PROTEIN ENERGY MALNUTRITION

Dr.Yulchair R,SpA
SMF Anak RSI Pd Kopi
 PEM

Nutrition Problems in Indonesia

t Protein Energy Malnutrition (PEM)

t Iron Deficiency Anaemia

t Iodine Deficiency (=GAKI)
t Zinc Deficiency
t Vitamin A Deficiency
t Obesity
Theoretical framework of Nutrition Problems.
Nutrition problems

Food intake Infect Disease direct

causes

Food availability Mother & child Health indirect

in household caring service causes

POOR FAMILY & EDUCATION, main

FOOD STUFF & JOB OPPORTUNITY problem

ECONOMIC & POLITIC CRISIS core

problem
Three level of determinants lead to nutrition status

Immediate :
Inadequacy of dietary intake
manifested : Intervention programs
- PEM
- Micronutr.deficiency Supply side :
- Diarrhea & worm disease - access : health care facilities
- ARI - supplementation of food &
Supply & coverage immuniz micronutrients.
- immunization
Underlying : - quality: provider’ skill
- information system: coverage
- Household food security
of supplement., fortification,
- Access to PHC
surveillance, etc.
- Community of awareness Health &
& care for children & women Nutrition
Status of
Basic : Children
- Socio-economic conditions Demand side:
(poverty & crisis) - empowerment
- Political factors - family awareness of nutrition
- Traditional practices (infant - subsidies / health insurance
feeding)
- Environment & sanitation
 PEM

The problems of PEM :

t the main health problem

t “primadonna” of nutritional diseases

t influencing morbidity & mortality among

underfives
t early detection and proper management are ver
important

t severe malnutrition should be hospitalized

t poor quality of life

 Protein Energy Malnutrition

t disease / clinical conditions caused by energy

& protein deficiency, usually accompanied by
deficiency of other nutrients.

t Primary : - nutr.intake <<

- quality / quantity of nutr. <<

t Secondary : - nutr. needs/output >>

Energy balance: negative
INPUT:
Infection
Poverty
Organic dis.
etc.

OUTPUT:
Infection
Chronic diarrhea/
Malabsorption
Hypermetabolism
etc.
 Protein Energy Malnutrition

T Nutr.status = spectrum :

Wt/Ht

undernutrition normal overnutrition

70 80 90 110 120 %
-3SD -2SD +2SD +3SD

PEM severe moderate mild overweight obese

-Kwashiorkor mild
-Marasmus moderate
-M-K severe
super
 PEM.

Classification :

1. GOMEZ (195..) : W/A

2. MacLarren (196..) : Clinical + laboratory
3. The Wellcome : Clinica+anthropometric
Trust Party (1970) (W/A)

4. Waterlow (1973) : W/H

5. WHO (1999) : Clinical+anthropometric
(Z-score)
 MEP.

Classification (WHO,1999) :
Moderate PEM Severe PEM

Symmetrical oedema -- +
(oedematous
malnutrition)

W/H -3< Z-score <-2 < -3 Z-score

(70-79%) (<70%)
(severe wasting)

H/A -3< Z-score <-2 < -3 Z-score

(85-89%) (<85%)
(severe stunting)
 PEM.

DIAGNOSIS :

1. Anamnesis

2. Physical examination

3. others : - laboratory
- anthropometry
- dietary analysis
 PEM.

Checklist : anamnesis
• Usual diet before current episode of
illness
• Breastfeeding history
• Food & fluids taken in past few days
• Recent sunken eyes
• Duration & freq. of vomiting / diarrhoea,
appearance of vomit / diarrhoeal stools
 PEM.

Checklist : anamnesis
• Time when urine was last passed
• Any deaths of siblings
• Birth weight?
• Milestones reached (sitting up, standing,etc)
• Contact with people with measles or
tuberculosis
• Immunizations
 PEM.

Checklist: Physical examination

• Weight, Length/Height
• Signs of circulatory collapse : cold hands &
feet, weak pulse, consciousness <<
• Temperature : hypothermic / fever
• Respiratory rate and type of respiration :
signs of pneumonia or heart failure.
• Severe pallor anaemia gravis
• Eyes : - corneal lesion vit.A deficiency
- sunken dehydration
Anaemia
 PEM.

Checklist: physical examination

• Thirst, dryness of lips & mouth
• ENT : evidence of infection?
• Abdominal distension, bowel sounds?
• Enlargement or tenderness of liver, jaundice
• Skin : infection, purpura, fat tissue?
• Oedema, muscles atrophy
• Apperance of faeces
 Severe PEM : Kwashiorkor
hair
face

‘Puffy’

Oedema
 Severe PEM : Kwashiorkor

Hepatomegaly
Crazy pavement oedema
dermatosis
 Severe PEM : Marasmus
face

hair

Muscles atrophy
SC fat <<
Ribs
Severe PEM : Marasmus + KP

lymphadenopathy
 Severe PEM : Marasmus + KP
‘Caverne’

‘Destroyed lung’ 6 weeks after th/

 PEM.

Laboratory tests:
• Tests that may be useful :
k Blood glucose : < 54 mg/dl = hypoglycaemia
 k Blood smear : parasit malaria
 k Hb or Ht : < 4 g/dl or < 12% = severe anaemia
 k Urine exam/culture: bacteria + or > 10 lekosit/HPF
infection
k Faeces : blood + disentri
Giardia + / parasit lain infeksi
 k X-ray : - thorax : l Pneumonia
l Heart failure

- bone : rickets, fracture

 k Tes tuberkulin : often negative

• Tests that are little ot no value : serum protein, HIV,

electrolytes
 PEM.

