Protein Energy Malnutrition & Intestinal Obstruction in Children
Comprehensive nursing notes for clinical practice and education
Table of Contents
Protein Energy Malnutrition (PEM)
Definition: Protein-Energy Malnutrition (PEM) is a form of malnutrition characterized by inadequate protein and energy intake, resulting in wasting, stunting, or both. It primarily affects children in developing countries and is a significant cause of childhood morbidity and mortality.
Classification of PEM
Marasmus
- Severe energy deficiency
- Characterized by severe wasting
- Weight <60% of expected for age
- “Skin and bones” appearance
- Alert and irritable
Kwashiorkor
- Protein deficiency with adequate calories
- Characterized by edema
- Fatty liver and skin changes
- Hair changes (flag sign)
- Apathetic and irritable
Marasmic Kwashiorkor
- Combined features of both
- Severe wasting with edema
- Highest mortality rate
- Most severe form of PEM
- Multiple deficiencies present
Etiology and Risk Factors
Clinical Features Comparison
| Feature | Marasmus | Kwashiorkor |
|---|---|---|
| Age of onset | 6-18 months | 18-36 months |
| Edema | Absent | Present (pitting) |
| Weight | <60% expected | 60-80% expected |
| Muscle wasting | Severe | Moderate, masked by edema |
| Subcutaneous fat | Severely reduced | Reduced but masked by edema |
| Hair changes | Dull, thin | Depigmented, easily pluckable (“flag sign”) |
| Skin changes | Dry, wrinkled | Flaky paint dermatosis, hyperpigmentation |
| Fatty liver | No | Yes |
| Mental state | Alert, irritable | Apathetic, irritable |
| Appetite | Good | Poor |
Pathophysiology
Assessment and Diagnosis
Anthropometric Measurements
- Weight for age
- Height/length for age
- Weight for height/length
- Mid-upper arm circumference (MUAC)
- BMI for age (for older children)
Clinical Signs
- Edema (bilateral pitting)
- Muscle wasting
- Hair changes
- Skin lesions
- Hepatomegaly
- Mental status changes
Laboratory Findings
- Low serum albumin and total protein
- Anemia
- Electrolyte abnormalities
- Hypoglycemia
- Reduced immune markers
- Elevated liver enzymes (in kwashiorkor)
Mnemonic: “WASTED” for Signs of Malnutrition
- W – Weight loss (severe)
- A – Atrophy of muscles
- S – Skin changes (dry, flaky, or with dermatosis)
- T – Temperature irregularities
- E – Edema (in kwashiorkor)
- D – Development delays (physical and cognitive)
Management of PEM
Important: Treatment of severe PEM is a medical emergency requiring a phased approach to prevent refeeding syndrome and other complications. The WHO guidelines outline a systematic approach.
WHO 10-Step Treatment Protocol
Phase 1: Initial Treatment (Stabilization)
- Treat/prevent hypoglycemia
- Treat/prevent hypothermia
- Treat/prevent dehydration
- Correct electrolyte imbalances
- Treat/prevent infection
- Correct micronutrient deficiencies
- Begin cautious feeding
Phase 2: Rehabilitation
- Increase feeding to recover lost weight (catch-up growth)
- Stimulate emotional and sensorial development
- Prepare for discharge and follow-up
Nutritional Rehabilitation
| Phase | Formula | Caloric Density | Duration | Goals |
|---|---|---|---|---|
| Initial (F-75) | Low protein, low energy | 75 kcal/100ml | 3-7 days | Metabolic stabilization |
| Transition | Intermediate | 100 kcal/100ml | 2-3 days | Testing readiness for rehabilitation |
| Rehabilitation (F-100) | High protein, high energy | 100 kcal/100ml | 2-6 weeks | Rapid weight gain (10-15g/kg/day) |
| RUTF | Ready-to-use therapeutic food | 520-550 kcal/100g | Variable | Outpatient rehabilitation |
Nursing Management
Assessment & Monitoring
- Daily weight monitoring
- Intake and output records
- Vital signs (every 4-6 hours)
- Signs of refeeding syndrome
- Monitor for infections
- Developmental assessment
Interventions
- Administer prescribed feeds
- Nasogastric feeding if necessary
- Administer prescribed medications
- Skin care and wound management
- Prevent hypothermia (Kangaroo care)
- Sensory stimulation and play
Education & Support
- Parent education on nutrition
- Feeding techniques and schedules
- Hygiene and infection prevention
- Developmental stimulation
- Community resource connection
- Follow-up care planning
Complications of PEM
Prevention Strategies
Individual Level
- Exclusive breastfeeding for first 6 months
- Appropriate complementary feeding after 6 months
- Continued breastfeeding up to 2 years
- Regular growth monitoring
- Prompt treatment of infections
- Micronutrient supplementation
Community/Policy Level
- Food security programs
- Economic development initiatives
- Education and awareness campaigns
- Clean water and sanitation
- Immunization programs
- Community-based management of acute malnutrition (CMAM)
Intestinal Obstruction in Children
Definition: Intestinal obstruction is a complete or partial blockage of the small or large bowel that prevents the normal passage of intestinal contents. In children, it presents unique challenges due to their developing anatomy and varied etiology based on age groups.
