07/24/20

PROTEIN ENERGY
UNDER NUTRITION
1

Getnet Aschale
Ass.Professor of Pediatrics and
Child Health
PROTEIN-ENERGY UNDER
NUTRITION (PEU)

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• PEU results when the body's needs for protein and energy
fuels are not satisfied by the diet.
• It is accompanied by deficiency of several micronutrients
• Severity ranges from milder forms weight loss or growth
retardation to distinct clinical features marasmus, kwashiorkor
or marasmic kwashiorkor

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 CONT’D…
 Primary PEU if food is not given the child
 Secondary PEU other disease lead to

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 low food ingestion,
 inadequate nutrient absorption or utilization,
 increased nutritional requirements,
 increased nutrient losses

3
 EPIDEMIOLOGY AND ETIOLOGY
 According
to the Ethiopia Demographic and Health
Survey (EMDHS) 2014 for under five children showed

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 The percentage of children who are stunted is 40%; of which
19% are severely stunted
 The percentage of children who are wasted is 9% & 3% are
severely wasted.
 And those of underweight is 25%.

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 CONT’D…
 Common in < 5 years of age due to:

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 High requirement per unit body weight
 Susceptibility to infections
 Can not get their own food

5
CAUSES

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• Social and Economic Factors
Poverty
Ignorance
Social and cultural problems
• Biological factors
Maternal malnutrition
Infection
• Dietary factor
bulky foods with low nutritional value
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 CONT’D…

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 Environmental factors
Overcrowded and/or unsanitary living
conditions Agricultural
patterns, droughts, floods, & wars
 Age of the host
more frequent among infants and young
children

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PATHOPHYSIOLOGY
 PEM develops gradually in weeks or months.

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 This allows a series of metabolic and behavioral adjustments
that result in decreased nutrient demands and a nutritional
equilibrium compatible with a lower level of cellular nutrient
availability.
 The systems of the body begin to “shut down” with severe
malnutrition.

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 CONT’D…
 The systems slow down and do less in order to allow survival on

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limited calories.
 This slowing down is known as reductive adaptation.

 Develops gradually allowing the body to adapt for the low food
intake, enabling survival in a compensated manner.

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 CONT’D…

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 The adaptive mechanisms:
1. functional limitation & ↓ interaction with the physical & social
environment.
2. hormonal changes in metabolism of proteins, CHO, &fats.
- Marked recycling of aminoacids (AA),

- ↓ urea synth & excretion t ½ of serum proteins ↑, rate of albumin

synth ↓ ,  shift of extracellular alb to intravascular space
(failure of this ↓ serum alb ↓ oncotic pressure  edema).

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 ↓Energy expenditure- Body fat mobilizn
↓ energy intake ↓ activity = wt loss

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↑ muscle pro
↓ dietary amino acids ↓Protein synt in viscera
Catabolism=↑
& muscles
AA for visceral
Synt of alb, LP

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CONT’D…

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 Adaptive endocrine changes result in:
- ↑ glycolysis & lipolysis,
- ↑ AA mobilization,
- ↓ storage of glycogen, fats, & proteins,
- ↓ energy expenditure.

3. hematological & Oxygen transport:

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 Low protein intake

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↓ physical act ↓ lean body mass Low availability
Of AA for protein
synth

Lower tissue oxy

demand Reduced Hgb & RBC
synth

Lower Hgb levels as body adapts to Lower needs

for oxy transport (no tissue hypoxia b/c of ↓ demand)
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CONT’D…

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 Rx with dietary protein & energy leads to ↑
tissue synth & lean body mass, and ↑ physical
activity  greater tissue oxy demand
 greater needs for hematopoietic factors. This
leads to:
 ↑ Hgb & RBC synth (when available),
 anemia & tissue hypoxia (if not available).
► iron should only be given during the recovery
phase.
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 CONT’D…
 4. CV & Renal functions

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 CV reflexes will be depressed, central circulation takes
precedence over the peripheral
 Smaller & thinner heart
 Decreased CO & stroke volume
 peripheral circulatory failure which sometimes
mimics hypovolumic shock.
 GFR & renal plasma flow will reduce but the clearance
& ability to concentrate & acidify urine remain normal.

