Written by Dr.Md.Redwanul Huq (Masum)

Monday, 16 January 2012 12:56

Definition:

Protein-energy malnutrition (PEM) consists of a wide range of clinical conditions occurring in infants and young children due to lack of protein and/or energy or both and associated with infection.

Classification of Protein-energy malnutrition (PEM):

Classification of Protein-energy malnutrition (PEM) is as following:

* Gomez classification (wt for age):

Grade of PEM	Weight for age (%)
Normal	90-100
Mild malnutrition, Grade I	75-89
Moderate malnutrition, Grade II	60-74
Severe malnutrition, Grade III	Less than 60

* Water low classification:

Grade of PEM	Stunting (low height for age)	Wasting (low wt for height)
Normal	95	90
Mild malnutrition	87.5-95	80-90
Moderate malnutrition	80-87.5	70-80
Severe malnutrition	Less than 80	Less than 70

* Welcome classification:

Weight for age	With edema	Without edema
60-80%	Kwashiorkor	Undernutrition
Less than 60%	Marasmic kwashiorkor	Marasmus

Differences between Kwashiorkor and Marasmus are given below:

Traits	Marasmus	Kwashiorkor
Cause	Mainly due to Calorie deficiency	Mainly due to protein deficiency
Time of onset	Onset is earlier, usually in first year of life	Onset is later, usually after breast feeding is stopped
Growth failure	More marked	Not very prominent
Edema	No edema	Edema present
Blood protein concentration	Reduced less noticeably	Reduced very much
Skin changes	Less frequent	Red boils and patches are typical symptoms
Liver infiltration with fat	Not infiltrated	Infiltrated
Recovery period	Prolonged in marasmus	Small in kwashiorkor

Risk factors of PEM:

i) Socioeconomic factors –  poverty, lack of parental awareness and education
ii) Feeding practices – introduction of formula, easy cessation of breast feeding, non- exclusive breastfeeding, insufficient complementary feeding practices
iii) Infections – water contamination and diarrhea are associated with PEM, malnutrition adversely affect the immune status and make the malnourished child more vulnerable to infections, during infections the child’s appetite is impaired. Moreover, wrong practices of withholding food, reducing feeding or diluting infant formula during the episodes of diarrhea may lead to PEM.
iv) Maternal factors – short maternal stature, anemia, low pre-pregnancy weight appear to be major factors in producing LBW babies who are more likely to develop PEM. Less birth space and large family size may also contribute to the poor nutritional status of mother.

Management of PEM (Protein energy malnutrition):

Investigations:

• Hb or PCV
• PBF
• Blood glucose
• S. electrolytes
• Serum protein
• Urine R/M/E & C/S
• Stool R/M/E
• Chest X-RAY
• Skin test for TB (MT)
• Test for HIV.

Possible findings in PEM:

In case of kwashiorkor:

• Hypoproteinemia
• Hypoalbuminemia
• Hypoglycemia
• Low levels of insulin and insulin like growth factor
• High levels of plasma cortisol and growth hormone
• Depletion of S. electrolytes, especially potassium and magnesium
• Decreased urinary excretion of urea
• LDH- Decreased
• Low levels of circulating lipids
• Ketonuria

In marasmus:

Increased urinary 3-methylhistidine

In both kwashiorkor and marasmus:

• Iron deficiency anemia
• Metabolic acidosis
• False-negative tuberculin skin test.
• Decreased urinary excretion of hydroxyproline

Treatment of protein energy malnutrition:

Treatment of protein energy malnutrition (PEM) is divided into 3 phases:

1. Initial treatment / resuscitation (For one week)
2. Rehabilitation (For 2 – 6 weeks)
3. Follow up (Upto 3 years).

1. Initial treatment:

The objectives are as follows:

* To treat or prevent hypoglycemia
* To treat or prevent hypothermia
* To treat or prevent dehydration
* To restore electrolyte balance
* To treat incipient or developed septic shock, if present
* To start to feed the child
* To treat infection
* To identify and treat vitamin deficiencies, severe anaemia and heart failure.

i) Treatment of hypoglycemia-

Blood glucose (mmol / L)	Condition of the child	Treatment
Less than 3 mmol/L or 54 mg/dl	Alert	50 ml bolus of 10% glucose or sucrose (Oral / NG)
Less than 3 mmol/L	Lethargic, unconscious or having convulsion	5 mg/Kg body weight 10% glucose I/V then50 ml bolus of 10% glucose or sucrose (Oral / NG)

ii) Treatment of hypothermia-

* Keeping the baby warm by wrapping with clothes, blankets, caps and socks
* Appropriate feeding.

iii) Treatment of dehydration-

Intravenous rehydration: It is indicated in-

1. Malnourished child with circulatory collapse
2. Child with septic shock

Solutions:

1. Ringer’s Lactate solution with 5% glucose
2. 0.45% normal saline with 5% glucose
3. Half strength Darrow’s solution with 5% glucose

Amount:

* I/V solution : 15 ml/Kg/hour I/V for 2 hours +
10 ml/ Kg/hour for 10 hours with ReSoMal orally or through NG feeding.

