Protein Energy MalnutritionCindy Howard, MD, MPHTMAssociate Director, Center for Global PediatricsUniversity of MinnesotaNovember 7, 2009

Time Magazine, August, 2008

The percentage of “under five mortality” worldwide caused in part by protein energy malnutrition is estimated at:

a) b) c) d)

24%

0%

66%

10%

a) 30%b) 20%c) 60%d) 5%

Definitions

Millennium Development Goals(MDG) 2000 United Nations

1. Eradicate extreme poverty & hunger2. Achieve universal primary education3. Promote gender equality and empower women4. Reduce child mortality5. Improve maternal health6. Combat HIV/AIDS, malaria, other diseases7. Ensure environmental sustainability8. Develop a global partnership for development

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

Underweight

• Define: weight-for-age less 80% expected• 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

Marasmus

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

Kwashiorkor(Edematous Malnutrition)

• Underweight with edema• Irritable, difficult to feed• Electrolyte abnormalities• Highest mortality – 50 to 60%

StuntingHeight for age less than 90% expected

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

Complications of SAM include:

A. B. C. D. E. F.

0% 0%

97%

2%1%0%

A. ARIB. DiarrheaC. Gram negative

septicemiaD. Poor feedingE. Electrolyte

abnormalitiesF. All of the above

Complications of SAM

• ARI• Diarrhea• Gram negative septicemia• Poor feeding• Electrolyte abnormalities

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%

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

A. B.

21%

79%A. TrueB. False

Ten Steps to Recoveryin Malnourished ChildrenAshworth A, Jackson A, Khanum S & Schofield C1996

THE WHO’s TEN STEPS

Steps 1 and 2: Prevent/treat hypoglycemia, hypothermia

1. Prevent/treat HYPOGLYCEMIA2. Prevent/treat HYPOTHERMIA

• KEY is frequent feeding – every two hrs night/day• Skin-to-skin contact with parent, warm lamp,

warm blanket, avoid exposure

Step 3: Treat/prevent dehydration

1. Give ReSoMaL or comparable oral solution. 2. 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.

Step 4: Correct Electrolyte Imbalances

* Excessive Na* Deficient potassium* Deficient magnesium

Remember: Two weeks minimum to correctPrepare meals w/o saltDo NOT use a diuretic to treat edema

Step 5: Treat Infection

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

Step 6: Correct Micronutrient Deficiencies

All severely malnourished children have vitamin and mineral deficiencies.

Recommend: Zinc, copper and MV dailyVitamin 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).

Step 7: Cautious Feeding

• 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

Step 8: Rebuild Tissues

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 9: Stimulation, Play and Loving Care

• Tender, loving care

• Structured play and physical activity as soon as the child is well enough

• Cheerful, stimulating environment

• Encourage mother’s involvement

• 90% expected weight for height ready for discharge

Step 10: Preparation for Discharge

• Nutritional education

• Immunization

• Home

• Follow Up

PHASE STABILISATION REHABILITATION

Day 1-2 Day 2-7+ Week 2-6 1. Hypoglycaemia 2. Hypothermia 3. Dehydration 4. Electrolytes 5. Infection 6. Micronutrients 7. Cautious feeding 8. Rebuild tissues 9. Sensory stimulation 10. Prepare for follow-up

no iron

with iron

Treatment of Malnutrition

Most important!

• Frequent reassessment of the child

Time Magazine, August, 2008

1. Hypoglycemia

2. Hypothermia

3. Dehydration

4. Infection

5. Severe anemia

Direct causes of death

Outpatient Management

• Malawi, Sudan, Ethiopia2001-200523,511 severely malnourished children74% treated solely as outpatientsCFR=4.1%Recovery rates=79.4%Default = 11%

• Niger, MSF60,000 children with SAM70% outpatientCFR=5%

Lancet, 2006

“Plumpy Nut”

• Ready-To-Use Therapeutic Food (RTUF)

• High protein• High energy: 500 kcal• Peanut-based paste• Ingredients: peanut paste,

vegetable oil, powdered milk, powdered sugar, vitamins and mineral including iron, iodine and zinc

Plumpy Nut, cont.

• Used with Unimix – a vitamin-enriched flour

• Twice daily, two to four weeks• no water preparation• no refrigeration• Two-year shelf life if not unwrapped• Nutriset, France

Plumpy Nut, cont.

• first used in Darfur – 30,000 children• packaged and used in Niger and Malawi

for SAM• $35/child for four weeks of Plumpy Nut

and Unimix

Don’t forget!

• Vitamin A (Day 1, Day 2 and 2 weeks later)0-5 months: 50,000 units6-11 months: 100,000 units12-60 months: 200,000 units

• Folic acid: 5 mg/day for two weeks• Vitamin D: 400 IU/day• Zinc: 1mg/kg/day for 10 days, then trace

element mixture for six wks

Remember:

• Measles vaccine – over 6 months old• Update all immunizations before discharge• Mebendazole: 100 mg BID for three days

or Albendazole: 400 mg once

• Metronidazole: 15 mg/kg/day ÷ TID x 5 days

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 Children NonserialPublicationAshworth, A., Khanum, S., Jackson, A., Schofield, C. World Health OrganizationISBN-13 9789241546096 ISBN-10 9241546093