Protein Energy Malnutrition

Child of Kwashiorkor and Marasmus
Child of Kwashiorkor and Marasmus

Protein Energy Malnutrition also known as PEM is a range of clinicopathological condition arising from lack of varying proportions of protein and calories, occurring most frequently in infants and young children and is usually associated with infection. It is the most common nutritional disorder in developing countries like Bangladesh, India, African countries etc. Department of Pediatrics under Faculty of Medical Sciences of University of Nigeria has conducted a research on “Under-five Protein Energy Malnutrition Admitted at the University of In Nigeria Teaching Hospital”. The online version was published at 14 June 2012 in Nutrition Journal. The objective of this study was to find out the risk factors, prevalence, case fatality rates etc. According to that study most common age groups with PEM were 6 to 12 months (55.7%). Marasmus (34.9%) was the most common form of PEM. The most common associated co-morbidities were Diarrhea and malaria. These children were mainly from low economic class. Case fatality rates approximately 40.1%. Marasmic-kwashiokor was mostly responsible for higher case fatality rates. This study suggested that improving the infant feeding systems by promoting exclusive breastfeeding for the first six months of life, followed by appropriate weaning with continued breast feeding can lower the effect. PEM mainly affects by two forms Marasmus and Kwashiorkor.

Most Common Nutritional disorder in Bangladesh:

  1. Protein Energy Malnutrition.
  2. Vitamin and other micro-nutrient deficiency.
  3. Nutritional anemia- Iron Deficiency anemia.
  4. Iodine deficiency disorder.

It is an important cause of death of under 5 children in Bangladesh. According to new WHO Growth Reference Standard, 2.5% Under 5 children in Bangladesh are severely wasted and the death rate is as high as 15% even with care in Hospital. United Sates has more cases of Secondary PEM as a complication of AIDS, Cancer, CKD, IBD and other systemic diseases that affect the absorption and utilization of nutrient. Kwashiorkor was first recognized by Prof. Cicely Williams in 1933 from Gold Coast. It means ‘red boy’, or ‘Deposed Child’.

According to an Article Published by NCBI:

Inappropriate infant and young child-feeding practices (breastfeeding and complementary feeding) have been identified as a major cause of malnutrition. The protocolized management of severe protein-energy malnutrition at the Dhaka hospital of ICDDR, B has reduced the rate of hospital mortality by 50%. A recent study at ICDDR, B has also documented that home-based management of severe protein-energy malnutrition without follow-up was comparable with a hospital-based protocolized management.

Classification of Protein Energy Malnutrition

There are several ways of classification of Protein Energy Malnutrition. 

Etiological classification:

  • Primary malnutrition: due to primary lack of food.
  • Secondary malnutrition: due to chronic disease or causes other than lack of food.

WHO classification Under-nutrition:

Moderate undernutritionSevere undernutrition
Symmetrical edemaNoYes
Weight for height (measure of wasting)SD score -2 to -3SD score <3
Height for age (measure of stunting)SD score -2 to -3SD score <-3

See more about: SD Score or Z Score.

Wellcome Trust Classification

It is calculated by Weight of the child divided by the normal weight of the child for that age. The result is multiplied by 100.

Wt. between 80 – 60 %
With edema– Kwashiorkor
Without edema– Under nutrition
Wt. between  < 60 %
With edema– Marasmic Kwashiorkor
Without edema– Nutritional Marasmus

Gomez Classification:

It is used in Bangladesh by BINP and NNP.

Weight for age (% of median)Grade of malnutrition
76-99Grade I  mild malnutrition
61-75Grade II moderate malnutrition
<60Grade III severe malnutrition

Difference between Marasmus and Kwashiorkor:

Difference between Marasmus and Kwashiorkor
Difference between Marasmus and Kwashiorkor
Age of maximum incidence6-12 months12-36 months
Essential features:

  1. Edema
  2. Wasting
  3. Growth retardation
  4. Mental change
  1. Absent
  2. Gross wasting
  3. Severe
  4. Sometimes
  1. Present
  2. Less obvious
  3. Less severe
  4. Present
Variable features:

