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PROTEIN ENERGY MALNUTRITION

Dr.Yulchair R,SpA SMF Anak RSI Pd Kopi

PEM

Nutrition Problems in Indonesia


t Protein Energy Malnutrition (PEM) t t t

Iron Deficiency Anaemia Iodine Deficiency (=GAKI) Zinc Deficiency

t
t

Vitamin A Deficiency
Obesity

Theoretical framework of Nutrition Problems. Nutrition problems

Food intake
Food availability in household

Infect Disease
Mother & child caring Health service

direct causes indirect causes

POOR FAMILY & EDUCATION, FOOD STUFF & JOB OPPORTUNITY

main problem

ECONOMIC & POLITIC CRISIS

core problem

Three level of determinants lead to nutrition status


Immediate :
Inadequacy of dietary intake manifested : - PEM - Micronutr.deficiency - Diarrhea & worm disease - ARI Supply & coverage immuniz

Intervention programs Supply side :


- access : health care facilities - supplementation of food & micronutrients. - immunization - quality: provider skill - information system: coverage of supplement., fortification, surveillance, etc.

Underlying :
- Household food security - Access to PHC - Community of awareness & care for children & women

Basic :
- Socio-economic conditions (poverty & crisis) - Political factors - Traditional practices (infant feeding) - Environment & sanitation

Demand side:
- empowerment - family awareness of nutrition - subsidies / health insurance

Health & Nutrition Status of Children

PEM

The problems of PEM :


t the main health problem t primadonna of nutritional diseases t influencing morbidity & mortality among

underfives
important

t early detection and proper management are very t severe malnutrition should be hospitalized t poor quality of life

Protein Energy Malnutrition


t disease / clinical conditions caused by energy

& protein deficiency, usually accompanied by deficiency of other nutrients.


t Primary : - nutr.intake <<

- quality / quantity of nutr. <<


t Secondary : - nutr. needs/output

>>

Energy balance: negative


INPUT: Infection

Poverty

Organic dis. etc.

OUTPUT: Infection Chronic diarrhea/ Malabsorption Hypermetabolism etc.

Protein Energy Malnutrition


T Nutr.status = spectrum : Wt/Ht

undernutrition
70 -3SD 80 90 -2SD

normal

overnutrition
110 +2SD 120 % +3SD

PEM severe moderate mild


-Kwashiorkor -Marasmus -M-K

overweight obese
mild moderate severe super

PEM.

Classification :
1. GOMEZ (195..)
2. MacLarren (196..)

: W/A
: Clinical + laboratory

3. The Wellcome Trust Party (1970)


4. Waterlow (1973) 5. WHO (1999)

: Clinica+anthropometric
(W/A)

: W/H
: Clinical+anthropometric (Z-score)

MEP.

Classification (WHO,1999) :
Moderate PEM Symmetrical oedema W/H -Severe PEM
(oedematous

malnutrition)

-3< Z-score <-2


(70-79%)

< -3 Z-score
(<70%) (severe wasting)

H/A

-3< Z-score <-2


(85-89%)

(<85%) (severe stunting)

< -3 Z-score

PEM.

DIAGNOSIS :

1. Anamnesis
2. Physical examination 3. others :
- laboratory - anthropometry - dietary analysis

PEM.

Checklist : anamnesis
Usual diet before current episode of illness Breastfeeding history

Food & fluids taken in past few days


Recent sunken eyes

Duration & freq. of vomiting / diarrhoea, appearance of vomit / diarrhoeal stools

PEM.

Checklist : anamnesis
Time when urine was last passed Any deaths of siblings Birth weight? Milestones reached (sitting up, standing,etc) Contact with people with measles or tuberculosis Immunizations

PEM.

Checklist: Physical examination


Weight, Length/Height Signs of circulatory collapse : cold hands & feet, weak pulse, consciousness << Temperature : hypothermic / fever

Respiratory rate and type of respiration : signs of pneumonia or heart failure.


Severe pallor anaemia gravis Eyes : - corneal lesion vit.A deficiency - sunken dehydration

Anaemia

PEM.

Checklist: physical examination


Thirst, dryness of lips & mouth ENT : evidence of infection? Abdominal distension, bowel sounds?

Enlargement or tenderness of liver, jaundice


Skin : infection, purpura, fat tissue? Oedema, muscles atrophy Apperance of faeces

Severe PEM : Kwashiorkor


hair face Puffy

Oedema

Severe PEM : Kwashiorkor

Hepatomegaly Crazy pavement dermatosis

oedema

Severe PEM : Marasmus


face

hair

Ribs

Muscles atrophy SC fat <<

Severe PEM : Marasmus + KP

lymphadenopathy

Severe PEM : Marasmus + KP


Caverne

Destroyed lung

6 weeks after th/

PEM.

Tests that may be useful :


k

Laboratory tests:

Blood glucose : < 54 mg/dl = hypoglycaemia k Blood smear : parasit malaria k Hb or Ht : < 4 g/dl or < 12% = severe anaemia k Urine exam/culture: bacteria + or > 10 lekosit/HPF infection k Faeces : blood + disentri Giardia + / parasit lain infeksi k X-ray : - thorax : l Pneumonia l Heart failure - bone : rickets, fracture k Tes tuberkulin : often negative electrolytes

Tests that are little ot no value : serum protein, HIV,

PEM.

