Protein-energy malnutrition (PEM) is a form of malnutrition caused by a lack of protein and calories. It includes conditions like marasmus, kwashiorkor, and intermediate states. PEM is characterized by wasting of muscle and tissue in marasmus or edema and liver damage in kwashiorkor. Common causes are improper complementary feeding, lack of breastfeeding, poverty, and infection. PEM has a high prevalence in children under 5 years old and is a major public health problem in India due to high mortality and long-term health effects. Treatment involves resolving medical issues, restoring nutrition, and ensuring rehabilitation through dietary management and nutrition education.

1. PROTEIN-ENERGY
MALNUTRITION
•PRESENTED BY:
•Manzar Bashir
Manzar Bashir

2. DEFINITIONS
 MALNUTRITION: 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.“ Malnutrition is the
condition that develops when the body does not get the right amount of the
vitamins, minerals, and other nutrients it needs to maintain healthy tissues and
organ function.
 PROTEIN ENERGY MALNUTRITION: Protein–energy malnutrition , sometimes
called protein-energy undernutrition is a form of malnutrition that is defined
as a range of pathological conditions arising from coincident lack of dietary-
protein and/or energy(calories) in varying proportions. The condition has mild,
moderate, and severe degrees.
 MARASMUS: is a form of severe malnutrition characterized by lack of food
energy. Represents simple starvation It can occur in anyone with severe
malnutrition but usually occurs in children.
 KWASHIORKOR: is a form of severe protein malnutrition characterized
by edema and an enlarged liver with fatty infiltrates. It is caused by sufficient
calorie intake, but with insufficient protein consumption, which distinguishes it
from Marasmus.Manzar Bashir

3. DESCRIPTION
Manzar Bashir

4. PROTEIN-ENERGY
MALNUTRITION
• PEM is also referred to as protein-calorie malnutrition.
• It is considered as the primary nutritional problem in India.
Also called the 1st National Nutritional Disorder.
• The term protein-energy malnutrition (PEM) applies to a
group of related disorders that include marasmus,
kwashiorkor or, and intermediate states of marasmus-
kwashiorkor
• PEM is due to “food gap” between the intake and
requirement.
Manzar Bashir

5. Protein-energy malnutrition’ (PEM) developed from the local name ‘Kwashiorkor’. The central
feature of severe PEM is edema; the classical theory suggests that the cause is a deficiency of
protein, but other factors are also involved. In the community mild-moderate PEM is defined by
deficits in growth. A distinction has to be made between low weight for height (wasting) and
low height for age (stunting), Stunting in particular affects some 50% of children worldwide.
In adults, severe PEM has essentially the same features as in children and includes the condition
famine edema or ‘hunger edema; there are again controversies about its cause. In the
community, chronic malnutrition is assessed by the body mass index (BMI) (Wt./Ht2). Grades of
deficiency have been defined and examples are given of functional consequences of a low BMI.
Manzar Bashir

6. AETIOLOGY
• Social and Economic Factors
• Biological factors
• Environmental factors
• Role of Free Radicals & Aflatoxin
• Age of the Host
Manzar Bashir

7. AMONGST THE SOCIAL,
ECONOMIC, BIOLOGICAL
AND ENVIRONMENTAL
FACTORS THE COMMON
CAUSES ARE:
Lack of breast
feeding and giving
diluted formula
Improper
complementary
feeding
Over crowding in
family
Ignorance
Illiteracy
Lack of health
education
Poverty
Infection
Familial
disharmony
Manzar Bashir

8. AETIOLOGY OF PROTEIN ENERGY MALNUTRITION:
Leading cause of death (less than 5 years of age)
Primary PEM: Protein + energy intakes below requirement for normal growth.
Secondary PEM: the need for growth is greater than can be supplied. Decreased nutrient absorption
Increase nutrient losses
Linear growth ceases
Static weight
Weight loss
Wasting
Malnutrition and its signs
Manzar Bashir

9. PREVALENCE:
• Protein-energy malnutrition is a basic lack of food (from famine) and a major cause of infant mortality and morbidity
worldwide.
• Children under five years is an important public health problem due to associated high mortality and long-term
health consequences
• Severe acute malnutrition (SAM), defined as severe wasting [weight-for-height Z score <−3 based on World Health
Organization (WHO) reference standard] and/or the presence of nutritional edema, is a life-threatening condition
which needs urgent attention and appropriate management to reduce mortality and promote recovery. India has a
high prevalence of SAM, representing a huge burden, and intriguingly, the recent National Family Health Survey-4
indicates a higher prevalence of severe wasting (7.5%) compared to the previous report (6.4%).
• A large volume of research in the first few decades of the 20th century dealt with Kwashiorkor or edematous
malnutrition, which had very high mortality with median case fatality rates of 20-30 per cent
• Protein-energy malnutrition caused 0.46% of all deaths worldwide in 2002, an average of 42 deaths per
million people per year.
Manzar Bashir

