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Protein Energy Malnutrition ([PEM) of Early Childhood

Posted by sammy on February 5, 2013 at 4:40 PM

Malnutrition in childhood.

 

The term malnutrition is derived from two French

 

words (mal = bad) and (Nutriture = nutrition) and

 

it literally means ‘bad nutrition’, and technically

 

includes under nutrition and over nutrition.

 

f

Malnutrition is a significant contributor/cause of

morbidity and mortality among children less than

five years of age in sub-Saharan Africa (SSA).

 

f

Malnutrition (PEM), singly or in combination with

other disease, is a significant contributor/cause

of morbidity and mortality among children less

than five years of age in Uganda as well.

 

f

PEM underlies two-fifth (. 40%) of childhood

deaths in Uganda.

 

f

Thus, protein energy malnutrition (PEM) is a

significant public health problem, mainly of the

under developed world.

 

f

Current accurate statistics on the magnitude of

the problem, both on the global and the local

level are scanty:

Examples:

-

850 million people are chronically hungry in

the world

 

UCG 2010

177

 

 

 

 8. Nutrition

-

4-6 million Ugandans suffer from chronic

energy deficiency.

-

20% Ugandans live in abject poverty and

suffer from chronic hunger.

 

-

About 39%, 22.5% and 4.0% of the under-five

year old children are stunted, underweight and

wasted respectively in Uganda.

 

f

In the under-five year old children, the most

prevalent form of malnutrition is protein energy

malnutrition (PEM).

 

f

Protein energy malnutrition (PEM) describes a

broad spectrum of clinical conditions ranging

from Marasmus (dry malnutrition) on one

extreme end to Kwashiorkor (wet malnutrition)

on the other extreme end with intermediate

forms, such as Marasmic – Kwashiorkor (mixed

malnutrition).

 

f

The intermediate forms constitute the majority of

cases.

 

Forms of PEM:

 

Primary PEM – Inadequate diet is the

primary cause;

Secondary PEM – disease or other medical

condition is the

primary cause;

diet is secondary.

Acute malnutrition – Is an indictor of current

nutritional status,

reflecting recent

weight changes or

disruption in nutrient

intake.

-

Acute malnutrition is the most appropriate

indicator of the current nutritional status and

appropriate indicator to use in an emergency

 

UCG 2010

178

 

 

 

 8. Nutrition

setting. The children are thinner than the

normal ones of same height.

 

-

Chronic malnutrition – Is an indicator of the

nutritional status overtime. Chronically

malnourished children are shorter (stunted)

than their comparable age group.

 

Aetiology/Causes of PEM:

 

Causes/contributing Factors to Malnutrition:

 

- Immediate causes: diet

 

 

disease

 

- Basic causes: Food Insecurity

Poor health services

Poor environmental

sanitation

 

 

- Underlying causes: Poverty

(4P’s) Politics

Policies

 

 

Programs

 

Food Factors:

-

Food insecurity

-

Balanced diet (6 principles of diet design)

-

Organoleptic characterisitics of food (e.g.

colour, taste, consistency, flavour)

-

Food preparation

-

Food taboos

Non-Food Factors

-

Infections and infestations

-

Poverty and corruption

-

Poor governance

-

Human rights and the right to food

UCG 2010

179

 

 

 

 8. Nutrition

-

Poor infrastructure

-

Poor marketing and distribution system

-

Underdeveloped Agro-Industry

-

Inter-sectoral nature of nutrition

-

Loan facilities

-

Nutrition education/advocacy

-

Political economy

-

Saving culture

 

Some of the factors responsible for

malnutrition include:

-

Excessive workload for women; No time to

 

prepare nutritious meals for the children.

 

-

Poverty

 

-

Inadequate food intake

 

-

Presence of disease

 

-

Poor weaning practices

 

-

Food insecurity

 

-

Poor maternal and child rearing practices

 

-

Inadequate water supply.

 

-

Harmful cultural practices/institutions

 

-

Poor environmental sanitation

 

-

Family instability

 

-

Low family incomes

 

-

Low education/or illiteracy

 

-

Lack of nutrition education (IEC component of

 

PHC)

 

(IEC = Information, Education,

 

Communication; PHC = Primary Health

 

Care)

 

Consequences of PEM

 

Several consequences of PEM in children

include:

-

Impaired growth and development

-

Impaired mental development.

