BSC NURSING SYLLABUS.

1. PROTEIN
ENERGY
MALNUTRITION
(PEM)

2. INTRODUCTION
Protein energy malnutrition (PEM) is the term
given to a group of clinical conditions which
occur due to inadequate protein and calorie
intake, especially in children.

3. • PEM applies to a group of related disorders
that include Marasmus, kwashiorkor and
intermediate states of marasmus-kwashiorkor.

4. DEFINITION
• The World Health Organization (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."

5. EPIDEMIOLOGY
1. More common in low-income countries
2. Occur in children with poverty
3. Primary diagnosis of intellectual disability
4. Chronic diseases such as-
• Malignancy,
• Cardiovascular disease,
• Genetic disease,
• Neurological disease,
• Multiple diagnoses,
• Prolonged hospitalization.

6. ETIOLOGY
• PRIMARY CAUSES: When PEM is purely due
to dietary deficiency, it is termed as the
primary type.
• This begins at the fetal stage and continues
into infancy and childhood.

7. Dietary factors contributing to PEM are
• Inadequate breast feeding by the mother due to
inadequate nutrition.
• Stopping breastfeeding early in case of working mothers.
• Inadequate supplementation of other foods.
• Ignorance of weaning and weaning foods.
• Inverted or cracked nipples in mother.
• Traditional methods such as not offering colostrum.

8. • Secondary Causes: Malnutrition that arises due to
a serious illness like tuberculosis, cancer or inability
of the body to absorb nutrients for e.g. in bowel
disease like ulcerative colitis, metabolic syndromes
and long standing gastro-enteritis.

9. Problems in the mother such as….
• Mental or psychiatric illnesses.
• post-natal depression (severe cases).
• Poor maternal health like anemia.
• Having too many children in quick succession.
• Having twins may lead to the mother producing not
enough milk to meet the demand of the infants.

10. All kinds of infections in the baby such
as…
• Oral ulcers
• Gastroenteritis
• Food poisoning
• Diarrhea
• Serious conditions such as congenital heart or kidney
disease may cause inability to suckle which causes
malnutrition.

11. PATHOPHYSIOLOGY
The initial metabolic response is decreased metabolic rate.
To supply energy, the body first breaks down adipose tissue.
later, when these tissues are depleted, the body may use
protein for energy, resulting in a negative nitrogen balance.
Visceral organs and muscle are broken down and decrease in
weight.
Loss of organ weight is greatest in the liver and intestine,
intermediate in the heart and kidneys, and least in the
nervous system.

12. CLINICAL CLASSIFICATION OF PEM
• Kwashiorkor (protein malnutrition predominant).
• Marasmus (deficiency in calorie intake).
• Marasmic Kwashiorkor (marked protein deficiency
and marked calorie insufficiency signs present,
sometimes referred to as the most severe form of
malnutrition)

13. Gomez classification
• Grade 1- 90-75% of expected weight.
• Grade 2 – 75-60% of expected weight.
• Grade 3 - <60% of expected weight.

14. WATERFLOW’S CLASSIFICATION

15. WHO CLASSIFICATION
• Assessment is done according to weight for height,
height for age and presence of edema.
• WHO recommends three terms for describing
malnutrition in under 5 children…
1. STUNTING
2. UNDERWEIGHT
3. WASTING

16. 1. Stunting: height for age being 2 SD below from median
height for age given in NCHS reference population.
2. Underweight: If weight for age is 2 standard deviation
below from median weight for age, given in NCHS
reference population.
3. Wasting: If the weight for height is 2 standard deviation
below from median weight for height, given in NCHS
reference population.
*The National Center for Health Statistics is a principal agency of the U.S.*

17. IAP CLASSIFICATION
• Based on weight for age values.
GRADE OF
MALNUTRITION
Weight for age of the standard (%)
Normal >80%
Grade I 71 – 80% (mild malnutrition)
Grade II 61 – 70% (moderate malnutrition)
Grade III 51 – 60 % (severe malnutrition)
Grade IV <50% (very severe malnutrition)
*IAP- Indian academy of pediatrics

18. CLINICAL FEATURES

19. KWASHIORKOR
• Kwashiorkor is common in children
between one and five years.
• It is due to a protein deficiency
which occurs after protein rich
foods are discontinued during
weaning and the child is given food
low in proteins and calories.

