Center for Global Pediatrics

Protein Energy Malnutrition

Cindy Howard, MD, MPHTMAssociate Director

Center for Global PediatricsUniversity of Minnesota

November 8, 2008

Center for Global PediatricsTime Magazine, August, 2008

Center for Global Pediatrics

The percentage of “under five mortality” worldwide caused in part by protein energy

malnutrition is estimated at:

a) b) c) d)

24%

0%

66%

10%

a) 30%

b) 20%

c) 60%

d) 5%

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Definitions

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Millennium Development Goals (MDG) 2000 United Nations

1. Eradicate extreme poverty & hunger2. Achieve universal primary education3. Promote gender equality and empower women4. Reduce child mortality5. Improve maternal health6. Combat HIV/AIDS, malaria, other diseases7. Ensure environmental sustainability8. Develop a global partnership for development

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Define: PEM

• Underweight: weight for age < 80% expected• Marasmus: weight for age < 60% expected• Kwashiorkor: weight for age < 80% + edema• Marasmic kwashiorkor: wt/age <60% + edema

• Wasting: weight for height• Stunting: height for age

• SAM: severe acute malnutrition

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Underweight

• Define: weight-for-age less 80% expected• Encompasses both wasting and stunting• Most global data• High correlation with stunting• Prevalence directly describes the magnitude of

the problem of growth faltering and stunting in young children

• 130 million children under the age of five years

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Marasmus

• Weight for age < 60% expected

• No edema

• Often stunted

• Hungry, relatively easier to feed

• CFR=20-30%

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Kwashiorkor(Edematous Malnutrition)

• Underweight with edema

• Irritable, difficult to feed

• Electrolyte abnormalities

• Highest mortality – 50 to 60%

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STUNTING Height for age less than 90% expected

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Severe Acute Malnutrition SAM

• Weight-for-height of 70% (extreme wasting)

• Presence of bilateral pitting edema of nutritional origin, “edematous malnutrition

• Mid-upper-arm circumference of less than 110 mm in children age 1-5 years old

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Complications of SAM include:

A. B. C. D. E. F.

0% 0%

97%

2%1%0%

A. ARI

B. Diarrhea

C. Gram negative septicemia

D. Poor feeding

E. Electrolyte abnormalities

F. All of the above

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Complications of SAM

• ARI

• Diarrhea

• Gram negative septicemia

• Poor feeding

• Electrolyte abnormalities

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TREATMENT of Undernutrition

• Varies depending on the type of malnutrition• Immediate cause:

lack of food, lack of appropriate foods for age, lack of protein, maternal death, acute or chronic infection.

• Resources available• Management protocols capable of reducing CFR

to 1 to 5%

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The first step in the treatment of SAM is toprevent and/or treat hypoglycemia.

A. B.

21%

79%

A. True

B. False

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Ten Steps to Recoveryin Malnourished Children

Ashworth A, Jackson A, Khanum S & Schofield C

1996

THE WHO TEN STEPS

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Steps 1 and 2

1. Prevent/treat HYPOGLYCEMIA

2. Prevent/treat HYPOTHERMIA

• KEY is frequent feeding – every two hrs night/day• Skin to skin contact with parent, warm lamp,

warm blanket, avoid exposure

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STEP

3

1. Give ReSoMaL or comparable oral solution.

2. Do not use the standard WHO oral rehydration salts solution. It contains too much sodium and too little potassium for severely malnourished children.

3. Do not use the IV route except in shock, and then do so with care to avoid flooding the circulation and overloading the heart.

4. Feed through diarrhea, continue breast feeding

Treat/prevent dehydration

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STEP

4

* Excessive Na* Deficient potassium* Deficient magnesium

Remember: Two weeks minimum to correct

Prepare meals w/o salt Do NOT use a diuretic to treat

edema

CORRECT ELECTROLYTE IMBALANCES

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STEP

5

Give to ALL severely malnourished children

• broad-spectrum antibiotic• measles vaccine to all children > 6 months.• Vitamin A• Mebendazole 100 mg BID x 3 days

• Consider HIV and TB

TREAT INFECTION

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STEP

6

All severely malnourished children have vitamin and mineral deficiencies.

Recommend: Zinc, copper and MV daily

Vitamin A and folic acid on Day 1

Do NOT give iron until the child has a good appetite and starts gaining weight (usually during the second week of treatment).

CORRECT MICRONUTRIENT

DEFICIENCIES

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STEP

7 Cautious Feeding

•Powdered milk, sugar and oil•May include electrolyte/mineral solution •Day 1 – 7 •Low in protein and iron, high in energy•Small, frequent feeds: 130ml/kg div q2

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Rebuild Tissues

Second week

Advance to 200 ml/kg/day div q 3 to 4 hours

Advance to local foods – peanut butter, beans, margarine – energy dense local foods

Step 8

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STEP

9

• tender, loving care

• structured play and physical activity as soon as the child is well enough

• a cheerful, stimulating environment.

• Encourage mother’s involvement

• 90% expected weight for height ready for discharge

Stimulation, Play and Loving Care

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STEP

10 Preparation for Discharge

Nutritional education

Immunization

Home

Follow Up

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PHASE STABILISATION REHABILITATION

Day 1-2 Day 2-7+ Week 2-6

1. Hypoglycaemia2. Hypothermia3. Dehydration4. Electrolytes5. Infection6. Micronutrients7. Cautious feeding8. Rebuild tissues9. Sensory stimulation10. Prepare for follow-up

no iron with iron

Treatment of Malnutrition

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Time Magazine, August, 2008

1. Hypoglycemia

2. Hypothermia

3. Dehydration

4. Infection

5. Severe anemia

Direct causes of death:

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Outpatient management

• Malawi, Sudan, Ethiopia2001-200523,511 severely malnourished children74% treated solely as outpatientsCFR=4.1%Recovery rates=79.4%Default = 11%

• Niger, MSF60,000 children with SAM70% outpatientCFR=5%

Lancet, 2006

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Bibliography• Stunting, Wasting, and Micronutrient Deficiency Disorders, Laura E. Caulfield, Stephanie A.

Richard, Juan A. Rivera, Philip Musgrove, Robert E. Black, Disease Control Priorities in Developing Countries, 2nd edition, 2006, pages:551-567

• Management of Severe Acute Malnutrition in Children, Steve Collins, Nicky Dent, Paul Binns, Paluku Bahwere, Kate Sadler, Alistair Hallam, Lancet, Vol. 368, December 2, 2006, pages: 1992-

2000.

• What works? Interventions for maternal and child undernutrition and survival. Bhutta ZA, Ahmed T, Black RE, Cousens S, Dewey K, Giugliani E, Haider BA, Kirkwood B, Morris SS, Sachdev HP, Shekar M; Maternal and Child Undernutrition Study Group, Lancet, February 2, 2008.

• Ten Steps to Recovery. Child Health Dialogue. 2nd and 3rd Quarter issues, 10-12.

• Guidelines for the Inpatient Treatment of Severely Malnourished Children Nonserial PublicationAshworth, A., Khanum, S., Jackson, A., Schofield, C. World Health Organization

ISBN-13    9789241546096 ISBN-10    9241546093