Center for Global Pediatrics Protein Energy Malnutrition Cindy Howard, MD, MPHTM Associate Director Center for Global Pediatrics University of Minnesota November 8, 2008

Center for Global Pediatrics Time Magazine, August, 2008

Center for Global Pediatrics The percentage of “under five mortality” worldwide caused in part by protein energy malnutrition is estimated at: a)30% b)20% c)60% d)5%

Center for Global Pediatrics Definitions

Center for Global Pediatrics 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

Center for Global Pediatrics Define: PEM 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

Center for Global Pediatrics Underweight 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

Center for Global Pediatrics Marasmus Weight for age < 60% expected No edema Often stunted Hungry, relatively easier to feed CFR=20-30%

Center for Global Pediatrics Kwashiorkor (Edematous Malnutrition) Underweight with edema Irritable, difficult to feed Electrolyte abnormalities Highest mortality – 50 to 60%

Center for Global Pediatrics STUNTING Height for age less than 90% expected

Center for Global Pediatrics 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

Center for Global Pediatrics Complications of SAM include: A.ARI B.Diarrhea C.Gram negative septicemia D.Poor feeding E.Electrolyte abnormalities F.All of the above

Center for Global Pediatrics Complications of SAM ARI Diarrhea Gram negative septicemia Poor feeding Electrolyte abnormalities

Center for Global Pediatrics 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%

Center for Global Pediatrics The first step in the treatment of SAM is to prevent and/or treat hypoglycemia. A.True B.False

Center for Global Pediatrics Ten Steps to Recovery in Malnourished Children Ashworth A, Jackson A, Khanum S & Schofield C 1996 THE WHO TEN STEPS

Center for Global Pediatrics Steps 1 and 2 1.Prevent/treat HYPOGLYCEMIA 2.Prevent/treat HYPOTHERMIA KEY is frequent feeding – every two hrs night/day Skin to skin contact with parent, warm lamp, warm blanket, avoid exposure

Center for Global Pediatrics STEP 3 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 Treat/prevent dehydration

Center for Global Pediatrics STEP 4 * 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 CORRECT ELECTROLYTE IMBALANCES

Center for Global Pediatrics STEP 5 Give to ALL severely malnourished children broad-spectrum antibiotic measles vaccine to all children > 6 months. Vitamin A Mebendazole 100 mg BID x 3 days Consider HIV and TB TREAT INFECTION

Center for Global Pediatrics STEP 6 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). CORRECT MICRONUTRIENT DEFICIENCIES

Center for Global Pediatrics 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

Center for Global Pediatrics 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 Step 8

Center for Global Pediatrics STEP 9 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 Stimulation, Play and Loving Care

Center for Global Pediatrics STEP 10 Preparation for Discharge Nutritional education Immunization Home Follow Up

Center for Global Pediatrics Treatment of Malnutrition

Center for Global Pediatrics Time Magazine, August, Hypoglycemia 2.Hypothermia 3.Dehydration 4.Infection 5.Severe anemia Direct causes of death:

Center for Global Pediatrics Outpatient management Malawi, Sudan, Ethiopia ,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

Center for Global Pediatrics 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, 2 nd edition, 2006, pages: 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: 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.Bhutta ZAAhmed TBlack RECousens SDewey KGiugliani EHaider BAKirkwood BMorris SSSachdev HP Shekar MMaternal and Child Undernutrition Study Group Ten Steps to Recovery. Child Health Dialogue. 2 nd and 3 rd Quarter issues, Guidelines for the Inpatient Treatment of Severely Malnourished Children Nonserial PublicationAshworth, A., Khanum, S., Jackson, A., Schofield, C. World Health Organization ISBN ISBN