Early (Presenting) Complications of PEM:
a) Infections include Common like ARI, Diarrhea, TB, helminthiasis. Severe Gram —ye sepsis, septic shock, DIC and Opportunistic Candidiasis
d) Fluid & electrolyte imbalance
e) Lactose intolerance
f) Severe anemia & other nutrient deficiencies
g) Congestive cardiac failure
Late (Recovery) complications:
a) Diarrhea (lactose intolerance)
b) CCF (high protein & solute diet)
c) Unmasking of subclinical vit/mineral deficiencies
d) Recovery syndromes (see text)
a) Growth retardation
b) Cognitive & learning disabilities
Hypomagnesemia, if present, should be treated with TM 50% magnesium sulfate (0.2 mllkg 12 hourly for 2-3 days).
Nutrient deficiencies: Iron-deficiency anemia due to poor dietary intake and/or co-parasitic infestations is common, which should be treated with oral iron therapy (1 mg/kg/d of elemental iron) along with deworming agents (P0 albendazole 400 mg, single dose). Blood transfusions, though necessary in severe cases, should be avoided in PEM due to risk of CCF and should not exceed 10 mI/kg of packed cells at one time.
Other necessary nutrient supplements in PEM include – single doses of Vitamin A (P0 50,000- 2,00,000 IU), Vitamin K (2.5 mg TM) and Mg SO4 (2 ml 50% sol TM) on admission and daily oral supplementation with folic acid (1 mg) and zinc (2 mg/kg), from first day onwards.
g) Congestive cardiac failure is not uncommon in kwashiorkor, due to impaired cardiac function, fluid overload, and sudden shift of edema fluid in intravascular compartment after blood/plasma transfusions. Diagnosis of CCF in an edematous child may be difficult, but absence of Weight loss despite reducing edema or presence of basal crepitations suggests this possibility. Digitalis therapy carries high risk of toxicity in PEM and hence in these cases, CCF should preferably managed with diuretics and supportive therapy, unless refractory.
Step II – Dietary management: Intensive and supervised dietary therapy needs to be started, soon after the control of complications.
For the sake of simplicity, dietary management may be divided into three steps calculation of nutritional requirements; selection of appropriate type, frequency and method of supplementation, and monitoring of nutritional intake.
a) Calculation of nutritional requirements: Dietary requirements in PEM are relatively higher than in well-nourished children due to additional needs for catch-up growth and replenishment of stores. However, most of them are anorexic or cannot tolerate higher intake due to mal absorption e.g. lactose intolerance. Cases with kwashiorkor also carry risk of CCF if treated with high protein diet since beginning. Hence, it is advisable to begin the dietary therapy with minimum essential intake i.e. 100 cal/kg and 2 gm/kg of proteins according to actual weight and increase by 10-20% every alternate day, till the final aim is achieved (Table 6.11).
b) Selection of appropriate feeds, frequency & mode of administration: Diet plan in PEM cannot be generalized and needs to be tailored in each case. Depending on the age, severity, acceptance and economic feasibility, early dietary therapy may be provided with — i) regular home-made diet in higher quantity and better quality (in mild to moderate PEM), ii) regular home diet, supplemented by high- energy feeds, or iii) therapeutic diets in initial phase, followed by gradual shift to home diet.
Some noteworthy principles of early dietary therapy are as follows —
• Diet should be age-appropriate, acceptable and closely resemble the home diet
• It should be energy-dense i.e. high caloric value with low-bulk. Caloric content and palatability may be improved by adding edible oil or animal- fats e.g. ghee, butter etc. Coconut oil is excellent source of extra calories and being a medium-chain triglyceride, absorbed directly without emulsification. Upto 10-15% of total calories may be given as visible fat in PEM.
• It is preferable to use high biological value proteins e.g. eggs. Protein content in vegetarian diet may be increased by using Soya-bean or ground-nut preparations.
• High-carbohydrate diet should be avoided in early stages, due to frequent lactose-intolerance in severe PEM.
• In anorexic patients, nasogastric feeding with relatively liquid diets e.g. enriched milk may be used initially followed by gradually thickening.
• Feeds should be given more frequently and in smaller aliquots, to improve acceptability. Breast feeding should be continued, if possible, even in older children as a source of additional energy.
