PEM | Malnutrition | Hypoglycemia

PROTEIN ENERGY MALNUTRITION

Prof. Ekram M. Helmy
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DEFINITION OF PEM 
A

range of pathological conditions  Caused by deficiency of energy + proteins  Usually accompanied by infection  Most frequently in infants & young children
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Wellcome Classification
Type of P.E.M.
MILD Marasmus
Weight Edema

Underweight 60-80 % < 60 %

+ +

SEVERE Kwashiorkor 60-80 %
Marasmic-Kw.

< 60 %

Weight =50 th centile of normal values of weight for age
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Weight (% of 50th centile) < 60 %
NO EDEMA + EDEMA

60-80%
+ EDEMA NO EDEMA UNDERWEIGHT Mild-Mod. Malnutr.

> 80%
NO EDEMA

M

MK

K

NORMAL

Severe P.E.M.

No Malnutr.A.Madkou
r

severe

forms

Mild & Moderate forms

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UNDERWEIGHT CHILD 
    

Growth failure ( Wt 60-80 % ) 60Infection ( GIT, chest, parasites ) Associated deficiencies ( vit., min.) Anemia ( iron, folic & protein def.) Retarded development Apathy, restlessness, dimin. activity
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UNDERWEIGHT CHILD

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M

MARASMUS
Form of PEM occurring during first 3 years of life (Usually 1st year).
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M 
  

CAUSES

NUTRITIONAL ( P + E deficiency) NON NUTRITIONAL : 
Diarrhea ( Recurrent / Persistent )

Malabsorption Syndromes Chronic Infections (T.B. etc.) Congenital Malformations Metabolic Disorders
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M CLINICAL FEATURES
1. 2. 3. 4. 5. 6. Growth failure ( Wt. < 60 %) Loss of subcutaneous fat Muscle wasting (limbs, Abd.) Hypothermia Associated Vitamin deficiencies Diarrhea & intercurrent Infections
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M 
   

CLINICAL FEATURES
Psychic changes : anxious, irritable excessively crying , Little sleeping Hungry ( except in severe infection) No Edema No Dermatosis No Hair changes ( Or mild ones )
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MARASMUS

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M 

LAB. FINDINGS

Plasma Proteins : +/- Normal +/ Blood Glucose : Hypoglycemia  Blood Picture : Anemia ( Iron deficiency, etc. )  Blood Urea : Very Low
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M 


COMPLICATIONS 

Hypoglycemia, Hypothermia

Diarrhea, Dehydration, Electr.Dist. Infection ( Thrush, TB, Empyema Otitis, Pyeloneph., Opportunistic ) 

Infection may be SILENT Depressed mental functions
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M 
  

CAUSES OF DEATH

HYPOTHERMIA HYPOGLYCEMIA ELECTR.DISTURBANCES INFECTION (PNEUMONIA)
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K

KWASHIORKOR
The one before the last The disease the first child gets when the 2nd one is on the way.

A severe form of PEM occurring mainly in the weaning & post-weaning periods when postthe diet is persistently deficient in essential proteins.
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K

ETIOLOGY OF KWASH.

DIETARY INADEQUACY: 
During Weaning & post-weaning periods post Unbalanced diet very low in protein &
consisting mainly of carbohydrate  Poverty + Ignorance + Poor hygiene

PRECIPITATING FACTORS: 
Acute infection: Measles, G. Enteritis  Malaria, helminthes (in some regions)
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K

CLINICAL MANIFESTATIONS

ALWAYS PRESENT (4) USUALLY PRESENT (2) OCCASIONALLY PR. (5)
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K 
 

ALWAYS PRESENT 

Growth Failure ( Wt, mid-arm ). midEdema with NO Ascitis. Muscle Wasting & Disturbed muscle / fat ratio Psychic Changes ( Apathy, etc.).
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EDEMA IN KWASHIORKOR

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K 

USUALLY PRESENT 

DIARRHEA : Infection Enzymatic deficiency Atrophic villi Fermentation HAIR CHANGES: (Dry, uncurled, loss of luster, pickable, discolored)
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K OCCASIONALLY PRESENT 
   

