Protein Energy Malnutrition (PEM) in Children

1. Protein Energy Malnutrition (PEM) in Children • Arturo S. Gastañaduy M.D. • Associate Professor of Pediatrics • Louisiana State University • July 2011

3. Learning Objectives • Epidemiology of PEM in children of developing and developed countries • Diagnosis and management of childhood PEM • Specific interventions for prevention of PEM

5. Immediate Causes of Childhood Deaths: 2008

6. Global Trends in the Prevalence of Moderate-Severe Malnutrition in Children Under Five

7. Prevalence (%) of Moderate-Severe Malnutrition in Children Under Five in Selected Countries(From World Health Organization Data Base)

9. Protein Energy MalnutritionWHO Classification • Moderate Severe • Edema No Yes • Wt / Ht Deficit1 (%)2 2-3 (70-79) >3 (<70) • Ht /Age Deficit1 (%)2 2-3 (85-89) >3(<85) • 1 Standard deviation from median of reference population • 2 Percentage of the median of reference population: NCHS/WHO

10. Protein Energy MalnutritionWaterlow Classification Ht/Age Wt/Ht

11. Mac LAREN SCORE • CLINICAL FINDINGS POINTS • Edema 3 • Dermatosis 2 • Edema & Dermatosis 6 • Hair Changes 1 • Hepatomegaly 1 • Serum Albumin 0 - 7 • (1 point for every 0.5 gram below 3.5 gm/dl)

12. TYPES OF MALNUTRITION • TYPE Mac Laren SCORE • Marasmus (M) 0 - 3 • Marasmus – Kwashiorkor (MK)* 4 - 8 • Kwashiorkor (K)* > 9 • *All MK and K patients have third degree malnutrition regardless of weight deficit (or excess)

19. Why is the new WHO classification recommended? • It is practical • Combines severity and type of malnutrition in one table • It does not require a laboratory or sophisticated equipment • It is easy to teach and use in the field • It has proven its utility in disaster situations

20. Protein Energy Malnutrition Basis of Management • 1. Restore and maintain hydro electrolytic balance. • 2. Aggressive diagnosis and treatment of infections. • 3. Nutritional therapy: oral feeding. • 4. Prevention and treatment of complications. • 5. Physical and psychological stimulation. • 6. Parental education and social evaluation.

21. Assessment of Hydration Status:History • Mild Moderate Severe • Diarrhea/day 1-5 6-10 >10 • Vomiting/day 0-3 4-6 >6 • Urine/last 12 hours >2 1-2 0

22. Assessment of Hydration Status:Physical Examination • Mild Moderate Severe • Mental Status Alert Depressed Coma • Response to stimulus Cry Weak cry No cry • Oral Mucosa Mild Dry Dry “parrot” • Tenting (Chest) No <2 sec. >2 sec. • Peripheral Pulses Present Weak No felt

23. Unreliable Signs of Dehydrationin severely malnourished children • *Sunken Eyes: Normal in Marasmus patients • Can not be seen with edema • *Tenting (abdomen) Normal in Marasmus patients • Difficult to assess with edema or abdominal distention • *Capillary refill Usually delayed: cold extremities (peripheral) edema

28. Assessment of Hydro-electrolytic Status:Laboratory evaluation • Basic Advanced • Hematocrit BMP • Total serum protein CMP • Urine specific gravity Zn, Cu, others • Accucheck Stool electrolytes

29. Expected Hydro-electrolytic Changes(“Well Hydrated” patient) • Total Body Water Excess • Sodium Excess • Potassium Deficit • Serum Albumin Normal - Low • Globulin Normal • Sodium 132-+ 4 mEq/L • Potassium 3.5 + 1 mEq/L • Urine Specific Gravity 1010 + 5

30. Treatment of Dehydration • Mild Moderate Severe • Rehydration ReSoMal ReSoMal IV Fluids* • IV Fluids* • 50cc/kg 80cc/kg 100 cc/Kg • in 4 hrs 8 hrs 12 hrs • Replacement Volume to Volume: ReSoMal. • Maintenance Feeding immediately after rehydration. • * RL or NS: 20 cc/kg bolus as needed. Add Dextrose 5%

31. ORS for Diarrhea and Malnutrition

32. Management of Infections in PEM • Effect of PEM in the Immune System • Cell Mediated Immunity • Ig A levels in secretions • Phagocyte Killing • Inflammatory response • Signs of infection ( Fever, WBC count) • Hypoglycemia and Hypothermia are signs of severe infection or septic shock

