PROTEIN ENERGY

MALNUTRITION
ZINC CASE
• A 6-month-old baby boy presents with diaper rash that resistant to
therapy. There is history of Intermittent diarrhea. He is on
breastfeeding and is not taking any solid food. Mother is a vegetarian.
On examination, he is thin and listless. There are dry plague-like,
sharply demarcated lesions around his mouth and eyes. Hair is coarse
and scanty.
Acrodermatitis enteropathica
• Acrodermatitis enteropathica is an autosomal recessive disorder.
• It is caused by an inability to absorb sufficient zinc from the diet
• The genetic defect is in the intestinal zinc-specific transporter gene.
• Zinc has a role in numerous metabolic pathways (including those of
copper, protein, essential fatty acids, and prostaglandins).
• Zinc is incorporated into many zinc metallo-enzymes.
Clinical findings
• Signs and symptoms usually appear in the first few months of life.
• There is cutaneous eruption characterized by vesiculobullous, eczematous, dry, scaly,
skin lesions.
• Skin lesions are symmetrically distributed in the perioral, acral, and perineal areas.
Other common sites are cheeks, knees, and elbows.
• Hair is of a peculiar, reddish tint.
• There may be alopecia.
• Other manifestations include: Ocular manifestations (photophobia, conjunctivitis,
blepharitis, and corneal dystrophy), Chronic diarrhea, Stomatitis Glossitis,
Paronychia, Nail dystrophy, Growth retardation, irritability, Delayed wound healing,
Intercurrent bacterial infections, Superinfection with Candida albicans
• Lymphocyte function is impaired.
• Free radical scavenging is also impaired.
• Chronic zinc deficiency may cause growth retardation and delayed development.
Diagnosis
• A low plasma zinc concentration (less than 50 we/dL)
• Levels of alkaline phosphatase (a zinc-dependent enzyme) may be
decreased
• Histopathologic changes in the skin (parakeratosis and pallor of the
upper epidermis)
Management

• Oral therapy with zinc is indicated Dose is 1-3 mg/kg/day of elemental

zinc
• Zinc therapy rapidly improves the manifestations of the disease
• The cause of underlying malnutrition should be treated
IODINE
• lodine is required for the synthesis of thyroid hormone, which in turn are
needed for the regulation of metabolic activities of all cells throughout the
life They are also required to ensure normal growth, especially of the brain,
which occurs from fetal life to the end of the third postnatal year.
• lodine deficiency will impair thyroid function, resulting in a lower metabolic
rate, growth retardation and brain damage. Long-term consequences are
irreversible mental retardation
• lodine deficiency is the most prevalent cause of preventable mental
retardation in the world
• The successful global campaign to iodize all edible salt is reducing the risk
associated with this deficiency
MALNUTRITION CASE
• A 15 months old boy is brought in emergency with complains of loose
motions and vomiting for last three days. His diet is not adequate. On
examination her weight is 7.5 kg mid upper arm circumference
(MUAC) 11 cm, length 68 cm.
Malnutrition
• Malnutrition is defined as a pathological state resulting from relative or
absolute deficiency of one or more essential nutrients.
• Severe acute malnutrition is defined as severe wasting and/or bilateral
edema.
• Severe wasting in infants of under 6 months of age is marked by visible severe
wasting.
• Whereas for children > month of age, severe wasting is assessed objectively
using anthropometric measurements (weight for length/height, mid-upper
arm circumference).
• Severe wasting is extreme thinness diagnosed by a weight-for-length for
height) below - 3 SD of the WHO Child Growth Standards.
• In children ages 6-59 months, mid-upper arm circumference <115 mm
also denotes extreme thinness color banded tape is a convenient way
of screening children in need of treatment
• Bilateral edema is diagnosed by grasping both feet, placing a thumb
on top of each, and pressing gently but firmly for 10 seconds. A pit
(dent) remaining under each thumb indicates bilateral edema.
• To be considered a sign of severe malnutrition, edema must appear in
both feet. If the swelling is only in one foot, it may just be a sore or
infected foot. The extent of edema is commonly rated in the following
way (WHO criteria)
• The simple name protein-energy malnutrition is avoided, as it does not show
the complex multi deficiency etiology.
• Marasmus means (severe wasting), kwashiorkor (characterized by edema),
and marasmic kwashiorkor means (severe wasting + edema). Every year
about 10.6 million children in the world die before 5 years of age. Seven out
of 10 of these deaths are due to diarrhea, pneumonia, measles, malaria or
malnutrition.
• Malnutrition is primary when there is deficiency of food availability or
secondary when food is available but body cannot assimilate it for one or
another reason.
• Malnutrition is common in children between the age of 3 months and 3 years
but it can also occur earlier or later.
• Mortality is highest in children who are suffering from malnutrition.
Malnutrition in infants and preschool children may have a permanent effect
on physical growth and development. It may affect mental development also.
Etiology

• Various causes of protein energy malnutrition (PEM) are as follows:

Primary Malnutrition
• Failure of lactation Breast milk me insufficient for the requirement of the child, e.g. if mother becomes
pregnant or she is suffering from certain illness
• Ignorance of weaning: Mother's milk is adequate up to the age of 4-5 months when the weaning food weaning
should be started. Most mothers are ignorant about weaning food, for not only the time at which to we the
type of weaning food to be introduced.
• Poverty: Parents may be unable to buy m eggs or other high calorie food. In addition adequate housing, clean
water supply and All these factors predispose the child to in malnutrition.
• Cultural patterns and food fads: Cultural far Influence nutrition. Some mothers instead nourishing food to the
child may give hi toffees or tea. Concept of 'hot food' usually withdrawal of eggs from the child's diet banana,
citrus fruit and rice are considered to food and withheld from the child's diet in dominated society, best food
such as meat, eggs, and fruits are first served to the adult male members family and left over are consumed by
the woman and children.
• Lack of Immunization and primary care: Repeated infections like diarrhea, respiratory infections major factors
leading to malnutrition, Lack of care results in vicious cycle of infection, malnutrition and further infections.
Lack of immunization a common Infectious diseases may result in me whooping cough or tuberculosis, sapping
energy of child and resulting in malnutrition.
• Lack of family planning: Malnutrition is common large, poor families where family planning is practiced.
Mother becomes weak following repeated pregnancies, overwork and lack of nutritive food Malnourished
mother in turn gives birth to low bine weight babies who become malnourished later on.
Secondary malnutrition
• It is caused by the infection, malabsorption, congenital malformations
or metabolic defects. It is not due to deficiency in the diet.
• Infections: Acute, chronic or recurrent infections of the major body
systems like gastrointestinal tract, respiratory tract, and urinary tract.
• Parasitic infestations like worms, parasites (giardia) and malaria
• Measles, whooping cough
• Primary tuberculosis
• Urinary tract infection
Congenital diseases Malabsorption:
• Heart diseases, e.g. Fallot's tetralogy • Giardiasis
ventricular septal defect
• Congenital lung diseases • Lactose intolerance
• Urinary tract anomalies, e.g. obstructive • Celiac disease
uropathy
• Obstruction to CSF flow, e.g. hydrocephalus • Tuberculosis of the intestine
• Cystic fibrosis
Metabolic disorders: Psychosocial deprivation

