Management of pcm and sam 2021

Management of PCM and SAM 2021
Pathology, Complications, Management, Prognosis, Prevention

1. Protein Energy Malnutrition
in Children
Pathology, Complications and Management
Prognosis and Prevention
Prof. Imran Iqbal
Prof of Paediatrics(2003-2018)
Prof of Pediatrics Emeritus, CHICH
Prof of Pediatrics, CIMS
Multan, Pakistan

3. AL –QURAN (76:8-9)
Surah Al-Insan(ayat8 -9)
And, because of the love of Allah; they give food to the
needy, the orphan, and the prisoner.
(they say) We feed you only for the sake of Allah, we do
not want any reward or thanks from you.

4. Protein –Calorie Malnutrition (PCM / PEM)
A pathological state resulting from
lack of protein and calories in diet
often associated with infection

5. Key Points
•Malnutrition is seen in about half of children under five in Pakistan
•Protein –Calorie Malnutrition can present as Low weight, Stunting
(short child, chronic malnutrition) or Wasting (thin child, acute
malnutrition)
•Severe Acute Malnutrition includes recognisedclinical pictures of
marasmus and kwashiorkor
•Children with Severe Acute Malnutrition have increased risk of death
•Low food intake (underfeeding) and recurrent infections are the
main immediate causes of malnutrition in children
•Poverty, low levels of education, contaminated environment and
inadequate health care are the major background factors

6. Clinical types of Malnutrition
•Underweight child –
low Weight for Age
(overall malnutrition)
•Stunting –
Low Height for Age
(indicates chronic malnutrition)
•Wasting –
Low Weight for Height
(indicates acute malnutrition)

7. Clinical Types of Malnutrition
Current terminology
(clinical picture)
•Marasmus
•Kwashiorkor
•MarasmicKwashiorkor
New terminology (measurements)
(Weight, Height, MUAC )
•Low weight (Weight for age)
•Stunting (Length for age)
•Wasting (Weight for Length/Height)
•Acute Malnutrition
•MAM (moderate acute malnutrition)
•SAM (severe acute malnutrition)

8. Severe Acute Malnutrition (SAM)
(Presence of anyof the following)
•Weight for Height < -3 z-score (< 70 %)
•MUAC < 115 mm
•Edema

9. Severe Acute Malnutrition
•Age = 11 months
•Length = 70 cm
•Weight = 5.5 kg ( -4 SD)

10. Patho-physiology of
Malnutrition

11. Patho-physiology of Malnutrition
Reductive adaptation
•Smaller size of body
•Thinness of tissues
•Smaller organs
•Reduced immunity

12. Physiological Effects of Malnutrition
•Cardiovascular -↓ cardiac output, ↓ blood pressure
•GI -mucosal atrophy, ↓ enzymes, malabsorption
•Renal -↓ glomerular filtration, ↓ waste excretion
•Immune -↓ immunoglobulins, ↓ cell-mediated immunity,
↓ phagocytosis, ↓ inflammatory response
•Liver -↓ glycogen, Hypoglycemia
•Endocrine -↓ insulin levels, ↓ IGF-1 levels
•Cellular function -↑ permeability of cell membranes
•Temperature regulation -↓ BMR, Hypothermia
•Skin, muscles, glands –atrophy, muscle fatigue

13. MALNUTRITION and INFECTION
-Immunoglobulins ↓
-T-CELL FUNCTION ↓
-POLYs FUNCTION ↓
-Complement levels ↓
-Transferrin levels ↓
-Macrophage function ↓
-Intestinal commenselflora-altered
↓
INFECTIONS

14. INDEQUATE DIET /DISEASE CYCLE
INFECTIONS
LOW
IMMUNITY
MALNUTRITION
INADEQUATE
DIETARY
INTAKE

15. Complications of Malnutrition

16. Acute Complications
•Hypoglycemia
•Hypothermia
•Diarrhea, Dehydration, Shock
•Fluid overload, Congestive Heart Failure
•Electrolyte imbalance –K
+
deficiency
•Acute infections –Diarrhea, pneumonia,
•Eyes –keratitis, keratomalacia
•Dermatosis
•Anemia
•Purpura

17. Chronic Complications
•Chronic infection e.gT.B
•Malabsorption / Chronic diarrhea
•Anemia
•Vitamin Deficiencies
•Growth retardation
•Learning disorders ( low IQ)

18. Management of
PCM and SAM

19. Initial Assessment and Management
•Assessment
-Severity and type of malnutrition
-Complications
-Anorexia
-Epidemiological factors leading to malnutrition
•Home treatment
-Moderate malnutrition
-Severe malnutrition --uncomplicated cases
•Hospital treatment
-Severe and complicated malnutrition

