This presentation included approach and classification of protein energy malnutrition and it's management, related complications in children

1. PEM
Dr. BABU LAL MEENA
MD PEDIATRICS
PGIMER CHANDIGARH

2. DEFINITION
Undernutrition-
• Inadequate consumption, poor absorption
or excessive loss of nutrients.
Overnutrition-
• Overindulgence or excessive intake of
specific nutrients
Malnutrition-
• Refers to both undernutrition as well as
overnutrition.

3. DEFN CONT…
Protein energy malnutrition
Range of pathological conditions arising from
lack , in varying proportions , of protein and
calories.
 Marasmus: weight for age < 60% expected
 Kwashiorkor: weight for age < 80% + edema
 Marasmic kwashiorkor: wt/age <60% +
edema

4. EPIDEMIOLOGY
 Global burden- more prevalent in developing
countries. “Often starts in the womb and ends in
the tomb”
 PEM affects every 4th child world-wide
 More than 50% of deaths in 0-4 years are
associated with malnutrition
 Median case fatality rate is-23.5% in severe
malnutrition reaching 50% in edematous
malnutrition

5. INDIAN SCENARIO
 Childhood malnutrition underlying cause of
death in 35% of all deaths under 5.
 During 1st 6 months, when most babies are
breastfed, 20-30% are already
malnourished.
 By 18-23 months, during weaning, 30% are
severely stunted, 1/5th are underweight.

6. CHILD MORTALITY
The major contributing factors are:
• Diarrhea 20%
• ARI 20%
• Perinatal causes 18%
• Measles 07%
• Malaria 05%
55% of the total have malnutrition

7. INDICATORS
Indicator Interpretation Interpretation
Stunting Low height for age Chronic malnutrition
Prolonged food
deprival/disease
Wasting Low weight for height Acute malnutrition
Recent food
deficit/illness
Underweight Low weight for age Combined indicator to
reflect both acute on
chronic malnutrition.

8. CLASSIFICATION
 WEIGHT-FOR-AGE
 HEIGHT-FOR-AGE
 WEIGHT-FOR-HEIGHT

9. WEIGHT-FOR-AGE

10. GOMEZ CLASSIFICATION
• Only wt for age taken into account
• No comment about height
• All cases of edema in 3rd degree
ireespective of wt for age
Nutritional status Wt FOR AGE ( % of expected )
normal > 90
1st degree PEM 75-90
2nd degree PEM 60-75
3rd degree PEM < 60

11. JELLIFFE’S CASSIFICATION
Nutritional status WEIGHT FOR AGE
( % of expected )
normal 90
1st degree PEM 80-90
2nd degree PEM 70-80
3rd degree PEM 60-70
4TH degree PEM < 60

12. WELLCOME TRUST / INTERNATIONAL CLASSIFICATION
Based on wt-for-age and presence of edema.
Weight-for-
age(Boston)
(% of expected )
Oedema Clinical type of PEM
60-80 + Kwashiorkor
60-80 _ Underweight
< 60 _ Marasmus
< 60 + Marasmic
kwashiorkor

13. IAP CLASSIFICATION(1972)
Grade of malnutrition Weight for age of the
standard
(median) %
Normal >80
Grade I 71-80 (mild malnutrition)
Grade II 61-70 (moderate malnutrition)
Grade III 51-60 (severe malnutrition)
Grade IV <50 (very severe malnutrition)

14. CLASSIFICATIONS- WHO
Moderate
malnutrition
Severe
malnutrition
Symmetrical
oedema
No Yes
(oedematous
malnutrition)
Weight-for-height SD score
between
-2 to -3
SD score
< -3
Severe wasting
Height-for-age SD score
between
-2 to -3
SD score
< -3
Severe stunting

15. AGE INDEPENDENT INDICES
 Weight for height
 Mid arm circumference
 Body mass index
 Index ( Kanawati, Dughdale, Rao &
Singh’s )
 Skin fold thickness

