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Protein Energy Malnutrition

   Saptharishi L G




                              
DEFINITION


• Inadequate intake of protein and energy either because the
  dietary intakes of these 2 nutrients are less than required
  for normal growth or because the needs for growth are
  greater than can be supplied by what otherwise would be
  adequate intake (Nelson 18th edition)

• Range of pathological conditions arising from coincident
  lack in varying proportions of protein and calories occurring
  mostly in infants and young children and commonly
  associated with infections ( WHO 1973)

• Severe childhood under nutrition: new terminology
• Primary malnutrition – reduced intake
• Secondary malnutrition – increased needs, decreased
  absorption, increased losses
Epidemiology


 The World Bank estimate : Rank 2 in the world in number
  of malnourished children, second only to Bangladesh. (47%)
  – 1998.
 In 2010 – India is the world capital of malnutrition in terms
  of numbers (43%) ; 4th in terms of percentage prevalence
 2.1 million children die before reaching age of 5 every year
  in India – from preventable diseases like diarrhea,
  pneumonia, etc
Worldwide prevalence of PEM
Distribution of PEM population
UNICEF Data




NFHS-3 (2005-06) : for under 3 yrs
  Underweight - 40%
  Stunted      - 45%
  Wasted        - 23 %
PEM and Hunger – distribution among states
Significance of PEM
What percentage of energy expenditure of a
child is contributed by each??




        Item              Energy expenditure
                                  (%)
         BMI                      50
       Activity                   25
       Growth                     12
      Fecal loss                  8
Specific dynamic action           5
DETERMINANTS


Determinants

Physical environment

Biological environment

Psycho socio cultural environment

Feeding Practices

Microenvironment
Patho-physiology -Theories

 Gopalan’s theory of adaptation and maladaptation - 1967

 Free radical injury theory – Golden’s

 Viteri’s theory 1964 – acute Vs chronic
Protein Energy malnutrition
PEM - Assessment


• Dietary factors

• Clinical features

• Anthropometry

• Biochemical parameters

• Morphological parameters

• Radiological parameters

• Epidemiological data
PEM - Assessment


                  Dietary assessment

• 24 hour recall method- accuracy increased by taking
  average of 3 days recall during midweek

• Food frequency table – records frequency intake of
  each food item after defining standard servings of
  each

• Weighing uncooked and cooked food and assessing
  nutritive value

• Breast feeding and bottle feeding practices, diet
  during illness
PEM - Assessment

Clinical Features..
       ORGAN           SIGNS
                  Hypochromotrichia
       Hair       Easily pluckable
                  Flag sign
                  Straightening
                  Altered texture
                  Flaky paint dermatosis
       Skin       Crazy pavement dermatosis
                  Secondary infections
                  Cutaneous diphtheria
                  Xerosis
                  Follicular hyperkeratosis
                  Pellagra
                  Depigmentation
       face       Noma
                  Moon facies
PEM - Assessment

Clinical Features..
       ORGAN            SIGNS

       eyes       Pale conjunctiva
                  Bitot spots
                  Conjunctival /corneal xerosis
        lips      Angular stomatitis
                  Angular scars
                  Cheilosis
      tongue      Edema
                  Scarlet/ raw tongue
                  Bald tongue
       Teeth      Mottled enamel
                  Spongy, bleeding gums
      Glands      Thyroid and parotid swelling

       nails      Koilonychia,Platynychia,
                  Leuconychia
PEM - Assessment

Clinical Features..
           ORGAN            SIGNS

    Subcutaneous      Edema/ gross reduction
    tissue
    musculoskeleta    Wasting
    l                 Craniotabes
                      Frontoparietal bossing
                      Epiphyseal enlargement/
                      tenderness
                      Beading of ribs
                      Wide open AF
                      Knock knees / bow legs
                      Thoracospinal deformities
                      bleeds
    GIT               Fatty liver
                      Hepatomegaly
                      Lactose intolerance
PEM - Assessment

