This document provides an overview of protein energy malnutrition (PEM). It defines key nutrition terms and discusses the indicators, epidemiology, etiology, clinical features, and consequences of undernutrition. PEM encompasses disorders like marasmus and kwashiorkor and results from prolonged food deprivation and illness. Globally, 150 million children suffer from stunting and 50 million from wasting. Undernutrition is still a major problem in Nepal, with 20-30% of children malnourished by age 6 months. Chronic undernutrition can impair growth and development while acute forms increase risks of infections and death.

1. Protein Energy Malnutrition
Presenter: Krishna Gharti
Moderator: Dr. Ram Pokharel

2. Some Terminologies
 Nutrition: also called nourishment, is the provision
to cells and organisms of the material necessary in
the form of food to support life.
 Nutrients: Our food is made up of essential, natural
substances called nutrients.
 Macronutrients: nutrients that are needed in large
quantities. e.g. carbohyrates, fats and proteins.
 Micronutrients: nutrients that are needed in tiny
quantities and are crucial for their role in metabolic
pathways and in enhancing immunity. E.g. minerals
and vitamins.

3.  Recommended dietary allowances (RDA): refers to the
average daily amounts of essential nutrients estimated to
be sufficiently high to meet the physiological needs of
practically all healthy persons in the group.
 Balanced diet: it is defined as nutritionally adequate and
appropriate intake of food items that provide all the
nutrients in required amounts and proper proportions.
 Exclusive breastfeeding:Exclusive breastfeeding
means that the infant receives only breast milk. No other
liquids or solids are given not even water with the
exception of oral rehydration solution, or drops/syrups of
vitamins, minerals or medicines.

4.  Complementary feeding: it refers to food which
complements breast milk and ensures that the child
continues to have enough energy, protein and other
nutrients to grow normally.
 Supplementary Feedings: Feedings provided in
place of breastfeeding. This may include expressed
breast milk. Any foods given prior to 6 months, the
recommended duration of exclusive feeding, are
thus defined as supplementary.

5. Introduction to PEM
 WHO defines malnutrition as “ the cellular imbalance
between the supply of nutrients and energy and the
body’s demand for them to ensure growth,
maintenance and specific functions”.
 Te term malnutrition encompasses both ends of the
nutrition spectrum, from undernutrition to overweight.
 However, sometimes terms malnutrition and protein
energy malnutrition (PEM) are used interchangeably
with undernutrition.
 The term PEM applies to a group of related
disorders that includes marasmus, kwashiorkor and
intermediate states of marasmus-kwashiorkor.

6. Indicators of undernutrition
Indicators Interpretation Comment
Stunting Low height for age Indicator of chronic
malnutrition, the result of
prolonged food
deprivation and/or
disease or illness
Wasting Low weight for height Suggests acute
malnutrition, the result of
more recent food deficit
or illness
Underweight Low weight for age Combined indicator to
reflect both acute and
chronic malnutrition

7. Epidemiology of PEM
 Globally, in 2017 stunting affected an estimated
22.2% or 150.8 million children of under 5.
 Wasting continued to threaten the lives of an
estimated 7.5% or 50.5 million children of under 5.
 An estimated 5.6% or 38.3 million children of under 5
around the world were overweight.
 13.5% or 91.3 million of children <5 yr of age were
underweight.

8.  Asia and Africa bear the greatest share of all forms
of malnutrition.
 In 2017, more than half (55%) of all stunted children
under 5 lived in Asia and more than 1/3rd (39%) lived
in Africa.
 Almost half (46%) of all overweight children under
lived in Asia and one quarter (25%) lived in Africa.
 More than 2/3rd (69%) of all wasted children under 5
lived in Asia and more than 1/4th (27%) lived in
Africa.
 Two out of 5 stunted children in the world live in
Southern Asia.

9. PEM in Nepal
 Despite a steady decline in recent years, child
under-nutrition is still unacceptable in Nepal.
 Maternal malnutrition is also a problem with 17 per-
cent of mothers suffering chronic energy deficiency
alongside the increasing trend of overweight mothers
(22 per cent).

10.  During 1st 6 months of life, 20-30% of children are
already malnourished, often because they were born
low birth weight.
 The proportions of undernutrition starts rising after 4-
6 months of age.
 The proportion of children who are stunted or
underweight increases rapidly with child’s age until
about 18-24 months of age.
 Mortality: worldwide almost 50% under 5 children
dies from protein energy malnutrition.

11. Measurement of undernutrition
 International standards of normal child growth under
optimum conditions from birth to 5 yr have been established
by the World Health Organization (WHO).
 To compile the standards, longitudinal data from birth to 24
months of healthy, breastfed, term infants were combined
with cross sectional measurements of children ages 18-71
months.
 The standards allow normalization of anthropometric
measures in terms of z scores (standard deviation scores).
 A z-score is the child’s height (weight) minus the median
height (weight) for the age and sex of the child divided by
the relevant standard deviation.