20. • The main sign is pitting edema, usually
starting in the legs and feet.
• Due to edema children may look healthy so
that their parents view them as well fed.
KWASHIORKOR

22. Symptoms of kwashiorkor
• Children appear smaller than their age
• Mild to gross edema
• Skin is pale, dry and flaky, hair turns reddish
• Desquamation and dyspigmentation (buttocks,
perineum and upper thigh)
• Muscles wasting
• Cheliosis and angular stomatitis

23. • Flag sign (alternate bands of hypopigmented and
normally pigmented hair pattern)
• Irritability with sad, intermittent cry
• Children frequently have digestive problems
• Anorexia, abdominal distension, watery or semisolid
• Anemia
• Cold, pale extremities due to circular insufficiency
• Very thin limbs, liver may be enlarged
Symptoms of kwashiorkor

24. MARASMUS
• This condition is generally seen in infants less than one
year old.
• It occurs due to a deficiency of proteins, carbohydrates
and fats.
• Marasmus in the childhood equivalent of starvation in
adults and is more serious than Kwashiorkor.
• It is characterized by marked wasting of fat and muscle.

26. Symptoms of marasmus
• Severe wasting of muscles.
• Wrinkled skin, loose skin of buttocks
• A large face over a shrunken body
• Eyes are sunken, cheeks are hollow giving a prematurely aged look
• Edema is absent, abdomen is curved inwards
• Skin is dry, loose and wrinkled due to loss of fat below the skin
• Hair may be normal or dry, thin and light colored.
• Muscles are wasted and have poor tone
• Bones are prominent due to absence of fat around them

27. DIFFERENCE BETWEEN MARASMUS AND KWASHIORKOR
Clinical findings Marasmus Kwashiorkor
Occurrence
Edema
Activity
Appetite
Liver enlargement
Mortality
Recovery
Infections
More common
Absent
Active
Good
Absent
Less
Recover early
Less prone
Less common
Present
Apathetic
Poor
Present
High in early stage
Slow recovery
More prone

28. MARASMIC KWASHIORKOR
• This includes symptoms of both Marasmus
and Kwashiorkor and represents the gravest
form of PEM.

29. DIAGNOSIS OF PEM
The WHO recommends the following laboratory tests:
• Detailed dietary history, growth measurements, body mass
index (BMI), and a complete physical examination are
indicated.
• Blood glucose.
• Examination of blood smears by microscopy or direct
detection testing.
• Hemoglobin.

30. • Urine examination and culture.
• Stool examination by microscopy for ova and parasites.
• Serum albumin.
• HIV test (This test must be accompanied by counseling of
the child's parents, and strict confidentiality should be
maintained.).
• Electrolytes .
DIAGNOSIS OF PEM

31. PRINCIPLES OF MANAGEMENT
• Patient is evaluated for severity of PEM and other
nutritional deficiencies like iron deficiency anemia.
• Careful surveillance and prompt treatment of
complications.
• Promotion of food intake.

32. MANAGEMENT PHASES
Initial phase
Rehabilitation
phase

33. INITIAL PHASE (1 – 2 weeks)
• Treatment of complications.
• Correction of nutritional deficiencies.
• Reversal of metabolic abnormalities.
• Beginning of feeding.

34. TREATMENT OF COMPLICATIONS
• S: Sugar level decreases (hypoglycemia).
• H: Hypothermia.
• I: Infections.
• EL: Electrolyte disturbances
• DE: Dehydration.
• D: Deficiency of nutrients.

35. REHABILITATIVE PHASE (2 – 6 weeks)
• Recovery of lost weight.
• Emotional and physical stimulation of the
child.
• Training the mother for domiciliary care.
• Preparation for discharge.

36. PREVENTION OF MALNUTRITION
–At national level
• Nutritional supplementation.
• Nutritional surveillance.
• Nutritional planning.

37. –At community level
• Health and nutritional education.
• Promotion of education and literacy.
• Growth monitoring.
• Family planning programme.
PREVENTION OF MALNUTRITION

38. –At family level
• Exclusive breast feeding.
• Appropriate weaning.
• Vaccination.
• Adequate birth spacing.
PREVENTION OF MALNUTRITION

39. REFERANCES