Protien Energy Malnutrition

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History and Examination

History of Present Illness: Vomiting, diarrhea, HIV, measles diarrhea, ARI.
Nutritional History: Usually poor feeding practices.
Immunization Status: Poor.
Developmental Milestone: Delayed or regressed.
Poor Socioeconomic Status.
Evidence of Wasting and Physical Findings of Micronutrient Deficiency.

Definition: The World Health Organization 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."

Types of Malnutrition

Malnutrition can be classified based on the particular nutrient(s) implicated in the balance between supply and body requirements:

Macronutrient Malnutrition (relating to energy and protein)

Protein – Energy Malnutrition
Overnutrition and Obesity (effects of nutrient excess)

Micronutrient Malnutrition (Hidden Hunger)

Vitamin Nutritional Disorders
Minerals and Trace Elements Nutritional Disorders

Protein Energy Malnutrition (PEM)

Protein Energy Malnutrition (PEM) is defined as a spectrum of diseases arising from an absolute or relative deficiency of calories and/or protein in the diet.
In children, PEM is defined by measurements that fall below 2 standard deviations under the normal:

Weight for age (underweight)
Height for age (stunting)
Weight for height (wasting)

Wasting indicates recent weight loss, whereas stunting usually results from chronic malnutrition.
Among children under the age of 5 years in developing countries:

About 31% are underweight.
38% have stunted growth.
9% show wasting.

PEM usually manifests early in children between 6 months and 2 years of age and is associated with:

Early weaning.
Delayed introduction of complementary foods.
A low-protein diet.
Severe or frequent infections.

Anthropometric Definitions of Malnutrition

In children, protein–energy malnutrition is defined by measurements that fall below 2 standard deviations under the normal:

Weight for age (underweight)
Height for age (stunting)
Weight for height (wasting)

Wasting indicates recent weight loss, whereas stunting usually results from chronic malnutrition.

Deaths associated with malnutrition

Underlying Causes / Risk Factors

Diet:

Insufficient food intake — Anorexia due to illness, eating disorders, dietary practices, or beliefs.
Insufficient food availability — Civil war, political instability, limited agricultural development.
Impaired nutrient absorption or excessive losses — Malabsorption syndromes, primary or secondary gastrointestinal diseases, short gut syndrome.

Infections:

Infections such as diarrhea, measles, and acute respiratory tract infection are associated with an increased incidence of Protein Energy Malnutrition (PEM).
Mechanisms by which infections lead to malnutrition include:

Reduced food intake.
Malabsorption of nutrients.
Metabolic losses during infection.

Socioeconomic Risk Factors for PEM:

Several socioeconomic factors have been implicated in the etiology of PEM. Poverty, infection, and malnutrition are related by a vicious cycle.
Factors include:

Insufficient household food security.
Inappropriate care for mother and child.
Inadequate health care services provision by the government.
Cultural beliefs, superstitions, and taboos about food also influence nutrient intake.

Diet:

Insufficient food intake — Anorexia due to illness, eating disorders, dietary practices, or beliefs.
Insufficient food availability — Civil war, political instability, limited agricultural development.
Impaired nutrient absorption or excessive losses — Malabsorption syndromes, primary or secondary gastrointestinal diseases, short gut syndrome.

Infections:

Infections such as diarrhea, measles, and acute respiratory tract infection are associated with an increased incidence of Protein Energy Malnutrition (PEM).
Mechanisms by which infections lead to malnutrition include:

Reduced food intake.
Malabsorption of nutrients.
Metabolic losses during infection.

Socioeconomic Risk Factors for PEM:

Several socioeconomic factors have been implicated in the etiology of PEM. Poverty, infection, and malnutrition are related by a vicious cycle.
Factors include:

Insufficient household food security.
Inappropriate care for mother and child.
Inadequate health care services provision by the government.
Cultural beliefs, superstitions, and taboos about food also influence nutrient intake.