• Feeds must be prepared hygienically, involving parents in the selection/preparation of therapeutic diets to improve their nutritional awareness.
• Dietary practices and cultural beliefs e.g. regarding consumption of eggs or non-vegetarian diet should be respected to improve acceptability.
Amylase rich foods (ARF) are easily digestible and enriched sources of proteins and vitamins, prepared by soaking common cereals or pulses in water for 12 hours > sprouting by wrapping in a moist cloth for 48 hours, > drying > roasting> grueling to make porridge. On soaking, the amylase breaks down grain-starch into easily-digestible maltodextrins, reducing the viscosity and bulk of diet. Germination also enhances vitamin content.
c) Monitoring: During dietary therapy, all cases should be closely monitored for dietary intake, signs of recovery, and recovery phase complications.
Common complications in recovery phase are —
a) Diarrhea due to relative lactase deficiency and other mal absorptive states, precipitated by increased nutritional intake,
b) Congestive cardiac failure due to shift of edema fluid in intravascular compartment, following high solute & protein diet,
c) Un-masking of subclinical vitamin & mineral deficiencies e.g. scurvy, zinc deficiency, due to disturbed adaptation.
Two well-defined clinical syndromes seen during the recovery phase are Kahn ‘.c and Gomez recovery syndromes, probably caused by unmasking of subclinical nutrient deficiencies.
Kahn’s recovery syndrome is characterized by sudden onset of tremors and encephalopathy, probably due to unmasked deficiency of gamma aminobutyic acid (GABA) – a major neuro-inhibitor.
Gomez recovery syndrome is characterized by progressive abdominal distension, ascites, hepatomegaly and diarrhea, due to secondary malabsurption and dyselectrolytemia e.g. hypokalemia.
Step III – Consolidation phase begins after 1-2 weeks of intensive dietary therapy and aims to maintain nutritional gains and prepare for discharge. Important steps in this phase include —
a) Gradual shift from therapeutic to home-diet,
b) Continued vitamin/mineral supplementation,
c) Completion of age-appropriate immunization,
d) Nutritional counseling to parents,
e) Evaluation of home environment,
f) Continuous growth monitoring.
Ideally, all PEMs need close supervision till complete recovery, defined as achievement of ideal Weight for Height, which nzay take 6-8 weeks. However, as to wait fill complete recovery in overcrowded hospitals is neither possible nor desirable, fulfillment of a discharge criteria should be adhered, to prevent the recurrence.
Prevention: Malnutrition is more of a socio-economic problem, rather than medical disease. A comprehensive approach is required, especially in developing countries to overcome it. Important preventive steps against PEM include —
I. Promotion of general health and nutrition
A) Actions at family level to promote:
• Correct Breast feeding & weaning practices
• Consumption of cheap, local, nutritive foods
• Correct cooking practices
• Avoidance of wrong food taboos & habits
• Equitable food distribution in the family
• Setting of kitchen gardens/poultry keeping
• Correct feeding practices during illnesses
• Nutrition in pregnant/lactating mothers
• General child health/hygiene,
Family planning practices
B) Action at community level:
• Nutritional surveillance
• Nutritional education
• Development of local low-cost foods
• General measures to improve child health e.g.
– Improved water supply and sanitation
— Widespread immunization services
— Preventive/curative health-care facilities
• Creation of local-job opportunities
C) Action at national level to promote:
• Agricultural production
• Food-storage facilities & public distribution
• General rural/urban-slum development
• Poverty-alleviation measures,
• Food-subsidies to high-risk population
• Targeted health and nutritional programs
D) Action at International level:
• International aid to stimulate socioeconomic development in developing countries.
• World food program (1963), to meet food requirements in needy countries.
• International cooperation during emergencies e.g. natural disasters and wars
U) Specific protection to high-risk children:
• Nutritional surveillance in pre-school children
• Nutritional supplementation/food fortification
• Periodic deworming & iron supplements etc.
• Immunization to control infections
III) Early diagnosis and management:
• Growth monitoring of under-5 children
• Nutritional assessment at all contact points
• Early diagnosis & management of PEM
• Early diagnosis & treatment of infections
IV) Follow-up and rehabilitation:
• Nutritional rehabilitation centers/services
• Follow-up of recovered cases