PEM

Protein-Energy
malnutrition

Presented by :
Anlet Jasmine T.M
 Definitions
 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 vitamins,minerals, and other nutrients
it needs to maintain healthy tissues and organ function.
PROTEIN-ENERGY MALNUTRITION
It is a group of body depletion disorders which include
kwashiokar,marasmus and the intermediate stages.

MARASMUS
Represents simple starvation. The body adapts to a chronic
state of insufficient caloric intake.

KWASHIOKOR
It is the body’s response to insufficient protein intake but
usually sufficient calories for energy.
 PROTEIN-ENERGY MALNUTRITION

It is considered as the primary nutritional problem in India.

Also called the 1st National Nutritional disorder.

The term PEM applies to group of related disorders that include

marasmus,kwashiokor and intermediate states of marasmus-kwashiokor.

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

 AETIOLOGY
Cultural and social factors
•Inappropriate infant and young child feeding particles
•Illiteracy
•Poverty
•Ignorance
•Lack of health education
•Over crowding in family
•Single parent form

Biological factors
•Low Birth Weight baby
•Twin/multiple birth
•Interval between the birth(shorter the gap higher the risk)
•Age of mother(20 years/>35 years)
•Family size
•Female child
 Leading cause of death (less than 5 years of age)

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
• Increases nutrient loses

Linear growth ceases

Static weight

Wasting

Malnutrition and its signs

 PREVALENCE

Global burden more prevalent in developing countries.

PEM affects every 4th child world wide.

More than 50% of death in 0-4 years are associated with

malnutrition.

Median case fatality rate is 23.5% in severe malnutrition

reaching 50% in edematous malnutrition.
 CLINICAL FEATURES

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

1. Kwashiorkor
2. Marasmic-kwashiorkor
3. Marasmus
4. Nutritional dwarfing
5. Underweight child
Classification of PEM(I.A.P)
Classification of PEM (FAO/WHO)
 Kwashiorkar
 Kwashiorkor, also called wet protein-energy malnutrition,is a form of PEM
characterized primarily by protein deficiency.

Occurs amongst weaning children to ages of about 5 years old.

Occurrence increases after 18 months.

Results from gross deficiency of protein with associated energy inadequately.

It causes fluid retention(edema); dry ,peeling skin and hair discoloration.

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
•Anorexia
•Diarrhea
•Failure to gain weight & grow
•Fatigue
•Hair changer(change in colour or
texture-thinning, flag sign)
•Increase & more severe infections due to
damaged immune system
•Irritability
•Large belly/abdominal distention
•Lethargy/apathy
•Dermatitis
•Shock(late stage)
•Pitting edema
•Moon face(due to fluid retention)
 Marasmus
 Marasmus is a form of severe protein-energy malnutrition characterised by
stunted growth and wasting of muscle and tissue.

Marasmus is common in childrens less than 3 years.

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

Oedema is absent and there is no skin and hair changes.

 SYMPTOMS
•Severe growth retardation
•Loss of subcutaneous fat loss
•Severe muscle wasting
•Child looks apparently thin & limbs
Appear as skin & bone
•Shrivelled body
•Wrinkled skin
•Bony prominence
•Associated Vit. Deficiency (Vit A)
•Failure to thrive
•Irritability, fretfulness & apathy
•Frequently watery diarrhoea
•Mostly hungry but some are anorectic
•Dehydration
•Temperature is subnormal
•Muscles are weak
•Oedema & fatty infiltration are absent
•Monkey face
Difference in C.F b/w Marasmus & kwashiorkor
 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 sings of marasmus,wasting of the

muscles of the upper arms,shoulders and
chest so that you can see the ribs.
 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.
 UNDERWEIGHT CHILD

Children with subclinical PEM can be

detected by their weight for age or
weight for height, which are
significantly below normal. They may
have reduced plasma albumin.They
are at risk for respiratory
and gastric infections.
 BIOCHEMICAL AND METABOLIC CHANGES
Biochemical Changes Marasmus Kwashiorkor
Serum albumin Normal or slightly low
decreased
Urinary urea per g of Normal or decreased low
the creatinine

Urinary Hydroxyproline low low

Index
Serum free amino acid Normal Elevated
ratio
Anaemia May be observed Common iron and
folate
deficiency may be
associated
Pancreatic secretions CHANGES
Reduced enzymatic
activity
Reduced enzymatic
activity
 TREATMENT
Treatment strategy can be divided into 3 stages

Resolving life threatening condition

Restoring nutritional status
Ensuring nutritional rehabilitation

There are 3 stages of treatment

1. Hospital management
The following condition 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
It 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.
 PREVENTION

 Promotion of breast feeding

 Development of low cost weaning
 Nutritional education and promotion of correct feeding practises
 Family planning and spacing of births
Immunization
Food fortification
Early diagnosis and treatment
THE END