2. Introduction
⚫Protein-energy Malnutrition (PEM) is the terminology
used for all kind of malnutrition as result of lack of
proteinand energy foods.
⚫Majorpublic health problem in India
⚫Particularly in children younger than 5 yearsold
⚫The most extreme forms of malnutrition, or (PEM),
are Kwashiorkorand Marasmus
3. 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.
4. Incidence
⚫Leading causeof mortalityand morbidity
⚫Susceptible to infectiousdiseases
⚫Incidence of malnutrition in Indiaand Africaare high
⚫30-40% children younger than 5 years
⚫7.6% have severe malnutrition
⚫
5. Causes and risk factors
⚫Age
⚫ Children between 6 months-4 yearsare in risk
⚫Sex
⚫ Boys are more
⚫Too manychildren in the same family (neglect)
⚫Lack of spacing between children
⚫Low birth weight baby
⚫Twin and multiple births
⚫Poorgrowth in the first few months
⚫ Mother’s failure to beast feed
⚫ Systemic disordersor GI structural disorders
6. Causes and risk factors
⚫Failureorstoppageof breast feeding
⚫Delay in weaning
⚫Infectiousdiseases
⚫Diarrhea
⚫ARI
⚫Measles
⚫Chronic diseases and certain congenital disorders
⚫Failure to thrive, CHD, Growth Retardation
⚫Lack of adequatecare for the pregnant women
⚫Acute illnessorsurgery
11. KWASHIORKOR
⚫Term ‘Kwashiorkor’ was introduced in 1935
⚫‘Red boy’ due tocharacteristics of pigmentary
changes
⚫Mainly found in preschool children or mayatanyage
⚫Infection precipitates
⚫Deficient intakeof both proteinand calories (
proteindeficiency are more predominant)
13. Grading
Grade I:Pedal oedema
Grade II: grade I+ facial puffiness
Grade III: grade II + oedemaof thechestwall and the
paraspinal area
Grade IV: grade III + ascites
14. MARASMUS
⚫Also termed as infantile atrophyorathrepsia
⚫Common infants may found in toddlers and even in later
life
⚫Deficient intakeof both proteinand calories ( calorie
deficiency are morepredominant)
⚫Looks likes looks likeold person with wizened and
shrivelled facedue to loss of buccal pad of fat.
⚫Initially thechild is irritable, hungry and craves for food
⚫Laterstages may become miserable, aptheticand refusal to
takeanything orally.
16. Grading of marasmus
⚫Grade I: lossof subcutaneous fat in the axillaand groin
⚫Grade II: grade I + lossof abdominal fat and fat in the
gluteal region
⚫Grade III: grade II + lossof fat in thechestwall and the
praspinal region
⚫Grade IV : grade III + lossof the buccal pad of fat
17.
18.
19. Marasmic kwashiorkor
⚫It is condition where thechild manifested both the
featuresof marasmusand kwashiorkor.
⚫The presence of edema is essential for thediagnosis
and other featursof kwashiorkor mayor may not
present
20. Prekwashiorkor
⚫It is a condition when thechild is having featuresof
kwashiorkorwithoutedema.
⚫If theearly management is initiated byearlydiagnosis
of thecondition
⚫Thechild may be protected from full-blown
kwashiorkor
21. Nutritional dwarfing
⚫It is condition when thechild is having significant low
weightand height for theage withoutanyovert
featuresof kwashiorkoror marasmus
⚫It is usuallyseen when the PEM continueover a
numberof years
24. Management of PEM
⚫Multidisciplinary approach
⚫Aim
⚫ To supplywhat has been lacking in diet
⚫ Topreventand treat infectionsand otherdiseases
⚫ To teach parents how to preventrelapse
25. Management of PEM
⚫Domiciliary management
⚫Managed at home
⚫Parents areeducated aboutdietary management
⚫ Nutritional counselling and demonstration
⚫ Less expensive locallyavailable food
⚫ Communitysupportsystem ( supervision)
⚫ Homevisit
⚫ Medical follow up ( weight monitoring )
26. ⚫Managementat hospital
⚫Needed atadvance cases
⚫Mild PEM
⚫Ruleout infections
⚫Provide nutritional counselling to parents
⚫Replace nutrientsand breast feed till 2 yearsof age, with
the introduction of supplementary feeding at 4-5
months
⚫Immunization
⚫Parents counselling and education
27. Moderate PEM
⚫Admit to hospital
⚫Treat underlying causeor problems
⚫Diet is the most importantpartof treatment
⚫Providea reinforced milk diet
⚫Teach preparation of milk diet
28. 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
29. Complications
⚫Acute
⚫Systemic local infections
⚫Severe dehydration
⚫Shock
⚫Hypoglycemia
⚫Hypothermia
⚫Bleeding disorders
⚫Hepatic dysfunction
⚫Long term
⚫Growth retardation
⚫Mental sub normalities
⚫Visual and learning
disabilities
32. Nursing diagnosis
⚫Imbalanced nutrition less than body requirement
⚫Fluid and electrolyte imbalance
⚫Risk for infection
⚫Potential forcomplications
⚫Knowledgedeficit
⚫Parental anxiety
⚫Body imagedisturbances
