Protein Energy Malnutrition: Incidence of Protein – Energy malnutrition amongst children aged 0-5.
Background of Study
Protein energy malnutrition describes severe malnutrition resulting from dietary inadequacy of protein or calories or both and indicates interdependence of the two (Ellis and Mitchell, 2000).
Protein energy malnutrition (PEM) is a potentially fatal body depletion disorder. It can also be referred to as protein calorie malnutrition.
According to Kessler and Dawnson, (1999), PEM is seen as the leading cause of death in children in developing countries.
Protein energy malnutrition according to Makara and Sains (2003) have been considered a range of pathological conditions arising from a coincident lack of varying proportion of proteins and calories. It develops in children whose consumption of protein and energy (Measured by Calorie) is insufficient to satisfy their nutritional needs.
In general, a diet predominantly deficient in calories will cause marasmus while a deficiency of mainly protein will lead to kwashiorkor but the two deficiencies usually occur together in varying degree and may result in syndromes having some features of both marasmus and kwashiorkor.
UNICEF (1998) estimates that over a 1/3 of the world’s children suffer some degree of malnutrition. Many forms of micronutrient deficiency exists. e.g Rickets, scurvy but the commonest is the general deficiency of all foods and the commonest term for the condition is protein-energy malnutrition. (PEM)
In developing countries, it is noted that PEM is the major cause of morbidity and mortality amongst children under 5years in developing countries. (Chandra et al., 1991). It slows down growth rate.
According to the World Health Organization (WHO 2000), it was estimated that malnourished children numbered 181.9 million, in 32% of developing countries. In addition, an estimated 149.6 million children younger than 5 years are malnourished when measured in terms of weight for age.
In South Central Asia and Eastern Africa, about half of the children have growth retardation due to protein energy malnutrition. This figure is five times the prevalence in the western world (WHO 2000).
Since the mid 1980’s, the Administrative Committee on Coordination/ Sub-Committee on Nutrition (ACC/SCN) of the United Nations periodically have examined the trends of malnutrition in the world’s children. In its third report on the world nutrition status, this committee using the data from 61 countries estimated the trends in stunting with two or more nationally representative survey. In this period (1980-1995) stunting declined globally at a rate of 0.54 percentages per year.
The sub Saharan Africa had an increase of 0.130 percentage point per year in the average prevalence of stunting. The remaining region of the world showed statistically significant decrease that ranged from -0.26 in Middle America and Caribbean to -0.90 in South East Asia.
Recent estimate about protein-energy malnutrition distribution at a worldwide level were compiled by the World Health Organization (WHO) programme on child growth and malnutrition. This data base covered 95 percent of the total population of children under age 5 who lived in 103 developing nations in 1995, as was reported in nationally representative survey available at that time.
According to the above data an estimated 206.2 million children, who represented 38 percent of all children under 5 years were stunted (low weight for age), 167.3 million children (31 percent). Were under weight (low weight for age) and 48.8 million children (9 percent) were wasted (low weight for height). (Onis and Blossner, 2005).
William (2007) noted some factors that make children susceptible to Protein Energy Malnutrition. These include but not limited to:
Inadequate food intake which could be secondary to insufficient or inappropriate food supplies, early ceasation of breast feeding, cultural and religious food customs, inadequate sanitation.
The most common forms of PEM are Kwashiorkor, Marasmus and Marasmic kwashiorkor and each of these forms present with different signs and symptoms which include anemia, diarrhea and weight loss.
All these tend to alter and slow down the physiological and immunological system of the children.
Treatment according to Brookes (1999) is designed to provide adequate nutrition, Restore normal body composition and Cure the condition that caused the deficiency.
The problem is that in most of the developing countries, these malnourished children are denied of the adequate nutrition and the resultant effect is death.
Chandra and Lancet (1983) review the initial work on interaction between nutrition and immunity which was carried out in young children with PEM and it was found out that infection and malnutrition were invariably linked together, each aggravating the other. All effort should therefore be geared towards preventing infection in children.