MANAGEMENT :

l Mild-moderate PEM :
- no specific clinical signs : thin, hypotrophic
- not necessary to hospitalize
- looking for the probable causes
- nutr. education & supplementation

l Severe PEM : should be hospitalized

 PEM.

Other criteria :
Very low BW : - W/H < 70%
- W/A < 60%
(- W/A > 60% + oedema)
+ clinical signs & symptoms :
- oedema (M-K)
- severe dehydration
- persistent diarrhoea and / or vomiting
- severe pallor, hypothermia, shock
- signs of systemic/local infection, URI
- severe anaemia ( Hb < 5 g/dl)
- jaundice
- anorexia
- < 1 yr of age
 PEM.

Signs & symptoms of dehydration :

- history of diarrhoea or no/diminished intake

- weak, apathetic  unconscious
- weak to absent radial pulse
- thirst, dry mouth and absent of tears
- sunken eyes and fontanel
- hypothermia
- cold hands and feet
- Urine flow << / -
Dehydration

Sunken eyes
 Dehydration

Turgor :
 PEM.

5 ASPECTS in the MANAGEMENT of Severe PEM :

A. 10 main steps

B. Treatment of underlying diseases

C. Failure to respond to treatment

D. Discharge before recover

E. Emergency
 PEM.
A : “10 main steps”
No Interven- Stabilization Transition Rehabilitation Follow-up
tion d.1-2 d.3-7 wk-2 wk 3-6 wk 7-26
1. Treat/prevent
hypoglycaemia
2. Treat/prevent
hypothermia
3. Treat/prevent
dehydration
4. Correct electr.
imbalance
5. Treat infection
6. Correct micro- without Fe + Fe
nutrients defic.
7. Begin feeding
8. Increase feeding
9. Stimulation
10. Prepare for
discharge
 PEM.

B. Treatment of underlying diseases / infection :

Bacterial infection :
- no apparent signs of infection/no complication:
cotrimoxazole ( 5 mg TMP/kg, 2x/d, 5 days )

- signs of infection / complications / sepsis :

- ampicilline 50 mg/kg/6 hrs, IM/IV,
for 2 days  oral (ampi / amoxy)
- gentamycin 7.5 mg/kg, IM/IV, 7 days
- KP +  anti-TB drugs

Viral infection : no specific th/

- all PEM should receive measles vaccine
 PEM.

C. Failure to respond to treatment :

Frequent causes of failure to respond :

a. Problems with the treatment facility :

- poor environment for malnourished children
- insufficient or inadequately trained staff
- inaccurate weighing machine
- food prepared or given incorrectly
 PEM.

C. Failure to respond to treatment :

Frequent causes of failure to respond :

b. Problems of individual children :

- insufficient food given
- vitamin-mineral deficiency
- malabsorption of nutrients
- rumination
- infections
- serious underlying disease
 PEM.

C. Failure to respond to treatment :

Criteria Time of admission

Primary failure to respond:
- failure to regain appetite Day 4
- Failure to start to lose oedema Day 4
- Oedema still present Day 10
- Failure to gain at least 5 g/kg/d Day 10

Secondary failure to respond :

- failure to gain at least 5 g/kg/d During rehabilitation
for 3 consecutive days
 PEM.

C. Failure to respond to treatment :

1. Death
= within first 24 hrs :
- hypoglicaemia
- hypothermia
- dehydration
- sepsis

= within 24 – 72 hrs :
- volume of formula >>
- caloric density >>
 PEM.

C. Failure to respond to treatment :

2. Inadequate gaining weight :

- infection
- diet
- psychologic

Weight gain :
= satisfactory: > 10 g/kg/d good =
= sufficient : 5-10 g/kg/d > 50 g/kg/wk
= poor : < 5 g/kg/d or < 50 g/kg/wk
 PEM.

D. Discharge before fully recover:

= Dietary advice :
- high protein and calorie
- frequent feeding ( 5x/d )
- finish all meals given
- vit-min supplementation & electrolytes
- continue BF
= frequent controle ( 1x/wk )
= Immunization
 5. Emergency :

5.1. Shock :
N2 or RLG5%
15 ml/kg, 1 hr

Improvement
_
+

Repeat 1 hr more sepsis

Resomal 10 ml/kg, 10 hrs Maintenance, 4 ml/kg/hr

Fresh blood, 10 ml/kg

Special formula
 5. Emergency :

5.2. Severe anaemia.

Hb ?

Hb < 4 g/dl Hb 4-6 g/dl

Resp.distress/heart failure?
Fresh blood 10 ml/kg* _
+

PRC 10 ml/kg* Observation

* : give furosemid 1 mg/kg, iv, before transfusion

 PEM.

Prepare for discharge :

- W/H : - 1 SD or severe PEM  moderate/mild

- Education for mother :
- hygiene & sanitation
- healthy foods
- immunization
- stimulation
- regular controle

- to continue the th/ of chronic diseases

- to completing immunization
On admission : 2 weeks later :
Sh, girl, 2 yrs, W : 4.750 g
W : 3.875 g H : 67.4 cm
H : 67 cm W/H : < -3 SD
W/H : < -4SD

4 weeks later : 5 weeks later :

W : 5.310 g W : 6.280 g
H : 67.7 cm H : 67.8 cm
W/H : + -3 SD W/H : - 2 SD
7 yrs,
10 kg

Recovery : 16 kg