DESCRIPTION OF DISEASE

PROTEIN ENERGY MALNUTRITION

The term malnutrition can be applied to any disorder that prevents an individual from achieving
an optimal nutritional state.Protein energy malnutrition is the state occurs due to insufficient or
imbalanced consumption of protein and energy.
INCIDENCE:
Malnutrition is the one of the major health problem in the world in children with in 5
years of age.It is estimated that 80% of preschooler suffer from various degrees of
malnutrition.At any given time there are 78 million children suffering from various degrees of
malnutrition.
NORMAL PROTEIN AND ENERGY REQUIREMENT OF CHILDREN
Age group Energy (in kcal/day) Protein (in grams/day)
0-6 months 108/ kg 2.0/kg
6-12 months 98/kg 1.65/kg
1-3years 1240 22
4-6years 1690 30

TYPES OF PROTEIN ENERGY MALNUTRITION

1.Marasmus: Weight less than 60% of expected weight to the age. It is a clinical syndrome
characterized by loss of subcutaneous fat and muscle wasting.
2.Marasmic Kwashiorkor: Weight less than 60% of expected body weight for the age with
features of Marasmus with edema.
3.Kwashiorkor: Weight below 60-80% of expected weight with growth
retardation and generalized body edema.

GRADING OF PROTEIN ENERGY MALNUTRITION

a) Gomez Classification:
Grade I - 76-90% of average of weight.
Grade II - 61-75% of average weight.
Grade III -60% and below 60% of average weight.

b) The Water Loo classification

 Nutritional Marasmus- below 60% of average weight without edema

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  Kwashiorkor - 60-80% of reference weight with edema.
 Marasmic Kwashiorkor - below 60% of reference weight and edema

c) Indian Academy of Pediatrics:

 Above 80% of expected weight - Normal

 70-80% of expected weight - Grade I
 60-70% of expected weight -Grade II
 50-60% of expected weight - Grade III
 Less than 50% of expected weight - Grade IV

MARASMUS
A severe form of malnutrition caused by inadequate intake of protein and calories, and it
usually occurs in the first year of life, resulting in wasting and growth retardation. Marasmus
accounts for a large burden on global health.

Nutritional Marasmus is a nutritional disorder results due the gross deficiency of energy though
protein deficiency accompanies it.

It is the common problem in developing countries in the time of draught. It occurs chiefly in first
year of life.

ETIOLOGY:
a) Primary Cause: Primary cause is the dietary cause. Inadequate diet both qualitatively and
quantitatively.

b) Secondary Causes:

 Age: Marasmus is more common in infant than in other ages. It is because of high
nutritional requirement of infant (Protein: 2-3gm/kg/day; Calorie: 1200 Kcal/day) and
hence Marasmus develops soon in infancy

 Congenital Disease: Congenital disease which limits the intake and digestion of food.

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  Chronic Vomiting: Disease like pyloric stenosis and relaxed cardiac sphincter, which
increase the risk of vomiting there by, decreases the absorption of the nutrients from the
GI tract.

 Chronic Infection: Chronic infections like Congenital syphilis, tuberculosis and

respiratory infection which results in protein loss.

 Repeated episodes of chronic diarrhea will impair the digestion and absorption of
nutrients from the mucosa of the Gastro Intestinal tract and results in deficiency of the
nutrients.

 Serious organic disorders of heart, brain and kidney and some metabolic disorders and
juvenile diabetes mellitus.

 Other causes include Transition from breastfeeding to nutrition, poor foods in infancy.

GRADING OF THE MARASMUS:

Grade I : Loss of fat in axillae and groin
Grade II : Grade I + loss of fat in abdomen and gluteal region.
Grade III : Grade I + Grade II + loss of fat in chest and Para spinal area.
Grade IV : Grade I + Grade II + Grade III + loss of fat in buccal pad.

CLINICAL MANIFESTATIONS
 Appearance of toothless old man and a monkey look.
 Growth retardation as evidenced by marked loss of weight and subnormal height.
 Gross muscle wasting
 Absence of edema.
 Eyes will be sunken
 Disappeared subcutaneous fat.
 Face will be round, till the loss of subcutaneous fat.
 Skin over the buttocks becomes wrinkled and saggy due to loss of adipose tissue.