• Diabetes mellitus
• Inborn errors of metabolism
• Diabetes insipidus
• Storage diseases
• Galactosemia
• Neurodegenerative disorders
PROTEIN ENERGY MALNUTRITION

• Definition : PEM has been defined by WHO as a range of pathological

conditions arising from coincidental lack in varying proportion of
protein and calories occurring most frequently in infants and young
children and commonly associated with infection.
• “Often starts in the womb and ends in the Tomb”
Ecology of Malnutrition
Conditioning influences
• Low birth weight
• Infections - e.g. Diarrhea, Respiratory infections- Measles Whooping cough, Tuberculosis and
Helminthiasis
Socio economic factors
• Poverty
• Ignorance
• Illiteracy
• Lack of knowledge regarding food values
• Unhygienic environment
• Large family size
• Over crowding
Food fads (personal likes & dislikes) Cooking practices

Cultural practices
• Food habits
• Customs and belief
• Tradition
• Religion
• Food fads (personal likes & dislikes)
• Cooking practices
• Child rearing practices
• Superstitious belief
Prevalence of Undernutrition
• Globally, in % of children <5 years of age were underweight (weight
for- age <−2 SD).
• Asia carries 69% of the global burden of underweight children, 58% of
the global burden of stunted children, and 70% of the global burden
of wasted children.
• Africa carries most of the remaining global burden.
• For children <5 yr, the global prevalence is estimated to be 33% for
vitamin A deficiency, 29% for iodine deficiency, 17% for zinc
deficiency, and 18% for iron-deficiency anemia.
Theories of Malnutrition
Dietary Hypothesis of PEM
• Kwashiorkor - Predominant protein malnutrition
• Marasmus - Predominant calorie deficiency
Gopalan’s hypothesis of inadaptation
• Failure of adaptation – Kwashiorkor
• Well adapted mechanism – Marasmus
• Mild adaptation – Nutritional dwarfism
• Inadaptation in a previously marasmic child – Marasmic kwashiorkor
Goldens hypothesis of Free Radical Damage
• Kwashiorkor – overproduction of free radicals and Breakdown of protective
mechanisms provided by antioxidants
Aflatoxin Hypothesis
• Kwashiorkor – aflatoxin contamination of food
Basis of Classification of PEM

• Weight - for – Age

• Weight- for – Age & Edema
• Weight – for – Height & Height-for-age
• SD Scores
• Mid-arm Circumference
Syndromal Classification
Wellcome trust Classification
Jelliffe’s Classification
Gomez’s Classification
Mc Laren’s Classification
Arnold Classification
Waterlow Classification
Udani’s Classification
Body Mass Index (BMI)
• It is calculated by dividing weight in kilograms by the square of height
in meters
• BMI = weight(kg)/height (m)
• For children, BMI is age and gender-specific.
• BMI-for-age can be used from birth to 20 years and is a screening tool
for thinness (<-2 SD), overweight (between +1 SD and +2 SD), and
obesity (>+2 SD).
Micronutrient deficiencies
• These are another dimension of undernutrition.
• Those of particular public health significance are vitamin A, iodine,
iron, and zinc.
Evaluation of the malnourished child

