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![Page 1: Center for Global Pediatrics Protein Energy Malnutrition Cindy Howard, MD, MPHTM Associate Director Center for Global Pediatrics University of Minnesota.](https://reader030.fdocuments.us/reader030/viewer/2022032517/56649c7f5503460f9493631a/html5/thumbnails/1.jpg)
Center for Global Pediatrics
Protein Energy Malnutrition
Cindy Howard, MD, MPHTMAssociate Director
Center for Global PediatricsUniversity of Minnesota
November 8, 2008
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Center for Global PediatricsTime Magazine, August, 2008
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Center for Global Pediatrics
The percentage of “under five mortality” worldwide caused in part by protein energy
malnutrition is estimated at:
a) b) c) d)
24%
0%
66%
10%
a) 30%
b) 20%
c) 60%
d) 5%
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Center for Global Pediatrics
Definitions
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Center for Global Pediatrics
Millennium Development Goals (MDG) 2000 United Nations
1. Eradicate extreme poverty & hunger2. Achieve universal primary education3. Promote gender equality and empower women4. Reduce child mortality5. Improve maternal health6. Combat HIV/AIDS, malaria, other diseases7. Ensure environmental sustainability8. Develop a global partnership for development
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Center for Global Pediatrics
Define: PEM
• Underweight: weight for age < 80% expected• Marasmus: weight for age < 60% expected• Kwashiorkor: weight for age < 80% + edema• Marasmic kwashiorkor: wt/age <60% + edema
• Wasting: weight for height• Stunting: height for age
• SAM: severe acute malnutrition
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Center for Global Pediatrics
Underweight
• Define: weight-for-age less 80% expected• Encompasses both wasting and stunting• Most global data• High correlation with stunting• Prevalence directly describes the magnitude of
the problem of growth faltering and stunting in young children
• 130 million children under the age of five years
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Center for Global Pediatrics
Marasmus
• Weight for age < 60% expected
• No edema
• Often stunted
• Hungry, relatively easier to feed
• CFR=20-30%
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Center for Global Pediatrics
Kwashiorkor(Edematous Malnutrition)
• Underweight with edema
• Irritable, difficult to feed
• Electrolyte abnormalities
• Highest mortality – 50 to 60%
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Center for Global Pediatrics
STUNTING Height for age less than 90% expected
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Center for Global Pediatrics
Severe Acute Malnutrition SAM
• Weight-for-height of 70% (extreme wasting)
• Presence of bilateral pitting edema of nutritional origin, “edematous malnutrition
• Mid-upper-arm circumference of less than 110 mm in children age 1-5 years old
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Center for Global Pediatrics
Complications of SAM include:
A. B. C. D. E. F.
0% 0%
97%
2%1%0%
A. ARI
B. Diarrhea
C. Gram negative septicemia
D. Poor feeding
E. Electrolyte abnormalities
F. All of the above
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Center for Global Pediatrics
Complications of SAM
• ARI
• Diarrhea
• Gram negative septicemia
• Poor feeding
• Electrolyte abnormalities
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Center for Global Pediatrics
TREATMENT of Undernutrition
• Varies depending on the type of malnutrition• Immediate cause:
lack of food, lack of appropriate foods for age, lack of protein, maternal death, acute or chronic infection.
• Resources available• Management protocols capable of reducing CFR
to 1 to 5%
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Center for Global Pediatrics
The first step in the treatment of SAM is toprevent and/or treat hypoglycemia.
A. B.
21%
79%
A. True
B. False
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Center for Global Pediatrics
Ten Steps to Recoveryin Malnourished Children
Ashworth A, Jackson A, Khanum S & Schofield C
1996
THE WHO TEN STEPS
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Center for Global Pediatrics
Steps 1 and 2
1. Prevent/treat HYPOGLYCEMIA
2. Prevent/treat HYPOTHERMIA
• KEY is frequent feeding – every two hrs night/day• Skin to skin contact with parent, warm lamp,
warm blanket, avoid exposure
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Center for Global Pediatrics
STEP
3
1. Give ReSoMaL or comparable oral solution.
2. Do not use the standard WHO oral rehydration salts solution. It contains too much sodium and too little potassium for severely malnourished children.