Clinical Features..
          ORGAN           SIGNS

                    Psychomotor changes
                    Confusion
                    Sensory loss
                    Motor weakness
     neurological
                    Loss of position sense
                    Loss of ankle and knee jerks
                    Calf tenderness
                    Tremors
                    Cardiomegaly
        CVS         Tachycardia

    Serous
    cavities           effusion
Differentiation


ITEM                  MARASMUS                           KWASHIORKAR
AGE                   infancy                            1-5 years
FEEDING               Poorly breast fed / diluted milk   Early removal from
                                                         breast
PREVALENCE            common                             rare
WEIGHT                <60%                               60-80%
GROWTH RETARDATION    ++                                 +
EDEMA                 -                                  +
APATHY                -                                  +
MOOD                  alert                              Lethargic
APPETITE              good                               Poor
HAIR / SKIN CHANGES   Mild                               Severe
FATTY LIVER           Absent                             ++
SERUM ALB             Low normal                         Very low
CATABOLISM            ++                                 +
PROGNOSIS             good                               poor
Assessment of PEM

Weight for Age        (acute)

Height for Age        (chronic)

Weight for Height     (acute on chronic)

Head circumference

Chest circumference                        
Protein Energy malnutrition
Age dependent indices
         of
       PEM




                        
Weight

 Technique

 No spring balance ; discourage bathroom scales

 Clinical significance of weight

 Formula for calculating weight:
   Weight = Age x 2 + 8 (1-6 yrs)
   Weight = (Age x 7 – 5)/2 (7-12 yrs)

 Calculation of weight age
Weight for age


AGE          WEIGHT    In terms of birth wt
Birth        3 kg      1
5 months     6 kg      2
1 yr         9 kg      3
2 yrs        12 kg     4
3 yrs        15 kg     5

5 yrs        18 kg     6
7 yrs        21 kg     7
10 yrs       30 kg     10
Malnutrition


 Based on weight for age : IAP classification 1972

       Grade of            Weight-for-age of Category
       malnutrition        the median %
       Normal              >80
       Grade I             71-80               mild
       Grade II            61-70               moderate
       Grade III           51-60               severe
       Grade IV            <50                 Very severe

                   Reference : 50th centile of Harvard standards
Malnutrition


 Wellcome trust 1970

       Weight for age   No edema        Edema


       60 – 80 %        underweight     kwashiorkor


       < 60 %           marasmus        Marasmic
                                        kwashiorkor



            Reference : 50 th centile of Boston standards
Malnutrition

 Gomez classification 1956

                              WEIGHT FOR AGE
               STATUS           % of expected
                                HARVARD

               NORMAL               >90
            1ST DEGREE PEM         75 – 90

            2ND DEGREE PEM         60 – 75

            3RD DEGREE PEM          <60
Malnutrition


 Jeliffe classification 1965

                                WEIGHT FOR AGE
                 STATUS           % of expected
                                  HARVARD



                 NORMAL               >90

              1ST DEGREE PEM         80 – 90

             2ND DEGREE PEM          70 – 80

              3RD DEGREE PEM        70 – 60

              4th DEGREE PEM          < 60
Length

•   Equipment-Infant Length
    Board (Infanto-meter)
•   It is a calibrated length board with
    fixed headpiece and movable foot
    piece
•   Two trained people are needed
•   Infant should be placed on its
    back. FHH parallel to the head
    piece. Both legs should be fully
    extended at knees
•   Measure length to 0.1 cm
Standing height

 > 2 yrs age

 Heels/ buttocks/ back – in contact with vertical board

 Frankfurt plane parallel to floor

 Bi-auricular plane – horizontal

 STADIOMETER
    Fixed
    Mobile
Height variation with age

Age                                  Length / Height
Birth                                50 cm
3 months                             60 cm
9 months                             70 cm
1 yr                                 75 cm
2 yrs                                90 cm
4.5 yrs                              100 cm