Factors that contribute to hunger and malnutrition:

Social and Economic Factors:

Poverty
Population growth
Urbanization

Infection and Disease
Political Disruptions and Natural Disasters:

War
Refugees
Sanctions
Floods, droughts, mudslides, hurricanes

Inequitable Food Distribution

Effects of hunger

How Infections Impair Nutritional Status

Reduced Food Intake:

Poor appetite
Mother/carer may withhold food

Increased Utilization by the Body:

Energy and nutrients

Losses During Diarrhoea:

Protein, zinc
Potassium, magnesium

The vicious cycle of infection and undernutrition

Spiral of Infection and Malnutrition

Malnutrition significantly influences the severity and frequency of infections, leading to a vicious cycle that can be fatal. Malnourished children have:

Lower Immunity:

Increased susceptibility to illness
More severe and longer-lasting infections

This cycle shows how children can become progressively more undernourished:

Cycle of Infection and Malnutrition:

Infection leads to increased nutrient requirements and losses
Malnutrition weakens immunity, leading to more frequent and severe infections
The cycle continues, worsening malnutrition and increasing the risk of death

When children are well-nourished, their immune systems function better, reducing the risk of severe infections and decreasing mortality rates.

Spiral of infection and malnutrition

Protein Energy Malnutrition (PEM) is a nutritional deficiency disorder resulting in growth failure and poor nutritional status, with distinctive clinical manifestations. The classification of PEM involves assessing anthropometric indicators (weight-for-age, height-for-age, and weight-for-height) along with clinical signs. The main classifications are:

Clinical Classification

Based on the presence or absence of edema, severe forms of PEM are:

Marasmus:

Characterized by severe wasting and loss of muscle mass.

Kwashiorkor:

Characterized by edema, often with a relatively normal weight but with other signs of malnutrition.

Marasmic Kwashiorkor:

Combination of severe wasting and edema.

Wellcome Classification of PEM
Weight for Age (%)	Edema Present	Edema Absent
60-80	Kwashiorkor	Underweight
<60	Marasmic-Kwashiorkor	Marasmus

Modified Wellcome Classification of PEM

Weight for Age (%)	Edema Present	Edema Absent
>80	Kwashiorkor	Normal Nutrition
60-80	Underweight-Kwashiorkor	Underweight
<60	Marasmic-Kwashiorkor	Marasmus

Community Survey Classifications

Community surveys assess the magnitude of malnutrition in a population using deficits in anthropometric measurements. Common thresholds include:

80% of weight for age: Level below which malnutrition is defined.
90% of height for age: Level below which stunting is defined.

Gomez Classification of PEM

The Gomez classification is widely used for classifying malnutrition based on deficits in weight for age. It categorizes malnutrition into three degrees:

Malnutrition	Body Weight (% of Standard)
First Degree	75-90
Second Degree	60-75
Third Degree	<60

Classification of Protein Energy Malnutrition (PEM)
Classification	Definition	Grading
Gomez	Weight below % median Weight-for-Age (WFA)	Mild: 75%-90% WFA Moderate: 60%-74% WFA Severe: <60% WFA
Waterlow	Z Scores (SD) below median Weight-for-Height (WFH)	Mild: 80%-90% WFH Moderate: 70%-80% WFH Severe: <70% WFH
WHO (Wasting)	Z Scores (SD) below median Weight-for-Height (WFH)	Moderate: -3% <= Z score <-2 Severe: Z score <-3
WHO (Stunting)	Z Scores (SD) below median Height-for-Age (HFA)	Moderate: -3% <= Z score <-2 Severe: Z score <-3
Kanawati	Mid-Arm Upper Circumference (MAUC) divided by Occipitofrontal Circumference	Mild: <0.31 Moderate: <0.28 Severe: <0.25
Cole	Z scores of BMI-for-Age	Grade 1: BMI for age Z score <-1 Grade 2: BMI for age Z score <-2 Grade 3: BMI for age Z score <-3

Definitions of Severe Malnutrition
Condition	Definition
Severe Malnutrition	Severe wasting and/or edema
Severe Wasting	Z-score <-3 SD weight-for-length or Mid-upper arm circumference (MUAC) <110mm for children aged 6-59 months