PEM is seen as a major cause of some detrimental effects on children therefore must be regarded as important index of nutritional standards in developing areas in the world. Their eradication depends on improving the stable diet and weaning habits in the areas where they are prevalent, support and encouragement of breast feeding proper care and handing of baby food and adequate health education to mothers about infant nutrition.
Statement of Problem
The benefit of good nutrition during a child formative years cannot be over emphasized. Lack of adequate nutrition can affect a child’s growth and development which include skills and functional capacity. Protein Energy Malnutrition possesses problems that affect children the most because they have less protein intake. The few rare cases found in the developed world are almost entirely found in small children as a result of fat diets or ignorance of the nutritional needs of children particularly in cases of milk allergy. (Howard, Macini, Weston, Drolet, Esterly. 2001).
Protein malnutrition is detrimental at any point in life but it prenatally has been shown to have significant life long effects. During pregnancy, one should aim for a diet that consist at least 20% protein for the health of the fetus.
During the course of the researchers posting in pediatric ward at the Federal Teaching Hospital, Abakaliki Ebonyi State, quite a number of children presented with protein energy malnutrition. This was the case despite increasing health education and counseling given at the antenatal and infant clinics.
This prompted the researcher to investigate the incidence of protein-energy malnutrition amongst children of ages 0-5years admitted into pediatrics ward at Federal Teaching Hospital Abakaliki, Ebonyi State.
Purpose of the Study
To determine the incidence of protein-energy malnutrition amongst children 0-5years admitted in Federal Teaching Hospital Abakaliki from 2009-2013.
Specific Objective of Study
· To determine the forms of malnutrition that mostly affect the children
· Ascertain number of new cases of PEM among the children
· To identify the age group mostly affected
· To determine the factors influencing the development of protein energy malnutrition among the children 0-5 years treated at Federal Teaching Hospital Abakaliki from August 2009- August 2013.
Significance of Study
· This study will provide information to mothers who have children between ages 0-5 years on how to prevent protein energy malnutrition.
· Information gotten during the study will increase the researchers knowledge on the subject and other related issues
· This study will stimulate further researches in the subject which might lead to more sensitization on the need for effective methods of prevention of the condition and this will add to the growth and development of nursing profession.
· What are the forms of protein-energy malnutrition that mostly affect children?
· What is the number of new cases of the disease?
· What age group is mostly affected?
· What are the factors influencing the development protein-energy malnutrition among the children ages 0-5 years treated at Federal Teaching Hospital Abakaliki from August 2009 – August 2013.
Scope of the Study
The study is delimited to children ages 0-5 years who were admitted with protein energy malnutrition into the pediatrics ward at the Federal Teaching Hospital Abakaliki from August 2009 – August 2013.
Operational Definition of Terms
Incidence: – This is the extent to which something happens or has effect. In this study, incidence include how many cases presented at Federal Teaching Hospital during the four years period, age group mainly affected, forms of malnutrition commonly seen and causes.
Protein-Energy Malnutrition: – This is malnutrition resulting from dietary inadequacy of protein or calories or both for the purpose of this research, the forms of PEM are Marasmus, Kwashiorkor and Marasmic kwashiorkor.
Marasmus:- This is deficiency of both calorie and protein leading to manifestations of signs and symptoms. E.g. Growth failure i.e. stunted growth, wasting body muscles, little old man’s appearance. In this study, a child with these signs and symptoms and diagnosed marasmus is included.
Kwashiorkor:- This is a deficiency of protein nutrition leading to manifestations of signs and symptoms e.g Growth retardation, pitting oedema, hair colour changes, skin hyperpigmented and superadded infection. In this study, a child with these signs and symptoms and diagnosed kwashiorkor is included.
Marasmic Kwashiorkor:- This is a marked protein deficiency and marked calorie insufficiency leading to manifestation of signs and symptoms of both kwashiorkor and marasmus.
Predisposing Factors:- This is an element that cause or contribute to the occurrence of a disorder and for the purpose of this work, it includes such factors as inadequate food intake, inadequate breastfeeding, ineffective weaning, poverty and ignorance etc.
