Causes, pathophysiology, classification and management strategies of Protein Energy Malnutrition in developing country

1. PROTEIN ENERGY
MALNUTRITION
Assessment , Clinical features,
Adaptation & Management
Dr Bedangshu Saikia
Registrar, Pediatrics and Neonatology
St Stephens Hospital, New Delhi
11/22/14 Bedangshu 1

2. 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 1973
11/22/14 Bedangshu 2

3. 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.

4. ___________________________________________________________________________
Distribution of under 5 deaths in developing nations -1995

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

9. 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 ratio
11/22/14 Bedangshu 9

10. 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 Bedangshu 10

11. 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
Malnutrition - <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
11/22/14 Bedangshu 11

12. 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)
Edem
a
Type of
PEM
60-80 + Kwasi
60-80 - Underwt
<60 - Maras
<60 + MarasKwas
i
11/22/14 Bedangshu 12

13. 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
11/22/14 Bedangshu 13

14. 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
11/22/14 Bedangshu 14

15. Classification:
 IAP Classification:
Nutritional Status Wt for Age (% of exp)
Normal >80
Gr I PEM 71-80
Gr II PEM 61-70
Gr III PEM 51-60
Gr IV PEM <50
Alphabet K is post fixed in presence of edema
11/22/14 Bedangshu 15

16. 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
11/22/14 Bedangshu 16

17. Clinical Features:
Organ Signs
1. Hair Lustureless, thin, sparse, straight, depigmented,
Flag Sign, easily pluckable
2. 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
11/22/14 Bedangshu 17

18. Clinical Features:
Organ Signs
8. Skin Xerosis, hypo/ hyperpigmentation, petechiae, Flaky
paint dermatosis, scrotal & vulval dermatosis
9. 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/ Microcardia
18

19. 11/22/14 Bedangshu 19

20. 11/22/14 Bedangshu 20

21. 11/22/14 Bedangshu 21

22. SPECTRUM OF PEM
 Invisible PEM: Toddlers frequent desire to
breast feed; monitor nutritional status; use
growth chart
 Underweight: 60-80% weight for age
expected
 Nutritional dwarfing: prolonged PEM with
evidence of stunting, no wasting-bonsai
 Prekwashiorkor: no edema; features of
kwashiorkor
 Marasmic kwashiorkor
11/22/14 Bedangshu 22

23. 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
11/22/14 Bedangshu 23

24. KWASHIORKOR
 1st recognized by Prof Cicely Williams in
1933 denotes “deposed child”
 Apathetic,miserable,stunted,oedema,hepato
megaly, anemia, hair and skin changes
Grd I- Pedal edema
Grd II- I + Facial edema
Grd III- II + paraspinal & chest edema
Grd IV- III + ascitis
11/22/14 Bedangshu 24

25. Item Marasmus Kwashiorkor
Appearance Old man like, gen wasting Moon facies, oedema, wasted UL
Age Infants 1-5 yrs
Prevalence Common Rare
Wt <60% 60-80%
GR ++ +
Edema Nil ++
Apathy Nil/ mild ++
Mood Usually alert Irritable
Appetite Good Very poor
Hair changes Nil/ mild +
Skin changes Nil/ mild +
Fatty liver Absent/ mild ++
Infections + ++
Life threat + ++
S/ protein, albumin Low Very low
Carrier protein Low Very low
Anabolism + Very low
Catabolism ++ +
Response to Rx Good poor

26. Adaptation
 Chemical and hormonal mechanisms :
Cortisol
Insulin
Growth hormone
Somatomedin
Glucagon
Thyroxin
11/22/14 Bedangshu 26

