Protein Energy Malnutrition

1
Protein Energy Malnutrition

• Cindy Howard, MD, MPHTM
• Associate Director
• Center for Global Pediatrics
• University of Minnesota
• November 8, 2008

2
Time Magazine, August, 2008
3
The percentage of under five mortality
worldwide caused in part by protein energy
malnutrition is estimated at

• 30
• 20
• 60
• 5

4
Definitions
5
Millennium Development Goals (MDG) 2000 United
Nations

• 1. Eradicate extreme poverty hunger
• 2. Achieve universal primary education
• 3. Promote gender equality and empower women
• 4. Reduce child mortality
• 5. Improve maternal health
• 6. Combat HIV/AIDS, malaria, other diseases
• 7. Ensure environmental sustainability
• 8. Develop a global partnership for development

6
Define PEM

• Underweight weight for age lt 80 expected
• Marasmus weight for age lt 60 expected
• Kwashiorkor weight for age lt 80 edema
• Marasmic kwashiorkor wt/age lt60 edema
• Wasting weight for height
• Stunting height for age
• SAM severe acute malnutrition

7
Underweight

• Define weight-for-age less 80 expected
• Encompasses both wasting and stunting
• Most global data
• High correlation with stunting
• Prevalence directly describes the magnitude of
  the problem of growth faltering and stunting in
  young children
• 130 million children under the age of five years

8
Marasmus

• Weight for age lt 60 expected
• No edema
• Often stunted
• Hungry, relatively easier to feed
• CFR20-30

9
Kwashiorkor(Edematous Malnutrition)

• Underweight with edema
• Irritable, difficult to feed
• Electrolyte abnormalities
• Highest mortality 50 to 60

10
STUNTING

• Height for age less than 90 expected

11
Severe Acute Malnutrition SAM

• Weight-for-height of 70 (extreme wasting)
• Presence of bilateral pitting edema of
  nutritional origin, edematous malnutrition
• Mid-upper-arm circumference of less than 110 mm
  in children age 1-5 years old

12
Complications of SAM include

• ARI
• Diarrhea
• Gram negative septicemia
• Poor feeding
• Electrolyte abnormalities
• All of the above

13
Complications of SAM

• ARI
• Diarrhea
• Gram negative septicemia
• Poor feeding
• Electrolyte abnormalities

14
TREATMENT of Undernutrition

• Varies depending on the type of malnutrition
• Immediate cause
• lack of food, lack of appropriate foods for age,
  lack of protein, maternal death, acute or chronic
  infection.
• Resources available
• Management protocols capable of reducing CFR to 1
  to 5

15
The first step in the treatment of SAM is
toprevent and/or treat hypoglycemia.

• True
• False

16
Ten Steps to Recoveryin Malnourished
ChildrenAshworth A, Jackson A, Khanum S
Schofield C1996
THE WHO TEN STEPS
17
Steps 1 and 2

• Prevent/treat HYPOGLYCEMIA
• Prevent/treat HYPOTHERMIA
• KEY is frequent feeding every two hrs night/day
• Skin to skin contact with parent, warm lamp,
• warm blanket, avoid exposure

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STEP3

• Treat/prevent dehydration

• Give ReSoMaL or comparable oral solution.
• Do not use the standard WHO oral rehydration
  salts solution. It contains too much sodium and
  too little potassium for severely malnourished
  children.
• 3. Do not use the IV route except in shock, and
  then do so with care to avoid flooding the
  circulation and overloading the heart.
• 4. Feed through diarrhea, continue breast
  feeding

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STEP4

• CORRECT ELECTROLYTE IMBALANCES

• Excessive Na
• Deficient potassium
• Deficient magnesium
• Remember Two weeks minimum to correct
• Prepare meals w/o salt
• Do NOT use a diuretic to treat edema

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STEP5

• TREAT INFECTION

• Give to ALL severely malnourished children
• broad-spectrum antibiotic
• measles vaccine to all children gt 6 months.
• Vitamin A
• Mebendazole 100 mg BID x 3 days
• Consider HIV and TB

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STEP6

• CORRECT MICRONUTRIENT DEFICIENCIES

• All severely malnourished children have vitamin
  and mineral deficiencies.
• Recommend Zinc, copper and MV daily
• Vitamin A and folic acid on Day 1
• Do NOT give iron until the child has a good
  appetite and starts gaining weight (usually
  during the second week of treatment).

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STEP7

• Cautious Feeding

• Powdered milk, sugar and oil
• May include electrolyte/mineral solution
• Day 1 7
• Low in protein and iron, high in energy
• Small, frequent feeds 130ml/kg div q2

23
Rebuild Tissues
Step 8

• Second week
• Advance to 200 ml/kg/day div q 3 to 4 hours
• Advance to local foods peanut butter, beans,
  margarine energy dense local foods

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STEP9

• Stimulation, Play and Loving Care

• tender, loving care
• structured play and physical activity as soon as
  the child is well enough
• a cheerful, stimulating environment.
• Encourage mothers involvement
• 90 expected weight for height ready for
  discharge

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STEP10

• Preparation for Discharge

Nutritional education Immunization Home
Follow Up

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Treatment of Malnutrition
27
Direct causes of death

• Hypoglycemia
• Hypothermia
• Dehydration
• Infection
• Severe anemia

Time Magazine, August, 2008
28
Outpatient management

• Malawi, Sudan, Ethiopia
• 2001-2005
• 23,511 severely malnourished children
• 74 treated solely as outpatients
• CFR4.1
• Recovery rates79.4
• Default 11
• Niger, MSF
• 60,000 children with SAM
• 70 outpatient
• CFR5

Lancet, 2006
29
Bibliography

• Stunting, Wasting, and Micronutrient Deficiency
  Disorders, Laura E. Caulfield, Stephanie A.
  Richard, Juan A. Rivera, Philip Musgrove, Robert
  E. Black, Disease Control Priorities in
  Developing Countries, 2nd edition, 2006,
  pages551-567
• Management of Severe Acute Malnutrition in
  Children, Steve Collins, Nicky Dent, Paul Binns,
  Paluku Bahwere, Kate Sadler, Alistair Hallam,
  Lancet, Vol. 368, December 2, 2006, pages
  1992-2000.
• What works? Interventions for maternal and child
  undernutrition and survival. Bhutta ZA, Ahmed T,
  Black RE, Cousens S, Dewey K, Giugliani E, Haider
  BA, Kirkwood B, Morris SS, Sachdev HP, Shekar M
  Maternal and Child Undernutrition Study Group,
  Lancet, February 2, 2008.
• Ten Steps to Recovery. Child Health Dialogue. 2nd
  and 3rd Quarter issues, 10-12.
• Guidelines for the Inpatient Treatment of
  Severely Malnourished Children Nonserial
  PublicationAshworth, A., Khanum, S., Jackson, A.,
  Schofield, C. World Health Organization
• ISBN-13    9789241546096 ISBN-10   
  9241546093