Protein Energy Malnutrition

Dr. Alaa AlgasimMBBS UGMD

SMSB
Definition Content
Pathophysiology
Classification
Clinical features
Management
omdurman teaching hospital feb
2014
 Failure to thrive (FTT) has classically been
the term used to describe children who are
not growing as expected.
malnutrition defined as an imbalance
between nutrient requirements and intake or
delivery that then results in deficits—of
energy, protein, or micronutrients—that may
negatively affect growth and development
malnutrition is a major underlying cause of
death and illness in children. Even children
with mild and moderate malnutrition have an
increased risk of death.
PATHOPHYSIOLOGY
1 gram of fat gives 9 calories
1 gram of protein gives 4 calories
1 gram of carbohydrate gives 4 calories
Malnutrition is a range of conditions occurring
when intake of one or more nutrients doesn’t
meet the requirements.
Øit is not only the deficiency of proteins but
inappropriate food (low in energy density,
protein and micronutrients ‐Vitamin A, Iron,
Zinc) Øpoor both quantitatively and
qualitatively
Fat and muscle are lost
Liver can’t cope with lots of
protein
Heart cannot cope with excess
fluid
Kidneys cannot get rid of excess
fluid or sodium
Gut has less enzymes and less
surface for absorbing nutrients
 Risk factors and causes
(1)failure to ingest sufficient calories, or
starvation (e.g., cardiac failure, fluid
restriction),
(2) increased nutrient losses (e.g., protein-
losing enteropathy, chronic diarrhea),
(3) increased metabolic demands, as seen in
extensive burn injuries, and
(4) altered nutrient absorption or utilization
Prematurity & low birth wt
Early and sudden weaning
Low birth spacing and over crowded
Poor complementary and supplemental
feeding
Recurrent gastroenteritis
chronic Illness
Malabsorbtion
Immunizable diseases
The main cause of PEM is food inadequacy
Clinical features
Classification
PEM is a spectrum of conditions ranging from
growth failure to overt marasmus or
kwashiorkor.
• Various classifications are given ØGomez
classification
ØIAP classification
ØNCHS (WHO) classification
ØWaterlow’s classification Ø
Welcomes classification
 Wellcome’s classification
• Parameter: Weight for age + oedema
• Reference standard (50th percentile)
• Grades:
Ø80‐60 % without oedema is under weight Ø80‐
60% with oedema is Kwashiorkor
Ø< 60 % with oedema is Marasmus‐Kwash
Ø< 60 % without oedema is Marasmus
Management
 Stabilizing the child
Children with severe acute malnutrition are
often
seriously ill: 5-25% will have
Anorexia
Severe infections

Will need admission until patient is stable

and appetite returns (2-7days)
Successful initial management requires :
Anticipation of common problems so they can be prevented
Recognizing and treating early
Constant monitoring-pulse rate, respiration rate, urine
frequency, stool/vomit frequency
omdurman teaching hospital feb
2014
WHO 10- steps for treatment of
SAM
 Dietary Treatment
Continue to breast feed
Give therapeutic milk formula diet
- F-75 used in the stabilization phase
- RUTF or F-100 used in rehabilitation
phase

May be easily prepared from basic

ingredients or commercially available
Feed 2-3 hourly by day and night
130 ml/kg/day
NG feeding
Initial phase ends when appetite returns
Step 5: Treat/prevent infections
Nearly all severely malnourished
children have bacterial infections
Often the usual signs are absent
Assume presence of infection
Prescribe all severely malnourished
children a broad spectrum antibiotic
starting on day of admission
Add other appropriate antibiotics to
treat specific infections
 Step 6: Correct
micronutrient deficiencies
Step 7: Start cautious
Feeding
Learning Objectives of Feeding
Planning feeding for 24- hour period
for;
A child taking F- 75.
Gradual transition; F-75 to RUTF/F-100
Feeding freely during rehabilitation.
Measuring and Giving feeds
Recording on Daily care Chart.
Daily Care.
Involving Mothers.
Feeding formula: F 75, RUTF & F-
100
F 75 is the starter formula and F 100
used as follow on formula. Water based.
RUTF is lipid based paste
They are being provided at S.C by WHO
They are mixed with water, therefore
high chance of getting contaminated
Should be used only for inpatients
Substitutes can be prepared using
locally available ingredients Renuka Jaytaissa /
MRI / 2009
 Feeding Techniques
Preferably Oral route.
Bottles should never be used.
Cup Feeding.
Naso-gastric feeding:
*If child’s intake is less than 80% of
total.
Painful lesions in mouth.
Disturbed conscious level.
Cleft palate.
Feed F75 during stabilistaion
F-75: 75 kcal, 0.9g
protein per 100ml

Ingredients: milk,
sugar, oil, electrolyte
mineral solution (or
CMV)

Use Nutriset sachets

or make from scratch
Preparation

Renuka Jaytaissa /
MRI / 2009
Renuka Jaytaissa /
MRI / 2009
 Readiness for transition
Look for these signs, usually after 2 –
3 days:
Return of appetite
Reduced oedema or minimal oedema

When these signs appear, the child

is ready for transition
 Requirements during
rehabilitation
Aim: To re-build wasted tissue
and gain weight by;

High energy (150-220

kcal/kg/day)
High protein (4-6g/kg/day)
Feed frequently to appetite
 Feed RUTF
Or use Ready to Use
Therapeutic Food
(RUTF)
200kcal/kg/day
This is done at
home
The child is referred
to a outpatient care
facility for follow up
and routine
medications
Feed F100 during rehabiltiation
F100: 100 kcal, 2.9g
protein per 100ml
Use Nutriset sachets
or make from
scratch
Or you may prepare
using local
ingredients
Daily Care during Stabilistaion

Handle the Child Gently;

While clothing
Bathing
Talk Softly
Encourage mother to provide care
Involving & Training Mothers
Emotional support essential for Early
recovery.
Use Toys to stimulate admitted
babies.
Mother is the only person who can
provide continuous support.
When involved in care at ward can
continue at home
Counseling for better Hygiene
 Take Home Message!
• Malnutrition does not mean undernutrition. •
There are various classifications for PEM.
• PEM is preventable and curable