Kwashiorkor and Marasmus

	Marasmus	Kwashiorkor
Age	Infancy (< 2 yrs)	Older infants (1-3 y.o.)
Cause	Severe deprivation	Low protein, infections
Onset	Develops slowly	Rapid onset
Weight Loss	Severe weight loss	Some weight loss
Muscle Wasting	Severe muscle wasting	Some muscle wasting
Growth	Low growth (<60%)	Growth: 60-80%
Edema/Fatty Liver	No edema, no fatty liver	Edema; enlarged fatty liver
Behavior	Anxiety, apathy	Apathy, misery, irritable
Appetite	Possible good appetite	Loss of appetite
Hair/Skin	Hair thin, dry; skin dry	Hair dry; skin lesions

clinical features

Marasmus

Marasmus is defined as a weight of <60% of the expected weight for age without edema.
It is characterized by progressive wasting of the subcutaneous tissue and muscle.
Marasmus is diagnosed when subcutaneous fat and muscle are lost due to endogenous mobilization of all available energy and nutrients.
This condition results from inadequate food intake and is often precipitated or preceded by failure of breastfeeding, infection, or congenital abnormalities.
Marasmus results from a negative energy balance. It represents a successful adaptation to continuous nutritional deficits, whereas kwashiorkor is a dysadaptation.
Adaptations to energy deficit include reduced activity, lethargy, decreased basal energy metabolism, slowing of growth, and subsequent weight loss.
Clinical presentation of marasmus includes:
- Prominent bones and joints
- Hanging skin folds over the buttocks and thighs
- Disappearance of buccal fat pads
- Distended abdomen
Changes in the skin and hair:
- The skin becomes loose and may eventually hang in folds, commonly on the buttocks and thighs. It may also be wrinkled, dry, or scaly.
- The buccal fats in the cheeks of young infants may persist long after other subcutaneous tissue has disappeared. Its disappearance is a poor prognostic sign.
The abdomen may be scaphoid or distended.
Anal or rectal prolapse (from loss of perianal fat) can occur.
Marasmic children are usually unhappy and irritable but generally respond normally to attention and feed more hungrily. Edema is usually absent.

Kwashiorkor

Kwashiorkor usually manifests with:
- Edema
- Changes to hair and skin color
- Anaemia
- Hepatomegaly
- Lethargy
- Severe immune deficiency
- Early death
It is common in children between one and three years old.
The four cardinal signs always present in kwashiorkor are:
- POOR GROWTH
- EDEMA
- MUSCLE WASTING
- MENTAL CHANGES
Other features include:
- Skin changes
- Hair changes
- Moon face appearance
- Signs of micronutrient deficiency
- Hepatomegaly
- Intractable diarrhea
Anaemia is a usual feature.
Kwashiorkor presents the worst form of PEM as it has the poorest prognosis.

Marasmic-Kwashiorkor

Children with both clinical features of kwashiorkor and marasmus.
In this condition, edema appears in a clinically undernourished child who has not been growing for weeks or months.
The degree of stunting is significantly greater, suggesting that the duration of illness is longer in marasmic–kwashiorkor compared to kwashiorkor.
Features such as psychosocial issues, skin and hair changes, and other characteristics of kwashiorkor are also present.

Investigations required for the diagnosis and treatment of Protein-Energy Malnutrition (PEM) include:

Complete Blood Count: Hemoglobin and packed cell volume are usually lower than normal. Leucocytosis or leucopenia may be present in the presence of infection. Platelet count is usually within normal limits.
Random Blood Sugar: Blood sugar levels might be low or normal.
Blood Electrolytes, Urea, and Creatinine: Evidence of derangement in these parameters can be present. High sodium and low potassium are typical due to active transport of sodium out of the cell as a result of increased cell permeability.
Serum Lipids and Protein Levels: Changes in serum protein in malnutrition include low serum albumin, transferrin, and apolipoprotein B.
Microbiological Cultures: Culture of blood and other body fluids such as urine and cerebrospinal fluid to identify the organisms responsible for any infection and their sensitivity patterns to antibiotics.
Stool Examination: For ova of parasites and occult blood to identify parasites if present.
Radiological Chest X-Ray: Important due to the higher association of malnutrition with tuberculosis.
HIV Screening: To establish the possibility of HIV, as PEM is commonly associated with HIV/AIDS.