            Height = 77 + (age x 6) [3-12 yrs age group]
Clinical significance of Height

 Indicator of Long term malnutrition

 Concept of MID-PARENTAL height

   ESTIMATED TARGET HEIGHT and TARGET RANGE.
 LOW Height for age  STUNTING
Stunting – based on Height for
             age

Percentage of the ideal height   Grade of stunting
expected for the age


>95 %                            No stunting

90 – 95%                         I

85 – 89%                         II

<85%                             III
Concept of
         ‘WEIGHT for HEIGHT’
 The concept of Wasting

 7 yr boy with Ht 104 cm and wt 12 kg. COMMENT
      What is the height age?
      What is the ideal wt for that age?
      What percentage of his ideal wt is his present wt?
  Wt for Ht as % of expected   Grade of Wasting
  >110                         overweight          Waterlow
                                                   classification
  91- 110                      Normal
  81 – 90                      I
  71 – 80                      II
  <70                          III
MALNUTRITION


 WATERLOW 1972
Protein Energy Malnutrition

WHO classification of Under-nutrition in Under-five children

                           Moderate                   Severe Undernutrition
                           Undernutrition

Symmetrical edema          No                         Yes (Kwarshiorkar &
                                                      marasmic kwarshiorkar)
                                                      Edematous malnutrition

Weight for height          70 – 79% expected          < 70% expected
                           WASTING                    SEVERE WASTING
                           -2 to -3 SD                < -3 SD

Height for age             85 -89% expected           < 85% expected
                           STUNTING                   SEVERE STUNTING
                           -2 to -3 SD                < -3SD
Head
    circumference

   Use a flexible, non-stretchable tape

   Measure to nearest 0.1 cm

   Position the tape just above the eyebrow, above the ears and
    around the biggest part on the back of the head

   Indicator of Brain growth

   HC < 2 SD  small head ; HC <3 SD microcephaly

   Microcephaly – usually late stages of malnutrition due to “BRAIN
    sparing effect”
Chest Circumference


 At the level of nipples Vs xiphoid process

 Tape parallel to the ground ; between insp and exp

 At birth, 3 cm < HC ; HC=CC by 1 yr, thereafter CC>HC

 Significance of CC in comparison to HC

 Not reliable in case of chest wall deformities
Age independent Indices
          of
         PEM




                          
Mid Arm Circumference


 For children 1 – 5 yrs

 Determine midpoint on arm – midway between acromion
  and olecranon
 Left arm loosely held by side of the child

 Crossed tape method

 No skin indentation

 Shakir’s tape
PEM - Assessment




UNICEF arm
circumference
tape
Mid arm circumference
               Interpretation

                                   MAC           Interpretation
 Kanawati & Mc Laren’s index
     MAC/ OFC                     >13.5         Normal
     >0.31        Normal         12.5 – 13.5   Moderate
     0.31 – 0.28  Mild PEM                     malnutrition
     0.28 – 0.25  Moderate PEM   <12.5         Severe
                                                 malnutrition
     <0.25        Severe PEM

                                   <11.5         SEVERE
                                                 wasting
•   QUAC stick
    Quaker arm circumference measuring stick - A stick used to measure height
    which also shows the 80th and 85th centiles of expected MUAC.

    Developed by a Quaker Service Team in Nigeria in the 1960s as a rapid and simple
    tool for assessment of nutritional status.

