PEM

WHO DEFINITION (1973)

A range of pathological conditions arising from

coincidental lack in varying proportions of

proteins and calories occurring most

commonly in infants & young children and

commonly associated with infections

Assessment and Classification of PEM

Classification of PEM

• Spectrum ranges from Growth failure to overt

marasmus and kwashiorkar

• Marasmus is characterized by gross wasting of

muscle and subcutaneous tissue resulting in

emaciation, marked stunting and no oedema.

Principle features of severe PEM

Irritable, moaning

and apathetic

Sometimes quiet

and apathetic

Mental Changes

Low but m/b

masked by edema

Very LowW/H

Present in lower

legs and usually in

face an dlower arm

NoneOedema

Fat often retained

but not firm

Severe loss of Sub

cut Fat

Fat wasting

Sometimes hidden

by edema and fat

ObviousMuscle wasting

Always presentClinical

KwashiorkarMarasmusFeatures

Principle features of severe PEM

Sometimes due to

accumulation of fat

NoneHepatic

enlargement

Sparse, Silky easily

pulled out

SeldomHair Changes

Diffuse

pigmentation. Flaky

paint dermatosis

Usually NoneSkin changes

PoorUsually goodAppetite

Sometimes presentClinical

KwashiorkarMarasmusFeatures

Features Marasmus Kwashiorkar

Biochemical

S. Albumin N / Slightly

decreased

Low (< 3g/100

ml)

Plasma/ Amino

acid ratio

N Elevated

Mid upper-arm circumference

Non stretchable tape method

• Measure the circumference mid way

between the acromion and olecranon

processes

• Normal for children b/w 4 m - 4 yrs is

13.5 – 16 cm.

Shakir tape method

Chest circ/ head circ

• It is 1 at the age of 1 yr or less

• If it is less than 1, it signifies

malnutrition

Green >13.5 cm Normal

Yellow 12.5 – 13.5 cm Borderline

Red <12.5 cm Wasted

Assessment of PEM

Gomez classification

< 60%3rd degree, severe

60 – 74%2nd degree, moderate

75 – 89%1st degree, mild

90 - 110%Normal

% Wt for ageStatus

Weight for age (%) =Weight of the child

Weight of a normal

child of same age

Χ 100

Waterlow’s Classification

H/A

W/H

Stunted

Normal

> M - 2SD

Wasted and

stunted

< M - 2SD

Wasted> M - 2SD

< M - 2SD

Weight / Height (%) =Weight of the child

Weight of a normal

child of same height

Χ 100

Height / Age (%) =Height of the child

Height of a normal

child of same age

Χ 100

Interpretation of Indicators

80 – 9087.5 – 95Mildly impaired

70 – 8080 – 87.5Moderately

impaired

Severely

impaired

Normal

Nutritional

status

< 80

> 95

Stunting

(%H/A)

< 70

> 90

Wasting

(% W/H)

Preventive measures

According to FAO/WHO Expert committee on nutrition:

1. Health Promotion

• Measures directed to pregnant and lactating

women (education, distribution of

supplements etc)

• Promotion of breast feeding

• Development of low cost weaning foods:

more frequent feeds

• Measures to improve family diet

Preventive measuresHealth Promotion contd….

• Nutrition education- Promotion of correct

feeding practices

• Home economics

• Family planning and spacing of birth

• Family environment

Preventive measures2. Specific protection

• The child’s diet must contain protein and

energy rich foods - Milk, eggs, fresh fruits

• Immunization

• Food fortification

Preventive measures3. Early diagnosis and treatment

• Periodic surveillance

• Early diagnosis of any lag in growth

• Early diagnosis and treatment of infectionsand diarrhea

• Development of programmes for earlyrehydration of children with diarrhea

• Development of supplementary feedingprogrammes during epidemics

• Deworming of heavily infested children

Preventive measures contd…4. Rehabilitation

• Nutritional rehabilitation services

• Hospital treatment

• Follow up care

Treatment - BEST approach

B – Beginning of feeding

E – Energy dense feeding

S – Stimulation of emotional & sensorial

development

T – Transfer to home-based diets

Concurrent nutritional deficiencies – treated

promptly

Hypochromic anemia – oral Fe sulphate

Macrocytosis of RBCs in peripheral blood

smear – Vit. B 12

Rickets – Vit. D

Assessment of Nutritional Status

Assessment methods

Include the following:

• Clinical examination

• Anthropometry

• Biochemical evaluation

• Functional assessment

• Assessment of dietary intake

• Vital and health statistics

• Ecological studies

Assessment methods & their relationship to natural history of disease.

