PEM Lecture Revised

7/27/2019 PEM Lecture Revised

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PROTEIN ENERGY MALNUTRITION

Dr.Yulchair R,SpA

SMF Anak RSI Pd Kopi


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PE

Nutrition Problems in Indonesia

t Protein Energy Malnutrition (PEM)

t Iron Deficiency Anaemiat Iodine Deficiency (=GAKI)t Zinc Deficiencyt Vitamin A Deficiencyt Obesity


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Theoretical framework of Nutrition Problems.

Nutrition problems

Food intake Infect Disease directcauses

Food availability Mother & child Health indirectin household caring service causes

POOR FAMILY & EDUCATION, main

FOOD STUFF & JOB OPPORTUNITY problem

ECONOMIC & POLITIC CRISIS core

problem


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Three level of determinants lead to nutrition status

Underlying :- Household food security

- Access to PHC

- Community of awareness

& care for children & women

Basic :- Socio-economic conditions

(poverty & crisis)

- Political factors

- Traditional practices (infant

feeding)

- Environment & sanitation

Intervention programs

Supply side :- access : health care facilities

- supplementation of food &

micronutrients.

- immunization

- quality: provider skill- information system: coverage

of supplement., fortification,

surveillance, etc.

Demand side:- empowerment

- family awareness of nutrition

- subsidies / health insurance

Health &

Nutrition

Status ofChildren

Immediate :Inadequacy of dietary intake

manifested:

- PEM

- Micronutr.deficiency

- Diarrhea & worm disease

- ARI

Supply & coverage immuniz


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PE

The problems of PEM :

tthe main health problemt primadonna of nutritional diseases

t influencing morbidity & mortality amongunderfives

t early detection and proper management are verimportant

t severe malnutrition should be hospitalized

t poor quality of life


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Protein Energy Malnutrition

tdisease / clinical conditions caused by energy

& protein deficiency, usually accompanied by

deficiency of other nutrients.

tPrimary : - nutr.intake


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OUTPUT:Infection

Chronic diarrhea/MalabsorptionHypermetabolismetc.

INPUT:

InfectionPovertyOrganic dis.etc.

Energy balance: negative


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Protein Energy Malnutrition

T Nutr.status = spectrum :

Wt/Ht

undernutrition normal overnutrition70 80 90 110 120 %

-3SD -2SD +2SD +3SD

PEM severemoderatemild overweightobese

-Kwashiorkor mild-Marasmus moderate-M-K severe

super


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PEM.

Classification :

1. GOMEZ (195..) : W/A

2. MacLarren (196..) : Clinical + laboratory

3. The Wellcome : Clinica+anthropometricTrust Party (1970) (W/A)

4. Waterlow (1973) : W/H5. WHO (1999) : Clinical+anthropometric

(Z-score)


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MEP.

Classification (WHO,1999) :Moderate PEM Severe PEM

Symmetrical oedema -- +(oedematousmalnutrition)

W/H -3< Z-score


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PEM.

DIAGNOSIS :

1. Anamnesis

2. Physical examination

3. others : - laboratory

- anthropometry- dietary analysis


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PEM.

Checklist : anamnesis Usual diet before current episode of

illness

Breastfeeding history Food & fluids taken in past few days

Recent sunken eyes

Duration & freq. of vomiting / diarrhoea,

appearance of vomit / diarrhoeal stools


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PEM.

Checklist : anamnesis Time when urine was last passed Any deaths of siblings

Birth weight?

Milestones reached (sitting up, standing,etc)

Contact with people with measles or

tuberculosis Immunizations


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PEM.

Checklist: Physical examination

Weight, Length/Height

Signs of circulatory collapse : cold hands &feet, weak pulse, consciousness


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Anaemia


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PEM.

Checklist: physical examination

Thirst, dryness of lips & mouth

ENT : evidence of infection?

Abdominal distension, bowel sounds? Enlargement or tenderness of liver, jaundice

Skin : infection, purpura, fat tissue?

Oedema, muscles atrophy Apperance of faeces


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Severe PEM : Kwashiorkorhair

face

Oedema

Puffy


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Severe PEM : Kwashiorkor

Crazy pavementdermatosis

oedemaHepatomegaly


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Severe PEM : Marasmus

face

hair

Ribs

Muscles atrophySC fat


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Severe PEM : Marasmus + KP

lymphadenopathy


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Severe PEM : Marasmus + KP

Caverne

6 weeks after th/Destroyed lung

PEM


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PEM.

Laboratory tests: Teststhat may be useful:k Blood glucose : < 54 mg/dl = hypoglycaemia

k Blood smear : parasit malaria

k Hb or Ht : < 4 g/dl or < 12% = severe anaemia

kUrine exam/culture: bacteria + or > 10 lekosit/HPF

infectionkFaeces : blood + disentri

Giardia + / parasit lain infeksi

kX-ray : - thorax : l Pneumonial Heart failure

- bone : rickets, fracture

k Tes tuberkulin : often negative

Tests that are little ot no value: serum protein, HIV,electrol tes

PEM


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PEM.

