PEM 2014 Block 10 - 1

Protein Energy Malnutrition and feeding requirements
February 2014
Dr Jean Cloete
What covering ?
1. Who ? 2. Why ?
3. What ?
4. How manage it ?
What covering ?
1. Who ?
Who susceptible?
Possible in any age group
Less frequent in older individuals

Requirements/ kg mass are not as great
1. Who ? 2. Why ?
Energy Requirement
Physical activity Growth Maintenance
Energy Requirement
Optimal growth
Total Protein
Energy intake
Protein Quality
Develop PEM
Total Protein
Energy intake
Protein Quality
Why ?
Diseases can cause PEM due to:
Intake Absorption Utilization of nutrients is interfered by disease and dysfunction
Why ?
Diseases can cause PEM due to:
Intake Absorption Utilization of nutrients is interfered by disease and dysfunction
Disease like
HIV infection Chronic diarrhoea Mal absorption
The Malnutrition Infection cycle

Inadequate intake
Anorexia Mal absorption Nutrient losses Nutrient requirements Weight loss Mucosal damage Immune deficiency
Susceptibility to infection
1. Who ? 2. Why ?
3. What ?
Definitions
What ?
Illness develop due to inadequate intake of Protein
Energy
Growth parameters
Weight for Age Indicates past and present malnutrition
Height for age Indicates Long term nutritional status Chronic growth delay Stunting
Growth parameters
Weight for height Present nutritional status Indicates recent weight loss Wasting
Mid upper arm circumference
Clinical presentation
Depends on: Age Degree of malnutrition Duration of protein and energy deficiency
Previous nutritional status

Modifications produced by disease
Clinical assessment
Wide spectrum of disorders
Previously used Waterloo and Gomez classification Now WHO Z scores for diagnosis PLUS any signs of visible severe wasting
PLUS presence of bipedal oedema
Severe acute malnutrition guidelines

Severe acute malnutrition And Moderate acute malnutrition
Severe Acute Malnutrition

Mostly after weaning from breast or bottle Present with: Failure to thrive Oedema Anorexia Diarrhoea Skin and mucus membrane lesions Misery and apathy
Severe Acute Malnutrition (SAM)

WHZ < -3 SD or Height for Age < -3 SD or Bilateral pitting oedema of nutritional origin or Mid-upper-arm circumference < 11.5 cm (children 1-5 years)
Moderate Acute malnutrition

-3 SD < WHZ < -2 SD or -3 SD < Height for age < -2 SD or No Bilateral pitting oedema of nutritional origin or 11.5 cm < Mid-upper-arm circumference < 12.5 cm (children 1-5 years)
Clinical features of SAM
Growth failure
Growth failure
Deceptively chubby appearance Due to oedema
Excess subcutaneous fat from high carbohydrate diet Muscle wasting
Oedema
Oedema
First appear on dorsum of the feet or lower tibia Oedema helps to differentiate between marasmus and kwashiorkor Pathophysiology is complex
Dermatosis
Dermatosis
Dry scaly pigmentation Crazy paving
Pseudo Purpura
Bullous desquamation
Hair changes
Sparse thin hair Changes in colour to Red & Grey
Immunosuppression
Inadequate intake
Anorexia Mal absorption Nutrient losses Nutrient requirements Weight loss Mucosal damage Immune deficiency
Immunosuppression
Nutritionally Acquired Immunodeficiency
Anorexia Mal absorption Nutrient losses Nutrient requirements Weight loss Mucosal damage Immune deficiency Inadequate intake
Immunosuppression
Infections are often more severe
Associated with complications High mortality
Deficiencies in Vit A and C