10. THE CLINICAL PRESENTATION DEPENDS UPON THE TYPE,
SEVERITY AND DURATION OF THE DIETARY DEFICIENCIES.
THE FIVE FORMS OF PEM ARE :
Kwashiorkor
Marasmus-
kwashiorkor
Marasmus
Nutritional
dwarfing
Underweight
child
Manzar Bashir

11. 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.
Manzar Bashir

12. • It causes fluid retention (edema) dry, peeling skin and hair discoloration.
• More recently, micronutrient and antioxidant deficiencies have come to
be recognized as contributory.
• Kwashiorkor was thought to be caused by insufficient protein consumption
but with sufficient calorie intake, distinguishing it from marasmus.
• 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.
Manzar Bashir

13. 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
Lethargy or apathy
Loss of muscle mass
Rash (dermatitis)
Shock (late stage)
Swelling (edema)Manzar Bashir

14. Manzar Bashir

15. MARASMUS
• The term Marasmus is derived from the Greek word marasmus, 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.
Manzar Bashir

16. 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 diarrhea and acid stools
Mostly hungry but some are anoretic
Dehydration
Temperature is subnormal
Muscles are weak
Edema and fatty infiltration are absent
Manzar Bashir

17. DIFFERENCES IN BETWEEN MARASMUS
AND KWASHIORKOR:
Manzar Bashir

18. DIFFERENCE IN CLINICAL FEATURES BETWEEN MARASMUS AND KWASHIORKOR
CLINICAL FEATURES MARASMUS KWASHIORKOR
-MUSCLE WASTING Obvious Sometimes hidden by edema and fat
-FAT WASTING Severe loss of subcutaneous fat Fat often retained but not firm
-EDEMA None Present in lower legs, and usually in face and
lower arms
WEIGHT FOR HEIGHT Very low May be masked by edema
MENTAL CHANGES Sometimes quite and apathetic Irritable, moaning, apathetic
-APPETITE Usually good Poor
-DIARRHOEA Often Often
-SKIN CHANGES Usually none Diffuse pigmentation, sometimes „flaky
paint dermatitis‟
-HAIR CHANGES Seldom Sparse, silky, easily pulled out
-HEPATIC ENLARGEMENT None Sometimes due to accumulation of fat
Manzar Bashir

19. MARASMIC-
KWASHIORKOR
A severely malnourished child with
features of both marasmus and
Kwashiorkor.
• The features of Kwashiorkor are
severe oedema of feet and legs
and also hands, lower arms,
abdomen and face. Also there is
pale skin and hair, and the child is
unhappy.
• There are also signs of marasmus,
wasting of the muscles of the
upper arms, shoulders and chest
so that you can see the ribs.Manzar Bashir

20. 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.
Manzar Bashir

21. UNDERWEIGHT
CHILD
•Children with subclinical 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
Manzar Bashir

22. BIOCHEMICAL & METABOLIC CHANGES
Significant findings in
kwashiorkor include
hypoalbuminemia (10-25 g/L),
hypoproteinemia (transferrin,
essential amino acids,
lipoprotein), and hypoglycemia.
Plasma cortisol and growth
hormone levels are high, but
insulin secretion and insulinlike
growth factor levels are
decreased.
The percentage of body water
and extracellular water is
increased.
Electrolytes, especially potassium
and magnesium, are depleted.
Levels of some enzymes
(including lactase) are decreased,
and circulating lipid levels
(especially cholesterol) are low.
Ketonuria occurs, and protein-
energy malnutrition may cause a
decrease in the urinary excretion
of urea because of decreased
protein intake.
In both kwashiorkor and
marasmus, iron deficiency
anemia and metabolic acidosis
are present.
Urinary excretion of
hydroxyproline is diminished,
reflecting impaired growth and
wound healing.
Manzar Bashir

23. TREATMENT
Treatment strategy can be
divided into three stages:
Resolving life threatening
conditions
Restoring nutritional
status
Ensuring nutritional
rehabilitation
Manzar Bashir

24. THERE ARE THREE STAGES OF TREATMENT.
Hospital Treatment The
following conditions should
be corrected. Hypothermia,
hypoglycemia, infection,
dehydration, electrolyte
imbalance, anaemia and other
vitamin and mineral
deficiencies.
01
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.
02
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.
03
Manzar Bashir

25. 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
Manzar Bashir

26. Manzar Bashir

27. THE END
THANKYOU SO MUCH
MANZAR
Manzar Bashir