catch up growth) Stimulate emotional and Senorial development ——— > Prepare for discharge ——— > Time frame for the management of child with severe undernutrition. A. Initial treatment: Life-threatening problems are identified & treated in a hospital, specific deficiencies are corrected, metabolic abnormalities are reversed and feeding is begun. 1. Treatment & prevention of hypoglycemia: Hypoglycemia (blood glucose <54mg/dl or <3mmol/l) may be caused by serious systemic infection or if feeding has been stopped for 4-6 hour. i. To prevent hypoglycemia feeding should be given 2-3 hourly over day and night. ii. If hypoglycemia is suspected, treatment should be given immediately without waiting for lab. diagnosis. If the patient is conscious and able to drink, give 50ml of 10% glucose or sucrose or F-75 diet (in absence of F-75 diet, full strength milk (20 k cal/oz) can be given) by mouth. If the child is losing consciousness, cannot be aroused or has convulsions, give 10% glucose, 5ml/kg i.v followed by 50ml of 10% glucose or sucrose by NG tube. If i.v glucose cannot be given immediately, give NG dose first. When child regains consciousness, give F-75 diet or glucose water (60gm/l). Continue frequent oral or NG feeding with F-75 diet to prevent recurrence, iii. All malnourished children with suspected hypoglycemia should also be treated with broad spectrum antibiotic for serious systemic infection. 2. Prevention of hypothermia: (Rectal temperature <35.5°C or underarm temperature <35°C). The child should not be kept near a window. The room temperature should be kept at 25-30°C. The child should be warmed by using kangaroo mother care by placing the child on the mother’s bare chest or abdomen (skin to skin) and covering both of them, or cloth the child well. During re-warming with lamp, rectal temperature should be monitored every 30 minutes for hyperthermia. All hypothermic children must also be treated for hypoglycemia and for serious systemic infection. 3. Correction of dehydration: Because severely malnourished children are deficient in potassium and have high levels of sodium, the ORS solution should contain less Na+ and more K+ than the standard WHO ORS. Magnesium, zinc and copper should be added to correct deficiencies. Rehydration solution for malnourished (Re-So-Mal) has been developed and available commercially. To restore normal hydration, Re-so-mal 70-l00ml/kg over 12 hours, starting 5ml/kg every 30 min. for 2 hours then 5-l0ml/kg/hour should be given orally or through NG tube. Reassess hourly and stop WHO ORS if the pulse and respiratory rate increases, jugular veins become engorged and there is increasing edema (puffy eyelids). Rehydration is completed when the child is no longer thirsty, urine is passed. For ongoing loses, children <2 years 50-100ml WHO ORS after each stool, while >2years should receive 100-200ml until the diarrhea stops. In some or severe dehydration 70-100ml/kg of WHO ORS can be given slowly over 12-24 hours. An NG tube should be used in all weak or exhausted children and in those who vomit, have fast breathing or painful stomatitis. The only indication for i.v infusion in a severely malnourished children is circulatory collapse. Solution used in order of preference are- half strength Darrow’s solution with 5% glucose, Ringers lactate solution with 5% glucose and 0.45% (half normal) saline with 5% glucose. Give 15ml/kg over 1 hour and monitor the child for signs of overhydration. Reassess the child after 1 hour. If improvement occurs (fall of pulse and respiratory rate), repeat i.v infusion 15ml/kg over another 1 hour and then switch to Re-So-Mal orally or by NG tube lOml/kg/hour for upto 10 hours. During rehydration, breast-feeding should not be interrupted and F-75 diet is given within 2-3 hours of starting rehydration therapy (early if child is alert) in alternate hours. Composition of ORS solution : Component Standard ORS (mmol/l) Re-So-Mal (mmol/l) Glucose 111 125 Sodium 90 45 Potassium 20 40 Chloride 80 70 Citrate 10 7 Magnesium - 3 Zinc - 0.3 Copper - 0.045 Osmolarity 311 300 Preparation of Re-So-Mal: It can be made by diluting 1 packet of WHO-ORS in 1 litre of water instead of ‘/2 litre and adding 25gm of sucrose and 20ml of mineral mix solution). 4. Treatment of septic shock: Every child with septic shock should immediately be given broad spectrum antibiotic (see below), to be kept warm and minimal handling. Measures are taken to prevent hypoglycemia. IV rehydration is done. If child doesn’t improve, blood transfusion (lOml/kg in 3 hours) is given. If signs of CCF are present, treat accordingly. 5. Treatment of infection: a. First line treatment: Children with no apparent signs of infection and no complication, cotrimoxazole is given orally. If complication is present combination of injection ampicillin plus gentamicin should be given, b. Second line treatment: If child fails to improve within 48 hours, injection chloramphenicol should be added. If specific infections are detected (dysentery, malaria, helminthiasis, candidiasis, otitis media) treatment should be given. Antitubercular drugs are given after diagnosis of tuberculosis. Two doses of measles vaccines should be given, one after admission and one before discharge from hospital. 