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Management of PEM : 

Management of PEM Somashekhar Chikkanna

Introduction : 

Introduction Malnutrition is widely prevalent in India 57 million children are underweight (moderate and severe) >50% of deaths in 0-4 years are associated with malnutrition Case fatality rate is 23.5% in severe malnutrition, reaching 50% in edematous malnutrition

Malnourished children : 

Malnourished children

Definition of Severe Malnutrition : 

Definition of Severe Malnutrition Weight for height/length <70% NCHS median or ≤3SD Visible severe wasting Bipedal edema MUAC < 11 cm

Initial Assessment : 

Initial Assessment Good history Physical examination

key points in history : 

key points in history Recent intake of food and fluids Usual diet (before the current illness) Breastfeeding Duration and frequency of diarrhea and vomiting Type of diarrhea (watery/bloody) Loss of appetite

Slide 7: 

Fever Symptoms suggesting infection at different sites Family circumstances (to understand the child’s social background Chronic cough and contact with TB Recent contact with measles Known or suspected HIV infection

Physical examination : 

Physical examination Anthropometry-weight, height/length, MUC Signs of dehydration Shock (cold hands, slow capillary refill, weak and rapid pulse) Lethargy or unconsciousness Severe palmar pallor

Slide 9: 

Localizing signs of infectionEar and throat infections, skin infection or pneumonia Fever(≥37.5ºC or ≥99.5ºF) or hypothermia (rectal temperature <35.5ºC or<95.9ºF) Mouth ulcers Skin changes of kwashiorkor & Eye signs of vitamin A deficiency Signs of HIV infection

Principles of Management : 

Principles of Management Treat/prevent hypoglycemia Treat/prevent hypothermia Treat/prevent dehydration Correct electrolyte imbalance Treat/prevent infection

Slide 11: 

Correct micronutrient deficiencies Start cautious feeding Achieve catch-up growth Provide sensory stimulation and emotional support Prepare for follow-up after recovery

Time table of Mx of PEM : 

Time table of Mx of PEM

Step 1: Treat/ Prevent Hypoglycemia : 

Step 1: Treat/ Prevent Hypoglycemia Measure glucose immediately at admission Hypothermia, infection and hypoglycemia generally occur as a triad Blood glucose level <54 mg/dL is hypoglycemia in PEM C/F-lethargy, unconsciousness ,Seizures, pallor,sweating,Peripheral circulatory failure and hypothermia If can`t measure , assume & treat

Rx of Hypoglycemia : 

Rx of Hypoglycemia Child has hypoglycemia, but is conscious Give 50 mL of 10% glucose or sucrose solution orally or by NG Start feeding 2 hourly day and night Start appropriate antibiotics

Slide 15: 

If the hypoglycemic child is symptomatic Give 10% dextrose i.v. 5 mL/kg Follow with 50 mL of 10% dextrose or sucrose solution by NG tube Start feeding with the starter F75 diet as quickly as possible and then continue the feeds 2-3 hourly day and night Start appropriate antibiotics

Prevention : 

Prevention The cornerstone of prevention is feeding at regular intervals Feed 2 hourly starting immediately (if necessary, rehydrate first) Ensure the child is fed regularly throughout the night

Step 2: Treat/ Prevent Hypothermia : 

Step 2: Treat/ Prevent Hypothermia Look for and manage hypoglycemia in a hypothermic child If Rectal temperature <35.5ºC or 95.5ºF Always measure blood glucose and screen for infections in the presence of hypothermia Hypothermia can occur in summers

Treatment : 

Treatment Feed the child immediately Clothe the child with warm clothes, ensure that the head is also covered Provide heat with an overhead warmer, an incandescent lamp or radiant heater kangaroo mother care Give appropriate antibiotics

Treatment of severe hypothermia : 

Treatment of severe hypothermia Give warm humidified oxygen. Give 5 mL/kg of 10% dextrose IV Start IV antibiotics Rewarm: Provide heat using radiation (overhead warmer), or conduction (skin contact) or convection (heat convector) Give warm feeds immediately Monitor temperature 2 hourly till it rises to more than 36.5ºC

Prevention : 

Prevention Feed the child every 2 hrs Ensure feeds in the night Always keep the child well covered Place the child’s bed away from doors and windows to prevent exposure to cold air Minimize exposure & minimize contact with wet clothes kangaroo mother care

Step 3: Treat/Prevent Dehydration : 

Step 3: Treat/Prevent Dehydration Dehydration tends to be over diagnosed and its severity overestimated in PEM it is safe to assume that all severely malnourished with watery diarrhea may have some dehydration Hypovolemia can co-exist with edema

Treatment : 

Treatment Do not use the IV route for rehydration except in cases of shock Give reduced osmolarity ORS with potassium supplements given additionally Feeding must be initiated within 2-3hours of starting rehydration Give F75 starter formula on alternate hours (e.g., hours 2, 4, 6) with reduced osmolarity ORS (hours 3,5,7)

Slide 23: 

Monitor the progress of rehydration half-hourly for 2 hours, then hourly for the next 4-10 hours Stop ORS for rehydration if any 4 hydration signs are present (child less thirsty, passing urine, tears, moist oral mucosa, eyes less sunken, faster skin pinch)

Severe Dehydration with Shock : 

Severe Dehydration with Shock Use half normal(N/2) saline with 5% dextrose Give oxygen Give rehydrating fluid at slower infusion rates of 15 mL/kg over the first hour Administer IV antibiotics If there is improvement at the end of the first hour, consider diagnosis of severe dehydration with shock

Slide 25: 

Repeat rehydrating fluid at the same rate over the next hour switch to reduced osmolarity ORS at 5-10 mL/kg/hour, either orally or by NG If there is no improvement or worsening after the first hour of the fluid bolus, consider septic shock and treat accordingly