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CONT’D…

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5. immune system:
- marked depletion of lymphocytes from the
thymus (atrophy of the gland),
- ↓ complement number & function (↓ opsonin
activity),
- phagocytosis, chemotaxis, & IC killing are all
impaired,
- the circulating levels of B-cells & Ig remain
normal, except for IgA- slightly depressed.

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 CONT’D…

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6. electrolytes:
- total body K+ ↓(↓ muscle protein & loss of IC K+,
- IC Na+ ↑ (low insulin action important for
mobilization of Na+-K+ into & out of the cell and ↓ in
ATP & phosphocreatinine).

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 CONT’D…
7. GI function:

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a. atrophy/edema of intestinal epithelium,
b. ↓ brush border enzymes (e.g. disaccharidase)
 mal absorption,
c. gastric, pancreatic, & billiary secretions will all be
depleted,
d. GI mobility ↓  paralytic ileus,
e. def of enzymes, overgrowth of bacteria  diarrhea,
f. fat accumulation in the liver from def of lipoprotein.

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CONT’D…

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8. CNS & peripheral NS:
a long term complication and includes:
- decreased growth of the brain,
- decreased myelination,
- decreased neurotransmitters,
 decreased velocity of nerve conduction.

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 PATHOGENESIS : KWASHIORKOR
Different proposed mechanisms :
Protein-energy deficiency(low albumin level)

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1.
2. Impaired renal function & decreased Na/K ATP ase
activity
3. Free radical theory ( imbalance between oxidants and
antioxidants)
4. Aflatoxin poisoning
No adequate explanation so far why some children
develop edematous malnutrition

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FREE RADICAL THEORY

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 Increased production of free radicals by
infection, toxins, iron, trauma sunlight exposure
and decreased scavenger mechanism that
removes free radicals (vit A, C,E, zinc, selinium)
& glutathione
=>Accumulation of free radicals
=>Damage to cell membrane and vessels
=>Alteration seen in kwashiorkor- fatty liver,
dermatosis, edema
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ASSESSMENT OF NUTRITINAL STATUS

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 Nutritional HX
 Dietary measurement
 P/E (signs)
 Anthropometric measurement
 Biochemical & histpathologic features

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CLASSIFICATION OF PEM

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 Welcome system uses weight for age measured by
Harvard curve(for age<5yrs only)
Weight for Edema- Edema +
age

60-80% Underweight Kwashiorkor

<60% Marasmic Marasmickwash

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CONT’D…

 Water low classification assess severity of wasting and

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stunting using the NCHS or WHO curve
Grade of Wt/ht (Wasting ) Ht /age
malnutrition (Stunting )

Normal ≥80%, >-2Z score ≥95%, >-1Z score

Mild -------------------- 90-94%,-1-(-2)Z

score
Moderate 70-79%,-2-(-3)Z score 85-89%, -2-(-3)Z
score
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severe <70%,< -3Z score <85%, <-3Z score
CLINICAL MANIFESTATION

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 Infants prematurely weaned from breast milk,
exposed to diluted and dirty formula =>repeated
GI infection=>develop marasmus before age 1yr
 Children with prolonged breast feeding, starchy
gruel, family diet & devoid of proteins => acute
infections => edema (kwashiorkor) more
frequently after age 18months.

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MARASMUS

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Greek term marasmos which means wasting
It is an adaptive process
Generalized muscle wasting and absence of
subcutaneous fat “bone and skin appearance”
or old man’s face
Hair = sparse, thin, dry & easily pulled out
Skin is dry, thin with little elasticity, and
wrinkles easily
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 CONT’D…

Patients are apathetic but usually aware and have

a look of anxiety on their face

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Some are anorexic, whereas others have
voracious appetite
Diarrhea, vomiting, abdominal distension
Heart rate, blood pressure, and body temperature
may be low
Hypoglycemia

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BAGGY PANTS
 KWASHIORKOR

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 Edema

◦ bilateral pitting ,painless of the feet and legs in severe cases

may involve the upper extremities and face
 Skin lesions are usually present
◦ include Hyperpigmentation, hypopigmentation desquamation
and ulceration (flaky paint dermatosis)
◦ affected site areas of edema, continuous pressure ( buttocks and
back), or frequent irritation (perineum and thighs).

