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1. PEM
By: Nabina Paneru
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2. Definition
• Undernutrition:
Inadequate comsumption, poor absorption or excessive loss of nutrients
• Overnutrition:
Overindulgence or excessive intake of specific nutrients
• Malnutrition:
Refers to both undernutrition as well as overnutrition
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3. Malnutrition according to WHO
The cellular imbalance between the supply of nutrients and energy and
the body’s demand for them to ensure growth, maintenance, and specific
functions.
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4. Protein Energy Malnutrition
• According to WHO: “ range of pathological condition arising out of
co-incident lack of protein and energy in varying proportions most
frequently seen in infant & young children & usually associated with
infection.”
• Marasmus: weight for age < 60% expected
• Kwashiorkor: weight for age <80% + edema
• Marasmic kwashiorkor: wt/age <60% + edemaNabina Paneru

5. Epidemiology
• Global Burden – more prevalent in developing countries. “Often starts
in the womb and ends in the tomb”
• PEM affects every 4th child world-wide
• More than 50% of deaths in 0-4 years are associated with malnutrition
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7. INDICATORS
Indicator Interpretation Interpretation
Stunting Low height for age Chronic malnutrition
Prolonged food
deprival/disease
Wasting Low weight for height Acute malnutrition
Recent food
deficit/illness
Underweight Low weight for age Combined indicator to
reflect both acute or
chronic malnutrition
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8. Classification
• Weight for age
• Height for age
• Weight-for-height
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9. Weight for age
• GOMEZ classification
- Only wt for age taken into account
- No comment about heightNutritional status Wt for age (% of
expected)
normal >90
1st degree PEM 75-90
2nd degree PEM 60-75
3rd degree PEM <60 Nabina Paneru

10. Welcome Trust/ International Classification
• Based on wt-for-age and presence of edema
Weight for age (% of expected) Edema Clinical type of PEM
60-80 + Kwashiorkor
60-80 - Underweight
<60 - Marasmus
<60 + Marasmic kwashiorkor
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11. IAP Classification (1972) (Indian Academy of
Pediatrics)
Grade of malnutrition Weight for age of the standard
Normal >80
Grade I 71-80 (mild malnutrition)
Grade II 61-70 (moderate malnutrition)
Grade III 51-60 (severe malnutrition)
Grade IV <50 (very severe malnutrition)
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12. Age independent Indices
• Weight for height
• Mid arm circumference
• Body mass index
• Index (Kanawati, Dughdale, Rao & singh’s)
• Skin fold thickness
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14. Risk Factors
• LBW
• Multiple birth
• Closely spaced birth
• Early stoppage of breastfeeding
• Too early or late weaning
• Recurrent infections
• Illiteracy, poverty
• Secondary due to malabsorption
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15. Kwashiorkor
• First introduced by Dr. Cicely Williams in 1935
• Kwashiorkor is caused due to inadequate protein
in diet despite an adequate calorie intake.
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16. Sign and symptoms
• Moon face: Baby has a fat clubby appearance with a moon face, the
baby’s face looks rounder than usual but on a closer look wasting of
muscles over buttocks and thighs.
• Edema: Mild in the beginning on the lower limbs but generalized later
on. Edema is the main sign which distinguishes kwashiorkor from
marasmus.
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17. Contd.
• Misery and apathy: looks unhappy. Child may cry miserably. Just sits
on mothers arms, sometime moaning and shows no interest in life.
Doesn’t want to play or crawl.
• Weak muscles: Sometimes a child is unable to sit or walk. His/her
abdomen sticks out (pot belly) because the muscles of her abdominal
wall are weak.
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18. Contd..
• Changes in skin: Skin becomes dry, pigmented and flabby. Dermatitis
can occur (skin is dry, ulcers and may peel)
• Lethargy: The child appears weak, unable to stand or walk
• Retarded growth: The child’s weight is less than 80% of the expected
age group. Sometimes the weight may be within normal range due to
presence of severe edema.
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19. Contd.
• Increased susceptibility to infections
• Poor appetite, nausea, vomiting.
• Lack of proper development of muscle and absence of muscle tone.
Gross muscle wasting is present but difficult to detect due to edema.
• Enlargement of liver and abdomen is usually distended.
• Mental deficiency
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20. Marasmus
• Marasmus is the severe form of malnutrition.
• It is caused by shortage of protein and calories
in the body. Marasmus is also referred to as wasting
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21. Sign and symptoms
• Wasting od subcutaneous fat and muscles with growth retardation and
extreme weight loss
- Grade 1: Wasting starts in axilla & groin
- Grade 2: Wasting extended to thigh and buttocks
- Grade 3: Chest and abdomen
- Grade 4: Wasting of buccal pad of fat also
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22. Contd..
• Sunken eyes
• Thin face
• Ribs and shoulders clearly visible through the skin
• Loose skin that sometime hangs in folds in the upper arms, thighs and
buttocks
• Persistent dizziness
• Diarrhea
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23. Contd.
• Active, alert and irritable behavior and crying all the time
• Frequent dehydration
• Frequent infections that don’t show external signs like fever or lesions
• Old man face (monkey face) develops
• Distended abdomen due to wasting
• Mental retardation
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24. Differences between Marasmus and kwashiorkor
Marasmus Kwashiorkor
Definition A kind of malnutrition caused due
to deficiency of proteins,
carbohydrate and fats in the diet
A kind of malnutrition primarily
caused due to insufficient intake
of proteins.Nabina Paneru

