Protein Energy Malnutrition

1. Protein Energy Malnutrition Cindy Howard, MD, MPHTM Associate Director Center for Global Pediatrics University of Minnesota November 8, 2008

2. Time Magazine, August, 2008

3. The percentage of “under five mortality” worldwide caused in part by protein energy malnutrition is estimated at: • 30% • 20% • 60% • 5%

4. Definitions

5. Millennium Development Goals (MDG) 2000 United Nations 1. Eradicate extreme poverty & hunger 2. Achieve universal primary education 3. Promote gender equality and empower women 4. Reduce child mortality 5. Improve maternal health 6. Combat HIV/AIDS, malaria, other diseases 7. Ensure environmental sustainability 8. Develop a global partnership for development

6. 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

7. 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

8. Marasmus • Weight for age < 60% expected • No edema • Often stunted • Hungry, relatively easier to feed • CFR=20-30%

9. Kwashiorkor(Edematous Malnutrition) • Underweight with edema • Irritable, difficult to feed • Electrolyte abnormalities • Highest mortality – 50 to 60%

10. STUNTING Height for age less than 90% expected

11. 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

12. Complications of SAM include: • ARI • Diarrhea • Gram negative septicemia • Poor feeding • Electrolyte abnormalities • All of the above

13. Complications of SAM • ARI • Diarrhea • Gram negative septicemia • Poor feeding • Electrolyte abnormalities

14. 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%

15. The first step in the treatment of SAM is toprevent and/or treat hypoglycemia. • True • False

16. Ten Steps to Recoveryin Malnourished ChildrenAshworth A, Jackson A, Khanum S & Schofield C1996 THE WHO TEN STEPS

17. Steps 1 and 2 • Prevent/treat HYPOGLYCEMIA • Prevent/treat HYPOTHERMIA • KEY is frequent feeding – every two hrs night/day • Skin to skin contact with parent, warm lamp, warm blanket, avoid exposure

18. Give ReSoMaL or comparable oral solution. 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 STEP3

19. * 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 STEP4

20. 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 STEP5

21. 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 STEP6

22. Cautious Feeding STEP7 • 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

23. 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 Rebuild Tissues

24. 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 STEP9

25. Preparation for Discharge STEP10 Nutritional education Immunization Home Follow Up

26. Treatment of Malnutrition

27. Direct causes ofdeath: • Hypoglycemia • Hypothermia • Dehydration • Infection • Severe anemia Time Magazine, August, 2008

28. Outpatient management • Malawi, Sudan, Ethiopia 2001-2005 23,511 severely malnourished children 74% treated solely as outpatients CFR=4.1% Recovery rates=79.4% Default = 11% • Niger, MSF 60,000 children with SAM 70% outpatient CFR=5% Lancet, 2006

29. 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 ChildrenNonserial PublicationAshworth, A., Khanum, S., Jackson, A., Schofield, C. World Health Organization ISBN-13    9789241546096 ISBN-10    9241546093