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Outpatient rehabilitation of severe protein energy malnutrition (PEM)

Yayah Kasbandiah Husaini, Zein Sulaeman, Sri Mulyati Basuki, and Darwin Karyadi
Nutrition Research and Development Centre, Ministry of Health, Bogor, Indonesia

Paul Matulessy
Nutrition Department, Medical Faculty, University of Indonesia

Paediatric Department, Medical Faculty, University of Indonesia


Protein energy malnutrition {PEM) is still a major public health problem in Indonesia. Approximately 25 to 30 per cent of children have mild or moderate PEM and 1 to 3 per cent are severe [11] . The mortality rate from severe PEM without hospitalization is about 50 per cent, but with hospital treatment it can be reduced by 10 to 30 per cent depending on the severity of the case and quality of the hospital facilities [2].

Because of the limitations imposed by socio-economic conditions and the inadequacy of hospital services, children with severe PEM are usually not hospitalized. This article reports on an unconventional method of treating children with severe PEM as outpatients at a nutrition clinic, emphasizing nutrition guidelines and education for the children's mothers.


One hundred and eight children suffering from third degree malnutrition who were outpatients at the Nutrition Clinic of the Nutrition Research and Development Centre in Bogor served as subjects for the study. Most of these children had been referred from community health centres surrounding Bogor, West Java.

Seventy-two children had nutritional marasmus with muscle-wasting, loss of subcutaneous fat, and a body weight of less than 60 per cent of the normal national standard weight for age. Five children had kwashiorkor with oedema, hair changes, and other typical symptoms of the disease, and a body weight 60 to 89 per cent of the standard weights for their ages. A marasmic-kwashiorkor group was composed of 31 children presenting with combined clinical features of marasmus and kwashiorkor and body weights below 60 per cent of the standard weight for age. Approximately 80 per cent of the marasmic cases were aged 6 to 29 months, while all the kwashiorkor cases were 18 to 29 months old. Children with marasmic-kwashiorkor were distributed fairly evenly over the age range of 6 to 36 months. The anthropometric standards used were obtained from the Directorate of Nutrition, Ministry of Health, and were slightly modified versions of the Harvard standards [3].

Supported by a grant from the second year (1981-1982} of the Third National Five-Year Plan, Ministry of Health, Republic Of Indonesia

The mothers and their children were asked to visit the clinic at least 12 times during the course of the study: weekly during the first month, biweekly from the second to the fourth month, and monthly during the fifth and the sixth months.

At the clinic, medical care was given to the subjects by a physician. While the child was being treated, the mothers were given nutrition guidance by nutritionists concerning appropriate feeding and care of their children, and they were encouraged to give them skimmed milk. Before additional nutrition counselling was given at subsequent visits, the mothers were asked about their experiences in feeding their children at home, including the children's reactions to the foods, and about any signs of improvement in their conditions.

Home visits were carried out by nutritionists or midwives in the first, sixth, tenth, sixteenth, and twentieth weeks of the study. During the visits, dietary information was collected, and nutritional practices at home, including child feeding child care, sanitation, and food hygiene, were observed. The health of the children was also observed by the field workers.

Dietary surveys were carried out for all children at the beginning of the intervention. The mothers were asked to report all food consumed by the child the previous day. Only data referring to the 24 hours prior to the interview were used in this report. An estimate of the nutrients consumed by the child was obtained by use of the food consumption tables developed by the Directorate of Nutrition, Ministry of Health [4].

The weight and height of all children were measured during clinic visits. The children were weighed unclothed with a Detecto scale, and heights were measured with a microtoise, using techniques similar to those described by Jelliffe [5].

Biochemical analyses were performed at the beginning and end of the treatments. Four to five ml of blood was taken from each child by finger-prick directly into capillary tubes. Haemoglobin and haematocrit tests were performed at the clinic. The haemoglobin was determined using cyan methemoglobin method, and haematocrit was estimated using the standard micro centrifuge method. The serum protein was evaluated by the Biuret method, and serum albumin by the bromcresol green method [6]. Serum vitamin A analysis was carried out using the method described by Neeld and Pearson [7].

TABLE 1. Nutritional classifications of children with severe PEM

  Severe PEM  
Marasmus Kwashiorkor Marasmic
6 4 - - 4
6-11 13 - 2 15
12-17 17 - 8 25
18-23 15 2 3 20
24-29 13 3 8 24
30-35 4 - 4 8
36 6 - 6 12
Total 72 5 31 108

Group means, standard deviations (SD), t-values, and chi-squares were calculated for the anthropometric and biochemical measurements.


As can be seen in table 1, marasmus and marasmic kwashiorkor were more common than kwashiorkor in the study area and occurred in somewhat younger children, starting at less than 6 months of age, whereas kwashiorkor appeared first at the age of 18 months.

