PEDIATRIC NURSING

1. Presented by
Ms Arifa T N,
Second year M.Sc Nursing, MIMS CON

2. Introduction

3. Introduction
 Protein-energy Malnutrition (PEM) is the terminology
used for all kind of malnutrition as result of lack of
protein and energy foods.
 Major public health problem in India
 Particularly in children younger than 5 years old
 The most extreme forms of malnutrition, or (PEM),
are Kwashiorkor and Marasmus

4. Introduction
Severe acute malnutriton (SAM)
 Edematous (kwashiorkor),
 Severe wasting (marasmus)
 Marasmic kwashiorkor (features of both marasmus and
kwashiorkor

5. Definition
A group of clinical conditions that may result
from varying degree of protein deficiency and
energy (calorie) inadequacy.
 Previously it was known as protein calorie
malnutrition.

6. Incidence
 Leading cause of mortality and morbidity
 Susceptible to infectious diseases
 Incidence of malnutrition in India and Africa are high
 30-40% children younger than 5 years
 7.6% have severe malnutrition


8. Causes and risk factors
 Age
 Children between 6 months-4 years are in risk
 Sex
 Boys are more
 Too many children in the same family (neglect)
 Lack of spacing between children
 Low birth weight baby
 Twin and multiple births
 Poor growth in the first few months
 Mother’s failure to beast feed
 Systemic disorders or GI structural disorders

9. Causes and risk factors
 Failure or stoppage of breast feeding
 Delay in weaning
 Infectious diseases
 Diarrhea
 ARI
 Measles
 Chronic diseases and certain congenital disorders
 Failure to thrive, CHD, Growth Retardation
 Lack of adequate care for the pregnant women
 Acute illness or surgery

10. Risk factors
 LBW
 Multiple birth
 Not breast fed
 High birth order
 Congenital defects poor socioeconomic background
 Single parents / orphans/ foster home
 Maternal deprivation

11. Classification
 According to severity
 Mild PEM
 Weight <3rd percentile for their age but above the -3 SD
 Growth curve flat tend to point downwards
 Moderate PEM
 Weight are equal to or below the -3 SD line but above the -4 SD
 No edema , skin or hair changes
 alert and appetite is normal
 Severe PEM
 Weight are equal or below the -4 SD
 Marasmus and Kwashiorkor

12. Classification
 IAP classification

15. Syndromal classification
 Kwashiorkor
 Nutritional marasmus
 Prekwashiorkor
 Nutritional dwarfing

16. KWASHIORKOR
 First descried by Dr Cicely Williams in 1933
 Term ‘Kwashiorkor’ was introduced in 1935
 ‘Red boy’ due to characteristics of pigmentary
changes
 Mainly found in preschool children or may at any age
 Infection precipitates
 Deficient intake of both protein and calories (
protein deficiency are more predominant)

17. Features
Essential
•Marked growth
retardation
•Muscle wasting
•Psychomotor changes
•Pitting edema
Non essential
•Hair change (flag sign)
•Skin changes
•Super added infections

18. Grading
Grade I:Pedal oedema
Grade II: grade I+ facial puffiness
Grade III: grade II + oedema of the chest wall and the
paraspinal area
Grade IV: grade III + ascites

19. MARASMUS
 Also termed as infantile atrophy or athrepsia
 Common infants may found in toddlers and even in later
life
 Deficient intake of both protein and calories ( calorie
deficiency are more predominant)
 Looks likes looks like old person with wizened and
shrivelled face due to loss of buccal pad of fat.
 Initially the child is irritable, hungry and craves for food
 Later stages may become miserable, apthetic and refusal to
take anything orally.

20. Features
Essential
•Marked growth
retardation
•Muscle wasting
•Marked stunting and
absence of edema
Non essential
•Hair change
(hypopigmented)
•Skin changes : dry, scaly
•Liver shrunk
•Crave for food
•Psychomotor changes
•Mineral deficiencies

21. Grading of marasmus
 Grade I: loss of subcutaneous fat in the axilla and groin
 Grade II: grade I + loss of abdominal fat and fat in the
gluteal region
 Grade III: grade II + loss of fat in the chest wall and the
praspinal region
 Grade IV : grade III + loss of the buccal pad of fat

24. Marasmic kwashiorkor
 It is condition where the child manifested both the
features of marasmus and kwashiorkor.
 The presence of edema is essential for the diagnosis
and other featurs of kwashiorkor may or may not
present

25. Prekwashiorkor
 It is a condition when the child is having features of
kwashiorkor without edema.
 If the early management is initiated by early diagnosis
of the condition
 The child may be protected from full-blown
kwashiorkor

26. Nutritional dwarfing
 It is condition when the child is having significant low
weight and height for the age without any overt
features of kwashiorkor or marasmus
 It is usually seen when the PEM continue over a
number of years

27. Assessment
 Nutritional assessment
 History
 Clinical findings
 24 hour retrospective dietary recall
 Societal and environmental assessment
 Growth chart
 Anthropometric measurement compare with
population standard

28.  Lab findings
 Serum albumin
 Transferrin
 Prealbumin
 Albumin globulin ratio (decr )
 Creatinine high index
 Nitrogen balance (protein anabolism and catabolism)
 Blood glucose level
 Blood urine and rectal swab cultures
 Mantoux’s test
 Microscopic examination of urine or stool

29. Management of PEM
 Multidisciplinary approach
 Aim
 To supply what has been lacking in diet
 To prevent and treat infections and other diseases
 To teach parents how to prevent relapse

30. Management of PEM
 Domiciliary management
 Managed at home
 Parents are educated about dietary management
 Nutritional counselling and demonstration
 Less expensive locally available food
 Community support system ( supervision)
 Home visit
 Medical follow up ( weight monitoring )

31.  Management at hospital
 Needed at advance cases
 Mild PEM
 Rule out infections
 Provide nutritional counselling to parents
 Replace nutrients and breast feed till 2 years of age, with
the introduction of supplementary feeding at 4-5
months
 Immunization
 Parents counselling and education

32. Moderate PEM
 Admit to hospital
 Treat underlying cause or problems
 Diet is the most important part of treatment
 Provide a reinforced milk diet
 Teach preparation of milk diet

33. Severe PEM
 Hospitalization
 Watch for complications
 Dietary treatment
 4 gm /kg protein
 Marsmus 150-200 kcal/kg per day
 Kwashiorkor 100 kcal /kg per day
 Reinforced milk or high calorie cereal milk can be given
 Children should be Fed with milk diet at the ratio of 125 ml/kg/ day
 Prevent hypoglycemia
 NG tube feeding
 Gradually increase the feed
 Schedule 8 feeds per day
 Supplement minerals and vitamin
 Treat infections

34. Complications
 Acute
 Systemic local infections
 Severe dehydration
 Shock
 Dyselectrolytemia
 Hypoglycemia
 Hypothermia
 CCF
 Bleeding disorders
 Hepatic dysfunction
 SIDS
 Convulsions
 Long term
 Cachexia
 Growth retardation
 Mental sub normalities
 Visual and learning
disabilities

35. Prevention
 Health promotion
 Specific protection
 Early diagnosis and treatment
 Rehabilitation

36. Nursing management
 Assessment
 History
 Physical examination
 Assessment of G&D
 Nutritional assessment
 Lab investigations

37. Nursing diagnosis
 Imbalanced nutrition less than body requirement
 Fluid and electrolyte imbalance
 Risk for infection
 Potential for complications
 Knowledge deficit
 Parental anxiety
 Body image disturbances

38. Interventions
 Contribute your points ………….

39. Evaluation
 The child regains weight as expected
 No infection and edema