Transcript Protein Energy Malnutrition

Protein Energy Malnutrition
Cindy Howard, MD, MPHTM
Associate Director
Center for Global Pediatrics
University of Minnesota
November 8, 2008
Center for Global Pediatrics
Center for Global Pediatrics
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)
30%
20%
60%
5%
66%
24%
10%
0%
a)
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b)
c)
d)
Definitions
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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
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Define: PEM
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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
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Underweight
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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
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Marasmus
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Weight for age < 60% expected
No edema
Often stunted
Hungry, relatively easier to feed
CFR=20-30%
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Kwashiorkor
(Edematous Malnutrition)
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Underweight with edema
Irritable, difficult to feed
Electrolyte abnormalities
Highest mortality – 50 to 60%
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STUNTING
Height for age less than 90% expected
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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
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Complications of SAM include:
A. ARI
B. Diarrhea
C. Gram negative
septicemia
D. Poor feeding
E. Electrolyte
abnormalities
F. All of the above
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97%
0%
0%
0%
1%
2%
A.
B.
C.
D.
E.
F.
Complications of SAM
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ARI
Diarrhea
Gram negative septicemia
Poor feeding
Electrolyte abnormalities
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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%
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The first step in the treatment of SAM is to
prevent and/or treat hypoglycemia.
79%
A. True
B. False
21%
A.
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B.
Ten Steps to Recovery
in Malnourished Children
Ashworth A, Jackson A,
Khanum S & Schofield C
1996
THE WHO TEN STEPS
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Steps 1 and 2
1. Prevent/treat HYPOGLYCEMIA
2. Prevent/treat HYPOTHERMIA
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KEY is frequent feeding – every two hrs night/day
Skin to skin contact with parent, warm lamp,
warm blanket, avoid exposure
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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
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STEP
4
CORRECT ELECTROLYTE
IMBALANCES
* 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
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STEP
5
TREAT INFECTION
Give to ALL severely malnourished children
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broad-spectrum antibiotic
measles vaccine to all children > 6 months.
Vitamin A
Mebendazole 100 mg BID x 3 days
• Consider HIV and TB
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STEP
6
CORRECT
MICRONUTRIENT
DEFICIENCIES
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).
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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
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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
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STEP
9
Stimulation, Play and Loving
Care
• 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
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STEP
10
Nutritional education
Immunization
Home
Follow Up
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Preparation for
Discharge
Treatment of Malnutrition
PHASE
STABILISATION
Day 1-2
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Hypoglycaemia
Hypothermia
Dehydration
Electrolytes
Infection
Micronutrients
Cautious feeding
Rebuild tissues
Sensory stimulation
Prepare for follow-up
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Day 2-7+
no iron
REHABILITATION
Week 2-6
with iron
Direct causes of death:
1. Hypoglycemia
2. Hypothermia
3. Dehydration
4. Infection
5. Severe anemia
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Time Magazine, August, 2008
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
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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
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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: 19922000.
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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.
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Ten Steps to Recovery. Child Health Dialogue. 2nd and 3rd Quarter issues, 10-12.
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Guidelines for the Inpatient Treatment of Severely Malnourished Children Nonserial
PublicationAshworth, A., Khanum, S., Jackson, A., Schofield, C. World Health Organization
ISBN-13 9789241546096 ISBN-10 9241546093
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