•   SHAKIRS TAPE
                       green- adequate
                     yellow- borderline
                      red – frank malnourishment
Skin-fold Thickness

 Techniques of measurement (NHANES III)
     General gudelines
       Hold 2 cm above measurement site
       Wait for 3 seconds
     Sub-scapular site
       Fold pointing towards ipsilateral elbow
     Supra-iliac site
       Fold pointing towards groin
Skin fold thickness


 Harpenden’s callipers
         > 10 mm – normal
         6 – 10 mm – mild malnourishment
        < 6 mm – severe malnourishment
• Age – sex specific charts used ideally to interpret
Skin-fold Thickness
Other Indices

Name of Index     Formula                  Normal         Malnutrition
                                           Value
Kanawati &        MAC/ OFC                 0. 32 - 0.33   < 0.25 severe
McLaren’s                                                 malnourishment
Rao & Singh’s     Wt (kg)/ Ht2(cm) x 100   0.14           0.12 -0.14
Dugdale’s         Wt (kg)/ Ht1.6 (cm)      0.88 -0.97     < 0.79

Quaker Arm        MAC expected for a Ht    QUAC stick     75 – 85% :mal
Circumeference                                            < 75% : sev.
                                                          mal
Jeliffe’s ratio   HC / CC                  >1 in an       >1 in a >1 yr child
                                           infant
Radiological assessment



RADIOLOGICAL INDICATORS

 Bone Age
 Rickets
 Scurvy
 Osteoporosis
NUTRITIONAL PARAMETERS


           ITEM                           REMARKS

Proteins             Reversal of alb/glob ratio
                     Increased NE/E AA

Carbohydrate         Low glycogen, hypoglycemia

Lipids               Increased NE/EFA ratio

Electrolytes         Normal/ high Na, low K

Water                Increased TBW,
                     High ECF/ICF ratio

minerals             Low Ca, P, Mg, K
Other Indicators

MORPHOLOGICAL INDICATORS
 mutilation of cells in buccal smear
 (normally < 10%)
 hair texture, shaft size
EPIDEMIOLOGICAL INDICATORS
  vital statistics, under 5 mortality is used to
  rank nations based on child health and
  nutritional status
PEM Management

Criteria for Admission:


• Severe wasting

• Symmetrical edema involving at least the feet

• Wt/age <60% with
                      diarrhea
                      shock
                      hypothermia
                      systemic infection
                      jaundice
                      bleeding
                      age<1 year
                      persistent loss of appetite
PEM Management



Basic Principles
• Careful initial evaluation

• Anticipation of problems

• Prevention of problems

• Early detection &treatment of problems

• Avoid intravenous infusions except when essential

• Promotion of food intake by all available means
Protein Energy malnutrition
PEM Management

• Routine treatment
                                  The 10 Steps
• Emergency treatment     1. Treat/prevent hypoglycemia S
                          2. Treat/prevent hypothermia
• Associated Conditions
                          3. Treat/prevent infection
• Treatment failure       4. Correct electrolyte imbalance
                          5. Treat/prevent dehydration
• Preparing Follow-up
                          6. Correct micronutrient deficiencies
                          7. Begin cautious feeding
                          8. Achieve catch-up growth E
                          9. Sensory Stimulation and emotional support
                          10. Prepare for follow-up T

                                            BEST
Weight gain during the rehabilitation
phase

Poor:    <5g/kg/d

Moderate: 5-10g/kg/d

Good:   >10 g/kg/d
Criteria for discharge

   Absence of infection.

   The child is eating at least 120-130 cal/kg/day and receiving
    adequate micronutrients

   There is consistent weight gain (of at least 5 g/kg/day for 3
    consecutive days) on exclusive oral feeding

   WFH is 90% of NCHS median; The child is still likely to have a
    low weight-for-age because of stunting.

   Absence of edema.

   Completed immunization appropriate for age.

   Caretakers are sensitized to home care.
Protein Energy malnutrition
PREVENTION


Determinants

Physical environment

Biological environment

Psycho socio cultural environment

Feeding Practices

Microenvironment
Prevention of Malnutrition

 NATIONAL LEVEL
    Nutrition supplementation
    Nutritional surveillance
    Nutritional planning

 COMMUNITY LEVEL
    Health & nutrition education
    Promotion of education & literacy
    Growth monitoring
    Integrated health package
    Family planning programs
Prevention of malnutrition


 FAMILY LEVEL
    EBF
    Appropriate weaning
    Vaccination
    Discourage iatrogenic food restriction during illnesses
    Adequate spacing
National Nutrition Policy