16. SHAKIR TAPE

17. RATIOS
Name of index Calculation Normal value Value in
malnutrition
Kanawati and Mc
laren
MUAC(cm)/HC(c
m)
0.32-0.33 <0.25
Rao and Singh wt (kg)/Ht (cm)2
X 100
0.14 0.12-0.14
Dughdale wt (kg)/ht in cm
1.6 X100
0.88-0.97 <0.79
Quaker arm
circumference
MAC expected
for a given height
75-85%-
malnourished
<75%-severely
malnourished
Jellife’s ratio HC/CC <1 in a child
>1year:
malnourished

18. RISK FACTORS
 LBW
 Multiple birth
 Closely spaced birth
 Early stoppage of breast feeding
 Too early or late weaning
 Recurrent infections
 Illiteracy, poverty
 Secondary due to malabsorption

19. PATHOGENESIS
•Protein defficiency
•Gopalan theory
•Golden theory

20. MARASMUS

21. KWASHIORKOR

22. CLINICAL FEATURES
• Depends on the severity and duration
nutritional deprivation, the age, presence or
absence of associated infections.

23. KWASHIORKOR
• Essential Features
• Marked growth retardation
• Psychomotor changes
• Wasting of muscles
• Dependent pitting edema

24. • General appearance- fat sugar baby
appearance.
• Skin changes-
• Hyperpigmentation, desquamation and
dyspigmentation.
• Flaky paint dermatosis( confluent areas )
• Enamel spots( individual spots )
• Typically involving buttocks, perineum and
upper highs.

25. • Mucus membrane lesions
 Smooth tongue
 Cheilosis, angular stomatitis
 Herpes simplex stomatitis
• Edema
• Muscle wasting- weak, hypotonic and unable to
stand or walk.

26. Hair Changes
• Hypopigmented hair.
• Sparseness (alopecia)
• Change in texture (coarse / silky)
• Easy pluckbility
• Flag sign
Mental Changes :
• Lethargy
• Apathetic
• Poor appetite – difficult to feed

27. – GI Manifestations
• Diarrhoea
• Infections / Parasitic infestations
• Mucosal atrophy
• Enteraopathy sec. to anemia
• Liver enlargement
• Fatty liver
–Mineral & Vitamin deficiency
–Super added infections
• Tuberculosis, bronchopneumonia, measles,
enteritis..

28. MARASMUS
Essential Features
• Gross wasting of muscles – skin and bones.
• Emaciation- loss of buccal pad of fat-monkey facies, loose skin of
buttocks hanging down- baggy pants appearance
• Marked stunting
• No edema
Non -essential Features
•Mineral and vitamin deficiency
• Indolent ulcers and sores
• GI symptoms – hungry
• Liver is shrunk
• Psychomotor changes – irritable

29. CONT…
Grade 1 : Wasting starts in axilla & groin
Grade 2 : Wasting extended to thigh and
buttocks
Grade 3 : Chest and abdomen
Grade 4 : Wasting of buccal pad of fat also

30. SEVERE ACUTE
MALNUTRITION
 Weight-for-height of 70% (extreme wasting)
 Presence of bilateral pitting edema of
nutritional origin, “edematous malnutrition
 Mid-upper-arm circumference of less than
115 mm in children age 1-5 years old

31. COMPLICATIONS OF SAM
 ARI
 Diarrhea
 Gram negative septicemia
 Poor feeding
 Electrolyte abnormalities

32. CAUSES OF DEATH
Hypoglycemia
Hypothermia
Dehydration
Infection
Severe anemia

33. MANAGEMENT
Mild and moderate malnutrition
 Mainstay of treatment is to give adequate amounts of
protein and energy
 Atleast 150kCal/kg/day, protein intake of 3g/kg/day
 Best measure of efficacy of the treatment is weight gain

34. Locally produced RUTF
Hyderabad mix
120 g = 500 Kcal
(Wheat, black gram, groundnut flour)
Limited success in uncontrolled studies

35. INPATIENT TREATMENT OF SEVERE
ACUTE MALNUTRITION
WHO TEN STEPS to recovery in
Malnourished Children
In 2 phases
•Initial stabilisation – 2 to 7 days
•Rehabilitation – several weeks

36. TIME FRAME FOR TEN STEPS

37. STEP 1
PREVENT/TREAT HYPOGLYCEMIA
Blood glucose <54mg/dl
If cant be measured assume hypoglycemia
TREATMENT
Asymptomatic-
• 50ml of 10% glucose or sucrose solution
orally or NG f/b 1st feed
• Feed with starter F-75 q 2hrly

