Comprehensive Clinical Notes on Malnutrition and Protein Energy Malnutrition (PEM) by Mrs. Muyunda

Definition and Classifications of Malnutrition

Malnutrition: A nutritional disorder where the amount of nutrients taken is less than the body's requirement. It is characterized by weight loss and retarded growth.
Severe Malnutrition (WHO 2005 Definition): Defined by the following measurement thresholds:
- Weight-for-height measurement of $70\%$ or more below the median.
- Minus three standard deviations ( $-3 SD$ ) below the median.
- Mid-upper arm circumference (MUAC) less than $110\,mm$ in children aged 6 to 60 months.
Wasting: A condition where a child’s weight is too low for their height. It is a key indicator for assessing the prevalence of childhood malnutrition.
Underweight: Classified when a child is in the bottom $5^{th}$ percentile for weight compared to their height (relative to children of the same age and height).
Stunting: Occurs when a child fails to grow to the proper height for his or her age.
Overweight: BMI-for-age greater than $1$ standard deviation ( $+1 SD$ ) above the WHO Growth Reference median.
Obesity: BMI-for-age greater than $2$ standard deviations ( $+2 SD$ ) above the WHO Growth Reference median.
Undernutrition: Insufficient intake of energy and nutrients to meet an individual's needs to maintain good health.
Overnutrition: A state where a child receives more energy and nutrients than required. It is a chronic condition causing weight gain when calorie consumption exceeds calorie expenditure.

Protein Energy Malnutrition (PEM)

General Concept: Also known as protein-calorie malnutrition. It develops when the consumption of protein and energy (calories) is insufficient to satisfy nutritional needs.
Kwashiorkor:
- Usually occurs after 12 months of age.
- Caused by inadequate or low protein intake.
- Clinical Features: characterized by edema, stunted growth, apathy, and a moon-shaped face (G.T. Heikens and M. Manary, 2006).
Marasmus:
- Can affect anyone but is primarily seen in children.
- Caused by insufficient or low carbohydrate (energy) intake.
- Clinical Features: Characterized by energy deficiency, excessive appetite, and excessive loss of weight.

Degrees of Acute Malnutrition and Clinical Categories

Moderate Acute Malnutrition (MAM):
- Weight-for-age between $-3$ and $-2$ z-scores below the median of the WHO child growth standards.
- Can result from low weight-for-height (wasting), low height-for-age (stunting), or both.
Severe Acute Malnutrition (SAM):
- Defined by the presence of edema of both feet OR severe wasting.
- Severe wasting thresholds: weight-for-height/length $< -3 SD$ or MUAC $< 115\,mm$ .
Uncomplicated SAM:
- Weight-for-height measurement of $70\%$ , weight-for-height Z score $< -3 SD$ , and/or MUAC $< 115\,mm$ in children aged 6 to 59 months without medical complications.
Complicated SAM:
- Children with SAM who also present with loss of appetite or any medical complications. This requires inpatient care.

Predisposing Factors and Causes of Malnutrition

Dietary and Behavioral: Reduced food intake, lack of breastfeeding, and early separation.
Social and Economic: Social and mobility problems affecting meal preparation, poor socioeconomic status.
Mental Health: Schizophrenia, depression, dementia, and anorexia nervosa.
Medical and Physiological: Digestive disorders (e.g., ulcerative colitis), stomach conditions, frequent infections, and worm infestation.

Signs and Symptoms of Marasmus and Kwashiorkor

Marasmus Symptoms:
- Severe wasting of body fat and tissue decomposition (child appears like a ‐little old man‐ or a ‐monkey‐).
- Visible ribs due to emaciation.
- Thin, flaccid, dry, and wrinkled skin; appears too big for the body (at the back, the child looks like they are wearing ‐baggy pants‐).
- Alert appearance; may cry at the sight of food despite emaciation (good appetite).
- Diarrhea due to infection and impaired absorption.
- Stunting from inadequate carbohydrate intake.
- Bitot’s spots: Superficial foamy spots on the conjunctiva, usually due to Vitamin A deficiency.
Kwashiorkor Symptoms:
- Pitting edema of the feet and ankles, spreading to the rest of the body due to reduced plasma protein.
- Apathy and anorexia (loss of appetite) due to inadequate food intake and impaired gastrointestinal mucosa.
- Moon-shaped face due to edema.
- Hair changes: Dry, thin, sparsely distributed, brownish-red, and easily pulled out (lack of protein needed for hair formation).
- Dermatosis: Hyper-pigmentation with patches; epidermis may peel leaving tender wet skin (risk of infection).
- Impaired immunity due to lack of protein for immune system function.

The Ten Principles of Malnutrition Management

Treat/prevent hypoglycemia.
Treat/prevent hypothermia.
Treat/prevent dehydration.
Correct electrolyte imbalance.
Treat/prevent infection.
Correct micronutrient deficiencies.
Start cautious feeding.
Achieve catch-up growth.
Provide sensory stimulation and emotional support.
Prepare for follow-up after recovery.