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GRADES OF NUTRITIONAL EDEMA

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 GRADES OF NUTRITIONAL DERMATOSIS
 The extent of dermatosis can be described in the following way:

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 + mild: discoloration or a few rough patches of skin
 + + moderate: multiple patches on arms and/or legs
 + + + severe: flaking skin, raw skin, fissures (openings in the
skin)

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CONT’D…

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CONT’D…

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 CONT’D…
 Hair

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 dry, fine, straight, without its normal sheen, and can be pulled
out easily
 Color usually changes to brown, red, or even yellowish white
 “Flag sign” Alternating periods of poor and relatively good
protein intake can produce alternating bands of depigmented
and normal hair

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CONT’D…

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FLAG SIGN

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CONT’D…

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 Mental status
 apatheticand irritable, cry easily, and expression of misery
and sadness
 Gastrointestinal
 Anorexia, postprandial vomiting, and diarrhea
 Hepatomegaly with a soft, round edge caused by severe
fatty infiltration
 abdomen protruding because of distended stomach and
intestinal loops (pot belly appearance)

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CONT’D…

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 Marasmic-kwashiorkor
 combines clinical characteristics of kwashiorkor and
marasmus
 edema of kwashiorkor, with or without its skin
lesions, and the muscle wasting and decreased
subcutaneous fat of marasmus

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 DIAGNOSIS
 Diagnostic criteria of severe acute malnutrition for

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6mn-5yr
 W/H or W/L < 70%,< -3Z score or
 MUAC < 115 mm with a Length > 65 cm
or
 Presence of bilateral pitting edema of nutritional origin.

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 CONT’D…
● Infants less than 6 months
 WFL < 70% of median, -3Z score or

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OR
 Visible severe wasting,

OR
 Edema of both feet of nutritional origin

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LABORATORY STUDIES

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 Blood glucose
 Hgb or HCT

 Blood film

 Stool microscopy

 Urine analysis and culture

 Chest x-ray

 Tests for tuberculosis

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 CONT’D…
 Serum concentrations of total proteins especially albumin
 are markedly reduced in edematous PEM, and they are normal

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or moderately low in severely wasted patients.
 Electrolytes
 intracellular concentrations of potassium and magnesium
decrease, and that of sodium increases

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 CONT’D…
 The ratio of nonessential to essential amino acids in plasma is

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elevated in kwashiorkor
 Serum free fatty acids are elevated particularly in kwashiorkor

 Urinary creatinine excretions markedly reduced particularly in

kwashiorkor

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 ADMISSION CRITERIA
1.Admission
to in patient

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SAM plus
Medical complication or
Failed appetite test or

Edema +++ or

Wt/ht< 70%, -3Z score or (MUAC<11.5cm )with

edema(marasmic kwash ) or
Infants below six months of age with SAM

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 CONT’D…
 Medical complications
 Unable to breast feed drink or feed or vomiting everything

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 Convulsions
 Very Weak, Lethargic or unconscious
 Pneumonia/severe pneumonia
 Hypothermia or Fever >38.5 0C
 Shock, DHN, Hypoglycemia
 Severe anemia, Jaundice, Bleeding Tendencies
 Dermatosis +++
 Dysentery, Persistent diarrhea

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 CONT’D…
2.Treatment at a outpatient treating program

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 WFL/H < 70% of median, -3Z score or
 MUAC <11.5cm or

 Edema of both feet (+, ++)

AND
 No medical complication AND pass appetite test

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MANAGEMENT OF SAM

1.Resolving Life-threatening conditions

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 Dehydration
 Septic Shock
 Heart Failure
 Hypothermia
 Severe Anemia
 Hypoglycemia
 Vitamin A Deficiency
 Other Conditions(abdominal Distension ,HIV)

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 IMPORTANT THINGS NOT TO DO AND
WHY
1.Do not give diuretics to treat edema.