38. Symptomatic
 10% dextrose i.v 5ml/kg
 Follow with 50ml of 10% glucose or sucrose
solution NG
 Feed with starter F-75 q 2hrly
 Start appropriate antibiotics
Prevention
 Feed 2 hrly starting immediately
 Prevent hypothermia

39. STEP 2
PREVENT AND TREAT HYPOTHERMIA
Rectal temp <35.5 C/95.5 F or axillary <35
C/95 F
Treatment
 Clothe the child with warm clothes
 Provide heat
 Avoid rapid rewarming
 Feed the child
 Give appropriate antibiotics

40. STEP 3
TREAT/PREVENT DEHYDRATION
 Assume all SAM with watery diarrhoea to have
some dehydration.
 Hypovolemia can co exist with edema.
Treatment
 Use reduced osmolarity ORS with potassium
supplements for rehydration and maintenance.
 Initiate feeding within 2-3 hrs of starting
rehydration with F-75 formula on alt hrs with
reduced osmolarity ORS
 Be alert for signs of overhydration.

41. STEP 4
CORRECT ELECTROLYTE IMBALANCE
Supplemental potassium at 3-4meq/kg/d for
atleat 2 weeks
On day1, 50% MgSO4 i.m once (0.3 ml/kg,
max upto 2ml)
thereafter give extra Mg(0.8-1.2 meq/kg daily)
Excess body sodium exists even though
plasma sodium may be low.
Prepare food without adding salt.

42. STEP 5
TREAT/PREVENT INFECTION
 Multiple infections common
 Usual signs of infection such as fever often
absent
 Majority of blood stream infections due to
gram negative bacteria.
 Assume serious infections and treat.
 Hypoglycemia and hypothermia are markers
of severe infections.

43. Treatment
 Ampicillin iv for atleast 2 days f/b oral amoxycillin
 i.v. gentamicin or amikacin for 7 days.
If no imrovement within 48hrs,
 i.v. cefotaxime
 Ceftriaxone
Prevention
 Follow standard precautions like hand hygiene
 Give measles vaccine if >6 months and not
immunised or if the child is more than > 9 months.

44. STEP 6
CORRECT MIRONUTRIENT DEFICIENCIES
1. Use upto twice the RDA of various vitamins
and minerals
2. On day1, Vit A orally (if age>1yr 2lac IU, 6-
12 mon 1 lac IU, 0-5 mon 50,000 IU)
3. Folic acid 1mg/day ( 5mg on D1)
4. Copper 0.2-0.3 mg/kg/d
5. Iron 3mg/kg/d, once child starts gaining wt,
after the stabilisation phase.

45. STEP 7
INITIATE RE-FEEDING
 Initiate feeding as soon as possible as frequent small
feeds
 If unable to take orally- NG feeds
 Total fluid recommended is 130ml/kg/d, reduce to
100ml/kg/d if there is severe, generalised edema
 Continue breast feeding ad libitum
 Start with F-75 starter feeds q 2 hrly
 F-75 contains 75kCal/100ml with 1g protein/100ml
 If persistent diarrhea, cereal based low lactose F-75 diet
as starter diet
 If diarrhea continues on low lactose diets give F-75
lactose free diets

46. STEP 8
ACHIEVE CATCH UP GROWTH
• Once appetite returns in 2-3 days, encourage higher feeds
• Increase volume offered in each feed and decrease the
frequency of feeds to 6 feeds/d
• Continue breast feeding on demand
• Make a gardual transition from F-75 to F-100 diet
• F-100 contains 100kCal/100ml with 2.5-3g protein/100ml
• Increase calories to 150-200 kCal/kg/d and proteins to 4-
6g/kg/d
• Add complementary foods as soon as possible to prepare
the child for home foods at discharge

47. STEP 9
PROVIDE SENSORY STIMULATION AND
EMOTIONAL SUPPORT
 A cheerful, stimluating environment
 Age appropriate structured play therapy for
atleast 15-30 mins/day
 Age appropriate physical activity as soon as
the child is well enough
 Tender loving care

