The document discusses protein-energy malnutrition (PEM) in children. It defines PEM as a group of pathological conditions arising from a lack of proteins and calories, most commonly seen in infants and young children. The three main forms of PEM are marasmus (predominant energy deficiency), kwashiorkor (predominant protein deficiency with some energy deficiency), and intermediate states. The document then discusses indicators used to assess malnutrition, the global and regional burden of PEM, clinical manifestations, classifications, management, preventive measures, and Indian government programs addressing PEM like ICDS and mid-day meals.

1. DR. DEVENDRA KUMAR

2. Introduction
 WHO defines PEM as range of pathological conditions
arising from coincidental lack in varying proportions of
proteins and calories,occuring most frequently in infants
& young children
 The term protein-energy malnutrition (PEM) applies
to a group of related disorders, that includes
Marasmus, Kwashiorkor, and intermediate states of
Marasmus-Kwashiorkor.
2

4. Indicators of malnutrition
Indicator Interpretation Comment
STUNTING Low height-for-age Chronic malnutrition,
prolonged food
deprivation and/or
disease or illness
WASTING Low weight-for-
height
Acute malnutrition,
more recent food
deficit or illness
UNDERWEIGHT Low weight-for-age Combined indicator ,
reflect both acute and
chronic malnutrition
In Z score classification, children below 2 standard
deviation (SD) are classified as malnourished.

5. Burden of PEM
Global overview
Source: UNICEF, WHO, World Bank Group joint malnutrition estimates, 2015
edition.

6. Source: UNICEF, WHO, World Bank Group joint malnutrition estimates, 2015
edition.

7. Source: UNICEF, WHO, World Bank Group joint malnutrition estimates, 2015
edition

8. Regional overview
*Asia (excluding Japan); **Oceania (excluding Australia and New Zealand)
Source: UNICEF, WHO, World Bank Group joint malnutrition estimates 2015 edition.

9. Indian Scenario
National Family Health Survey (NFHS-3), India, 2005-06.

10. Trends in Malnutrition Among Children
Under Three Years
National Family Health Survey (NFHS-3), India, 2005-06
Note: The estimates of malnutrition for each of the three indicators are based on
children under three years of age born to ever-married women because that is the
only group of children weighed and measured in NFHS-2.

11. National Family Health Survey (NFHS-3), India, 2005-06.

12. National Family Health Survey (NFHS-3), India, 2005-06
Percentage of Children
Under Five Years Who
Are Underweight

13. Stunting , wasting and underweight among
children under 5 years by residence
National Family Health Survey (NFHS-3), India, 2005-06

14. Web of causation for PEM

16. CLINICAL MANIFESTATIONS
The Iceberg of Malnutrition

17. Initial response to nutritional deprivation is of two
types:
1. Dynamic children: The infants remain active but
fail to gain weight and later length, and
2. Sedentary children: The children who maintain
their growth initially by limiting their activities. But
ultimately they also fail to grow.

18.  Marasmus and Kwashiorkor - two different extreme
forms of a continuous process of malnutrition.
 Nutritional Marasmus - predominant energy
deficiency
 Kwashiorkor - predominant protein deficiency though
some energy deficiency may co-exist.
 These children may manifest as Kwashiorkor,
Marasmus, Marasmic Kwashiorkor .

19. CLINICAL FEATURES

22. 22
Marasmic -Kwashiorkar
Initially marasmic---then edema develops

23. Classification of PEM
 Gomez classification
 IAP classification
 NCHS (WHO) classification
 Arnold’s classification
 Welcomes classification

24. This is the first proposed classification based on
weight for age.

25. IAP Classification:
Nutritional Status Wt for Age (% of exp)
Normal >80
Gr I PEM 71-80
Gr II PEM 61-70
Gr III PEM 51-60
Gr IV PEM <50
Alphabet K is post fixed in presence of edema
25

26. WHO Classification
Moderate Severe
Edema No Yes
Wt / Ht Deficit1 (%)2 2-3 (70-79) >3 (<70)
Ht /Age Deficit1 (%)2 2-3 (85-89) >3 (<85)
1 Standard deviation from median of reference population
2 Percentage of the median of reference population:
NCHS/WHO

27. Arnold’s classification
 Based on mid upper arm circumference(MUAC) or
mid arm circumference (MAC)
Nutritional status MAC(in cm)
a) Normal 13.5 and above
b) Mild to moderate PEM 12.5-13.4
c) Severe PEM 12.4 or less

28.  Wellcome Trust / International Classification

29. Assessment of nutritional status
 Nutritional Anthropometry
 Clinical Examination
 Assessment of Dietary intake
 Laboratory tests

30. Nutritional Anthropometry
 Anthropometric parameters can be classified into 2
main groups:
 Age dependent and Age independent criteria.

31. Age Dependent Criteria
 Weight for Age –(Growth chart)
 Height for age

33. Age Independent criteria
 Mid arm circumference
 Weight for height
 Skin fold thickness
 Index ( Kanawati & Mclaren, Dughdale, Rao & Singh’s ,
Jellife’s ratio )

34.  Mid-upper arm circumference (MUAC) or Mid-Arm
Circumference (MAC): Between 6 m to 5 years,
< 12.5 cm - undernourished.
 Weight for height: degree of wasting
 Skin fold thickness:
Sites- the Triceps and Subscapular region.
Instrument - Skin Caliper of Harpenden and Best
type.

