Protein Energy Malnutrition

Protein-energy malnutrition (PEM), sometimes called protein-energy undernutrition (PEU), is a form of malnutrition that is defined as a range of pathological conditions arising from a coincident lack of dietary protein and/or energy (calories) in varying proportions.

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Ganga Prasad V
M.Sc (N) in Child Health Nursing
PROTEIN ENERGY
MALNUTRITION

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DEFINITION
Protein-Energy Malnutrition (PEM), is also called Protein-Energy Undernutrition (PEU), is a
form of malnutrition that is defined as a range of pathological conditions arising from a lack of
dietary protein and/or energy (calories) in varying proportion.

PREVALENCE RATE OF PEM

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SYNDROMAL CLASSIFICATION OF PEM
 Nutritional Marasmus:
 This term is derived from Greek word 'Marasmos', which means withering or
wasting. Marasmus occurs due to inadequate intake of proteins and calories and is
characterized by emaciation.







 Kwashiorkor:
 This word means 'sickness of weaning'. Kwashiorkor involves inadequate intake
of proteins and is characterized by presence of edema.







 Prekwashiorkor:
 It is a condition when the child is having features of Kwashiorkor without edema.
 If the early management is initiated by early diagnosis of the condition, child can
be prevented from full-blown Kwashiorkor.

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 Nutritional Dwarfing:
 It is condition when the child is having significant low weight & height for the
age without any overt features of Kwashiorkor & Marasmus.

 Marasmic Kwashiorkor
 It is a mixed form of PEM and manifests as edema occurring in children who
may or may not have other signs of kwashiorkor and have varied manifestations
of marasmus.
CLASSIFICATION OF PEM
Protein Energy malnutrition is classified on the following basis
 Weight for Age classification by Gomez




If, weight for age is:
 90 % - Normal nutritional status
 76-90 % - 1st degree malnutrition
 61-75 % = 2nd degree malnutrition
 60 % - 3rd degree malnutrition

 Waterlow's classification on the basis of Height for Age:






Weight of the child
Weight for age (%) = X 100
Weight of normal child of same age

Height of the child
Height for age (%) = X 100
Height of normal child of same age

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If, height for age is:
 95 % = Normal
 90-95 % - Mild malnutrition
 85-90 % = Moderate malnutrition
 < 85 % - Severe malnutrition.

 Classification Given by Indian Academy of Pediatrics (IAP) on the Basis of Weight for
Age.
The IAP takes weight of more than 80 % of expected weight for age, as normal. The
grades of malnutrition are:

If, weight for age is:
 80 % = Normal
 71-80 % = Grade I malnutrition
 61-70 % - Grade Il malnutrition
 51-60 % Grade Ill malnutrition
 50 % Grade IV malnutrition.

 Wellcome Trust Classification on the Basis of Weight for Age and presence of Edema
Classification
Weight for age Edema
Kwashiorkor
. 60-80 % Present
Under nutrition
60-80 % Absent
Marasmus
> 60 % Absent
Marasmic kwashiorkor
> 60 % Present

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 WHO Classification
WHO recommends three terms for describing malnutrition in under 5 children:
 Stunting: It is defined as, height for age being 2 standard deviation below from
median height for age, given in NCHS reference population.
 Stunting refers to a child who is too short for his or her age.
 Underweight: If weight for age is 2 standard deviation below from median
weight for age, given In NCHS reference population, it is termed as
undernutrition.
 Wasting: If the weight for height is 2 standard deviation below from median
weight for height, given in NCHS reference population, it is termed as wasting.
 Wasting refers to a child who is too thin for his or her height.

ETIOLOGICAL FACTORS OF PEM
The etiology of protein- energy malnutrition is multifactorial. Worldwide, the most common
cause of malnutrition is due major three aspects:
Immediate determinants:
 Low dietary intake
 Low birthweight
 Infection: Diarrhea, Pneumonia
Underlying determinants:
 Dietary intake: Due to lack adequate nutrients in diet.
 Care from mother & children: Inadequate household food security, breastfeeding &
complementary feeding.
 Health environment & services: due to lack of access to curative & preventive health
services.

