Pem PDF

PROTEIN ENERGY
MALNUTRITION & SEVERE
ACUTE MALNUTRITION
IAP UG Teaching slides 2015-16 1

MAGNITUDE OF MALNUTRITION ‐ INDIA
• % <5yrs Moderate ‐ 47
• % <5yrs Severe ‐ 18 •Underweight ‐ 40.4%
• % Wasting<5yrs ‐ 16 •Wasted ‐ 22.9%
(moderate & severe) •Stunted ‐ 44.9%
• % Stunting <5yrs ‐ 46
(moderate & severe) (NFHS 3 DATA 2005‐2006)
(Data based on NFHS2 findings 1998‐99)

IAP UG Teaching slides 2015-16 3 3
THEORIES OF MALNUTRITION
Protein deficiency :resulting in Kwashiorkor
Viteri’s Time bound theory: time to adapt  marasmus
Toxic theory: Organ dysfunction  kwashiorkor
Niacin theory: deficiency  dermatosis
Increased ferritin level  ADH like action & edema
Dr. Gopalan’s dysadaptation theory  effective catabolism &
near normal anabolism in marasmus, failure of anabolism in
kwashiorkor

THEORIES OF MALNUTRITION‐NEW THEORIES
•Free radical theory
•Aflatoxin poisoning

FREE RADICAL THEORY
Free oxygen radicals are potentially toxic to cell
membrane and are produced during various
infections
These oxides are normally buffered by proteins and
neutralized by antioxidants such as Vit. A, C & E and
selenium
In malnourished child deficiency of these nutrients in
the presence of infection or aflatoxin may result in
the accumulation of toxic – free oxygen radicals
These may damage liver cells giving rise to
Kwashiorkor.

FREE RADICAL THEORY OF KWASHIORKOR
Noxious agent
(NoxA)
Inadequate
protective Free Radicals
pathway
Fe Catalyzed
Macro molecular damage
Malnutrition
Inadequate Repair
Fatty Liver

AFLATOXIN POISONING
NoXa
Low protein diet  growth stops   Stunting

D
I Very low protein  Anorexia   Marasmus
E
T Insufficient diet  weight loss   wasting ,edema

(kwashiorkor/marasmic
kwashiorkor)

CLINICAL FEATURES
• Hair changes • Anaemia
• Skin changes • Features of vitamin deficiencies
• Muscle wasting • Dehydration
• Oedema • Hepatomegaly
• Psychomotor • Cardiac failure
changes

MARASMUS‐GRADE IV


KWASHIORKOR‐ GRADE IV

KWASHIORKOR & MARASMUS
Marasmus Kwashiorkor
Age (Yr.) <1 1 – 3
Edema None Lower legs or
generalized
Wasting Gross, loss of Hidden
subcutaneous fat, skin
and bone
Muscle wasting Obvious Hidden

Growth retardation Obvious Present
Mental change late feature Irritable, moaning,
apathetic
Appetite Good Poor
Diarrhea May be present Usually present
KWASHIORKOR & MARASMUS
Marasmus Kwashiorkor
Hair & Skin Seldom Often diffuse
change depigmentation/ flag sign
occasional flanky paint
dermatosis of skin
Serum. Albumin Low Normal Low
Urinary Urea / Low Normal Low
Creatinine
Urinary Low Low
Hydroxyproline /
Creatinine
Serum Essential Low Low
amino acid
Anemia Uncommon Common

Hepatomegaly ‐ Fatty Liver
IAP UG Teaching slides 2015-16
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MARASMIC KWASHIORKOR

POOR PROGNOSTIC CRITERIA IN PEM
• Age: infants •Total serum protein <3 g/dl
• Wt/Ht >70%/ 3 SD & Albumin <2 g/dl
• MUAC < 11.5 cm •Severe anaemia with
• Stupor or coma clinical signs of hypoxia
• Severe gram negative •Liver dysfunction, altered
sepsis LFT
• Hemorrhagic tendencies, •Extensive exudative or
Thrombocytopenia
exfoliative dermatosis
• Signs of CCF/respiratory
distress •Hypoglycaemia/hypotherm
ia
•Low gamma globulin
fraction

SEVERE ACUTE MALNUTRITION
• Severe Acute malnutrition is defined as the
presence of severe wasting
– Weight for height/length <‐3SD and or
– MUAC <11.5 cm for children 6‐59 months and or
– Presence of bilateral edema
• Children with severe acute malnutrition have
nine times higher risk of death.

