PEM MANAGEMENTBy – Uzagare Joshua John

Complications•SHIELDED S- Sugar def i.e., Hypoglycemia H- Hypothermia I- Infection and septic shock EL - Electrolyte imbalance (hypokalemia) D - Def of Fe, Vitamins and other micronutrients

The ten steps for routine care

1. Hypoglycaemia

2. Hypothermia

3. Dehydration

4. Electrolysis

5. Infection

6. Micronutrients

7. Cautious feeding

8. Catch-up growth

9. Sensory stimulation

10. Prepare for follow-up

Stabilization Rehabilitation

Days 1-2 Days 3-7 Weeks 2-6

No iron With iron

Criteria for admission

•Children weighing less than 60% for age with: Edema Severe dehydration Diarrhea Hypothermia Shock Systemic infection Jaundice Bleeding Persistent loss of appetite Severe wasting or edematous nutrition

STEP 1 PREVENT/TREAT HYPOGLYCEMIA• Blood glucose <54mg/dl• If cant be measured assume hypoglycemia • Hypoglycemia, hypothermia and infections generally occour as a

triad

TREATMENT

Asymptomatic-

• 50ml of 10% glucose or sucrose solution orally or NG f/b 1st feed

• Feed with starter F-75 q 2hrly

Symptomatic

• 10% dextrose i.v 5ml/kg • Follow with 50ml of 10% glucose or

sucrose solution NG • Feed with starter F-75 q 2hrly • Start appropriate antibiotics

PREVENTION

• Feed 2 hrly starting immediately • Prevent hypothermia

STEP 2 PREVENT AND TREAT HYPOTHERMIA

Rectal temp <35.5 C/95.5 F or axillary <35 C/95 F

Treatment

• Avoid Rapid Rewarming• Clothe with warm cloths• Ensure head is also covered well with a scarf or a cap• Provide heat with overhead warmer, incandescent lamp or radiant

warmer, warm water bottles, warm pads, etc.• Give appropriate antibiotics• Feed 2 hrly starting immediately after admission• Always keep child covered, Place bed away from doors and

windows• Minimize exposure after bathing or clinical exam.• Let child sleep in close contact with mother• Kangaroo mother care

STEP 3 TREAT/PREVENT DEHYDRATION• Assume all SAM with watery diarrhoea to have some

dehydration. • Hypovolemia can co exist with edema.

• Treatment

• Use reduced osmolarity ORS with potassium supplements for rehydration and maintenance.

• Initiate feeding within 2-3 hrs of starting rehydration with F-75 formula on alt hrs with reduced osmolarity ORS

• Be alert for signs of overhydration.

ReSoMal• Severely malnourished children have low potassium and

abnormally high sodium• ORS should contain less sodium and more potassium

than the standard WHO-recommended solution.• Magnesium, zinc and copper should also be given to

correct deficiencies of these minerals. •ReSoMal Can be prepared by: Diluting 1 pack of standard ORS in 2 litres of water

(instead of 1L) and adding 50g sucrose and 40 ml of mineral mix solution

- NO DEHYRATION : ReSoMal with each loose stool

<2yrs 50-100 ml/loose stool

>2yrs 100-200 ml/ loose stool Till Diarrhoea Stops

-MILD TO MOD :

SEVERE : 100ml/kg of NS/RL in 3-6 hrs, add dextrose

to this, also add potassium

K + supplement – 2-4meq/kg/day,, if acidosis, give sodium

bicarbonate 2ml/kg

70-100 ml/Kg 2 Hours 10 Hours

Give By Oral Or NG route

5 ml/Kg every 30 Min.

5-10 ml/Kg per hour

STEP 4 CORRECT ELECTROLYTE IMBALANCE

• Supplemental potassium at 3-4meq/kg/d for at least 2 weeks

• On day1, 50% MgSO4 i.m once (0.3 ml/kg, max upto 2ml) thereafter give extra Mg(0.8-1.2 meq/kg daily)

• Excess body sodium exists even though plasma sodium may be low.