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Basic determinants:
 Socioeconomic status
 Education level of family
 Women’s empowerment
 Cultural taboos regarding food & health

CLINICAL FEATURES:
Marasmus:
The clinical features of marasmus are as follows:
Essential features of marasmus:
 Growth retardation: 60 % of the expected weight for age & subnormal height/length.
 Severe muscle wasting.
 Loss of subcutaneous fat resulting as aged child, wrinkled skin referred as monkey facie.






 Marked stunting and absence of edema with loose skin of the buttocks hanging down.
Axillary pad of the fat is diminished referred as Baggy pants.

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Nonessential features of marasmus:
 Hair changes: Hypopigmented and appear dull brown or yellow in color.
 Abdomen is distended due to muscle wasting and hypotonia of abdominal wall muscles.
 Superadded infection.
 Mid arm circumference is reduced.
 Liver shrunk & child having craving for hunger.
 Child psychomotor changes may be alert but irritable.
Grading of nutritional marasmus is done depending upon the areas of loss of fat.
 Grade I is considered when there is loss of fat from axilla
 Grade II for loss of fat from abdominal wall and gluteal region
 Grade III for loss of fat from chest and back
 Grade IV for loss of buccal pad of fat.

Kwashiorkor:
It usually affects children aged 1-4 yr. The main sign is pitting edema, usually starting in the legs
and feet and spreading, in more advanced cases, to the hands and face.
 General appearance: Child may have a fat sugar baby appearance.
 Edema:
 It ranges from mild to gross and may represent up to 5-20 % of the body weight.
 Muscle wasting: The child is often weak, hypotonic and unable to stand or walk.
 Skin changes:
 The skin lesions consist of increased pigmentation, desquamation and
dyspigmentation.
 Pigmentation may be confluent resembling flaky paint or in individual enamel
spots.
 Petechiae may be seen over abdomen.

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 Outer layers of skin may peel off and ulceration may occur. The lesions may
sometimes resemble burns.
 ‘Flaky Paint’ appearance to the skin and is known as Flaky Paint Dematitis.
 Mucous membrane lesions: Smooth tongue, cheilosis and angular stomatitis are
common. Herpes simplex stomatitis may also be seen.
 Hair:
 Changes include dyspigmentation.
 Loss of characteristic curls and sparseness over temple and occipital regions.
 Hairs also lose their lustre and are easily pluckable.
 Mental changes:
 Includes unhappiness
 Apathy or irritability with sad, intermittent cry.
 They show no signs of hunger and it is difficult to feed them.
 Gastrointestinal system:
 Anorexia, sometimes with vomiting, is the rule.
 Abdominal distension is characteristic.
 Stools may be watery or semisolid, bulky with a low pH and may contain
unabsorbed sugars.
 Fatty liver can seen.
 Anemia: It may also be seen, as in mild PEM, but with greater severity.
 Cardiovascular system:
 The findings include cold, pale extremities due to circulatory insufficiency.
 Prolonged circulation time
 Bradycardia,
 Diminished cardiac output and hypotension.

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 Renal function:
 Glomerular filtration and renal plasma flow are diminished.
 There is aminoaciduria and inefficient excretion of acid load.
 Infection:
 GI tract infection causes diarrhea, Vomiting, anorexia & dehydration.
 Respiratory infection (ARI, Tuberculosis)
 Skin infection
 Other associated condition:
 Mineral & vitamin deficiencies
 Hepatomegaly
 Intestinal parasitosis
 Metabolic disorder
 Malabsorption syndrome

DIAGNOSTIC EVALUATION:
W.H.O recommends the following laboratory tests for diagnosis of PEM
 Heath history must be taken.
 A thorough physical examination
 Anthropometric assessment:
 Peripheral Blood Film (PBF): PBF shows microcytic or macrocytic RBCs.
 Stool examination for presence of ova and parasites.
 Blood hematology and biochemistry:
 Blood glucose estimation (it reveals hypoglycemia).
 Serum albumin estimation (it reveals hypoalbuminemia)
 Blood Hemoglobin (it is low)

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 Serum electrolytes estimation (it reveals hypokalemia, hypomagnesaemia,
hypocalcemia and hypernatremia).
 Serum cholesterol (it is low)
 Blood PH (metabolic acidosis may be present).
 Urine examination shows decreased urinary excretion of hydroxyproline, reflecting
impaired growth and wound healing.