The clinical data are shown in table 2. The most prevalent infections among children with severe PEM were respiratory and gastrointestinal illnesses. The most frequently occurring upper respiratory illnesses were rhinitis, pharyngitis, and tonsillitis; the lower respiratory illnesses most frequently encountered were bronchitis, bronchopneumonia, and tuberculosis; the most frequent gastrointestinal illnesses were diarrhoea and gastro-enteritis; and the most common skin illnesses were dermatitis and scabies. All the children suffered from one or more of these diseases. Thirty-four of the children, or 31.5 per cent, suffered from only one infectious disease; 48 children, or 44.4 per cent, from two; and 14 children, or 13 per cent, from three or more.

The biochemical findings are presented in table 3. Anaemia determined by haemoglobin values occurred in 80 children (80.4 per cent) and by haematocrit values in 75 children (73.5 per cent). The serum protein values were below normal in 61 children (60.4 per cent), and the serum albumin values in 62 children (60.2 per cent). Serum vitamin A values were below 10 p9 per cent in 82 children, indicating deficiency in 85.4 per cent of the sample; these values were low-between 10 to 20 p9 per cent-in 14, or 14.6 per cent of the sample, and above 20 p9 per cent-in the normal range -in only one child or less than 1 per cent of the sample.

The dietary intakes are summarized in figure 1. The mean calorie intake was 30.7 per cent of the AER and protein intake 71.9 per cent of the RDA. Other nutrients were consumed in very small amounts.

TABLE 2. Clinical findings in children with severe PEM

Nutritional status Classification No. Upper respiratory illnesses Lower respiratory illnesses Gastrointestinal illnesses Skin illnesses
Marasmus 72 26 44 28 3
Kwashiorkor 5 - 5 2 3
Marasmic-kwashiorkor 31 9 28 11 5
Total 108 35 77 41 11

The number of children who died or dropped out of the study is shown in table 4. Eighteen or 16.6 per cent of the children died, and the percentage of the cases with marasmus, kwashiorkor, and marasmic-kwashiorkor who died was approximately 8, 40 and 32 respectively.

Children who visited the clinic less than 12 times were regarded as having dropped out. Most of the children who dropped out visited the clinic an average of five to seven times. The major reasons given for not completing the study were that mothers were busy, had a new baby, or regarded the children as healthy, or that they had transportation problems. Some children in the study were hospitalized, and were therefore classified as having dropped out.

Body weights before and after treatment are shown in table 5. The average body weight increment was 36 per cent of the initial body weight. Nine children (18.4 per cent) were relatively unchanged in nutritional status by the intervention, that is, they were still classified as having severe PEM. Forty children (81.6 per cent) gained weight in the range of from 1.5 to 4.2 kg. The differences in body weight before and after treatment were highly significant using the Student's t-test (P<0.01). Seventeen children or 34.7 per cent had oedema at the beginning of the study; it had disappeared in all of them by the end of the intervention.

Table 6 shows nutritional status based on weight for height as a percentage of the national standard before and after treatment. A child was classified as being well-nourished when the weight for height was above 90 per cent; as having mild to moderate PEM with a weight for height of between 70 and 90 per cent; and as having severe PEM with a weight for height of below 70 per cent of the national standard, which is a modified version of the Harvard standard. As can be seen from table 6, improvement of nutritional status was clearly demonstrated.

TABLE 3. Biochemical findings in children with severe PEM

Parameters No. Marasmus Kwashiorkor Marasmic kwashiorkor Total
1. Haemoglobin 97        
<11 mg per cent (anaemic)   51 5 24 80
>11 mg per cent (non-anaemic)   13 - 4 17
2. Haematocrit 102        
<35 per cent (below normal)   47 5 23 75
>35 per cent (normal)   20 - 7 27
3 Protein 101        
6 g per cent (below normal)   38 2 21 61
6 g per cent (normal)   30 4 6 40
4. Albumin 1 03        
3.5 g per cent (below normal)   39 5 18 62
3.5 g per cent (normal)   35 - 6 41
5. Vitamin A 97        
10. mg per cent (deficient)   58 4 20 82
10-20 mg percent (low)   5 1 8 14
20. mg per cent (adequate)   1 - - 1

TABLE 4. Number of children who dropped out of study or died

Nutritional status Classification   After
Before Died Dropped out Following programme
No. % No. % No % No %
Marasmus 72 100 6 8.3 34 47.3 32 44.4
Kwashiorkor 5 100 2 40.0 - - 3 60.0
Marasmic-kwashiorkor 31 100 10 32.3 7 22.5 14 45.2
Total 108 100 18 16.6 41 38.0 49 45.4

Table 7 shows the nutritional status of the study children determined by plotting the body weight on the growth chart. A child with a weight for age of above 80 per cent was regarded as well-nourished; a child with a weight for age of 60 to 80 per cent of the standard as having mild to moderate PEM; and one with a weight for age of below 60 per cent of the national standard as having severe PEM. As can be seen in the table, the status of 40 children, or 81.6 per cent, improved and that of 9 children, or 18.4 per cent, was unchanged.