There are ten essential steps in the treatment of Protein-Energy Malnutrition (PEM):

Treat/Prevent Hypoglycemia: Ensure blood sugar levels are monitored and managed to prevent or treat hypoglycemia.
Treat/Prevent Hypothermia: Maintain body temperature with appropriate clothing and environmental control to prevent or treat hypothermia.
Treat/Prevent Dehydration: Rehydrate with oral rehydration solutions or intravenous fluids as needed to correct dehydration.
Correct Electrolyte Imbalance: Monitor and correct electrolyte levels, including sodium, potassium, and chloride.
Treat/Prevent Infection: Identify and treat any existing infections with appropriate antibiotics or other treatments.
Correct Micronutrient Deficiencies: Supplement essential vitamins and minerals to address deficiencies.
Start Cautious Feeding: Begin feeding with small, frequent meals and gradually increase the amount to avoid overloading the compromised digestive system.
Achieve Catch-Up Growth: Provide adequate nutrition to support growth and development, aiming for catch-up growth in affected children.
Provide Sensory Stimulation and Emotional Support: Offer appropriate sensory stimulation and emotional support to aid in the child’s overall recovery and well-being.
Prepare for Follow-Up After Recovery: Plan for regular follow-up visits to monitor growth, nutritional status, and any ongoing health issues.

These steps are accomplished in two phases:

Initial Stabilization Phase (2-6 weeks): Manage acute medical conditions, including treating hypoglycemia, hypothermia, dehydration, electrolyte imbalances, and infections. Correct micronutrient deficiencies, start cautious feeding, and provide sensory stimulation and emotional support.
Rehabilitation Phase (6 months): Focus on achieving catch-up growth, providing ongoing nutritional support, and preparing for long-term recovery. Continue to monitor and address any persistent health issues or complications.

Follow-Up: Regular follow-up visits are essential to monitor the child's growth, nutritional status, and overall health. This ensures continued progress and addresses any ongoing or new concerns.

Phases of treatment

Where Should Severely Malnourished Children Be Treated?

Stabilization Phase: Requires inpatient treatment to manage acute medical conditions effectively. This phase involves intensive medical care and monitoring.

Rehabilitation Phase: Treatment can be provided either in the hospital or at home (community-based) if the child's progress can be closely monitored. This phase focuses on continued nutritional support and long-term recovery.

Treating Hypoglycemia

If the child is conscious and dextrostix shows <3mmol/l or 54mg/dl:

Administer 50 ml bolus of 10% glucose or 10% sucrose solution (1 rounded teaspoon of sugar in 3.5 tablespoons water) orally or by nasogastric (NG) tube.
Follow with starter F-75 every 30 minutes for two hours, giving one quarter of the two-hourly feed each time.
Administer antibiotics as needed.
Continue two-hourly feeds, both day and night.

If the child is unconscious, lethargic, or convulsing:

Give IV sterile 10% glucose (5ml/kg), followed by 50 ml of 10% glucose or sucrose via NG tube or orally with F-75 diet.
Provide F-75 frequently as soon as the patient regains consciousness to prevent recurrence.
If unable to test blood glucose levels, assume all severely malnourished children are hypoglycemic and treat accordingly.

Treating Hypothermia

If the rectal temperature is <35.5°C (<95.9°F):

Feed the child immediately (or start rehydration if needed).
Rewarm the child by:
- Clothing the child (including the head), covering with a warmed blanket, and placing a heater or lamp nearby (do not use a hot water bottle).
- Placing the child on the mother’s bare chest (skin-to-skin) using the kangaroo method.
Administer antibiotics.
Nurse the child in a radiant warmer.
Measure rectal temperature every 30 minutes.

Prevention

Feed every two hours, starting immediately (see step 7).
Ensure feeds are given throughout the day and night.
Keep the child covered and away from draughts.
Maintain dryness; change wet nappies, clothes, and bedding. Avoid exposure (e.g., bathing, prolonged medical examinations).
Allow the child to sleep with the mother/carer at night for warmth.

Treating Dehydration

Low blood volume can coexist with edema. Avoid using the IV route for rehydration except in cases of shock, and do so with caution. Infuse slowly to prevent flooding the circulation and overloading the heart.