6. Dietary treatment: To avoid overloading of intestine, liver and kideny frequent feeding with small amount of food is recommended through NG tube. Total energy requirement is 100 kcal/kg/day and fluid requirement is 100ml/kg/day. Feeding should be given round the clock, 2-3 hourly over day and night. Two formula diets are recommended, F-75 diet during the initial treatment and F-100 diet during the rehabilitation phase. In absence of these diets, full strength milk may be used with other food ad libitum. Energy density of feeds may be increased by adding sugar, glucose or soyabean oil; low lactose formula (Infant formula Lactose-free al 110, Sweet Baby SN etc.) may be given temporarily in lactose intolerance. Preparation of F-75 and F-100 diets: Amount Ingredient F-75 Formula F-100 Formula Dried skimmed milk 25g 80g Sugar 70g 50g Cereal flour 35g - Vetgetable oil 27g 60g Mineral mix 20ml 20ml Vitamin mix 140mg 140mg Water to make 1000ml 1000ml 7. Correction of vitamin & mineral deficiencies, very severe anemia, heart failure: a. In vitamin A deficiency: Give vitamin A supplementation as high potency capsule containing 2 lac units, or commercially available 50,000 units capsule. Above 1 year- 2 lac units 1 st & 2nd day & after 1 or 2 weeks, then on every six month for upto 6 years. Below 1 year age- 1 lac units-same regimen, as above. Folic acid 5mg orally on day-1 then Img daily. Multivitamin drops 0.6ml (10 drops)/day. Other vitamins- can be given, if signs of specific deficiency is present e.g vita-C in scurvy. b. In mineral deficiency: Mist, potassium chloride 5mmol/kg/day for 1-2 weeks (1 tsf = l0mmol); Inj. magnesium sulphate lOmg/kg/day for 2-3 weeks (1ml = l0mg); Syp. zinc sulphate l-2mg/kg/day for 2-3 weeks (5ml = l0mg). c. If Hb concentration <4gm/dl or packed cell volume <12%, lOml/kg packed cell should be transfused slowly over 3 hours, d. When heart failure is caused by fluid overload, stop fluid intake (oral & i.v) until the heart failure is improved. Frusemide injection Img/kg i.v should be given. Give digoxin 5mg/kg single dose i.v or orally, when diagnosis of heart failure is confirmed and plasma K+ level is normal. Diuretics should never be used in edema with severe malnutrition without CCF. 8. Dermatosis of Kwashiorkor: In diaper area, apply nystatin ointment or cream twice daily for 2 weeks and oral nystatin (1,00,000 i.u) 4 times daily. In other affected areas, application of zinc & castor oil ointment, petroleum jelly or paraffin gauze dressing helps to relieve pain & prevent infection. Bathing the affected area with 1% potassium permanganate solution for 10-15 minutes is quiet effective. Systemic antibiotic therapy may be required. B. Rehabilitation: In this intensive feeding is given, emotinal and physical stimulation are increased, mother is trained to continue care at home, making preparations for discharge. 1. Nutritional rehabilitation a. Calorie & diet: During rehabilitation phase most children require calory between 150-220 kcal/kg/day. F-100 diet is given every 4 hours, night and day and increasing the amount of diet at each feed by 10ml until the child refuses to finish the feed. F-100 diet should be continued until the child achieves- 1 SD of median of NCHS value for weight or height. For older children, mixed diet can be introduced 3 times daily and F-100 diet 3 times daily to increase the absorption of vitamins and minerals. b. Vitamins and minerals: Children with moderate or severe anemia, elemental iron 3mg/kg/day (maximum 60mg/day) in two divided doses should be given for 3 months. Other vitamins & minerals should be continued. c. Monitoring: Daily weight of the child is measured before meal and plotted, presence or absence of edema noted. Height or length is measured weekly. The usual weight gain is about 10-15gm/kg/day, weight given <5gm/kg/day for 3 consecutive days is failing to respond to treatment. 2. Emotional and physical stimulation Rooms should be brightly coloured, with decorations that interest children. Colorful mobiles should be hung over every cot. Toys should always be available in the child’s cot and room. Play therapy: Two sessions per day. Following play sessions can be adopted: a. Language: Teach local songs, rhymes. Action words with activities e.g “ang bang” with drum, “ta ta” as he/she waves. Talking while dressing, undressing, feeding, b. Motor skills can be developed adopting following measures: Holding child by placing hand under the shoulder & allowed to bounce. Placing a block- encourage to hold, push, transfer the block. By means of some toys e.g ring on a string, rattle and drum, putting coin inside a bottle and taking it out by turning upside down. 3. Immunization- should be done according to national guideline. 