REFERAT PROTEIN ENERGY MALNUTRITION

ARLHA APORIA DEBINTA 07120100068

Fakultas Kedokteran Universitas Pelita Harapan
Kepaniteraan Klinik Ilmu Kesehatan Anak
RS Bhayangkara Tk.I R.S. Sukanto-Jakarta
Periode: 3 Nov 2014 11 Januari 2014

Definition
Malnutrition as "the cellular imbalance

between the supply of nutrients and

energy and the body's demand for them
to ensure growth, maintenance, and
specific functions." (WHO)
Formerly

known as Protein Energy

Malnutrition (PEM), now is used to
describe a group of related disorders that
include marasmus, kwashiorkor, and
intermediate
states
of
marasmuskwashiorkor.

Epidemiology
At any time approximately 100 million

children suffer from the moderate or

severe forms of PEM.
According to Riset Kesehatan Dasar

(Riskesdas) in 2007, Indonesias child

nutrition problem has slightly showed an
improvement, from 5,4% in 2007 to 4,9%
in 2010.

Etiology
Etiology of PEM may be divided into:
Illness-related
Non-illness Related

Illness-related comprise of:

Gastrointestinal disorders
E.g Pancreatic insufficiency, enteritis,

retroperitoneal fibrosis.
Wasting disorders
AIDS, Cancer, COPD

Condition that increases metabolic demands

Endocrine disorders e.g Pheochromocytoma

Etiology
Non-Illness related include:

Socio-economic factor

Financial restrain causing families

not to be able to buy proper food
containing nutrients required for
childrens growth.
Parental lack of nutritional
information
mothers do not know or even able
(financially) to how to provide
enough nutrients to their children
Inadequate health resources
Lack of medical services and
public health services in
developing countries results to
many prevention acts innefective

Growth Status
It is important to know a growth status of a child before

making a diagnosis of PEM.

Important data includes height, weight, age.
Weight

Those children who weigh less than the mean weights of

children in their age group are thus called "wasted.
Acute forms of malnutrition chiefly affect body weight more
than height.

Height

Those children whose heights are less than the mean

heights of children in their age group are called 'stunted.
Chronic form both height and weight are affected

 Several method of classification is used

such as
1. Gomez classification
2. Waterlow classification
3. WHO classification
4. McLarens scoring suystem for protein

energy malnutrition
5. Wellcome Trust Party system

 Gomez classification
The Gomez classification does not take

height into consideration therefore it is

oftenly criticized for being inaccurate.

 Waterlow classification
Waterlow

combines
weight-for-height
(indicating acute episodes of malnutrition)
with height-for-age to show the stunting
that results from chronic malnutrition.

WHO Classification
The

World Health Organization (WHO)

defines severe acute malnutrition as:

a mid upper arm circumference (MUAC)

<11.5cm,

a
weight-for-height
z-score
(WHZ)
below3, or
the presence of bilateral pedal oedema in
children with kwashiorkor.

Classification of Nutritional Status based on

weight/age (WFA) indicator:
Malnutrition

: Z score <-3

Less Nutrition : 0 Zscore> = -3.0 s / d

Zscore <-2
Good Nutrition : 0 Zscore> = -2.0 s / d

Zscore <= 2
More Nutrition : 0 Zscore> 2.0

Classification of Nutritional Status based on

height/age (HFA) indicators:
Very Short
Short

: Zscore <-3.0

: Zscore> = - 3.0 s / d Zscore <-

2.0
Normal

: Zscore> = -2.0

Classification of Nutritional Status based on

weight / height indicator:
Very Skinny : Zscore <-3
Skinny

: 0 Zscore> = -3.0 s / d

Zscore <-2
Normal

: 0 Zscore> = -2.0 s / d
Zscore <= 2

Chubby

: 0 Zscore> 2.0

Classification of Nutritional Status based on combined

height/age (HFA) and weight/height (WFH) indicators:
Short-Skinny

: Zscore TB / U <-2.0 and ZScore weight /

height <-2.0
Short-Normal : Zscore TB / U <-2.0 and Zscore weight /

height between -2.0 s / d 2.0

Short-Fat

: Zscore TB / U <-2.0 and Zscore BB / TB> 2.0

Normal-Thin TB: TB Zscore / U> = -2.0 and Zscore weight /

height <-2.0
Normal-Normal TB: TB Zscore / U> = -2.0 and Zscore weight /
height between -2.0 s / d 2.0 TB
Normal-Fat : Zscore TB / U> = -2.0 and Zscore BB / TB> 2.0