INVESTIGATIONS
• Blood glucose
• Peripheral smear
Other Tests:
• Hemoglobin • Serum proteins,
• TC,DC,ESR • Serum albumin
• Urine Examination
• Electrolytes
• Stool Examination
• Chest X‐ray • Calcium, Magnesium,
• RFT, LFT Phosphorus
• Cultures • Immunoglobulin
• Mantoux Test profile
• HIV

COMPLICATIONS
• Hypoglycemia
• Hypothermia
• Infections (bacterial, viral & fungal)
• Hypokalemia
• Hyponatremia
• Dehydration & shock
• Heart failure

UNCOMPLICATED
• Age: > 6 months of age
• Alert
• Preserved appetite
• Clinically assessed to
be well
• Living in a conducive
home environment.

CRITERIA FOR ADMISSION

• Age: <6 months or
• > 6 months but not fulfilling the criteria for
uncomplicated also considered "complicated".
• Institutional care is considered mandatory

WHO GUIDELINES FOR IN‐PATIENT TREATMENT
OF SEVERELY MALNOURISHED CHILDREN (SAM)

MANAGEMENT
A. General principles for routine care
(the’10 steps’)
B. Emergency treatment of shock and severe
anemia
C. Treatment of associated conditions
D. Failure to respond to treatment
E. Discharge before recovery is complete

GENERAL PRINCIPLES FOR ROUTINE CARE
• These steps are accomplished in two phases:
• an initial stabilization phase where the acute
medical conditions are managed; and
• a longer rehabilitation phase.
• Note that treatment procedures are similar for
marasmus & kwashiorkor.

THE 10 STEPS

STEP 1. TREAT/PREVENT HYPOGLYCAEMIA
Blood sugar level <54 mg/dl or 3 mmol/L
Assume hypoglycemia when levels cannot be determined.
CONSCIOUS CHILD‐ 50 ml bolus of 10% glucose by
nasogastric (NG) tube.
UNCONSCIOUS CHILD, lethargic or convulsing ‐IV sterile
10% glucose (5ml/kg), followed by 50ml of 10% glucose or
sucrose by NG tube.
Start two‐hourly feeds, day and night

STEP 2. TREAT/PREVENT HYPOTHERMIA
• If axillary temperature <35oC, take rectal
temperature
• If the rectal temperature is <35.5oC (<95.9oF):
‐ rewarm the child: 2 layer clothes, cover with
warmed blanket & place a heater or lamp nearby
or put the child on the mother’s bare chest (skin to
skin) and cover them – Kangaroo mother care
‐ feed straightaway

STEP 3. TREAT/PREVENT DEHYDRATION
• Difficult to estimate dehydration using clinical
signs alone
• Assume all children with watery diarrhea may
have dehydration
• Do not use the IV route for rehydration except in
cases of shock
• Continue feeding

ASSESSMENT OF DEHYDRATION IN SEVERELY
MALNOURISHED CHILDREN
Basic format remains the same
Some signs unreliable
• Mental state
• Mouth, tongue and tears
• Skin turgor
• Urine output: quantity/color/osmolarity
Edema and hypovolemia can coexist

DIAGNOSIS OF DEHYDRATION IN SEVERELY
MALNOURISHED CHILDREN
• History of diarrhea ( with large volume of
stools)
• Increased thirst
• Recent sunken eyes
• Prolonged CFT, weak/absent radial pulse,
decreased or absent urine flow
Difficult using clinical signs alone
Best to assume that all with watery diarrhea
have some dehydration
Treat with ORS unless shock is present
REHYDRATION SOLUTION FOR
MALNUTRITION (ReSoMal)
Std. WHO WHO ReSoMal

ORS Reduced
osmolarity
ORS
Sodium 90 75 45
Potassiu 20 20 40
m
Glucose 111 75 125

