Protein-Energy

Malnutrition

Mrs. Chinchu M
II year MSc Nursing

Identification data

Name : Baby Juel Maria

Age: 1 year
Sex : female
Date of admission: 06/05/2016
Diagnosis: Grade II PEM
Bronchopnemonia
Chief complaints: running nose, cough ,
brathlessnes, increased cry, and fever
St.Ann's Degree College for
Women

Nutritional
assessment

Weight : 8 kg
Length : 78 cm
Head circumfreance: 46 cm
MAC : 13 cm
Degree of malnutrition: 76%
Remarks : Grade I PEM

St.Ann's Degree College for

Women

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 thevitamins,
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 kwashiorkor, marasmus and the
intermediate stages
MARASMUS
Inadequate intake of protein and calories and
is characterized by emaciation
KWASHIORKOR
Inadequate protein intake with reasonable or
normal caloric (energy) intake

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
includemarasmus,
kwashiorkor, and
intermediate states of
marasmus-kwashiorkor.
PEM is due to food gap
between the intake and
requirement.

EPIDEMIOLOGY
WHO 181.9 million malnourished

children in developing countries

India 50.46% of under five
children were suffering from
malnutrition

ETIOLOGY:

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

PATHOPHISIOLOGY OF
PEM:

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

Secondary PEM:

decreased nutrient absorption

increase nutrient losses

Linear growth ceases
Static weight
Weight loss
Wasting
Malnutrition and its signs

CLASSIFICATION
1. Gomez classification (based on weight-for-age

standards)
Classification

Percentage of standard weight for age

Normal

>90

Grade I (mild malnutrition)

75-89.9

Grade II (moderate malnutrition)

60-74.9

Grade III (severe malnutrition)

<60

CLASSIFICATION
2. Waterlow criteria (Type and Chronicity)

Type of Malnutrition

Acute (Weight for

Height) (%)

Chronic (Height for

Age) (%)

Normal

> 90

> 95

Mild

80 90

90 95

Moderate

70 80

85 90

Severe

< 70

< 85

CLASSIFICATION
3. Wellcome classification of severe forms of

protein- energy malnutrition

Percentage of standard
With edema
weight for age
60-80
Kwashiorkor
<60
Marasmic kwashiorkor

Without edema
Undernourishment
Nutritional marasmus

CLASSIFICATION
4. IAP classification (based on weight-for-age

standards)
Nutritional status

Percentage of standard weight for age

Normal

>80

Grade I PEM

71-80

Grade II PEM

61-70

Grade III PEM

51-60

Grade IVPEM

<50

KWASHIORKOR

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

insufficientprotein consumption but with
sufficient calorie intake, distinguishing it
frommarasmus.
More recently,micronutrient and
antioxidantdeficiencies have come to be
recognized as contributory.
Victims of kwashiorkor fail to
produceantibodiesfollowingvaccinationagai
nst diseases, includingdiphtheriaandtyphoid.
Generally, the disease can be treated by
addingfood 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 inskin 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 that sticks out
(protrudes)
Lethargyor apathy
Loss of muscle mass
Rash (dermatitis)
Shock (late stage)
Swelling (edema)

St.Ann's Degree College for

Women

MARASMUS

The term marasmus is derived from the Greek

wordmarasmos, which means withering or wasting.
Marasmusis a form of severeprotein-energy
malnutritioncharacterized byenergy 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
chronicdiarrhea.

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

DIFFERENCE IN CLINICAL FEATURES BETWEEN MARASMUS AND

KWASHIORKOR

CLINICAL
FEATURES
-MUSCLE
WASTING

MARASMUS

KWASHIORKOR

Obvious

Sometimes
hidden by
edema and fat

-FAT WASTING

Severe loss of
subcutaneous fat

Fat often retained

but not firm

-EDEMA

None

Present in lower
legs, and usually
in face and lower
arms

-WEIGHT FOR
HEIGHT

Very low

May be masked by
edema

-MENTAL
CHANGES

Sometimes quite
and apathetic

Irritable,
moaning,
apathetic

DIFFERENCE IN CLINICAL FEATURES BETWEEN MARASMUS AND

KWASHIORKOR

CLINICAL
FEATURES

MARASMUS

KWASHIORKOR

-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

-HEPATIC
ENLARGEMENT

None
Sometimes due to
accumulation of
fat

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 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 & METABOLIC

Significant findings in kwashiorkor include
CHANGES

hypoalbuminemia, hypoproteinemia (transferrin, essential

amino acids, lipoprotein), and hypoglycemia.
Plasma cortisol and growth hormone levels are high, but
insulin secretion and insulin like growth factor levels are
decreased.
The percentage of body water and extracellular water is
increased.
Electrolytes, especially potassium and magnesium, are
depleted.
Levels of some enzymes (including lactase) are decreased,
and circulating lipid levels (especially cholesterol) are low.
Ketonuria occurs, and protein-energy malnutrition may
cause a decrease in the urinary excretion of urea because
of decreased protein intake.
In both kwashiorkor and marasmus, iron deficiency anemia
and metabolic acidosis are present.

TREATMENT

Treatment strategy can be divided into three stages.

Resolving life threatening conditions
Restoring nutritional status
Ensuring nutritional rehabilitation.
There are 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 under
supervision 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

THANK YOU