Dermatosis Hepatomegaly Anemia ( multifactorial ) Vitamin & Mineral defic. Associated Infection
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DERMATOSIS OF KWASHIOKOR

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Infection was detected at autopsy in 100 % of children dying from PEM INFECTION MAY BE SILENT Infection may run a complicated course
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KWASHIORKOR

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KWASHIOKOR-TREATED

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K

BIOCHEM.CHANGES
Plasma Proteins ( < 4g / dl ) S.Albumin ( < 2g/dl ) Serum E and F globulins Enzymes ( Cellular & G.I.T ) Serum g globulins ( relative )
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˜ Proteins :

K 


CARBOHYDRATES

HYPOGLYCEMIA: Asymptomatic 20-40 mg/dl 20Symptomatic < 20 mg /dl DIABETIC GLUCOSE TOL. CURVE Low Insulin Secretion Resistance to Insulin in cells
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K 
Low

LIPIDS

Plasma Cholest. & Triglyc.  Fatty Liver due to : Mobilization of FFA from Fat F. A. synthesis from glucose Oxidation of F.A. in liver Release of fat from liver
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K 
   

HEMATOLOGICAL FIND.
Low Hemoglobin Low RBC count Low WBC count Low / Normal platelets High serum ferritin (infection)
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K 
 

WATER & ELECTROL.
Overhydration HypoHypo-osmolar ( < 270 mOsm/L) High total body Sodium Low serum Sodium (dilutional) Low body & Serum Potassium Low body & Serum Magnesium
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K 
    

COMPLICATIONS
Hypothermia Severe hypoglycemia Diarrhea, dehydration... Infections & septicemia Heart failure Depression of mental functions
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K 
  

CAUSES OF DEATH
Dehydration & electr. disturb. Infections & septicemia Severe hypoglycemia Heart failure
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MARASMIC-KWASHIORKOR

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AFFECTION OF: 
Weight

only

=

Recent (acute) Malnutrition (M, K,MK, UnderWt) 
Weight

+ Height =

Early (prolonged)Malnutrition: eg. Nutr.Dwarfism 
Wt

+ Ht + Head Circumf. =
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Very early or fetal Malnutrition: eg. Nutr.Dwarfism

NUTRITIONAL DWARFISM
Left: Child aged 2 ys Middle: Child aged 4 ys Right: Child aged 5.5 ys The last child shows evidence of marked growth retardation but the weight/Height ratio is normal.
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MANAGEMENT OF P.E.M.

Management of Mild P.E.M. At Home
Treat infections & parasites  Nutritional advice + supplementation: Calories: 100 - 150 kcal/kg/day Proteins: 2 - 3 g/kg/day  Vitamins A, D, Folic acid  Minerals: Iron, etc.... 

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Management of Severe P.E.M. In Hospital
Clinical assessment & Investigations  Stabilization & Emergency treat. of complic.  Rehabilitation & Restoring nutritional status  Preparation for discharge  Preventing recurrence 

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CLINICAL ASSESSMENT
1- HISTORY 
Nutritional

& Social history  Developmental milestones  Present complaint:diar.,ear discharge  Past history of measles, etc...
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CLINICAL ASSESSMENT
2- PHYSICAL EXAMINATION
Vital signs: temp., pulse & resp. rates...  Wasting, edema, pallor, dermatosis«  Signs of dehydration  Signs of vitamin deficiencies (Eye)  Signs of heart failure  Systematic physical exam. + E.N.T. exam. exam. 

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YOU SHOULD EXCLUDE
Otitis Media  Respiratory infection  Tuberculosis  Urinary tract infection  Meningitis  Parasites  Small intestinal bacterial overgrowth 

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CLINICAL ASSESSMENT
3- ANTHROPOMETRIC DATA
Length / Height (use percentile charts)  Weight for age & weight for height  Head, chest & abdominal circumf.  Mid-arm circumference Mid Others: skin fold thickness, etc.... 