MANAGEMENT
 Hypoglycemia
 Blood glucose level 54 mg/dl.
 If blood glucose cannot be measured, assume hypoglycemia
 Hypoglycemia, hypothermia and infection generally occur as a triad.
Treatment
Asymptomatic hypoglycemia
 Give 50 ml of 10 % glucose or sucrose solution orally or by nasogastric tube
followed by first feed.
 Feed with starter F-75 every 2 hourly day and night
Symptomatic hypoglycemia
 Give 10 % dextrose IV 5 ml / kg Follow with 50 ml of 10 % dextrose or
sucrose solution by nasogastric tube
 Feed with starter F-75 every 2 hourly day and night Start appropriate
antibiotics
 Prevention Feed 2 hourly starting immediately Prevent hypothermia
 Hypothermia:
 Rectal temperature less than < 35.5 ° C or 95.5 ° F or axillary temperature less
than 35 ° C or 95 ° F.

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 Always measure blood glucose and screen for infections in the presence of
hypothermia
Treatment
 Clothe the child with warm clothes, ensure that the head is also covered with a
scarf or cap.
 Provide heat using overhead warmer, skin contact or heat convector.
 Avoid rapid rewarming as this may lead to disequilibrium.
 Feed the child immediately
 Give appropriate antibiotics
Prevention
 Place the child's bed in a draught free area
 Always keep the child well covered; ensure that head is also covered well
 May place the child in contact with the mother's bare chest or abdomen (skin-to-
skin )
 Feed the child 2 hourly starting immediately after admission
 Dehydration:
 Difficult to estimate dehydration status accurately in the severely malnourished
child
 Consider severely malnourished children with watery diarrhea have some
dehydration
 Low blood volume (hypovolemia) can coexist with edema
Treatment
 Use ORS with potassium supplements for rehydration and maintenance
 Amount depends upon volume of stool loss, and whether the child is vomiting
 Initiate feeding within 2-3 hours of starting rehydration, use F - 75 formula on
alternate hours along with reduced osmolarity ORS
 Be alert for signs of overhydration

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Prevention
 Give ORS at 5-10 ml/kg after each watery stool, to replace stool losses breastfed,
continue breastfeeding
 Initiate refeeding with starter F - 75 formula
 Electrolyte:
 Give supplemental potassium at 3-4 mEq/kg/day for at least 2 weeks
 On day one, give 50 % magnesium sulphate (equivalent to 4 mEq/ml) IM once
(0.3 ml / kg maximum of 2 ml).
 Thereafter, give extra magnesium (0.8-1.2 mEq/kg daily)
 Excess body sodium exists even though the plasma sodium may be low,decrease
salt in diet.
 Infection:
 Usual signs of infection such as fever are often absent
 Majority of bloodstream infections are due to gram-negative bacteria
 Hypoglycemia and hypothermia are markers of severe infection
Treatment
 Treat with parenteral Ampicillin 50 mg/kg/dose 6 hourly for at least 2 days
followed by oral Amoxicillin 15 mg/kg 8 hourly for 5 days
 Gentamicin 75 mg/kg or Amikacin 15-20 mg/kg IM or IV once daily for 7 days
 If no improvement occurs within 48 hr, change to IV Cefotaxime (100-150 mg/kg
/day 6-8 hourly) or Ceftriaxone (50-75 mg/ kg/day 12 hourly)
 If other specific infections are identified, give appropriate antibiotics.
Prevention
 Follow standard precautions like hand hygiene
 Give measles vaccine if the child is 6 months and not immunized or if the child is
> 9 months and had been vaccinated before the age of 9 months.

