Protein Energy Malnutrition

 Protein Energy Malnutrition (PEM)

1. Marasmus

Inadequate intake of colories (energy) and protein, characterized by wasting.

2. Kwashiorkor

Inadequate intake of protein, characterized by oedema.

3. Marasmic - kwashiorkor 

Classification of protein energy malnutrition (PEM)

1. Weight for age classification by Gomez

Weight for age (%) = weight of child/ weight of normal child of same age X 100

90%; normal nutritional status

76-90%; 1st degree malnutrition 

61-75%; 2nd degree malnutrition 

<60%; 3rd degree malnutrition 

2. Waterlow's classification; on the basis of Height for age

Height for age (%) = Height of the child/ Height of normal child of same age

95% = normal nutritional status

90-95%; mild malnutrition

85-90%; moderate malnutrition

<85%; Severe malnutrition

3. By Indian academy of paediatrics (IAP); on basis of weight for age; grade of malnutrition.

Weight for age(%) 

>80%; normal nutritional status 

71-80%; grade 1 malnutrition 

61-70%; grade ll malnutrition 

51-60%; grade lll malnutrition 

<50%; grade IV malnutrition 

4. Wellcome trust classification on the basis of weight for age and presence of edema

Classification         Weight for age            Edema 

1. Kwashiorkor        60-80%                      Present 

2. Under nutrition.   60-80%                      Absent

3. Marasmus.         >60%.                    Absent 

4. Marasmus.        >60%.                     Present 

Kwashiorkor 

5. WHO classification; describing malnutrition

a. Stunting; height for age

b. Underweight; weight for age

c. Wasting; weight for height

Etiology of PEM

1. Starvation

2. Infection

Gastrointestinal infection

HIV infection

3. Disease condition

Cystic fibrosis, chronic renal failure

Childhood malignancies, neuromuscular disease, congenital Heart disease

4. Lack of breast feeding

5. Lack of health education

6. Poverty

7. Improper supplementary feeding

8. Malabsorption

9. War and conflict

10. Poor mental status

11. Poor quality of diet

12. Illiteracy

13. Psychiatric disease; anorexia nervosa

14. Inappropriate management of food allergies

Clinical features

Marasmus

1. Due to deficiency of both calories and proteins

2. Severe muscle wasting

3. Sunken features (eyes)

4. Loss of subcutaneous fat and body weight

5. Wrinkled skin

6. Thin and bony face

7. Ribs clearly visible through skin

8. Hair are hypopigmented (dull brown or yellow in colour)

9. Face aged look, due to loss of subcutaneous fat of cheeks (buccal pads).

10. No edema present

11. Temperature is usually subnormal and pulse is slow.

12. Severe growth retardation

13. No hepatic enlargement

14. Dry atrophic skin

15. Mental change

16. Loss of weight

17. Skin appear dry, scaly, inelastic and is prone to infection.

Kwashiorkor 

1. Due to deficiency of protein in diet.

2. Edema

3. Moon face

4. Protruding abdomen

5. Fatty liver is seen

6. Nail plates are thinand soft (may fissured or ridged)

7. Depigmentation of ski 

8. Muscle wasting of upper limb but lower limb sowllen

9. Anemia

10. Dermatosis ( skin lesion)

11. Loss of appetite

12. Mental retardation

13. Serum protein low

14. Failure to thrive (height and weight fall below)

15. Hair changes very prominent (flag sign), alternate bands of hypopigmented.

16. Often suffer from recurrent episodes of Diarrhea, respiratory and skin infection.

17. Skin hyperpigmented (flaky paint), petechiae or ecchymosis appear in severe cases.

Diagnostic Evaluation

WHO recommends;

1. History taking and physical examination

2. Anthropometric Assessment

a. Weight for age

b. Weight for height

c. Height for age

3. Peripheral blood film (PBF)

Shows microcytic, macrocytic rbcs. 

4. Stool examination

Presence of Ova, parasites

5. Blood hematology and biochemistry

6. Urine examination

Management of Protein Energy Malnutrition (PEM)

1. Evaluate severity of PEM and other nutritional deficiency.

2. Assess the fluid and electrolyte lab investigation report

3. Prompt treatment of complication

4. Correct fluid and electrolyte abnormalities and to treat any infection.

5. Assess protein energy ratio and energy requirements.

6. Immunization, deworming of children and oral rehydration therapy for Diarrhea.

7. Nutrition counseling to parents

8. Medical follow up (weight monitoring)

9. Rule out infection

10. Parent counseling and education

11. Promote Breastfeeding

12. Supplementary food (weaning food)

Treatment of Protein Energy Malnutrition done in;

1. Initial phase (1-2 weeks) and 

2. Rehabilitation phase 

Treatment in initial phase (1- 2 weeks) includes;

1. Treatment of complications;

Hypoglycemia

Hypothermia

Infection

Electrolyte imbalance

Dehydration

Deficiency of nutrients

2. Correct nutritional deficiencies

3. Reversal of metabolic Abnormalities

4. Beginning of feeding; initiation of feeding

a. Energy dense feeding

b. Stimulation of emotional and sensorial development

c. Education about home based diet befor discharge

2. Rehabilitative phase (2-6 weeks)

a. Recovery of lost weight

b. Emotional and physical stimulation to child

c. Training to mother for care

d. Preparation for discharge

Recovery and discharge

Indication of child recovery;

1. Return of appetite

2. Disappearance of hepatospleenomegaly 

3. Gain in body weight

4. Rising serum albumin level

5. Absence of oedema

6. Educate parent to review and follow up periodically.

Prevention of Malnutrition

1. Prevention at family level

Brest feeding

Weaning

Immunization

Birth spacing 

2. Prevention at community level

Early detection and treatment

Integrated health packages;

Immunization, chemoprophylaxis, oral rehydration, periodic dewaorming

Growth monitoring

Nutritional education

Family planning education

3. Prevention at National level

Fortification of food

Nutritional rehabilitation services