20. Assess and Classify Malnutrition
•Edema feet
•Weight for Height / Length (determine z-score as per
chart or table)
•MUAC (age > 6 months)
•Medical complications (extensive infections, severe
dehydration, severe anemia, hypothermia / high fever,
hypoglycemia, lethargy, convulsions, severe vomiting
•Anorexia

21. Severe Acute Malnutrition
Medical complications
•extensive infections,
•severe dehydration,
•severe anemia,
•hypothermia / high fever,
•hypoglycemia,
•lethargy,
•convulsions,
•severe vomiting
Anorexia (low appetite)

22. Principles in Management of Malnutrition
•Treat Acute complications (emergency) -hypothermia,
hypoglycemia, dehydration, diarrhea, infection
•Adequate diet (increase slowly) which the child can digest
(150 –200 calories / kg / day)
•Micronutrients ( Vitamin A )
•Growth monitoring (assess weight daily or weekly)
•Follow-up (monthly to prevent relapse)

23. Uncomplicated Malnutrition
Home Care

24. No Acute Malnutrition
•Wtfor Ht> -2 z-score (> 80 % )
•MUAC > 125 mm
•Compliment the mother
•Give Feeding advice
•Micronutrients if needed

25. MAM -Moderate Acute Malnutrition
•Wtfor Htbetween –3 and –2 z-score (70 -80 % )
•MUAC = 115 -125 mm
•Assess the Child Feeding
•Give Feeding advice
•Micronutrients

26. SAM -Severe Acute Malnutrition
•Wtfor Htless than –3 z-score (less than 70 % )
•MUAC = less than 115 mm
•Edema (nutritional cause)
•No Medical Complications
•No Anorexia -Able to feed adequately
•Assess the Child Feeding
•Give Feeding advice
•Micronutrients
•Give Therapeutic Feeds (RUTF)

27. Uncomplicated Malnutrition
Nutritional Management

28. Feeding Advice for Malnutrition
1.Assess child’s nutritional status
2.Assess present caloric intake
3.Generally child is taking 50 calories per kg of his present
weight
4.Calculate the required number of calories as 100 calories
per kg of actual weight
5.Gradual increase in calories will be required at the rate of
20 to 50 calories per day
6.If possible, increase daily intake of calories to 150 –200
Cal/kg or more after 2 to 6 weeks

29. Select foods to be given
1.Decide the types of foods suitable for the
infant/child according to his age
-CONTINUE MOTHER’S MILK FEEDS
-milk (with added sugar/oil) for < 3 months
-milk and semisolids for 3 –12 months
-mainly semisolids & solids after one year
2. DIVIDE the calculated calories in 6 –8 feeds or
foods given in 24 hours

30. Optimum Diet for 1yr old 6 kg child
Gradual increase to 900 Calories (150 Cal/kg/d)
•Rice kheer 3 oz 100 calories
•Egg half fried + 1 slice 100
•Banana 2 small 100
•Khitchri6 tsp 100
•Fried potato chips 100
•Milk 5 oz 100
•Biscuits in milk 3 oz 100
•Fried Roti ¼ / choori 100
•Cereals in milk/Cerelac5 tsp 100

31. Micronutrients
•Vitamin A 1-2 lac units once
•Zinc 1-2 mg per kg daily
•Folic acid 1 mg daily
•Vitamin D 400 IU daily
•Vitamin C / Vitamin K if clinical signs of deficiency
•Iron 1-2 mg per kg daily (start when gaining weight)

32. Other treatments as needed
•Antibiotics for infection
•Blood transfusion for severe anemia (Hb< 4 gm/dl)
•Petrolatum jelly / Zinc paste for dermatosis
•Oral antifungals (miconazole/ nystatin) for oral thrush
•Careful IV fluids if needed
•Diuretics must be avoided

33. Daily or Weekly Follow-up
•Ask about the foods taken in last 24 hours
•Calculate the total calories taken
•Ensure that the daily caloric intake is increasing as
compared to last visit
•Compare the calories taken with the target calories
•Give appropriate advice about feeding

34. Management of
Complicated Malnutrition

35. Severe Acute Malnutrition with complications
•Any of the following signs:
SAM + Medical complications (acute illness)
SAM + poor appetite
SAM + severe edema
•Admit / Refer for Inpatient care
•Admit in Stabilization Centre (SC)
•Manage according to Guidelines
•Phase I (Stabilization)
•Phase II (Rehabilitation)

36. Principles in Management of Malnutrition
•Treat Acute complications -hypothermia, hypoglycemia,
dehydration, diarrhea, infection
•Adequate diet which the child can digest (150 –200 calories /
kg / day)
•Micronutrients ( Vitamin A )
•Growth monitoring (assess weight daily or weekly)
•Follow-up (monthly to prevent relapse)