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 Micronutrients:
 Use up to twice the recommended daily allowance of various vitamins and
minerals
 On day one. give vitamin A orally (if age >1 yr give 2 lakh IU; age 6-12 months
give 1 lakh IU; age 0-5 months give 50,000 IU)
 Folic acid 1 mg/day (give 5 mg on day 1)
 Zinc 2 mg/kg/day
 Copper 0.2-0.3 mg/kg/day Iron 3 mg/kg/day, once child starts gaining weight
after the stabilization phase.
 Initiate feeding:
 Start feeding as soon as possible as frequent small feeds If unable to take orally,
initiate nasogastric feeds.
 Total fluid recommended is 130 ml/kg/day; reduce to 100 ml/kg/day if there is
severe edema.
 Continue breastfeeding ad libitum (Diet is available at all times)
 Start with F-75 starter feeds every 2 hourly
 If persistent diarrhea, give a cereal based low lactose F-75 diet as starter diet
 If diarrhea continues on low lactose diets give, F-75 lactose free diets (rarely
needed)
 Catch - up growth:
 Once appetite returns in 2-3 days, encourage higher intakes
 Increase volume offered at each feed and decrease the frequency of feeds to 6
feeds per day
 Continue breastfeeding ad libitum
 Make a gradual transition from F-75 to F-100 diet
 Increase calories to 150-200 kcal/kg/day, and proteins to 4-6 g/kg/day

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 Add complementary foods as soon as possible to prepare the child for home foods
at discharge.
 Sensory stimulation
 A cheerful, stimulating environment
 Age appropriate structured play therapy for at least 15-30 min/day
 Age appropriate physical activity as soon as the child is well enough
 Tender loving care
 Prepare for followup
Primary failure to respond is indicated by:
 Failure to regain appetite by day 4
 Failure to start losing edema by day 4
 Presence of edema on day 10
 Failure to gain at least 5 g/kg/day-by-day 10
Secondary failure to respond is indicated by:
 Failure to gain at least 5 g/kg/day for consecutive days during the rehabilitation
phase.






COMPLICATIONS OF PEM:
PEM has acute and long-term complications which influence the outcome.
Acute complications
 Systemic or local infections
 Severe dehydration
F-75 & F-100 Formula: Therapeutic milk products designed to treat severe malnutrition. F-75 is
considered the "starter" formula, and F-100 the "catch-up" formula. The designations mean that the
product contains respectively 75 and 100 kcals per 100 ml.
To know preparation of Formula click on this link:
https://motherchildnutrition.org/malnutrition-management/info/feeding-formulas-f75-f100.html



 Bleeding disorders
 Hepatic dysfunction

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 Shock
 Convulsions
Long-term complications:
 Cachexia
 Growth retardation
 Mental subnormality
 Visual and learning disabilities

PREVENTION OF MALNUTRITION
 Prevention at Family Level
 Exclusive breast feeding for first 6 months of age.
 Weaning must be started at the age of 6 months.
 Milk, egg, meat and food items of high biological value must be given to the
children.
 Immunization must be done to prevent children from communicable diseases.
 Birth spacing should be followed.

 Prevention at Community Level
 Early detection of malnutrition and early interventions.
 Growth monitoring
 Integrated health packages including immunization, chemoprophylaxis, oral
rehydration, periodic deworming and early diagnosis and treatment of common
illnesses.
 Family planning services
 Income generation activities
 Promotion of education and literacy in community.
 Health & Nutrition education to people.
 Hypoglycemia
 Hypothermia
 Sudden infant death syndrome (SIDS)

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 Prevention at National Level
 Provision of nutritional supplements for infants and children.
 Nutritional surveillance.
 Nutritional planning.

