Protein Energy Malnutrition (PEM)
in Children
Arturo S. Gastañaduy M.D.
Associate Professor of Pediatrics
Louisiana State University
July 2011
Learning Objectives
Epidemiology of PEM in children of developing and
developed countries
Diagnosis and management of childhood PEM
Specific interventions for prevention of PEM
Immediate Causes of Childhood Deaths: 2008
Global Trends in the Prevalence of Moderate-Severe
Malnutrition in Children Under Five
Region
1990
1995
2000
2008
%
Million
%
Million
%
Million
%
Africa
27.3
30.1
27.9
34.0
28.5
38.3
24
Asia
36.5
141.3
32.8
121.0
29.0
108.0
31
LatinAmerica
10.2
5.6
8.3
4.5
6.3
3.4
7.0
Developing
world
32.1
177.0
29.2
159.5
26.7
149.6
22
Million
178.0
Prevalence (%) of Moderate-Severe Malnutrition in Children
Under Five in Selected Countries
(From World Health Organization Data Base)
Country/Year
Weight/Age
Height/Age
Weight/Height
-2 SD
-2 SD
-2 SD
USA/2004
1.5
4.1
0.7
Germany/2006
1.2
1.5
1.1
Belarus/2005
1.8
5.7
2.8
Bulgaria/2004
2.6
12.7
4.5
Ukraine/2000
5.4
35.6
12
China/1998
8.2
25.6
3.0
Protein Energy Malnutrition
WHO Classification
Moderate
Edema
No
Severe
Yes
Wt / Ht Deficit1 (%)2
2-3 (70-79)
>3 (<70)
Ht /Age Deficit1 (%)2
2-3 (85-89)
>3 (<85)
1 Standard deviation from median of reference population
2
Percentage of the median of reference population: NCHS/WHO
Protein Energy Malnutrition
Waterlow Classification
Ht/Age
Wt/Ht
SD
Median
1-2
%
Median
80-89
SD
Median
1-2
%
Median
90-95
Moderate
2-3
70-79
2-3
85-90
Severe
>3
<70
>3
<85
Mild
Mac LAREN SCORE
CLINICAL FINDINGS
Edema
Dermatosis
Edema & Dermatosis
Hair Changes
Hepatomegaly
Serum Albumin
POINTS
3
2
6
1
1
0-7
(1 point for every 0.5 gram below 3.5 gm/dl)
TYPES OF MALNUTRITION
TYPE
Mac Laren SCORE
Marasmus (M)
Marasmus – Kwashiorkor (MK)*
Kwashiorkor (K)*
0-3
4-8
> 9
*All MK and K patients have third degree malnutrition
regardless of weight deficit (or excess)
Why is the new WHO classification
recommended?
• It is practical
• Combines severity and type of malnutrition in
one table
• It does not require a laboratory or sophisticated
equipment
• It is easy to teach and use in the field
• It has proven its utility in disaster situations
Protein Energy Malnutrition
Basis of Management
1. Restore and maintain hydro electrolytic
balance.
2. Aggressive diagnosis and treatment of
infections.
3. Nutritional therapy: oral feeding.
4. Prevention and treatment of complications.
5. Physical and psychological stimulation.
6. Parental education and social evaluation.
Assessment of Hydration Status:
History
Diarrhea/day
Vomiting/day
Urine/last 12 hours
Mild
Moderate
Severe
1-5
0-3
>2
6-10
4-6
1-2
>10
>6
0
Assessment of Hydration Status:
Physical Examination
Mental Status
Response to stimulus
Oral Mucosa
Tenting (Chest)
Peripheral Pulses
Mild
Moderate
Severe
Alert
Cry
Mild Dry
No
Present
Depressed
Weak cry
Dry
<2 sec.
Weak
Coma
No cry
“parrot”
>2 sec.
No felt
Unreliable Signs of Dehydration
in severely malnourished children
*Sunken Eyes:
Normal in Marasmus patients
Can not be seen with edema
*Tenting (abdomen)
Normal in Marasmus patients
Difficult to assess with edema or
abdominal distention
*Capillary refill
(peripheral)
Usually delayed: cold extremities
edema
Assessment of Hydro-electrolytic Status:
Laboratory evaluation
Basic
Advanced
Hematocrit
Total serum protein
Urine specific gravity
Accucheck
BMP
CMP
Zn, Cu, others
Stool electrolytes
Expected Hydro-electrolytic Changes
(“Well Hydrated” patient)
Total Body Water
Sodium
Potassium
Excess
Excess
Deficit
Serum
Normal - Low
Normal
132-+ 4 mEq/L
3.5 + 1 mEq/L
Albumin
Globulin
Sodium
Potassium
Urine Specific Gravity
1010 + 5
Treatment of Dehydration
Rehydration
Mild
Moderate
Severe
ReSoMal
ReSoMal
IV Fluids*
80cc/kg
8 hrs
IV Fluids*
50cc/kg
in 4 hrs
100 cc/Kg
12 hrs
Replacement
Volume to Volume: ReSoMal.