The effect of the treatment on anaemia was as follows: 82.5 per cent of the cases were anaemic at the beginning of the intervention and 72.2 per cent at the end. The percentage of cases with a serum protein level below 6 9 per cent was reduced from 60.4 to 49.5 per cent after treatment. The percentage of children with a serum vitamin A level below 10 mg per cent was markedly reduced from 84.5 to 70.1 per cent. However, the treatment had no clear effect on serum albumin.


The children in the study sample with severe PEM consumed nutrients, including calories, protein, vitamins, and minerals at very low levels, and all of them had infections of some kind. These are very important considerations in treatment and rehabilitation. The best mode of treatment is hospitalization in a good clinical environment for an adequate period of time. However, this mode is very costly and is usually impracticable because of the cultural and socio-economic condition of the family [8], and the lack of good clinical facilities.

TABLE 5. Average body weight before and after treatment

Nutritional status classification No. Body weight Increments (kg±SD) Increments from the initial weight (%)
Marasmus 32 6.17±1.28 8.22±1.57 2.04±1.57 33.1
Kwashiorkor 3 6.70 9.22 2.52 37.6
Marasmic-kwashiorkor 14 6.68±0.97 9.47±1.40 2.79±0.81 41.8
Average 49 6.35±1.20 8.63±1.63 2.28±0.96 35.9

TABLE 6. Nutritional status of children before (B) and after (A) treatment

Nutritional status No. Weight for height
<70% 70-79% 80-89% >90%
Marasmus 32 6 1 21 7 5 18 - 6
Kwashiorkor 3 1 - 1 - 1 2 - 1
Marasmic-kwashiorkor 14 5 - 9 - - 9 _ 5
Total 49 12 1 31 7 6 29 - 12

TABLE 7. Distribution of the nutritional status of the children based on weight for age before and after treatment

  Before After
Severe PEM(unchanged) Mild and moderate PEM Well-nourished
  No. % No. % No. % No. %
Marasmus 32 100 7 21.9 24 75.0 1 3.1
Kwashiorkor 3 100 1 33.3 1 33.3 1 33.3
Marasmic-kwashiorkor 14 100 1 7.1 8 57.2 5 35.7

FIG. 1. Percentage of calorie intake compared to AER and nutrient intake compared to RDAs

This study demonstrated the effects of an unconventional approach using home therapy on outpatients admitted to the Nutrition Clinic of the Nutrition Research and Development Centre in Bogor. Third degree malnourished children who were not severely ill were treated. Two children had, however, been referred to hospital for rehydration treatment, and after one week they were assigned to the study.

The study clearly demonstrated the effectiveness of the treatment. Case fatality was reduced to 16.6 per cent, compared to the 50 per cent mortality rate for children with severe untreated PEM reported by Suskind [2]. The children's body weight increased significantly, with increments of from 33 to 42 per cent of the initial weight. In all study children oedema disappeared. The nutritional status improved significantly, and the rate of other deficiency disorders appeared to have decreased.

The absence of a control group weakens any conclusions that may be drawn, but in this case, as in many studies, use of a control group would not be ethical [9] .

Curative medical care, supplemented by nutrition education for mothers, regular visits to the clinic, and an appropriate schedule of home visits, offers one alternative in the rehabilitation of severely malnourished children. Education concerning the proper feeding of special dietary items which conform to local cultural practices, and which are made from familiar and locally available foods, appears to be of permanent nutritional benefit.


1. Ministry of Health, Republic of Indonesia, Report on Health Research and Development Workshop, Jakarta, 24-27 April 1978.

2. R. Suskind, "The Inpatient and Out-patient Treatment of the Child with Severe Protein-Calorie Malnutrition," in R. E. Olson, ed., Protein-Calorie Malnutrition (Academic Press, New York, 1975).

3. Directorate of Nutrition, Ministry of Health, Indonesia, Manual for the Standardization and Evaluation of Data for the Assessment of the Nutrition Health of a Community Using Field Survey Techniques in Rural Areas (Ministry of Health, Jakarta, 1971).

4. Directorate of Nutrition, Ministry of Health, Food Composition Table (Ministry of Health, Jakarta, 1976).

5. D. B. Jelliffe, The Assessment of the Nutrition of the Community, World Health Monograph Series, no. 53 (WHO, Geneva, 1976).

6. I. G. McPherson and D. W. Everard, "Serum Albumin Estimation: Modification of the Bromcresol Green Method," Olin. Chim. Acts, 37: 117 (1972).

7. J. B. Neeld and W. B. Pearson, "Macro- and Micro-methods for the Determination of Serum Vitamin A Using Trifluoroacetic Acid," J. Nutr., 79:454 (1963).

8. E. M. DeMaeyer, "Protein-Energy Malnutrition," in Nutrition in Preventive Medicine, WHO Monograph Series, no. 62 (WHO, Geneva, 1976).

9. F. Solon, T. L. Fernandez, M. C. Latham, and B. M. Popkin, "An Evaluation of Strategies to Control Vitamin A Deficiency in the Philippines," Am. J. Clin. Nutr., 32: 1445 (1979).

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