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  Bones will be prominent.
 Anemia
 Subnormal temperature.
 Skin becomes ashen gray because of anemia
 Atrophy and wasting of body tissues especially subcutaneous fat.
 The child will be apathetic and lethargic.
 Recurrent infections
DIAGNOSIS
History collection : Regarding the dietary habits and recurrent attacks of diseases.

Physical examination : To rule out the signs of the Marasmus.

Biochemical Investigation : Biochemical investigation to estimate the plasma protein level.

Plasma protein levels will not be noticeably reduced.

Pathological references : Liver does not show pathological fatty infiltration.

Reduced organ weight of lung and heart

MANAGEMENT:

 Calorie requirement of the undernourished infants are greater than those of normal infants
it almost doubled.

 The aim of treatment is to provide sufficient proteins, calories, and other nutrients for

nutritional rehabilitation and maintenance.

 In case of severe PEM, restoring fluid and electrolyte balance parentally is the initial
concern. A patient who shows normal absorption may receive enteral nutrition after
anorexia has subsided.

 When possible, the preferred treatment is oral feeding. Foods are introduced slowly.
Carbohydrates are given first to supply energy, and then high-quality protein foods,
especially milk, and protein-calorie supplements, are given.

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  Start with the concentrated food of about 200 Cal/kg body weight gradually 2-3 weeks and
continued till the weight gain.

 Protein requirement should be 4gm/kg body weight /day.

 No of feeds should be increased usually 7 feeds a day.

 A patient who’s unwilling or unable to eat may require supplementary feedings through a
naso-gastric tube or Total Parenteral Nutrition (TPN).

 Secondary causes should be treated

 Accompanying infection must also be treated, preferably with antibiotics that don’t inhibit
protein synthesis.

KWASHIORKOR
Kwashiorkor is one of the more severe forms of protein malnutrition and is caused by
inadequate protein intake. It is, therefore, a macronutrient deficiency.

It is type of severe protein-energy malnutrition refers to a combination of edema, lethargy

(mental apathy) and growth failure.

INCIDENCE:
It is a major problem in South India (Andra Pradesh) and Orissa, Bengal and some parts
of Maharashtra.

In India it is estimated that about 1-2% of preschooler suffer from Kwashiorkor.

ETIOLOGY:

Book Picture Patient Picture

 Unavailability of suitable protein rich -
foods
 Faulty feeding habits -
 Super imposition of infection and Suspected case of worm infestation
infestations
 Age Incidence Age is 3y, peak age of incidence

Higher incidence is found between 1 to 3

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 years. Breast feed till 2 years of age.
 Prolonged breast feeding -
 Seasonal Incidence -

 Family size Lack of awareness of health services

 Lack of Accessibility and availability of

Health Services

CLINICAL MANIFESTATION
Book Picture Patient Picture
 Onset: Insidious in onset over periods of weeks and months. Insidious in onset
 Apathy: Gradually loss of interest and activity. The degree Has less interest in
unresponsiveness will be proportional to severity of the disease. play activities.

 Diarrhea: Nearly 2/3rd of Kwashiorkor cases will be presenting with Absent

the complaints of loose stools with infective in origin.
 Edema: Edema is a constant feature and is extremely variable in Pedal edema with
degree. Inspite of gross edema, ascites will be minimal. ascites
 Muscle wasting: Due to degeneration and reduction in the anterior No muscle wasting
horn cells may lead to weakness and hypotonia as suggested by one
postulate (Kwashiorkor myelopathy). Protein deficiency also causes
muscle wasting.
 Skin changes: 40% to 60% of the florid kwashiorkor will have skin Skin is dry and scaly
changes. Dry and scaly skin: Common over skin
 Pavement dermatosis: Jet black, later exfoliate exposing underlying Absent
and also there will be peeling.
 Petichae and ecchymoses. Absent
 Arabinoflavinosis Absent
 Hair changes: The hair is scanty, lusterless commonly brownish. Hairs are scanty and
The light color hair is known as dyschromotrichia. brown in color

 Hepatomegally with fatty infiltration. Liver is enlarged 4cm

below the RCM
Moon face is present
 Face: Moon face due to edema
No symptoms
 Associated Avitaminosis