• Prepare food without adding salt.

STEP 5 TREAT/PREVENT INFECTION• Multiple infections common• Usual signs of infection such as fever often absent• Majority of blood stream infections due to gram negative bacteria. • Assume serious infections and treat. • Hypoglycemia and hypothermia are markers of severe infections.• Treatment

• Ampicillin 50mg/kg/dose q6h iv for atleast 2 days f/b oral amoxycillin 15mg/kg q8h * 5 days and gentamycin 7.5mg/kg or amikacin 15-20mg/kg i.m. or i.v. OD * 7 days

• If no imrovement within 48hrs, i.v. cefotaxime 100-150mg/kg/day q6h or Ceftriaxone 50-75mg/kg/day q12h

• If other specific infections are identified give appropriate antibiotics

Prevention • Follow standard precautions like hand hygiene • Give measles vaccine if >6 months and not immunised or if the child is more than >

9 months.

STEP 6 CORRECT MIRONUTRIENT DEFICIENCIES

1. Use upto twice the RDA of various vitamins and minerals

2. On day1, Vit A orally (if age>1yr 2lac IU, 6- 12 mon 1 lac IU, 0-5 mon 50,000 IU)

3. Folic acid 1mg/day ( 5mg on D1)

4. Copper 0.2-0.3 mg/kg/d

5. Iron 3mg/kg/d, once child starts gaining wt, after the stabilisation phase.

ANEMIA –

•-Severe anemia , give 5-10ml/kg of packed cell transfusion with lasix,

•-mild to moderate anemia, give 2-6mg/kg elemental iron after patient has been stabilised and dewormed.

Iron is not given early because unbound iron in gut may lead to over growth of E.coli

STEP 7 INITIATE RE-FEEDING• Initiate feeding as soon as possible as frequent small

feeds • If unable to take orally- NG feeds • Total fluid recommended is 130ml/kg/d, reduce to

100ml/kg/d if there is severe, generalised edema • Continue breast feeding ad libitum • Start with F-75 starter feeds q 2 hrly • F-75 contains 75kCal/100ml with 1g protein/100ml • If persistent diarrhea, cereal based low lactose F-75 diet

as starter diet • If diarrhea continues on low lactose diets give F-75

lactose free diets

STEP 8 ACHIEVE CATCH UP GROWTH

• Once appetite returns in 2-3 days, encourage higher feeds

• Increase volume offered in each feed and decrease the frequency of feeds to 6 feeds/d

• Continue breast feeding on demand • Make a gardual transition from F-75 to F-100 diet• F-100 contains 100kCal/100ml with 2.5-3g protein/100ml • Increase calories to 150-200 kCal/kg/d and proteins to 4-

6g/kg/d • Add complementary foods as soon as possible to prepare

the child for home foods at discharge

STEP 9 PROVIDE SENSORY STIMULATION AND EMOTIONAL SUPPORT

• A cheerful, stimluating environment • Age appropriate structured play therapy for atleast 15-30

mins/day • Age appropriate physical activity as soon as the child is

well enough • Tender loving care

STEP 10 PREPARE FOR FOLLOW UP AFTER RECOVERY

• Said to have recovered when wt for ht is 90% of NCHS median and has no edema

Restoration•Calories and protein: goal is

• -150-200 kcal / kg,

• -3-4 g protein / kg and

• -100-165 ml fluid / kg

Calorie requirement is calculated based on actual weight irrespective of edema

Total calorie calculated is to be divided into 6-8 feeds and may be given orally or using a feeding tube

Coconut oil as fat supplement as it is rich in MCTs

Oil supplementation can be up to 10 – 15 % of calculated

calories

50% of calories from CHOs

15% from proteins

35% from fat

• Feeding methods – if breast fed, continue it, add on MCT

• If > 4 months add on cereals, legumes, milk, oil, fruits etc

• MVT, micronutrients should be started early

READY RECKONER FOR TAKING DIET HISTORYMILK EXCHANGE Each milk exchange contains *prt. 3g *CHO 4g, Fat 4g, K. Cals 65 Cow’s milk - 100ml ( ½ cup) Buffalo’s milk - 50ml ( ½ cup) Curds - 100ml ( ½ cup) Skimmed milk - 200ml ( 1 cup) Skimmed milk powder 18g 5tsp Whole milk powder 13g (3tsp) Fat negligible

