Protein Energy Malnutrition

1.Introduction:
The World Health Organization (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. The term protein-energy malnutrition (PEM) applies to a
group of related disorders that include marasmus, kwashiorkor and intermediate states of
marasmus-kwashiorkor.
1.1. Protein Energy Malnutrition:
Ranges of pathological conditions arise from lack, in varying proportions, of proteins and
calories.
 Marasmus. Weight for age <60% expected
 kwashiorkor. Weight for age <80% and edema

 Marasmic kwashiorkor. Wt./age<60% and edema

2.Marasmus and kwashiorkor:

2.1. Kwashiorkor:

Kwashiorkor is a form
of malnutrition that occurs when there is
not enough protein in the diet.

Causes:

Kwashiorkor is most common in areas

where there is:

 Famine
 Limited food supply
 Low levels of education (when people do not understand how to eat a proper diet)

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This disease is more common in very poor countries. It often occurs during a drought or other
natural disaster, or during political unrest. These conditions are responsible for a lack of food,
which leads to malnutrition.

Kwashiorkor is very rare in children in the United States. There are only isolated cases.
However, one government estimate suggests that as many as 50% of elderly people in nursing
homes in the United States do not get enough protein in their diet.

When kwashiorkor does occur in the United States, it is most often a sign of child abuse and
severe neglect.

Symptoms include:

 Changes in skin pigmentation
 Loss of muscle mass
 Diarrhea
 Failure to gain weight and grow
 Fatigue
 Hair changes (change in color or texture)
 Irritability
 Large belly that sticks out (protrudes)
 Lethargy or apathy
 Rash (dermatitis)
 Shock (late finding)
 Swelling (edema)
Outlook (prognosis):
Getting treatment early generally leads to good results. Treating kwashiorkor in its late stages
will improve the child's general health. However, the child may be left with permanent physical
and mental problems. If treatment is not given or comes too late, this condition is life
threatening. Possible Complications

Complications may include:

 Coma

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  Permanent mental and physical disability
 Shock

Prevention:

 To prevent kwashiorkor, make sure the diet has enough carbohydrates, fat (at least 10%
of total calories), and protein (12% of total calories).

2.2. Marasmus:
Marasmus is a form of malnutrition that results
when subcutaneous fat and muscle are lost
because of mobilization of all
available energy and nutrients. Deficiency
of protein as well as energy nutrients (that
is carbohydrates and fats) in the diet may lead to
marasmus. Marasmus typically occurs in children
below the age of 1 year.

Causes:

Kwashiorkor is most common in areas where there is:

 Famine

 Limited food supply

 Low levels of education (when people do not understand how to eat a proper diet)

This disease is more common in very poor countries. It often occurs during a drought or other
natural disaster, or during political unrest. These conditions are responsible for a lack of food,
which leads to malnutrition. Marasmus is very rare in children in the United States. There are
only isolated cases. However, one government estimate suggests that as many as 50% of elderly
people in nursing homes in the United States do not get enough protein in their diet. When
marasmus does occur in the United States, it is most often a sign of child abuse and severe
neglect.

Symptoms:

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  Patient appears like an 'elderly man'
 Dry and flaking/peeling skin but no changes in color
 Loss of muscle mass
 Sunken eyes
 Protruded cheeks
 Swelling of body (edema) is generally not seen in marasmus
 Sunken belly
 Diarrhea
 Failure to gain weight and grow
 Fatigue
 Hair changes (change in color or texture)
 Irritability
 Shock (late finding)
 Swelling (edema)

Outlook (prognosis):

Treatment early generally leads to good results. Treating marasmus in its late stages will improve
the child's general health. However, the child may be left with permanent physical and mental
problems. If treatment is not given or comes too late, this condition is life threatening.

Complications:

 Coma
 Permanent mental and physical disability

 Shock

3.Risk Factors:
Common risk factors in the development of protein energy malnutrition may be classified
as maternal and environmental. The causes of protein energy malnutrition may be distributed
unequally and thus, the degree of protein–energy malnutrition disorders

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including kwashiorkor and marasmus may vary in a given population depending on many factors
including:

 The political and economic situation of the area

 The level of education amongst the people
 The sanitary conditions

3.1. Maternal factors:

 Formal education of mother:

 Children of mothers with little or no formal education have an increased risk of
developing protein energy malnutrition when compared with the children of the mothers
who have a secondary education or higher
 Number of children under 5 years:
 Mothers who have three or more children under 5 years have an increased risk of
having a child with protein energy malnutrition when compared to mothers who only
have one
 Young maternal age
 Occupation of the mother
 Marital status of the mother

3.2. Environmental and child factors:

 Area of residence: Rural vs. urban dwelling
 Very low economic status of the family
 Unprotected source of water
 Use of firewood as only source of fuel
 Use of charcoal as main source of fuel
 Use of paraffin as main source of fuel
 Poor hygiene/cleanliness

4.History:

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The history of protein-energy malnutrition includes a failure to thrive in children less than 1 year
of age especially after they have just been weaned of breast milk. It is important to document a
detailed history of the kind of food that the infant eats. An infant affected by protein-energy
malnutrition has a history of eating a meal that is deficient in protein for a prolonged period. A
history of recurrent infections is usually present due to a poorly developed immune system and
living in crowded environment. Changes in skin with peeling and flaking of skin that is usually
reported by the mother of the infant. 