 Integrated Child development services Program (ICDS)

   Mid-day meals programme – 2007
       15th aug 1995
       450 kcal + 12 g protein
       700 kcal + 20g protein

 National nutritional anemia prophylaxis programme – 1970
       100 mg Iron + 0.5 mg folic acid
       20 mg Iron + 0.1 mg folic acid x 100 days (1-5 yrs)
Protein Energy malnutrition
item             amt             kcal    prot
roti             1(30gm)         100     3.6
daliya           1(30gm)         100     3.6
Suji             1(30 gm)        100     3.0
dal              1(30gm)         100     6.8
khichdi          1 bowl(20+20)   140     6.0
Veg.(gr.Leafy)   ½ cup           30-40   -
 (others)        1/2 cup         50-60   -


bread            2(40gm)         100     3.0
egg              1               80      6.6
paneer           25              60      4.6

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Protein Energy malnutrition

  • 1. Protein Energy Malnutrition Saptharishi L G 
  • 2. DEFINITION • Inadequate intake of protein and energy either because the dietary intakes of these 2 nutrients are less than required for normal growth or because the needs for growth are greater than can be supplied by what otherwise would be adequate intake (Nelson 18th edition) • Range of pathological conditions arising from coincident lack in varying proportions of protein and calories occurring mostly in infants and young children and commonly associated with infections ( WHO 1973) • Severe childhood under nutrition: new terminology • Primary malnutrition – reduced intake • Secondary malnutrition – increased needs, decreased absorption, increased losses
  • 3. Epidemiology  The World Bank estimate : Rank 2 in the world in number of malnourished children, second only to Bangladesh. (47%) – 1998.  In 2010 – India is the world capital of malnutrition in terms of numbers (43%) ; 4th in terms of percentage prevalence  2.1 million children die before reaching age of 5 every year in India – from preventable diseases like diarrhea, pneumonia, etc
  • 5. Distribution of PEM population
  • 6. UNICEF Data NFHS-3 (2005-06) : for under 3 yrs Underweight - 40% Stunted - 45% Wasted - 23 %
  • 7. PEM and Hunger – distribution among states
  • 9. What percentage of energy expenditure of a child is contributed by each?? Item Energy expenditure (%) BMI 50 Activity 25 Growth 12 Fecal loss 8 Specific dynamic action 5
  • 10. DETERMINANTS Determinants Physical environment Biological environment Psycho socio cultural environment Feeding Practices Microenvironment
  • 11. Patho-physiology -Theories  Gopalan’s theory of adaptation and maladaptation - 1967  Free radical injury theory – Golden’s  Viteri’s theory 1964 – acute Vs chronic
  • 13. PEM - Assessment • Dietary factors • Clinical features • Anthropometry • Biochemical parameters • Morphological parameters • Radiological parameters • Epidemiological data
  • 14. PEM - Assessment Dietary assessment • 24 hour recall method- accuracy increased by taking average of 3 days recall during midweek • Food frequency table – records frequency intake of each food item after defining standard servings of each • Weighing uncooked and cooked food and assessing nutritive value • Breast feeding and bottle feeding practices, diet during illness
  • 15. PEM - Assessment Clinical Features.. ORGAN SIGNS Hypochromotrichia Hair Easily pluckable Flag sign Straightening Altered texture Flaky paint dermatosis Skin Crazy pavement dermatosis Secondary infections Cutaneous diphtheria Xerosis Follicular hyperkeratosis Pellagra Depigmentation face Noma Moon facies