History
• Usual diet before current episode of illness
• Breastfeeding history
• Food and fluids taken in past few days
• Recent sinking of eyes
• Duration and frequency of vomiting or diarrhea
• Appearance of vomit or diarrheal stools
• Time when urine was last passed
• Contact with people with measles or tuberculosis
• Any deaths of siblings
• Birth weight
• Milestones reached (sitting up, standing, etc)
• Immunization
PHYSICAL
• Weight and length (or height)
• Edema
• Enlargement or tenderness of liver, jaundice
• Abdominal distension, bowel sounds, abdominal splash (a splashing sound in the abdomen)
• Severe pallor
• Signs of circulatory collapse: Cold hands and feet, weak radial pulse, diminished
consciousness
• Temperature: Hypothermia or fever
• Thirst
• Eyes: Corneal lesions indicative of vitamin A deficiency
• Ears, mouth, throat: Evidence of infection
• Skin: Evidence of infection or purpura
• Respiratory rate and type of respiration Signs of pneumonia or heart failure Investigations
INVESTIGATIONS
• Blood glucose: Glucose concentration <54 mg/dl indicates hypoglycemia
• Examination of blood smear by microscopy: Presence of malaria parasites indicates infection
• Hemoglobin or packed cell volume: Hemoglobin<4 g/dl or packed cell volume <12% indicates very
severe anemia.
• Examination and culture of urine specimen: Presence of bacteria on microscopy (or >10
leukocytes per high power field) is indicative of infection.
• Examination of feces by microscopy: Presence of blood indicates dysentery. Presence of giardia
cysts or trophozoites indicates infection.
• Chest X-ray: Pneumonia causes less shadowing of the lungs in malnourished children than in well-
nourished children. Vascular engorgement is indicative of heart failure. Bones may show rickets.
• Skin test for tuberculosis: Often negative in children with tuberculosis or those previously
vaccinated with BCG vaccine.
• Serum proteins: Not useful in management, but may guide prognosis.
• Electrolytes: Rarely helpful and may lead to inappropriate therapy.
MARASMUS
CASE
• A 2-year-old child presents with fever, irritability and diarrhea. His
weight is 7 kg (weight loss. There is marked muscle wasting
• It is 20 times more common than kwashiorkor
• It usually occurs below 2 years of age but can occur in older children
Etiology: (Causes of primary malnutrition)
• Marasmus is most commonly due to dietary deficiency or sometime due
to severely restricted food intake Child's diet is deficient in calories, which
fails to satisfy the minimum requirement of the rapidly growing child.
• Over diluted milk is given to the child either due to ignorance or from fear
of cost.
• Weaning food are not started at all or weaning is done later than 4-5
months of age.
• Infections: Diarrhea, measles, pertussis and primary tuberculosis may
cause malnutrition. Mothers may starve the child following the attack of
diarrhea for fear of aggravating it.
• Other Secondary factors responsible for marasmus are less frequently
Figure 6. 11. Marasmus
Clinical findings
• The clinical picture consists of growth retardation, marked muscle wasting and loss
of subcutaneous fat.
• The face is shriveled and has no buccal pad of fat, thighs and buttocks are shriveled
and skin becomes loose and hangs in folds.
• Abdomen is protuberant due to hypotonic muscles.
• The temperature is subnormal.
• The tendon reflexes are diminished and plantar reflexes may be absent in extreme
cases.
• Child resents being examined but he is usually alert and has a good appetite.
• Edema is never present.
• Skin and hair changes are absent.
• Signs always present
• Extreme growth failure and weight below 60% of the expected
weight.
• Marked muscle wasting and loss of subcutaneous fat.
• Patient is usually alert and has a good appetite.
• Face is wizened and shriveled like "little old man" or monkey face.
There are virtually no buttocks and head seems large in proportion to
the body.
• Signs occasionally present
• Anemia
• Diarrhea and signs of dehydration
• Signs of vitamins deficiencies, e.g. cheilosis, dermatosis and rickets
• Respiratory infections, tuberculosis and measles may complicate the
clinical picture.
Prevention
• Detection and treatment of early malnutrition
• Promote breastfeeding up to the age of 1-2 years
• Avoid artificial feeding till the age of 4-6 months
• Introduce semi-solids at 4-6 months of age
• Immunization and primary care
• Prevention of infective diarrhea, e.g. hand wash
MARASMUS

• In Greek marasmus, which means wasting.

• Marasmus is characterized by failure to gain weight and irritability,
followed by weight loss and listlessness until emaciation results.
• Severe wasting , Severe growth retardation,
• No edema or hair changes or fatty liver,
• Alert but miserable, Hungry
• Child is alert, irritable with voracious appetite.
• Body weight is less than 60% of expected weight for age
• The loss of subcutaneous fat gives rise to certain characteristic features:
Large head with depressed anterior fontanelle, Sunken, lusterless eyes,
Prominent bony points, Loose folds of skin are prominent over gluteus
and inner aspect of thigh, Contour of atrophic muscles is evident under
skin.
• Hypopigmented hair
• Skin is dry, wrinkled, scaly and inelastic
• Distended abdomen with wasting and hypotonia of abdominal muscles.
KWASHIORKAR

• Kwashiorkor was first described by Cicely Williams. The word means

“red boy” in Ga language of Ghana. Later, it was considered as
“deposed child” (disease of the child when the next child is born and
the first deprived of breast-feeding and tender loving care).
Kwashiorkor was thought to have resulted from failure of adaptation .
KWASHIORKOR CASE
• A 2 year-old child presents with progressive weight loss and edema
feet. On examination, there is muscular atrophy, loss of skin turgor,
and hypothermia. Heh dark desquamating skin rash over most of the
press points on the body. His hair is very thin and reddish.
• It usually occurs between 1-5 years of age. But, occur earlier or later.
• Edema is always present but does not involve serous cavities.
• Supply of required calories may be a little less proteins are grossly
deficient.
Signs always present

• Generalized edema
• Growth failure (wasting masked by edema)
• The child is weak and wasted but has some subcutaneous fat
• Psychomotor changes, e.g. apathy and irritability
Signs usually present
• Hair changes: Hair fine, straight and sparse, discolored
• Anemia: Inadequate production of RBCs due to:
• Low iron stores and folic acid
• Low protein supply due to malnutrition
• Hookworm infestation
• Malaria
• Loose stools due to:
• Infective diarrhea
• Secondary lactase deficiencies
Signs occasionally present
• Skin
• Flaky dermatitis and either or hyperpigmentation on covered areas
• Ulcers or open sores may be present
• Signs of vitamin deficiencies
• Liver:
• Liver is enlarged due to fatty infiltration
Kwashiorkor (Body Fails to Adapt)
“Constant features” of Kwashiorkor
• Mental changes: Lethargic, listless, apathetic with little interest in
surroundings and food.
• Growth failure is always present.
• Edema: Starts from lower extremities and later involves upper limbs and face.
• Ascites is uncommon. Face is moon shaped and puffy. The cause of edema is
multifactorial; hypoalbuminemia giving rise to decreased plasma volume,
resulting in reduced cardiac output and GFR leading to retention of Na+ and
water, which is also aided by renin-angiotensin mechanism coming in to play,
due to decreased renal blood flow, as well as increased ADH.
• Muscle wasting is masked by edema
• Hair changes: Thin, dry, easily pluckable, hypopigmented
• Flag sign: Alternate band of hypopigmented and normal pigmented
hair It signifies alternate episodes of good and poor nutrition.
• Skin changes: Dry and scaly skin
• Marbelization: Soft and shiny skin with marble-like feel.
• Enamel paint dermatoses: Hyperpigmented patches of skin in flexural
areas and which desquamate.
• Flaky paint dermatoses: When above areas becomes confluent.
• Crazy pavement dermatoses: Seen in extensor surfaces (over shins);
depigmented skin is covered with dark shiny patches which crack like
parched earth.
• Petechiae and ecchymosis
Occasionally present signs

