Protein Energy Malnutrition

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
Assessment of malnutrition
 Gomez Classification:

• The child’s weight is compared to that of a normal child

(50th percentile) of the same age.
• Percent of reference weight for age = [(patient weight) /
(weight of normal child of same age)] * 100

• 90-110% Normal nutritional status

• 75-89% Mild malnutrition
• 60-74% Moderate malnutrition
• < 60 % Severe malnutrition
 Waterlow Classification:
• Percent weight for height = [(weight of patient) / (weight of a
normal child of the same height)] * 100
• Percent height for age = [(height of patient) / (height of a
normal child of the same age)] * 100
 Wellcome Classification:
• Evaluates the child for edema and with the
Gomez classification system.

Weight for Age

With Edema Without Edema
(Gomez)

60-80% kwashiorkor undernutrition

marasmic-
< 60% marasmus
kwashiorkor
IAP CLASSIFICATION
 Mid upper arm circumference
Normal(1-5 years) 15-17cm

Moderate malnutrition 12.5-13.5 cm

Severe malnutrition <12.5 cm

 Protein–energy malnutrition (PEM)

• Protein–energy malnutrition (PEM) is a form of malnutrition

that is defined as a range of pathological conditions arising
from coincident lack of dietary protein and/or energy
(calories) in varying proportions.
 Etiology
Different combinations of many aetiological factors can lead to PEM in children. They a
Amongst the Social, Economic, Biological and Environmental Factors the common
causes are:

Lack of breast feeding and giving diluted formula

 Role of Free Radicals &
Aflatoxin:
• Two new theories have been postulated recently to explain
the pathogenesis of kwashiorkor.
• These include Free Radical Damage & Aflatoxin Poisoning .
• These may damage liver cells giving rise to kwashiorkor.
 Age Of Host :

• Frequent in Infants & young children whose rapid growth

increases nutritional requirement.
• PEM in pregnant and lactating women can affect the growth,
nutritional status & survival rates of their fetuses, new born
and infants.
• Elderly can also suffer from PEM due to alteration of GI
System
Types
 Kwarshiorker
• The term kwashiorkor is taken from the Ga 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.
• It causes fluid retention (edema); dry, peeling skin; and
hair discoloration
• Kwashiorkor was thought to be caused by insufficient
protein consumption but with sufficient calorie intake,
distinguishing it from marasmus.
• More recently, micronutrient and antioxidant
deficiencies have come to be recognized as contributory.
• Victims of kwashiorkor fail to produce antibodies
following vaccination against diseases, including
diphtheria and typhoid.
• Generally, the disease can be treated by adding food energy
and protein to the diet; however, it can have a long-term
impact on a
• child's physical and mental development, and in severe
cases may lead to death.
 SYMPTOMS
• Changes in skin pigment.
• Decreased muscle mass
• Diarrhea
• Failure to gain weight and grow
• Fatigue
• Hair changes (change incolor or texture)
• Increased and more severe infections due to damaged
immune system
• Irritability
• Large belly that sticks out (protrudes)
• Lethargy or apathy
• Loss of muscle mass
• Rash (dermatitis)
• Shock (late stage)
• Swelling (edema)
• )

Flag sign
(Alternate band of hyperpigmented
and hypopigmented hair)
 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.
 SYMPTOMS
• Severe growth retardation
• Loss of subcutaneous fat
• Severe muscle wasting
• The child looks appallingly
thin and
• limbs appear as skin and bone
• Shriveled body
• Wrinkled skin
• Bony prominence
• Associated vitamin deficiencies
• Failure to thrive
• Irritability, fretfulness and
apathy
• Frequent watery
diarrhoea and acid stools
• Mostly hungry but some
are anoretic
• Dehydration
• Temperature is subnormal
• Muscles are weak
• Oedema and fatty
infiltration are absent
 DIFFERENCE IN CLINICAL FEATURES BETWEEN
MARASMUS AND KWASHIORKOR
Clinical Marasmus Kwashiorkar
features
MUSCLE Obvious Sometimes
WASTING
Severe loss of Hidden by edema and
FAT WASTING subcutaneous fat Fat. Fat often retained but
not firm

EDEMA None Present in lower legs,

and usually in face
and lower arms
Clinical features Marasmus Kwashiorkar
-MENTAL Sometimes Irritable, moaning,
CHANGES quite and apathetic
Apathetic
APPETITE Usually good Poor

-DIARRHOEA Often Often

-SKIN CHANGES Usually none Diffuse pigmentation,

sometimes „flaky paint
dermatitis‟
HAIR CHANGES Seldom Sparse, silky, easily
pulled out
 MARASMIC-KWASHIORKOR
• A severely malnourished child with features of both
marasmus and Kwashiorkor.
• The features of Kwashiorkor are severe oedema of feet and
legs and also hands, lower arms, abdomen and face.
• Also there is pale skin and hair,and the child is unhappy.
• There are also signs of marasmus, wasting of the muscles of
the upper arms,shoulders and chest
 NUTRITIONAL DWARFING OR STUNTING

• Some children adapt to prolonged insufficiency of food-

energy and protein by a marked retardation of growth.
• Weight and height are both reduced and in the same
proportion, so they appear superficially normal.
 TREATMENT
• Treatment strategy can be divided into three stages.
• Resolving life threatening conditions
• Restoring nutritional status
• Ensuring nutritional rehabilitation.
 Three stages of treatment.

• 1. Hospital Treatment
• The following conditions should be corrected.
• Hypothermia, hypoglycemia, infection, dehydration,
electrolyte imbalance, anaemia and other vitamin and
mineral deficiencies.
 2. 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.
 3. 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 undersupervision and using local
foods.
 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