  1. Skin changes
  2. Hair change
  3. Appetite
  4. Diarrhoea
  5. Hepatomegaly
  6. Fatty liver
  7. Stunting

  1. Infrequent
  2. Infrequent
  3. Good
  4. Infrequent
  5. Absent
  6. Absent
  7. Severe
  1. Present
  2. Present
  3. Poor
  4. Present
  5. Present
  6. Present
  7. Moderate
Biochemical changes:

  1. Serum albumin
  2. Serum enzyme
  3. Blood sugar
  4. Blood urea
  5. Serum triglycerides
  6. Serum cholesterol
  7. Serum fatty acids

  1. Mild Decreased
  2. Normal
  3. Normal
  4. Normal
  5. Normal
  6. Normal
  7. Elevated

  1. Decreased
  2. Decreased
  3. Low/normal
  4. Decreased
  5. Decreased
  6. Decreased
  7. Elevated
Endocrine changes:

  1. Serum cortisol
  2. Serum growth hormone
  3. Serum insulin
  4. Serum glucagon
  5. ADH
  6. Growth hormone
  7. T3, T4
  8. TSH
  1. Markedly elevated
  2. Normal
  3. Normal
  4. Increased
  5. Increased
  6. Decreased
  7. N or decreased
  8. Normal or high
  1. Elevated
  2. Elevated
  3. Low or normal
  4. Increased
  5. Increased
  6. Increased
  7. Normal or high
  8. Normal or decreased
Malnourished Child of Kwashiorkor and Marasmus
Malnourished Child of Kwashiorkor and Marasmus

Prevention of protein energy malnutrition:

The child survival concept (GOBIFFF) described in the document state of the world children 1982-83, UNICEF has created a revolutionary thought on child health care throughout the world.

  • Growth monitoring: WHO had devised a simple growth chart the road to health card. In Bangladesh the national Nutrition Council (NNC) has recently developed the health & nutrition card containing the message of GOBIFFF.
  • Oral rehydration therapy: It is a break-through in the management of diarrhea.
  • Breast feeding: Breast milk is the best food for a baby in a society. Breast feeding can be continued upto 2 years, but given exclusively for the initial 6 months.
  • Universal child Immunization: It should be done against measles, diphtheria, tetanus, pertussis, poliomyelitis & tuberculosis.
  • Female education: Female education is the utmost importance, because mother is the first & most important primary health worker for the children.
  • Food supplementation: It should be done for the mother during pregnancy, especially in the first trimester & lactationel period. Complimentary feeding started from 6 months of age.
  • Family spacing: Family spacing will have a revolutionary impact on the health of mother’s growth & survival of their children. Size of the family should be limited.
  • Vit A supplementation, deworming & salt intake are also other important measures for the prevention of PEM.

Risk Factors for development of PEM

There are some biological factors related to mother and baby. And some social and cultural factors varying from country to country.

Biological Factors of PEM:

  1. Low birth weight baby
  2. Twin birth or multiple birth
  3. Order of birth specially first and fifth pregnancy
  4. Interval between the birth, shorter the gap higher the risk.
  5. Age of mother (<20 years or >35 years)
  6. Family size (Larger the family size, more the risk)
  7. Female child

Cultural and Social Factors:

  1. Inappropriate infant and young child-feeding practices.
  2. Illiteracy
  3. Poverty
  4. Ignorance
  5. Single parent family
  6. Bad environmental condition
  7. Recurrent infection.

Severe Acute Malnutrition

It is defined as the presence of oedema of both feet and severe wasting or clinical signs of severe malnutrition.  This definition is given by WHO’ 2005. Here no distinction is made between the clinical conditions of Kwashiorkor, Marasmus, marasmic-kwashiorkor because the approach of treatment. Bangladesh has adopted this strategy to fight malnutrition.

Treatment of Protein Energy Malnutrition:

Treatment of mild to moderate PEM:

  1. These cases are best managed at their homes or in a local health center.
  2. Nutritional education should be given to the family & the community.
  3. Locally available & affordable nutritious balanced diet should be given to the patient.
  4. Treatment at home should be supervised & monitored-weekly visit to a nearby nutrition rehabilitation center or OPD of a hospital should be advised.
  5. Weight should be measured & plotted on growth chart.