-

Impaired body resistance/immune system.

-

Increased risk of adult chronic diseases

 

UCG 2010

180

 

 

 

 8. Nutrition

-

Increased risk for the cycle of inter-

generational malnutrition

 

 

-

Contributes a lot to the loss of millions of

dollars to the national economy and overall

development.

 

Clinical Features of PEM

 

Marasmus:

-

Severe wasting (severe weight loss of

muscle tissue and subcutaneous fat).

-

Wasting is less than 60% (= - 3SD) of the

expected weight for age (% Harvard

Standard)

 

-

Absence of bilateral pitting oedema of both

feet.

 

-

“Old man’s face” – because of severe

wasting of muscles and subcutaneous fat on

the face.

 

-

The ‘excess skin’ hangs/gathers around the

buttocks (baggy pants)

-

The ribs are prominent, so are the zygoma

 

bones.

-

Scapular blades and extremities (the limbs)

-

Eyes are sunken (due to loss of orbital fat).

-

Apathetic/or at times irritable in case of

 

medical complications

-

Appetite is fairly good

-

Skin is almost normal

-

Hair demonstrates some changes – Not as

 

dramatic as in Kwashiorkor.

-

Organomegaly is rare (liver, spleen –

enlargement)

 

Kwashiorkor

-

Presence of bilateral pitting oedema

(oedema of both feet)

-

Miserable

-

Apathetic

 

 

UCG 2010

181

 

 

 

 8. Nutrition

-

Moon face

-

Appears adequately nourished due to

excess extra cellular fluid.

-

Skin changes (dermatosis) (flacky paint

dermatitis)

-

Hair changes . silky, straight, sparsely

distributed, easily, painlessly pluckable.

-

Severe pallor of the conjunctiva, mucous

membranes, palms and soles.

-

Loss of skin turgor (dehydration) +

malnutrition

-

Organomegaly (Liver, spleen) is common.

 

Marasmic – Kwashiorkor

Presents with features of both Marasmus and

Kwashiorkor, such as:

-

Oedema of both feet

-

Marked wasting (due to loss of muscles +

 

 

fat)

-

Apathy/Misery

-

Skin changes (Dermatosis)

-

Hair changes (silky, pluckable)

-

Some degree of organomegaly (Liver,

 

Spleen)

 

UCG 2010 182

 

 

 

 8. Nutrition

Biochemical and Immunological Features

 

Variable Marasmus Kwashiorkor

 

•Total protein .

..

•Serum Albumin .

..

•Serum Globulin .

.. or

Normal

•Serum Transferrin .

..

•Serum Immunoglobulins . or .

.. or .

(IgG, IgM, IgA)

•Serum complement ..

•Cortisol .

..

•Insulin ..

•Glucagon ..

•Serum Electrolytes . or Normal . or

Normal

•Serum Sodium . or Normal . or

Normal

•Serum Potassium ..

•Serum magnesium ..

•Serum Zinc ..

•Serum Selenium ..

•Serum Iron . or .. or .

•Serum Copper ..

Differential Diagnosis

 

-Nephrotic syndrome (Nephritis)

 

-Liver disease

 

-Heart disease

 

-Malabsorption syndrome

 

-Malignancy (e.g. Gastro intestinal tract

 

cancer,

 

-Liver Cancer/Hepatocellular carcinoma).

 

UCG 2010 183

 

 

 

 8. Nutrition

Investigations:

The following investigations are useful in

establishing a diagnosis of PEM and

differential diagnoses.

 

 

History: - especially Dietary history

Blood: - Complete Blood count (Full

Haemogram) (e.g. Hb, ESR, white blood cells

(WBC) (total and differential)

Red blood cells (RBC), Haematocrit

Blood sugar, serum electrolytes, serum protein

(total and Albumin, globulins), serum

complement, transferin immunoglobulins (IgG,

IgM, IgA); haemoparasites, Malaria, HIV/AIDS

Urine:

 

Urinalysis – Urine sugar, protein, casts

(granular, hyaline), electrolytes, amino acids/

or amino acid metabolites, microorganisms,

cells (WBC or RBC).