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  Anemia of moderate degree. Hb 5.2gm/dl
 Growth retardation
 Psychomotor changes: Earlier the onset of the malnutrition; severe Absent
will be the psychomotor changes (mental deprivation) Irritable and restless

Kwashiorkor sufferers show signs of thinning hair,

edema, inadequate growth, and weight loss. The
stomatitis on the pictured infant indicates an
accompanying Vitamin B deficiency
DIAGNOSIS:-

Book Picture Patient Picture

 History and Physical examination Done
 Anthropometric measurements MAC-14cm

 Biochemical investigation
o Low serum albumin (<3.5-5gm/dl) Not done

o A/G ratio will be reversed(1:1.5) Not done

o Decreased serum amino acid level. Not done

Not done
o Decreased blood cholesterol level.
Not done
o Decreased pancreatic enzymes.
Not done
o Decreased serum Iron and Copper.
 Organ Changes elicited by Imaging studies:
Present and enlarged 4cm below
o Fatty liver RCM
Not elicited
o Atrophy of acinary cells of pancreas Not elicited.
o Atrophic changes in stomach and intestinal villi.
MANAGEMENT
1. Dietary modifications

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 2. Control and Treatment of infections

Book Picture Patient Picture

Management: 1.Dietary modifications
Dietary Management:
Liberal protein rich foods to be given with adequate calories.
Proteins: High protein diet with 7-8 feeds a day
About 5 to 6 gms of protein/kg/day.
The total average protein intake of child is 50-60gm/day.
Calories:
Calories should be in range of 120-150 Kcal/kg/day.
1. Control and Treatment of infections On antibiotic therapy (Inj. Amikacin
225mg BD)
On Becosule capsule for
2. Correction of Vitamin deficiencies
Vit-B and C Supplementation

3. Correction of Vitamin deficiencies

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 NURSING CARE PLAN
SR.NO NURSING PLANNING
ASSESSMENT OBJECTIVE INTERVENTIONS IMPLEMENTATION EVALUATION
. DIAGNOSIS
1 Subjective data: Imbalanced Child will achieve -Assess the - Child is severely Nutrition of child
Mother says “My nutrition; less than and maintain nutritional status malnourished. i.e. 3rd is improved to
son is not gaining body requirement normal nutritional and degree of degree malnutrition. some extent as
weight adequately” related to decreased status as evidenced malnutrition. evidenced by
utilization of by weight gain. increased interest
-Assess the causes for
Objective data: nutrients secondary - Decreased utilization of to take food and
malnutrition.
Weight:7kg to fatty infiltration nutrients due to fatty mild increase in
(expected wt 14 of the liver. infiltration of liver. weight. i.e. 8.2kg.
kg)
-Prepare diet plan and - Prepared diet menu
educate mother to plan based on the child
Grade III
serve food condition.
malnutrition:
accordingly.

-Identify for the signs

- Vitamin deficiency
of vitamin
present.
deficiencies

-Administer Vitamin
Supplements - Provided oral Vitamin
Supplements.

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 SR PLANNING
NURSING
ASSESSMENT OBJECTIVE INTERVENTION IMPLEMENTATION EVALUATION
NO.
DIAGNOSIS
S
2.
Subjective data: Hyperthermia Child will -Monitor vital signs Body Temperature is Child’s body
Mother says “My related to achieve and 100oF. temperature is
son’s skin is inflammatory maintain -Loosen the Loosen the clothing within normal
somewhat hot” reaction normal body clothing and switch and provided proper limits
secondary to temperature as on the fan. ventilation.
Objective data: Hepatomegally. evidenced by -Provide plenty of Advise the mother to Temperature:
Temperature: 100oF temperature fluids to drink provide plenty of 98.6F
Pulse: 92bts/min within normal water and fluids.
limits. -Apply cold Advised mother to
compress keep wet cloth on fore
head to reduce the
temperature.
-Provide tepid -----
sponge.
-Administer Administered Inj

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 prescribed Paracetamal
antipyretics Intramusularly.