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AFFECTION OF: 
Weight

only

=

Recent (acute) Malnutrition (M, K,MK, UnderWt) 
Weight

+ Height =

Early (prolonged)Malnutrition: eg. Nutr.Dwarfism 
Wt

+ Ht + Head Circumf. =
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Very early or fetal Malnutrition: eg. Nutr.Dwarfism

CLINICAL ASSESSMENT
4- SIGNS OF VITAMIN DEF. 
Night

blindness  Bitôt¶s spots Bitô  Corneal xerosis, ulceration  Rickets  Other signs of vitamin deficiency
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Assessment of Dehydration  

 

UNRELIABLE Skin turgor : loss of subc. fat or edema Sunken eyes (maras.) Irritability (marasmus) Apathy (kwashiorkor) 

   

RELIABLE Eagerness to drink Dry mouth & tongue Lethargy Weak rapid pulse Oliguria / anuria

IMPOSSIBLE to distinguish moderate from severe dehydr.
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INVESTIGATIONS
Complete blood count + Red cell indices  Urinalysis (pus cells) + Urine culture  Stools analysis for ova & parasites  Chest radiography  Serum proteins (in Kwashiorkor) 

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Stabilization & Emergency Treat. For Life Threatening Complications
PRINCIPLE
AGGRESSIVE Treatment for infections  GENTLE & CONSERVATIVE approach: ‡ For Rehydration ‡ For Nutritional rehabilitation 

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Stabilization & Emergency Treat.
For Life Threatening Complications
1. Hypothermia 2. Hypoglycemia 3. Heart failure 4. Dehydration & Electrolyte disturb. 5. Infections & Parasites 6. Start Cautious Initial Feeding
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DEHYDRATION
& ELECTROLYTE DISTURBANCES PRINCIPLE
Route: ORAL or NASOGASTRIC  Avoid I.V. (overhydration, heart failure)  I.V. used only in: ‡ Shock ‡ Failure of Oral 

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REMEMBER: 
   

In Severe PEM

total Body Water (>110% in marasm.) (>110% total body Sodium ( Serum Na+) total body Potassium ( Serum K+ ) total body Magnesium ( Serum Mg+) Serum osmolarity ( < 270 mOsm/ liter)

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REHYDRATION FOR PEM
FLUID SHOULD CONTAIN : 
Less

Sodium  More Potassium  Magnesium  Trace elements (Zn, Cu, I, Se)
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ORAL REHYDRATION FLUID
WATER 400 ml SUCROSE 10 grams REHYDRAN 1 Packet

+

Pot. Cl. 1 gram

+

2 ml Mag. Sulf. (50 % Sol.) I.M., ONCE (50 I.M.,
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REHYDRATION FOR P.E.M.
HOW MUCH: 7 0 - 100 ml / kg  DURATION: Very Slow (over 12 hours)  ORAL / NASOGASTRIC : First 2 hours : 10 ml / kg / hour Next 10 hours: 5 - 8 ml / kg / hour  INTRAVENOUS : 5 - 10 ml / kg/ hour Shift to Oral as soon as possible 

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INFECTION 
In

Severe PEM: PEM: Severe PEM children: children: Remember

INFECTION IS ALWAYS PRESENT 
All

SHOULD RECEIVE ANTIBIOTICS

AGGRESSIVE TREAT. FOR INFECTION
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TREATMENT OF INFECTION 

SILENT INFECTIONS (No S & S): ‡ Cotrimoxazole, or ‡ Ampicillin+Gentamisin+Chloramph. Ampicillin+Gentamisin+ ‡ Metronidazole for anaerobes  MANIFEST INFECTION : above + ADD Appropriate antibiotic / chemother. chemother.  PARASITES, FUNGI: Appropriate therapy
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HYPOTHERMIA (<35.5oC)
Frequent feeding (every 2 hours)  Heater: room temperature 30 - 33oC  Baby sleeps close to his mother  Wrap child in warm blankets  Avoid unnecessary expopsure of baby 

