Protein energy malnutrition

PEDIATRIC NURSING

1. Protein-Energy Malnutrition Presented by Ms Arifa T N, Second year M.Sc Nursing, MIMS CON

2. Introduction

3. Introduction Protein-energy Malnutrition (PEM) is the terminology used for all kind of malnutrition as result of lack of protein and energy foods. Major public health problem in India Particularly in children younger than 5 years old The most extreme forms of malnutrition, or (PEM), are Kwashiorkor and Marasmus

4. Introduction Severe acute malnutriton (SAM) Edematous (kwashiorkor), Severe wasting (marasmus) Marasmic kwashiorkor (features of both marasmus and kwashiorkor

5. Definition A group of clinical conditions that may result from varying degree of protein deficiency and energy (calorie) inadequacy . Previously it was known as protein calorie malnutrition.

6. Incidence Leading cause of mortality and morbidity Susceptible to infectious diseases Incidence of malnutrition in India and Africa are high 30-40% children younger than 5 years 7.6% have severe malnutrition

7. Causes and risk factors Age Children between 6 months-4 years are in risk Sex Boys are more Too many children in the same family (neglect) Lack of spacing between children Low birth weight baby Twin and multiple births Poor growth in the first few months Mother’s failure to beast feed Systemic disorders or GI structural disorders

8. Causes and risk factors Failure or stoppage of breast feeding Delay in weaning Infectious diseases Diarrhea ARI Measles Chronic diseases and certain congenital disorders Failure to thrive, CHD, Growth Retardation Lack of adequate care for the pregnant women Acute illness or surgery

9. Risk factors LBW Multiple birth Not breast fed High birth order Congenital defects poor socioeconomic background Single parents / orphans/ foster home Maternal deprivation

10. Classification According to severity Mild PEM Weight <3 rd percentile for their age but above the -3 SD Growth curve flat tend to point downwards Moderate PEM Weight are equal to or below the -3 SD line but above the -4 SD No edema , skin or hair changes alert and appetite is normal Severe PEM Weight are equal or below the -4 SD Marasmus and Kwashiorkor

11. Classification IAP classification

12. Syndromal classification Kwashiorkor Nutritional marasmus Prekwashiorkor Nutritional dwarfing

13. KWASHIORKOR First descried by Dr Cicely Williams in 1933 Term ‘ Kwashiorkor ’ was introduced in 1935 ‘Red boy’ due to characteristics of pigmentary changes Mainly found in preschool children or may at any age Infection precipitates Deficient intake of both protein and calories ( protein deficiency are more predominant)

14. Features Essential Marked growth retardation Muscle wasting Psychomotor changes Pitting edema Non essential Hair change (flag sign) Skin changes Super added infections

15. Grading Grade I:Pedal oedema Grade II: grade I+ facial puffiness Grade III: grade II + oedema of the chest wall and the paraspinal area Grade IV: grade III + ascites

16. MARASMUS Also termed as infantile atrophy or athrepsia Common infants may found in toddlers and even in later life Deficient intake of both protein and calories ( calorie deficiency are more predominant) Looks likes looks like old person with wizened and shrivelled face due to loss of buccal pad of fat. Initially the child is irritable, hungry and craves for food Later stages may become miserable, apthetic and refusal to take anything orally.

17. Features Essential Marked growth retardation Muscle wasting Marked stunting and absence of edema Non essential Hair change ( hypopigmented ) Skin changes : dry, scaly Liver shrunk Crave for food Psychomotor changes Mineral deficiencies

18. Grading of marasmus Grade I: loss of subcutaneous fat in the axilla and groin Grade II: grade I + loss of abdominal fat and fat in the gluteal region Grade III: grade II + loss of fat in the chest wall and the praspinal region Grade IV : grade III + loss of the buccal pad of fat

19. Marasmic kwashiorkor It is condition where the child manifested both the features of marasmus and kwashiorkor. The presence of edema is essential for the diagnosis and other featurs of kwashiorkor may or may not present

20. Prekwashiorkor It is a condition when the child is having features of kwashiorkor without edema. If the early management is initiated by early diagnosis of the condition The child may be protected from full-blown kwashiorkor

21. Nutritional dwarfing It is condition when the child is having significant low weight and height for the age without any overt features of kwashiorkor or marasmus It is usually seen when the PEM continue over a number of years

22. Assessment Nutritional assessment History Clinical findings 24 hour retrospective dietary recall Societal and environmental assessment Growth chart Anthropometric measurement compare with population standard

23. Lab findings Serum albumin Transferrin Prealbumin Albumin globulin ratio ( decr ) Creatinine high index Nitrogen balance (protein anabolism and catabolism) Blood glucose level Blood urine and rectal swab cultures Mantoux’s test Microscopic examination of urine or stool

24. Management of PEM Multidisciplinary approach Aim To supply what has been lacking in diet To prevent and treat infections and other diseases To teach parents how to prevent relapse

25. Management of PEM Domiciliary management Managed at home Parents are educated about dietary management Nutritional counselling and demonstration Less expensive locally available food Community support system ( supervision) Home visit Medical follow up ( weight monitoring )

26. Management at hospital Needed at advance cases Mild PEM Rule out infections Provide nutritional counselling to parents Replace nutrients and breast feed till 2 years of age, with the introduction of supplementary feeding at 4-5 months Immunization Parents counselling and education

27. Moderate PEM Admit to hospital Treat underlying cause or problems Diet is the most important part of treatment Provide a reinforced milk diet Teach preparation of milk diet

28. Severe PEM Hospitalization Watch for complications Dietary treatment 4 gm /kg protein Marsmus 150-200 kcal/kg per day Kwashiorkor 100 kcal /kg per day Reinforced milk or high calorie cereal milk can be given Children should be Fed with milk diet at the ratio of 125 ml/kg/ day Prevent hypoglycemia NG tube feeding Gradually increase the feed Schedule 8 feeds per day Supplement minerals and vitamin Treat infections

29. Complications Acute Systemic local infections Severe dehydration Shock Dyselectrolytemia Hypoglycemia Hypothermia CCF Bleeding disorders Hepatic dysfunction SIDS Convulsions Long term Cachexia Growth retardation Mental sub normalities Visual and learning disabilities

30. Prevention Health promotion Specific protection Early diagnosis and treatment Rehabilitation

31. Nursing management Assessment History Physical examination Assessment of G&D Nutritional assessment Lab investigations

32. Nursing diagnosis Imbalanced nutrition less than body requirement Fluid and electrolyte imbalance Risk for infection Potential for complications Knowledge deficit Parental anxiety Body image disturbances

33. Interventions Contribute your points ………….

34. Evaluation The child regains weight as expected No infection and edema

35. Thank you