Protein-Energy Malnutrition (PEM): Understanding Clinical Manifestations and Community-Level Management

1. PROTEIN
ENERGY
MALNUTRITION

3. Specific Learning Objectives

4. PRE-BIRTH & POST-
BIRTH
0-6
MONTHS
6-72
MONTHS
ADOLOSCENT

7. Stunting3 = chronic
• Moderate stunting – Height or
length Z-score -2 to -3
• Severe stunting – Height or length
Z-score <-3
1. GROWTH
MONITORING
AND
IDENTIFICATION
Clinical measure
Classification%
Moderate acute
malnutrition
Severe acute
malnutrition
Wasting
*
Mid-upper arm
circumference
(MUAC)
11.5 to 12.4 cm <11.5 cm
Weight-for-
height Z-score
(WHZ)
¶
–2 to –3 <–3
Kwashiorkor
Symmetrical
pitting edema
Absent Present
Δ
* Severe wasting is also
known as marasmus.
% Infants zero to six months
●Weight-for-age Z-score (WAZ) <-3 SD
●Weight-for-length Z-score (WLZ) <-3 SD
●MUAC <11 cm (for ages 6 weeks to 6
months)
●Presence of edema

8. Height and weight
Low weight for height (wasting).
Low height for age (stunting), if also chronically malnourished.
Weight for age is variable.
Low height for age (stunting) if also chronically
malnourished.
Head Appears large relative to body, with staring eyes.
Moon face (with or without facial edema. May appear
plump.
Extremities
Emaciated arms, thighs, and buttocks, with loose folds due to
loss of subcutaneous fat.
EDEMA: Mild (1+) Moderate (2+) Severe (3+)
Behavior Typically irritable, fretful. Typically apathetic, listless; may be irritable
Abdomen Distended, dilated intestinal loops; hepatomegaly.
Skin Thin, dry skin.
Thin, dry and peeling skin, with areas of hyperkeratosis
and hyperpigmentation
Hair Thin, sparse hair that is easily plucked.
Dry, dull, and hypopigmented hair that falls out or is
easily plucked (flag sign).
Marasmus Kwashiorkor

10. GROWTH
MONITORING
• AWW
APPETITE
TEST
• AWC
MEDICAL
ASSESSMENT
• ANM/MO
COUNSELLING
• NUTRITION
• WASH
VISIT AND
REFERRAL
• AWW
• PHC
MONITORING
• 2 MONTHS
• UPTO 6
YEARS
DECIDAL OF
CARE
• AWC/NRC
NUTRITIONAL
Mx
• NFSA
MEDICAL
MANAGEMENT
• MO

11. Child (6 to 59 months of age)*
Weight-for-height increased to at least 2 standard deviations below WHO median
reference values (ie, Z-score ≥-2)
¶
MUAC ≥12.5 cm
No edema for at least 1 to 2 weeks
Infections have been empirically treated and other conditions have been or are being
addressed, including anemia, diarrhoea, intestinal parasitic infections, malaria,
tuberculosis, and HIV
Full immunization program started
Mother or caretaker
Able and willing to look after the child
Knows how to prepare appropriate foods and feed the child
Knows how to give home treatment for diarrhoea, fever, and acute respiratory infections
and how to recognize the signs that mean she must seek medical assistance
Health worker
Able to ensure follow-up of the child and support for the mother
Criteria for discharge from care
for malnutrition