  • 16. PEM - Assessment Clinical Features.. ORGAN SIGNS eyes Pale conjunctiva Bitot spots Conjunctival /corneal xerosis lips Angular stomatitis Angular scars Cheilosis tongue Edema Scarlet/ raw tongue Bald tongue Teeth Mottled enamel Spongy, bleeding gums Glands Thyroid and parotid swelling nails Koilonychia,Platynychia, Leuconychia
  • 17. PEM - Assessment Clinical Features.. ORGAN SIGNS Subcutaneous Edema/ gross reduction tissue musculoskeleta Wasting l Craniotabes Frontoparietal bossing Epiphyseal enlargement/ tenderness Beading of ribs Wide open AF Knock knees / bow legs Thoracospinal deformities bleeds GIT Fatty liver Hepatomegaly Lactose intolerance
  • 18. PEM - Assessment Clinical Features.. ORGAN SIGNS Psychomotor changes Confusion Sensory loss Motor weakness neurological Loss of position sense Loss of ankle and knee jerks Calf tenderness Tremors Cardiomegaly CVS Tachycardia Serous cavities effusion
  • 19. Differentiation ITEM MARASMUS KWASHIORKAR AGE infancy 1-5 years FEEDING Poorly breast fed / diluted milk Early removal from breast PREVALENCE common rare WEIGHT <60% 60-80% GROWTH RETARDATION ++ + EDEMA - + APATHY - + MOOD alert Lethargic APPETITE good Poor HAIR / SKIN CHANGES Mild Severe FATTY LIVER Absent ++ SERUM ALB Low normal Very low CATABOLISM ++ + PROGNOSIS good poor
  • 20. Assessment of PEM Weight for Age (acute) Height for Age (chronic) Weight for Height (acute on chronic) Head circumference Chest circumference 
  • 22. Age dependent indices of PEM 
  • 23. Weight  Technique  No spring balance ; discourage bathroom scales  Clinical significance of weight  Formula for calculating weight:  Weight = Age x 2 + 8 (1-6 yrs)  Weight = (Age x 7 – 5)/2 (7-12 yrs)  Calculation of weight age
  • 24. Weight for age AGE WEIGHT In terms of birth wt Birth 3 kg 1 5 months 6 kg 2 1 yr 9 kg 3 2 yrs 12 kg 4 3 yrs 15 kg 5 5 yrs 18 kg 6 7 yrs 21 kg 7 10 yrs 30 kg 10
  • 25. Malnutrition  Based on weight for age : IAP classification 1972 Grade of Weight-for-age of Category malnutrition the median % Normal >80 Grade I 71-80 mild Grade II 61-70 moderate Grade III 51-60 severe Grade IV <50 Very severe Reference : 50th centile of Harvard standards
  • 26. Malnutrition  Wellcome trust 1970 Weight for age No edema Edema 60 – 80 % underweight kwashiorkor < 60 % marasmus Marasmic kwashiorkor Reference : 50 th centile of Boston standards
  • 27. Malnutrition  Gomez classification 1956 WEIGHT FOR AGE STATUS % of expected HARVARD NORMAL >90 1ST DEGREE PEM 75 – 90 2ND DEGREE PEM 60 – 75 3RD DEGREE PEM <60
  • 28. Malnutrition  Jeliffe classification 1965 WEIGHT FOR AGE STATUS % of expected HARVARD NORMAL >90 1ST DEGREE PEM 80 – 90 2ND DEGREE PEM 70 – 80 3RD DEGREE PEM 70 – 60 4th DEGREE PEM < 60
  • 29. Length • Equipment-Infant Length Board (Infanto-meter) • It is a calibrated length board with fixed headpiece and movable foot piece • Two trained people are needed • Infant should be placed on its back. FHH parallel to the head piece. Both legs should be fully extended at knees • Measure length to 0.1 cm
  • 30. Standing height  > 2 yrs age  Heels/ buttocks/ back – in contact with vertical board  Frankfurt plane parallel to floor  Bi-auricular plane – horizontal  STADIOMETER  Fixed  Mobile