33. Management of Infections in PEM Therefore: Infections are the rule Multiple infections coexist Diagnosis as aggressive as possible Empiric treatment should be started immediately

34. Management of Infections:Laboratory Evaluation Basic Advanced WBC & Differential Cultures: Blood Urine dipstick Urine Stool microscopy Stool lugol, methylene blue Others Scotch tape Ova and Parasites x3 KOH Duodenal aspirate Thick blood smear CXR, PPD, Serology for HIV and others

35. Infections in Severely Malnourished ChildrenPoints to Remember • * PEM patients are immunosuppressed (Cellular) • * Gram Negative enteric bacteria are common • * Rule out sepsis: Fever, hypothermia, poor feeding, abdominal distention, paralytic ileus, lethargy • * Most deaths occur in 1st 48 hours of admission • * Risk factors: Age <6m especially <4m, Edema, Jaundice • Petechiae, Respiratory distress • * Suspect Infection: Poor weight gain, persistent edema

36. Treatment of Common Infections • DIARRHEA: • Watery: Usually non-specific Hydration-Nutrition • Cholera: Doxycycline, single dose • Tetracycline x 3 days • Ciprofloxacin, TMP-SMX • Bloody: Shiguella: Ampicillin, TMP-SMX x 5days • Ciprofloxacin, Ceftriaxone • Campylobacter: Erythromycin x 5 d • Azythromycin • SEPSIS: Ceftriaxone: 100 mg/Kg/day IV X 10-14 days • Amikacin: 15 mg/Kg/day IV X 10-14 days

37. Treatment of Common Infections • UTI: TMP-SMX, Cephalosporin 3, Gentamicin • PNEUMONIA: Ceftriaxone 100mg/Kg/day IV X 2 days • Consider Vancomycin • OTITIS: Amoxicillin 90 mg/Kg/day PO X 10 days

38. Infection Management: WHO

39. Other Important infections • TBC: No weight gain could be only sign • PPD usually negative, check for exposure • Drug therapy according to local susceptibility • UTI: Common • US, IVP, & VCUG for recurrent disease • Parasites: Giardia: Metronidazole, Tinidazole • Strongyloides: Ivermectin, Albendazole • Ascaris: Albendazole, Mebendazole • HIV: Increasing Prevalence • Wasting syndrome: Poor prognosis • Management: depends on drug availability

40. Nutritional Therapy in PEM • Effects of PEM on the GI System • Gastric acid production • Intestinal motility • Bile & Pancreatic enzymes • Nutrient absorption • Atrophy of intestinal mucosa • GI infections and diarrhea are very common

41. Diet (Formula) Composition • 1. Energy provided by: • Protein 8-10 % • Fat 45 % • Carbohydrate 45 % • 2. Volume: Marasmus 100 - 120ml/kg/day • MK - K 75 ml/kg/day

42. Formula (Diet) Composition • 3. Caloric Density .75 - 1.2 kcal/ml • 4. Osmolality < 300 m 0sm/L • 5 Sodium 2 mEq/Kg/day • 6. Potassium: Marasmus: 3 mEq/Kg/day • Kwashiorkor: 5-8 mEq/Kg/day • 7. Vitamins & Minerals > 1.5 RDA

43. Useful Diets for the Treatment of Severe Malnutrition • DIET COMMENT • Breast Milk Use it when available • Cow’s Milk Lactose-malabsorption possible • Lactose - Free Formulas Expensive- Not available • Milk- Staple + Oil Safe, inexpensive, available • Cereal – Legume Inexpensive, available • Chicken Based Also Useful • WHO: F75, F100 No kitchen , out-patient

47. Milk-Rice-Oil Diet Composition • Amount* Energy* Protein* Fat* CHO* • (g) (Kcal) (g) (g) (g) • Milk** 7.0 33.3 1.9 1.80 2.4 • Rice Flour 10.0 35.9 0.6 0.07 7.9 • Vegetable Oil 3.9 30.7 -- 3.41 --- • TOTAL 100.0 2.5 5.25 10.3 • (% of energy) 10.0 48.8 41.2 • Water added to complete 100-125ml/Kg/day. Vitamins and Minerals to • satisfy 1.5 RDA. * Amount /Kg/day. ** Whole dried cow milk • *

49. Preparation of WHO F-75 and F-100 diets Add: vitamin mix 140 mg, mineral mix 20 ml and water to make 1,000 ml

50. Nutrient in 100 ml of F-75 and F-100 diets