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PEM
t
t
Vitamin A Deficiency
Obesity
Food intake
Food availability in household
Infect Disease
Mother & child caring Health service
main problem
core problem
Underlying :
- Household food security - Access to PHC - Community of awareness & care for children & women
Basic :
- Socio-economic conditions (poverty & crisis) - Political factors - Traditional practices (infant feeding) - Environment & sanitation
Demand side:
- empowerment - family awareness of nutrition - subsidies / health insurance
PEM
underfives
important
t early detection and proper management are very t severe malnutrition should be hospitalized t poor quality of life
>>
Poverty
undernutrition
70 -3SD 80 90 -2SD
normal
overnutrition
110 +2SD 120 % +3SD
overweight obese
mild moderate severe super
PEM.
Classification :
1. GOMEZ (195..)
2. MacLarren (196..)
: W/A
: Clinical + laboratory
: Clinica+anthropometric
(W/A)
: W/H
: Clinical+anthropometric (Z-score)
MEP.
Classification (WHO,1999) :
Moderate PEM Symmetrical oedema W/H -Severe PEM
(oedematous
malnutrition)
< -3 Z-score
(<70%) (severe wasting)
H/A
< -3 Z-score
PEM.
DIAGNOSIS :
1. Anamnesis
2. Physical examination 3. others :
- laboratory - anthropometry - dietary analysis
PEM.
Checklist : anamnesis
Usual diet before current episode of illness Breastfeeding history
PEM.
Checklist : anamnesis
Time when urine was last passed Any deaths of siblings Birth weight? Milestones reached (sitting up, standing,etc) Contact with people with measles or tuberculosis Immunizations
PEM.
Anaemia
PEM.
Oedema
oedema
hair
Ribs
lymphadenopathy
Destroyed lung
PEM.
Laboratory tests:
Blood glucose : < 54 mg/dl = hypoglycaemia k Blood smear : parasit malaria k Hb or Ht : < 4 g/dl or < 12% = severe anaemia k Urine exam/culture: bacteria + or > 10 lekosit/HPF infection k Faeces : blood + disentri Giardia + / parasit lain infeksi k X-ray : - thorax : l Pneumonia l Heart failure - bone : rickets, fracture k Tes tuberkulin : often negative electrolytes
PEM.
MANAGEMENT :
l Mild-moderate PEM : - no specific clinical signs : thin, hypotrophic - not necessary to hospitalize - looking for the probable causes - nutr. education & supplementation
l Severe PEM : should be hospitalized
PEM.
Other criteria :
Very low BW : - W/H < 70% - W/A < 60% (- W/A > 60% + oedema) + clinical signs & symptoms :
-
oedema (M-K) severe dehydration persistent diarrhoea and / or vomiting severe pallor, hypothermia, shock signs of systemic/local infection, URI severe anaemia ( Hb < 5 g/dl) jaundice anorexia < 1 yr of age
PEM.
Signs & symptoms of dehydration : - history of diarrhoea or no/diminished intake - weak, apathetic unconscious - weak to absent radial pulse
Dehydration
Sunken eyes
Dehydration
Turgor :
PEM.
A. 10 main steps
B. Treatment of underlying diseases C. Failure to respond to treatment D. Discharge before recover E. Emergency
A : 10 main steps
No Interven1. Treat/prevent hypoglycaemia 2. Treat/prevent hypothermia 3. Treat/prevent dehydration 4. Correct electr. imbalance 5. Treat infection 6. Correct micronutrients defic. 7. Begin feeding 8. Increase feeding 9. Stimulation 10. Prepare for discharge
PEM.
tion
without Fe
+ Fe
PEM.
Bacterial infection :
PEM.
PEM.
PEM.
Time of admission
Day 4 Day 4 Day 10 Day 10
Secondary failure to respond : - failure to gain at least 5 g/kg/d for 3 consecutive days
During rehabilitation
PEM.
PEM.
Weight gain : = satisfactory: > 10 g/kg/d = sufficient : 5-10 g/kg/d = poor : < 5 g/kg/d or
PEM.
= Dietary advice :
- high protein and calorie - frequent feeding ( 5x/d ) - finish all meals given - vit-min supplementation & electrolytes - continue BF
5. Emergency :
5.1. Shock :
N2 or RLG5% 15 ml/kg, 1 hr
Improvement
+
Repeat 1 hr more Resomal 10 ml/kg, 10 hrs Special formula
_
sepsis
5. Emergency :
5.2. Severe anaemia.
Hb ?
Hb < 4 g/dl Hb 4-6 g/dl
Resp.distress/heart failure? _ +
PRC 10 ml/kg* Observation
PEM.
7 yrs, 10 kg Recovery : 16 kg