  • 31. Height variation with age Age Length / Height Birth 50 cm 3 months 60 cm 9 months 70 cm 1 yr 75 cm 2 yrs 90 cm 4.5 yrs 100 cm Height = 77 + (age x 6) [3-12 yrs age group]
  • 32. Clinical significance of Height  Indicator of Long term malnutrition  Concept of MID-PARENTAL height  ESTIMATED TARGET HEIGHT and TARGET RANGE.  LOW Height for age  STUNTING
  • 33. Stunting – based on Height for age Percentage of the ideal height Grade of stunting expected for the age >95 % No stunting 90 – 95% I 85 – 89% II <85% III
  • 34. Concept of ‘WEIGHT for HEIGHT’  The concept of Wasting  7 yr boy with Ht 104 cm and wt 12 kg. COMMENT  What is the height age?  What is the ideal wt for that age?  What percentage of his ideal wt is his present wt? Wt for Ht as % of expected Grade of Wasting >110 overweight Waterlow classification 91- 110 Normal 81 – 90 I 71 – 80 II <70 III
  • 36. Protein Energy Malnutrition WHO classification of Under-nutrition in Under-five children Moderate Severe Undernutrition Undernutrition Symmetrical edema No Yes (Kwarshiorkar & marasmic kwarshiorkar) Edematous malnutrition Weight for height 70 – 79% expected < 70% expected WASTING SEVERE WASTING -2 to -3 SD < -3 SD Height for age 85 -89% expected < 85% expected STUNTING SEVERE STUNTING -2 to -3 SD < -3SD
  • 37. Head circumference  Use a flexible, non-stretchable tape  Measure to nearest 0.1 cm  Position the tape just above the eyebrow, above the ears and around the biggest part on the back of the head  Indicator of Brain growth  HC < 2 SD  small head ; HC <3 SD microcephaly  Microcephaly – usually late stages of malnutrition due to “BRAIN sparing effect”
  • 38. Chest Circumference  At the level of nipples Vs xiphoid process  Tape parallel to the ground ; between insp and exp  At birth, 3 cm < HC ; HC=CC by 1 yr, thereafter CC>HC  Significance of CC in comparison to HC  Not reliable in case of chest wall deformities
  • 40. Mid Arm Circumference  For children 1 – 5 yrs  Determine midpoint on arm – midway between acromion and olecranon  Left arm loosely held by side of the child  Crossed tape method  No skin indentation  Shakir’s tape
  • 41. PEM - Assessment UNICEF arm circumference tape
  • 42. Mid arm circumference Interpretation MAC Interpretation  Kanawati & Mc Laren’s index  MAC/ OFC >13.5 Normal  >0.31  Normal 12.5 – 13.5 Moderate  0.31 – 0.28  Mild PEM malnutrition  0.28 – 0.25  Moderate PEM <12.5 Severe malnutrition  <0.25  Severe PEM <11.5 SEVERE wasting
  • 43. QUAC stick Quaker arm circumference measuring stick - A stick used to measure height which also shows the 80th and 85th centiles of expected MUAC. Developed by a Quaker Service Team in Nigeria in the 1960s as a rapid and simple tool for assessment of nutritional status. • SHAKIRS TAPE green- adequate yellow- borderline red – frank malnourishment
  • 44. Skin-fold Thickness  Techniques of measurement (NHANES III)  General gudelines  Hold 2 cm above measurement site  Wait for 3 seconds  Sub-scapular site  Fold pointing towards ipsilateral elbow  Supra-iliac site  Fold pointing towards groin
  • 45. Skin fold thickness  Harpenden’s callipers  > 10 mm – normal  6 – 10 mm – mild malnourishment  < 6 mm – severe malnourishment • Age – sex specific charts used ideally to interpret
  • 47. Other Indices Name of Index Formula Normal Malnutrition Value Kanawati & MAC/ OFC 0. 32 - 0.33 < 0.25 severe McLaren’s malnourishment Rao & Singh’s Wt (kg)/ Ht2(cm) x 100 0.14 0.12 -0.14 Dugdale’s Wt (kg)/ Ht1.6 (cm) 0.88 -0.97 < 0.79 Quaker Arm MAC expected for a Ht QUAC stick 75 – 85% :mal Circumeference < 75% : sev. mal Jeliffe’s ratio HC / CC >1 in an >1 in a >1 yr child infant