4.1. Past medical history:

A patient affected by protein-energy malnutrition may have the following past medical history: 

 Poor weight gain or weight loss

 Diarrhea
 Dermatitis
 Slowing of linear growth
 Behavioral changes (irritability, apathy, decreased social responsiveness, anxiety,
and decreased attention span)
 Non-healing wounds

4.2. Social history:

A patient suffering from protein-energy malnutrition may belong to a low socioeconomic class
and/or may belong to a region of low literacy rate.

5.Epidemiology:
In worldwide more prevalent in developing countries. “Often starts in the womb and ends in the
tomb”. PEM effects every fourth child in word wide.
More than fifty percent deaths in 0-4 years are associated with malnutrition.
Median case fatality rate is 23.5%in severe malnutrition reaching 50% in edematous
malnutrition.
According to Indian scenario childhood nutrition underlying cause of death in 35% of all death
under 5.
During 1st 6 months, when babies are breastfeeding, 20-30% is already.

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By 18-23 months, during weaning, 30% are severely stunted, 1/5th are underweight.

The prevalence of protein energy malnutrition in children under 5 years is estimated to be 41,600

per 100,000 children in developing countries like Nigeria.

The table below shows the prevalence of protein energy malnutrition in children less than 5 years of age in
developing countries in 1995.

Region Stunting Underweight Wasting (%)

(%) (%)

Africa 39 28 8

Asia 41 35 10

Latin America and the Caribbean 18 10 3

Oceania 31 23 5

6.Classification:
Weight- for -age
Height- for- age
Weight- for –height
6.1. Weight for age:
6.1.1. Gomez Classification. Only weight for age taken into account in Gomez classification
not height. Cases of edema in 3rd degree irrespective of weight for age.
Nutritional status Wt. for age (% of expected)

Normal >90
1st degree PEM 75-90
2nd degree PEM 60-75
3rd degree PEM <60
6.1.2. Jelliffe’s Classification: This classification also based on weight for age not height
involved in this classification.

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 Nutritional Status Weight for age
(%of expected)
Normal >90
1st degree PEM 80-90
2nd degree PEM 70-80
3rd degree PEM 60-70
4th degree PEM <60
6.1.3. International Classification: This classification based on wt. for age and in the
presence of edema.
Weight for age
(Boston) edema Clinical type of
(% of expected) PEM
60-80 kwashiorkor
60-80 _ Underweight
<60 _ Marasmus
<60 Marasmic-kwashiorkor
6.1.4.IAP classification (1972): IAP Classification is based on weight for age.
Grade of malnutrition Weight for age of the standard
(median)%
Normal >80
Grade I 71-80(Mid malnutrition)
Grade II 61-70(Moderate malnutrition)
Grade III 51-60(Severe malnutrition)
Grade IV <50(very severe malnutrition)
6.1.5. Classification-WHO:
Moderate malnutrition Severe malnutrition
Symmetrical Edema No Yes
Weight- for- Height SD score SD score
Between -2 to -3 <-3
Severe wasting
Height- for –age SD score SD score
Between -2 to -3 <-3
Severe wasting
7.Age independent Indices:
 Weight for Height
 Mid arm Circumference
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  Body mass index
 Index (kanawati, Dugdale, Rao& Singh’s)
 Sink folding thickness

8.Nutritional Status Indicators:

Indicators Interpretations Interpretations
Stunting low weight for age Chronic malnutrition
prolonged food deprived/
disease
Wasting low weight for height Acute malnutrition recent food
deficit/illness
Underweight low weight for age Combined indicator to reflect
both acute or chronic
malnutrition

9.Severe Acute Malnutrition:

Severe acute malnutrition is the most extreme and visible form of under nutrition. Its face is a
child – frail and skeletal – who requires urgent treatment to survive. Children with severe acute
malnutrition have very low weight for their height and severe muscle wasting. They may also
have nutritional edema – characterized by swollen feet, face and limbs. About two thirds of these
children live in Asia and almost one third live in Africa. Severe acute malnutrition is a major
cause of death in children under 5, and its prevention and treatment are critical to child survival
and development

10.Complications f PEM:

 Hypoglycemia
 Hypothermia
 Dehydration
 Infections

 Severe anemia

11.Management of P.E.M:
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  S-Correction of Sugar deficiency
 H-Prevention of Hypothermia
 I-Treatment of infections and correction of water & electrolyte imbalance
 EL-Correction Of electrolyte imbalance
 De-Correction of Dehydration
 D- To treat Deficiency conditions

Reference:

 PEM risk factors (article) Edited by C. Michael/ Gibson

 Article PEM by Hadi Atassi updated on March11, 2019
 www.Unicef.org/nutrition index
 emedicine.medscape.com/article/1104623/overview
 www. Healthline.com

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 ASSIGNMENT NO.01

TOPIC: PROTEIN ENERGY MALNUTRITION

Submitted by: Ayesha Razzaq

Submitted to: Mam Afrah

Subject: Inherited Nutritional Disorders

Registration no: FA18-FSN-004

Department: Biosciences

Submission date: 18-09-2019

Comsats University Islamabad, Sahiwal Campus

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