4. Teaching parents: How to prevent malnutrition from recurring- explain the parents about causes of malnutrition and its prevention by appropriate nutritious food, preparation of nutritous food, stimulating physical and mental development, regular deworming (6 monthly) during treatment of diarrhea and other infections. 5. Criteria for discharge: Criteria Child Weight for height has reached- 1 SD (90%) of NCHS/WHO median reference values. Eating an adequate amount of a nutritious diet that the mother can prepare at home. Gaining weight at a normal or increased rate. All vitamins and mineral deficiencies have been treated. All infections and other conditions have been or are being treated including anemia, diarrhea, intestinal parasitic infections, malaria, tuberculosis & otitis media. Full immunization program started. Mother or carer Able and willing to look after the child. Knows how to prepare appropriate foods and to feed the child. Knows how to make appropriate toys and to play with the child. Knows how to give home treatment for diarrhea, fever & acute respiratory infections and how to recognize the signs that mean he/she must seek medical assistance. Health worker Able to ensure follow-up of the child and support for [the mother. C. Follow-up Followed up to prevent relapse and to ensure growth and develoment. The children are followed up at interval of one week, two weeks and then one month until they achieve a WH>90% or WA>65% and these usually takes 6-8 months. Thereafter follow up visits should be twice a year and ideally continued at every visit and age, weight, height or lenght & MUAC are recorded. Multivitamin and zinc are continued for one month and iron should be continued for 3 months in usual doses. D. Prevention of protein energy malnutrition The child survival concept (GOBI FFF) described in the document state of world children 1982-83 written by James P Grant, Ex-executive director UNICEF has created a revolutionary thought on child health throughout the world. Oral rehydration therapy (ORT): It is a break-through in the management of diarrhea. It has been described in the Lancet as potentially the most important medical advance in this century. Breast Feeding: Breast milk is the best food for a baby in any society. Breast feeding can be continued upto 2 years, but given exclusively for the initial 6 months. Immunization (Universal child immunization): It should be done against measles, diphtheria, tetanus, pertussis, poliomyelitis, and tuberculosis. Female education: Female education is of utmost importance, because mother is the first and most important primary health worker for her children. Children of educated mother have more chance of survival and of healthy living than those of an illiterate mother in the same socio-economic group. Food supplementation: Food supplementation should be done for mother during pregnancy, specially during the last trimester and lactational period. Complementary feeding started from 5 to 6 months of age. Family spacing: Family spacing would have revolutionary impact on the health of the mother, and growth and survival of their children. Size of the family should be limited, births should be spaced at 3-5 years intervals. Vit A, iron supplementation, deworming & salt (iodized) intake (AIDS) are also other important measures for the prevention of PEM. |
| Introduction | WHO definition of PEM (in 1973): Protein-energy malnutrition is ‘a range of clinicopathological conditions arising from lack of varying proportions of protein and calories, occuring most frequently in infants and young children and is usually associated with infection.’ |
| History | |
| Etiology | see under causes |
| Clinical Features | Clinical presentation of PEM: Clinical presentations in PEM vary with the degree & duration of malnutrition. The age of the child & the presence of associated vitamin, mineral & trace element deficiencies. PEM of all degrees is most common in the post-weaning phase (9 to 24 mons. of age) but can occur at any age. A. Mild PEM: 1. Failure to thrive (mostly revealed by anthropo-metric measurements). Anthropometric abnor-malities include - a. Cessation or slowing of weight gain or weight loss, b. Cessation or slowing of height gain, c. Normal or diminished weight/height ratio, d. Decreased mid arm circumference (MAC), e. Delayed bone maturation. 2. Intercurrent infection particularly gastroen-teritis, measles. & pneumonia & infestation of worms (e.g hook worm). 3. Anemia- may be present. 4. Activity is diminished. 5. Hair around the temples may be sparse 6. Retardation of mental development. B. Severe form of PEM: Marasmus- 1. Gross failure to thrive presented as markedly emaciated body (< 60% Gomez classification). Accompanying features are- - the body has a shrunken, wasted & stark appearence due to loss of subcutaneous fat. - buccal pad of fat is usually present till extreme malnutrition. - eyes are deeply sunken due to dehydration. - there is marked wasting of the buttock. - Loose folds of skin, specially wasted over the buttock & the inner side of thigh. 