The document discusses protein-energy malnutrition (PEM) as a major public health issue in Pakistan, particularly affecting children under five, with kwashiorkor and marasmus being the most severe forms. It outlines the causes, risk factors, classification, and management strategies for PEM, including nutritional assessments and both home-based and hospital treatments. The document emphasizes the importance of preventing malnutrition through education, community support, and prompt medical intervention.

1. Common health
problems in
Pakistan.

3. PROTEIN ENERGY
MALNUTRITION
P R E S E N T E D B Y : M AV I A N O O R

4. Objectives
 At the end of this lecture students will be able to:
 Describe what is malnutrition.
 Describe the kwashiorkor.
 Describe the marasmus.
 Differentiate the kwashiorkor and marasmus.
 Discuss nursing assessment, diagnosis , and
management of child with protein energy malnutrition.

5. Definition
A group of clinical conditions that may result
from varying degree of protein deficiency and
energy (calorie) inadequacy.
• Previously it was known malnutrition. as protein
calorie

6. 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 most countries.
• Particularly in children younger than 5 years old
• The most extreme forms of malnutrition, or
(PEM), are Kwashiorkor and Marasmus

7. Introduction
Severe acute malnutrition (SAM)
• Edematous (kwashiorkor),
• Severe wasting (marasmus)
• Marasmic kwashiorkor (features of both
marasmus and kwashiorkor)

8. 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.

10. 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

11. 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

12. Risk factors
• LBW
• Multiple birth
• Not breast fed
• High birth order
• Congenital defects poor socioeconomic background
• Single parents / orphans/ foster home
• Maternal deprivation

13. Classification
• Mild PEM
• Moderate PEM
• Severe PEM
According
to severity
• Kwashiorkor
• Nutritional marasmus
• Prekwashiorkor
• Nutritional dwarfing
Syndromal
classificatio
n

14. • According to severity • Mild PEM
• Weight <3rd percentile for
their age but above the -3
SDGrowth 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

15. 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)

16. Features
Essential
•Marked growth retardation
• Muscle wasting
• Psychomotor changes
•Pitting edema
Non essential
•Hair change (flag sign)
•Skin changes
•Super added infections

17. Grading
• Grade I:Pedal oedema
• Grade 11: grade I+ facial puffiness
• Grade III: grade II + oedema of the chest wall and the
paraspinal area
• Grade IV: grade III + ascites

18. 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 shriveled face due to loss of
buccal pad of fat.
• Initially the child is irritable, hungry and craves for food
• Later stages may become miserable, apathetic and refusal to take anything orally.

19. Features
Essential
•Marked growth
retardation
•Muscle wasting
•Marked stunting and
absence of edema
Non essential
•Hair change(hypopigmented)
•Skin changes: dry, scaly
•Liver shrunk
•Crave for food
•Psychomotor changes
•Mineral deficiencies

20. 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
paraspinal region
• Grade IV: grade III + loss of the buccal pad of fat

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 features 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. Assessment
• Nutritional assessment
• History
• Clinical findings
• 24 hour retrospective dietary recall
• Societal and environmental assessment
• Growth chart
• Anthropometric measurement compare with
population standard

27. 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

28. 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)

29. 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

30.  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

31. Severe PEM
• Hospitalization
• Watch for complications
• Dietary treatment
 4 gm/kg protein
 Marasmus 150-200 kcal/kg per day
 Kwashiorkor 100 kcal/kg per day
• Reinforced milk or high calorie cereal milk can be givenChildren should be
Fed with milk diet at the ratio of 125 ml/kg/dayPrevent hypoglycemia• NG tube
feedingGradually increase the feed• Schedule 8 feeds per day• Supplement
minerals and vitamin• Treat infections

32. • Hospitalization
• Watch for
complications
Dietary treatment
4 gm/kg protein
Marasmus 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

33. Complication
• Acute
• SIDS
• Systemic local infections
• Convulsions
• Severe dehydration
• Long term
• Shock
• Cachexia
• Dyselectrolytemia
• Growth retardation
• Hypoglycemia
• Mental sub normalities
• Hypothermia
• Visual and learning disabilities
• CCF
• Bleeding disorders
• Hepatic dysfunction

34. Prevention
• Health promotion
• Specific protection
• Early diagnosis and treatment
• Rehabilitation

35. Nursing management
• Assessment
• History
• Physical examination
• Assessment
• Nutritional assessment
• Lab investigations

36. 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

37. Thank you
References