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2.Do not give iron during phase 1 and transition phase of treatment.
3.Do not give high protein formula(<1.5gm/Kg).
4.Do not give IV fluids routinely.

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 CONT’D…
A. Dehydration

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-Almost all signs of dehydration in normal child are present in
severe malnourished children with no dehydration
-History of significant recent fluid loss and history of a recent
change in the child’s appearance
Rx – Resomal = 5ml/kg every 30 minute for the first two hour &
then 5-10 ml/kg every one hour for upto10 hour.

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 CONT’D…
 Replace ongoing loss with 30 ml of ReSoMal per watery stool for
oedematous children,with 50-100 ml for non-oedematous

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children under 2 years,100-200ml for above 2yrs.
 If the child has already received IV fluids for shock and is
switching to ReSoMal, omit the first 2-hour treatment and start
with the amount for the next period of up to 10 hours.

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ALGORITHM FOR TREATMENT OF DEHYDRATION IN
CHILDREN WITH SAM

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FIGURE

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 CONT’D…
B. Congestive heart failure

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 C/F weight gain, tachycardia, tachypnea, engorged neck
veins, gallop rhythm, increase in lived size and tender,
creptation
 Rx
 Stop all fluids and feeds, small sugar in water solution orally
 Identify the causes of heart failure
 Furosemide 1mg/kg single dose, repeat if necessary.

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 CONT’D…
3.Anemia

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 Very severe anemia if Hgb <4g/dl or HCT <12% during the first
48hrs of admission .
 As malnutrition is usually not the cause of severe anemia, it is
important to investigate other possible causes such as malaria
and intestinal parasites (for example, hookworm).
 Mild or moderate anemia is very common in severely
malnourished children and should be treated later with iron, after
the child has stabilized.

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CONT’D…
 Rx

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 1.Stop all oral intake and IV fluids during the transfusion.
 2. Look for signs of congestive heart failure such as fast
breathing, respiratory distress, rapid pulse, engorgement of
the jugular vein, cold hands and feet, cyanosis of the
fingertips and under the tongue.
 3. Give a diuretic to make room for the blood. Furosemide
(1 mg/kg, given by IV) is the most appropriate choice.
 4. If there are no signs of congestive heart failure,
transfuse whole fresh blood at 10 ml/kg slowly over 3
hours. If there are signs of heart failure, give 10 ml/kg
packed cells over 3 hours instead of whole blood.
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 CONT’D…
4.Hypoglycemia

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 In severely malnourished children, the level considered low is
less than <54 mg/dl
 Clinical signs that occur in normal person doesn’t occur in
malnourished children
 Eye lead retraction is one important sign

 Rx
 If conscious -50 ml of 10%sugar in water or F75 diet by
mouth/ naso -gastric tube .
 If unconscious - 5ml/kg of 10% glucose solution IV, followed
by 50 ml of 10% sugar by NG tube.
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 CONT’D…
 Start feeding F-75 half an hour after giving glucose and give it
every half-hour during the first 2hours.

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 For a hypoglycemic child, the amount to give every half-hour is
¼ of the 3-hourly amount for him.
 Take another blood sample after 2 hours and check the child’s
blood glucose again.
 If blood glucose is now 54 mg/dl (3mmol/l) or higher, change to
3-hourly feeds (8 feeds per day) of F-75.
 If still low, make sure antibiotics and F-75 have been given.

 Keep giving F-75 every half-hour and Treat with second-line

antibiotics.