3. Do not use the IV route except in shock, and then do so with care to avoid flooding the circulation and overloading the heart.
4. Feed through diarrhea, continue breast feeding
Treat/prevent dehydration
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Center for Global Pediatrics
STEP
4
* Excessive Na* Deficient potassium* Deficient magnesium
Remember: Two weeks minimum to correct
Prepare meals w/o salt Do NOT use a diuretic to treat
edema
CORRECT ELECTROLYTE IMBALANCES
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Center for Global Pediatrics
STEP
5
Give to ALL severely malnourished children
• broad-spectrum antibiotic• measles vaccine to all children > 6 months.• Vitamin A• Mebendazole 100 mg BID x 3 days
• Consider HIV and TB
TREAT INFECTION
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Center for Global Pediatrics
STEP
6
All severely malnourished children have vitamin and mineral deficiencies.
Recommend: Zinc, copper and MV daily
Vitamin A and folic acid on Day 1
Do NOT give iron until the child has a good appetite and starts gaining weight (usually during the second week of treatment).
CORRECT MICRONUTRIENT
DEFICIENCIES
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Center for Global Pediatrics
STEP
7 Cautious Feeding
•Powdered milk, sugar and oil•May include electrolyte/mineral solution •Day 1 – 7 •Low in protein and iron, high in energy•Small, frequent feeds: 130ml/kg div q2
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Center for Global Pediatrics
Rebuild Tissues
Second week
Advance to 200 ml/kg/day div q 3 to 4 hours
Advance to local foods – peanut butter, beans, margarine – energy dense local foods
Step 8
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Center for Global Pediatrics
STEP
9
• tender, loving care
• structured play and physical activity as soon as the child is well enough
• a cheerful, stimulating environment.
• Encourage mother’s involvement
• 90% expected weight for height ready for discharge
Stimulation, Play and Loving Care
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Center for Global Pediatrics
STEP
10 Preparation for Discharge
Nutritional education
Immunization
Home
Follow Up
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Center for Global Pediatrics
PHASE STABILISATION REHABILITATION
Day 1-2 Day 2-7+ Week 2-6
1. Hypoglycaemia2. Hypothermia3. Dehydration4. Electrolytes5. Infection6. Micronutrients7. Cautious feeding8. Rebuild tissues9. Sensory stimulation10. Prepare for follow-up
no iron with iron
Treatment of Malnutrition
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Center for Global Pediatrics
Time Magazine, August, 2008
1. Hypoglycemia
2. Hypothermia
3. Dehydration
4. Infection
5. Severe anemia
Direct causes of death:
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Center for Global Pediatrics
Outpatient management
• Malawi, Sudan, Ethiopia2001-200523,511 severely malnourished children74% treated solely as outpatientsCFR=4.1%Recovery rates=79.4%Default = 11%
• Niger, MSF60,000 children with SAM70% outpatientCFR=5%
Lancet, 2006
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Center for Global Pediatrics
Bibliography• Stunting, Wasting, and Micronutrient Deficiency Disorders, Laura E. Caulfield, Stephanie A.
Richard, Juan A. Rivera, Philip Musgrove, Robert E. Black, Disease Control Priorities in Developing Countries, 2nd edition, 2006, pages:551-567
• Management of Severe Acute Malnutrition in Children, Steve Collins, Nicky Dent, Paul Binns, Paluku Bahwere, Kate Sadler, Alistair Hallam, Lancet, Vol. 368, December 2, 2006, pages: 1992-
2000.
• What works? Interventions for maternal and child undernutrition and survival. Bhutta ZA, Ahmed T, Black RE, Cousens S, Dewey K, Giugliani E, Haider BA, Kirkwood B, Morris SS, Sachdev HP, Shekar M; Maternal and Child Undernutrition Study Group, Lancet, February 2, 2008.
• Ten Steps to Recovery. Child Health Dialogue. 2nd and 3rd Quarter issues, 10-12.
• Guidelines for the Inpatient Treatment of Severely Malnourished Children Nonserial PublicationAshworth, A., Khanum, S., Jackson, A., Schofield, C. World Health Organization
ISBN-13 9789241546096 ISBN-10 9241546093