Classification of Intestinal Obstruction
By Type
Mechanical
- Due to physical blockage
- Can be complete or partial
- May lead to strangulation
Functional (Paralytic Ileus)
- No physical blockage
- Impaired intestinal motility
- Often secondary to other conditions
By Location
Small Bowel Obstruction
- Earlier, more severe vomiting
- Central abdominal pain
- May have minimal distention
Large Bowel Obstruction
- Later onset of vomiting
- Significant abdominal distention
- May present with constipation
By Onset
Acute
- Sudden onset
- Rapid progression
- Often emergency situation
Chronic/Recurrent
- Gradual or intermittent
- May have periods of improvement
- May progress to acute obstruction
Etiology by Age Group
| Age Group | Common Causes | Key Features |
|---|---|---|
| Neonates (0-1 month) |
Intestinal atresia Meconium ileus Malrotation with volvulus Hirschsprung’s disease Imperforate anus | Often congenital, presents early, may be associated with other anomalies |
| Infants (1-12 months) |
Intussusception Incarcerated hernia Pyloric stenosis Hirschsprung’s disease Adhesions (if previous surgery) | May present with irritability, lethargy, vomiting, sometimes bloody stool |
| Toddlers (1-3 years) |
Intussusception Foreign body ingestion Incarcerated hernia Adhesions Meckel’s diverticulum | May present with intermittent abdominal pain, vomiting, abdominal distention |
| Older Children (4-12 years) |
Adhesions Appendicitis Foreign body Meckel’s diverticulum Inflammatory bowel disease | Better able to communicate symptoms, may have history of previous surgery |
| Adolescents (13-18 years) |
Adhesions Crohn’s disease Malignancy Endometriosis (females) Appendicitis | Similar to adult patterns, chronic conditions more common |
Common Causes in Detail
Intussusception
Telescoping of one segment of intestine into another, usually ileocolic.
- Peak age: 6-18 months
- Classic triad: colicky abdominal pain, vomiting, “currant jelly” stools
- May feel sausage-shaped mass in RUQ
- Often idiopathic in children; may follow viral illness
- Diagnosis: Ultrasound (target or donut sign)
- Treatment: Air/hydrostatic enema reduction; surgery if enema fails
Malrotation with Volvulus
Abnormal rotation of intestine during fetal development with subsequent midgut twisting.
- Most present in first month of life
- Bilious vomiting is the hallmark symptom
- Surgical emergency – can lead to bowel ischemia
- May be associated with other congenital anomalies
- Diagnosis: Upper GI series (corkscrew appearance, abnormal duodenal position)
- Treatment: Emergency surgery (Ladd’s procedure)
Intestinal Atresia/Stenosis
Congenital absence or narrowing of a portion of the intestine.
- Presents in neonatal period
- Duodenal atresia associated with Down syndrome
- Bilious vomiting, abdominal distention
- May be detected on prenatal ultrasound
- Diagnosis: X-ray (double bubble sign in duodenal atresia)
- Treatment: Surgical repair
Hirschsprung’s Disease
Congenital absence of ganglion cells in the distal colon.