Phases of Inpatient Treatment

1. Stabilization Phase

Purpose: Manage acute medical conditions; requires a cautious approach due to fragile physiological state and reduced homeostatic capacity.
Feeding Strategy: Small, frequent feeds with low osmolarity and low lactose ( $F-75$ ). Use oral or nasogastric (NG) tubes; never parenteral.
Nutritional Targets:
- Energy: $100\,kcal/kg/d$ .
- Protein: $1\text{ to }1.5\,g\text{ protein}/kg/d$ .
- Fluid: $130\,ml/kg/d$ ( $100\,ml/kg/d$ if severe edema is present).
F-75 Starter Formula: Contains $75\,kcal/100\,ml$ and $0.9\,g\text{ protein}/100\,ml$ .
Feeding Schedule (F-75):
- Days 1-2: 2-hourly feeds ( $11\,ml/kg/feed$ ).
- Days 3-5: 3-hourly feeds ( $16\,ml/kg/feed$ ).
- Days 6-7+: 4-hourly feeds ( $130\,ml/kg/d$ (total daily volume)).
Monitoring: Note amounts offered/leftover, vomiting, watery stool frequency, and daily weight. Diarrhea should diminish and edema should decrease (weight loss in edematous children).
Heart Failure Warning Signs: Monitor Respiratory Rate (RR) and Pulse. If RR increases by $\ge 5\,breaths/min$ and Pulse increases by $\ge 25\,beats/min$ for two successive 4-hourly readings, reduce volume (transition to $F-100$ at $16\,ml/kg/feed$ for 24 hours, then scale up slowly).

2. Transition Phase

Purpose: Monitor adjustment capacity to sudden diet change (to avoid electrolyte disequilibrium).
Diet: Introduce $F-100$ formula or Ready-to-use Therapeutic Food (RUTF).
Duration: 1-3 days.
F-100 Content: $100\,kcal$ energy and $2.9\,g$ protein per $100\,ml$ .
Expected Weight Gain: approximately $6\,g/kg/d$ .

3. Rehabilitation Phase

Target Feeding:
- Energy: $150\text{ to }220\,kcal/kg/d$ .
- Protein: $4\text{ to }6\,g\text{ protein}/kg/d$ .
Weight Gain Assessment:
- Poor: $< 5\,g/kg/d$ (requires re-assessment).
- Moderate: $5\text{ to }10\,g/kg/d$ (check for infection or intake targets).
- Good: $> 10\,g/kg/d$ (target is $8\,g/kg/d$ ).
Outpatient Transfer: If appetite is good and no medical complications exist, the child may be transferred to outpatient care with RUTF only.

4. Discharge and Follow-Up

Discharge Criteria:
- Weight-for-Height/Length $\ge 85\%$ on at least two weighing sessions.
- Absence of edema for 14 days.
Follow-up Support:
- Enroll in nutritional support program for 4-6 months.
- First 2 months: attend every two weeks; then once per month.
- Prioritize family for public food rations.

Therapeutic Foods and Formulas

General Composition: Mixture of protein, carbohydrates, lipids, vitamins, and minerals.
F-75: Milk-based liquid for phase one (stabilization). $75\,kcal/100\,ml$ ; $0.9\,g\text{ protein}/100\,ml$ .
F-100: High-energy, high-protein milk-based liquid for phase two (rehabilitation). $100\,kcal/100\,ml$ ; $2.9\,g\text{ protein}/100\,ml$ .
Ready-to-Use Therapeutic Food (RUTF):
- Energy-dense, micronutrient-enriched pastes (nutritional profile similar to $F-100$ ).
- Standard four ingredients: Sugar, dried skimmed milk, oil, and vitamin/mineral supplement (CMV). Often incorporates peanuts.
- Safe for children 6-59 months even with diarrhea; must be offered with safe drinking water as RUTF contains no water.

Comprehensive Nursing Care

Prevention of Hypoglycemia: Provide regular feeds ( $F-75$ / $F-100$ ), allow breastfeeding, and monitor blood glucose levels.
Prevention of Hypothermia:
- Maintain environment at $27\text{ to }30^{\circ}C$ .
- Provide warm clothing and keep windows closed.
- Staff must warm hands before touching the child.
Prevention of Dehydration:
- Use fluid balance charts to monitor intake/output.
- Assess skin turgor.
- ReSomal: $130\,ml/day$ to prevent dehydration and correct electrolytes.
- Zinc Sulphate: Administered to help formation of microvilli to reduce diarrhea.
Infection Control:
- Nurse in a specific malnutrition unit.
- Use reverse barrier nursing and aseptic techniques for peeling skin.
- Wash hands before and after patient contact; restrict visitors with active infections.
Rest and Activity (Sensory Stimulation):
- Complete bed rest in acute/severely anemic phases ( $Hb$ monitoring) to reduce oxygen demand and conserve energy.
- Block nursing procedures together to allow periods of uninterrupted rest.
- Control noise: Play radio at low volume, oil squeaking trolleys, and answer phones promptly.
Psychological Care and Bonding:
- Promote mother-child bonding by encouraging the mother to hold and play with the child.
- Explain the disease process and all procedures to the caregiver to allay anxiety.
Observations:
- Monitor vital signs and Blood Pressure as baseline data.
- Monitor for respiratory distress/dyspnea; prop up older children or have mothers hold younger children to promote lung expansion.
- Perform daily weights to monitor growth and decrease of edema.

Complications and Prevention

Complications:
- Heart failure (compromised cardiac function).
- Hepatomegaly (fatty liver).
- Susceptibility to infections (compromised immunity).
- Permanent growth retardation.
Prevention Strategies:
- Breastfeeding: Exclusive breastfeeding for the first 6 months (7-8 times per day). Proper weaning after 6 months.
- Nutrition Education: Teaching mothers how to prepare balanced diets and store food to preserve nutrients.
- Growth Monitoring: Monthly ‐Under 5‐ clinics and timely vaccinations.
- Hygiene and Sanitation: Reduces the incidence of infectious diseases that trigger malnutrition.
- Cultural Practices: Discourage traditions where the father receives more or better quality food than the small children.