Limitations of Study
In the course of the study, the following problems were encountered:-
v Difficulty in accessing information from the available data
v Lack of time for data collection
In this chapter, relevant literature are reviewed under the following headings
Definition of protein energy malnutrition, Incidence of protein energy malnutrition, Types/classifications of PEM, Effects of PEM, Diagnosis of PEM and Prevention of PEM.
Conceptual/Theoretical frame work
Summary of literature review
Definitions of PEM: According to Jelliffe, 2004, protein-energy malnutrition applies to a group of related disorders that include marasmus, kwashiorkor and intermediate states of marasmus-kwashiorkor.
Jelliffe discovered this condition in the early 1920’s in most developing countries with increase frequency in hospitalization and chronically in children.
Mark (2004) sees protein-energy malnutrition as a syndrome characterized by its progressive on set and a series of symptoms and signs that encompass a continuum, ranging from clinically undetected manifestations to a full blown clinical picture of marasmus or kwashiorkor. It is the most common form of nutritional deficiency among patients who are hospitalized in the United States.
The World Health Organization (WHO, 2002) defines malnutrition as the cellular imbalance between the supply of nutrient and the body demand for them to ensure growth maintenance and specific function.
Protein-energy malnutrition is a potentially fatal body-depletion disorder. It can also be referred to as protein-calorie malnutrition.
Ellis and Mitchell (2000), defines PEM as severe malnutrition resulting from dietary inadequacy of protein or calories or both. It is considered a range of pathological conditions arising from a coincident lack of varying proportions of proteins and calories (Makara and Sain, 2003).
Incidence of Protein-Energy Malnutrition
In 2000, the World Health Organization (WHO) estimated that malnourished children numbered 181.9 million, 32% in developing countries. In addition, an estimated 149.6 million children younger than 5 years are malnourished when measured in terms of weight for age.
In South Central Asia and Eastern Africa, about half the children have growth retardation due to protein-energy malnutrition. This figure is five times the prevalence in the Western World (WHO, 2000).
In a survey in a large children hospital in the United State, the prevalence of acute and chronic protein-energy malnutrition was more than half. In a different survey focusing on low income areas of the United State, 22-35% of children aged 2-6 years were below the 15th percentile for weight. Poor growth is seen in 10% of children in rural population. (Mark, 2004).
It was noted in a study in 1979 among 42 children with marasmus, investigators found out that only those children with low serum level of zinc developed skin ulcerations. (Williams et al 2007).
Since the mid 1980’s, the administrative committee on cordination/sub-committee on nutrition (ACC/SCN) of the United Nations periodically have examined the trends of malnutrition in the world’s children and from the data gotten by this committee from 61 countries, estimated the trends of stunting which is as a result of malnutrition. In this period (1980-2004) stunting declined globally at a rate of 0.54 percentages per year.
In 1998, UNICEF estimated that over a 3rd of the world’s children suffer some degree of malnutrition and therefore described malnutrition as the commonest worldwide problem affecting children.
In the developing countries, infection occurring with malnutrition is a major cause of morbidity in all age groups and is responsible for two-thirds of all death under 5 years of age. (Chandra and Clin, 1991).
In Nigeria, it was estimated that about hundred percent of the children admitted at the University of Benin Teaching Hospital were admitted for malnutrition (Akpe, 2010).
A similar research was also carried out in Benue State, Nigeria on the prevalence of PEM among children 0-5 years and it was noted that 41.6% of children were found to have low weight for height while 54.8% of the malnourished children belong to mothers who were illiterates (Abidoye and Sikabofori, 2000).
Types/Classifications of PEM
The 3 major types of protein-energy malnutrition are:-
Kwashiorkor: – This is the deficiency intake of both proteins and calories but protein lack is more predominant.
It is an acute form of childhood protein-energy malnutrition characterized by edema, irritability, anorexia, ulcerating dermatoses, and an enlarged liver with fatty infiltrates. The presence of edema caused by poor nutrition defines kwashiorkor (Ciliberto, Briend, Ashorn, Bier, Manary, 2005). Kwashiorkor was thought to be caused by insufficient protein consumption but with sufficient calorie intake, distinguishing it from marasmus.
