WHAT IS PEM

Protein-energy malnutrition (PEM) is a potentially fatal body-depletion

disorder. It is the leading cause of death in children in developing countries.

PEM is also referred to as protein-calorie malnutrition. It develops in children

whose consumption of protein and energy (measured by calories) is
insufficient to satisfy their nutritional needs. While pure protein deficiency
can occur when a person's diet provides enough energy but lacks an
adequate amount of protein, in most cases deficiency will exist in both total
calorie and protein intake. PEM may also occur in children with illnesses that
leave them unable to absorb vital nutrients or convert them to the energy
essential for healthy tissue formation and organ function. The kids might
have a good diet consisting of a large amount of calories and also their
physical attributes saying so with them having a bloated belly. However, that
doesn’t mean the kid might not suffer from it.

Types of PEM
Primary PEM results from a diet that lacks sufficient sources of
protein. Secondary PEM is more common in the United States, where it
usually occurs as a complication of AIDS , cancer, chronic kidney
failure, inflammatory bowel disease, and other illnesses that impair
the body's ability to absorb or use nutrients or to compensate for
nutrient losses. PEM can develop gradually in a child who has a
chronic illness or experiences chronic semi-starvation. It may appear
suddenly in a patient who has an acute illness.
The diseases known as ‘kwashiorkor’ and ‘marasmus’ represent
extreme forms of protein calorie malnutrition. In 1933, a pediatrician,
Cicelly William, working in West Africa used the local term
Kwashiorkor which means ‘displaced child’ meaning “the sickness
which a child develops when the next baby is born and the older one
gets deprived of breast milk”. Kwashiorkor occurs due to the imbal-
ance between proteins and carbohydrates. The term marasmus is
derived from a Greek word meaning “to waste”. ‘Marasmus’ is also the
result of a continued deficiency of calories, protein and other
nutrients.
Kwashiorkor, also called wet protein-energy malnutrition, is a form of
PEM characterized primarily by protein deficiency. This condition
usually appears at about the age of 12 months when breast-feeding is
discontinued, but it can develop at any time during a child's formative
years. It causes fluid retention (edema); dry, peeling skin; and hair
discoloration.
Marasmus, a PEM disorder, is caused by total calorie/energy depletion
rather than primarily protein calorie/energy depletion. Marasmus is
characterized by stunted growth and wasting of muscle and tissue.
Marasmus usually develops between the ages of six months and one
year in children who have been weaned from breast milk or who suffer
from weakening conditions such as chronic diarrhea .

CAUSES
i. Inadequate diet.

Inadequacy of dietary intake may be due to several reasons such as:

a. Low purchasing power; inappropriate choice of foods; non-

availability of foods.

b. Prolonged breastfeeding, late introduction of supplementary foods.

c. Diarrhea and intestinal parasitism in children due to unhygienic

feeding habits.
d. Shortening the period of breastfeeding without satisfactory
supplements.

ii. Lack of knowledge.

Ignorance of the requirements of a growing child and the improper use

of available resources.

iii. Traditions, Customs-and-Beliefs

Aare often responsible for certain food habits. Even child-rearing

practices in the rural areas (ignorant older girls in the family are given
charge of looking after the young infant) are responsible for this
deficiency.

Consequences
Muscle Wasting

(MARASMUS)

Many of your body proteins have a short half-life, which means they are quickly used and
degraded. This rapid turnover rate necessitates continuous protein production and an ongoing
supply of new protein building blocks, or amino acids, from your diet. If you have a protein
deficiency, your body breaks down its own proteins to harvest the amino acids needed to
manufacture critical new proteins. Because your muscles contain a large amount of protein,
they are a favorite site for amino acid harvesting. With chronic protein malnutrition, your
muscles shrink -- a condition known as muscle wasting. Loss of muscle mass and fat leads to
the characteristic "skin and bones" appearance of starvation.

Poor Wound Healing

When you sustain an injury, protein production in the area shifts into overdrive to replace the
damaged tissue. With a protein deficiency, this process may be markedly slowed. A cut that
would normally heal within a matter of days may persist for weeks. With a large injury, you may
develop a chronic open wound, or skin ulcer.

Frequent Infections

Your immune system is particularly susceptible to the adverse effects of protein deficiency.
Inadequate protein consumption can lead to a diminished immune system response and
frequent infections. Your ability to recover from infections is also likely to be compromised if
your diet lacks sufficient protein.

Swelling

Protein deficiency disrupts the chemical balance in your body, which can lead to leakage of fluid
into your body tissues, or edema. With mild edema, the swelling is most noticeable in your
hands, feet and ankles. Your face and abdomen become involved with more severe edema.
Protein deficiency accompanied by edema is called kwashiorkor and most commonly occurs in
young children. Elderly people with a protein deficiency are also vulnerable to developing
kwashiorkor.