Wellcome Trust Working Party system, as shown in

the table below : 4
Kwashiorkor

: Body weight > 60% from normal

+ edema
Marasmus

: Body weight < 60% from normal

without edema

MarasmicKwashiorkor : Body weight > 60% from

normal + edema

Classification
Firstly malnutrition can be divided into:
Primary

malnutrition
which
means
malnutrition resulting from inadequate
food intake

Secondary

malnutrition which means

there is increased nutritional need or
decreased
nutrient
absorption
or
increased nutrient losses.

 Two distinct clinical syndromes have been

described, kwashiorkor and marasmus,

and represent the severe forms of PEM.

 Marasmus (non-edematous SCU with

severe wasting)
Non-edematous SCU was believed to

result primarily from inadequate calorie

intake

 Kwashiorkor (edematous SCU)

Edematous SCU was believed to result

primarily from inadequate protein intake.

 Marasmic - Kwashiorkor, has features of

both disorders (wasting and edema).

Marasmic - Kwashiorkor is a mixture of

both conditions. Sometimes a child can

switch from one to the other.

Pathophysiology
Dietary deficit is the biggest contributor causing

malnutrition.
In the case of Marasmus:
Insufficient energy intake

Body uses it own stores

Supressed insulin production

Catabolic hormones
starts to act
Muscle breakdown

Produce ketone bodies

Further breakdown and ammonia synthesis

Lean body mass utilized causing wasting

 In the case of kwashiorkor:

Insufficient protein intake
Hypoproteinemia and edema
Body unable to produce lipoprotein
Fats accumulate in liver (fatty liver)
Immune proteins are not synthesized
Affect all organ system

Clinical Manifestation
Marasmus
Old man face: Simian (Monkey like)

appearance of face since the child

appearance only comprise of skin and
bones.
Failure to thrive: Children will have below

normal standards of weight. There will be

prominent ribs and loss of subcutaneous
fat.
Wasting: Muscle wasting is prominent,

skin hanging is especially seen around

buttocks and thighs, namely baggy
pants appearance.
Less iritable : Compared to kwashiorkor,

marasmic children have deep sunken eyes

and rather less irritable.
Hair changes in texture more than color.

Kwashiorkor
Edema due to hypoproteinemia

leading to fluid retention. The

edema is pitting and may vary
from mild pitting to anasarca.
Mental changes: the child might

be apathetic and lethargic.

Skin changes : shows crazy

pavement appearance showing

hyperpigmented and
desquamated skin, sometimes
with mosaic form.
Hepatomegaly due to fatty

infiltration of the liver.

 Other features occuring in both Marasmus and

Kwashiorkor:
Vomiting and diarrhoea leading to dehydration.
Anemia due to reduced dietary intake of

hematopoietic factors like preotein and folic acid. Most

common type of anemia is iron deficiency anemia.
Infection such as respiratory infection
Other nutritional deficiency such as:
Xerophtalmia (lack of Vitamin A)
Vitamin B complex deficiency

Diagnosis
Used often to diagnose malnutrition in

Indonesia is a guideline provided by WHO

that states:
Weight for height < -3SD or <70% from

50th percentile
Edema on dorsal part of the feet to all

parts of the body or

Kwashiorkor weight for height > -3 SD
Marasmic-Kwashiorkor < -3 SD

Initial history taking should include

information regarding:
Asking whether there is sudden deep

sunken eyes
Diarrhea and vomitting information
Urination
Whether extremities feel cold

Further information regarding this information should also be

obtained:
Dietary habit before sickness
Breastfeeding information
Feeding intake
Whether or not there is a decline in appetite
Contact with patient diagnosed with tuberculosis
Whether within the last three months, patient suffer from

measles

Chronic cough
Information regarding (death of) siblings
Birth weight
Child developmental milestones
Immunization history
Whether there is monthly documentation of weight increment
Environmental information (including family and social

background)