The standard oral rehydration salts solution (90 mmol sodium/l) contains too much sodium and too little potassium for severely malnourished children. Instead, use a special Rehydration Solution for Malnutrition (ReSoMal).

It is difficult to estimate dehydration status in a severely malnourished child using clinical signs alone. Therefore, assume all children with watery diarrhea may have dehydration and provide:

ReSoMal 5 ml/kg every 30 minutes for two hours, orally or by nasogastric tube. Then, give 5-10 ml/kg/hour for the next 4-10 hours.
The exact amount should be determined by the child's appetite, stool loss, and vomiting.
Replace ReSoMal doses at 4, 6, 8, and 10 hours with F-75 if rehydration is continuing at these times, then continue feeding starter F-75.
If the child is passing stools and is less than 2 years old, give 50-100 ml for each loose stool.

ReSoMal Preparation

To prepare ReSoMal, mix the following ingredients:

Water (boiled and cooled) – 2 liters
WHO-ORS – 1 sachet
Sugar – 50 grams
CMV (Commercial Milk Powder) – 1 scoop

ReSoMal contains:

45 mmol Na (Sodium) per liter
40 mmol K (Potassium) per liter
3 mmol Mg (Magnesium) per liter

Component	Concentration (mmol/l)
Glucose	125
Sodium	45
Potassium	40
Chloride	70
Citrate	7
Magnesium	3
Zinc	0.3
Copper	0.045
Osmolarity	300

Preventing Dehydration with Continuing Watery Diarrhea

When a child has continuing watery diarrhea, follow these guidelines:

Continue feeding with starter F-75 (see step 7).
Replace the approximate volume of stool losses with ReSoMal. As a guide, give 50-100 ml after each watery stool. Note: It is common for malnourished children to pass many small unformed stools; these should not be confused with profuse watery stools and do not require fluid replacement.
If the child is breastfed, encourage continued breastfeeding.

Correcting Electrolyte Imbalances

For severely malnourished children, follow these guidelines to address electrolyte imbalances:

All severely malnourished children have excess body sodium, even though plasma sodium levels may be low. Avoid giving high sodium loads as this can be fatal.
Deficiencies of potassium and magnesium are common and may take at least two weeks to correct. Edema is partly due to these imbalances. Do not treat edema with diuretics.
Provide extra potassium: 3-4 mmol/kg/day.
Provide extra magnesium: 0.4-0.6 mmol/kg/day.
When rehydrating, use low sodium rehydration fluids such as ReSoMal.
Prepare food without added salt.

Treating and Preventing Infection

In cases of severe malnutrition, infections may not present with typical signs such as fever, and they can be hidden. Therefore, it is important to:

Administer broad-spectrum antibiotic(s) routinely upon admission.
Give the measles vaccine if the child is older than 6 months and has not been immunized. (Delay vaccination if the child is in shock.)

Correct Micronutrient Deficiencies

All severely malnourished children have vitamin and mineral deficiencies. It is essential to correct these deficiencies to aid recovery:

Vitamin A: Administer orally on Day 1. Dosage is as follows:
- For children >12 months: 200,000 IU
- For children 6-12 months: 100,000 IU
- For children 0-5 months: 50,000 IU
Ensure that this dose has not been given in the last month.
Daily for at least 2 weeks:
- Multivitamin supplement
- Folic acid 1 mg/day (give 5 mg on Day 1)
- Zinc 2 mg/kg/day
- Copper 0.3 mg/kg/day
- Iron 3 mg/kg/day, but only when the child is gaining weight and has a good appetite

Feeding

Stabilisation Phase

Target:
- 100 kcal/kg/day
- 1g protein/kg/day
Give F75:
- 75 kcal and 0.9g protein/100ml

Rehabilitation Phase (Catch-up Growth)

Target:
- 150-220 kcal/kg/day
- 4-6g protein/kg/day
Give:
- F100 (100 kcal and 2.9g protein/100ml)
- RUTF (Ready-to-Use Therapeutic Food)
- Modified family foods

Dietary Management

Continue breastfeeding if still on breast milk.
Use F-75 and F-100 diet:
- F-75 is used in the initial phase.
- F-100 is used in the rehabilitation phase.
Start F-75 as soon as possible (2-3 hours after admission).
Feed frequently and in small amounts.