Zinc, Iron, Folate and trace elements
Infection
Infections
Gardia Lambdia parasites Measles Tuberculosis
Gram negative Septicaemia
Cell mediated Immunity
Herpes Simplex (Disseminated)
Infective Mononucleosis Gastro enteritis
Other presentations
Apathy and irritability
Major problems Structural and functional changes in gut Atrophic bowel
Other presentations
Liver enlargement Fatty changes
Other presentations
Glucose intolerance with Hypoglycaemia
Hypokalaemia Ileus and Anaemia
Purpura due to low platelets
? WORRY
Severe infection
Hypoglycaemia
Jaundice Hypothermia
Collapse due to dehydration
Severe malnutrition
First year of life After weaning Due to prolonged severe diarrhoea
Severe malnutrition
Presenting symptoms: Failure to thrive Irritable crying Apathy Frequently diarrhoea
Severe malnutrition
Presenting symptoms: Failure to thrive Irritable crying Apathy Frequently diarrhoea Degree of UWFA is extreme < -3 Z Score weight for length If chronic diarrhoea Distended abdomen With visible bowel loops
Severe malnutrition
Presenting symptoms: Failure to thrive Irritable crying Apathy Frequently diarrhoea Degree of UWFA is extreme < -3 Z score weight for length If chronic diarrhoea Distended abdomen With visible bowel loops
Differential Diagnosis Chronic infections like TB AIDS Tropical infestations Psychological factors
Mixed type
Wasted forms
+
Clinical dermatosis
And / Or Oedema
What covering ?
1. Who ? 2. Why ?
3. What ?
4. How manage it ?
GENERAL PRINCIPLES FOR ROUTINE CARE (the 10 Steps)

There are ten essential steps:
1. Treat/prevent hypoglycaemia 2. Treat/prevent hypothermia 3. Treat/prevent dehydration 4. Correct electrolyte imbalance 5. Treat/prevent infection 6. Correct micronutrient deficiencies 7. Start cautious feeding 8. Achieve catch-up growth 9. Provide sensory stimulation and emotional support 10. Prepare for follow-up after recovery
Management
Day 1 - 2 Day 3 - 7 Week 2 - 6
Hypoglycaemia Hypothermia
Dehydration
Electrolytes Infection Micronutrients Initiate feeding Catch up growth Sensory stimulation Prepare for follow up
No Iron With Iron

Step 1 Prevent & Treat hypoglycaemia

Hypoglycaemia and hypothermia occur together Check for hypoglycaemia always Especially when hypothermia (axillary<35.0oC; rectal<35.5oC All malnourished children must have a blood glucose on admission. If no dextrostix a lab blood glucose should be requested AND Patient should be treated as if the patient may have hypoglycaemia
Step 1. Prevent/ treat hypoglycaemia

Prevention:
Feed two-hourly, start straight away or if necessary, rehydrate first Always give feeds throughout the night
Step 1 Treatment of Hypoglycaemia

If the child is conscious and dextrostix shows < 3 mmol/l give :
Immediate feed of DF-75 (or start up formula) OR 10 % Sugar solution Oral 5 ml/kg OR Dextrose 10 % ivi bolus

Monitor: Blood glucose: if this was low, repeat hourly. Once treated, most children stabilise within 30 min. Continue feeds

If blood glucose remains < 3 mmol/l give a ivi bolus of 10 % dextrose water 5ml/kg
Continue feeding
If rectal temp <35.5oC or Loss Of Consciousness Remember to repeat dextrostix and treat accordingly

Step 2 Prevent & Treat hypothermia

If the axillary temperature is < 36.0C ( If the rectal temperature is <35.5oC)
Feed straight away (or start rehydration if needed) Rewarm the child by:
Clothing the child (including head) Cover with a warmed blanket and place a heater or lamp nearby Put the child on the mothers bare chest (skin to skin) and cover them. Do not use a hot water bottle as scolding may occur
Step 2 Prevent & Treat hypothermia

Monitor:
Body temperature: During rewarming take temperature two hourly until it rises to >36.5 oC Take half-hourly if heater is used Ensure the child is covered at all times, especially at night Remember to feel for warmth
Hypo glycaemia
Hypo thermia

Step 3 Prevent & Treat dehydration

Golden Rules
It is difficult to estimate dehydration status in a severely malnourished child using clinical signs alone.
Do not use the IV route for rehydration except in cases of shock and then do so with care Infusing slowly to avoid flooding the circulation and overloading the heart

Assume all children with watery diarrhoea may have dehydration : Sorol 5 ml/kg every 30 min. for two hours, orally or by nasogastric tube Then 5-10 ml/kg/h for next 4-10 hours: The exact amount to be given should be determined by how much the child wants, and stool loss and vomiting.