NURSES RESPONSIBILITY:
 Assessment of nutritional status of the children with collection of appropriate history.
 Assisting in diagnostic investigations whenever necessary.
 Maintenance of growth chart by regular health check-up at home, clinic or health centers
for early detection of growth failure.
 Participating in the hospital management in complications and life - threatening situations
related to PEM and other related illnesses.
 Implementing nutritional rehabilitation activities.
 Encouraging the parents for home care and follow-up at regular interval.
 Nutrition education, demonstration and counseling according to identified problems of
particular child.
 Promoting preventive measures for individual, family and community to overcome the
problem of PEM.
 Co-operating with other team members and acting with different sectors for the
implementation of various nutritional services (e.g. working with Anganwadi workers) .
 Maintaining records and reports related to nutritional assessment of individual or
community.
 Assisting in implementation of national nutritional programs for prevention of various
malnutrition.
 Participating in nutritional research project and assisting in modification of nutritional
behaviors by creating awareness in individual, family and community towards status.

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NURSING DIAGNOSIS
1. Imbalanced Nutrition: less than body requirements relatd to inadequate intake, anorexia and
diarrhea.
2. Fluid Volume Deficit related to a decrease in oral intake and increased loss due to diarrhea.
3. Altered Growth and Development related to caloric and protein intake is not adequate.
4. Risk for aspiration related to the provision of food / beverages per-sonde and increased
tracheo-bronchial secretion.
5. Ineffective airway clearance related to increased secretion of tracheo-bronchial secondary to
respiratory tract infections.

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Diagnosis Goal Outcome Intervention Rational

Imbalanced
Nutrition: less than
body
requirements related
to inadequate
intake, anorexia and
diarrhea.







The client will show an
increase in nutritional
status.

 Family clients can explain
the cause of nutritional
deficiencies experienced by
the client, the needs of
recovery nutrition, menu
structure and processing of
a healthy balanced diet.
 With the help of the nurse,
the client can demonstrate
provision of family diet
suitable dietetic program.

 Explain to the family about the
causes of malnutrition,
nutritional needs recovery,
menu structure and a healthy
balanced food processing, show
an example of the type of food
sources by major socio-
economic status of clients.
 Implement the provision of
appropriate treatment programs.
 Measure anthropometric
measurement and the thick folds
of skin every morning.







 Improve understanding of
the family
 Increased appetite,
absorption process and
meet the deficits that
accompany malnutrition.
 Assessing the development
of a client problem.

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Diagnosis Goal Outcome Intervention Rational

Fluid Volume
Deficit related to a
decrease in oral
intake and increased
loss due to diarrhea.










The client will show the
state of adequate
hydration.

 Adequate fluid intake as
needed plus deficits.
 No signs/symptoms of
dehydration (vital signs
within normal limits, with
the consistency of
defecation solid/semi-
solid).


 Perform/observations fluid
administration by intravenous /
oral rehydration programs
appropriate.
 Explain to the family of
rehydration efforts and the
expected participation of the
family in maintaining the
patency of the infusion.
 Assess the state of development
of dehydration.
 Calculate the fluid balance.


 Rehydration efforts need to
be done to address the
problem of lack of fluid
volume.
 Increase understanding of
the family and family roles
rehydration efforts in the
implementation of
rehydration therapy.
 Assessing the development
of a client problem.
 It is important to establish
subsequent rehydration
program.

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REFERENCES:
 Essentials of Pediatric Nursing, Japee Publications, 2
nd
edition, Rimple Sharma, Chapter
12, Page No. 225-232.
 Pediatric Nursing, Japee Publications, 3
rd
edition, Parul Dutta, Chapter 12, Page No. 195-
200
 Essentials Pediatric, CBS Publications, 8
th
edition, Ghai, Chapter 6, Page No. 95-109
 https://www.who.int/data/gho/data/indicators/indicator-details/GHO/severe-wasting-
numbers-in-millions
 https://causesofdeathin.com/malnutrition-death-rate-by-country/2
 https://nanda-diagnosis.blogspot.com/2014/08/nursing-care-plan-for-marasmic.html
 https://www.who.int/data/gho/data/indicators/indicator-details/GHO/stunting-numbers-
(in-millions)