3. Introduction
Protein-energy Malnutrition (PEM) is the terminology
used for all kind of malnutrition as result of lack of
protein and energy foods.
Major public health problem in India
Particularly in children younger than 5 years old
The most extreme forms of malnutrition, or (PEM),
are Kwashiorkor and Marasmus
4. Introduction
Severe acute malnutriton (SAM)
Edematous (kwashiorkor),
Severe wasting (marasmus)
Marasmic kwashiorkor (features of both marasmus and
kwashiorkor
5. Definition
A group of clinical conditions that may result
from varying degree of protein deficiency and
energy (calorie) inadequacy.
Previously it was known as protein calorie
malnutrition.
6. Incidence
Leading cause of mortality and morbidity
Susceptible to infectious diseases
Incidence of malnutrition in India and Africa are high
30-40% children younger than 5 years
7.6% have severe malnutrition
7.
8. Causes and risk factors
Age
Children between 6 months-4 years are in risk
Sex
Boys are more
Too many children in the same family (neglect)
Lack of spacing between children
Low birth weight baby
Twin and multiple births
Poor growth in the first few months
Mother’s failure to beast feed
Systemic disorders or GI structural disorders
9. Causes and risk factors
Failure or stoppage of breast feeding
Delay in weaning
Infectious diseases
Diarrhea
ARI
Measles
Chronic diseases and certain congenital disorders
Failure to thrive, CHD, Growth Retardation
Lack of adequate care for the pregnant women
Acute illness or surgery
10. Risk factors
LBW
Multiple birth
Not breast fed
High birth order
Congenital defects poor socioeconomic background
Single parents / orphans/ foster home
Maternal deprivation
11. Classification
According to severity
Mild PEM
Weight <3rd percentile for their age but above the -3 SD
Growth curve flat tend to point downwards
Moderate PEM
Weight are equal to or below the -3 SD line but above the -4 SD
No edema , skin or hair changes
alert and appetite is normal
Severe PEM
Weight are equal or below the -4 SD
Marasmus and Kwashiorkor
16. KWASHIORKOR
First descried by Dr Cicely Williams in 1933
Term ‘Kwashiorkor’ was introduced in 1935
‘Red boy’ due to characteristics of pigmentary
changes
Mainly found in preschool children or may at any age
Infection precipitates
Deficient intake of both protein and calories (
protein deficiency are more predominant)
18. Grading
Grade I:Pedal oedema
Grade II: grade I+ facial puffiness
Grade III: grade II + oedema of the chest wall and the
paraspinal area
Grade IV: grade III + ascites
19. MARASMUS
Also termed as infantile atrophy or athrepsia
Common infants may found in toddlers and even in later
life
Deficient intake of both protein and calories ( calorie
deficiency are more predominant)
Looks likes looks like old person with wizened and
shrivelled face due to loss of buccal pad of fat.
Initially the child is irritable, hungry and craves for food
Later stages may become miserable, apthetic and refusal to
take anything orally.
21. Grading of marasmus
Grade I: loss of subcutaneous fat in the axilla and groin
Grade II: grade I + loss of abdominal fat and fat in the
gluteal region
Grade III: grade II + loss of fat in the chest wall and the
praspinal region
Grade IV : grade III + loss of the buccal pad of fat
22.
23.
24. Marasmic kwashiorkor
It is condition where the child manifested both the
features of marasmus and kwashiorkor.
The presence of edema is essential for the diagnosis
and other featurs of kwashiorkor may or may not
present
25. Prekwashiorkor
It is a condition when the child is having features of
kwashiorkor without edema.
If the early management is initiated by early diagnosis
of the condition
The child may be protected from full-blown
kwashiorkor
26. Nutritional dwarfing
It is condition when the child is having significant low
weight and height for the age without any overt
features of kwashiorkor or marasmus
It is usually seen when the PEM continue over a
number of years
27. Assessment
Nutritional assessment
History
Clinical findings
24 hour retrospective dietary recall
Societal and environmental assessment
Growth chart
Anthropometric measurement compare with
population standard
28. Lab findings
Serum albumin
Transferrin
Prealbumin
Albumin globulin ratio (decr )
Creatinine high index
Nitrogen balance (protein anabolism and catabolism)
Blood glucose level
Blood urine and rectal swab cultures
Mantoux’s test
Microscopic examination of urine or stool
29. Management of PEM
Multidisciplinary approach
Aim
To supply what has been lacking in diet
To prevent and treat infections and other diseases
To teach parents how to prevent relapse
30. Management of PEM
Domiciliary management
Managed at home
Parents are educated about dietary management
Nutritional counselling and demonstration
Less expensive locally available food
Community support system ( supervision)
Home visit
Medical follow up ( weight monitoring )
31. Management at hospital
Needed at advance cases
Mild PEM
Rule out infections
Provide nutritional counselling to parents
Replace nutrients and breast feed till 2 years of age, with
the introduction of supplementary feeding at 4-5
months
Immunization
Parents counselling and education
32. Moderate PEM
Admit to hospital
Treat underlying cause or problems
Diet is the most important part of treatment
Provide a reinforced milk diet
Teach preparation of milk diet
33. Severe PEM
Hospitalization
Watch for complications
Dietary treatment
4 gm /kg protein
Marsmus 150-200 kcal/kg per day
Kwashiorkor 100 kcal /kg per day
Reinforced milk or high calorie cereal milk can be given
Children should be Fed with milk diet at the ratio of 125 ml/kg/ day
Prevent hypoglycemia
NG tube feeding
Gradually increase the feed
Schedule 8 feeds per day
Supplement minerals and vitamin
Treat infections
34. Complications
Acute
Systemic local infections
Severe dehydration
Shock
Dyselectrolytemia
Hypoglycemia
Hypothermia
CCF
Bleeding disorders
Hepatic dysfunction
SIDS
Convulsions
Long term
Cachexia
Growth retardation
Mental sub normalities
Visual and learning
disabilities
37. Nursing diagnosis
Imbalanced nutrition less than body requirement
Fluid and electrolyte imbalance
Risk for infection
Potential for complications
Knowledge deficit
Parental anxiety
Body image disturbances