35. RATIOS
NAME OF INDEX CALCULATION NORMAL
VALUE
VALUE IN
MALNUTRITION
KANAWATI AND
MCLAREN
MUAC(cm)/HC(cm) .32-.33 <0.25
RAO AND SINGH WT(kg)/HT(cm)2X
100
0.14 0.12-0.14
DUGHDALE WT(kg)/HT(cm) 1.6
X 100
0.88-0.97 <0.79
QUAKER ARM
CIRCUMFERENCE
MAC Expected for a
given height
75-85%
Malnourished
<75%- Severly
Malnourished
JELLIFE’S RATIO HC/CC <1 In a child
>1 year:
Malnourished

36. MANAGEMENT OF PEM
 Mild to moderate PEM is best managed at home.
 Domiciliary Management
 The energy recommended is 120 to 150 kcal/day and
protein 2 to 3 g/kg/day.
 Some basic advice is also given, for management of
diarrhoea by oral rehydration solution (ORS)

37. Severe Malnutrition
 Severe malnutrition is defined in these guidelines as
the presence of severe wasting (< 70 % weight for
height or – 3 SD and/or edema).
 Complicated or uncomplicated severe PEM
 Infection, including diarrhoea with accompanying
water and electrolyte disturbances is common, worst
prognostic factor.

38.  WHO guidelines for the inpatient case management of
severe malnutrition.
 1. Resuscitation: lasts for 6 to 24 hours.
 2. Acute phase: 1 day to 1 week+
 3. Rehabilitation: Through second and third week to 6
weeks.

39. Phase of Resuscitation/Stabilization and
Treatment of Complications
 In mild dehydration, ORS (WHO-sodium chloride 3.5
g, potassium chloride 1.5 g, sodium citrate 2.9 g,
glucose 20 g) should be given.
 Severely malnourished children with dehydration may
not tolerate this high sodium low potassium ORS.
 For them special rehydration solution for malnutrition
ResoMal 5 ml/kg every 30 minutes may be given
 ResoMal— 45 mmol Na,
40 mmol K and
3 mmol Mg/l).

40.  Hypothermia
 Hypoglycemia
 Infection
 Anemia
 Xerophthalmia
 Congestive heart failure
 Hypocalcaemia
 Zinc deficiency

41. Dietary Management of Severe PEM
 Initial Phase
 The regime recommended is one that provides near
maintenance requirement, i.e. ~80 cal/kg/day and 0.7
g protein/kg/day
 WHO has recommended milk-based formulas- starter
F-75 - 75 cal/100 ml and 0.9 g protein/100 ml in the
initial feeding schedule & then gradually increasing to
F-100 and F-135 supplying 100, 2.9 g and 135 calories,
3.3g /100 ml of feed respectively for catch up growth.

42.  Phase of High Energy Feeding
 Gradually increase the calorie intake to approximately
150 to 180 cal/kg/day.

43. Preventive Measures
 From WHO expert committee on nutrition
Health Promotion
1.Measures directed to pregnant and lactating women
2.Promotion of breast feeding
3.Meal given at frequent intervals
4.Improve family diet
5.Nutrition education-Promotion of correct feeding practices
6.Family planning and spacing of births
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44. Specific Protection
1. Diet must contain protein and energy rich foods – milk, egg,
fresh fruit if possible
2. Immunization
3.Food fortification
Early Diagnosis and treatment
1.Early diagnosis of any lag of growth
2. Early diagnosis and treatment of infections and diarrhoea
3.Rehydration
4.Deworming
44

45. Integrated child development service
(ICDS) programme
 Services are provided at Aanganwadi
 Package of six services under ICDS scheme
1) Supplementary nutrition
Beneficiaries Calories,Kcal Protein ,g
Children <3 yr 300 8-10
Children 3-6 yr 300 8-10
Severely
malnourished
children
600
(double of above)
16-20
Pregnant and
lactating mother
500 20-25

46. 2) Immunization
3) Nonformal preschool education
4) Health check up – by ANM , Medical officers
under RCH
5) Referral services
6) Nutrition and health education

47. National Family Health Survey (NFHS-3), India, 2005-06

48. National programme of mid-day meals
in schools
 National programme of Nutritional support to primary
education ( rechristened National programme of mid-day
meals in school in 2007) ,
 launched as centrally sponsored scheme on 15th august 1995
, 2408 blocks
 Covers ~9.70 crore children at primary stage of education ,
govt aided schools in ~ 9.50 lakh govt. (including local
bodies) & centres run under education guarantee scheme
 Mid day meal of 450 kcal & 12 g protein – at primary stage
 Uppper primary stage – 700 kcal & 20 g

49.  Benefits- protecting child from classroom hunger,
increasing school enrollment & attendance, improving
socialization

50. National Nutrition Anemia Prophylaxis
Programme
 Launched-1970
 Prevent Nutritional Anemia in mothers and children
 100mg Elementary iron & 0.5 mg folic acid
 Children 1-5 yr ,20 mg elementary iron (60 mg of
ferrous sulphate) and 0.1 mg folic acid , 100 days