MANAGEMENT :
l Mild-moderate PEM : - no specific clinical signs : thin, hypotrophic - not necessary to hospitalize - looking for the probable causes - nutr. education & supplementation
l Severe PEM : should be hospitalized

PEM.

Other criteria :
Very low BW : - W/H < 70% - W/A < 60% (- W/A > 60% + oedema) + clinical signs & symptoms :
-

oedema (M-K) severe dehydration persistent diarrhoea and / or vomiting severe pallor, hypothermia, shock signs of systemic/local infection, URI severe anaemia ( Hb < 5 g/dl) jaundice anorexia < 1 yr of age

PEM.

Signs & symptoms of dehydration : - history of diarrhoea or no/diminished intake - weak, apathetic unconscious - weak to absent radial pulse

- thirst, dry mouth and absent of tears


- sunken eyes and fontanel - hypothermia - cold hands and feet - Urine flow << / -

Dehydration

Sunken eyes

Dehydration

Turgor :

PEM.

5 ASPECTS in the MANAGEMENT of Severe PEM :

A. 10 main steps
B. Treatment of underlying diseases C. Failure to respond to treatment D. Discharge before recover E. Emergency

A : 10 main steps
No Interven1. Treat/prevent hypoglycaemia 2. Treat/prevent hypothermia 3. Treat/prevent dehydration 4. Correct electr. imbalance 5. Treat infection 6. Correct micronutrients defic. 7. Begin feeding 8. Increase feeding 9. Stimulation 10. Prepare for discharge

PEM.

tion

Stabilization Transition Rehabilitation Follow-up


d.1-2 d.3-7 wk-2 wk 3-6 wk 7-26

without Fe

+ Fe

PEM.

B. Treatment of underlying diseases / infection :

Bacterial infection :

- no apparent signs of infection/no complication: cotrimoxazole ( 5 mg TMP/kg, 2x/d, 5 days )


- signs of infection / complications / sepsis : - ampicilline 50 mg/kg/6 hrs, IM/IV, for 2 days oral (ampi / amoxy) - gentamycin 7.5 mg/kg, IM/IV, 7 days - KP + anti-TB drugs

Viral infection : no specific th/

- all PEM should receive measles vaccine

PEM.

C. Failure to respond to treatment : Frequent causes of failure to respond :


a. Problems with the treatment facility : - poor environment for malnourished children - insufficient or inadequately trained staff - inaccurate weighing machine

- food prepared or given incorrectly

PEM.

C. Failure to respond to treatment : Frequent causes of failure to respond :


b. Problems of individual children : - insufficient food given - vitamin-mineral deficiency - malabsorption of nutrients - rumination - infections - serious underlying disease

PEM.

C. Failure to respond to treatment : Criteria


Primary failure to respond: - failure to regain appetite - Failure to start to lose oedema - Oedema still present - Failure to gain at least 5 g/kg/d

Time of admission
Day 4 Day 4 Day 10 Day 10

Secondary failure to respond : - failure to gain at least 5 g/kg/d for 3 consecutive days

During rehabilitation

PEM.

C. Failure to respond to treatment : 1. Death


= within first 24 hrs : - hypoglicaemia - hypothermia - dehydration - sepsis

= within 24 72 hrs : - volume of formula >> - caloric density >>

PEM.

C. Failure to respond to treatment :

2. Inadequate gaining weight :


- infection - diet - psychologic

Weight gain : = satisfactory: > 10 g/kg/d = sufficient : 5-10 g/kg/d = poor : < 5 g/kg/d or

good = > 50 g/kg/wk < 50 g/kg/wk

PEM.

D. Discharge before fully recover:

= Dietary advice :

- high protein and calorie - frequent feeding ( 5x/d ) - finish all meals given - vit-min supplementation & electrolytes - continue BF

= frequent controle ( 1x/wk )


= Immunization

5. Emergency :
5.1. Shock :
N2 or RLG5% 15 ml/kg, 1 hr
Improvement

+
Repeat 1 hr more Resomal 10 ml/kg, 10 hrs Special formula

_
sepsis

Maintenance, 4 ml/kg/hr Fresh blood, 10 ml/kg

5. Emergency :
5.2. Severe anaemia.
Hb ?
Hb < 4 g/dl Hb 4-6 g/dl

Fresh blood 10 ml/kg*

Resp.distress/heart failure? _ +
PRC 10 ml/kg* Observation

* : give furosemid 1 mg/kg, iv, before transfusion

PEM.

Prepare for discharge :


- W/H : - 1 SD or severe PEM moderate/mild

- Education for mother :


- hygiene & sanitation - healthy foods - immunization - stimulation - regular controle

- to continue the th/ of chronic diseases - to completing immunization

On admission : Sh, girl, 2 yrs, W : 3.875 g H : 67 cm W/H : < -4SD

2 weeks later : W : 4.750 g H : 67.4 cm W/H : < -3 SD

4 weeks later : W : 5.310 g H : 67.7 cm W/H : + -3 SD

5 weeks later : W : 6.280 g H : 67.8 cm W/H : - 2 SD

7 yrs, 10 kg Recovery : 16 kg

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