25. Always present
Marasmus Kwashiorkor
Fat wasting Severe loss of
subcutaneous fat
Fat often retained but not firm
Edema None Present in lower legs usually in
face and lower arms
Weight for height Very low Low but may be masked by
edema
Mental changes Sometimes quiet and
apathetic
Irritable, moaning apathetic
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26. Contd..
Sometime present
Marasmus Kwashiorkor
Appetite Usually good Poor
Diarrhea Often ( current & past) Often (Current and past)
Skin changes Usually none Differ pigmentation, sometimes flaky
paint dermatosis
Hair changes
Hepatic enlargement
Seldom
None
Sparse, silky/easily pulled out
Sometimes due to accumulation of fatNabina Paneru

27. Contd.
Biochemical
Marasmus Kwashiorkor
Serum albumin Normal or decreased Low
Urinary urea per gram,
creatinine
Normal or slightly
decreased
Low
Hydroxyproline/creatinine
ratio
Low Low
Plasma/amino acid ratio Normal Elevated
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28. Marasmic Kwashiorkor
• Combination of signs and symptoms of marasmus and kwashiorkor.
• Child is severely underweight less than 60% of the expected weight
for his/her age
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29. Treatment of protein calorie malnutrition
according to WHO protocol
WHO Ten steps to recovery in Malnourished Children
In 2 Phase
• Initial stabilization – 2 to 7 days
• Rehabilitation – several weeks
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31. Step 1
Prevent/ Treat Hypoglycemia
Blood glucose <54mg/dl
If cant be measured assume hypoglycemia
Treatment
Asymptomatic-
• 50 ml of 10% glucose or sucrose solution orally or NG
• Feed with starter F-75 q2hrly
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32. Contd.
• Symptomatic
- 10% dextrose i.v 5ml/kg
- Follow with 50ml of 10% glucose or sucrose solution NG
- Feed with starter F-75 2hrly
- Start appropriate antibiotics
Prevention
- Feed two hourly, start straightaway or if necessary rehydrate first
- Prevent hypothermia
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33. Step 2
Prevent and Treat Hypothermia
• Rectal temp <35.5 C/ 95.5 F or axillary <35 C/95 F
Treatment
- Cloth the child with warm clothes
- Provide heat
- Avoid rapid rewarming
- Feed the child
- Give appropriate antibiotics Nabina Paneru

34. Step 3
Treat/ Prevent Dehydration
• Assume all SAM (Severe acute malnutrition) with watery diarrhea to have some
dehydration
• Hypovolemia can co exist with edema
Treatment
- Use reduced osmolarity ORS with potassium supplements for rehydration and
maintenance
- Initiate feeding within 2-3 hrs of starting rehydration with F-75 formula on alt hrs with
reduced osmolarity ORS
- Be alert for signs of overhydration Nabina Paneru

35. Step 4
Correct Electrolyte imbalance
• Supplemental potassium at 3-4 meq/kg/d for atleast 2 weeks
• On day 1, 50 % MgSO4 i.m once (0.3 ml/kg, max upto 2ml)
Thereafter give extra Mg (0.8 – 1.2 meq/kg daily)
• Excess body sodium exists even though plasma sodium may be low
Prepare food without adding salt.
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36. Step 5
Treat/ Prevent Infection
• Multiple infection common
• Usual signs of infection such as fever often absent
• Majority of blood stream infections due to gram negative bacteria
• Assume serious infections and treat
• Hypoglycemia and hypothermia are markers of severe infection
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37. Contd.
• Treatment
- Ampicillin iv atleast 2 days f/b oral amoxicillin
- i.v gentamycin or amikacin for 7 days
If no improvement within 48 hrs
• i.v cefotaxime
• Ceftriaxone Nabina Paneru