SIGNS AND SYMPTOMS
The defining sign of kwashiorkor in a malnourished child is pedal edema (swelling of the feet). Other signs include a distended abdomen, an enlarged liver with fatty infiltrates, thinning hair, loss of teeth, skin depigmentation and dermatitis. Children with kwashiorkor often develop irritability and anorexia (Ciliberto et al; 2005).
There are various explanations for the development of kwashiorkor and the topic remains controversial (Krawinkel, 2003) It is now accepted that protein deficiency, in combination with energy and micronutrient deficiency, is necessary but not sufficient to cause kwashiorkor. The condition is likely due to deficiency of one of several types of nutrients (e.g., iron, folic acid, iodine, selenium, vitamin C), particularly those involved with anti-oxidant protection. Important anti-oxidants in the body that are reduced in children with kwashiorkor include glutathione, albumin, vitamin E and polyunsaturated fatty acids. Therefore, if a child with reduced type one nutrients or anti-oxidants is exposed to stress (e.g. an infection or toxin) he/she is more liable to develop kwashiorkor.
Ignorance of nutrition can be a cause. Dr. Latham (2003), director of the Program in International Nutrition at Cornell University cited a case where parents who fed their child cassava failed to recognize malnutrition because of the edema caused by the syndrome and insisted the child was well-nourished despite the lack of dietary protein.
One important factor in the development of kwashiorkor is aflatoxin poisoning. Aflatoxins are produced by molds and ingested with moldy foods. They are toxified by the cytochromeP450 system in the liver, the resulting epoxides damage liver DNA. Since many serum proteins, in particular albumin, are produced in the liver, the symptoms of kwashiorkor are easily explained. It is noteworthy that kwashiorkor occurs mostly in warm, humid climates that encourage mold growth.
Protein should be supplied only for anabolic purposes. The catabolic needs should be satisfied with carbohydrate and fat. Protein catabolism involves the urea cycle, which is located in the liver and can easily overwhelm the capacity of an already damaged organ. The resulting liver failure can be fatal. This means in patients suffering from kwashiorkor, protein must be introduced back into the diet gradually.
Marasmus: This is the nutritional inadequacy of protein and calorie in diet. It is a form of malnutrition that arises most commonly in infants in the developing countries who are less than one year of age. It is an extreme type of emaciation and wasting resulting due to lack of protein and energy in the body.
The condition is mainly characterized by reduced weight gain. The rate of weight gain is lower than that of increase in height which creates a mismatch. Consequently, the head of affected children appear quite large than the rest of their body.
One of the most distinct features of this disorder is a progressive wasting of muscle and subcutaneous fat of the body. Due to this, there is a rapid decrease in the amount of body fat which makes the skin appear quite loose and the bones more prominent. Patients generally suffer from lethargy as their bodies attempt to conserve energy. Extreme hunger and irritability are two of the most common signs of wasting. Acute wasting for a prolonged duration may lead to permanent retardation.
The condition primarily results from a lack of essential nutrients, particularly protein, in the human body. Protein consists of polymers of amino acids which are important for the growth of animals as well as for the repair of tissues. The disease also arises due to an inability to digest nutrients properly. Both causes can result in malnutrition, a problem where the body does not receive enough protein and calories essential for its functioning and growth. Malnutrition, which is one of the most serious types of PEM in the world, can range from an inadequacy of some vitamins to complete starvation.
Maramus is commonly caused when an infant undergoes a transition from breast milk to other foods. As is known, breast milk is a wholesome food for babies and supplies them with all the essential nutrients needed for their survival and growth. Women often stop breastfeeding due to various reasons, which range from social pressure to an inability to develop milk. If breast milk is not followed up with a similar wholesome diet, Maramus can arise as a consequence.
The condition may also be caused due to acute and chronic infections, particularly in case of children who are already susceptible as a result of borderline malnutrition.
Some of the other major causes of this disease are:
· Early loss of mother, resulting in lactation failure without any alternative means for breastfeeding
· Long-term starvation as a part of medical treatment for diarrhea
· Lack of food
· Infective diarrhea, caused by the use of unsterilized feeding bottles.