- Failure to pass meconium within 48 hours of birth
- Chronic constipation, abdominal distention
- May present as enterocolitis (emergency)
- More common in males and Down syndrome
- Diagnosis: Rectal biopsy (absence of ganglion cells)
- Treatment: Surgical resection with pull-through procedure
Pathophysiology
Mechanical Obstruction
- Physical blockage prevents intestinal contents from passing
- Fluid and gas accumulate proximal to obstruction
- Bowel distends → increased pressure → decreased blood flow
- Bacterial overgrowth in stagnant fluid
- Prolonged obstruction → bowel wall ischemia → perforation
- Fluid sequestration → hypovolemia → shock if untreated
Strangulating Obstruction
- Obstruction plus compromised blood supply
- Venous congestion occurs first → edema
- Arterial occlusion follows → ischemia → necrosis
- Bacterial translocation into circulation
- Toxic metabolites released from damaged bowel
- Can rapidly progress to septic shock and death
Consequences of Obstruction
Local Effects
- Bowel dilation and edema
- Mucosal damage and bleeding
- Ischemia and potential necrosis
Systemic Effects
- Fluid and electrolyte imbalances
- Hypovolemia and acidosis
- Systemic inflammatory response
- Bacterial translocation → sepsis
Clinical Presentation
Mnemonic: “7 P’s of Intestinal Obstruction”
Pain – Colicky, intermittent abdominal pain
Projectile vomiting – Often bilious with distal obstruction
Protuberance – Abdominal distention
Peritonitis – Signs of peritoneal irritation in advanced cases
Peristaltic waves – Visible in thin children
Poor passage of stool – Constipation or obstipation
Perils – Shock, dehydration, electrolyte imbalances
| Clinical Feature | Small Bowel Obstruction | Large Bowel Obstruction |
|---|---|---|
| Pain | Periumbilical, colicky, frequent | Lower abdominal, less frequent |
| Vomiting | Early, profuse, often bilious | Later onset, may be feculent |
| Distention | Moderate, central | Marked, more peripheral |
| Bowel movements | May continue until distal bowel empties | Early obstipation |
| Dehydration | More rapid, severe | Less rapid |
| Bowel sounds | Initially hyperactive, high-pitched | May be normal initially |
Diagnostic Evaluation
History & Physical Examination
Key History Elements
- Onset and character of pain
- Vomiting (bilious or non-bilious)
- Last bowel movement
- Previous abdominal surgeries
- Medical conditions
Physical Examination
- Vital signs (fever, tachycardia)
- Hydration status
- Abdominal distention
- Bowel sounds (hyperactive/absent)
- Tenderness, masses, hernias
- Rectal examination
Laboratory Studies
Basic Studies
- Complete blood count
- Electrolytes, BUN, creatinine
- Liver function tests
- Amylase, lipase
- Urinalysis
Specific Findings
- Leukocytosis (infection/inflammation)
- Hypokalemia, hypochloremia (vomiting)
- Elevated BUN/Cr (dehydration)
- Metabolic acidosis (ischemia)
- Elevated lactate (bowel ischemia)
Imaging Studies
Initial Imaging
- Abdominal X-ray (dilated loops, air-fluid levels)
- Ultrasound (intussusception, pyloric stenosis, appendicitis)
Advanced Imaging
- Upper GI series (malrotation)
- Barium/contrast enema (Hirschsprung’s, intussusception)
- CT scan (appendicitis, tumors, complicated cases)
- MRI (selected cases)
Warning Signs Requiring Immediate Intervention:
- Bilious vomiting in a neonate (until malrotation with volvulus is ruled out)
- Signs of peritonitis (rigid abdomen, rebound tenderness)
- Hemodynamic instability (tachycardia, hypotension)
- Fever with abdominal tenderness
- Severe, unrelenting pain
- Signs of bowel ischemia (persistent pain, bloody stool, acidosis)
Management Approaches
Initial Management
- NPO (nothing by mouth)
- Nasogastric tube placement for decompression
- IV fluid resuscitation
- Electrolyte correction
- Broad-spectrum antibiotics if infection/ischemia suspected
- Pain management
- Serial abdominal examinations
Non-operative Management
Appropriate for select conditions:
- Partial obstruction with clinical improvement
- Uncomplicated adhesive obstruction
- Hydrostatic/pneumatic reduction for intussusception
- Paralytic ileus expected to resolve
- Foreign body that may pass spontaneously
Note: Close monitoring essential to detect deterioration
Surgical Management
| Condition | Surgical Approach | Key Considerations |