27. Cortisol
27

28. Insulin
11/22/14 Bedangshu 28

29. Growth hormone
11/22/14 Bedangshu 29

30. Dysadaptation in kwashiorkor
11/22/14 Bedangshu 30

31. ↓insulin in kwashiorkor
11/22/14 Bedangshu 31

32. Pathogenesis of edema
11/22/14 Bedangshu 32

33. 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
11/22/14 Bedangshu 33

34. 11/22/14 Bedangshu 34

35. 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
11/22/14 Bedangshu 35

36. Sequential Approach for Mgmt of Severe PEM
Day 1-2
Rx of
complications
Day 3-7
Initiate
feeding
2-6 wks
Catch up
Growth &
Rehab
6-8 wks
Discharge
8-36 wks
FU
Sugar def
Hypothermia
Infection
ELectrolyte
DEhydration
Def of micro nutrn
Begin feeding
Restore wt for ht
Energy dense feeding
Stimulation
Prevent relapse
Transfer to home diet
11/22/14 Bedangshu 36

37. 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 11/22/14 Bedantgilslh uBS becomes normal 37

38. 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
11/22/14 Bedangshu 38

39. 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 11/22/14 of sBtoedoanl glsohuss, vomiting 39

40. 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
11/22/14 Bedangshu 40

41. 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
11/22/14 Bedangshu 41

42. 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 11/22/14 salt in diet Bedangshu 42

43. 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
11/22/14 Bedangshu 43

44. Management:
 Infection: choice of BSA
 Ampicillin for 2 days followed by Amoxycillin for 5 days
and
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
11/22/14 Bedangshu 44

45. 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
11/22/14 Bedangshu 45

46. 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 11/22/14 Bedangshu wt, by wk 2 46

47. 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
11/22/14 Bedangshu 47

48. 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
11/22/14 Bedangshu 48

49. Management: Starter Diets
Content
F-75 Starter F-75 Starter
(per 100ml)
(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)
- - - 2.5 (¾ tsf) 6 (2 tsf)
powdered rice
Veg oil (gm) 2 (½ tsf) 2.5 (½+ tsf) 3 (¾ tsf)
Water (ml) 100 100 100
Energy (kcal) 75 75 75
Protein (gm) 0.9 1.1 1.2
Lactose 11/22/14 (gm) 1.2 Bedan1g.s2hu 1.0 49

50. 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
7 (2+ tsf)
(gm)
Veg oil (gm) 4 (1 tsf)
Water (ml) 100
Energy (kcal) 75
Protein (gm) 1
11/22/14 Bedangslahuctose 0 50

51. 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 Bedangshu 51

52. Management:Catch up
Growth
Content (per
100ml)
F 100 F 100
(cereal based)
F 100
(low lactose)
F 100 (no
lactose)
Milk (ml) 95 75 25
Egg 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) 100 100 100 100
Energy (kcal) 101 100 100 100
Protein (gm) 2.9 2.9 2.9 3
1L1/a22c/t1o4se (g) 3.8 3 Bedangshu 1 0 52

53. 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
11/22/14 Bedangshu 53

54. 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
11/22/14 Bedangshu 54

55. 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
11/22/14 Bedangshu 55

56. 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/11/22/14 AIDS, psychBoeldoanggsihcual problems 56

57. 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, 11/22/14 Bedangs hsutructured play therapy 57

58. Management
Discharge 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,6mth
Aim : To prevent relapse and assure continued physical, mental and emotional development
11/22/14 Bedangshu 58

59. Causes of death
 Dehydration
 Dyselectrolytemia
 Hypothermia
 Hypoglycemia
 Anemia in CHF
11/22/14 Bedangshu 59

60. Bad prognostic signs
 Hypoglycemia
 Hypothermia
 Dehydration
 Infection
 CHF
 Hepatic failure
 Seizure
 Altered sensorium
 Severe dermatosis
 Bleeding diathesis
11/22/14 Bedangshu 60

61. Undesirable phenomenon
during rehabilitation
 CHF
 Nutritional recovery syndrome
 Neurological syndromes
 Pseudotumour cerebri
 Rickets
 Anemia
11/22/14 Bedangshu 61

62. Malnutrition is often found
to start in the womb and end in
the tomb
11/22/14 Bedangshu 62

63. THANK YOU
11/22/14 Bedangshu 63