Protein-Energy

Malnutrition

Presented By :
Hamza Y. Habeb
Presented to:
Dr. Anwar sheikh khalil

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.
Under-nutrition
Supply is less than the demand
Over-nutrition
Supply is more than the demand

 PROTEIN ENERGY MALNUTRITION

It is a group of body depletion disorders which
include kwashiorkor, marasmus and the
intermediate stages
MARASMUS
From the Greek word marasmos (wasting).
Represents simple starvation . The body adapts
to a chronic state of insufficient caloric intake
KWASHIORKOR
From Ga Language "the sickness of the weaning."
It is the bodys response to insufficient protein
intake but usually sufficient calories for energy

Protein-Energy
Malnutrition

PEM is also referred to as

protein-calorie
malnutrition.
PEM is due to food gap
between the intake and
requirement.

Decreased level of zinc

causes "flaky paint"
dermatosis of kwashiorkor or
acrodermatitis enteropathica.
Associated with impaired
glucose clearance that
relates to dysfunction of
pancreatic beta-cells

Epidemiology

In 2000, the WHOestimated that

Undernourished children numbered 181.9
million (32%) in developing countries, 149.6
million children younger than 5 years.
A cross-sectional study of Palestinian
adolescents found that 55.66% of boys and
64.81% of girls had inadequate energy intake,
with inadequate protein intake in 15.07% of
boys and 43.08% of girls. The recommended
daily allowance for micronutrients was met by
less than 80% of the study subjects.


Mortality/Morbidity
Approximately 50% of the 10 million deaths
each year in developing countries occur
because of malnutrition in children younger
than 5 years.
In kwashiorkor, mortality tends to decrease as
the age of onset increases.


Age
Marasmus most commonly occurs in children younger
than 5 years. This period is characterized by increased
energy requirements and increased susceptibility to viral
and bacterial infections.
In some studies, the protein-energy malnutrition
prevalence among elderly persons is estimated to be:
- 4% for those living in the community,
- 50% for those hospitalized in acute care units or
geriatric rehabilitation units, and
- 30-40% for those in long-term care facilities.

AETIOLOGY

Different combinations of many

aetiological factors can lead to PEM in
children. They are:
Social and Economic Factors
Biological factors
Environmental factors
Role of Free Radicals & Aflatoxin
Age of the Host

 Amongst the Social, Economic, Biological

and Environmental Factors the common
causes are:

Lack of breast feeding and giving diluted formula

Improper complementary feeding
Over crowding in family
Ignorance
Lack of health education
Poverty
Infection
Familial disharmony


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
most common cause of malnutrition is inadequate food
intake
rapid growth increases nutritional requirement.
immature immune systems causing a greater
susceptibility to infection
Gastrointestinal (Parasitic) infections can and often do
precipitate clinical protein-energy malnutrition
In developed countries protein-energy malnutrition is
more often caused by decreased absorption or
abnormal metabolism


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
decreased appetite, dependency on help for eating,
frequent acute illnesses with gastrointestinal losses
polypharmacy, decreased ability to concentrate urine.
psychosocial factors such as isolation and depression

AETIOLOGY of
PEM:

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

increase nutrient losses

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

History

poor weight gain or weight loss; slowing of linear growth.

behavioral changes: irritability, apathy, decreased social
responsiveness, anxiety, and attention deficit may
indicate PEM
Kwashiorkor characteristically affects children who are
being weaned
Signs include diarrhea and psychomotor changes
Adults generally lose weight, although edema can mask
weight loss.
Patients may describe listlessness, easy fatigue, and a
sensation of coldness.
PEM can also present with non-healing wounds.

Clinical features

The clinical presentation depends upon the

type , severity and duration of the dietary
deficiencies. The five forms of PEM are :
1.
2.
3.
4.
5.

Kwashiorkor
Marasmic-kwashiorkor
Marasmus
Nutritional dwarfing
Underweight child

Classification of PEM
(FAO/WHO)

Body weight
as percentage
of standard

Edema

Kwashiorkor

60 80

Marasmic
kwashiorkor

< 60

++

Marasmus

< 60

++

Nutritional
dwarfing

< 60

Minimal

60 80

Underweight
child

Deficit in
weight for
height

Source: FAO / WHO 1971 Expert

Committee on Nutrition 8th Report.
WHO Technical Report Series 477

KWASHIORKOR

The term kwashiorkor is taken from the Ga

language of Ghana and means "the sickness
of the weaning.
Inadequate protein intake with reasonable
caloric (energy) intake.
Kwashiorkor, also called wet protein-energy
malnutrition.
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.

 Kwashiorkor was thought to be caused by

insufficientprotein consumption but with
sufficient calorie intake, distinguishing it
frommarasmus.
More recently,micronutrient and antioxidant
deficiencies have come to be recognized as
contributory.
Victims of kwashiorkor fail to produce antibodies
followingvaccinationagainst diseases, including
diphtheriaandtyphoid.
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

Failure to Thrive
Moon facies
Changes inskin pigment.
Decreased muscle mass
Diarrhea
Fatigue
Hair changes (change in
color or texture)
damaged immune system
infections
Irritability or apathy
swollen abdomen
(potbelly), and a fatty liver
Lethargy
Rash (dermatitis)
Flaky paint dermatosis
Shock (late stage)
Edema, Ascites


Depigmentation of hair causes it to be reddish
yellow to white. Curly hair becomes
straightened.
If periods of poor nutrition are interspersed
with good nutrition, alternating bands of pale
and dark hair, respectively, called the flag
sign.
Also, hairs become dry, lusterless, sparse, and
brittle; they can be pulled out easily.