COMPOSITION OF RESOMAL
Ingredient Mass (g) mmol per 20 ml
Potassium chloride (KCl) 224 24
Tripotassium citrate 81 2
Magnesium chloride (MgCl2.6H20) 76 3
Zinc acetate (Zn accetate.2H20) 8.2 0.3
Copper sulphate (CuSO4.5H20) 1.4 0.045
• To be added to diet or oral rehydration salts solution.
• Add 20 ml of the solution to a liter of diet or oral rehydration salts.
However, appropriate Vitamin mineral mix is not available in India.
In this scenario, one may use combinations of various commercial
preparations available

WHICH ORS SHOULD BE USED IN
SEVERE MALNUTRITION?
OPTIONS
• Low osmolarity ORS with potassium supplements
• ReSoMal (not available in India)
IAP endorses the use of LOW OSMOLARITY WHO
ORS for all types of diarrhea and nutritional status
for logistics and programmatic advantages.

TREATMENT OF DEHYDRATION
ONLY Rehydrate until the weight deficit (measured or estimated)
is corrected and then STOP – DO not give extra fluid to “prevent
recurrence”
Unconscious
Conscious
IV fluid
Resomal
5ml/kg /30min for first 2hrs Ringer lactate & 5% dextrose at 15ml/kg the
first hr & reassess
‐ If improving, 15ml/kg 2nd hr;
‐ If conscious, NGT: ReSoMal
‐ If not improving =Septic shock
STEP 4. CORRECT ELECTROLYTE IMBALANCE
• Plasma sodium may be low though body
sodium is usually high. Sodium
supplementation may increase mortality.
• Potassium & Magnesium are usually
deficient and needs supplementation; may
take at least two weeks to correct.
• Edema if present is partly due to these
imbalances. Do NOT treat edema with a
diuretic

POTASSIUM
• In SAM children, there is too little potassium
inside cells.
• All SAM children should be given potassium
supplements (3‐4 mmol/kg/day) for 2 weeks.
• Potassium Chloride syrup is the most available
medicine of which every 15ml contains 20
mmol potassium.
Give extra potassium daily for 2 weeks
Do not treat oedema with diuretic since most diuretics
increase loss of potassium and make electrolyte
imbalance worse.
MAGNESIUM
• In SAM children, there is too little magnesium
inside cells.
• On 1st day 0.3 ml/kg of 50% magnesium
sulphate (up to a maximum of 2ml) should be
given IM once.
• After this from 2nd day onwards magnesium
should be given orally (0.1ml/kg/day/0.4‐0.6
mmol/kg/day) X 2 weeks.
Give extra magnesium daily
STEP 5. TREAT/PREVENT INFECTION
Usual signs of infection, such as fever, are often absent.
Give broad spectrum antibiotics to all.
Hypoglycemia/hypothermia usually coexistent with
infection. Hence if either is present assume infection is
present as well
No complications ‐ Co‐trimoxazole / Amoxicillin
Severely ill ‐ Ampicillin + Gentamicin
If the child fails to improve clinically within 48 hours, add:
cefotaxime/ceftrioxone as per Facility based ‐ FIMNCI

STATUS ANTIBIOTICS
Infected child or  IV AMPICILLIN 50 mg/kg/dose q 6hrly
complications* present and IV GENTAMICIN 2.5 mg/kg/dose q
8hrly/ once daily
 Add IV CLOXACILLIN 100 mg/kg/day q
6hrly if staphylococcal infection is
suspected.
For septic shock or No  Add third generation cephalosporins i.e.
improvement or worsening IV CEFOTAXIME 100 mg/kg/day q 8hrly
in initial 48 hours
Meningitis  IV Cefotaxime 200mg/kg/day IV q 6hrly
with IV amikacin 15 mg/kg/day q 8hrly
Dysentery  CIPROFLOXACIN 30mg/kg/day in 2
divided doses.
 IV ceftriaxone 50mg/kg/day in od or q
12 hourly if child is sick or has already
received nalidixic acid

STEP 6. CORRECT MICRONUTRIENT
DEFICIENCIES
• All severely malnourished children have vitamin and
mineral deficiencies
• Vitamin A orally on Day 1
• Give daily :
– Multivitamin supplement
– Folic acid 1 mg/d (give 5 mg on Day 1)
– Zinc 2 mg/kg/d
– Iron 3 mg/kg/d after first week