Prepathogenic period Period of pathogenesis

Diminishing

reserves

Reserves

exhausted

Physiological

And

Metabolic

alterations

Non

Specific

signs and

symptoms

Illness

Permanent

damage

Death

Food

balance

sheets

Dietary

surveys Biochemical studies

Anthropometric studies

Clinical signs and morbidity

Mortality data

Clinical examinationWHO classification

• Not related to nutrition: e.g. alopecia,

pyorrhoea, pterygium

• That need further investigation: e.g malar

pigmentation, corneal vascularisation,

geographic tongue

• Known to be of value e.g. angular stomatitis,

bitot’s spot, calf tenderness, absence of knee

and ankle jerks (beri-beri), enlargement of

the thyroid gland (endemic goitre)

Anthropometryincludes height, weight, skin fold thickness,

arm circumference, head and chest

circumference.

Laboratory and biochemical assessment

Used to increase the sensitivity of the

clinical signs

Laboratory tests: Hb estimation, stools and

urine examination

Biochemical tests: S retinol, S. Iron, urinary

iodine, Prothrombin Time, S Albumin

Functional indicatorsinclude Erythrocyte fragility, capillary fragility,

tensile strength, PT, Nerve conduction etc

Assessment of dietary intake

a) Weighment of raw foods: weigh the food to

be cooked and that which is wasted (Food

Cycle)

b) Weighment of cooked foods

c) Oral questionnaire method: nature and

quantity of food eaten during previous 24 or

48 hrs.

Assessment of dietary intake: Diet Survey

a) Oral Questionnaire method/ Interview

method/ 24 hours dietary recall method: The

investigator will collect information from the

homemaker regarding the nature and

quantity of foods eaten during the past 24

hours.

Advantage: large number of families can be

covered in a short time.

Not an accurate method: Calculation of

calories in a food item is dissicult.

Assessment of dietary intake: Diet Survey

a) Questionnaire method: The investigator will

distribute proformas regarding the total

number of persons in that family, their age

and sex, food items consumed daily, to the

head of the family with a request to fill them

daily for one week. He will never interview

them or discuss with them.

b)Disadvantage: Head of family or house wife

has to be literate.

Functional indicatorsFunctional indices of nutritional status

System & Nutrients

1. Structural integrity-

- Erythrocyte fragility- Vit E, Se

- Capillary fragility – Vit C

- Tensile strength - Cu

Functional indicators2. Host defence

- Leucocyte chemotaxis- P/E, Zn

Leucocyte phagocytic capacity- P/E, Fe

- Leucocyte bactericidal capacity- P/E, Fe, Se

-T cell blastogenesis-P/E, Zn

-- Delayed cutaneous hypersensitivity- P/E, Zn

3. Hemostasis –

Prothrombin time- Vit. K

4. Reproduction –

Sperm count - Energy, Zn

Functional indicators5. Nerve function

-Nerve conduction-P/E, Vit Bl, B12

- Dark adaptation-Vit A, Zn

-EEG-P/E

6. Work capacity

-Heart rate- P/E, Fe

- Vasopressor response- Vit. C

Vital statisticsMorbidity and mortality data – identifies high

risk groups.

Assessment of ecological factors

a) Food balance sheet

b) Socio Economic Status

c) Health and educational services

d) Conditioning influences: Parasitic, Viral and

bacterial infections

Ecology of malnutrition• Conditioning influences: Infectious diseases

• Cultural influences:

Food habits, customs, beliefs, tradition and

attitudes

Religion

Food fads

Cooking practices

Child rearing practices

• Socioeconomic factors

• Food production and distribution

• Health and other services: Remedial actions by

health sector could include Nutritional surveillance,

rehabilitation, supplementation & Health education

Thank You