Replace the Sorol doses at : 4, 6, 8 and 10 hours with F-75 if rehydration is continuing at these times, Then continue feeding starter F-75

During treatment:
rapid respiration and pulse rates should slow down Urine should be passed
Monitor progress of rehydration: Observe half-hourly for 2 hours then hourly for the next 6-12 hours, recording: pulse rate respiratory rate urine frequency stool/vomit frequency

Return of tears, moist mouth, eyes and fontanelle appearing less sunken, and improved skin turgor, are also signs that hydration is improving. It should be noted that many severely malnourished children will not show these changes even when fully rehydrated. Continuing rapid breathing and pulse during rehydration suggest coexisting infection or over hydration.

Signs of excess fluid (over hydration) are
Increasing respiratory rate Increasing pulse rate, Increasing oedema Puffy eyelids.
If these signs occur, stop fluids immediately and reassess after one hour

Step 4 Correct electrolyte imbalance

All severely malnourished children have excess body sodium even though plasma sodium may be low Deficiencies of potassium and magnesium are also present and may take at least two weeks to correct. Oedema is partly due to these imbalances. Do NOT treat oedema with a diuretic.
Step 4 Correct electrolyte imbalance

Give: Potassium Potassium chloride solution 25 50 mg/kg/dose oral 3 times daily until oedema subsides < 10 kg 250 mg > 10 kg 500 mg Extra magnesium 0.4-0.6 mmol/kg/d

Step 5. Prevent & Treat infection

In severe malnutrition the usual signs of infection, such as fever, are often absent, and infections are often hidden. Choice of broad-spectrum antibiotics: Ampicillin ivi 50 mg/kg IM/IV 6-hourly for 2 days, then follow with oral amoxycillin 30 mg/kg 8-hourly for 5 days, AND Aminoglicoside Gentamicin 6 mg/kg IM/IV once daily for 7 days Amikacin 15 mg/kg once daily ivi for 7 days.
Step 5. Prevent & Treat infection

Where specific infections are identified, ADD Specific antibiotics if appropriate Antimalarial treatment if the child has a positive blood film for malaria parasites For Gastro intestinal infections/infestations Metronidazole Oral 7.5 mg/kg/dose 8 hourly for 5 7 days For dysentery Cefotaxime ivi 25 50 mg.kg.dose 6 8 hourly OR Ceftriaxone ivi 50 75 mg/kg once daily.

Step 6. Correct micronutrient deficiencies

All severely malnourished children have vitamin and mineral deficiencies. Although anaemia is common, do NOT give iron initially but wait until the Child has a good appetite and starts gaining weight (usually by the second week), as giving iron can make infections worse.

Give: Vitamin A orally on Day 1 for age >12 months, give 200,000 IU for age 6-12 months, give 100,000 IU for age 0-5 months, give 50,000 IU Unless there is definite evidence that a dose has been given in the last month

Give daily for at least 2 weeks: Multivitamin supplement Folic acid 1 mg/d (give 5 mg on Day 1) Zinc 2 mg/kg/d Copper 0.3 mg/kg/d Iron 3 mg/kg/d but only when gaining weight

Step 7. Start cautious feeding

Initial phase Begin feeding immediately If hypoglycaemia or danger signs feed more regularly 2 hourly If feeds refused or not taken give via Nasogastric Tube

Days 1-2 3-5 6-7+ Frequency 2-hourly 3-hourly 4-hourly Vol/kg/feed Vol/kg/day 11 ml 16 ml 22 ml 130 ml 130 ml 130 ml
For children with a good appetite and no oedema, this schedule can be completed in 2-3 days 24 hours at each level

Monitor and note:
amounts offered and left over vomiting frequency of watery stool daily body weight

Step 8. Achieve catch-up growth

Readiness to enter the rehabilitation phase is signalled by a return of appetite To change from starter to catch-up formula: 1. Replace starter DF-75 with the same amount of catch-up formula DF- 100 for 48 hours 2. Increase each successive feed by 10 ml until some feed remains uneaten. 3. The point when some remains unconsumed is likely to occur when intakes reach about 30 ml/kg/feed (200 ml/kg/d).