Marasmic Kwashiorkor: – This is a marked protein deficiency and marked calorie insufficiency. It is a malnutrition disease, primarily of children resulting from the deficiency of both calories and protein. The condition is characterized by severe tissue wasting, dehydration, loss of subcutaneous fat, lethargy and growth retardation.
Other classifications are as follows
a. Pre-Kwashiorkor: This is a condition where the child manifest features of kwashiorkor without oedema. If managed early, the child is protected from full blown kwashiorkor.
b. Nutritional dwarfing: In this condition, the child present with significant low weight and height for age without any overt feature of kwashiorkor or marasmus (ParulDatta 2007).
c. Classification by Indian Academy of pediatrics
· Normal PEM
This occurs when a child is having weight more than 80% of expected weight for age.
· Grade I
This occurs when the child is having weight between 71-80% of expected weight for age.
· Grade II
This occurs when the child is having weight between 61-70% of expected weight for age.
· Grade III
This grade of malnutrition occurs when the child’s weight is between 51-60% of expected weight for age.
· Grade IV
This occurs in children with 50% or less of weight expected for that age.
In the above classifications, PEM is graded with reference to the weight for age as a percentage of the expected weight.
d. Classification by the World Health Organization, 2003
This classification according to WHO recommends three terms for assessing the magnitude of malnutrition in children under five years. The terms include:- Stunting, under weight and wasting.
· Stunting is defined as a child being below 2 Standard Deviation (SD) score from the median height for age of National centre for health statistic reference population (-3SD for severe stunting).
· Underweight is defined in a child below 2 Standard Deviation (SD) from the median weight for age of National centre for Health Statistics (NCHS) reference population. (3SD for severe underweight)
· Wasting is defined in a child below 2 Standard Deviation (SD) from median weight for height of National Centre for Health Statistics (NCHS) reference population. (3 SD for severe underweight).
e. Classification according to Mid Arm Circumference (MAC) (Gupta, 2007)
This is known as an age independent anthropometric criteria between the ages of 1 to 5 years. Mid Arm Circumference between the ages of 1 to 5 years should be more than 13.5cm. Those with a MAC of less than 12.5cm are considered malnourished. Children with MAC between 12.5cm and 13.5cm are termed borderline.
Effects of Protein-Energy Malnutrition
Protein-Energy Malnutrition has several effects on both the affected children and the country. Some of its effects include:-
· Increased Mortality Rate
Approximately 50% of 10 million deaths each year in developing countries occur because of malnutrition in children younger than 5 years. In kwashiorkor, mortality rate tends to decrease within increase in age (WHO 2000).
· Physical and Development Manifestation which include poor weight gain and slowing of linear growth.
· Impaired Immunity
Impaired immunological functions which mimic those observed in children with AIDS predispose them to opportunistic and other typical children infections.
· Behavioural Changes
Chronically malnourished children exhibit behavioural changes including irritability, apathy and decrease social responsiveness, anxiety and attention deficit.
· Cognitive Deficit
Infant and children who are malnourished frequently demonstrate cognitive deficit. The degree of delay depends on the severity and duration of nutritional compromise and the age at which malnutrition occurs.
Diagnosis of Protein-Energy Malnutrition
These are the areas to be assessed and for through examination to be performed when PEM is suspected. The areas include:-
· The use of Mid Arm Circumference (MAC)
· Body fat composition and muscle strength
· Eating habits and weight changes
· Presence of underlying illness
· Gastro intestinal symptoms
· Developmental delays and loss of acquired milestones in children
· Nutritional status through
v Comparing height and weight to standardized norms
v Calculating body mass index
v Measuring skin fold thickness.
