COMMUNITY NUTRITION 3 (1+2)

Lesson 8 : Protein Energy Malnutrition

Measures to combat protein Energy Malnutrition

Treatment: Severe cases of PEM, especially those with complications like severe infection or dehydration require intensive care and should be admitted to a hospital for treatment. Once the condition is controlled, the treatment can be continued outside the hospital. Nutrition support is the primary consideration in such cases.

Dehydration

• Patients with mild to moderate dehydration can be treated by oral or nasogastric administration of fluids.
• The oral rehydration solution (NaCl 3.5 g: NaHCO3 2.5g: KCL 1.5 g and glucose 20 gm dissolved in 1 lit of water) recommended by the WHO can be safely used for correcting dehydration in PEM children.
• This amount should be given in small quantities at frequent intervals over a period of 4-6 hours.
• For patients with severe dehydration, intravenous fluid therapy is required to improve the circulation and expand plasma volume rapidly.
• About 70-100 ml of fluid can be given in the first 3-4 hours.
• As soon as urine flow is established, potassium supplements can be given orally (1-2g/kg/day).

Infections

• Diarrhoea and measles are often the immediate cause of death of PEM.
  Appropriate antibiotics therapy can be given.
• Intestinal infections such as giardiasis and ascariasis must be treated with appropriate deworming agents.

Hypothermia: Marasmic children are prone to have low body temperature. If the room is cold, the child should be properly covered with a blanket. The state of shock should be treated with intravenous injection of glucose-saline or blood transfusion.

Anaemia: Severe anemia is dangerous as it can result in heart failure. If the haemoglobin falls below 5g/day, blood transfusion should be given.

Dietary management

• The child should be given a diet providing sufficient quantities of calories and protein in gradually increasing amounts, without provoking vomiting or diarrohoea.
• It is best to begin with a liquid formula with diluted milk.
• When this is accepted, vegetable oil can be added to increase energy content.
• Milk based formulae should be used for feeding children.
• If the child has milk intolerance, milk formulas can be substituted by buttermilk or cereal foods.
• In elder children, easily digestible solid foods like bread +milk +sugar can be given.
• A mixed cereal based diet can be given with added oil to increase energy density.

Suggested diet during convalescence

• Increasing the quantity of existing food .
• Increasing the number of meals to satisfy calorie and protein requirement.
• Addition of oil or ghee 1 to 2 tsp to increase calories without increasing bulk.
• Consumption of sugar and banana can be increased to increase calories in the diet.
• The child can be given cereal and pulse mixture in 5:1 proportion.
• If the patient can afford, milk, egg and skimmed milk can be included in the diet.
• Locally available, inexpensive and easily digestible foods should be used.

The following steps are suggested by FAO/WHO nutrition expert committee.

Health promotion

1. Measures directed to pregnant and lactating women (education, distribution of supplements).
2. Promotion of breast feeding.
3. Development of low cost complementary foods. The child should be made to eat more food at frequent intervals.
4. Measures to improve family diet.
5. Nutrition education, promotion of correct feeding practices.
6. Home economics.
7. Family planning and spacing of births.
8. Improving family environment.

Specific protection

1. The child’s diet must contain protein and energy rich foods, milk, eggs, fresh fruits should be given if possible.
2. Immunization schedule should be followed.
3. Food fortification may help the child in meeting requirements.

Early diagnosis and treatment

1. Periodic surveillance.
2. Early diagnosis of any lag in growth.
3. Early diagnosis and treatment of infections and diarrhea.
4. Development of programmes for early rehydration of children with diarrhea.
5. Development of supplementary feeding programmes during epidemics.
6. Deworming of heavily infested children.

Integrated child development services (ICDS): Isolated feeding programmes will not be effective unless efforts are made simultaneously to improve the environment and control infections.

Supplementary food is therefore integrated with other health activities like

1. Immunization
2. Treatment of minor illness
3. Growth monitoring
4. Health education
5. Supplementary feeding.

Nutrition Education: Education to improve child nutrition should stress

1. The importance of breast feeding
2. Timely introduction of supplements. Use of local available foods.
   Feeding sufficient quantity
   Maintenance of hygiene.
3. Feeding balanced diets for children