Physical examination should include:

Whether edema is present
Assess nutritional status
Sign of dehydration (thirst, sunken eyes, poor skin turgor)
Presence of shock signs (cold extremities, poor capilarry refill

time)
Fever
Respiratory rate
Pallor
Assess hepatosplenomegaly
Distended abdomen (look for bowel sound)

Treatment
The usual approach to the treatment of the child with severe
malnutrition is divided into three phases (Table 43-5). These are:

Initial treatment (days 1-7):

life-threatening problems are identified and treated in a

hospital or a residential care facility,

specific
deficiencies
are
corrected,
metabolic
abnormalities are reversed and feeding is begun.

Rehabilitation (weeks 2-6):

intensive feeding is given to recover most of the lost

weight, emotional and physical stimulation are increased,
the mother or carer is trained to con tinue care at home,
preparations are made for discharge of the child.

Follow-up (weeks 7-26): after discharge,

the child and the childs family are followed to prevent

relapse and assure the continued physical, mental and
emotional development of the child.

The guidelines for the treatment of

severe malnutrition are divided in
five sections:
A. General principles for routine care
(the10 steps)
B. Emergency treatment of shock
and severe anaemia
C. Treatment of associated conditions
D. Failure to respond to treatment
E. Discharge before recovery is
complete

A. GENERAL PRINCIPLES FOR

ROUTINE CARE
There are ten essential steps:
1.Treat/prevent hypoglycaemia
2. Treat/prevent hypothermia
3. Treat/prevent dehydration
4. Correct electrolyte imbalance
5. Treat/prevent infection
6. Correct micronutrient deficiencies
7. Start cautious feeding
8.Achieve catch-up growth
9.Provide sensory stimulation and
emotional support
10. Prepare for follow-up after recovery

1.Prevent hypoglycemia
Criteria
Dextrostix <54g/dl

Prevention
10% of glucose, frequent feeding every 2 hour.

Treatment
50ml 10% glucose or sucrose (1 teaspoon sugar in three tablespoon

water)
F75 therapeutic milk every 2 hour for the first 24 hour, continue
every 2 or 3 hour.
If the child is unconcious, treat with 10% glucose via NGT
Monitor
Monitor blood glucose, if found to be low, repeat measurement 30

mins afterwards.
Watch for unconciousness, rectal temperature < 35.5 0C, repeat test.

2.Prevent hypothermia
Watch

if
axillary
o
tempertture <35 C, take
rectal temperature. If
rectal
temperature
o
<35 C:

feed

straightaway
start
rehydration
needed)

(or
if

rewarm the child: either

clothe
the
child
(including head), cover
with a warmed blanket
and place a heater or
lamp nearby (do not use
a hot water bottle), or
put the child on the

Monitor:
body

temperature:
during
rewarming
take
rectal
temperature two- hourly until
it rises to >36.5oC (take halfhourly if heater is used)

ensure the child is covered at

all times, especially at night

feel for warmth
blood glucose level: check for

hypoglycaemia
whenever
hypothermia is found

3.Prevent dehydration
Treatment:
The

standard
oral
rehydration salts solution
(90
mmol
sodium/l)
contains
too
much
sodium and too little
potassium for severely
malnourished
children.
Instead
give
special
Rehydration Solution for
Malnutrition (ReSoMal).

ReSoMal 5 ml/kg every 30

min. for two hours, orally or

by nasogastric tube, then
5-10 ml/kg/h for next 4-10

hours: the exact amount to

be given should be
determined by how much the
child wants, and stool loss
and vomiting. Replace the
ReSoMal doses at 4, 6, 8 and
10 hours with F-75 if
rehydration is continuing at
these times, then
continue feeding starter F-75

4.Correct electrolyte
imbalance
All

severely malnourished
children have excess body
sodium
even
though
plasma level may be low.
Give:

extra potassium
mmol/kg/d

3-4

extra magnesium 0.4-0.6

mmol/kg/d

when rehydrating, give

low sodium rehydration
fluid (e.g. ReSoMal)

prepare food without salt

5. Prevent Infection
In severe acute malnutrition, the

usual signs of bacterial infection,

such as fever, are often absent,
yet multiple infections are
common.