• Hepatomegaly-due to fatty liver; enlarged with rounded lower

margins and soft consistency.
• Dehydration
• Cardiomyopathy & Failure
• Signs of Vitamin Deficiency
• Signs of Infections
Complications
• Hypothermia
• Hypoglycemia
• Cardiac failure (shock)
• Infections
• Vitamin A deficiency (corneal clouding and ulceration)
• Severe anemia
• Dermatosis
• Watery diarrhea and/or vomiting and dehydration
• Abdominal distension
 Biochemical changes
• There is hypoproteinemia and reversal of albumin globulin ratio.
• There is ketonuria due to starvation.
• Glucose tolerance curve is like diabetic patients Although peak blood sugar is not very
high but decline of blood sugar is very slow.
• There is aminoaciduria.
• Plasma amino acids are low.
• Urinary excretion of hydroxyproline is less as compared to creatinine.
• Serum cholesterol is low. Serum cholinersterase, lipase, alkaline phosphatase and 17-
ketosteroid are decreased
• There is deficiency of vitamin K and tendency for bleeding
• Serum growth hormone level is increased
Management in severe malnutrition
• Successful management of the severely malnourished child requires
that both medical and social problems be recognized and corrected.
• If the illness is viewed as being only a medical disorder, the child is
likely to relapse when he or she returns home, and other children in
the family will remain at risk of developing the same problem.
Initial Treatment: (2-3 days)
• Life-threatening problems (hypoglycemia, hypothermia, infection and
fluid electrolyte balance) are identified and treated in a hospital.
• Specific deficiencies are corrected.
• Metabolic abnormalities are corrected.
• Feeding has begun.
Rehabilitation
• Early rehabilitation (3-7 days)
• Late rehabilitation (2-6 weeks)
• Intensive feeding is given to recover most of the lost weight.
• Emotional and physical stimulation are increased
• The mother is trained to continue care at home.
• Preparations are made for discharge of the child
Follow up: (4 6 months) -
• After discharge, the child and the child's family are followed to
prevent relapse and assume the continued physical, mental and
emotional development of the child
Emergency treatment (first phase)
• Initial treatment begins with admission to hospital and lasts until the
child's condition is stable and his/her appetite has returned, which is
usually after 2-7 days If the initial phase takes longer than 10 days, the
child is failing to respond.
• The principal tasks during initial treatment are: - To treat or prevent
hypoglycemia
• To treat and prevent hypothermia
• To treat or prevent dehydration and restore electrolyte balance
• To treat incipient or developed septic shock, if present
• To start feeding the child
• To treat infection
• To identify and treat any other problem, including vitamin deficiency,
Severe anemia, and heart failure
• These patients require hospitalization and need careful evaluation for
complications like dehydration and acute infections, which may
threaten life
• Give oxygen, IV glucose, and IV fluids for shock
• Main principles of management are given below
Fluids and electrolyte balance
• Intravenous rehydration (IV infusion) is only indicated in a severely malnourished child with circulatory collapse caused by severe
dehydration or septic shock. IV fluids can easily cause fluid overload and heart failure in a severely malnourished child (only give IV
fluids to children with signs of shock).
Use one of the following solutions in order of preference):
• Ringer's lactate solution with 5% dextrose
• Normal (0.9%) saline with 5% dextrose
• Half-strength Darrow's solution with 5% dextrose
• Give 15 ml/kg Intravenous over 1 hour and monitor the child carefully for signs of over-hydration.
• Reassess the child after 1 hour.
• If the child is severely dehydrated, repeat the IV treatment (15 ml/kg over 1 hour) and the switch to ResoMal orally or by NG tube.
There should be an improvement with IV treatment and his or her respiratory and pulse rates should fall. In this case, if the child fails
to improve after the first IV treatment and his or her radial pulse is still absent, then assume that the child has septic shock and treat
accordingly.
• ResoMal is a rehydration solution for children with severe acute malnutrition (SAM). It is a modification of the standard Oral
Rehydration Solution (ORS) recommended by WHO. ResoMal contains less sodium, more sugar, and more potassium than standard
ORS and is intended for severely malnourished children with diarrhea. It should be given by mouth or by nasogastric tube. Do not give
standard ORS to severely malnourished children.
• Contents of ResoMal as prepared from standard ORS:
• For a child who has dehydration but no sign of shock give ResoMal as
follows, in amounts based in the child's weight:
• The amount offered in this range should be a the child's willingness to drink
and the an ongoing losses in the stool.
• If the child has already received IV fluids for shock is switching to ResoMal,
omit the first treatment and start with the amount for the period of up to
10 hours.
• Replace ongoing loss with 30 ml of ResoMal per watery stool for edematous
children and with 50-100 ml for non-edematous children under 2 years and
100 to 200 ml for non edematous children 2 years and above.
Hypoglycemia
• All severely malnourished children are at risk of developing hypoglycemia (blood glucose <54 mg/dl) is an
important cause of death during the first 2 day of treatment.
• Hypoglycemia may be caused when:
• A serious systemic infection is present.
• A malnourished child has not been fed for hours.
• To prevent hypoglycemia, the child should be led least every 2-3 hours day and night.
• Signs of hypoglycemia are low body temperature (<36.5°C), lethargy, drowsiness, limpness, loss of
consciousness, sweating and pallor usually do not occur in malnourished children with hypoglycemia.
• If hypoglycemia is suspected, treatment should be given immediately without laboratory confirmation
will give no harm, even if the diagnosis is incorrect. In a conscious child, give 50 ml of 10% glucose or
sucrose Stay with the child until he/she is fully alert. If the child is losing consciousness and cannot take
orally, give 5 ml/kg sterile 10% glucose IV, followed 50 ml of 10% glucose or sucrose by Nasogastric tube.
• If glucose cannot be given immediately, the NG dose first. Continue frequent oral or NG feeds to prevent
a recurrence.
Control of Infection
• Infections such as tuberculosis, urinary and septicemia should be
treated. Antibiotics are usually used to control infection.
• Give all severely malnourished children antibiotics for presumed infection even if they
do not have clinical signs of systemic infections. Give the first dose of Antibiotics while
other initial treatments are going on, as soon as possible
• Children with no apparent signs of infection and no complications should be given
amoxicillin or cotrimoxazole orally for 5 days.
• Children with complications (septic shock, hypoglycemia, hypothermia, skin
infections, respiratory or urinary tract infections, or who appear lethargic or sickly)
should be given: Ampicillin (50 mg/kg IM or IV every 6 hours for 2 days), followed by
amoxicillin (15 mg/kg orally every 8 hours for 5 days) and gentamicin (7.5 mg/kg IM
or IV once daily for 7 days.
• If the child fails to improve within 48 hours, add ceftriaxone 100 mg/kg divided into 2
doses IV or IM for 5 days.
• If specific infections are identified which require a specific antibiotic not already being
given, give an additional antibiotic to address that infection. For example, dysentery
may require additional antibiotics. Certain skin infections such as candidiasis require
specific treatment. Antimalarial treatment should be given accordingly. Hypothermia
Hypothermia
• A severely malnourished child is hypothermic if the rectal temperature is below 35.5'C or if the
axillary temperature is below 35°C.
• Infants and children with marasmus are highly susceptible to hypothermia due to large areas of
damaged skin or serious infections,
• If the underarm temperature is below 35°C (95°F), the child should be warmed.
• Following techniques may be used to warm the child:
• Kangaroo technique by placing the child on the mother's bare chest or abdomen (skin-to-skin) and
covering both of them.
• Clothe the child well (including the head), cover with a warmed blanket and place an incandescent
lamp over, but not touching, the child's body.
• Temperature must be measured every 30 minutes during rewarming with a lamp to prevent
hyperthermia.
• All hypothermic children must also be treated for hypoglycemia and for serious systemic infections.
Severe anemia
• Severe anemia is a hemoglobin concentration of <4 g/dl (or
hematocrit<12%). If it is not possible to test hemoglobin, rely on clinical
judgment.
• Severe anemia can cause heart failure and must be treated with a
blood transfusion. As malnutrition is usually not the cause of severe
anemia, it is important to investigate other possible causes such as
malaria and intestinal parasites (for example, hookworm).
• Give blood transfusion in the first 48 hours if:
• Hb is <4 g/dl, (Het is <12%), or
• Hb 4 to 6 gm/dl (Hct 12 to 18%) and respiratory distress
Corneal clouding and ulceration
• Corneal clouding and ulceration are dangerous conditions that may
lead to loss of vision if not treated urgently
• Give vitamin A and atropine eye drops immediately for corneal
ulceration
• Vitamin A dose is given in next table.
• You should instill one drop atropine (1%) into the affected eye(s) to
relax the eye and prevent the lens from pushing out. Tetracycline eye
drops and bandaging are also needed (WHO recommendation)
Dietary management
• The principle of dietary treatment is adequate amount of protein and
calories.
• Initially, small frequent feeds are given as these patients are anorexic and prone to vomiting. Tube
feeding is required in severe cases.
• Milk is one of the best form for providing both calories and proteins.
• After 7-10 days of dietary management, solid feeds are required for children older than 4-6 months.
These include dalia, khichri, feerni and eggs.
• In first 3-4 days, give 90-150 ml/kg skimmed milk or half diluted cow's milk.
• Three to four days later, add one solid feed per day.
• Add another solid feed/day after another 3-4 days later
• By 20th day of rehabilitation, add three solid feeds/day.
• What is reductive adaptation? The systems of the body begin to "shut down" with severe malnutrition.
The systems slow down and do less in order to allow survival on limited calories. This slowing down is
known as reductive adaptation. As the child is treated, the body's systems must gradually "learn to
function fully again. Rapid changes (such as rapid feeding or fluids) would overwhelm the systems, so
feeding must be slowly and cautiously increased.
Feeding formulas
FS and F 100
• F-75 is the starter formula to use during initial management, beginning as
soon as possible and continuing for 2-7 days until the child is stabilized.
• Severely malnourished children cannot tolerate usual amounts of protein
and sodium at this stage, or high amount of fat. They may die if given too
much protein or sodium. They also need glucose, so they must be given a
diet that is low in protein and sodium and high in carbohydrate.
• F-75 is especially made to meet the child's needs without overwhelming
the body's systems in the initial stage of treatment.
• Use of F-75 prevents deaths.
• F-75 contains:
• 75 kcal
• 0.9 g protein/100 ml
• As soon as the child is stabilized on F-75, F-100 is used as a catch-up
formula to rebuild wasted tissues.
• F-100 contains more calories and protein
• 100 kcal
• 2.9 g protein/100 ml
Mineral mix
• Mineral mix is included in each recipe for F-75 and F-100. It is also
used in making ResoMal.
• The mix contains potassium, magnesium, an essential minerals. 6 and
the
Recipe for F-75
Re-feeding syndrome
• It occurs if aggressive carbohydrates are given. There is an increased
insulin level resulting in shifting of potassium, phosphate and
magnesium into the cells.
• The severe hypophosphatemia during re-feeding produces weakness,
rhabdomyolysis, neutrophil dysfunction, cardio-respiratory failure,
seizures, altered level of consciousness or sudden death.
Rehabilitation
• Rehabilitation phase is started when the child's appetite has returned.
• A child who is still on NG tube feeding is not considered ready to
enter the rehabilitation phase. Principles of management:
Principle tasks during rehabilitation phase are:
• To encourage the child to eat as much as possible
• To re-initiate and/or encourage breastfeeding as necessary
• To stimulate emotional and physical development
• To prepare the mother to continue to look after the child after
discharge
Criteria for transfer to nutritional rehabilitation:
• Child should remain in hospital for the first part of the rehabilitation phase. The
child should be transferred to nutritional rehabilitation when all the criteria given
below have been met (usually 2-3 weeks after admission)
• Eating well
• Mental state has improved: smiles, responds to stimuli, Interested in surroundings
• Sits, crawls, stands or walks (depending on age)
• Normal temperature (36.5-37.5°C)
• No vomiting or diarrhea
• No edema o Gaining weight: >5 g/kg of body weight per day for 3 successive days
Nutritional rehabilitation:

• The most important determinant of the rate of recovery is the amount of energy consumed.
• Infants under 24 months can be fed exclusively on liquid or semi-liquid diets. Older children
can be given solid food.
• Nearly all severely malnourished children have anemia and should be given supplementary
folic acid and iron Iron should never be given during the initial phase of treatment, but must
be given during the rehabilitation phase. Giving iron early in treatment can have toxic
effects and interfere with the body's ability to resist infection. Iron is given in a dose of 3
mg/kg/day in 2 divided doses for 3 months. Folic acid is given 5 mg on day one and then 1
mg/day thereafter.
• Child should be weighed daily. The usual weight gain is about 10-15 e/kg/day. A child who
does not gain at least 5 /k/day for 3 consecutive days is failing to respond to treatment.
With high energy feeding most severely malnourished children reach their target weight for
discharge after 2-4 weeks.
Recovery:
• As described above, recovery takes place in o Initial recovery occurs in
2-3 weeks when edema disappears and other signs improve.
• Consolidation phase: In next 2-3 months, child regains normal weight
and is considered clinically recovered.
Criteria for discharge from hospital: two stages:
1 Child:
• Weight gain is adequate (at a normal or increased rate).
• Eating an adequate amount of nutritious diet that the mother can prepare at home.
• All vitamin and mineral deficiencies have been treated.
• All infections and other conditions have been or are being treated, including anemia, diarrhea, intestinal parasitic infections, malaria,
tuberculosis, and otitis media
• Full immunization program started. (All children from 9 months who are not vaccinated should be given measles vaccine both on
admission and discharge. The first measles dose often does not give a protective antibody response. It is given because it ameliorates
the severity of incubating measles and partially protects from nosocomial measles. The second dose is given to provoke protective
antibodies).
2. Mother:
• Able and willing to look after the child
• Knows how to prepare appropriate food and to feed the child
• Knows how to make appropriate toys and to play with the child
• Knows how to give home treatment for diarrhea, fever, and ARI, and how to recognize the signs that mean she must seek medical
assistance
• Should be counseled strongly on exclusive breastfeeding
3. Health worker:
• Able to ensure follow-up of the child and support for the mother
Follow up
• Planned follow up of the child at regular intervals after discharge is
essential
• As the risk of relapse is greatest soon after discharge, the child should
be seen after 1 week, 2 weeks, 1 month, 3 months, and 6 months.
• If a problem is found, visits should be more frequent until it is
resolved.
• After 6 months, visits should be twice yearly until the child is at least
3-year-old.
Management in mild and moderates cases .