  • 48. Radiological assessment RADIOLOGICAL INDICATORS Bone Age Rickets Scurvy Osteoporosis
  • 49. NUTRITIONAL PARAMETERS ITEM REMARKS Proteins Reversal of alb/glob ratio Increased NE/E AA Carbohydrate Low glycogen, hypoglycemia Lipids Increased NE/EFA ratio Electrolytes Normal/ high Na, low K Water Increased TBW, High ECF/ICF ratio minerals Low Ca, P, Mg, K
  • 50. Other Indicators MORPHOLOGICAL INDICATORS mutilation of cells in buccal smear (normally < 10%) hair texture, shaft size EPIDEMIOLOGICAL INDICATORS vital statistics, under 5 mortality is used to rank nations based on child health and nutritional status
  • 51. PEM Management Criteria for Admission: • Severe wasting • Symmetrical edema involving at least the feet • Wt/age <60% with diarrhea shock hypothermia systemic infection jaundice bleeding age<1 year persistent loss of appetite
  • 52. PEM Management Basic Principles • Careful initial evaluation • Anticipation of problems • Prevention of problems • Early detection &treatment of problems • Avoid intravenous infusions except when essential • Promotion of food intake by all available means
  • 54. PEM Management • Routine treatment The 10 Steps • Emergency treatment 1. Treat/prevent hypoglycemia S 2. Treat/prevent hypothermia • Associated Conditions 3. Treat/prevent infection • Treatment failure 4. Correct electrolyte imbalance 5. Treat/prevent dehydration • Preparing Follow-up 6. Correct micronutrient deficiencies 7. Begin cautious feeding 8. Achieve catch-up growth E 9. Sensory Stimulation and emotional support 10. Prepare for follow-up T BEST
  • 55. Weight gain during the rehabilitation phase Poor: <5g/kg/d Moderate: 5-10g/kg/d Good: >10 g/kg/d
  • 56. Criteria for discharge  Absence of infection.  The child is eating at least 120-130 cal/kg/day and receiving adequate micronutrients  There is consistent weight gain (of at least 5 g/kg/day for 3 consecutive days) on exclusive oral feeding  WFH is 90% of NCHS median; The child is still likely to have a low weight-for-age because of stunting.  Absence of edema.  Completed immunization appropriate for age.  Caretakers are sensitized to home care.
  • 58. PREVENTION Determinants Physical environment Biological environment Psycho socio cultural environment Feeding Practices Microenvironment
  • 59. Prevention of Malnutrition  NATIONAL LEVEL  Nutrition supplementation  Nutritional surveillance  Nutritional planning  COMMUNITY LEVEL  Health & nutrition education  Promotion of education & literacy  Growth monitoring  Integrated health package  Family planning programs
  • 60. Prevention of malnutrition  FAMILY LEVEL  EBF  Appropriate weaning  Vaccination  Discourage iatrogenic food restriction during illnesses  Adequate spacing
  • 61. National Nutrition Policy  Integrated Child development services Program (ICDS)  Mid-day meals programme – 2007  15th aug 1995  450 kcal + 12 g protein  700 kcal + 20g protein  National nutritional anemia prophylaxis programme – 1970  100 mg Iron + 0.5 mg folic acid  20 mg Iron + 0.1 mg folic acid x 100 days (1-5 yrs)
  • 63. item amt kcal prot roti 1(30gm) 100 3.6 daliya 1(30gm) 100 3.6 Suji 1(30 gm) 100 3.0 dal 1(30gm) 100 6.8 khichdi 1 bowl(20+20) 140 6.0 Veg.(gr.Leafy) ½ cup 30-40 - (others) 1/2 cup 50-60 - bread 2(40gm) 100 3.0 egg 1 80 6.6 paneer 25 60 4.6