Explore a comprehensive 10-step approach to effectively treating protein-energy malnutrition (PEM) in individuals of all ages. From screening and assessment to nutritional rehabilitation and psychosocial support, this presentation offers practical insights and evidence-based strategies for healthcare professionals and communities to combat PEM and promote holistic recovery.

1. 10 Step Approach To
PEM Treatment
by Sunidhi Singh
IM 434

2. Treatment of PEM:
• Varies depending on the type of malnutrition.
• The basic strategy for treatment includes, first of all treatment of life
threatening conditions. Then restoring the nutritional status.
And then, ensuring nutritional rehabilitation.
The WHO has provided a 10 stepped guideline for the treatment of
PEM.
All the 10 steps are carried out in 2 phases: stabilisation and
rehabilitation.

4. 10 steps of treatment:
1. Prevent/treat hypoglycemia
2. Prevent/treat hypothermia
3. Prevent/treat dehydration
4. Correct electrolyte imbalance
5. Prevent/treat infection
6. Correct micronutrient deficiencies
7. Start cautious feeding
8. Achieve catch-up growth
9. Provide sensory stimulation and emotional support
10.Prepare for follow-up after recovery

5. Step 1 & 2: Prevent/treat hypoglycemia and
hypothermia
• blood glucose < 3.3mmol/l
• axillary/rectal temperature <35c; cold hands and feet
• hypoglycemia and hypothermia usually occur together.
• Treatment: 5ml/kg of 10% Glucose given through IV (in case of severe severe
hypoglycemia)
Followed by f-75 starter formula orally or NGT.
Two hourly feeds for the first day.
• keep the child warm and dry. Use warm blanket and/or heater.
• put the child on mother’s bare breast and cover them.
• monitor body temperature and glucose level every two hours.

6. Step 3: dehydration
• correct dehydration according to severity.
• Special solution is used for dehydrated malnourished children -
ReSoMal. standard WHO solution is not given becuase of too much
sodium
• 5ml/kg every 30 mins for 2 hours.
• continue feeding F-75
• observe stool, vomit and urine frequency for the next 2 hours.
• for prevention, feed F-75 formula and provide ReSoMal after each
stool

7. Step 4: electrolyte imbalance
• excess sodium, with low potassium and magnesium. Edema can be
seen.
• Treatment is with F-75. Oral potassium of 4mmol/kg/day and
magnesium .4 to .6 mmol/kg/day.
• prepare meals without salt.
• electrolyte imbalance takes 2 weeks for correction
• dont use diuretic for edema

8. Step 5: Infection
• signs are often hidden.
• all malnourished children should be treated with a broad spectrum
antibiotic
• Vitamin A
• penicillin for oral thrush, metronidazole for intestinal bacteria,
tetracycline for eye infection like pus and ulceration.
• amoxycillin for severely ill child.
• Mealses vaccine for children less than 6 months

9. Step 6: Micronutrient deficiency
• all sevrely malnourished children have vitamin deficiencies.
• Vitamin A on day 1.
• >6 months, 50000 IU
• 6-12 months, 100000 IU
• >12 months, 200000 IU
• folic acid 1 mg/day.
• multivitamins
• Zinc (2mg/kg/day) and copper (.3mg/kg/day)
• iron only when child is gaining weight
• should be given for atleast 15 days.

10. Step 7: cautious feeding
• Start feeding as soon as possible after admission.
• F-75 starter 100-130 ml/kg/day orally
• low osmolarity and low lactose feeds orally
• protein 1-1.5g/kg/day
• calories 100kcal/kg/day
• continue breastfeeding

11. Step 8: rebuild tissues and catch up growth
• start of weight gain, return of appetite are signs of rehabilitation
phase.
• replace the starter formula with catch up formula, for 2 days.
• increase the amount every day by 10 ml/kg/day
• target weight gain: >10g/kg/day

12. Step 9: provide sensory stimulation
• malnutrition can cause delayed physical and mental development.
• therefore it is important to provide:
• loving care
• toys/play therapy
• physical activity
• maternal involvement

13. Step 10: Prepare for follow up after recovery
• 90 percent weight to height is considered ready for discharge.
• good feeding, hygiene and sensory stimulation should be continued
at home.
• ensure the immunizations are regularly given. Booster doses are
given.
• Vitamin A every 6 months.
• follow up check ups in the hospital should take place at regular
intervals.