Maintenance
Feeding immediately after rehydration.
* RL or NS: 20 cc/kg bolus as needed. Add Dextrose 5%
ORS for Diarrhea and Malnutrition
Component
(mmol / L)
Normal ORS
ReSoMal
Glucose
Sodium
Potassium
Chloride
111
90 - 75
20
80
125
45
40
70
Citrate
Magnesium
Zinc
20
-
7
3
0.3
Copper
Osmolality
310
0.045
300
Management of Infections in PEM
Effect of PEM in the Immune System
• Cell Mediated Immunity
• Ig A levels in secretions
• Phagocyte Killing
• Inflammatory response
• Signs of infection ( Fever, WBC count)
• Hypoglycemia and Hypothermia are signs of
severe infection or septic shock
Management of Infections in PEM
Therefore:
• Infections are the rule
• Multiple infections coexist
• Diagnosis as aggressive as possible
• Empiric treatment should be started
immediately
Management of Infections:
Laboratory Evaluation
Basic
Advanced
WBC & Differential
Cultures: Blood
Urine dipstick
Urine
Stool microscopy
Stool
lugol, methylene blue
Others
Scotch tape
Ova and Parasites x3
KOH
Duodenal aspirate
Thick blood smear
CXR, PPD, Serology
for
Infections in Severely Malnourished Children
Points to Remember
* PEM patients are immunosuppressed (Cellular)
* Gram Negative enteric bacteria are common
* Rule out sepsis: Fever, hypothermia, poor feeding, abdominal
distention, paralytic ileus, lethargy
* Most deaths occur in 1st 48 hours of admission
* Risk factors: Age <6m especially <4m, Edema, Jaundice
Petechiae, Respiratory distress
* Suspect Infection: Poor weight gain, persistent edema
Treatment of Common Infections
DIARRHEA:
Watery:
Usually non-specific Hydration-Nutrition
Cholera: Doxycycline, single dose
Tetracycline x 3 days
Ciprofloxacin, TMP-SMX
Bloody:
SEPSIS:
Shiguella: Ampicillin, TMP-SMX x 5days
Ciprofloxacin, Ceftriaxone
Campylobacter: Erythromycin x 5 d
Azythromycin
Ceftriaxone: 100 mg/Kg/day IV X 10-14 days
Amikacin:
15 mg/Kg/day IV X 10-14 days
Treatment of Common Infections
UTI:
TMP-SMX, Cephalosporin 3, Gentamicin
PNEUMONIA:
Ceftriaxone 100mg/Kg/day IV X 2 days
Consider Vancomycin
OTITIS:
Amoxicillin 90 mg/Kg/day PO X 10 days
Infection Management: WHO
No apparent complications Complications: lethargy, fever,
hypothermia, hypoglycemia
TMP/SMX BID for 5 days
Ampicillin 50 mg/Kg IM/IV Q 6 hours
for 2 days
Amoxicillin 15 mg/kg PO Q 8 hours
for 5 days
+
Gentamicin 7.5 mg/Kg IM/IV QD
for 7 days
If no improvement in 48 hours
add
Chloramphenicol 25 mg/Kg IM/IV
For 5 days
Other Important infections
TBC: No weight gain could be only sign
PPD usually negative, check for exposure
Drug therapy according to local susceptibility
UTI: Common
US, IVP, & VCUG for recurrent disease
Parasites: Giardia: Metronidazole, Tinidazole
Strongyloides: Ivermectin, Albendazole
Ascaris: Albendazole, Mebendazole
HIV: Increasing Prevalence
Wasting syndrome: Poor prognosis
Management: depends on drug availability
Nutritional Therapy in PEM
Effects of PEM on the GI System
• Gastric acid production
• Intestinal motility
• Bile & Pancreatic enzymes
• Nutrient absorption
• Atrophy of intestinal mucosa
GI infections and diarrhea are very common
Diet (Formula) Composition
1. Energy provided by:
Protein
Fat
Carbohydrate
8-10 %
45 %
45 %
2. Volume: Marasmus
MK - K
100 - 120ml/kg/day
75 ml/kg/day
Formula (Diet) Composition
3. Caloric Density
4. Osmolality
5 Sodium
6. Potassium: Marasmus:
Kwashiorkor:
7. Vitamins & Minerals
.75 - 1.2 kcal/ml
< 300 m 0sm/L
2 mEq/Kg/day
3 mEq/Kg/day
5-8 mEq/Kg/day
> 1.5 RDA
Useful Diets for the Treatment of Severe
Malnutrition
DIET
COMMENT
Breast Milk
Cow’s Milk
Lactose - Free Formulas
Milk- Staple + Oil
Cereal – Legume
Chicken Based
WHO: F75, F100
Use it when available