SR NO. NURSING PLANNING

ASSESSMENT OBJECTIVE INTERVENTIONS IMPLEMENTATION EVALUATION
DIAGNOSIS
3. Subjective data: The Fluid volume To maintain -Assess the child for - Child is having Child’s edema
mother complaint excess related to fluid volume in sites of edema. facial puffiness, has reduced as
that her son is fluid the body and to periorbital edema, & evidenced by
having swelling of accumulation in reduce the -Assess the signs of pedal edema. abdominal girth
face. tissues as edema. ascities and reduced to 45
- Abdominal girth is
evidence by measure cms.
49cms
Objective data: puffiness of abdominal girth.
The child is having face, periorbital -Assess the dietary
puffiness of face, and pedal pattern of the child.
-
periorbital edema edema, and -Provide small and
and edema at feets. abdominal frequent meals.
distension.
- Advised mother to
-Increase food items
give small and
that contain
frequent meals.
protein.

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 - Provided the list of
-Consider likes and protein rich foods to
dislikes of the mother.
child.
- Instructed mother
to serve food in
utensils which the
child used to have
food.

SR NURSING PLANNING
NO. ASSESSMENT IMPLEMENTATION EVALUATION
DIAGNOSIS OBJECTIVE INTERVENTIONS
4. Subjective data Deficient Parents will -Assess the level of -Understanding level Parents gained
Mother says they knowledge of gain knowledge understanding of of the parents is knowledge
have not taken child the parents regarding the parents. poor.ucated mother regarding the
-Educate the parents regarding the
for immunization. related to nutritional nutritional
regarding the condition of their
nutrition and requirement of requirements of
causes and child.
Objective data immunization the child and symptoms of the child, and its
Child not received need of child immunization malnutrition. management and
immunization need of child. -Explain the parents -Educated parents immunization
vaccines and food regarding the daily regarding the need of child.
nutritional measures to improve
pattern was
requirement of the the nutrition status
inappropriate

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 child. and prescribed menu
-Educate the parents plan.
regarding the -Explained the
importance of importance and
immunization of schedule of
the under-five vaccination and
child. encouraged for future
-Educate regarding immunization.
the measures to -Educated parents
prevent regarding the
complications of prevention and
malnutrition. management of
complications.

SR NURSING PLANNING
ASSESSMENT OBJECTIVE INTERVENTIONS IMPLEMENTATION EVALUATION
NO. DIAGNOSIS
5. Subjective data: The High risk for Child will -Assess the risk -Facial puffiness and The child‘s skin
mother complaint that impaired skin achieve and factors for the pedal edema present. display no
my son is having integrity related maintain good impairment of skin evidence of
edema. to fluid skin texture and integrity. redness and
overload. integrity. -Provide meticulous irritation. The
-Provided the skin
Objective data: skin care. mother is
care.
Child having facial -Avoid tight applying cream
puffiness and pedal clothing. to the child
edema.

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 -Cleanse and -Advised mother to
powder opposing avoid tight clothing.
skin surfaces
-Cleansed and
several times per
powdered skin
day.
surfaces.
-Change the
position frequently.

-Advised mother to
-Use pressure
change the position
relieving
frequently.
mattresses as
needed to prevent -------
ulcer.

HEALTH EDUCATION
 I educate them (patient & family member) to –
 Take high caloric diet and iron rich diet.
 To avoid activities which causes fatigue.
 To take proper rest and sleep.
 Do not perform any heavy work.
 Take the medicine on time and care for the follow up.

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 BIBLIOGRAPHY:
1. Marlow DR, Redding BA. Text Book of Pediatric Nursing. 6th ed. New Delhi: Elsevier India Private Limited; 2006.
2. Wilson D & Hockenberry MJ. Nursing Care of Infants and Children. 8th ed. New Delhi: Elsevier Private Ltd; 2007.
3. http://en.wikipedia.org/wiki/Marasmus

4. http://www.faqs.org/nutrition/Kwa-Men/Marasmus.html

5. http://wrongdiagnosis.com/m/marasmus/intro.htm

6. http://social.jrank.org/pages/378/Marasmus.html

7. http://en.wikipedia.org/wiki/Kwashiorkor

8. http://www.umm.edu/ency/article/001604.htm

9. http://www.wrongdiagnosis.com/k/kwashiorkor/intro.htm

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