Protein-energy malnutrition (PEM) refers to a range of pathological conditions caused by insufficient protein and calories. It most commonly affects infants and young children. The main forms of PEM are kwashiorkor, marasmus, nutritional dwarfing, underweight, and stunting. Kwashiorkor is characterized by edema and skin changes and is caused by low protein intake with adequate calories. Marasmus involves severe wasting and is caused by low energy intake. PEM is a major global issue, affecting over 1/3 of the world's population, especially in Asia and Africa. Causes include poverty, poor hygiene, frequent infections, and inappropriate feeding practices. Treatment involves medical care, dietary management with nutrient-dense foods

1. A.AARADHANA
Ist MSc. Food Technology and Management
1619101
PROTEIN-ENERGY
MALNUTRITION
PEM

2. DEFINITION
Is defined as a range of pathological conditions
arising from coincident lack of varying
proportions of protein and calorie, occurring
most frequently in infants and young children
and often associated with infection (WHO)
PEM

3. PEM

4. The worldwide magnitude of protein-energy malnutrition: an
overview from the WHO Global Database on Child Growth
World
 More than 1/3 of the world’s population.
For all indicators of PEM, a total of 80% of
the children affected live in Asia (mainly in
southern Asia).
 43% of children in developing countries are
stunted. 50% of child deaths in developing
countries are related to malnutrition
PEM

5. National family health survey-NFHS
reports
PEM

6. Types of PEM
The five forms of PEM are :
1. Kwashiorkor
2. Marasmus
3. Nutritional dwarfing
4. Underweight child
PEM

7. 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.
PEM

8. • 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.PEM

9. 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)
PEM

10. 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.
PEM

11. 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 anorectic
• Dehydration
• Temperature is subnormal
• Muscles are weak
• Edema and fatty infiltration are absent
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12. PEM

13. 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.
PEM

14. 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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15. PEM

16. Different factors lead to PEM in children
ETIOLOGY/CAUSES
1. Socioeconomic
2. Biological
3. Environmental
4. Role of free radical and aflatoxin
5. Age of host
• Among the socioeconomic, biological and environmental factors the common
causes are
• Lack of breast feeding and giving diluted formula, Overcrowding in the family,
Ignorance, Illiteracy, Lack of health education, Poverty, Infection
• Role of free radicals and aflatoxin- two new theories have been postulated
recently to explain the pathogenis of kwashiorkor. These include free radical
damage and aflatoxin poisoning. These may damage liver cells causing
kwashiorkor.
• Age of host- frequent in infants and young children whose rapid growth increases
the nutritional requirement. PEM in pregnant mothers can affect the nutritional
status and survival of foetus, new born and infants. Elderly can also suffer from
PEM due to alteration of GI systems.
PEM

17. ECOLOGY OF PEM
PEM
Early weaning
from breast
Increased
intestinal loss,
anorexia
Inadequate interfamilial
food distribution Low birth
weight
Late weaning
High birth rate
Material
malnutrition
Poverty and ignorance
illiteracyInadequate medical
facilities
Poor hygiene
sanitation water
supply
Large NO of %
children
Social modes of
feeding and cultural
practices
Occurrence of
infectious
diseases
PEM

18. THEORY OF ADAPTATION
PEM

19. NUTRITIONAL REQUIRMENT:
NUTRIENT AMOUNT NEEDED
ENERGY 150-200Kcal/kg/BW for existing weight
Older children-150kcal/kg/BW
Important to produce calories otherwise
protein will be utilized for providing
energy instead of building tissues. 50%
calories can be from carbohydrate
PROTEINS 5g/kg/BW for existing weight
Calorie derived form protein should be
10% of total calculated calories per day if
the main source is animal protein
FAT 40% of total calorie from fat
Saturated fats like butter are preferred
over unsaturated fats like oil as
unsaturated fatty acid worsens diahorrea.
PEM

20. COMPLICATIONS OF PEM
Hypoglycemia
Hypothermia
Dehydration and shock
Electrolyte imbalance - hypokalaemia -
hyponatremia
Infections (bacterial, viral and thrush)
 Micronutrient deficiencies
PEM

21. TREATMENT
There are three stages of treatment.
1. Hospital Treatment
The following conditions should be corrected. Hypothermia, hypoglycemia, infection,
dehydration, electrolyte imbalance, anemia 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.
PEM

22. HOSPITAL TREATMENTS
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24. DIETARY MANAGEMENT
 Energy dense feeding-established daily, graduated intake of
 4-5g protein per kg/BW
 200 Kcal of energy/kg/BW
 Breast milk
 Liquid feeds of skimmed milk, oil, sugar,
 Soft cereal gruels with milk,
 Soft ripe fruit, cooked vegetables
 Fortify oil with ghee to make it energy dense
 Micronutrient supplementation- to treat clinical conditions
and to prevent further deficiencies
 Route oral or nasogastric in small amount, more frequent
small feeds better than large meals
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26. REHABILITATION
• Residential units- the mothers are admitted along with their children. Under the
guidance of the nutrition demonstrator they work as a group and prepare suitable
therapeutic diet with available focus and feed their children
• Day care centers- in these centers mothers help in cooking and feeding in one or
two days a week, though the children attend daily. It therefore takes longer for
mothers to appreciate the essential message about better feeding.
• Domiciliary rehabilitation- it is done at home is more personal as nutritional
advice and help is given in one to one basis by a nutrition demonstrator.
• Successful nutritional rehabilitation requires detailed knowledge about local foods,
cooking and feeding practices. Based on knowledge diet should be prepared and
can be practiced by poor families. Mothers who take active part in preparation of
food and feeding their children and watching them recover to their health and
vitality are more likely to retain idea and continue with a similar regime at home.
PEM

27. 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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31. REFERENCE
• www.medecine.ups-tlse.fr/anglais/docs/DCEM1-
Malnutrition.pdf
• gmch.gov.in/e-
study/e%20lectures/Community%20Medicine/PEM.pd
f
• ocw.jhsph.edu/courses/International
Nutrition/PDFs/Lecture2.pdf
• www.oxfordjournals.org/tropej/online/mcnts_chap7.pdf
• www.who.int/nutrition/publications/en/childgrowth_dat
abase_overview.pdf
• Nutrition and dietetics by Shrilakshmi- vol V
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32. PEM