|---|---|---|
| Intussusception | Manual reduction; resection if ischemic | Try enema reduction first; check for lead point |
| Malrotation with volvulus | Ladd’s procedure | Surgical emergency; high risk of bowel loss |
| Intestinal atresia | Resection with primary anastomosis | Check for multiple atresias; associated anomalies |
| Hirschsprung’s disease | Pull-through procedure | May need staged approach with temporary colostomy |
| Adhesive obstruction | Adhesiolysis | Minimize manipulation; avoid unnecessary dissection |
| Incarcerated hernia | Hernia reduction and repair | Check bowel viability; minimize mesh in children |
Nursing Management
Assessment & Monitoring
- Frequent vital signs (q2-4h or more often if unstable)
- Strict intake and output monitoring
- Serial abdominal assessments (distention, tenderness)
- NG tube output measurement and characteristics
- Pain assessment using age-appropriate scales
- Monitor for signs of complications (sepsis, shock)
- Post-op: wound assessment, drainage tubes
Interventions
- Maintain NPO status
- Proper NG tube care and management
- IV fluid administration as ordered
- Medication administration (antibiotics, analgesics)
- Positioning to optimize comfort and drainage
- Early mobilization when appropriate
- Wound care post-operatively
- Ostomy care if applicable
Education & Support
- Age-appropriate explanation of procedures
- Parental education and involvement
- Pre-operative preparation
- Post-operative care expectations
- Discharge planning and home care instructions
- Signs and symptoms requiring medical attention
- Developmentally appropriate activities
- Dietary progression as appropriate
Mnemonic: “ABCDEF” for Nursing Care in Pediatric Bowel Obstruction
- Airway, breathing, circulation – Monitor vital signs
- Bowel decompression – NG tube management
- Circulating volume – Maintain fluid/electrolyte balance
- Discomfort management – Pain assessment and treatment
- Education of family – Include parents in care planning
- Follow-up care planning – Prepare for discharge needs
Complications
Immediate Complications
- Bowel ischemia and necrosis
- Bowel perforation and peritonitis
- Septic shock
- Severe dehydration and electrolyte imbalances
- Aspiration pneumonia
- Respiratory compromise from abdominal distention
Long-term Complications
- Short bowel syndrome (after extensive resection)
- Intestinal failure
- Adhesive small bowel obstruction (recurrent)
- Chronic motility disorders
- Malabsorption syndromes
- Growth and developmental issues
- Psychological impact of hospitalization
Prevention and Education
Parental Education
- Age-appropriate supervision to prevent foreign body ingestion
- Recognition of warning signs of bowel obstruction
- Importance of seeking medical attention for bilious vomiting
- Proper diet and hydration for children with chronic constipation
- Appropriate follow-up after abdominal surgery
- Awareness of family history of congenital gastrointestinal disorders
References and Further Reading
- World Health Organization. (2013). Guideline: Updates on the management of severe acute malnutrition in infants and children. WHO Press.
- Kliegman, R. M., St. Geme, J. W., Blum, N. J., Shah, S. S., Tasker, R. C., & Wilson, K. M. (2020). Nelson Textbook of Pediatrics (21st ed.). Elsevier.
- Golden, M. H., & Grellety, Y. (2018). Management of severe acute malnutrition: A manual for physicians and other senior health workers. World Health Organization.
- Woo, T., & Robinson, M. (2020). Pharmacotherapeutics for Advanced Practice Nurse Prescribers (5th ed.). F.A. Davis Company.
- Farthing, M., Salam, M. A., Lindberg, G., Dite, P., Khalif, I., Salazar-Lindo, E., Ramakrishna, B. S., Goh, K., Thomson, A., Khan, A. G., Krabshuis, J., & LeMair, A. (2013). Acute diarrhea in adults and children: a global perspective. Journal of Clinical Gastroenterology, 47(1), 12-20.
- Langer, J. C. (2017). Intestinal Rotation Abnormalities and Midgut Volvulus. Surgical Clinics of North America, 97(1), 147-159.
- Waseem, M., & Rosenberg, H. K. (2016). Intussusception. Pediatric Emergency Care, 32(6), 402-407.
- Zani, A., Eaton, S., Rees, C. M., & Pierro, A. (2008). Incidentally detected Meckel diverticulum: to resect or not to resect? Annals of Surgery, 247(2), 276-281.