38. Contd.
Prevention
• Follow standard precautions like hand hygiene
• Give measles vaccine if >6 month and not immunized or if the child is
more than >9 months
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39. Step 6
Correct Micronutrient deficiencies
• Use upto twice the RDA (Recommended Dietary Allowance) of
various vitamins and minerals
• On day 1, Vit A orally (if age >1yr 2lakh IU, 6-12 month 1lakh IU, 0-5
month: 50,000 IU)
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40. Contd.
• Folic acid 1mg/day (5mg on Day 1)
• Copper 0.2-0.3 mg/kg/d
• Iron 3mg/kg/d, once child starts gaining wt, after stabilization phase.
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41. Step 7
Initiate Re-feeding
• Initiate feeding as soon as possible as frequent small feeds
• If unable to take orally – NG feeds
• Total fluid recommended is 130ml/kg/d, reduce to 100ml/kg/d if there
is severe, generalized edema
• Continue breast feeding as desire
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42. Contd.
• Start with F-75 starter feeds q2hrly
• F-75 contains 75kCal/100ml with 1g protein/100ml
• If persistent diarrhea, cereal based low lactose F-75 diet as starter diet
• If diarrhea continues on low lactose diets give F-75 lactose free diets
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43. Step 8
Achieve Catch up growth
• Once appetite returns in 2-3 days, encourage higher feeds
• Increase volume offered in each feed and decrease the frequency of
feeds to 6 feed/d
• Continue breast feeding on demand
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44. Contd.
• Make a gradual transition from F-75 to F-100 diet
• F-100 contains 100kCal/100ml with 2.5-3g protein/100ml
• Increase calories to 150-200 kCal/kg/d and proteins to 4-6g/kg/d
• Add complementary foods as soon as possible to prepare the child for
home foods at discharge
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45. Step 9
Provide Sensory Stimulation and Emotional Support
• A cheerful, stimulating environment
• Age appropriate structured play therapy for atleast 15-30 mins/day
• Age appropriate physical activity as soon as the child is well enough
• Tender loving care
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46. Step 10
Prepare for Follow up after Recovery
Said to have recovered when wt for ht is 90% of NCHS (National Centre for
Health statistics) median and has no edema
Primary failure to respond if
• Failure to gain appetite by D4
• Failure to start losing edema by D4
• Presence of edema on D10
• Failure to gain atleast 5g/kg/d by D10
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47. Contd.
Secondary failure to respond if
• Failure to gain at least 5g/kg/d for consecutive days during the
rehabilitation phase
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48. Prevention of PEM
Primary prevention:
• Health promotion
- MCH nutrition supplementation & education
- Exclusive breast feeding
- Dvt of low cost weaning foods: the child should be made to eat food at
frequent intervals
- Nutrition education
- Family planning
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49. Contd.
• Specific protection
- High protein-energy-rich diet to the child. Milk, eggs, fresh fruits
should be given if possible
- Immunization
- Food fortification
- Supplementary nutrition
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50. Secondary prevention
• Early diagnosis and prompt treatment
- Nutrition surveillance treatment
- Diagnosis of PEM
- Early diagnosis and treatment of infections and diarrhea
- Therapeutic nutrition
- Deworming
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51. Tertiary Prevention
• Nutrition rehabilitation
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52. Use of Pitho
Super flour porridge (Sarbottam pithoko lito)
• In Nepal weaning traditionally begins with the rice feeding ceremony
(pasne), where children receive their first meal.
• One of the most common traditional weaning food is super flour or
pitho or sarbottam pitho or lito.
• It is the porridge made from the finely ground flour of roasted cereal,
grains and pulses.
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53. Ingredients for super flour
• One parts pulse – soybeans are best but either small beans, grains or
peas can be used.
• Two part whole grain cereal such as maize or rice.
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54. Method of preparing surbottam pitho
• The pulses and grains are cleaned
• Roasted well (separately)
• Grounded into fine flour (separately or together)
• The flour can be stored in a airtight container for one to three months.
• The flour is stirred into boiling water and cooked for a short time. The
proper amount and consistency of the porridge will depend on the age
and condition of the child. Salt should not be added.
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55. Amount needed for child
• Porridge made from one or two pinchfull of supper flour given twice
a day is enough.
• Gradual increase to 50 gms.
• Older children will be able to eat foods made from more than 50 gram
of the supper flour and will be eating increasing amounts of other
foods as well.
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56. Advantages of super flour
• It is a convenient and adaptable food that stores well.
• For older children the flour can be eaten dry (as satu) or added in fresh
boiled milk or any other liquid without further cooking as all the
ingredients are preroasted.
• Infants like the roasted flavor.
• Super flour is highly recommended for use with severely malnourished
childhood.
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57. Use of flour
• For babies of six months of age or more porridge made with one or
two teaspoons of super flour given two or three times a day is enough
with breastfeeding.
• As the child grows, the amount of porridge used will gradually
increase until about 100gm (four tablespoons) of super flour each day.
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58. Contd.
• Adding green leafy vegetables in the porridge provide vitamin A to the
child as flour itself doesn’t supply enough vitamin A for a chlild daily
need.
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59. • Rice flour porride (lito): from roasted rice or with beaten rice
(cheura)
• Roasted cereal grain flour (saatu or sattu): from roasted maize,
wheat, barley etc.
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