View
4
Download
0
Category
Preview:
Citation preview
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
Recommended