12.  Height-for-age (or length-for-age for children <2
yr) : A low height-for-age typically reflects
socioeconomic disadvantage.
 Weight-for-height, or wasting, usually indicates
acute malnutrition. Conversely, a high weight-for-
height indicates overweight.
 Weight-for-age: Weight-for-age has the
advantage of being somewhat easier to measure
than indices that require height measurements.
 Body mass index (BMI) is calculated by dividing
weight in kilograms by the square of height in
meters.

13. Age independent indices to diagnose
undernutrition
Mid upper arm
circumference (MUAC): (16
to 17 cm).
Shakir tape method
Bangle test
Skinfold thickness

14. Classification of undernutrition
 Basic grouping
1. Underweight: refers to child who is too light for his
or her age.
2. Stunted: refers to child who is too short for his or
her age.
3. Wasted: refers to child who is too thin for his or her
weight. Wasting is result of recent rapid weight loss
or failure to gain weight.

15.  Gomez classification (underweight)
 Waterlow classification (wasting)
Weight for age Gradeing
75-90% Grade I (mild)
60-75% Grade II (moderate)
60% Grade III (severe)
Weight for height Grading
80-90% Mild
<70% Severe

16.  Waterlow classification (stunting)
 WHO classification (wasting)
 WHO classification (stunting)
Height for age Grading
90-95% Mild
85-90% Moderate
<85% Severe
Weight for height Grading
<-2 SD to >-3 SD Moderate
>-3 SD Severe
Height for age Grading
<-2 SD to >-3SD Moderate
>-3 SD Severe

17.  WHO classification (wasting for age group 6-59
months)
 IAP classification
MUAC (MM) Grading
115 – 125 mm Moderate
<115 mm Severe
Weight for age Grading
>80% Normal
71-80% (mild) Grade I
61-70% (moderate) Grade II
51-60% (severe) Grade III
<50% (very severe) Grade IV

18.  Based on appearance
1. Marasmus (Greek word; marasmos means
withering or wasting)
2. Kwashiorkor (Ga language of Ghana means
sickness of weaning)
3. Marasmic kwashiorkor

19. Etiology of undernutrition

20. Severe acute malnutrition
 Severe acute malnutrition is defined as severe wasting
and/or bilateral edema.
 Severe wasting is extreme thinness diagnosed by a
weight-for-length (or height) below -3 SD of the WHO
Child Growth Standards. In children ages 6-59 mo, a
mid-upper arm circumference <115 mm also denotes
extreme thinness: a color-banded tape is a convenient
way of screening children in need of treatment.
 Bilateral edema is diagnosed by grasping both feet,
placing a thumb on top of each, and pressing gently but
firmly for 10 seconds. A pit (dent) remaining under each
thumb indicates bilateral edema.

21. Clinical features of undernutrition
 Mild malnutrition
 Growth failure
 Infection
 Anemia
 Decreased activity
 Skin and hair changes

22.  Moderate to severe malnutrition: it is
associated with one of classical syndromes
namely marasmus, kwashiorkor or with
manifestations of both.
Marasmus
 it results from rapid deterioration in nutritional
status.
 Acute starvation or acute illness over a
borderline nutritional status could precipitate this
form of under nutrition.

23. Clinical features of marasmus

24. Kwashiorkor
 it usually affects children aged 1-4 years. Main sign
is pitting edema usually starting from legs and feet
and spreading in more advanced cases, to hands
and face.

25. Clinical features

26. Difference between marasmus and
kwashiorkor
Clinical findings Marasmus Kwashiorkor
Occurrence More common Less common
Edema Absent Present
Activity Active Apathetic
Appetite Good Poor
Liver enlargement Absent Present
Mortality Less than kwashiorkor High in early stage
Recovery Recovery early Slow recovery
Infections Less prone More prone

27. Consequences of undernutrition
 Fetal growth restriction
 Premature death
 Increased risk of infectious diseases
 LBW is associated with an increased risk of
hypertension, stroke, and type 2 diabetes in adults.
 Stunting before the age of 3 yr is associated with poorer
motor and cognitive development and altered behavior in
later years.
 Undernutrition can have substantial economic
consequences for survivors and their families.

28. References
 Nelson’s Textbook of Pediatrics 20th edition
 OP Ghai Essentials of Pediatrics 8th edition
 UNICEF / WHO / World Bank Group Joint Child
Malnutrition Estimates 2018
 Medscape.com
 Annual report 2073/74

29. Thank You