Protein-energy malnutrition (PEM) is a potentially fatal body-depletion disorder.

1. Presented By :
Qurrot Ulain Taher
(B.Sc-IInd Yr)
St. Ann’S College for Women.
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2. 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 the vitamins,
minerals, and other nutrients it needs to maintain healthy
tissues and organ function.
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3.  PROTEIN ENERGY MALNUTRITION
It is a group of body depletion disorders which
include kwashiorkor, marasmus and the intermediate
stages
 MARASMUS
Represents simple starvation . The body adapts to a
chronic state of insufficient caloric intake
 KWASHIORKOR
It is the body’s response to insufficient protein intake
but usually sufficient calories for energy
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4. DESCRIPTION
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5. 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
include marasmus, kwashiork
or, and intermediate states of
marasmus-kwashiorkor.
 PEM is due to “food gap”
between the intake and
requirement.
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6. AETIOLOGY
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7. 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
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8.  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
 Illiteracy
 Lack of health education
 Poverty
 Infection
 Familial disharmony
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9.  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 whose rapid
growth increases nutritional requirement.
 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
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10. AETIOLOGY of PEM:
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
 increase nutrient losses
Linear growth ceases
Static weight
Weight loss
Wasting
Malnutrition and its signs
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11. PREVALENCE
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12. PREVALENCE:
• Protein-energy
malnutrition is a basic
lack of food (from
famine) and a major
cause of infant
mortality and
morbidity worldwide.
• Protein-energy
malnutrition caused
0.46% of all deaths
worldwide in 2002, an
average of 42 deaths
per million people per
year.
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13. Child Malnutrition in
India
2005-2006
Urban 36.4
Rural 49.0
 Malnutrition is the direct St.Ann's Degree College for Women 50% of deaths in children.
or indirect cause of more
 PEM is a silent killer in many children.

14. CLINICAL FEATURES
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15. 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
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16. Classification of PEM
(FAO/WHO)
Body weight
as percentage  Oedema Deficit in
weight for
of standard height
Kwashiorkor 60 – 80 + +
Marasmic < 60 + ++
kwashiorkor
Marasmus < 60 0 ++
Nutritional < 60 0 Minimal
dwarfing
Underweight 60 – 80 0 +
child
Source: FAO / WHO 1971 Expert
St.Ann's Degree College for Women Committee on Nutrition 8th Report.
WHO Technical Report Series 477

17. 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.
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18.  Kwashiorkor was thought to be caused by
insufficient protein consumption but with
sufficient calorie intake, distinguishing it
from marasmus.
 More recently, micronutrient and
antioxidant deficiencies have come to be
recognized as contributory.
 Victims of kwashiorkor fail to
produce antibodies following vaccination against
diseases, including diphtheria and typhoid.
 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.
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19. SYMPTOMS
 Changes in skin 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)
 Lethargy or apathy
 Loss of muscle mass
 Rash (dermatitis)
 Shock (late stage)
 Swelling (edema) St.Ann's Degree College for Women

20. St.Ann's Degree College for Women

21. MARASMUS

 The term marasmus is derived from the Greek
word marasmos, which means withering or wasting.
 Marasmus is a form of severe protein-energy
malnutrition characterized by energy 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 chronic diarrhea.
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22. 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 are
absent
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23. DIFFERENCE IN CLINICAL FEATURES
BETWEEN MARASMUS AND
KWASHIORKOR
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24. St.Ann's Degree College for Women

25. DIFFERENCE IN CLINICAL FEATURES BETWEEN MARASMUS AND KWASHIORKOR
CLINICAL MARASMUS KWASHIORKOR
FEATURES
-MUSCLE
WASTING Obvious Sometimes
hidden by edema and
fat
-FAT WASTING Severe loss of Fat often retained but
subcutaneous fat not firm
-EDEMA None Present in lower legs,
and usually in face
and lower arms
May be masked by
-WEIGHT FOR Very low edema
HEIGHT
Irritable, moaning,
-MENTAL Sometimes quite and apathetic
CHANGES apathetic
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26. DIFFERENCE IN CLINICAL FEATURES BETWEEN MARASMUS AND KWASHIORKOR
CLINICAL MARASMUS KWASHIORKOR
FEATURES
-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 None Sometimes due to
ENLARGEMENT accumulation of fat
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27. 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.
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28. 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.
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29. UNDERWEIGHT CHILD
 Children with sub-
clinical 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
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30. BIOCHEMICAL & METABOLIC
CHANGES
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31. BIOCHEMICAL & METABOLIC CHANGES
 Significant findings in kwashiorkor include 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 insulinlike 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.
 Urinary excretion of hydroxyproline is diminished, reflecting
impaired growth and wound healing.
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32. St.Ann's Degree College for Women

33. TREATMENT
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34. 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.
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35. PREVENTION
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36. 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
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37. THANK YOU
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