62
 CONT’D…
5.Hypothermia

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 Rectal temperature below 35.5oC or under arm temperature
below 35oC
 Commonest cause is due to environmental or lack of cover
 Use the “kangaroo technique” for children with a caretaker
 Put a hat on the child and wrap mother and child together 

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 CONT’D…
 The room should be kept warm, especially at night thermo-neutral
temperature range for malnourished patients is 28oC to 32oC

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 Keep the child covered at night.
 Warm your hands before touching the child.
 Avoid leaving the child uncovered while being examined,
weighed, etc.
 Promptly change wet clothes or bedding.
 Dry the child thoroughly after bathing.
 Treat for hypoglycemia and give second-line antibiotic treatment

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6.INFECTIONS
 Give all severely malnourished children antibiotics for

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presumed infection even if they do not have clinical sign of
systemic infections.
 Antibiotics of choice

 If no complications, give first line antibiotics: oral Amoxicillin

(preferred) or Cotrimoxazole if Amoxicillin is not available.

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 CONT’D…
 If complications present, give second line antibiotics:
If the child has shock, respiratory distress, unconsciousness, and

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

very sick ,Give, Gentamicin, plus IV Ampicillin for 2 days followed

by oral Amoxicillin.
 If the child has complications other than mentioned above, give oral

Amoxicillin and I.M. Gentamicin.

 If the child fails to improve within 48 hours, add
chloramphenicol or Ceftriaxone.
 If specific infections are identified which require a specific
antibiotic not already being given, give an additional antibiotic to
address that infection.

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07/24/20
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7.ABSENT BOWEL SOUNDS, GASTRIC DILATATION AND
INTESTINAL SPLASH WITH ABDOMINAL DISTENSION

 The following measures should be taken:

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 Give first and second line antibiotic treatment by intra-muscular
injection.
 Consider adding third line antibiotics
 Stop all other drugs that may be causing toxicity (such as
metronidazole)
 Give a single IM injection of magnesium sulphate (2ml of 50%
solution).
 Pass an NG-tube and aspirate the contents of the stomach, then
“irrigate” the stomach with isotonic clear fluid (5% dextrose or 10%
sucrose –the solution does not need to be sterile).

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 CONT’D…
 Do this by introducing 50ml of solution into the stomach and
then gently aspirating all the fluid back again. This should be
repeated until the fluid that returns from the stomach is clear.

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 Put 5 ml/kg of sugar-water (10% sucrose solution) into the

stomach and leave it there for one hour. Then aspirate the
stomach and measure the volume that is retrieved. If the volume
is less than the amount that was introduced then either a further
dose of sugar-water should be given or the fluid returned to the
stomach.
 Keep the child warm.

 Monitor the child carefully for 6 hours, without giving any other

treatment
 If there is intestinal improvement then start to give small amounts

of F75 by NG tube (half the quantities given in the feeding table

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– subsequently adjust by the volumes of gastric aspirated).

 CONT’D…
 If there is no improvement after 6 hours then:
 Consider putting up an IV drip. It is very important that the

fluid given contains adequate amounts of potassium.

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 Sterile Potassium Chloride (20mmol/l) should be added to all

solutions that do not contain potassium.

 If it is available use one-fifth normal saline in 5% dextrose,

otherwise use Ringer-Lactate in 5% dextrose or half-strength

saline in 5% dextrose.
 The drip should be run VERY SLOWLY – the amount of fluid

that is given should be NO MORE THAN 2 to 4 ml/kg/h.

 Start to give the first and second line antibiotics intravenously.

 When the gastric aspirates decrease so that one half of the fluid

given to the stomach is absorbed, discontinue the IV treatment

and continue with oral treatment only. 70
8.CARE FOR THE EYES

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 CONT’D…
 Chloramphenicol or tetracycline eye drops are given for eye
infection or possible eye infection.

