Protein Energy Malnutrition

 

 

 

 

 

 

 

 

 

Protein Energy Malnutrition

Clinical Syndromes of PEM

—Nutritional Dwarfism

—Marasmus

—Marasmus Kwashiorkor

—Kwashiorkor

PEM: Associated deficiencies

—Vit A Def.

—Iron & folic acid

—Zinc

—Potassium

—Magnesium

PEM & Immunity

• Cell mediated immunity

• Non specific immune mechanisms

• Lysozyme

• Bactericidal property of leucocytes

• Secretory IgA

• Total Immunoglobulins

• IgG

Protein Energy Malnutrition

Protein Energy Malnutrition (PEM) is defined as a range of pathological conditions arising from coincident lack of varying proportions of protein and calorie, occurring most frequently in infants and young children and often associated with infection (WHO,1973) PEM affects children under 5 years of age belonging to the poor underprivileged communities.

Under nutrition is a complex condition with multiple deficiencies such as proteins,energy and micro nutrient deficiencies often occurring together. According to WHO, malnutrition is an underlying factor in over 50 % of the 10 – 11 million yearly deaths of children under 5 years.

KWASHIORKOR

Epidemiology

—2nd year of life

—Rural > Urban

—Weaned from breast to low protein staple

—Emotional deprivation

—Precipitating infection

Skin changes

—Hyperpigmentation

—Hypopigmentation

—Cracking

—Peeling

—“ Crazy paving”

—“ Flaky paint dermatosis”

Hair changes

—Hypopigmentation

—Thin

—Sparse

—Easily pluckable

—“Flag sign”

his disease was first reported to occur in children in Africa by Dr.Cicely Williams in 1935.

It is caused by deficiency of proteins in the diet. The important symptoms of the disease are:

· Growth failure

· Oedema of the face and lower limbs

· Muscle wasting

· Fatty liver

· Anorexia(loss of appetite)

· Diarrhoea

· Change in the colour, sparse, soft and thin hair.

· Change in the colour of the skin(hypo and hyperpigmentation)

· Anaemia

· Vitamin A deficiency

· Angular stomatitis(Cracks in the corners of mouth)

· Cheilosis (inflammation and cracks in lips)

· Moon face

Marasmus

Clinical features

—Weight < 60% STD

— subcutaneous fat

—Muscle wasting

—Psycho motor changes ( Apathy, Irritability)

—Skin and hair changes – Rare

—No edema

II. Marasmus

This is caused by severe deficiency of proteins and calories in the diet. The important features are as follows:

· Severe wasting of muscles

· Loss of subcutaneous fat (Limbs appear as skin and bones)

· Skin is dry and atrophic

· Anaemia

· Eye lesions due to Vitamin A deficiency

· Irritability and fretfulness

· Diarrhoea

· Dehydration

· Body temperature is sub-normal

· Failure to thrive

· Wrinkled skin - Old man’s face

· Grossly underweight

III. Marasmic Kwashiorkor

Children suffering from this disease show signs of both kwashiorkor and marasmus.

PRINCIPLES OF MANAGEMENT

In severe EPM principles

v Correction of dehydration

v Screening and treatment of infection

v Intensive nutrition therapy

v Nutrition rehabilitation

v Correction of associated deficiency

v Prevention of hypothermia

v Stimulation and play therapy

v Community follow up

NUTRITION THERAPY

NUTRITION SUPPLIMENTATION

NUTRITION INTERVENTION

FOOD FORTIFICATION

Nutrition therapy

vUsually in a hospital

vIn liquid form initially

vMay need NG feeds

vFrequent small feeds initially

2 –3 hourly 4 – 6 hourly

150ml/Kg/day

150/200 KCAL/Kg/Day

vUse energy rich formulae

vUse local ingredients

e.g. kwashiokor mix

skimmed milk

coconut oil

sucrose

Correction of dehydration

v ORS- Commonly

v IVF – Rarely

Screening for Infection

v Clinical history and examination

v Urine FR

v Stool AOC

v Blood for MP

v CXR

Routine antibiotics empirically on best guess basis

v Poor response

v Think of TB/HIV

Correction of Associated deficiency

nVit. A 200,000 units oil muscle P.O. routinely

nIron-Total dose IM/IV – use normogram

nFolic acid routinely

nIf Hb < 3.0g with packed RBC

nZinc supplements for skin lesions/diarrhoea

nPotassium Supplements

Prevention of hypothermia

nHypothermia can be lethal in severe EPM

Magnesium

Nutrition Rehabilitation

Follows nutrition therapy criteria for suitability for N.R.

v Absence of oedema

v Return of appetite

v Commencement of weight gain

Aims of N.R.

v Achieve median weight for Ht.

v Complete immunisation

v Psycho- social recovery

v Educate mother

v Establish contact with field health team

Community follow up of ERM

v In local CWC

vBy local health team

vGrowth monitoring

vNutr. Supplementation

vComplete immunisation

vNutrition education

vFamily planning

vSanitation

vTreatment of minor ailments

vHome visiting

vSocial support

http://www.mri.gov.lk/assets/Nutrition/2007-SAM-manual-health-workers.pdf