Stool

 

Stool microscopy – for ova and cysts, occult

blood, parasites.

Chest x-ray

 

Look for evidence of Tuberculosis or other chest

abnormalities.

The Management of Protein Energy

 

Malnutrition of Early childhood

 

Assessment of the Nutritional status:

-

Histories

-

Physical examination

-

Anthropometric measures

-

Biochemical indicators

-

Immunological indicators

-

Clinical features.

UCG 2010

184

 

 

 

 8. Nutrition

Dietary history:

-

Obtain a detailed history on food intake of

the child, especially the 24-hour dietary

recall.

-

History on breast-feeding and

weaning/complementary feeding should

also be sought.

-

History of both present and past

infections/illness and their management.

 

-

History of immunization against the six

common immunizable diseases (Measles,

Tuberculosis, Whooping cough/Pertussis,

diphtheria, Polio, Tetanus) and now also

against influenza and meningitis plus

hepatitis B in adults.

 

Clinical Examination

Anthropometry (physical body dimensions)

-

Weight for age (W/A)

-

Height for age (H/A)

-

Weight for Height (W/H)

-

Mid upper arm circumference (MUAC)

-

Quack stick Index (MUAC/Ht)

SYSTEMS REVIEW (SYSTEMIC EXAMINATION)

 

 

Examination should be systematic; from head to toe.

 

CNS:

-evidence of mental retardation

 

EENT:

-

Symmetry of eyes, ears and relation to nose

-

Evidence of infection (e.g. otitis media,

conjunctivitis)

-

Evidence of nutrient deficiency (e.g. bitot

spot, angular stomatitis, cheilosis, magenta

tongue).

 

-

Pallor of mucous membranes

-

Mouth ulcers

 

 

UCG 2010

185

 

 

 

 8. Nutrition

R/S:

-

Evidence of chest infection (e.g. cough,

dyspnoea)

-

Increased respiratory rate (RR)

 

CVS:

-Increased heart rate (HR); increased pulse

rate(PR)

 

P/A:

-

Bowel movements

-

Abdominal distension – Ascites,

organomegaly (e.g. enlarged liver, spleen)

 

-

Bowel sounds (e.g. Alterations in paralytic

ileus/dehydration, obstruction

(constipation/worms)

 

Urinary system/Urogenital System

(UGS)

-

Painful micturition/crying on passing urine

-

Blood in urine

-

Pain around public area – evidence of

 

cystitis (bladder infection)

-

Pus in urine (Pyuria)

 

 

Integumental System:

-

Skin turgor (malnutrition, dehydration)

-

Skin lesions/dermatosis, flaky paint

dermatitis, ulcers

 

Musculoskeletal System

-

Wasting (loss of muscle tissue and

subcutaneous fat)

-

Bilateral pitting oedema of both feet –

(may present in grades 0 up to 3)

-

Flabby muscles.

 

General examination

-

Temperature

-

Cyanosis

-

Jaundice/icterus

UCG 2010

186

 

 

 

 8. Nutrition

General Principles of Initial Treatment

 

Management

a) Treatment/Prevention of Hypoglycaemia

(blood sugar <3mmol/l or <55mg/dl)

Give 2ml/Kg of 25% glucose/dextrose solution IV

-

Prepare by diluting 50% glucose/dextrose

solution with an equal volume of saline or

Ringer’s Lactate infusion or – give 10%

glucose solution – 2ml/Kg by mouth.

-

Use common table sugar/sucrose if glucose

is not available or 5mls/Kg/hr of Glucose

5% (50g sugar in 1 litre of water).

- Prepare by dissolving 2 teaspoonful of

sugar in half a mug (18 teaspoonful

=100mls) of clean water.

-

Begin feeding quickly upon admission.

- Provide frequent and regular small feeds

(3 hourly day and night)

-

Treat infections promptly

- If the patient can drink, give a small feed

of an intensive therapeutic diet (F75,

SENUSU, DISCO 150).