Hair Breakage and Loss

Your hair is composed of a specialized protein called keratin. Protein malnutrition disrupts your
hair growth. With a mild to moderate protein deficiency, you may notice your hair is brittle and
breaks easily. Hair loss with noticeable thinning also commonly occurs. In most cases, your hair
will regrow when you reestablish adequate protein intake.

Sexual and Reproductive Problems

Protein-deficiency malnutrition commonly leads to loss of sexual interest. Among

women of childbearing age, protein deficiency may lead to irregular menstrual cycles or
temporary loss of fertility. Protein malnutrition during pregnancy is dangerous for you
and your baby. The risk of pregnancy-related complications increases if you are
malnourished, and your baby is at high risk of not growing and developing normally.

SHORT TERM EFFECT

Three groups of Ugandan children (20 in each group) and one
comparison group of 20 children were examined between 11 and 17
years of age. The first three groups had been admitted to hospital for
treatment of protein energy malnutrition between the ages of eight to
15, 16 to 21 and 22 to 27 months, respectively. The comparison group
had not been clinically malnourished throughout the whole period up
to 27 months of age. All the children came from one tribe and were
individually matched for sex, age, education and home environment. It
was found that the three malnourished groups fell significantly below
the comparison group in anthropometric measurements and in tests of
intellectual and motor abilities. No evidence was found for a
relationship between the deficit and age at admission. Further analysis
among the 60 malnourished children revealed that anthropometry and
intellectual and motor abilities are the more affected the greater the
degree of 'chronic undernutrition' at admission, but no correlation was
found with the severity of the 'acute malnutrition'. The results show a
general impairment of intellectual abilities, with reasoning and spatial
abilities most affected, memory and rote learning intermediately and
language ability least, if at all, affected.
LONG TERM EFFECT
Three groups of Ugandan children, 18 in each group, and one
comparison group of 18 children were examined at 11-17 years of age.
The three groups had previously been admitted for treatment of
protein energy malnutrition between the ages of 8 to 15, 16 to 21 and
22 to 27 months respectively. The comparison group had not been
clinically malnourished throughout the period up to 27 months of age.
The children came from one tribe and from similar socio-economic
background, and were individually matched on age and sex. The bone
age was estimated by hand wrist radiography scored for maturity by
the Tanner & Whitehouse method. The metacarpal index, a ratio
derived from the medullary width and full diameter of the mid-point of
the second metacarpal, was used as a measure of bone cortical
thickness. The three malnourished groups are significantly shorter in
height than the comparison group, but are not different in bone age
and metacarpal index. No differences are observed between the three
groups of children who had been admitted for protein energy
malnutrition at different ages.

Diagnosis

When the physician suspects PEM, A thorough physical examination is

performed, and these areas assessed:

 eating habits and weight changes

 body-fat composition and muscle strength
 gastrointestinal symptoms
 presence of underlying illness
 developmental delays and loss of acquired milestones in children
 nutritional status

Doctors further quantify a patient's nutritional status by:

 comparing height and weight to standardized norms

  calculating body mass index (BMI)
 measuring skinfold thickness or the circumference of the upper arm

Treatment

Treatment is designed to provide adequate nutrition , restore normal

body composition, and cure the condition that caused the deficiency.
Tube feeding or intravenous feeding is used to supply nutrients to
patients who cannot or will not eat protein-rich foods.
In patients with severe PEM, the first stage of treatment consists of
correcting fluid and electrolyte imbalances, treating infection
with antibiotics that do not affect protein synthesis, and addressing
related medical problems. The second phase involves replenishing
essential nutrients slowly to prevent taxing the patient's weakened
system with more food than it can handle. Physical therapy may
benefit patients whose muscles have deteriorated significantly.

Prevention

Breastfeeding a baby for at least six months is considered the best

way to prevent early-childhood malnutrition. Talking to a doctor before
putting a child on any kind of diet, such as vegan, vegetarian, or low-
carbohydrate, can help assure that the child gets the full supply of
nutrients that he or she needs.
Every child being admitted to a hospital should be screened for the
presence of illnesses and conditions that could lead to PEM. The
nutritional status of patients at higher-than-average risk should be
more thoroughly assessed and periodically reevaluated during
extended hospital stays.

http://www.healthofchildren.com/P/Protein-Energy-Malnutrition.html
https://www.ncbi.nlm.nih.gov/pubmed/171909
https://www.livestrong.com/article/18874-symptoms-protein-
malnutrition/
https://www.ncbi.nlm.nih.gov/pubmed/820586