48. STEP 10
PREPARE FOR FOLLOW UP AFTER
RECOVERY
Said to have rcovered when wt for ht is 90% of NCHS
median and has no edema
Primary failure to respond if
• Failure to gain appetite by D4
• Failure to start losing edema by D4
• Presence of edema on D10
• Failure to gain atleast 5g/kg/d by D10
Secondary failure to respond if
• Failure to gain at least 5g/kg/d for consecutive days
during the rehabilitation phase

49. Complication during rehabilitation
Nutritional Recovery Syndrome
Treated with very high proteins
Abdominal distension (hepatomegaly, ascites,
splenomegaly), prominent veins, hypertrichosis,
parotid swelling, gynaecomastia, eosinophilia,
hyper-Ig
Incresed estrogen and recovering pituitary
Kwashi shake/encephalitis states (too much of
proteins)
Pseudotumor cerebri
Refeeding syndrome

50. REFEEDING SYNDROME
Definition
Refeeding syndrome (RFS) is a term that describes
the metabolic and clinical changes that occur on
aggressive nutritional rehabilitation of a malnourished
patient.
- Exact incidence in pediatric patients not known.
- 30% to 38% in adults on TPN with phosphorus.
- 100% in adults on TPN without phosphorus.
- 25% of adults with cancer.

51. RISK FACTORS

52. PATHOPHYSIOLOGY

53. Starvation
- Increased catabolism
- Increased glycogen depletion
- Breakdown of proteins to aminoacids for
gluconeogenesis
- Production of ketone bodies from fatty acids

54. ON REFEEDING

55. • Altered membrane
potenial – Cardiac
arrythmias
• Neuromuscular
dysfunction
• Sodium retention
• Fluid overload
• Fatty liver
• Hypokalemia
• Increased
corticosteroids.
• Ketoacidosis
• Altered menbrane
potential
• Impaired Na+K+ ATPase
activity
• Co-factor for enzymes
in oxidative
phosphorylation and
ATP production
• Decreased ventricular
mass
• Decreased sarcomere
contractility
• Decreased production of
ATP
• Rhabdomyolysis
Hypo PO4
2-
(onset <72 hrs,
nadir 7 days)
Hypomagnesemia
(Onset <72 hrs)
HypokalemiaHyperinsulinemia
and
Hyperglycemia

56. CLINICAL FEATURES
< 2 weeks
- Increased weight gain, tachypnoea, features of cardiac failure,
dilutional hyponatermia – s/o fluid overload.
- Neuromuscular symptoms like weakness, paresthesias,
cramps, respiratory muscle weakness – altered membrane
potential due to electrolyte imbalance.
- Cardiac failure, rhabdomyolysis, altered mental status,
confusion, coma, hemolysis, thrombocytopenia and leukocyte
dysfunction – hypophosphatemia.
- Abdominal distention, increasing hepatomegaly, ascites,–
Fatty liver.

57.  2 weeks
- Prominient thoraco-abdominal venous network
- Hypertrichosis (after 60 days)
- Parotid swelling
- Gynaecomastia
- Eosinophilia (after 60 days)
- Spleenomegaly
Cause: Not clear. Probably due to excessive intake of high quality
protein during rehabilitation, leading to increase in various trophic
hormones produced by the recovering pituitary gland.
Gomez et al, Pediatrics 1952; 10:513-526

58. DIAGNOSIS AND EARLY RECOGNITION IS
THE KEY
- There is no defined diagnostic criteria for refeeding syndrome in
children.
- Monitoring of biochemical parameters for hypophosphatemia,
hypomagnesemia, hyperglycemia, hypoalbuminemia.
- Daily weight monitoring for the initial 7 days.
- Goal of weight gain should not be more than 1 Kg/week.
- Fluid status (intake/output) should be moniitored.
- Cardiorespiratory monitoring during the initial.
- Assess frequently for neuromuscular weakness and mental status.

59. MANAGEMENT
- Stop all sources of calorie and protein until the electrolyte
imbalances are corrected.
- Start with 50% of the caloric intake at which the patient
developed symptoms.
- Supplement with multivitamins (including thiamine)
- Watch for recurrence of refeeding syndrome by monitoring
clinical and biochemical parameters daily.
- Limit sodium and fluid intake.
- Gradually increase the caloric requirement every 3 days.
“Start low and go slow”.
- Protein restriction is not recommended, 1.5 g/Kg/day rich in
essential aminoacids is required for anabolism to occur.