HOW TO CORRECT VITAMIN A DEFICIENCY ?
Vitamin A orally IMMEDIATELY on Day 1‐ unless
there is definite evidence that a dose has been
given in the last month or if bilateral edema
 < 6 months ‐‐ 50,000 IU or 0.5 ml
 6‐12 months ‐‐ 100,000 IU or 1 ml
 > 12 months ‐‐ 200,000 IU or 2 ml
 In edematous patient, give one dose once
edema has subsided.
Repeat dose on day 2 and day 14 if there is
any sign of xerophthalmia, as children can go
blind very quickly – WITHIN HOURS!
HOW TO CORRECT ANEMIA?

DO NOT give iron initially
Giving iron too early is DANGEROUS because the blood may have too little
protein to bind the iron and keep it safe.
Unbound iron can stimulate the growth of bacteria and make infections
worse.
Start iron supplements in the catch‐up/rehabilitation phase when there has
been time for iron to be bound and antibiotics to reverse the infection.

HOW TO CORRECT ANEMIA ? Cont…
 Fe 3mg/kg body weight per day.
 If the anemia is very severe (i.e. severe pallor of the
palms of the hands) and there is a risk of heart
failure, then treat with a very carefully administered
small blood transfusion.

HOW TO CORRECT OTHER MICRONUTRIENT
DEFICIENCY?
 To correct deficiencies of riboflavin, ascorbic acid,
pyridoxine, thiamin and fat soluble vitamins
–ADEK‐ give Multivitamin Supplement (without
Iron)
 Folic acid orally: On 1st day 5 mg and from 2nd day
onwards 1mg/day daily in > 6 mo. old .
 Zinc: 2 mg / kg / day.
 Copper: 0.2 ‐ 0.3 mg / kg / day.
 Continue giving nutritious mixed diet
**All these micronutrients may be available together in a premixed packet,
ready to add to formula.

STEP 8. ACHIEVE CATCH‐UP GROWTH
• Readiness to enter the rehabilitation phase is
signaled by a RETURN OF APPETITE, usually about
one week after admission
• Do appetite test & plan phase II
• Recommended milk‐based F‐100 contains 100 kcal &
2.9 ‐3 g protein/100 ml
• In rehabilitation phase vigorous approach to feeding
is required to achieve very high intakes & rapid
weight gain of >10 g gain/kg/d

TO CHANGE FROM STARTER TO CATCH ‐ UP
FORMULA
• Replace starter F‐75 with the same amount of catch‐
up formula F‐100 for 48 hours then,
• Increase each successive feed by 10 ml until some
feed remains uneaten.
• The point when some remains unconsumed is likely
to occur when intakes reach about 30 ml/kg/feed
(200 ml/kg/d & 6 g/kg protein/day)
• Daily record weight & plot (Tick sign may be seen in
edematous SAM due to initial weight loss)

RECIPIES FOR STARTER AND CATCH‐UP
FORMULAS

LOCALLY PREPARED PREPARATIONS
F75 F100
 Full Cream milk‐ 30 ml/  Full Cream milk‐ 90 ml/
 5 g powder  15 g powder
 10 g sugar  5 g sugar
 ½ tsp MCT Oil  ½ tsp MCT Oil
 Water up to 100 ml  Water up to 100 ml
 75 – 80 Kcals. & 1 g protein  100 kcals. & 3 g protein
 RUTF, 20 g = 100 ml of F100  F100 with Skimmed Milk
 100 g = 500 Cal. & 15 g  10 g SM powder
protein  10 g sugar +1/2 tsp oil

PRINCIPLE OF MANAGEMENT
• Phase I
– Patients without an adequate appetite and /or
– Medical complications
• Transition phase
– Introduced when appetite improves & edema decreases
• Phase II
– Good appetite and no major medical complications
– Patients with good appetite are admitted directly into phase
II
– RUTF (ready to use therapeutic food ) peanut based
– 20 g = 100 kcal. & 3 g protein
– ARF (Amylase Rich Food) – usage of germinated cereals &
pulses

