Program: B.Sc.

Nursing, V Semester, Third Year

BNSG502 : Child Health Nursing
Unit No - 5
Unit Name -Nursing Management in Common
Childhood Diseases

Topic Name- Protein Energy Malnutrition

Lecture No.- 1
Mr. Ravi Rai Dangi
Assistant Professor, SONS
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Outlines
• Introduction
• Definition
• Kwashiorkor
• Marasmus
• Management
• Prevention
• Exercise
• Learning outcome
• References

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 Introduction
• Nutritional disease, any of the nutrient-related diseases and conditions
that cause illness in humans. They may include deficiencies or excesses
in the diet, obesity and eating disorders, and chronic diseases such as
cardiovascular disease, hypertension, cancer, and diabetes mellitus.

• Nutritional diseases also include developmental abnormalities that can be

prevented by diet, hereditary metabolic disorders that respond to dietary
treatment, the interaction of foods and nutrients with drugs, food allergies
and intolerances, and potential hazards in the food supply.

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 MALNUTRITION
• WHO defines Malnutrition as "the cellular imbalance between the
supply of nutrients and energy and the body's demand for them to
ensure growth, maintenance, and specific functions. Malnutrition is the
condition that develops when the body does not get the right amount of
the vitamins, minerals, and other nutrients it needs to maintain healthy
tissues and organ function.”

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 PROTEIN ENERGY MALNUTRITION

It is a group of body depletion disorders which include kwashiorkor,

marasmus and the intermediate stages.

MARASMUS

Represents simple starvation . The body adapts to a chronic state of

insufficient caloric intake.

KWASHIORKOR

It is the body’s response to insufficient protein intake but usually sufficient

calories for energy.
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 Protein-Energy Malnutrition

• PEM is also referred to as protein-calorie malnutrition.

• It is considered as the primary nutritional problem in India.

• Also called the 1st National Nutritional Disorder.

• The term protein-energy malnutrition (PEM) applies to a group of related

disorders that include marasmus, kwashiorkor or, and intermediate states of
marasmus-kwashiorkor.

• PEM is due to “food gap” between the intake and requirement.

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 ETIOLOGY
Different combinations of many etiological factors can lead to PEM in
children. They are:

• Social and Economic Factors

• Biological factors
• Environmental factors
• Role of Free Radicals & Aflatoxin
• Age of the Host


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• Amongst the Social, Economic, Biological and Environmental
Factors the common causes are:

• Lack of breast feeding and giving diluted formula

• Improper complementary feeding
• Over crowding in family
• Ignorance
• Illiteracy
• Lack of health education
• Poverty
• Infection
• Familial disharmony

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 PATHOPHYSIOLOGY of PEM:

Primary PEM:
Protein + energy intakes below requirement for normal growth.

Secondary PEM:
the need for growth is greater than can be supplied.
decreased nutrient absorption increase nutrient losses

Linear growth ceases and Weight loss

Wasting Malnutrition

St.Ann's Degree College for Women

 CLINICAL FEATURES
The clinical presentation depends upon the type , severity and duration of
the dietary deficiencies. The five forms of PEM are :

• Kwashiorkor
• Marasmic-kwashiorkor
• Marasmus
• Nutritional dwarfing
• Underweight child

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 KWASHIORKOR
• The term kwashiorkor is taken from the language of Ghana and means
"the sickness of the weaning”.

• Williams first used the term in 1933, and it refers to an inadequate

protein intake with reasonable caloric (energy) intake.

• Kwashiorkor, also called wet protein-energy malnutrition, is a form of

PEM characterized primarily by protein deficiency.

• This condition usually appears at the age of about 12 months when

breastfeeding is discontinued, but it can develop at any time during a
child's formative years.

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• Victims of kwashiorkor fail to produce antibodies following vaccination
against diseases, including diphtheria and typhoid.

• It causes fluid retention (edema); dry, peeling skin; and hair

discoloration.

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 SYMPTOMS
• Changes in skin pigment.
• Decreased muscle mass
• Diarrhea
• Failure to gain weight and grow
• Fatigue
• Hair changes (change in color or texture)
• Increased and more severe infections due to damaged immune system
• Irritability
• Large belly
• Lethargy
• Loss of muscle mass
• Rash (dermatitis)
• Shock (late stage)
• Swelling (edema)
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 MARASMUS
• The term marasmus is derived from the Greek word marasmos, which
means withering or wasting.

• Marasmus is a form of severe protein-energy malnutrition characterized

by energy deficiency and emaciation.

• Primarily caused by energy deficiency, 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 like chronic diarrhea.

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 SYMPTOMS
• Severe growth retardation

• Loss of subcutaneous fat

• Severe muscle wasting

• The child looks appallingly thin and limbs appear as skin and bone

• Wrinkled skin

• Bony prominence

• Associated vitamin deficiencies Failure to thrive

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 SYMPTOMS
• Irritability

• Frequent watery diarrhea and acid stools

• Dehydration

• Temperature is subnormal

• Muscles are weak

• Oedema and fatty infiltration are absent

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 DIFFERENCE IN CLINICAL FEATURES
BETWEEN
MARASMUS AND KWASHIORKOR

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 DIFFERENCE IN CLINICAL FEATURES

Clinical Features Marasmus Kwashiorkor

-Muscle
Wasting Obvious Sometimes
Hidden by edema and
Fat
-Fat wasting Severe loss of Fat often retained but
subcutaneous fat not firm

-Edema None Present in lower legs,

And usually in face
And lower arms

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 DIFFERENCE IN CLINICAL FEATURES
Clinical Features Marasmus Kwashiorkor

-EDEMA None Present in lower legs,

and usually in face

and lower arms
May be masked by
-WEIGHT FOR Very low edema
HEIGHT
Irritable, moaning,
-MENTAL Sometimes quite and apathetic
CHANGES apathetic

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 Diagnostic Investigation
• Physical Examination

• Blood Investigation

• Serum Electrolyte

• Blood urea nitrogen

• Lipid profile

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 TREATMENT
Treatment strategy can be divided into three stages.

• Resolving life threatening conditions

• Restoring nutritional status

• Ensuring nutritional rehabilitation.

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 TREATMENT
There are three stages of treatment.

Hospital Treatment

• Hypothermia, hypoglycemia, infection, dehydration, electrolyte

imbalance, anemia and other vitamin and mineral deficiencies.

Dietary Management

• The diet should be from locally available staple foods - inexpensive,

easily digestible, evenly distributed throughout the day and increased
number of feedings to increase the quantity of food.

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 TREATMENT
Rehabilitation

• The concept of nutritional rehabilitation is based on practical nutritional

training for mothers in which they learn by feeding their children back
to health under supervision and using local foods.

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 PREVENTION
• Promotion of breast feeding

• Development of low cost weaning

• Nutrition education and promotion of correct feeding practices

• Family planning and spacing of births

• Immunization

• Food fortification

• Early diagnosis and treatment

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 Exercise
• Write down the health education for prevention of PEM.

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 Learning Outcomes
The student will be able to explain following:-

• Define PEM.
• Explain the etiology.
• Discuss the pathophysiology.
• Explain the clinical sign and symptoms
• Describe the management and prevention.

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 References

1. Whaley & Wongs , Essential of Pediatric Nursing , 5th Edition, Mosby

Publisher.

2. Parul Datta, Pediatric Nursing, 3rd Edition, Jaypee Brothers Medical

Publishers Pvt Ltd.

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SELO

2. Clear understanding of professional ethics.

4. Lifelong learning ability.

8. Ability to understand subject related concepts clearly along with

contemporary issues.

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