 

Classification of Malnutrition (PEM)

Biochemical Classification

-

Macro-nutrient malnutrition (PEM in children)

-

Micro-nutrient malnutrition (Hidden Hunger)

 

Public Health Classification

-

Stunting (height/age - 2SD)

-

Underweight (weight/age - 2SD)

-

Wasting (weight/height -2SD)

Clinical Classification Underweight

-

Mild

-

Moderate

-

Severe

UCG 2010

187

 

 

 

 8. Nutrition

Severe Underweight

-

Kwashiorkor (wet malnutrition)

-

Marasmus (Dry malnutrition)

-

Marasmic –Kwash (Mixed malnutrition)

 

Overweight/obesity

-

In children

-

Majority cases are adults

 

 

b) Treatment/Prevention of Hypothermia

 

-

Measure body temperature twice daily

-

Ensure that the patient is well covered

with cloths, hats and blankets.

-

Ensure enough covering/blankets are

provided at night.

 

-

Encourage caretaker/mother to sleep next

to her child (body to body contact,- direct

heat/warmth transfer from mother to

child).

 

-

Keep the ward closed during the night

and avoid wind drafts inside.

 

-

Quickly clean the patient with a warm wet

towel and dry immediately. Avoid

washing the baby directly in the first few

weeks of admission.

 

-

Provide frequent and regular small feeds

(3 hourly day and night).

-

Hypothermia is axillary temperature

<35oC and rectal temperature <35.5oC.

 

c)

Treatment of Dehydration

 

Dehydration is a clinical condition

brought about by the loss of significant

qualities of fluids and salts from the

body.

Common causes of dehydration include:

-

Diarrhoea

-

Excessive sweating as in high fever

UCG 2010

188

 

 

 

 8. Nutrition

-

Vomiting

-

Respiratory distress

 

 

Management of dehydration is with

plans A, B, C.

This dehydration treatment modality is

based on the degree of dehydration.

Plan A

 

-

There is no clinical dehydration yet

-

It is meant to prevent clinical dehydration

 

1.

Advise the mother/Caretaker on

the 3 rules of home treatment (i.e.

extra fluids, continue feeding,

appointment to come back for review)

Give extra fluids – as much as the child

can/will take.

2.

Advise mother to:

-

Continue/increase breast feeding

 

-

If the child is exclusively breastfed

give oral rehydration solution (ORS)

or clean water in addition to milk.

 

-

If the child is not exclusively breast

fed, give one or more of:

 

• ORS

• Soup

• Rice-water

• Yoghurt drinks

• Clean water

-

In addition to the usual fluid intakes

give ORS after each loose stool or

Episode of vomiting.

 

• < 2yrs . give 50 –100ml

• > 2 yrs . give 100 – 200ml

-

Give the mother 2 packets of ORS to

use at home

-

Giving ORS is especially important if

the child has been treated with Plan B

or Plan C during current visit.

 

UCG 2010

189

 

 

 

 8. Nutrition

-

Give small but frequent sips of ORS from

a cup.

 

-

If the child vomits, wait for 10 minutes,

then give more ORS slowly.

 

-

In a child with high fever or respiratory

distress, give plenty of fluids to counter

the increased fluid losses in these

conditions.

 

-

Continue giving extra fluid as well as ORS

until the diarrhoea or other cause of

dehydration ceases.

 

3. Advise the mother on:

-

Correct breastfeeding and other feeding

 

during sickness and health

 

-

Increasing fluids during illness

 

-

How to maintain her own health

 

-

When to return to the health

 

worker/health facility for review.

 

Plan B

-

There is some clinical dehydration

-

Give ORS in the following amount during

the first 4 hours:

 

Age (Mo) <4 4-12 13-24 25-60

 

Weight (Kg) <6 6-9.9 10-11.9 12-19

 

ORS (ml) 200-400 400-700 700-900 900-1400

 

Notes:

 

1.

Only use the child’s age when the weight is not

known.

2.

Yuo can also calculate the approximate amount

of ORS to give a child in the first 4 hours as:

Weight (KG) x 75ml

-

Show the mother how to give the ORS:

Give frequent small sips from a cup.

If the child wants more than is shown in the

table, give more as required.

UCG 2010

190

 

 

 

 8. Nutrition

If the child vomits, wait 10 minutes, then

continue more slowly

-

For infants <6 months who are not

breastfed, also give 100-200ml of clean

water during the first 4 hours.

 

-

Reassess the patient frequently (every

30-60 minutes) for the classification of

dehydration and the selection of the

treatment plan.

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