Prevention of Protein-Energy Malnutrition
The prevention of malnutrition in children starts with emphasis on prenatal nutrition and good prenatal care
a) Health education should be given to:-
· Nursing mothers and expected mothers on the importance of breast feeding in the first year of life
· Parents on the appropriate introduction of nutritious supplementary foods
· Health care providers should continue to provide age appropriate nutritional counseling at every opportunity.
b) There should be improvement in hygienic practices and sanitation as this reduces the incidence of malnutrition
c) Promotion of programmes addressing micronutrient supplementation and fortification of certain food item as this have been successful in decreasing the incidence of specific micronutrient deficiencies e.g iodine, vitamin D.
A similar research carried out in Asia by Onis and Blossner 2005 using child growth and malnutrition revealed that about 95% of the total population of children under age 5 were malnourished.
Another research carried out by Akpe, 2010 using children admitted at the University of Benin Teaching Hospital revealed that about 100% of children were admitted for malnutrition.
Theoretical Frame Work
Erickson’s Development Theory (1902-1994).
This is found suitable to support this work because it involves biological adaptation to developmental crisis which is achieved through adequate nutrition.
Erickson proposed that life is in a sequence of developmental stages or levels of achievements. Each stage signals a task that must be accomplished. The resolution of the task can be complete, partial or unsuccessful.
He believed that the more successes an individual has at each developmental stage, the healthier the personality of the individual, failure to complete any developmental stage, influences the persons ability to progress to the next stage/level. These developmental stage can be viewed as a series of crisis which are the development crisis i.e expected life events that occurs in most individuals and situational crisis which occurs when specific external events upsets an individual psychological equilibrium.
Individuals are expected to adapt biologically, psychologically and socially to these crisis. Successful resolution of these crisis support healthy age development, failure to resolve the crisis damages the ego.
Biologically, one can adapt to crisis through good nutritional status, healthy environment etc. In the absence of adequate nutrition, the biology of the systems, organs, tissues of the body as well as the individual as a whole will be disrupted. An individual with a deviation in normal height and weight for age, deviation in body mass index and whose mid arm circumference also shows a deviation signals a deficit in biological development and therefore such individual will find it difficult to cope or handle biological crisis as well as crisis as a whole.
Malnourished children are not capable of handling biological crisis due to their poor biological development which turns out to reduce their ego as age progresses.
Erickson describes eight stages of development which reflects both positive and negative aspect of the critical life periods. Each stage has its own development task and the individual must find a balance between them.
These stages are:-
Trust versus mistrust
Autonomy versus doubt and shame.
Initiative versus guilty
Industry versus inferiority
Identity versus role confusion
Intimacy versus isolation
Generating versus stagnation
Ego integration versus despair
These eight stages of Erickson’s development theory are characterized by different conflict that must be resolved by the individual. When the environment makes new demand on people, conflict arises. The person is faced with a choice between two methods of coping with crisis which may be adaptive or maladaptive. It is only when each crisis is resolved that the person has sufficient strength to deal with the next stage of development.
If the person is not able to resolve the crisis, the person becomes fixated on one stage or regress to a previous stage under anxious or stressful condition.
Application to Study
The researcher applied this theory based on the various stages of development from infancy to pre school age. During infancy stage, satisfaction of a child’s basic needs which include nutrition, warmth, love, security in a consistent manner results in the proper developmental manifestations which helps to build up the child’s trust. If these needs are not met, especially the nutritional need, it predisposes the child to malnutrition, impaired immunological function, behavioural changes as well as cognitive deficit. The child seeing him/herself being/looking different in appearance from other children around, tend to isolate him/herself.
Unsuccessful accomplishment in one stage affects progress to the next stage leading to mal development of the child. Proper nutrition is therefore important to the development and upbringing of a child.
Summary of Literature Review
Various aspects of PEM were reviewed and it was noted that the most predominant ones are Kwashiorkor, Marasmus and Marasmic kwashiorkor.
Most of the literature reviewed pointed out that Protein Energy Malnutrition is a common worldwide problem affecting children. It was also reviewed that millions of people on every generation from rural areas of the developing countries who live in poverty suffer from malnutrition.
The predisposing factors were reviewed and it was noted that the children in the rural, poor families and those children who had faulty weaning as a result of ignorance suffered it most.
The various forms of prevention of malnutrition were also reviewed with health education to mothers as one of the important aspects.