STEP 9. PROVIDE SENSORY STIMULATION AND
EMOTIONAL SUPPORT
• Delayed mental and behavioral development is present
• Provide:
– Tender loving care (TLC)
– Cheerful, stimulating environment
– Structured play therapy 15‐30 min/d
– Physical activity as soon as the child is well enough
– Maternal involvement when possible (e.g.
Comforting, feeding, bathing, play, skin to skin, eye
to eye contact)
STEP 10. PREPARE FOR FOLLOW‐UP AFTER
RECOVERY
•Target weight for discharge: > 15% of baseline weight
•A child who is 90% weight‐for‐length (equivalent to ‐1SD)
can be considered to have recovered
•Show parent or caregiver how to:
– Feed frequently with energy ‐ and nutrient‐dense foods
– Give structured play therapy
•Advise parent or caregiver to:
– Bring child back for regular follow‐up checks
– Ensure booster immunizations are given
– Ensure vitamin A is given every six months

WHEN TO DISCHARGE THE CHILD (6‐60 MONTHS)
FROM PROGRAM ?
Measure Cutoff
Bilateral edema absent for last 10 days
And/or
Weight‐for‐height 15% weight gain from the
weight on admission or weight
on the day free of oedema
And/or
Medical complications None
SAM < 6 months of age need special regimen
Phase 1 –INFANTS YOUNGER THAN 6 MONTHS
• Breastfeed every 3 hours, duration at least 20 minutes to ensure hind milk,
more often if the child ask for more, at least 8 times/day.
• One hour after breast‐feeding, complete with F100 diluted using the
supplementary suckling technique:
• F‐100 diluted: 130ml/kg/day 100 kcal/kg/day & 3 g protein/kg/d in 8
feeds.


ROUTINE MEDICINE
• Vitamin A: 50.000UI at admission only
• Folic acid: 5mg (1tab) in unique dose
• Ferrous sulphate: when the child sucks
well and starts to grow. Take the quantity
of F100 enriched with ferrous you need
in phase II. Iron can be given separate
also
• Antibiotics: Amoxicillin (from 2kg):
20mg/kg 3 times a day (60mg/day)

EMERGENCY TREATMENT OF SHOCK
AND SEVERE ANEMIA

Use intravenous or intraosseous route
Fluid therapy in severe dehydration
Ringers Lactate with 5% dextrose or ½ normal saline with 5% dextrose
at 15 ml/kg/hour for the first hour
* do not use 5% dextrose alone
Continue monitoring every 5-10 min.
Assess after 1 hour
If no improvement or worsening If improvement(pulse slows/faster

consider capillary refill /increase in blood
pressure)
septic shock consider severe dehydration with
shock
Repeat Ringers Lactate 15 ml/kg over1 h
Assess
If accepts orally start ORS Clinically better but not accepting orally give
10ml/kg/h till accepts
orally
SEVERE ANAEMIA
• Blood transfusion is required if:
– Hb < 4 g/dl or if there is respiratory distress
& Hb 4‐6 g/dl
• Give:
– Whole blood 10 ml/kg slowly over 3 hours
– Furosemide 1 mg/kg IV at start of transfusion
• If CARDIAC FAILURE present, transfuse packed
cells (5‐7 ml/kg) rather than whole blood
• Monitor RR & HR every 15 minutes. If either of
them rises, transfuse more slowly.
• Give oral iron for two months to replenish iron
stores

HOW TO DIAGNOSE AND TREAT ANAEMIA?
Check Hb at admission if any clinical
suspicion of anaemia
‐ Hb >= 4g/% or - Hb < 4g/% or
‐Packed cell vol>=12% ‐ Packed cell vol<12%
‐ or between 2 and 14 days after
admission ONLY during the first 48
hours after admission:
No acute treatment
Give 10ml/kg packed cells
Iron during phase 2 3hours ‐ No food for 3 to 5
hrs
TREATMENT OF ASSOCIATED
CONDITIONS