CEREAL EXCHANGE Each cereal exchange contains *prt. 1-3g *CHO 18-21g Fat negligible, K Cals 85 Rice - 25g (2 Tbsp) Cooked Rice - ½ cup Wheat Ravai - 25g (2 Tbsp) Broken Rice - 25g (2 Tbsp) Sooji - 25g (2 Tbsp) Oats - 25g (3 ½ Tbsp) Vermicelli - 25g (2 ½ Tbsp) Flakes - 25g (5 Tbsp) Wheat flour - 25g (3 ½ Tbsp) Ragi flour - 25g (3 ½ Tbsp) Rice flour - 25g (3 Tbsp) Arrow root - 25g (2 Tbsp) Sago - 25g (3 Tbsp) Iddli - 1 medium size Dosai - 1 medium size Chappathi - 1 medium size Uppuma - ½ cup Noodles/spaghetti - ½ cup Potato - 100 g Yam - 75g Colccasia - 100g Sweet potato - 75g Tapioca - 50g Bread - 2 half inch slices Protein negligible

MEAT EXCHANGE Each meat exchange contains *prt. 75g *CHO nil, Fat 6g, K. Cals 85 Beef - 75g Chicken - 75g Liver - 75g Pork muscle - 75g Egg - 1 medium Meat - 50 g Fish - 75-100g Fish and liver contain small amounts of CHO. There is wide variation between items in this exchange

DHAL EXCHANGE Each exchange contains CHO 15g, Prt. 6g, K.Cals 85, Fat negligible Pulses - 25g ( ½ cup cooked) Legumes - 25g ( ½ cup cooked) FAT EXCHANGE Each Fat exchange contains Fat 10g K. Cals 90 * Prt & CHO, nil Oil (any variety) - 10g (3 tps) Ghee - 10g (2 tps) Butter - 12g (2 ½ tps) Vanaspathi - 10g (2 tps) Margarine - 10g

FRUIT EXCHANGE Each fruit exchange contains CHO 10g, K. Cal 40, Prt. & Fat negligible Amla - 4.5 Apple - 1 small Apricots - 2 fresh Banana - ½ small Custard apple - 1 small Dates - 2 Grapes - 20 Grape fruit - ½ small Guava - 1 medium Jack fruit - 3 pieces Jambu - 10 small Mango - 1 small Melon - 1 slice Orange - 1 average Papaya - 2” x 3” slice Peach - 1 medium Pear - 1 small Pineapple - 1 slice Plums - 2 Sapota - 1 small Straw berries - 1 cup Sweet lime - 1 medium size Water melon - 1 slice (200 g)

A weight gain of 0.5kg/week in children and 70g/kg/week in infants is the target. 150-200g/week is expected in newborns and young infants

Restoration of wt for ht may take about 8- 12 weeks

Oedema clears and social smile returns in 1-2 weeks

Rehabilitation phase Frequent feeding. Treating concurrent deficiencies Routine advice for easily available , cheap,culturally acceptable food.

•PEM can be improved by Overall socioeconomic development. Better standard of living. Improved sanitary conditions. Exclusive breast feeding during first 6 months. Optimum weaning practices. Supplementary feeding. Micronutrient supplementation. Universal immunisation. Nutrition & health education. Nutrition & health of girl child.