Step 9. Provide sensory stimulation and emotional support

In severe malnutrition there is delayed mental and behavioural development. Provide: tender loving care a cheerful, stimulating environment structured play therapy 15-30 min/d physical activity as soon as the child is well enough maternal involvement when possible
Step 10. Prepare for follow-up after recovery

A child who is 90% weight-for-length (equivalent to -1 SD) can be considered to have recovered. The child is still likely to have a low weight-for-age because of stunting.
Show parent or carer how to: feed frequently with energy- and nutrient-dense foods give structured play therapy
Step 10. Prepare for follow-up after recovery

Advise parent or carer to: Bring child back for regular follow-up checks Ensure booster immunizations are given Ensure vitamin A is given every six months
Thanks for your attention !

PEM 2014 Block 10 - 1

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PEM 2014 Block 10 - 1

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Protein Energy Malnutrition and feeding requirements

Less frequent in older individuals

The Malnutrition Infection cycle

Mid upper arm circumference

Previous nutritional status

PLUS presence of bipedal oedema

Severe acute malnutrition guidelines

Severe Acute Malnutrition

Severe Acute Malnutrition (SAM)

Moderate Acute malnutrition

Clinical features of SAM

Deficiencies in Vit A and C

Gram negative Septicaemia

Cell mediated Immunity

Herpes Simplex (Disseminated)

Infective Mononucleosis Gastro enteritis

Major problems Structural and functional changes in gut Atrophic bowel

Liver enlargement Fatty changes

Hypokalaemia Ileus and Anaemia

Purpura due to low platelets

Collapse due to dehydration

First year of life After weaning Due to prolonged severe diarrhoea

GENERAL PRINCIPLES FOR ROUTINE CARE (the 10 Steps)

GENERAL PRINCIPLES FOR ROUTINE CARE (the 10 Steps)

Step 1 Prevent & Treat hypoglycaemia

Step 1. Prevent/ treat hypoglycaemia

Step 1 Treatment of Hypoglycaemia

Step 1 Treatment of Hypoglycaemia

Step 1 Treatment of Hypoglycaemia

GENERAL PRINCIPLES FOR ROUTINE CARE (the 10 Steps)

Step 2 Prevent & Treat hypothermia

Step 2 Prevent & Treat hypothermia

GENERAL PRINCIPLES FOR ROUTINE CARE (the 10 Steps)

Step 3 Prevent & Treat dehydration

Step 3 Prevent & Treat dehydration

Step 3 Prevent & Treat dehydration

Step 3 Prevent & Treat dehydration

Step 3 Prevent & Treat dehydration

Step 3 Prevent & Treat dehydration

GENERAL PRINCIPLES FOR ROUTINE CARE (the 10 Steps)

Step 4 Correct electrolyte imbalance

Step 4 Correct electrolyte imbalance

GENERAL PRINCIPLES FOR ROUTINE CARE (the 10 Steps)

Step 5. Prevent & Treat infection

Step 5. Prevent & Treat infection

GENERAL PRINCIPLES FOR ROUTINE CARE (the 10 Steps)

Step 6. Correct micronutrient deficiencies

Step 6. Correct micronutrient deficiencies

Step 6. Correct micronutrient deficiencies

GENERAL PRINCIPLES FOR ROUTINE CARE (the 10 Steps)

Step 7. Start cautious feeding

Step 7. Start cautious feeding

Step 7. Start cautious feeding

GENERAL PRINCIPLES FOR ROUTINE CARE (the 10 Steps)

Step 8. Achieve catch-up growth

GENERAL PRINCIPLES FOR ROUTINE CARE (the 10 Steps)

Step 9. Provide sensory stimulation and emotional support

Step 10. Prepare for follow-up after recovery

Step 10. Prepare for follow-up after recovery

Thanks for your attention !

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