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 Atropine eye drops are used to relax the eye when there is corneal
involvement (i.e., corneal clouding or ulceration).
 Instill drops into the affected eye(s):

• chloramphenicol or tetracycline (1%): 1 drop, 3-4 times daily

• atropine (1%): 1 drop, 3 times daily

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CONT’D…

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9.CARE FOR SKIN AND BATHE THE
CHILD

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 Bathe children daily unless they are very sick.
 If a child is very sick, wait until the child is recovering to
bathe him.
 If the child does not have skin problems, or has only mild or
moderate dermatosis, use regular soap for bathing.
 If the child has severe (+++) dermatosis, bathe for 10-15
min/day in 1% potassium permanganate solution.
 Sponge the solution onto affected areas while the child is
sitting in a basin.
 If potassium permanganate solution is not available, affected
areas may be dabbed with gentian violet. 74
 CONT’D…
 If the child has severe dermatosis but is too sick to be bathed,

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dab 1% potassium permanganate solution on the bad spots, and
dress oozing areas with gauze to keep them clean.
 Apply barrier cream to raw areas.

 Useful ointments are zinc and castor oil ointment, petroleum

jelly, or paraffin gauze dressing.
 These help to relieve pain and prevent infection..

 If the diaper area becomes colonized with Candida, use

nystatin ointment or cream after bathing.
 Leave off diapers (nappies) so the affected area can dry.

 Be sure to dry the child well after a bath and wrap the child
warmly. 75
2.Restoration of nutritional status

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 Start with:
 low protein & energy diet
 Low sodium Small
 Low osmolar diet &
frequent
 Liquid/ semisolid diet
feeding
-Increase slowly and divide into phases

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PHASE 1

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Principles of phase 1 treatment
 Prevent, diagnose and treat complications

 Feed the patient F 75

 Routine medications

 Monitor the patient

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CONT’D…

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1. F75 =75 kcal per 100ml
Has less Na, proteins, fats, lower osmolarity
and renal solute load
Less energy dense
75kcal/100ml and 0.9g protein / 100ml
Is given 8 times per day

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CONT’D…

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 Use NG tube when
 Taking less than 75% of prescribed diet per 24 hours
in Phase 1
 Pneumonia with a rapid respiration rate
 Painful lesions of the mouth
 Cleft palate or other physical deformity
 Disturbances of consciousness

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CONT’D…
2. Routine medicines

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A. Folic acid : single dose of folic acid 5mg to children with
clinical signs of anaemia.
B.Antibiotics: amoxicillin
C.Measles vaccine: all children > 9 months without a vaccination
card on admission and discharge after Phase

80
 CONT’D…
3. Surveillance (monitoring)

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 Weight each day
 degree of edema each day

 Vital signs QID then BID after 48 hrs of admission.

 stool, vomiting, dehydration, cough, respiration and liver size

assessed each day
 MUAC is taken each week

 Length or Height is taken after 21 days

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 TRANSITION PHASE
 Thecriteria to progress from Phase 1 to Transition

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Phase are :
 Return of appetite (90%)and
 Beginning of loss of edema and
 No IV line, no NGT

 F100(100kcal/100ml) is given same amount as phase 1,

8times per day
 Lasts 1 to 5 days

 Energy intake increases by 30%

 Expected wt gain is 6g/Kg/day

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 CONT’D…
 Criteria to move back from Transition phase to Phase 1

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 Rapid weight gain greater than 10g/kg/d
 Edema increasing or development of edema
 Rapid increase in the size of the liver
 Any signs of fluid overload develop
 Tense abdominal distension
 significant re-feeding diarrhea resulting weight loss
 Naso-Gastric Tube is needed
 If patient takes less than 75% of the feeds in Transition Phase

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 CONT’D…
 Criteria to progress from Transition phase to Phase 2

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 Good appetite (100%)
 Complete loss of edema
 No other medical problems

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 PHASE 2
 F100 (100ml = 100 kcal): five feeds per day or Ready to use

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therapeutic feeding(RUTF)
 Add 10ml of milk after each feed if the patient finishes the
required amount.
 One porridge may be given for patients who are more than 8kg

 Phase 2 management can be done as out patient at home or in

therapeutic feeding center
 Wt gain ≥8g/kg/day

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CONT’D…

 Routine medications

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 Iron: is added to the F100 in Phase 2(200mg in 2L of F 100
milk)
 De-worming: Albendazole or Mebendazole is given at the start
of the Phase 2

86
 07/24/20
87
TABLE
III REHABILITATION ( NUTRITIONAL
PSYCHOSOCIAL)