VITAMIN A DEFICIENCY
If eye signs of deficiency, give orally:
vitamin A on days 1, 2, 14
>12 months ‐200,000 IU
6‐12 months ‐100,000 IU
< 6 months ‐50,000 IU
If corneal clouding/ulceration, give additional eye care to
prevent extrusion of the lens:
instill chloramphenicol or tetracycline eye drops (1%)
2‐3 hourly for 7‐10 days
instill atropine eye drops (1%),
1 drop three times daily for 3‐5 days
DERMATOSIS
• Signs: hypo‐or hyper pigmentation
• desquamation, ulceration, exudative lesions
• ZINC DEFICIENCY is usual in affected children. Skin
quickly improves with zinc supplementation
• > 6 mo. 20 mg/day X 14 days & 2‐6 mo. 10 mg/day
• In addition:
• apply barrier cream (zinc & castor oil ointment,
or petroleum jelly or paraffin gauze) to raw
areas
• omit nappies so that the perineum can dry

CONTINUING DIARRHEA
• Common feature but it should subside during the
first week of treatment with cautious feeding. In
the rehabilitation phase, loose, poorly formed
stools are no cause for concern provided weight
gain is satisfactory.
• Mucosal damage & giardiasis
– Stool microscopy
– Give: metronidazole (7.5 mg/kg 8‐hourly for 7
days)

CONTINUING DIARRHEA – Cont..
• Lactose intolerance.
– Only rarely due to lactose intolerance.
– Treat only if continuing diarrhea is
preventing general improvement
– Starter F‐75 is a low‐lactose feed. In
exceptional cases:
• substitute milk feeds with yogurt or
lactose‐free infant formula
• reintroduce milk feeds gradually in
the rehabilitation phase

OSMOTIC DIARRHEA
• Suspected if diarrhea worsens substantially
with hyperosmolar starter F‐75 and
• Ceases when the sugar content is reduced
and osmolarity is <300 mOsmol/l.
• In these cases: use isotonic F‐75 or low
osmolar cereal‐based F‐75. Introduce F‐100
gradually
PARASITIC WORMS
• Give mebendazole 100 mg orally, twice daily
for 3 days

TUBERCULOSIS (TB)
If strongly suspected (contacts with adult TB
patient, poor growth, despite good intake,
chronic cough, chest infection not responding to
antibiotics):
– Mantoux test (false negatives are frequent)
– Chest X‐ray if possible
– If test is positive or strong suspicion of TB,
treat according to national TB guidelines

FAILURE TO RESPOND TO TREATMENT
• Good wt gain (>10 g/kg/day): continue
same
• Mod. wt gain (5‐10 g/kg/day), check intake
& infection
• Poor wt gain (<5 g/kg/day),
• Inadequate feeding,
• Untreated infection,
• Specific nutrient deficiencies,
• Tuberculosis & HIV/AIDS
• Psychological problems

FAILURE TO RESPOND
TO TREATMENT
PRIMARY FAILURE TO RESPOND
•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 5g/kg/day by day
10
SECONDARY FAILURE TO RESPOND
•Failure to gain at least 5g/kg/day for 3
consecutive days during rehabilitation
CRITERIA FOR DISCHARGE
• Recovered when reaches 90% weight‐for‐length /
1SD & no edema
• Absence of infection
• Eating at least 120‐130 cal/kg/day & receiving
adequate micronutrients
• Consistent weight gain
• (of at least 5 g/kg/day for 3 consecutive days) on
exclusive oral feeding
• Completed immunization appropriate for age
• Caretakers sensitized to home care
CHILDREN DISCHARGED EARLY: WHAT TO DO
• Recovery complete if 90% W/L/ Wt/Ht;
• But can be discharge early for domiciliary if‐
• The child: > 1yr; good appetite & wt gain; no edema,
antibiotic treat completed.
• The mother: available at home, motivated & trained to
look after; have resources; reside near hospital.
• Local Health Worker/ anganwadi/nutrition
rehabilitation center : Can provide support; trained;
motivated

CHILDREN DISCHARGED EARLY: WHAT TO DO
• Monitoring Feeding at Home
Essential:
• Feed frequently at least 5 times a
day
• Modify home food to suit F‐100
• High energy snacks between meals
• Assistance to complete each meal
• Give electrolyte/ mineral solutions
• Breastfeeding should continue

Thank You

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PROTEIN ENERGY

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Low protein diet  growth stops   Stunting

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Muscle wasting Obvious Hidden

Anemia Uncommon Common

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Std. WHO WHO ReSoMal

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Continue monitoring every 5-10 min.

Assess after 1 hour

If no improvement or worsening If improvement(pulse slows/faster

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