Choice of antibiotics:

Uncomplicated acute
malnutrition, give amoxcillin
for 5 days.

Benzylpenicillin (50.000 IU/kg

IM or IV every 6 h)
orampicillin (50 mg/kg IM or
IV every 6 h) for 2 days, then
oral amoxicillin (2540 mg/kg
every 8 h for 5 days) .

Gentamicin 7.5 mg/kg IM or

IV) once a day for 7 days.

Treat other infection as

appropriate (e.g meningitis,
respiratory infection)

Treatment
Give all severely malnourished

children:

broad-spectrum antibiotic

measles vaccine if the child is

6 months and not vaccinated or
was vaccinated before 9 months
age. Delay vaccination if the
child is in shock.

6. Correct micronutrient
deficiency
Treatment

Multivitamins
including
vitamin A and folic acid, zinc
and
copper
are
already
present in F-75, F-100 and
ready-to-use therapeutic food
packets.

Dosage is 50.000 IU for <6

months, 200.000 IU for 6-12
months and 200.000 for >12
months.

When premixed packets are

used, there is no need for
additional doses.In addition,

Give vitamin A on day 1 and repeat

on days 2 and 14 only if child has
any signs of vitamin A deficiency
like corneal uleration or history of
measles.

Start iron at 3 mg/kg/day for 2 days

on F-100 catch up formula. give the
following micronutrients daily for at
least 2 weeks:

Folic acid 5mg on day 1 and

1mg daily

if there are no eye signs or

history of measles, then do not
give a high dose of vitamin A
because the amounts already
present in therapeutic foods
are enough.

7. Cautious Feeding
Initial feeding

frequent (every 23 h) oral

small feeds of low osmolality
and low lactose

nasogastric feeding if the

child is eating 80% of the
amount offered at two
consecutive feeds

calories at 100 kcal/kg per

day

protein at 11.5 g/kg per day

liquid at 130 ml/kg per day

or 100 ml/kg per day if the
child has severe oedema

8. Achieve catch up growth

Target gain >10g

gain/kg/day

Day 1 and 2: Give F75

(starter)
On Day 3 make gradual
transition to F100

If weight gain is:

poor (<5 g/kg/d), child requires full
reassessment
moderate (5-10 g/kg/d), check
whether intake targets are being met,
or if infection has been overlooked
good (>10 g/kg/d), continue to
praise staff and mothers

Monitor
during
the
transition for signs of
heart failure:
respiratory rate
pulse rate
If respirations increase by
5 or more breaths/min and
pulse by 25 or more
beats/min
for
two
successive
4-hourly

9. Sensory stimulation and emotional support

Provide:

tender loving care

a cheerful, stimulating environment

structured play therapy 15-30 min/d
physical activity as soon as the child is well

enough
maternal involvement when possible

(e.g. comforting, feeding, bathing, play)

10. Follow up after recovery

A child who is 90% weight-for-length

(equivalent to -1SD) can be considered to

have recovered. .
Advise parent or carer to:
bring child back for regular follow-up

checks
ensure booster immunizations are given
ensure vitamin A is given every six

months

B. Emergency treatment of shock and severe anaemia

In the case of shock:

give oxygen
give sterile 10% glucose (5 ml/kg) by IV
give IV fluid at 15 ml/kg over 1 hour. Use Ringers lactate

with 5%
dextrose; or half-normal saline with 5% dextrose; or half-

strength Darrows solution with 5% dextrose; or if these are

unavailable, Ringers lactate
measure and record pulse and respiration rates every 10

minutes
give antibiotics

If there are signs of improvement

(pulse and respiration rates fall)
repeat IV 15 ml/kg over 1 hour; then

switch to oral or nasogastric rehydration

with ReSoMal, 10 ml/kg/h for up to 10
hours.
Give ReSoMal in alternate hours with

starter F-75, then

continue feeding with starter F-75

If the child fails to improve after the first hour of treatment

(15 ml/kg), assume that the child has septic shock. In this case:
give maintenance IV fluids (4 ml/kg/h) while waiting for blood,
when blood is available transfuse fresh whole blood at 10

ml/kg slowly over 3 hours; then

begin feeding with starter F-75 (step 7)
If the child gets worse during treatment (breathing

increases by 5 breaths or more/min and pulse increases by 25

or more beats/min):
stop the infusion to prevent the childs condition worsening

In the case of severe anemia:

A blood transfusion is required if:
Hb is less than 4 g/dl
or if there is respiratory distress and Hb is between

4 and 6 g/dl
Give:
whole blood 10 ml/kg body weight slowly over 3

hours
furosemide 1 mg/kg IV at the start of the transfusion

C. Treatment of associated conditions

1. Vitamin A deficiency
If the child shows any eye signs of deficiency, give orally:
vitamin A on days 1, 2 and 14 (for age >12 months, give

200,000 IU; for age 6-12 months, give 100,000 IU; for age 05 months, give 50,000 IU). If first dose has been given in the
referring centre, treat on days 1 and 14 only
If there is corneal clouding or ulceration, give

additional eye care to prevent extrusion of the lens:

instil chloramphenicol or tetracycline eye drops (1%) 2-3

hourly as required for 7-10 days in the affected eye

instil atropine eye drops (1%), 1 drop three times daily for 35 days
cover with eye pads soaked in saline solution and bandage

 2. Dermatosis
Signs: hypo-or hyperpigmentation, desquamation ,

ulceration (spreading over limbs, thighs, genitalia,

groin, and behind the ears), exudative lesions
(resembling severe burns) often with secondary
infection, including Candida
Zinc deficiency is usual in affected children and the

skin quickly improves with zinc supplementation (see

step 6). In addition:

apply barrier cream (zinc and castor oil ointment, or

petroleum jelly or paraffin gauze) to raw areas
omit nappies so that the perineum can dry

 Parasitic worms

give mebendazole 100 mg orally, twice daily for 3 days

Diarrhea
Mucosal damage
Give metronidazole (7.5 mg/kg 8-hourly for 7 days)

Lactose intolerance
Substitute milk feeds with yoghurt or a lactose-free

infant formula
Osmotic diarrhea
Use isotonic F75
Introduce F100 orally

 5. Tuberculosis (TB)

If TB is strongly suspected (contacts with adult

TB patient, poor growth despite good intake,
chronic cough, chest infection not responding to
antibiotics):

perform Mantoux test (false negatives are

frequent)
chest X-ray if possible

If test is positive or there is a strong suspicion of

TB, treat according to national TB guidelines.

D. Failure to respond to
treatment
Failure is indicated if:
High mortality
Low weight gain during rehabilitation

phase
Important to check on:
Inadequate feeding
Specific nutrient deficiency
Untreated infection
HIV/AIDS
Psychological problems

E. Discharge before recovery is complete

A child may be considered to have recovered

and be ready for discharge when she/he
reaches 90% weight-for-length.

Home based treatment is given if:

is aged >12 months

has completed antibiotic treatment
has good appetite and good weight gain
has
taken
potassium/magnesium/mineral/vitamin
supplement for 2 weeks (or continuing
supplementation at home is possible)

Complication
ON MALNUTRITION
Fatty liver may be result as it is often seen in Kwashiorkor. Fat

content may be up as high as 50%, due to increase in fluz of

fatty acids from adipose tissue for production of energy and
decreased hepatic synthesis o P-lipoporetein that normaly
transport triglycerides from the liver.
Pancreas shows marked atrophy of acinar cells.
Heart muscles atrophy leads to reduced cardiac output,

resulting to congestive cardiac failure.

Hemopoietic system results in anemia
Muscle shows glycogen depletion and disorganization of the

sarcomere

ON REFEEDING
Refeeding syndrome:
Severe

hypophosphatemia
(Serum
phosphate levels of 0.5 mmol/L ) during
1st week of refeeding.
Causing
weakness,
rhabdomyolisis,
cardiorespiratory
failure,
arryhtmias,
sudden death

Prognosis

Malnutrition affects
system in the body.

many

organs

and

In acute state, PEM cause hypothermia,

hypoglycemia,
dehydration
electrolyte imbalance.

and

In long term, it cause speech and growth

retardation that
cognitive function

leads

to

decrease