Advise the parents

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
 Avoid the cause of the malnutrition
 Nutritional advise- using local foods to maintain
 Energy 130-150 Kcal/kg/day
 Protein 3-5gm/kg/day

88
FEEDING INFANTS LESS THAN 6
MONTHS

 Malnourished infants<6 months should always be treated in

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inpatient facilities.
 The management of complication is the same as children 6
moths to 5 years.
 The feeding of infants is different from older children and it is
also different for infants on breast feeding or with a caretaker
willing to breast feed and for infants who can not be breast-fed.
 RUTF is not suitable for them, as the reflex of swallowing is not
present yet.

89
 CONT’D…
 1. Infants below six months with a female caretaker

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 Infants who are malnourished are weak and do not suckle strongly
enough to stimulate adequate production of breast milk.
 The objective of treatment of these children is:

 To return them to full exclusive breastfeeding.

 To supplement the child while stimulating production of breast
milk.
 This is achieved through the Supplementary Suckling (SS)
technique

90
 CONT’D…

 Diluted F100 is given at 130 ml/kg/day, distributed in 6 meals .

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 If the infant has no edema, there are not separate phases in the
treatment of infants with the SS technique.
 There is no need to start with F75 and then switch to F100diluted
unless the infant has oedema.
 If the infant presents with oedema, start treatment with F75
instead of F100 diluted.
 After resolution of oedema, change to F100 diluted.

 Note: F100 undiluted is never used for small infants (less than
3kg)
 One packet of F100 is diluted in 2.7 liters of water, instead of 2
liters.
SUPPLEMENTARY SUCKLING
TECHNIQUE

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92
 CONT’D…
 Follow up

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 The child is weighed every day.

 When the child is gaining weight at 20 g/day (absolute weigh

gain) the quantity of F100 diluted in the cup is reduced by half so
that the child gets more breast milk.
 If weight gain is maintained then stop the supplement suckling
completely.
 When it is certain that the child is gaining weight on breast milk
alone he/she should be discharged, whatever his weight or
weight-for-length.
 Care for the mothers(2 liters of water per day, 2500 kcal/day and
micronutrient supplementation ). 93
 CONT’D…
2. Infants below six months who can not be breast-fed
 Standard protocols are followed except that F100 is given diluted

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in the phase 1 (stabilization phase) (instead of F75) for children
without edema.
 Children with oedema are fed with F75.

 In transition and phase 2 use Diluted F100 at inpatient facility.

 During Transition Phase, the amount of diluted F100 in phase 1

is increased by one third.

94
FAILURE TO RESPOND TO
TREATMENT

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95
CAUSES OF TREATMENT
FAILURE

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 Problems with the treatment facility
 Poor environment for malnourished children
 Poorly trained staff

 Inaccurate weighing machines

 Food prepared or given incorrectly

96
 CONT’D…

 Problems of individual children

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 Insufficient food given
 Malabsorption

 Infection, especially: Diarrhoea, dysentery, pneumonia,

tuberculosis, urinary infection
 Other serious underlying disease: congenital abnormalities (e.g.
Down’s syndrome)

97
DISCHARGE CRITERIA

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98
CONT’D…

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99
CONT’D…

Follow-up after discharge

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 The patients should be enrolled in a Supplementary Feeding
Program and given nutritional support for another 4 months

100
REFERENCE VALUES FOR THE MAIN
INDICATORS

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101
 POOR PROGNOSTIC FACTORS FOR
PEM
 Age <6 months

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 Deficit in wt/ht >30%, or in wt/ age >40%

 Signs of circulatory collapse

 Altered mental status

 Infections

 Bleeding tendencies

 Dehydration and electrolyte disturbances

102
 CONT’D…

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 Congestive heart failure
 Total serum proteins <30 g/L

 Severe anemia

 Clinical jaundice or elevated serum bilirubin

 Extensive exudative or exfoliative cutaneous lesions or

deep decubitus ulcerations
 Hypoglycemia or Hypothermia

103
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104