Protein Energy Malnutrition

Protein Energy Malnutrition (PEM) is the deficiency of macronutrients or energy and protein in
the diet. It is a nutritional disorder, which affects all the segments of population like children, women
and adult males particularly from the backward and downtrodden communities. It is the leading cause
of death in children in developing countries.

Types of PEM:

Different Types of PEM

Clinical forms Sub-clinical forms

o Kwashiorkor Underweight
o Marasmus Wasting
o Marasmic kwashiorkor Stunting

Kwashiorkor is one of the serious forms of PEM. it is seen most frequently in children one to
three years of age, when they are completely weaned (taken off the breast). But it may occure
at any age. It is found in children who have a diet that is usually insufficient in energy and
protein and often in other nutrients.

Clinical Signs of Kwashiorkor:

All cases of kwashiorkor have oedema to some degree, poor growth, wasting of muscles and
fatty infiltration of the liver. Other signs include mental changes, abnormal hair, a typical
dermatosis, anaemia, diarrhoea and often evidence of other micronutrient deficiencies.

Oedema: The accumulation of fluid in the tissues casuses swelling in kwashiorkor this condition is
always present to some degree. It usually starts with a slight swelling of the feet and often spread up the
legs. Later, the hands and face may also swell. To diagnose the presence of oedema the medical
attendant presses with finger or thumb above the ankle. If oedema is present the pit formed takes a few
seconds to return to the level of the surrounding skin.

Poor growth: Growth retardation is the earliest manifestation.

The child will be lighter and shorter than its normal peers of same age and weigh about 60 to 80% of
standard or below 2SD.
Sometimes, in cases of gross swelling, the body weight may be relatively higher. The child will also be
wasted (thinner). The child's arms and legs will appear thin as a result of wasting.

Wasting: Muscle wasting is also a typical but may not be evident because of oedema. The child’s arms
and legs are thin because of muscle wasting.

Fatty infiltration of the liver: this condition is always found in post-mortem examination of
kwashiorkor cases. It may cause palpable enlargement of the liver (hepatomegaly).

Mental changes: kwashiorkor child has no interest in the surrounding. The child will also be irritable
and prefers to stay at one place and in one position.

Hair changes: In kwashiorkor, the hair loses its healthy sheen and becomes silkier and thinner. It takes
coppery red colour (referred to as 'discoloured hairy).You could easily pluck small tufts of hair without
causing any pain (referred to as easy pluck ability) just by passing your hands through the hair.

Skin change: Dermatosis in some but not all cases of kwashiorkor. It tends to occur first in areas of
friction or of pressure such as the groin, behind the knees and at the elbow. Darkly pigment patches
appeared which may give rise to “flaky-paint Dermatosis”.

Anemia: Most cases have some degree of anemia because of the protein required to synthesize blood
cells. Anemia may be complicated by iron deficiency, malaria, hookworm etc.

Diarrhoea: Stools are frequently loose and contain undigested particles of food sometime they have an
offensive smell or are watery or tinged with blood.

Moonface: the cheeks may appear to be swollen with either fatty tissue or fluid, giving the
characteristic appearance known as “moonface”.

Signs of other deficinces: in kwashiorkor some subcutaneous fat is usually palpable, and the amount
gives an indication of the degree of energy deficiency. Mouth and lip changes charactertic of vitamin B
deficiency are common. Xerophthalmia resulting from vitamin A deficiency may be seen.

Marasmus: Marasmus is common in children 6 month to 1 years of age.

The marasmic children are so weak that they may not have even energy to cry, which most often is
barely audible.

The child is extremely wasted with very little subcutaneous fat with the skin hanging loosely particularly
over the buttocks.
Clinical signs of marasmus:

Poor growth: in all cases the child fails to grow properly. Weight will be found to be extremely low by
normal standards (below 60% or -3SD of the standards). In severe cases the loss of flesh is obvious, the
ribs are prominent; the belly, in contrast to the rest of bpdy, may be protuberant; the face has a
characteristic simian (monkey-like) appearance; and the limbs are very emaciated. The child appears to
be skin and bones. An advanced case of the disease is unmistakable, and once seen is never forgotten.

Wasting: The muscles are always extremely wasted. There is little if any subcutaneous fat left. The skin
hangs in wrinkles, especially around the buttocks and thighs. When the skin is taken between forefinger
and thumb, the usual layer of adipose tissue is found to be absent.

Alertness: children with marasmus are quite often not disinterested like those with kwashiorkor. Instead
the deep sunken eyes have a rather wide-awake appearance. Similarly, the child may be miserable and
less irritable.

Appetite: the child often has a good appetite. In fact, like any starving being, the child may be
ravenous. Children with marasmus often violently suck their hands or clothing or anything else available.
Sometime they make sucking notices.

Anaemia: anaemia is usually present.

Differences between Kwashiorkor and Marasmus

Clinical Signs Kwashiorkor Marasmus

Causes Deficiency of proteins. Deficiency of both proteins and
calories.
Age factors Between the age of 6 months and 3 Between the age of 6 months and 1
years of age. year of age.
Oedema Present. Absent.
Subcutaneous fat Present. Absent.
Weight loss There is some weight loss. There is severe weight loss.
Symptoms The thinning of muscles and limbs. The thinning of limbs.
Fatty liver cells There is an enlargement in the fatty There is no enlargement in the
liver cells. fatty liver cells.
Appetite Voracious feeder. Poor appetite.
The texture of the skin Flaky paint appearance on the skin. Dry and wrinkled skin.
Requirement of Nutrition Adequate amounts of proteins Adequate amounts of proteins,
carbohydrates and fats.
Marasmic Kwashiorkor:

Children with features of both nutritional marasmus and kwashiorkor are diagnosed as having marasmic
kwashiorkor. In the welcome classification this diagnosis is given for a child with severe malnutrition
who is found to have both oedema and a weight for age below 60% of that expected for his or her age.
Children with marasmic kwashiorkor have all the feature of nutritional marasmus including severe
wasting, lack of subcutaneous fat and poor growth, and in addition to oedema, which is always present,
they may also have any of the features of kwashiorkor described above. There may be skin changes
including flaky-paint Dermatosis, hair changes, mental changes and hepatomegaly. Many of these
children have diarrhea.