60. PREVENTION
A) MONITORING
Before initiating refeeding through any route and during initial 3 –
5 days,
- Hydration and fluid assessment. Early weight gain may be
secondary to weight gain.
- Daily electrolytes: Initial glucose and albumin. Daily sodium,
potassium, calcium, phosphorus, magnesium, urea and
creatinine.
- Cardiac status. (ECG ± ECHO)

61. B) ORAL FEEDING REGIMEN
1. Initial volume and calories
• In more severe cases an initial starting volume of 75% of total daily
requirements has been used
- < 7 years old - 80–100 kcal/kg/day
- 7–10 years - 75 kcal/kg/day
- 11–14 years - 60 kcal/kg/day
- 15–18 years - 50 kcal/kg/day
• If the initial food challenge is tolerated, this may be increased over 3–
5 days (Target 150 kcal/kg/day – Rehabilitation phase).
• Each requirement should be tailored to an individual’s need and the
above values may need to be adjusted by as much as 30%.
• Frequent small feeds (every 2 hrly) are recommended initially. Slowly
increase the volume per feed, max of 22 ml/kg/feed (130 ml/kg/day)
• Feeds should provide minimum of 1 kcal/ ml (F-100) to minimize
volume overload.

62. 2. PROTEIN
• If a milk-based feed induces diarrhoea with positive faecal
reducing substances, a hydrolysate may be used.
• An initial regimen for malnourished children suggests 0.6–1
g/kg/day
• The feed should be rich in essential amino acids and gradually
increased as an intake of 1.2–1.5 g/kg/ day is needed for
anabolism to occur.
• Slowly increase proteins to 4 – 6 g/kg/day during the catch up
phase (Rehabilitation phase after 2 weeks).
3. SUPPLEMENTS
• Twice the recommended daily allowance for vitamins and
minerals (Na, K, Ca, PO).
• Supplement with Zinc, copper, folic acid, Vit B12.
• Oral Vit A on day 1.

63. TAKE HOME MESSAGES
- Refeeding syndrome is due to the metabolic and hormonal
changes that occur due to aggressive nutritional
rehabilitation.
- START LOW AND GO SLOW.
- IDENTIFICATION of patients at risk and monitoring
patients during nutritional rehabilitation is the key to
prevention.
- AWARENESS of the potential complications involved in
reintroducing feeds to an undernourished patient is
crucial

64. CRITERIA FOR DISCHARGE FROM
NON-RESIDENTIAL CARE
 Weight-for-height has reached -1 SD (90%) of NCHS/WHO median
reference values
 Eating an adequate amount of a nutritious diet that the mother can
prepare at home
 Gaining weight at a normal or increased rate
 All vitamin and mineral deficiencies have been treated
 All infections and other conditions have been or are being treated,
including anaemia, diarrhoea, intestinal parasitic infections, malaria,
tuberculosis and otitis media
 Full immunization programme started

65. FOLLOW UP
 Child should be seen after 1week, 2 weeks, 1
month, 3 months and 6 months. More frequently if
any problem found.
 After 6 months, visits should be twice yearly until the
child is at least 3 years old.
 The child should be examined, weighed and
measured, and the results recorded.
 Any needed vaccine, vit A should be given.
 Training of the mother should focus on areas that
need to be strengthened, especially feeding
practices, and mental and physical stimulation of the
child.

66. PREVENTION
At national level
1. Nutrition supplementation- Fortification, iodination
2. Nutritional surveillance- define the character and
magnitude of nutritional problems and strategies to
tackle.
3. Nutritional planning- formulation of nutrition policy,
improve food production and supplies, ensure
distribution.

67. PREVENTION
At community level-
• Health and nutritional education
• Promotion of education and literacy in the
community
• Growth monitoring
• Integrated health package
• Vigorous promotion of family planning programs

68. PREVENTION
At family level
 Exclusive breast feeding
 Complementary feeds at 6 months
 Vaccination
 Spacing between pregnancies

69. THANK YOU