Nutritional

Deficiency
Disorder/
(PEM)
 Introduction
• Malnutrition means more than feeling hungry or
not having enough food to eat.
• It is a condition that develops when the body does
not get the proper amount of protein, calories,
vitamins and other nutrients it needs to maintain
healthy tissues and organ function.
• It occurs in children who are either
undernourished or over nourished. Children who
are over nourished may become over weight or
obese and those who are under nourished are more
likely to have severe long term consequences.
 Definition of PEM
Protein-energy malnutrition defined as a group
of clinical conditions that may result from
varying(different) degree of protein deficiency
and energy deficiency.
 Definition
Malnutrition includes:
Under nutrition: Lack of sufficient nutrients in
the body.
Insufficient intake of energy and nutrients.
Excessive loss of nutrients.
Over nutrition:
Excessive intake of specific nutrients.
 Types Of PEM
PEM includes
 Marasmus
 Kwashiorkor
 Marasmic-kwashiorkor
 Classification
• Weight –for- age
• Height- for- age
• Weight –for -height
 A. Wright for Age
• Weight for age classification by Gomez.
• It also called Gomez classification

Weight of the child

Wt for Age= X 100
Wt of normal child of same age
 B. Height for age
• Waterlow’s classification on the basis of height
for age

Height of the child

Ht for Age= X 100
Ht of normal child of same age
• If, height for age is;

> 95%= is called normal

90-95 % = Mild malnutrition

85-90 % = Moderate malnutrition

< 85 % = Severe malnutrition

Indian Academy of Pediatric
Welcome Trust Classification
 Etiology Of PEM
• Primary causes –

Due to dietary deficiency

• Secondary causes –

As an effect of some other illness

 1. Primary Causes:
i)Dietary factors:
 Breast feeding
– Ignorance of lactation
– Increasing use of artificial feed
– Local breast conditions like retraction of nipple, infection
etc.
Maternal death
Disturbed maternal child relationship
-Unwanted pregnancy
-Female child
-Chronic illness in child
-Mentally abnormal child
 Multiple gestation- Feeding of too many children
 Poor health of mother
 Weaning
-Late weaning
-Misconceptions – ‘Hot and Cold’ foods
-Withholding foods during diarrhea disease and mild
illnesses like ARI
Conti…..
ii) Social factors:
-Social customs
-Illiteracy
-Inequitable intra family distribution of food
iii) Economical factors:
• Poor socio economic factor
• Insufficient education
• Ignorance
• Lack of knowledge regarding food values
• Inadequate sanitary environment
• Large family size
• Working mothers
 (B) Secondary cause:
• ARI
• Diarrhea
• Intestinal parasitosis
• Measles
• Whooping cough
• Tuberculosis, Malaria
• Deliberate restriction of food during illness
• Loss of appetite
• Increased catabolism during fever
• Poor absorption in intestinal
 Marasmus
It is a severe wasting of muscle in children,
characterized by sunken features, loss of
subcutaneous fat & body weight, which is
below 60 % of the expected wt. for age.

It is a form of severe PEM characterized by

energy deficiency.
 Clinical features/ Assessment of Marasmus
• failure a to thrive ,loss of weight (weight < 60%of
expected)
• loss of subcutaneous fat : measured at many parts of
the body according to the degress:-
• 1 st degree : s.c fat in the abd. wall
• 2 nd degree : s.c fat in the abd. wall and limbs
• 3 rd degree : s.c fat in the abd. wall and limbs and face
Conti…..
 Muscle wasting ( thin muscles and prominence of
bony surfaces )
 G.I.T disturbances as anorexia in advanced cases,
hungry, constipation or diarrhea or starvation
diarrhea
 liability to infection
 Hypovolemia
 Weak pulse, abnormal temp, pulse rate
 Old men’s or monkey face
 Sunken eyes
 Dry skin
 Kwashiorkor
• Malnutrition produced by a
severely inadequate amount of
protein in the diet.
• Kwashiorkor, also known as
“edematous malnutrition”
because of its association with
edema (fluid retention),
 Grades/Degree of Kwashiorkor
• Grade I- Pedal edema
• Grade II- Grade I + Facial puffiness
• Grade III- Grade II+ Edema of chest wall &
paraspinal area
• Grade IV- Grade III + Ascitis
 Clinical features/ Assessment of
Kwashiorkor
• Failure to thrive
• Edema
• Moon like face
• Protruding abdomen
• Muscle wasting of upper limb but lower limb
are swollen.
• Child is lethargic
• Fatty liver is seen
Conti….
• Skin changes- dry, hyper pigmented
• Hair changes- thin, dry, dull , easily pluckable,
hypopigmented & straight. This is known as
Flag sign.
• Loss of appetite
 Investigations
1. History collection
2. Physical examination- anthropometric
3. Blood analysis : (W.B.C ,Electrolytes Sugars,
ketones,Plasma proteins , normal or lowered )
4. Urire analysis: culture, sugar, ketones, ca,
phosphate, aminoacids
5. Stool analysis for parasites
6. X- ray for chest and heart
7. Tuberculin test for T.B
8. E.N.T examination for otitis media
 Treatment
1- Prevention :-
– proper diet ( balanced nutritional diet )
– encourage breast feeding up to weaning
– proper weaning
– proper vaccination as measles , T.B. whooping
cough
– Education regarding the cheap sources of
balanced diet, family planning.
– Proper follow up of the growth rate
– Early treatment of defects or associated diseases
2 – Curative treatment:-
A- Proper dietary management:-
 Adequate balanced feeding. teaching about nutritional
needs. preparation of diet, technique of administration
of food
 If there is vomiting or anorexia, give IV fluids or
naso gastric tube feeding.
 Gradual increase the amount and concentration of
formula (total calories is120-200cal kg d)
B – Treatment of the cause
C- Emergency treatment for complications
D – Blood transfusion
E – Vitamins and minerals supplementation
 Rx Of Complication
• The acronym ‘shielded’ represent the
complication which may arise because of
protein energy malnutrition.
S- Sugar level of blood is low (Hypoglycemia)
H- Hypothermia
I- Infection
EL – Electrolyte disturbances
DE- Dehydration
D- Deficiency of nutrients
 Difference B/W kwashiorkor & marasmus
Features Marasmus Kwashiorkor

Deficiency Energy Protein

Muscle Wasting Obvious Some times hidden by edema & fat

Fat wasting Absent Present in lower leg, face

Face Monkey face Moon Face

Appetite Usually good Poor

Skin changes Usually none Diffuse pigmentation, flaky paint

dermatitis
Hair change Seldom Silky, easy to pluck out

Edema Absent Present

 Marasmic-kwashiorkor
Marasmic kwashiorkor is the third form of
protein-energy malnutrition that combines
features and symptoms of both
marasmus and kwashiorkor. A person
with marasmic kwashiorkor may: - be
extremely thin.
 Prevention of Malnutrition
A. Prevention at family level-
- Exclusive BF for first 6 month of age.
- Weaning must be started at the age of 6
month
-Milk, egg, meat & food items of high
biological value must be given to the
children.
-Immunization must be done
- Birth spacing should be followed
Conti…

B. Prevention at community level-

-Early detection of malnutrition & early
intervention.
-Growth monitoring
-Immunization, ORT
- Family planning services
- Nutrition education to people
Conti…

C. Prevention at national level-

-Provision of nutritional supplements for
infants & children.
-Nutritional surveillance
-Iodization of common salt