Failure to respond

•PRIMARY FAILURE1. Failure to regain appetite by day 42. Failure to lose edema by day 4

3. Failure of disappearance of edema by day 10

4. Failure to gain wt atleast 5g/kg/day by day 10•SECONDARY FAILURE• Child does not gain >5g/kg/d body wt for 3

consecutive days

Frequent causes of failure to respondProblems with the treatment facility:• Poor environment for malnourished children• Insufficient or inadequately trained staff• Inaccurate weighing machines• Food prepared or given incorrectly

Problems of individual children:

• Insufficient food given• Vitamin or mineral deficiency• Malabsorption of nutrients• Rumination• Infections, especially diarrhoea, dysentery, otitis media, pneumonia, tuberculosis,urinary tract infection, malaria, intestinal helminthiasis and HIV/AIDS• Serious underlying disease

Poor prognostic factors

Depressed sensorium Marasmic Kwashiorkor Hypothermia Hypoglycemia Albumin < 1.5 gm Gram negative sepsis Purpura Severe dermatosis Xerophthalmia Elevated bilirubin and liver enzymes Marked hepatomegaly Electrolyte and fluid imbalances

Nutrition Recovery Syndrome

• Definition: Apparent worsening of a child with PEM while on nutritional rehabilitation

• Clinical features:• Increasing hepatomegaly• hypertrichosis• parotid swelling• ascites• splenomegaly• eosinophilia• gynecomastia• Tremors-it is a self limiting condition.

Treatment: observation; continue nutritional rehabilitation.

-occurs due to excess of hormones(estrogen) produced nutritional rehab

• Pseudotumor cerebri • Over energetic nutritional correction in malnourished infants may be

accompanied by transient rise in ICT• Benign and self limiting

• Encephalitis like syndromes• Upto 1/5th of children with kwashiorkor may become drowsy within 3-4

days after initiation of diatery therapy• Self limiting• Occasionaly accompanied by progressive unconsciousness with fatal

outcome• Rarely with a transient phenomena marked by coarse tremors,

parkinsonian rigidity, bradykinesia and myoclonus may appear several days after starting the dietary rehabilitation

• Encephalitis like states result of too much protein in the diet

DISCHARGE criteria for PEM

Child should have atleast 90% of his ideal Weight for

his height. Weight gain should be 70gm/kg/week. All infections, vitamin& mineral deficiencies should

have been treated, Serum Albumin--> 3 gm/dl. Immunization should have been initiated. Mother should have been educated regarding domiciliary

care

Follow up • Child should be seen after 1week, 2 weeks, 1 month, 3

months and 6 months.• More frequently if any problem found. • After 6 months, visits should be twice yearly until the child

is at least 3 years old. • The child should be examined, weighed and measured,

and the results recorded. • Any needed vaccine, vit A should be given. • Training of the mother should focus on areas that need to

be strengthened, especially feeding practices, and mental and physical stimulation of the child.

Prevention Antenatal care should be emphasised and strengthened. Health and nutritional status of the adolescent girls should be improved•At national level

• Nutrition supplementation- Fortification, iodination • Nutritional surveillance- define the character and magnitude of nutritional problems and

strategies to tackle. • Nutritional planning- formulation of nutrition policy, improve food production and supplies,

ensure distribution.

• At community level- • Health and nutritional education• Promotion of education and literacy in the community• Growth monitoring • Integrated health package• Vigorous promotion of family planning programs

• At family level• Exclusive breast feeding • Complementary feeds at 6 months • Vaccination • Spacing between pregnancies

NIMFES N – nutrition and growth monitoring I – immunisation

M – medical checkup and medical care during illness

F – family welfare(timing, limiting and spacing of

births) E – education

S – stimulation, developmental surveillance

and TLC

In Short…• RESUSCITATION (Goal:

treatment of medical emergencies)

• RESTORATION (Goal: wt for height )

• REHABILITATION (Goal: wt for age)

• PREVENTION

- Hypoglycemia, hypothermia, infections, dehydration, CCF

-Nutritional therapy, deworming, MVT

-Food supplementation

-NIMFES

Sources • Fundamentals of pediatrics by Dr. K.E. Elizabeth• Ghai Essential Pediatrics 7th edition• Management of severe malnutrition: a manual for

physicians and other senior health workers By World Health Organization, Geneva

• Scott’s Pedia Tricks

Thank You