2. Skin- appears dry, inelastic, is prone to infection. 3. Hairs- often hypopigmented. 4. The chest & ribs are unduly prominent. 5. Abdomen is usually distended. 6. Temperament- often irritable, crying or apathetic. 7. The appearence- resembles to those of old age. 8. Appetite- marasmic child has a voracious appetite. 9. Intercurrent infection such as gastroenteritis, measles, bronchopneumonia, SOM, skin infec-tions etc. 10. Eye changes due to vita-A deficiency. 11. Bowel habit- there is usually chronic watery diarrhoea, but the stools may be semisolid 12. The child may be anemic & may have signs of rickets. Kwashiorkor/Marasmic kwashiorkor: In this the characteristic features are: 1. Oedema - usually generalized; face appears puffy & moon shaped. 2. Hairs- characteristic changes - - dry & coarse, depigmented to reddish or brown or hypopigmented. - loss of curliness & become straight. - brittle & easily flakable (i.e pulled out easily & painslessly). - may be alternate black & brown. 3. Skin- dermatosis; some times petechie & echymosis may appear in severe cases. 4. Angular stomatitis & cheilosis may be present. 5. The child is often lethergic, listless & apathetic. 6. Anorexia is severe & vomiting is common. 7. Anemia- is always present. 8. Diarrhoea- the baby often suffers from diarrohea. 9. Eye changes- due to vita-A deficiency & signs of other vitamin deficiencies are also marked including scurvy. 10. Mental changes occurs invariably including apathy & intellectual deterioration. 11. In some children liver is enlarged & shows ext-ensive fatty infiltration. Cirrhosis is uncommon. 12. By definition, in kwashiorkor weight is >60% & in marasmic kwashiorkor weight is <60%. Once the picture of kwashiorkor is developed death is almost certain without treatment, even in hospital, mortality rate may reach 20%. |
| Preventions | Addressing the underlying cause. Economic and social factors are a major contributor to malnutrition. |
| Treatment | Oral feeding. Avoiding lactose. Supportive care. Reduction in poverty. Improving nutritional education and public health measures. Starvation can be treated by providing a balanced diet. Multivitamin supplements. Treat infections and fluid and electrolyte abnormalities, in severe cases. |
| Complications | Hypothermia. Hypoglycemia. Encephalopathy. Diarrhea. Heart failure. Infection. |
| Prognosis | |
| Types | |
| Classification | Classification of PEM:17 A. Weight for age classification: Measure the degree of undernutrition. c. Gomez classification Weight for age Grade of malnutrition (% of median) 76-90 Grade I mild malnutrition 61-75 Grade II moderate malnutrition <60 Grade III severe malnutrition b. Welcome trust classification Weight for age With edema Without (% of median) edema 60-80 <60 Kwashiorkor Under nutrition Marasmic Marasmus kwashiorkor B. WHO classification of undernutrition: Moderate Severe undernutrition undernutrition Symmetrical No Yesa edema SD scoreb -2 to -3 SD score < 3 Weight for height (70-79% of (< 70% of (measure of expected0) expected) wasting) Height for age SD scoreb -2 to -3 SD score < -3 (measure for (85-89% of (< 85% of stunting) expected0) expected) a. This includes Kwashiorkor and marasmic Kwashiorkor b. SD score (z) = Obsereved value- expected value (median) Standard deviation c. Median (50th percentile of NCHS standards). Finding out of Z score of a PEM patient: Example: A boy of 75cm tall weighing 7kg- find out his weight for height z score (WZH). 1SD = Median reference - 3rd centile reference weight at 75cm weight at 75cm = 10kg - 8.5kg 2 = 0.75 Now, Z score = Observed wt - expected wt (median wt at 75cm) = 7kg - 10kg = -4 0.75 C. Classification of PEM based on Z score: Anthropometric indicator Cut-off values Terms describing outcome Weight for age Z score (WAZ) - 3 to < - 2 Moderate underweight < - 3 Severe underweight Weight for height Z score (WHZ) - 3 to < - 2 Moderate wasting < - 3 Severe wasting Height for age Z score (HAZ) - 3 to < - 2 Moderate stunting < - 3 Severe stunting D. Classification: based on mid upper arm circumference (MUAC) Circumference Level of nutrition > 13.5cm (green) Normal 12.5 -13.5cm (yellow) Borderline < 12.5cm (red) Malnourished * The classification by MUAC is useful between the ages 1 & 5 years. E. Etiological classification : a. Primary malnutrition : due to primary lack of food b. Secondary malnutrition : due to chronic disease or causes other than lack of food. F. Classification: Based on BMI BMI Level of nutrition (weight in kg/m2 of height or length) >20 Normal 18.5-20 Marginal 17-18.4 Mild malnutrition 16-16.9 Moderate malnutrition <16 Severe malnutrition |
| Observation | |
| Pathology |
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