Treatment of severe PEM:

A. Initial treatment:

  • Treatment & prevention hypoglycemia: To prevent hypoglycemia feeding should be given 2-3 hrly day & night.  If hypoglycemia is suspected, treatment should be given immediately without waiting for lab diagnosis.
  • Prevention of hypothermia: The child should not keep near a window, the room tem kept at < 350C.
  • Correction of dehydration: By ORS solution.
  • Treatment of septic shock: Every child with septic shock should immediately be given broad spectrum of antibiotic, kept warm, minimally handled. Measures are taken to prevent hypoglycemia. IV rehydration is done. If signs of CCF present treat accordingly.
  • Treatment of infection:

1st line treatment: No apparent signs of infection & no complication, cotrimoxazole if given orally. If complication is present combination of Inj. ampicillin plus gentamycin should be given.

2nd line treatment: If child fails to improve within 48 hrs. Inj. chloramphenicol should be added. Antitubercular drugs are given after diagnosis of tuberculosis.

  • Dietary treatment: Frequent feeding with small amount food is recommended through the NG tube.
  • Correction of vitamin deficiencies, mineral deficiencies, very severe anemia, heart failure.

B. Rehabilitation:

  • Nutritional rehabilitation
  1. Calorie & diet: During rehabilitation phase most children take between 150-220 kcal/kg/day.
  2. Vitamins & minerals: Children with moderate or severe anemia, elemental iron 3 mg/kg/day in 2 divided doses should be given for 3 months. Other vitamin & minerals should be continued.
  3. Monitoring.
  • Emotional & physical stimulation

Play therapy: Language, Teach local songs, rhymes and Motor skill development.

  • Immunization: According to national guideline.
  • Teaching parents how to prevent malnutrition from recurring.
  • Some special criteria for discharge.

C. Follow-up:

The children are followed up at interval of one week, 2 weeks & then 1 month until they achieve a WH> 90% or WA>65% & these usually takes 6-8 months. Multivitamin & Zinc are continued for one month & iron should be continued for 3 months in usual doses.

Treatment of Severe Acute Malnutrition:

The treatment of Severe Acute Malnutrition comprised of 10 steps of management protocol. It is a common question in Community Medicine. The easy way to remember this is “HHDI EM SAPP” [Mnemonics]. I used this Mnemonics to remember it easily. You can made it your own.

  1. Prevent Hypoglycemia.
  2. Prevent Hypothermia.
  3. Prevent Dehydration.
  4. Prevent Infection.
  5. Correct Electrolyte imbalance.
  6. Correct Micro-nutrient deficiency.
  7. Start feeding with caution.
  8. Achieve catch up growth.
  9. Provide sensory stimulation and emotional support.
  10. Prepare for discharge and follow up after recovery.
Treatment of Severe Acute Malnutrition
Treatment of Severe Acute Malnutrition

Resources and Bibliography:

Books of Step on to Pediatrics by Abid Hossain Mollah, Prof. Dr. M R Khan, Dr. M R Mollah etc

Severe Acute Malnutrition-WHO Community and Inpatient treatment

Updates on the management of severe acute malnutrition in infants and children Download
Publication date: 2013

WHO child growth standards and the identification of severe acute malnutrition in infants and children Download

10 facts on nutrition

For the integrated management of SAM: in- and out-patient treatment.

More information PEM_Management

Treatment of protein-energy malnutrition in chronic nonmalignant disorders American Society for Clinical Nutrition

Download Power Point Presentation PPT on Protein Energy Malnutrition

Download PDF on Protein Energy Malnutrition

About Dr. Alamgir Hossain Shemul 94 Articles
Passionate about Child Health and Well Being. MD Resident of Pediatric Hematology and Oncology in BSMMU. Passed MBBS from Rajshahi Medical College. Completed FCPS Part 1 in Paediatrics. Ex-Honorary Medical Officer at Dhaka Medical College Hospital and NICU Medical officer at Anwer Khan Modern Hospital, Dhaka.

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