Feeding during rehydration :

* Breast feeding
* F – 75 diet after 2 – 3 hours of rehydration.

iv) Treatment of Septic shock:

* I/V rehydration and oral / NG feeding
* Blood / plasma transfusion -10ml/Kg body weight slowly over 3 hours.
* Inj: Vitamin K 1 -1 mg I/M single dose.

v) Dietary treatment:

* NG tube feeding- interval : 1^st day 2 hourly and from 2^nd day 4 hourly, day and night
* Diet : F-75(75 Kcal/100ml)
* Fluid : Chart of F-75 Diet(100ml/Kg/day)
* Calorie: Not less than80 Kcal/Kg/day(100ml/Kg/day) and not more than 100 Kcal/Kg/day.
* Preparation of F-75 and F-100 Diets:

Ingredients	F-75 Diet	F-100 Diet
Skimmed milk powder	25 g	80 g
Sugar	70 g	50 g
Cereal flour	35 g	–
Vegetable oil	27 g	60 g
Mineral mix	20 ml	20 ml
Vitamin mix	140 mg	140 mg
Water to make	1000 ml	1000ml

vi) Treatment of infection:

1.For severely malnourished children choice of antibiotics are-

* Amoxycillin
* Ampicillin
* Benzyl penicillin
* Gentamycin
* Chloramphenicol
* Cotrimoxazole.
* Best combination is [C-penicillin + Gentamycin] or, [Ampicillin + Gentamycin].

2. For amboebiasis and Giardiasis- choice is Metronidazole.
3. For dysentery choice is Nalidixic acid.
4. For helminthiasis the choices are-

• Albendazle – 400 mg once
• Mebendazole – 100 mg twice daily for 3 days
• Pyrantel pamoate – 1 mg /Kg single dose
• Levamisole.

5. For tuberculosis the drugs are-

* Isoniazid
* Rifampicin
* Pyrazinamide
* Ethambutol.

6. For malaria-

* For P. vivax, P. malariae and P. ovale – Cloroquine
* For P. falciparum malaria:

• Cloroquine
• Quinine
• Pyrimethamine + Sulfadoxine

7. For measles

* Vaccination
* Antibiotic
* Antipyretic

8.For dermatosis:

* For Candida infection in diaper area-

• Nystatin ointment or cream (100000 IU) bd for 2 weeks
• Oral nystatin (100,000 IU qds)

* For other affected areas:

• Zinc
• Castor oil ointment
• 1% potassium permanganate
• Povidone iodine
• Petroleum jelly
• Paraffin gauge dressing.

vii) Treatment of vitamin deficiency:

* Treatment of clinically vitamin A deficiency children-

Timing	Age of the child	Dosage
Day 1	Less than 6 months	50,000 IU
	6 – 12 months	1,00,000 IU
	More than 12 months	2,00,000 IU
Day 2		Same age specific dose
2 weeks later		Same age specific dose

* Ocular inflammation or ulceration:

– Application of eye pads soaked in 0.9% saline
– Tetracycline eye drops (1%)
– Atropine eye drops (0.1%).

viii) Treatment of severe anemia:

Blood transfusion (10ml/Kg over 3 hours)
– If Hemoglobin is less than 40 gm/L or PCV is less than 12%.

ix) Treatment of congestive heart failure:

* All oral intake and I/V fluid are stopped
* Diuretics: Frusemide (1mg/Kg)
* Digitalis (Digoxin).

x) Treatment of mineral deficiency:

* KCl : 3-5 mEq/kg/day for 2 weeks (1 tsf = 10 mEq)
* MgSO4: 10 mg/kg/day 2 weeks
* Zinc: 2 mg/Kg/day for 2-3 weeks(1 tsf = 50 mEq).
* Iron: 3 mg/Kg/day in 2 divided doses for 3 months.

2. Rehabilitation:

Criteria for transfer to a nutrition rehabilitation centre:

* Eating well
* Sits, crawls, stands or walks
* Normal temperature
* Improved mental state
* No edema
* No vomiting
* No diarrhea
* Gaining weight – more than 5 gm/kg/day for 3 consecutive days.

Nutritional rehabilitation:

* Less than 2 years-

– Liquid or semi-liquid fluid
– F- 100 diet- every 4 hours, night and day, increasing amount of diet at each feed by 10 ml until child refuses to finish the feed
– Calorie- 120-220 Kcal/kg/day

* More than 2 years-

– F-100 diet and solid food
– F-100 diet and mixed diet- alternatively 6 times daily.

Stimulation of emotional & sensorial development:

• Environment facilities
• Playing facilities
• Physical activities.

Immunization:

Vaccination to the child if not yet taken.

Criteria for discharge:

A child with PEM should continue to be followed up in the nutrition clinic until the following criteria are fulfilled:

1.  Weight-for-age of the child increases to above -2SD for three consecutive visits.
2. The child is gaining weight at a normal or an increased rate.
3. The child can eat the recommended amounts of nutritious foods at the frequency and nutritional quality recommended.
4. The child is not pale and has been given the required doses of vitamins and minerals.
5. The child is not suffering from any apparent illness or infection.
6. Mother is able to carry out the feeding recommendations, manage minor health problems at home and she knows when to seek medical advice.
7. Health worker is capable to communicate with the Community Support Group members in the community and ensure follow up of the child.

3. Follow Up:

* 1^st Follow up- After 7 days
* 2^nd Follow up- After 30 days
* 3^rd Follow up- After 3 months
* 4^th Follow up- After 6 months
* Next Follow up- Twice yearly for at least 3 years.

Complications of PEM:

* Infection
* Hypoglycemia
* Hypothermia
* Dehydration
* Electrolyte imbalance.