• These patients respond rapidly to dietary therapy unless they have gastroenteritis or
other infections.
• Mainstay of treatment is enough food, which is prepared fresh and is not
contaminated.
• Milk alone is adequate for 4-6 months old infant while weaning food are given to
older children.
Their requirements are
• Calories 120 Cal/kg/day
• Protein 2-3 g/kg/day
• Vitamin A 1500 IU/day
• Other requirements are same as for se patients
OBESITY AND OVERWEIGHT
CASE
• A 12-year-old boy presents for evaluation of Physical examination is
normal but his weight is 67 kg (99.6th centile) and height 151 cm
(75th centile) giving a BMI of 29 (obese).
• Body Mass Index (BMI) is used as a screen identify possible weight
problems in children
• It is calculated by dividing weight in kilogram square of height in
meters.
Definition
• BMI (body mass index) between the 85 percentiles indicates
overweight.
• BMI >95 percentile indicates obesity
Main points
• Many obese children become obese adults, risk of remaining obese
increases with age and of obesity. the 85 and
Mechanism of Immunosuppression in PEM

• Decreased cell mediated immunity

• Decreased humoral immunity (IgG, IgM, secretory IgA are not
significantly affected in mild to moderate PEM, hence host responds
well to bacterial infections and viral vaccines. But depressed in severe
PEM)Decreased polymorphonuclear activity
• Decreased complement factors
• Decrease in lysozymes and interferon
• Decrease in transferrin level
• Damage to epithelial barrier leads to delayed wound healing.
Diagnostic Evaluation
History- including detailed dietary Laboratory test
history. physical exam
• Full blood counts
Anthropometric measurements.
• Weight • Blood glucose profile
• Length/height • Septic screening Stool & urine for
• Mid upper arm circumference MUAC) parasites & germs
Chest circumference • Electrolytes, Ca, Ph & ALP, serum
• Head circumference proteins
• Skin fold measurements: Tricipital and
Subscapular • Mantoux test
• Anthropometric Measurements of • HIV testing & malabsorption
Nutritional Status
 Complications

• Hypoglycemia
• Hypothermia
• Infections (bacterial, viral & fungal)
• Hypokalemia
• Hyponatremia
• Dehydration & shock
• Heart failure
MANAGEMENT

• A. General principles for routine care (the’10 steps’)

• B. Emergency treatment of shock and severe anemia
• C. Treatment of associated conditions
• D. Failure to respond to treatment
• E. Discharge before recovery is complete
A. GENERAL PRINCIPLES FOR
ROUTINE CARE
• Note that treatment procedures are similar for marasmus &
kwashiorkor.
STEP 1. TREAT/PREVENT
HYPOGLYCAEMIA
• Blood sugar level <54 mg/dl or 3 mmol/L is defined as hypoglycemia
in a severely malnourished child. Assume hypoglycemia when levels
cannot be determined.
• CONSCIOUS CHILD- 50 ml bolus of 10% glucose by orally / nasogastric
(NG) tube.
• UNCONSCIOUS CHILD- lethargic or convulsing -IV sterile 10% glucose
(5ml/kg), followed by 50ml of 10% glucose by NG tube.
• Start two-hourly feeds, day and night
STEP 2. TREAT/PREVENT HYPOTHERMIA
If rectal temperature is less than 35.5ºC or 95.5ºF:
• Feed the child immediately (if necessary rehydrate first).
• Cloth the child with warm clothes and warm blanket. Ensure that the
head is also covered well.
• Provide heat with an overhead warmer, an incandescent lamp or
radiant heater.
• Child could be put in kangaroo mother care.
STEP 3.TREAT/PREVENT DEHYDRATION
• It is difficult to estimate dehydration status using clinical signs alone.
Assume all children with watery diarrhea may have dehydration.
• Treat with ORS unless shock is present
• Low osmolarity ORS with potassium supplements
RESOMAL- Rehydration Solution For Malnutrition

• Continue feeding
• For Severe Dehydration ,Ideally Ringer lactate with 5% dextrose should be
used as rehydrating fluid. If not available, use half normal (N/2) saline with
5% dextrose.
STEP 4. CORRECT ELECTROLYTE IMBALANCE

• Plasma sodium may be low though body sodium is usually high.