37. Time frame for the management of
a child with severe malnutrition
Stabilization Rehabilitation
Days 1-2 Days 3-7 Weeks 2-6
1. Hypoglycaemia
2. Hypothermia
3. Dehydration
4. Electrolytes
5. Infection
6. Micronutrients no iron with iron
7. Initiate feeding
8. Catch up growth
9. Sensory stimulation
10. Prepare for follow-up
Source: WHO

38. Steps for successful management of the severely malnourished child
1-2.Treat/prevent hypothermia and hypoglycemia (which are often related) by feeding,
keeping warm, and treating infection
3. Treat/prevent dehydration using Rehydration Solution for Malnutrition (Resomal).
4. Correct electrolyte imbalance (by giving feeds and ReSoMal prepared with mineral
mix or CMV).
5. Presume and treat infections with antibiotics.
6. Correct micronutrient deficiencies (by giving feeds prepared with mineral mix or CMV
and by giving extra vitamins and folic acid as needed).
7. Start calculating feeding with F-75 to stabilize the child (usually 2-7 days).
8. Rebuild wasted tissues through higher protein/caloric feeds (F-100).
9. Provide stimulation, play and loving care.
10. Prepare parents to continue proper feeding and stimulation after discharge.

39. ReSoMal
(Rehydration Solution for Malnutrition)
•Sodium Chloride 1.75 gm
•Sodium Citrate 1.45 gm
•Potassium Chloride 2.54 gm
•Potassium Citrate 0.65 gm
•Magnesium Chloride 0.61 gm
•Zinc Acetate 0.0656 gm
•Copper Sulphate 0.0112 gm
•Glucose 10 gm
•Sucrose 25 gm

40. Therapeutic diets given in SAM
•Mother milk as available
•Oral feeds / Nasogastric tube for feeding
•F –75 diet (milk, sugar, cereal flour, vegetable oil, water)
-75 calories / 100ml –(Amount of Feed: 135 ml/kg/day)
•F –100 diet (milk, sugar, vegetable oil, water)
-100 calories / 100ml –(Amount of Feed : 200 ml/kg/day)
•RUTF (Ready to use therapeutic food) -available in SC in hospitals
•Semisolid and solid home foods which the child can take easily (e.g.
blended egg, rice, banana, potato)

41. Recipe for F-75 and F-100
Alternatives Ingredient Amount for F-75 Amount for F-100
Dried whole Milk Dried whole milk
Sugar
Cereal flour
Vegetable oil
Mineral mix*
Water to make 1000 ml
35 g
70 g
35 g
20 g
20 ml
1000 ml**
110 g
50 g
30 g
20 ml
1000 ml**
Fresh cow’s Milk Fresh cow’s milk, or full
cream (whole) long life
milk
Sugar
Cereal flour
Vegetable oil
Mineral mix*
Water to make 1000 ml
300 ml
70 g
35 g
20 g
20 ml
1000 ml
880 ml
75 g
20 g
20 ml
1000 ml

42. Semisolid and Solid Foods
•Composition of RUTF (supplied by Unicef)
•Peanuts (ground into a paste)
•Vegetable oil
•Powdered sugar
•Powdered milk
•Vitamin and mineral mix (special formula)
•Semisolid and solid home foods
•Egg, rice, banana, potato (mashed and blended)
42

43. Prognosis

44. Recovery from PCM / SAM
•WEIGHT GAIN should be 5 –10 gm / kg / day
•Catch-up growth occurs during the period
of recovery from malnutrition
•During this period child grows at above
the normal growth rate
•Child is considered to be recovered when
–1 SD weight for length / height
(90 % of expected)
has been achieved

45. Hifsa’s journey from malnutrition to health

46. Prevention of
Malnutrition

47. PREVENTION OF MALNUTRITION
•Nutrition education
(health care providers, child caretakers)
•Adequate feeding and diet
•Growth monitoring
•Protection against infections

48. Adequate feeding and diet
•Breast feeding for 2 Yrs
•Weaning at 4 –6 months
•Adequate diet for children
•Feeding during illness

49. Growth Monitoring
•Weigh the baby/ child every month uptofive years of age
•Plot the weight on the Growth chart
•Ensure increased feeding if low weight

50. Protection against Infections
•Vaccination
•Handwashing
•Use Masks
•Social distancing
•Unpolluted air
•Breastfeeding
•Adequate Nutrition
•Micronutrients
•Safe water
•Clean food

51. SAM(Pathology, Management, Prevention)
•Children with SAM -Severe Acute Malnutrition (marasmus and
kwashiorkor) have increased risk of complications and death
•Their bodies have major patho-physiological disturbances
•Initial management addresses acute medical complications
Nutritional rehabilitation is started at the same time with
semisolid mainly carbohydrate feeds and micronutrients
•Subsequent feeding includes high calorie, high protein solid
foods
•Prevention of malnutrition in children requires Nutrition
education, Adequate feeding and diet, Growth monitoring and
Protection against infections

52. Thank you