Lactose-malabsorption possible
Expensive- Not available
Safe, inexpensive, available
Inexpensive, available
Also Useful
No kitchen , out-patient
Milk-Rice-Oil Diet Composition
Amount*
(g)
Milk**
7.0
Rice Flour
10.0
Vegetable Oil 3.9
TOTAL
(% of energy)
Energy*
(Kcal)
33.3
35.9
30.7
100.0
Protein*
(g)
Fat*
(g)
CHO*
(g)
1.9
0.6
-2.5
1.80
0.07
3.41
5.25
2.4
7.9
--10.3
10.0
48.8
41.2
Water added to complete 100-125ml/Kg/day. Vitamins and Minerals to
satisfy 1.5 RDA. * Amount /Kg/day. ** Whole dried cow milk
Preparation of WHO F-75 and F-100 diets
Ingredients
F-75
F-100
Dry skimmed
milk (g)
Sugar (g)
25
80
70
50
Cereal flour (g)
35
-
Vegetable oil (g)
27
60
Add: vitamin mix 140 mg, mineral mix 20 ml and water to make 1,000 ml
Nutrient in 100 ml of F-75 and F-100 diets
Energy (kcal)
Protein (g)
Fat (g)
CHO (g)
Lactose (g)
Potassium (mmol)
Sodium (mmol)
Magnesium(mmol)
Zinc (mg)
Cooper (mg)
mOsmol/L
F-75
75
0.9
2.7
11.8
1.3
3.6
0.6
0.43
2.0
0.25
333
F-100
100
2.9
5.9
8.75
4.2
5.9
1.9
0.73
2.3
0.25
419
Volume (ml) of F-75 per feed to provide 100
Kcal/kg/day
Wt (kg)
2.8
3.2
Q 2h
30
35
Q 3h
45
55
Q 4h
60
70
3.6
4.0
4.6
40
45
50
60
65
75
80
90
100
5.0
5.4
6.0
55
60
65
80
90
100
110
120
130
Treatment and Prevention of
Complications
Hypoglycemia:
Hypothermia:
Hypoprothrombinemia:
Vitamin A Deficiency
Hypomagnesaemia
Hypocupremia
Severe Anemia
Prevent Infections
Frequent feedings (Q2-3h)
Dextrose 5% in IV Fluids
Keep patient warm, quick and organized
bath and changing of clothing
Vat. K 1 mg IM on admission
Vit. A 50,000 - 100,000, 200,00 IU
Mg So4 1-2 mEq/Kg/day
Cu So4 -15mg/Kg/day (1%Sol)
Pack RBC 10ml/Kg
Routine Immunization, Isolation
procedures as needed
Psycho-Sensorial Stimulation
Effect of PEM on the Central Nervous System
• Brain Size
• Cortical Thickness
• Synaptic Connections
• Neurotransmitters
• PEM Vs Emotional Deprivation
• Recovery Towards “Normal “ is the rule
Gunston, G.D. et al. Reversible cerebral shrinkage in
Kwashiorkor: an MRI study. Arch Dis Child. 1992, 67:
1030-1032
Psycho-Sensorial Stimulation
•
•
•
•
•
•
•
•
Start immediately
Encourage parental participation
No limits for visiting hours
Surrogate mothers and aunts
Play therapist
Toys
Bright colors
Songs, Music
Parental Education & Social Evaluation
• Start immediately
• Practical Hygiene Measures
• Hand washing, safe excretal disposal
• Clean & Nutritional appropriate diets
• Breast feeding, avoid bottles
• Solid foods, Food preparation, Best buy
• Health Education: Immunizations
• Social services
Protein Energy Malnutrition
Time-Frame for Therapy
Treat
Dehydration
Electrolyte
imbalance
Hypoglycemia
Hypothermia
Infections
Feeding
Micro nut.
Deficits
Psychosensorial
Days 1-2
Days 3-7
Weeks 2-6
--------- - - - - - >
----------------------------------------------------
-------- - - - - - - >
-------- - - - - - - >
--------------------------
Begin-------------------
No iron -----------------
Weeks 7-26
Increase--------------------------
With Iron-
---------------------------------------------------------------------------
* Modified from Management of severe malnutrition: a manual for physicians
and other senior health workers, WHO Geneva 1999
Prevention of Malnutrition
Interventions that work
• Maternal and birth outcomes:
Maternal supplements micronutrients*
Reduce tobacco consumption*
• Newborn babies:
Promotion of breast feeding by Individual and group
counseling
Prevention of Malnutrition
Interventions that work
•
Immunization*
•
Hygiene: Hand washing, excretal disposal*
•
Vitamin A, Zn, Iodine*
•
Treatment of diarrhea and acute malnutrition*
•
Malaria prevention*
•
Education for complementary feedings*