Sodium supplementation may increase mortality.
• Potassium & Magnesium are usually deficient and needs
supplementation Give supplemental potassium at 3-4 mmol/kg/day
for at least 2 weeks. Potassium can be given as syrup potassium
chloride. On day 1, give 50% magnesium sulphate intramuscular once
(0.3 ml/kg up to a max of 2 ml).
• Edema if present is partly due to these imbalances. Do NOT treat
edema with a diuretic
STEP 5. TREAT/PREVENT INFECTION

• In addition to complete clinical evaluation, following investigations may be done for identifying
the infections:
• Hemoglobin, TLC, DLC, peripheral smear
• Urine analysis and urine culture
• Blood culture
• Chest X-ray
• Mantoux test
• Gastric aspirate for AFB
• Peripheral smear for malaria (in endemic areas)
• CSF examination (if meningitis suspected).
• Hypoglycemia/hypothermia usually coexistent with infection. Hence if either is present assume
infection is present as well
Choice of Broad Spectrum Antibiotics

• Give parenteral antibiotics Ampicillin and Gentamicin to all admitted

children for seven days.
• If the child fails to improve within 48 hours, change to Intravenous
Cefotaxime /Ceftriaxone.
• If meningitis is suspected, perform lumbar puncture and treat the
child with intravenous Cefotaxime and intravenous Amikacin for days.
• staphylococcal infection is suspected add intravenous Cloxacillin.
• antimalarial treatment if the child has a positive blood film for
malaria.
STEP 6. CORRECT MICRONUTRIENT DEFICIENCIES

• All severely malnourished children have vitamin and mineral deficiencies

• Vitamin A orally on day 1 (if age >1 year give 2,00,000 IU; age 6-12
months give 1,00,000 IU; age 0-5 months give 50,000 IU)
• Give Daily Multivitamin supplement containing Thiamin, Riboflavin,
Nicotinic acid and vitamins A,C,D,E, and B12 .Folic acid 1 mg/day (give 5
mg on day 1).Zinc 2 mg/kg/day.
• Copper mg/kg/day.
• Iron 3 mg/kg/day only once child starts gaining weight; after the
stabilization phase. Giving iron early may make infections worse.
STEP 7. START CAUTIOUS FEEDING

• Start feeding as soon as possible as frequent small feeds through oral or

nasogastric tube.
• Recommended daily energy and protein intake from initial feeds is 100
kcal/kg and g/kg respectively.
• Total fluid recommended is 130 ml/kg/day; reduce to 100 ml/kg/day if
there is severe, generalized edema.
• Continue breast feeding.
• The cereal-based low lactose (lower osmolarity) diets are recommended
as starter diets.
RECIPES FOR STARTER AND CATCH-UP
FORMULAS
STEP 8. ACHIEVE CATCH-UP
GROWTH
• Once appetite returns, decrease frequency of feeds to 6 feeds/day and the
increase volume offered at each feed.
• It is recommended that each successive feed is increased by 10 ml until some is
left uneaten.
• Breast feeding should be continued.
• Make a gradual transition from F-75 diet to F-100 diet. The starter F-75 diet
should be replaced with F-100 diet in equal amount in 2 days.
• The calorie intake should be increased to kcal/kg/day, and the proteins to 4-
6g/kg/day.
• For children with persistent diarrhea, who do not tolerate low lactose diets,
lactose free diet can be started.4/26/2017 8:59 PM
STEP 9. PROVIDE SENSORY STIMULATION AND
EMOTIONAL SUPPORT

• Delayed mental and behavioral development often occurs in severe

malnutrition.
Provide:
• Tender loving care
• Cheerful, stimulating environment
• Structured play therapy min/d
• Physical activity as soon as the child is well enough
• Maternal involvement when possible(e.g.Comforting, feeding,
bathing, play)
STEP 10. PREPARE FOR FOLLOW-UP AFTER RECOVERY

• Review periodically after 1 week, 2 weeks, 1 month, 3 months and 6 months after discharge.
• A child who is 90% weight-for-length (equivalent to -1SD) can be considered to have
recovered
Show parent or caregiver how to:
• Feed frequently with energy - and nutrient-dense foods
• Give structured play therapy
Advise parent or caregiver to:
• Bring child back for regular follow-up checks
• Ensure booster immunizations are given
• Ensure vitamin A is given every six months4/26/2017 8:59 PM
B. EMERGENCY TREATMENT OF SHOCK AND SEVERE ANEMIA
FLUID THERAPY IN SEVERE DEHYRDATION
SEVERE ANAEMIA

• Blood transfusion is required if:

Hb < 4 g/dl or if there is respiratory distress & Hb 4-6 g/dl
• Whole blood 10 ml/kg slowly over 3 hours
• Furosemide 1 mg/kg IV at start of transfusion
• If CARDIAC FAILURE present, transfuse packed cells (5-7 ml/kg) rather
than whole blood.
• Monitor RR & HR every 15 minutes. If either of them rises, transfuse
more slowly.
• Give oral iron for two months to replenish iron stores
C.TREATMENT OF ASSOCIATED
CONDITIONS
VITAMIN A DEFICIENCY
• If eye signs of deficiency, give orally:vitamin A on days 1, 2, 14
• >12 months 200,000 IU
• 6-12 months 100,000 IU
• 0-5 months 50,000 IU
• If corneal clouding/ulceration, give additional eye care to prevent
extrusion of the lens:instill chloramphenicol or tetracycline eye drops
(1%) 2-3 hourly for 7-10 days and instill atropine eye drops (1%), 1
drop three times daily for 3-5 days.
DERMATOSIS

• Hypo-or hyper pigmentation, desquamation, ulceration, exudative

lesions.
• ZINC DEFICIENCY is usual in affected children. Skin quickly improves
with zinc supplementation.
• In addition: apply barrier cream (zinc & castor oil ointment, or
petroleum jelly or paraffin gauze) to raw areas.
• omit nappies so that the perineum can dry.
PARASITIC WORMS

• Give mebendazole 100 mg orally, twice daily for 3 days.