Feeding the Child

Give F-75 every 2/3/4 hours.
Provide 130ml/kg/day.
Gradually decrease the frequency of feeding and increase the volume.
Use an NG tube if the child is unable to feed orally.
End the initial phase when the child is hungry, usually after 2-7 days.
Replace the F-75 diet with an equal amount of F-100 for 2 days before increasing the volume.
Recording is important to monitor progress.

Start Cautious Feeding

In the stabilization phase, a cautious approach is required due to the child’s fragile physiological state and reduced homeostatic capacity. Feeding should be started as soon as possible after admission and should be designed to provide just sufficient energy and protein to maintain basic physiological processes. The essential features of feeding in the stabilization phase are:

Small, frequent feeds of low osmolarity and low lactose.
Oral or nasogastric (NG) feeds (never parenteral preparations).
100 kcal/kg/day.
1-1.5 g protein/kg/day.
130 ml/kg/day of fluid (100 ml/kg/day if the child has severe edema).
If the child is breastfed, encourage continued breastfeeding but give the prescribed amounts of starter formula to ensure the child’s needs are met.

Achieve Catch-Up Growth

In the rehabilitation phase, a vigorous approach to feeding is required to achieve very high intakes and rapid weight gain of >10 g/kg/day. The following guidelines are essential:

The recommended milk-based F-100 contains 100 kcal and 2.9 g protein/100 ml.
Modified porridges or modified family foods can be used, provided they have comparable energy and protein concentrations.
Readiness to enter the rehabilitation phase is signaled by a return of appetite, usually about one week after admission.
A gradual transition is recommended to avoid the risk of heart failure, which can occur if children suddenly consume large amounts of food.

Provide Sensory Stimulation and Emotional Support

Severe malnutrition often leads to delayed mental and behavioral development. To support recovery, provide:

Tender loving care
A cheerful, stimulating environment including structured play therapy (15-30 minutes per day)
Physical activity as soon as the child is well enough
Maternal involvement when possible (e.g., comforting, feeding, bathing, and play)

Prepare for Follow-Up After Recovery

Advise the parent or carer to:

Bring the child back for regular follow-up checks
Ensure booster immunizations are given
Ensure vitamin A is administered every six months

Infection: Infections such as diarrhea, measles, and pneumonia, often severe, reflecting impaired immunological status.
Hypoglycemia
Hypothermia
Cardiac failure
Age < 6 months
Weight/Height > 2 Z scores
Severe dehydration and acidosis
Stupor or coma
Arm muscle area < 5th percentile
Serum albumin < 2.5 g/dL
Serum transferrin < 100 μg/dL

Risk of Hypoglycemia

Poor treatment practices that can increase the risk of hypoglycemia include:

Kept waiting: In queue, to be examined by the doctor, or to get to the ward.
Not fed at night
Not tube fed if anorexic
Not fed every 2-3 hours
Draughty, cold wards: No blankets and left in wet clothes

Risk of Cardiac Failure

Poor treatment practices that can increase the risk of cardiac failure include:

Too much fluid: Dehydration may be overestimated, inappropriate use of IV route, and lack of monitoring during rehydration.
Sodium not restricted
Potassium deficiency not corrected
Diuretics given to get rid of oedema

Risk of Infection

Poor treatment practices that can increase the risk of infection include:

No (or delayed) antibiotics
Giving iron too early
Cross-infection

Why should we worry?

We should be concerned for two main reasons:

Malnutrition is closely linked with child mortality.
Malnutrition has long-term adverse effects, including:

Cognitive function
School achievement and job opportunities
Mental health
Working capacity

Specific Impacts:

Increased susceptibility to infection.
Chronic weight loss.
Affects the optimum height a child can attain.
Impacts education attainment; cognitive impairments are directly related to the severity of stunting and Iron Deficiency Anaemia.
Affects economic productivity; mental impairment caused by iodine deficiency is permanent and linked to productivity loss.

Public Health Measures
Infection Control
Hygiene
Immunization
Dietary Diversification and Breastfeeding Promotion
Supplementation

Single or multiple micronutrients

Fortification

Staple foods (flour, oil, sugar, salt)

Home-Fortification

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