This document provides information on protein-energy malnutrition (PEM). It defines PEM and describes its main forms: kwashiorkor, marasmus, and marasmic-kwashiorkor. Kwashiorkor is characterized by edema and results from insufficient protein intake with adequate calories. Marasmus is caused by severe energy deficiency and presents as wasting. Marasmic-kwashiorkor shows features of both. The document discusses the prevalence of PEM in India, clinical features, biochemical changes, treatment involving rehydration and diet, and prevention through breastfeeding promotion and nutrition education.

1. Presented By :
Qurrot Ulain Taher
(B.Sc-IInd Yr)
St. Ann’S College f o r Women.
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2.  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 specificfunctions.“
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.
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Definitions


3.  PROTEIN ENERGY MALNUTRITION
It is a group of body depletion disorders which
include kwashiorkor, marasmus and the intermediate
stages
 MARASMUS
Represents simple starvation . The body adapts to
a chronic state of insufficient caloric intake
 KWASHIORKOR
It is the body’s response to insufficient protein intake
but usually sufficient calories for energy
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4. DESCRIPTION
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5. 
Protein-Energy
Malnutrition
 PEM is also referred to
as
protein-calorie
malnutrition.
 It is considered as the p
r
i
m
a
r
y
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,
kwashiork or, and
intermediate states of
marasmus-kwashiorkor.
 PEM is due to “food
g
a
p
”
between the intake and
requirement.
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6. AETIOLOGY
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7. AETIOLOGY:
Different combinations of many aetiological
factors can lead to PEM in children. They
are:
 S o c i a l and Economic Factors
 B i o l o g i c a l factors
Environmental factors
 R o l e of Free Radicals & Aflatoxin
 A g e of the Host
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8.  Amongst the Social, Economic,
Biological a
n
d
Environmental Factors the
common causes are:
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 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

9.  Role of Free Radicals & Aflatoxin: Two new
t
h
e
o
r
i
e
shave been postulated recently to explain the
pathogenesis of kwashiorkor. These include Free
Radical Damage & Aflatoxin Poisoning . These may
damage liver cells giving rise to kwashiorkor.
 Age Of Host :
 Frequent in Infants & young children whose rapid
growth increases nutritional requirement.
 PEM in pregnant and lactating women can affect the
growth, nutritional status & survival rates of their
fetuses, new born and infants.
 Elderly can also suffer from PEM due to alteration of
GI System
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10. 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
AETIOLOGY of PEM:
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11. PREVALENCE
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12. • Protein-energy
malnutrition is a
basic lack of food
(from famine) and a
major cause of
infant mortality and
morbidity
worldwide.
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• Protein-energy
malnutrition caused
0.46% of all deaths
worldwide in 2002,
an average of 42
deaths per million
people per year.
PREVALENC
E:

13. Child Malnutrition
in India
2005-2006
Urban
Rural
36.4
49.0
 Malnutrition is the direct S
ot
.
rA
n
in
n's
dD
ire
g
er
ce
e
tC
co
al
l
ue
g
se
ef
o
orf
W
m
o
m
o
e
n
r
e50% of deaths inchildren.
 PEM is a silent killer in many children.

14. CLINICAL FEATURES
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15. The clinical presentation depends upon the type
, severity and duration of the dietary deficiencies. The
five forms of PEM are :
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1. Kwashiorkor
2. Marasmic-kwashiorkor
3. Marasmus
4. Nutritional dwarfing
5. Underweight child

16. 
Body weight
as percentage
of standard
Oedema Deficit in
weight for
height
Kwashiorkor 60 – 80 + +
Marasmic
kwashiorkor
< 60 + ++
Marasmus < 60 0 ++
Nutritional
dwarfing
< 60 0 Minimal
Underweight
child
60 – 80 0 +
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Classification of PEM
(FAO/WHO)
Source: FAO / WHO 1971 Expert
Committee on Nutrition 8th Report.
WHO Technical Report Series 477

17. KWASHIORKOR

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 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
1
2months when breastfeeding is discontinued, but it
can develop at any time during a child's formative
years.
 It causes fluid retention (edema); dry,
peeling skin; and hair discoloration.

18.  Kwashiorkor was thought to be
caused by insufficient protein
consumption but with sufficient calorie
intake, distinguishing it from marasmus.
 More recently, micronutrient
and antioxidant deficiencies have
come to be recognized as contributory.
 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.
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19. 
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SYMPTOM
S
 Changes in skin
pigment.
 Decreased muscle
mass
 Diarrhea
 Failure to gain
weight a
n
d
grow
 Fatigue
 Hair changes
(change in color or
texture)
 Increased and more
s
e
v
e
r
e infections due to
damaged immune
system
 Irritability
 Large belly that
sticks o
u
t(protrudes)
 Lethargy or apathy
 Loss of muscle
mass
 Rash (dermatitis)
 Shock (late stage)
 Swelling
(
e
d
e
m
a
)

20. St.Ann's Degree College for Women

21. MARASMUS

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 The term marasmus is derived from the Greek
word marasmos, 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.

22. 
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SYMPTOM
S
Severe muscle
wasting
 Severe growth
retardation
 Loss of
subcutaneous fat


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 diarrhoea and
acid stools
 Mostly hungry but
some a
r
e
anoretic
 Dehydration
 Temperature is subnormal
 Muscles are weak
 Oedema and fatty
infiltration are
absen
t

23. DIFFERENCE IN CLINICAL FEATURES
BETWEEN MARASMUS AND
KWASHIORKOR
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24. St.Ann's Degree College for Women

25. CLINICAL MARASMUS KWASHIORKOR
FEATURES
-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
May be masked by
-WEIGHT FOR
HEIGHT
Very low edema
Irritable, moaning,
-MENTAL Sometimes quite
and
apathetic
DIFFERENCE IN CLINICAL FEATURES BETWEEN MARASMUS ANDKWASHIORKOR

26. CLINICAL
FEATURE
S
MARASMUS KWASHIORKOR
-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
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DIFFERENCE IN CLINICAL FEATURES BETWEEN MARASMUS ANDKWASHIORKOR

27. 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.
MARASMIC-KWASHIORKOR
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28.  Some children adapt to prolonged insufficiency
o
ffood-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.
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NUTRITIONAL DWARFING
OR
STUNTING

29.  Children with sub-
clinical 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
UNDERWEIGHT CHILD
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30. BIOCHEMICAL & METABOLIC
CHANGES
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31.  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,
a
n
d
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 a
n
d
metabolic acidosis are present.
 Urinary excretion of hydroxyproline is diminished, reflecting
impaired growth and wound healing.
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BIOCHEMICAL & METABOLIC CHANGES

32. St.Ann's Degree College for Women

33. TREATMENT
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34. 
Treatment strategy can be divided into three
stages.
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 Resolving life threatening
conditions
 Restoring nutritional
status
 Ensuring nutritional rehabilitation.
There are three stages of treatment.
1.Hospital Treatment
The following conditions should be corrected.
Hypothermia, hypoglycemia, infection, dehydration, electrolyte
imbalance, anaemia and other vitamin and mineral deficiencies.
2.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.
3.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.
TREATMENT

35. PREVENTION
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36.  Promotion of breast feeding
 Development of low cost weaning
 Nutrition education and promotion of c
o
r
r
e
c
t
feeding practices
 Family planning and spacing of births
 Immunization
 Food fortification
 Early diagnosis and treatment
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PREVENTION

37. THANK YOU
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