Step 4: Correct Electrolyte Imbalance : 

Step 4: Correct Electrolyte Imbalance Give supplemental potassium at 3-4 mmol/kg/day for at least 2 weeks On day 1, give 50% MgSo4 IM once (0.3 mL/kg up to a maximum of 2 mL) Give extra magnesium (0.4-0.6 mmol/kg daily)orally Injection magnesium sulphate can be given orally Prepare food without adding salt

Step 5: Treat/ Prevent Infection : 

Step 5: Treat/ Prevent Infection All severely malnourished children should be assumed to have a serious infection Hypoglycemia and Hypothermia are considered markers

Investigations : 

Investigations Hb, TLC, DLC, peripheral smear Urine analysis and urine culture Blood culture X-ray chest Mantoux test Gastric aspirate for AFB Peripheral smear for malaria (in endemic areas) CSF examination (if meningitis suspected)

Treatment : 

Treatment Ampicillin 50 mg/kg/dose 6 hourly I.M. or I.V.for at least 2 days; followed by oral Amoxycillin15 mg/kg 8 hourly for five days Gentamicin 7.5 mg/kg or Amikacin 15-20 mg/kg I.M or I.V once daily for seven days If the child fails to improve within 48 hours, change to IV Cefotaxime (100-150 mg/kg/day 6-8hourly)/Ceftriaxone (50-75 mg/kg/day 12 hourly)

Slide 31: 

Give appropriate antibiotics for specific infections (such as pneumonia, dysentery, skin or softtissue infections) Add anti-malarial treatment if the child has positive blood film for malaria Tuberculosis is common, ATT should only be given when tuberculosis is diagnosed

Step 6: Correct Micronutrient Deficiencies : 

Step 6: Correct Micronutrient Deficiencies Vitamin A orally on day 1 (if age >1 year give 200,000 IU; age 6- 12 m give 100,000 IU;age 0-5 m give 50,000 IU) Aim for a formulation that is truly multi (e.g.,one that has vitamins A, C, D, E, and B12 ) Folic acid 1 mg/d (give 5 mg on day 1) Zinc 2 mg/kg/d

Slide 33: 

Copper 0.2-0.3 mg/kg/d Iron 3 mg/kg/d, only once child starts gaining weight; after the stabilization phase

Step 7: Initiate re-feeding : 

Step 7: Initiate re-feeding Osmolarity less than <350 mosm/L Lactose not more than 2-3 g/kg/day Appropriate renal solute load (urinary osmolarity <600 mosm/L) Initial percentage of calories from protein of 5%

Slide 35: 

Adequate bioavailability of micronutrients Low viscosity, easy to prepare and socially acceptable Adequate storage, cooking and refrigeration

Start cautious feeding : 

Start cautious feeding Start feeding early & as frequent small feeds Initiate NG feeds if the child is not able to take orally Recommended daily energy and protein intake from initial feeds is 100 kcal/kg and 1-1.5 g/kg Total fluid recommended is 130mL/kg/day If severe edema reduce to 100 mL/kg/day Continue breast feeding ad-libitum

Starter diets : 

Starter diets

Feeding pattern in the initial days : 

Feeding pattern in the initial days Gradually increase volume while decreasing the frequency of feeds

Step 8: Achieve Catch up Growth : 

Step 8: Achieve Catch up Growth Make a gradual transition from F-75 diet to F-100 diet Diets as shown below contain 100 kcal/ 100 mL with 2.5-3.0 g protein/100 mL The calorie intake should be increased to 150-200kcal/kg/day, and the proteins to 4-6g/kg/day

Catch-up diets : 

Catch-up diets

Step 9:Sensory stimulation &emotional support : 

Step 9:Sensory stimulation &emotional support A cheerful, stimulating environment Age appropriate structured play therapy for at least 15-30 min/day Age appropriate physical activity as soon as the child is well enough Tender loving care

Step 10: Prepare for follow-up after recovery : 

Step 10: Prepare for follow-up after recovery Primary Failure: Failure to regain appetite by day 4. Failure to start losing edema by day 4. Presence of edema on day 10. Failure to gain at least 5g/kg/day by day 10. Secondary failure: Failure to gain at least 5 g/kg/day for 3 consecutive days during the rehabilitation phase.

Poor weight gain : 

Poor weight gain Good weight gain is >10 g/kg/day continue with the same treatment Moderate weight gain is 5-10 g/kg/day Food intake checked & screened for systemic infection Poor weight gain is <5 g/kg/day Screening for inadequate feeding, untreated infection, tuberculosis & psychological problems

Possible causes of poor weight gain : 

Possible causes of poor weight gain Inadequate feeding Specific nutrient deficiencies Untreated infection HIV/AIDS Psychological problems

Criteria for discharge : 

Criteria for discharge Absence of infection. The child is eating at least 120-130 cal/kg/day with adequate micronutrients. Consistent weight gain & on exclusive oral feeding. WFH is 90% of NCHS median Absence of edema. Immunization appropriate for age. Caretakers are sensitized to home care

Expect healthy child after appropriate management : 

Expect healthy child after appropriate management

Slide 47: 

Thank you


HUMAN NUTRITION Nutrients are substances that are crucial for human life, growth & well-being. Macronutrients (carbohydrates, lipids, proteins & water) are needed for energy and cell multiplication & repair. Micronutrients are trace elements & vitamins, which are essential for metabolic processes.

Slide 49: 

Obesity & under-nutrition are the 2 ends of the spectrum of malnutrition. A healthy diet provides a balanced nutrients that satisfy the metabolic needs of the body without excess or shortage. Dietary requirements of children vary according to age, sex & development.

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