MANAGEMENT :

l Mild-moderate PEM :- no specific clinical signs : thin, hypotrophic

- not necessary to hospitalize- looking for the probable causes

- nutr. education & supplementation

l Severe PEM : should be hospitalized

PEM


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PEM.

Other criteria :

Very low BW :- W/H < 70%- W/A < 60%(- W/A > 60% + oedema)

+ clinical signs & symptoms :- oedema (M-K)- severe dehydration- persistent diarrhoea and / or vomiting- severe pallor, hypothermia, shock

- signs of systemic/local infection, URI- severe anaemia ( Hb < 5 g/dl)- jaundice- anorexia

- < 1 yr of age

PEM


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PEM.

Signs & symptoms of dehydration :

- history of diarrhoea or no/diminished intake

- weak, apathetic unconscious

- weak to absent radial pulse- thirst, dry mouth and absent of tears

- sunken eyes and fontanel

- hypothermia- cold hands and feet

- Urine flow


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Dehydration

Sunken eyes


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Dehydration

Turgor :

PEM


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PEM.

5 ASPECTS in the MANAGEMENT of Severe PEM :

A. 10 main steps

B. Treatment of underlying diseases

C. Failure to respond to treatment

D. Discharge before recover

E. Emergency

PEM


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PEM.

A : 10 main steps

No Interven- StabilizationTransition Rehabilitation Follow-up

tion d.1-2 d.3-7 wk-2 wk 3-6 wk 7-261. Treat/preventhypoglycaemia

2. Treat/preventhypothermia

3. Treat/preventdehydration4. Correct electr.

imbalance5. Treat infection6. Correct micro- without Fe + Fe

nutrients defic.7. Begin feeding8. Increase feeding9. Stimulation10. Prepare for

discharge

PEM


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PEM.

B. Treatment of underlying diseases / infection :

Bacterial infection :- no apparent signs of infection/no complication:

cotrimoxazole ( 5 mg TMP/kg, 2x/d, 5 days )

- signs of infection / complications / sepsis :- ampicilline 50 mg/kg/6 hrs, IM/IV,

for 2 days oral (ampi / amoxy)

- gentamycin 7.5 mg/kg, IM/IV, 7 days- KP + anti-TB drugs

Viral infection :no specific th/

- all PEM should receive measles vaccine

PEM


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PEM.

C. Failure to respond to treatment :

Frequent causes of failure to respond :

a. Problems with the treatment facility :

- poor environment for malnourished children

- insufficient or inadequately trained staff

- inaccurate weighing machine- food prepared or given incorrectly

PEM


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PEM.


Frequent causes of failure to respond :

b. Problems of individual children :

- insufficient food given- vitamin-mineral deficiency

- malabsorption of nutrients

- rumination- infections

- serious underlying disease

PEM


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PEM.


Criteria Time of admissionPrimary failure to respond:

- failure to regain appetite Day 4

- Failure to start to lose oedema Day 4- Oedema still present Day 10

- Failure to gain at least 5 g/kg/d Day 10

Secondary failure to respond :

- failure to gain at least 5 g/kg/d During rehabilitation

for 3 consecutive days

PEM


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PEM.


1. Death= within first 24 hrs :

- hypoglicaemia- hypothermia- dehydration- sepsis

= within 24 72 hrs :- volume of formula >>- caloric density >>

PEM


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PEM.


2. Inadequate gaining weight :- infection- diet

- psychologic

Weight gain :

= satisfactory: > 10 g/kg/d good == sufficient : 5-10 g/kg/d > 50 g/kg/wk

= poor : < 5 g/kg/d or < 50 g/kg/wk

PEM


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PEM.

D. Discharge before fully recover:

= Dietary advice :- high protein and calorie

- frequent feeding ( 5x/d )- finish all meals given- vit-min supplementation & electrolytes- continue BF

= frequent controle ( 1x/wk )

= Immunization

5 Em n :


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5. Emergency :

5.1. Shock :

N2 or RLG5%15 ml/kg, 1 hr

Repeat 1 hr more

Resomal 10 ml/kg, 10 hrs

Special formula

sepsis

Maintenance, 4 ml/kg/hrFresh blood, 10 ml/kg

Improvement+

_

5 E


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5. Emergency :

5.2. Severe anaemia.

Hb ?

Hb < 4 g/dl Hb 4-6 g/dl

Resp.distress/heart failure?

Fresh blood 10 ml/kg*PRC 10 ml/kg* Observation

* : give furosemid 1 mg/kg, iv, before transfusion

+

_

PEM


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PEM.

Prepare for discharge :

- W/H : - 1 SD or severe PEM moderate/mild

- Education for mother :- hygiene & sanitation- healthy foods- immunization- stimulation

- regular controle

- to continue the th/ of chronic diseases

- to completing immunization


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On admission :Sh, girl, 2 yrs,W : 3.875 g

H : 67 cmW/H : < -4SD

2 weeks later :W : 4.750 gH : 67.4 cm

W/H : < -3 SD

4 weeks later :W : 5.310 g

H : 67.7 cmW/H : + -3 SD

5 weeks later :W : 6.280 g

H : 67.8 cmW/H : - 2 SD


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7 yrs,10 kg

Recovery : 16 kg

Documents

PEM Lecture Revised