TUBERCULOSIS (TB)

• If strongly suspected (contacts with adult TB patient, poor growth,

despite good intake, chronic cough, chest infection not responding to
antibiotics):
• Mantoux test (false negatives are frequent)
• Chest X-ray if possible
• If test is positive or strong suspicion of TB, treat according to national
TB guidelines4/26/2017 8:59 PM
DIARRHEA

• Common feature but it should subside during the first week of

treatment with cautious feeding.
• In the rehabilitation phase, loose, poorly formed stools are not cause for
concern provided weight gain is satisfactory.
Mucosal damage & giardiasis
• Stool microscopy
• Give: metronidazole (7.5 mg/kg 8-hourly for 7 days)4/26/2017 8:59 PM
OSMOTIC DIARRHEA

• Suspected if diarrhea worsens substantially with hyperosmolar starter

F-75 and Ceases when the sugar content is reduced and osmolarity is
<300 mOsmol/l.
• In these cases: use isotonic F-75 or low osmolar cereal-based F-75
and Introduce F-100 gradually.
LACTOSE INTOLERANCE.

• Only rarely due to lactose intolerance.

• Treat only if continuing diarrhea is preventing general improvement
Starter F-75 is a low-lactose feed.
• In exceptional cases:
• Substitute milk feeds with yogurt or lactose-free infant formula
• Reintroduce milk feeds gradually in the rehabilitation phase4/26/2017
8:59 PM
D. FAILURE TO RESPOND TO
TREATMENT
• Good weight gain (>10 g/kg/day): continue same
• Mod. weight gain (5-10 g/kg/day): check intake & infection
• Poor weight gain (<5 g/kg/day): Inadequate feeding, Untreated
infection, Specific nutrient deficiencies, Tuberculosis & HIV/AIDS,
Psychological problems.
FAILURE TO RESPOND

• PRIMARY FAILURE TO RESPOND

• Failure to regain appetite by day 4Failure to start losing edema by day
4Presence of edema on day 10Failure to gain at least 5g/kg/day by
day 10
• SECONDARY FAILURE TO RESPOND
• Failure to gain at least 5g/kg/day for 3 consecutive days during
rehabilitation
• This slide classifies different weight gain patterns.
• The recovery is also defined.
E.DISCHARGE BEFORE RECOVERY IS COMPLETE

DISCHARGE
• Recovered/ready for discharge when reaches 90% weight-for-length & no
edema
• Absence of infection
• Eating at least cal/kg/day & receiving adequate micronutrients
• Consistent weight gain (of at least 5 g/kg/day for 3 consecutive days) on
exclusive oral feeding
• Completed immunization appropriate for age
• Caretakers sensitized to home care
• This slide lists the criteria for discharge.
Failure to Thrive and Obesity
Failure to Thrive

• Attained growth
• Weight <3rd percentile
• Weight for height <5th percentile
• Weight 20% or more below ideal weight for height.
• Triceps skinfold thickness < 5 mm
• Rate of growth
• Depressed rate of weight gain
• < 20 g/d from 0 to 3 months of age
• < 15 g/d from 3 to 6 months of age
• Fall-off from previously established growth curve
• Downward crossing of >2 major percentiles
• Documented weight loss
Causes of inadequate weight gain
• INADEQUATE INTAKE
Inadequate food offered
• Food insecurity
• Poor knowledge of child’s needs
• Formula dilution or excessive juice
• Breastfeeding difficulties
• Medical child abuse/caregiver fabricated illness (Munchausen by proxy)
• Medical neglect
• Food fads including “rice” milk as substitute for formula or cow milk
• Child not taking enough food
• Oromotor dysfunction, neurologic disease
• Developmental delay
• Behavioral feeding problem (altered oromotor sensitivity, pain and conditioned aversion)
• Anorexia from systemic causes
INADEQUATE INTAKE

Emesis
• Pyloric stenosis
• Gastroesophageal reflux
• Eosinophilic esophagitis
• Vascular rings
• Malrotation with intermittent volvulus
• Increased intracranial pressure and other neurologic disorders
• Inborn errors of metabolism
• Rumination
• Cyclic vomiting
Hepatobiliary disease

MALABSORPTION
• Cystic fibrosis
• Celiac disease
• Hepatobiliary disease
• Food protein allergy, insensitivity, or intolerance
• Infection (giardiasis)Short gut syndrome
INCREASED METABOLIC DEMAND

• Insulin resistance (intrauterine growth restriction)

• Congenital infections (human immunodeficiency virus, TORCHES)
• Syndromes (Russell-Silver, Turner, Down)
• Malignancy
• Chronic disease (cardiac, pulmonary, renal)
• Metabolic disorders
• Immunodeficiency/autoinflammatory disorders
• Endocrine (diabetes mellitus, diabetes insipidus, hyperthyroidism)
Obesity

• Obesity or increased adiposity is defined using the body mass index

(BMI), which is an excellent proxy for more direct measurement of
body fat.
• BMI = weight in kg/(height in meters)^2
• Obesity and overweight are defined using BMI percentiles; children >2
year old with a
• BMI ≥95th percentile meet the criterion for obesity
• BMI between the 85th and 95th percentiles fall in the overweight .
Causes of pathological obesity
Drugs: Endocrine:
• Corticosteroids • Hypothyroidism
• Sodium valproate • Growth hormone deficiency
Miscellaneous: • Cushing syndrome
• Achondroplasia Genetic:
• Muscular dystrophy • Laurence-Moon-Biedl syndrome
• Severe mental retardation • Prader-Willi syndrome
• Down syndrome
Obesity-Associated Comorbidities
CARDIOVASCULAR NEUROLOGIC
• Hypertension • Pseudotumor cerebri
• Migraines
• Dyslipidemia
ORTHOPEDIC
ENDOCRINE • Blount disease (tibia vara)
• Type 2 diabetes mellitus • Musculoskeletal problems
• Metabolic syndrome • Slipped capital femoral
• Epiphysis
• Polycystic ovary syndrome
PSYCHOLOGICAL
GASTROINTESTINAL • Behavioral complications
• Gallbladder disease • PULMONARY
• Nonalcoholic fatty liver disease • Asthma
• Obstructive sleep apnea
Time frame for the management of the child
with severe malnutrition