PROTIEN ENERGY MALNUTRITION FOR UNDERGRADUATE STUDENTS

PROTIEN ENERGY MALNUTRITION

1. PEM : PROTIEN ENERGY MALNUTRITION Mrunmayee Phatak Roll no. 101

2. Definitions Malnutrition : Malnutrition refers to deficiencies, excesses or imbalances in a person’s intake of energy and/or nutrients. The term malnutrition covers 2 broad groups of conditions – undernourished and overweight. PEM – group of clinical conditions that may result from a varying degree of protein deficiency and calori e deficiency commonly seen in under 5 children. Its most extreme forms are Marasmus and Kwashiorkor. S tunting : low height for age i.e two standard deviations below the WHO Child Growth Standards median W asting : low weight for height i. e two standard deviations below the WHO Child Growth Standards median U nderweight : low weight for age i.e two standard deviations below the WHO Child Growth Standards median

3. BURDEN-global Data according to : UNICEF-WHO-The World Bank: Joint Child Malnutrition Estimates (JME) — Levels and Trends – 2023 edition The following image shows Global p ercentage of children under 5 affected by stunting, wasting and overweight, global, 2000–2022

4. Numbers in India According to the NFHS 5 (2019-2021 ) According to UNICEF-WHO-The World Bank: Joint Child Malnutrition Estimates (JME) — Levels and Trends – 2023 edition STUNTING WASTING UNDERWEIGHT LOWEST % Odisha Sikkim Sikkim HIGHEST % Jharkhand Assam Jharkhand According to the NFHS 5 (2019-2021) , IN KARNATAKA :

5. CLASSIFICATIONS WHO CLASSIFICATION IAP CLASSIFICATION ARNOLD CLASSFICATION GOMEZ CLASSIFICATION WELLCOME TRUST CLASSIFICATION WATERLOW’S CLASSIFICATION CLINICAL CLASSIFICATION

6. 1.WHO CLASSIFICATION MODERATE SEVERE EDEMA NO YES Weight for height deficit Between minus 2-3 SD i.e 70-79% of expected value Lesser than 3 SD i.e less than 70% of expected value Height for age deficit Between minus 2-3 SD i.e 85-89% of expected value Lesser than 3 SD i.e less than 85% of expected value

7. 2. ARNOLD CLASSIFICATION Based on mid upper arm circumference (MUAC) or mid arm circumference (MAC) Measured using Shakir’s tape NUTRITIONAL STATUS MAC IN CM NORMAL >13.5 (RED) MILD-MODERATE 12.5-13.4 (YELLOW) SEVERE <12.5 (GREEN)

8. 3.GOMEZ CLASSIFICATION NUTRITIONAL STATUS WEIGHT FOR AGE % NORMAL >90% GRADE 1 75-90% GRADE 2 60-75% GRADE 3 <60% All cases of EDEMA are placed in grade 3 irrespective of the wt for age

9. 4. IAP CLASSIFICATION The letter ‘K’ is added if there is presence of edema

10. 5. Wellcome trust classification WT FOR AGE % EDEMA + EDEMA - 60-80 KWASHIRKOR UNDERWEIGHT <60 MARASMIC KWASHIORKOR MARASMUS

11. 6. Waterlow’s classification

12. 7.CLINICAL CLASSIFICATION KWASHIORKOR - MARASMUS MARASMIC KWASHIORKOR

13. Clinical features - KWASHIORKOR

14. FLANKY PAINT DERMATOSIS

15. Grading of kwashiorkor Grade 1 : pedal edema Grade 2 : grade 1 + facial puffiness Grade 3 : grade 2 + edema of chest wall and paraspinal area Grade 4 : grade 3 + ascites

16. Clinical features - marasmus Marasmus occurs in age group of 3 – 9 months The main sign is severe wasting shoulders, arms, buttocks and thighs The child appears very1thin (skin and bones) and has no fat. The loss of buccal pad of fat creates the aged or wrinkled appearance, referred to as monkey facies There is NO EDEMA Monkey facies

17. Grading of marasmus Grade 1 : loss of subcutaneous fat in axilla and groin Grade 2: grade 1 + loss of abdominal and gluteal fat Grade 3 : grade 2 + loss of fat in chest wall and paraspinal area Grade 4 : grade 3 + loss of buccal pad of fat

18. Management General principals for routine care Not to use diuretics for oedema : may aggravate already existing intravascular hypovolemia, leading to hypovolemic shock Avoid initial intake of high protein and high calorie diet : cardiovascular and gastrointestinal system cannot cope with sudden increase in proteins, calorie and fluid intake Minimum use of IV fluid : Intravenous fluid may be administered only for 2 hours as they may cause heart failure due to fluid overload in severely malnourished children. Frequent feeding Give antibiotics empirically : Since infections in malnourished children are catastrophic (as they are immune compromised), SAM children are given routine broad spectrum antibiotics on admission.

19. 10 STEPS IN THE MANAGEMENT OF CHILDREN WITH SAM Initial Stabilization phase (containing 7 steps) Usually achieved in 1st week Step 1:Treat/ prevent Hypoglycaemia Step 2:Treat/ prevent Hypothermia Step 3:Treat/ prevent Dehydration Step 4:Correct electrolyte imbalance . Step 5:Treat/ prevent Infection Step 6:Correct Micronutrient deficiency Step 7:Start cautious feeding including breast feeding Rehabilitation phase (containing 3 steps) Usually achieved in 2-6 weeks Step 8:Achieve catch up growth Step 9:Provide sensory stimulation and emotional support Step 10:Prepare for discharge and follow up regularly

20. Prevention Primary Secondary Tertiary Health education Early diagnosis & treatment Specific protection Rehabilitation Promotion of breast feeding. Development of low cost weaning foods Measure to improve family diet. Nutritional education: promotion of correct feeding practices. Family planning & spacing of births . Food fortification Immunization Periodic surveillance. Early diagnosis of any lag in growth. Early diagnosis & treatment of infections. Development of programmes for adequate growth of children. Development of Supplementary feeding programmes during epidemics. De-worming of heavily infested children. Nutritional rehabilitation services. Hospital treatment. Follow-up care .

21. Health programs and govt initiatives Janani Shishu Suraksha Karyakram MAA programme Rashtriya Bal Swasthya Karyakarm INMCI RNMCH+A School Health Services – Midday Meal Scheme Poshan Abhiyan

22. REFERENCES https://pib.gov.in/PressReleasePage.aspx?PRID=1806601 https://www.wikidoc.org/index.php/Protein_energy_malnutrition_classification https://data.unicef.org/resources/jme-report-2023/ https://www.who.int/news-room/fact-sheets/detail/malnutrition https://www.jscimedcentral.com/public/assets/articles/nutritionaldisorders-2-1008.pdf

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