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

Monkey facies
Loss of subcutaneous fat
Severe muscle wasting
The child looks appallingly thin
and limbs appear as skin and
bone
Wrinkled skin
Bony prominence
Associated vitamin
deficiencies
Failure to thrive
Irritability, fretfulness and
apathy
watery diarrhoea and acid
stools
Mostly hungry but some are
anoretic
Dehydration
Temperature is subnormal

DIFFERENCE 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

-MENTAL
CHANGES

Sometimes quite
and apathetic

May be masked
by edema
Irritable,
moaning,
apathetic

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 (10-25 g/L), 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 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.

Investigation

The WHO recommends the following laboratory tests:

Blood glucose
Examination of blood smears by microscopy or direct
detection testing
Hemoglobin
Urine examination and culture
Stool examination by microscopy for ova and parasites
Serum albumin
HIV test (This test must be accompanied by counseling of
the child's parents, and strict confidentiality should be
maintained.)
Electrolytes

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.

Ten Steps to
Recovery
in Malnourished
Children

Ashworth A, Jackson A,
Khanum S & Schofield C
1996

Steps 1 and 2

1. Prevent/treat HYPOGLYCEMIA
2. Prevent/treat HYPOTHERMIA

KEY is frequent feeding every two hrs

night/day
Skin to skin contact with parent, warm
lamp,
warm blanket, avoid exposure

Step 3

Treat/prevent dehydration
1. Give ReSoMaL or comparable oral solution.
2. Do not use the standard WHO oral
rehydration salts solution. It contains too
much sodium and too little potassium for
severely malnourished children.
3. Do not use the IV route except in shock, and
then do so with care to avoid flooding the
circulation and overloading the heart.
4. Feed through diarrhea, continue breast feeding

Step 4

CORRECT ELECTROLYTE IMBALANCES

* Excessive Na
* Deficient potassium
* Deficient magnesium
Remember: Two weeks minimum to correct
Prepare meals w/o salt
Do NOT use a diuretic to treat edema

Step 5

TREAT INFECTION
Give to ALL severely malnourished children

broad-spectrum antibiotic
measles vaccine to all children > 6 months.
Vitamin A
Mebendazole 100 mg BID x 3 days

Consider HIV and TB

Step 6

CORRECT MICRONUTRIENTDEFICIENCIES
All severely malnourished children have vitamin
and mineral deficiencies.
Recommend: Zinc, copper and MV daily
Vitamin A and folic acid on Day 1
Do NOT give iron until the child has a good
appetite and starts gaining weight (usually during
the second week of treatment).

Step 7

Cautious Feeding
Powdered milk, sugar and oil
May include electrolyte/mineral
solution
Day 1 7
Low in protein and iron, high in
energy

Step 8

Rebuild Tissues
Second week
Advance to 200 ml/kg/day div q 3 to 4 hours
Advance to local foods peanut butter, beans,
margarine energy dense local foods

Step 9

Stimulation, Play and Loving

Care

tender, loving care

structured play and physical activity as soon as the
child is well enough
a cheerful, stimulating environment.
Encourage mothers involvement
90% expected weight for height ready for
discharge

Step 10

Preparation for
Discharge

Nutritional education
Immunization
Home
Follow Up

Treatment of Malnutrition

PHASE

STABILISATION
Day 1-2

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Hypoglycaemia
Hypothermia
Dehydration
Electrolytes
Infection
Micronutrients
Cautious feeding
Rebuild tissues
Sensory stimulation
Prepare for follow-up

Day 2-7+

no iron

REHABILITATION
Week 2-6

with iron

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

Quiz

St.Ann's Degree College for

Women

Q. 1

Protein-energy malnutrition (PEM) refers to a

state where the infant's dietary intake is
insufficient in:
a)
b)
c)
d)

Protein
Overall calorie
Carbohydrates
Both A and B

Q. 2

PEM occurs most frequently and has its most

devastating consequences during:
a)
b)
c)
d)

Infancy only
Infancy and early childhood
Early childhood and adolescence
Adolescence and adulthood

Q. 3

Of all the behavioral symptoms associated

with marasmus and kwashiorkor, _________ and
__________________ are the most commonly
observed
a)
b)
c)
d)

Irritability; sadness
Crying; frequent loss of appetite
Lethargy; reduced activity
Apathy; lessened interest in the environment

Q. 4

The ideal first food for the newborn and young

infant up to age six months is:
a)
b)
c)
d)

Iron-fortified formula
Breast milk
Rice cereal
Soy milk

Q. 5

the first indication that PEM has resulted in

permanent brain damage is:
a)
b)
c)
d)

Premature birth
Low birth weight
Slowed reflexes at birth
A reduced head circumference

References
St. Ann's Degree College for Women
Center for Global Pediatrics - University
of Minnesota
Medscape
Up-to-date
Dr. Anwar Lecture

THE END

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