PEM


 protein-energy malnutrition: is also referred to as protein-
calorie malnutrition. It develops in children whose
consumption of protein and energy (measured by calories) is
insufficient to satisfy their nutritional needs. IT INCLUDES:
 Kwashiorkor
 Marasmus
 Marasmic kwashiorkor:
 Kwashiorkor

 severe malnutrition chiefly affecting young children
especially of poor regions that is characterized by
failure to grow and develop, changes in the
pigmentation of the skin and hair, edema, fatty
degeneration of the liver, anemia, and apathy and is
caused by a diet excessively high in carbohydrate and
extremely low in protein
 Causes & symptoms

 Infectious: measles or dysentery breakout
 Environmental stress: famine, natural disaster

 Kwashiorkor taken from the Gana language and

occur between 1-4 yrs of age, when wean from breast
feeding after the second baby is born
 Kwashiorkor

Symptoms
1.Thin wasted extremities, ascites, low albumen
(ascites makes the childs looks less deblitated than actual)
2. Scaly & dry skin, depigmentation
3. Permanent blindness result from severe vit deficiency
4. Low iron, zinc, ca skin rash, hair loss, low immune,
GI problem, slow healing, failure to thrive)
Diarrhea from lowered immunity
They may develop HIV infection
Anemia
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 Marasmus

 Result from general malnutrition of calories
 Occur in under developed country during time of
famine
 In cultures where adults eat first
 It is a syndrome of physical & emotional deprivation
 Seen in infant as young as 3 mon
 Signs & symptoms

 Child appears very old loose & wrinkled skin
 Same as kwashiorkor but no ascites, no
depigmentation,
 Smaller head size
 The child is agitated, apathic, withdrawn, lethargic
 Frequent infection as TB, parasitosis, HIV, dysentry
 Slower recovery after treatment

 
 Marasmic kwashiorkor:
Edema, wasted growth, electrolyte disturbances,
hypothermia, hypoglycemia.
 Associated with poor prognosis
 Therapeutic
management

 Three management goals:
1. Rehydration with an oral rehydration, solution that
also replaces electrolyte
2. Administration of medications such as antibiotics
and antidiarrheals
3. Provision of adequate nutrition by either
breastfeeding or proper weaning diet
 Therapeutic
management

Treatment protocol includes three phases :
1.Acute phase first 2-10 wks: initiation of treatment for oral
rehydration, diarrhea, intestinal parasite, prevent
hypoglycemia & hypothermia
Ng care in this phase:
* Care is taken to prevent fluid over load ( cardiac failure),
observe for signs of food intolerance, refeeding syndrome.
1.Recovery or rehabilitation phase 2-6 wks: focusing on
increase dietary intake & weight gain
2.Follow-up phase: focusing on out patient and to prevent
relapse & promote weight gain
 Therapeutic
management

 Give vitamin and mineral supplement: vit A, zinc &
copper
 Skin care to prevent skin breakdown
 Encourage breast feeding if the mother and child
have the ability
 Give rehydration solution, amino-acid elemental
food
 I.V & oral antibiotics
 Nursing care
management

 Parents education about feeding practice.
 Promotion of maternal nutrition & well being for the
lactating mother
 Provision of essential physiologic needs, as nutrient
intake, protection from infection, skin care, body
temperature
 Education about vaccination to prevent illness
 Emotional care for child and family
 Vitamin deficiency &
hypervitaminosis

 Vitamins:
 Essential components of cofactors in a wide range of metabolic
pathways
 ƒƒ Vitamin deficiencies are rare in developed countries;
ƒƒ Supplemental vitamins are probably unnecessary for the
healthy child over 1 year who consumes a healthy diet ƒƒ Fat
--soluble vitamin (ADEK)
 deficiencies must be considered in pts with malabsorption (CF,
pancreatic insufficiency), biliary tract disorders, liver disease ƒƒ
 Special attention is required when caring for patient on
restricted diets (i.e. vegetarian diets)



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

 Failure to thrive (FTT (

 It`s a sign of inadequate growth resulting from
inability to obtain or use calories required for growth
 Weight & sometimes height falls below the 5th
percentile for the child`s age
 Growth parameters are not used alone to diagnose
FTT
 FFT

 There are three major categories of FTT:
1. Organic failure to thrive: result from physical cause
as congenital heart defect, neurologic lesion,
microcephaly, chronic renal failure, GERD,
malabsorption syndrome, cystic fibrosis, endocrine
dysfunction
 FTT

2. Nonorganic FTT: most often results of psychosocial
factors as inadequate nutritional information by the
parent, deficiency in maternal care, disturbance in the
child`s ability to separate from the parent leading to
food refusal to maintain attention
 FTT

3. Idiopathic FTT: unexplained by the usual organic or
environmental etiology
Nonorganic and idiopathic account for the majority
of cases
 FTT causes

1. Inadequate calorie intake, incorrect formula
preparation, neglect, food fads, excessive juice
consumption, poverty, behavioral problem affecting
eating, neurological problem affecting intake
2. Inadequate absorption: cystic fibrosis, celiac
disease, vit or mineral deficiency, billiary atresia,
hepatic disease
 FTT cause

3. Increased metabolism: hyperthyroidism, congenital
heart defect, immunodeficiency
4. Defective anomalies: genetic anomalies, congenital
infection, metabolic storage disease
5. others: poverty, health or child rearing disease,
inadequate nutritional knowledge, family stress,
insufficient breast milk, feeding resistance
 Diagnostic evaluation

 Growth parameters
 Physical examination
 Developmental assessment
 Family assessment
 dietary intake history
 Lab test: lead toxicity, anemia, occult blood, zinc
level- not enough alone for Dx
 Therapeutic
management

 The primary management is aimed at reversing the
cause of growth failure
1. Provide sufficient calories to support growth
(polycose, fortified rice cereal, vit supplement)
2. Offering referrals to welfare agencies and
supplemental food programs
3. Temporary placement in foster home till family
stressors vanished
4. Behavioral modification: aimed at mealtime rituals
and family social time
 FTT

 Hospital admission should be in the following:
1. Severe acute malnutrition
2. Child abuse and neglect
3. Significant dehydration
4. Caregiver substance abuse or psychosis
5. Outpatient management that does not result in gain
weight
 Prognosis

 Poor prognosis of FTT is related to the following
factors:
 Severe food resistance
 Lack of awareness and cooperation from parent
 Low family income
 Low maternal educational level
 Young mother
 Nursing management

 Providing a positive feeding environment
 Teaching the family successful feeding strategies
 Supporting the child & family
 Accurate assessment of weight and daily weight
 Minimise fruit juice consumption before age of 6
mon
 Use tube feeding in extreme case of malnourishment
 Effort should be made to teach the parent how to
play with their child
 References

 Hockenberry M,. Wilson, D.( 2013) . Essentials of
Pediatric Nursing. ( 8th ed ). Mosby , Elsevier
 Hockenberry M,. Wilson, D.( 2009) . Essentials of
Pediatric Nursing. ( 8th ed ). Mosby , Elsevier
 
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