PROTEIN ENERGY MALNUTRITION

 

PROTEIN ENERGY MALNUTRITION

Introduction:

            PEM is a common nutritional problem among children. This name replaces the older name i.e., protein – calorie malnutrition by the recommendation of the WHO and Food and Agriculture Organization (FAO) at international level.

Definition:

            WHO defines PEM as a range of pathological condition arising from coincidental lack in varying proportions of proteins and calories, occurring most frequently in infants and young children.

Classification of PEM

            PEM may be classified as follows;

1.      Indian Academy of Pediatrics (IAP) Classification:

            This is a weight for age classification weight of more than 80% of expected for age is taken as normal grades of malnutrition as follows.

·        Grade I PEM : 71 – 80%

·        Grade II PEM : 61 – 70%

·        Grade III PEM : 51 – 60%

·        Grade IV PEM : <50%

1.      WHO Classification

This is based on all four paraments i.e., weight for age, height for age, weight for height and edema. WHO recommends three terms i.e., stunting, under weight and wasting for assenssing the magnitude of magnitude of malnutrition is under five children.

1.      Midarm Circumference (MAC)

            This is known as an age independent anthropometric criteria b.w the ages of 1 and 5 years midarm circumference b.w the age of 1-5 years should be more than 13.5cm. Those with MAC of less than 12.5cm are considered malnourished children with MAC b.w 12.5 and 13.5cm are termed borderline.

Etiology (or) Causes of PEM

            PEM occurs primarily due to food deprivation, but other factors play a major role also.

            These can be discussed as:

·        Low birth weight and infections

o   Recurrent diarrhea

o   Communicable diseases

·        Food deprivation

o   Poverty

o   Large families

·        Food taboos and myths

o   Consumption of specific type of food

o   Weaning

·        Ignorance

o   Uneducated mothers

o   Negligence

Spectrum of PEM

            There are three forms of PEM recognized based on the clinical presentation

·        Kwashiokar

·        Marasmus

·        Marasmic Kwashiokar

 

1. Kwashiorkor

            The word Kwashiorkor was first described by Dr.Cicely Williams in 1933. The typical signs of PEM are described by the following associated abnormalities.

·        Body: All body parts especially buttocks, arms and legs have decreased subcutaneous fat layer.

·        Skin: The skin appears dry and falky. Hyper pigmented plaqcus may be visible over areas of trauma.

·        Hair: It become thin, sparse and brittle. It also turns dull brown (or) red, giving on appearance of a ‘flag sign’.

·        Nails: There will be fissures (or) ridges and increased fragility.

·        Abdomen: The presence of edema due to accumulation of ascetic fluid and also hepatomegaly, makes abdomen appear distended.

·        Mouth: Signs of Vit B group deficiency cheilosis, angular stomatitis and papillary atrophy are commonly present.

·        Behavior: They have a poor appetite and refuse to eat

·        Deficiencies: It is common to observe deficiency signs of vitamins, like Vit A, D & B group and mineral like iron and iodine.

 

 

2. Marasmus:

            The term marasmus is derived from the Greek ‘marasmus’ which means wasting. A marasmic subject is markedly emaciated.

·        The body weight is less than 60% of the expected weight for the age.

·        The skin appears dry and inelastic and is prone to be infected.

·        The bony points appearunduly prominent due to emaciation.

·        The baby appears alert but is often irritable

·        Marasmic children may show voracious appetite

 

3. Marasmic Kwashiorkar:

            This condition is intermediary b.w marasmus and kwashiorkor, since such children present with a mixed picture. The body weight is less than 60% of expected with the presence of edema.

 

Management of PEM

1. Nutritional Therapy: Nutritional treatment is based on estimate of the degree of malnutrition.

I. Moderate Malnutrition:

·        The parents are advised to increase the food intake of the child by available means.

·        The child should receive adequate amount of calories and protein in the diet, which should be prepared from the locally available inexpensive foods.

·        The child should be under surveilance by using a growth card and effort, should be mode that he does not slip down to severe malnutrition.

Hyderabad Mixture:

Hyderabad Mix: it is mixture of

·        Whole  wheat – 40gm

·        Jiggery – 20gm

·        Bengal gram – 16gm

·        Ground nut – 10gm

Total is – 86gm

·        We can remember as will “John Beat Goat”

·        It was developed by NIN (National Institute of Nutrition)

·        86 grams of Hyderabad mix gives 330k cal energy and 11.33 gm of proteins.

Dawangere Mix: It is similar to Hyderabad mix, In this whole rate replaced by Ragi. It consist of

·        Ragi – 25gm

·        Jaggery – 25gm

·        Bengal gram – 25gm

·        Ground nut – 25gm

Total – 100gm

·        This can be remembered as “Ram and John Beat Goat”

·        100gms of Davangere mix use 400k calories of energy and 14gm of protein.

These Hyderabad and Davangere mix used mainly for home base therapy in PEM

Advantages:

·        It is easily prepared by mothers

·        Economical and socially acceptable

·        It is made by the routene commonly used house hold food material

II. Severe Malnutrition:

            Severely malnourished children should be treated in the hospital, vigorous and prompt treatment is necessary to save them from death (or) irreversible functional handicaps.

2. Identify and Treat Complications:

·        Intravenous infusion of 50 to 100ml of 10% glucose solution should be given at the start of therapy to prevent hygoglycemia deaths.

·        Dehydration should be treated promptly. Lactose content of the diet should be low in the initial phases of treatment.

·        Salt should be restricted to prevent sodium over load and water retention during the initial phases of treatment. Sodium in the diet may precipitate congestive heart failure.

3. Therapeutic Diet

            Therapeutic diet should provide 150k cal/kg /day for moderately under nourished and about 200k cal/kg/day for severally malnourished children. About 10 to 15% of total calories should be obtained from proteins.

·        Milk based diets may not be tolerated by some malnourished infants in the first few days due to transient lactose intolerance. If tolerated, milk based diets are most suitable at the beginning of the treatment.

·        Sugar and oil should be added to provide extra calories. Calories and protein content, a week after the start of the therapy.

4. Treating Associated Condition:

·        Concurrent nutritional deficiencies should be treated promptly.

·        Administer vitamin A immediately on admissions other wise the child may become blind.

·        Also, give packed cell transfusion, if there is severe anemia.

·        Immediately give vitamin K, folic acid and magnesium sulphate

·        Provide all vitamin and mineral supplements

·        Start oral iron therapy

·        These patients should also be treated with vitamin D

Prevention of PEM:

1.      Nutritional Planning

·        To stimulate increased food production

·        Increasing the capacity of people to buy nutritious food in adequate quantity.

2.      Direct Nutrition Intervention

·        Nutrition education

·        Mothers meeting

3.      Nutrition supplementation

·        Treat and rehabiliate severely malnourished subjects

·        Accelerate the physical growth and mental development of children

·        Improve the academic performance and learning abilities of children

 

Summary:

            Maintenance Hemodialysis (MHD) patients have incidence of PEM. Which reflects the importance of maintaining an adequate nutrients intake. Many causes lead to malnutrition. However, it seems that the most important one is the decreased nutrients intake of the patients.

References

1. INTERNET

COLLECTED FROM The Short Test Book of Paediatric