HYPOTHERMIA & HYPOGLYCEMIA CAN BE MANIFESTATIONS OF SEPTICEMIA
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HYPOGLYCEMIA ( <55 mg/dl ) 

SILENT (mild to moderate) in most cases Prevented: frequent feeding (2 hourly) (2 Treatment:oral glucose in water / milk Treatment:oral SEVERE (PROFOUND): B.S.< 20 mg /dl (PROFOUND): Treatment : 50 ml Glucose 10% in water or milk 10% (or 1 heaped spoon sugar in 50ml) 50ml) I.V. 50% glucose : 1 ml / kg of body weight 50%
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HEART FAILURE
l MANIFESTATIONS: 

 allop rhythm yG   nlarged liver yE
l MANAGEMENT: 
No 

 asal crepitation yB   irculat. failure yC 

digitalis  Fluid restriction + Diuretics  Oxygen + supportive measures
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NUTRITIONAL REHABILITATION
1. CAUTIOUS INITIAL FEEDING :
Little, Frequent, Isotonic feeds Do not exceed metabolic capacity Oral or NGT route Parenteral nutr. ONLY as last resort

2. SUBSEQUENT FEEDING :
High-energy diet + Vit. + Minerals HighStimulation (emotional support)
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3. HIGH ENERGY DIET : catch-up growth catch4. CORRECTION OF ELECTROLYTES : Electrolyte / Mineral Solution (EMS) 5. MICRONUTRIENTS SUPPLEMENTS: Vitamins Minerals Trace elements 6. STIMULATION, PLAY & EMOTIONAL SUPPORT: better mental development
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CAUTIOUS INITIAL DIET
From admission to return of appetite
Daily Amount : 100 ml / kg / day  Caloric content : 75 kcal / 100 ml of food  Protein content : <1 gram / 100 ml of food <1  Frequency : 10 small feeds / day  Amount of feed : 10 ml / kg / feed  How given : Oral or NGT (in anorexia) 

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Example of Initial Diet
TO MAKE 100 ml : Whole Milk Sucrose Vegetable Oil E M Solution Water, add to make : 30 ml : 10 grams : 2 ml : 2 ml : 100 ml
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If intolerant to lactose: use lactose-free formula lactose-

SUBSEQUENT DIET
After regain of appetite ( 5-7 days )
Daily Amount : 120-130 ml / kg / day 120 Caloric content : 100 kcal / 100 ml of food  Protein content : 2.5-3 gram / 100 ml food  Frequency : 8 feeds / day  Amount of feed : 15 ml / kg / feed  How given : Oral or NGT (in anorexia) 

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Example of Subsequent Diet
TO MAKE 100 ml : Whole milk Sucrose Vegetable Oil E M Solution Water, add to make : 85 ml : 7.5 grams : 2 ml : 2 ml : 100 ml

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VITAMIN A DEFICIENCY : 50,000-200, 50,000-200,000 IU, Orally, Once  OTHER VITAMINS : Double RDA with food or alone  POT., MAG. & TRACE ELEMENTS : Given with Oral rehydration  IRON: not given until infection is treated 3 mg/kg elemental iron per day 

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CRITERIA OF CURE
Mood changes disappear in few days  Child starts to eat with increasing appetite  Diarrhea stops  Edema increases then disappears (10 days) (10  Skin lesions : rapid healing in 10 days  Weight : initial loss then gain  Return to normal health in 3 months 

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KWASHIOKOR-TREATED

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FAILURE TO RESPOND
‡

‡

‡

FEEDING PROBLEMS : Inappropriate preparation Inadequate amounts UNDIAGNOSED ASSOCIATED COND.: COND.: Infection : OM,TB, UTI, etc.. Congenital, Chronic & Metab. dis. PSYCHOLOGICAL: Emotional deprivation
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NUTRITIONAL DWARFISM
Left: Child aged 2 ys Middle: Child aged 4 ys Right: Child aged 5.5 ys The last child shows evidence of marked growth retardation but the weight/Height ratio is normal.
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