Protein-Energy Malnutrition (PEM)

Protein-Energy Malnutrition (PEM)

• PEM is the term used for malnutrition resulting from a lack of protein and energy foods
• PEM is a major public health problem in India
• PEM occurs particularly in children younger than 5 years old
• The most extreme forms of PEM are kwashiorkor and marasmus

Severe Acute Malnutrition (SAM)

• Edematous malnutrition is kwashiorkor
• Severe wasting is marasmus
• Marasmic kwashiorkor includes features of both marasmus and kwashiorkor

Definition of PEM

• PEM is a group of clinical conditions resulting from varying degrees of protein deficiency and energy inadequacy.
• PEM was previously known as protein-calorie malnutrition

Incidence of PEM

• PEM is a leading cause of mortality and morbidity
• PEM increases susceptibility to infectious diseases
• The incidence of malnutrition in India and Africa is high
• 30-40% of children younger than 5 years are affected
• 7.6% of children have severe malnutrition

Causes and Risk Factors for PEM

• Age: Children between 6 months and 4 years are at risk
• Sex: Boys are more commonly affected
• Too many children in the same family contribute to neglect
• Lack of spacing between children increases risk
• Low birth weight is a risk factor
• Twin and multiple births are risk factors
• Poor growth in the first few months of life is a risk factor
• Failure or stoppage of breastfeeding is a risk factor
• Delayed weaning is a risk factor
• Infectious diseases like diarrhea, ARI and measles are risk factors
• Chronic diseases and certain congenital disorders are risk factors
• Lack of adequate care for pregnant women is a risk factor
• Acute illness or surgery are also risk factors
• High birth order contributes
• Congenital defects and poor socioeconomic background are risk factors
• Single parents, orphans, and foster homes are risk factors
• Maternal deprivation is a risk factor

Classification of PEM by Severity

• Mild PEM:
  • Weight below the 3rd percentile but above -3 SD for age
  • Growth curve tends to flatten
• Moderate PEM:
  • Weight equal to or below -3 SD but above -4 SD
  • No edema, skin, or hair changes; alert with normal appetite
• Severe PEM:
  • Weight equal to or below -4 SD
  • Includes Marasmus and Kwashiorkor

IAP Classification of Malnutrition

• Normal: >80% of the standard weight for age
• Grade 1: 71-80% of standard weight, mild malnutrition
• Grade 2: 61-70% of standard weight, moderate malnutrition
• Grade 3: 51-60% of standard weight, severe malnutrition
• Grade 4: <50% of standard weight, very severe malnutrition

Wellcome Classification

• Weight for age 60-80%: Undernourished, no nutritional edema
• Weight for age <60% (-4SDS):
  • Kwashiorkor: Edema present
  • Marasmus: Edema absent
  • Marasmic-kwashiorkor: Edema present

Gomez Classification

• Only considers weight for age
• Makes no comment about height
• All cases with edema are classified as 3rd-degree malnutrition
• Normal nutritional status: >90% of expected weight for age
• 1st degree PEM: 75-90% of expected weight for age
• 2nd degree PEM: 60-75% of expected weight for age
• 3rd degree PEM: <60% of expected weight for age

Syndromal Classification

• Kwashiorkor
• Nutritional Marasmus
• Prekwashiorkor
• Nutritional Dwarfing

Kwashiorkor

• First described by Dr. Cicely Williams in 1933
• The term 'Kwashiorkor' was introduced in 1935
• Also known as 'Red boy' due to pigmentary changes
• Mainly found in preschool children but can occur at any age
• Infection precipitates condition
• Characterized by deficient intake of both protein and calories, with protein deficiency being predominant

Features of Kwashiorkor

• Essential features:
  • Marked growth retardation
  • Muscle wasting
  • Psychomotor changes
  • Pitting edema
• Non-essential features:
  • Hair change (flag sign)
  • Skin changes
  • Super added infections

Grading of Edema in Kwashiorkor

• Grade I: Pedal edema
• Grade II: Grade I + facial puffiness
• Grade III: Grade II + edema of the chest wall and paraspinal area
• Grade IV: Grade III + ascites

Marasmus

• Also termed infantile atrophy or athrepsia
• Common in infants and toddlers
• Deficiency in both protein and calories, with calorie deficiency being predominant
• Children looks like an old person with a wizened and shriveled face due to loss of buccal pad of fat
• Initially, the child is irritable, hungry, and craves food
• Later stages may involve misery, apathy, and refusal to eat

Features of Marasmus

• Essential features:
  • Marked growth retardation
  • Muscle wasting
  • Marked stunting and absence of edema
• Non-essential features:
  • Hair change (hypopigmented)
  • Skin changes (dry, scaly)
  • Liver shrunk
  • Crave for food
  • Psychomotor changes
  • Mineral deficiencies

Grading of Marasmus

• Grade I: Loss of subcutaneous fat in the axilla and groin
• Grade II: Grade I + loss of abdominal fat and fat in the gluteal region
• Grade III: Grade II + loss of fat in the chest wall and the praspinal region
• Grade IV: Grade III + loss of the buccal pad of fat

Marasmic Kwashiorkor

• Features of both marasmus and kwashiorkor are present
• The presence of edema is essential for diagnosis

Prekwashiorkor

• Features of kwashiorkor are present without edema
• Early management initiated by early diagnosis may prevent full-blown kwashiorkor

Nutritional Dwarfing

• Significant low weight and height for age without overt features of kwashiorkor or marasmus
• Typically seen when PEM continues over years

Assessment of PEM

• Nutritional assessment:
  • History
  • Clinical findings
  • 24-hour retrospective dietary recall
  • Societal and environmental assessment
• Growth chart
• Anthropometric measurements compared with population standards
• Lab findings:
  • Serum albumin
  • Transferrin
  • Prealbumin
  • Albumin globulin ratio (decreased)
  • Creatinine high index
  • Nitrogen balance
  • Blood glucose level
  • Blood/urine/rectal swab cultures
  • Mantoux test
  • Microscopic examination of urine or stool

Management of PEM

• Multidisciplinary approach
• Aim: -To supply what has been lacking in diet -To prevent and treat infections and other diseases -To teach parents how to prevent relapse
• Domiciliary management: -Managed at home -Parents are educated about dietary management -Nutritional counseling and demonstration -Less expensive, locally available food -Community support system (supervision) -Home visit -Medical follow-up (weight monitoring)
• Management at hospital: -Needed at advanced cases
• Mild PEM: -Rule out infections -Provide nutritional counseling to parents -Replace nutrients and breastfeed till 2 years of age, with the introduction of supplementary feeding at 4-5 months -Immunization -Parental counseling and education
• Moderate PEM: -Admit to hospital -Treat underlying cause or problems -Diet is the most important part of treatment -Provide a reinforced milk diet -Teach preparation of milk diet
• Severe PEM: -Hospitalization -Watch for complications -Dietary treatment: -4 gm/kg protein -Marasmus 150-200 kcal/kg per day -Kwashiorkor 100 kcal/kg per day -Reinforced milk or high calorie cereal milk can be given -Feed milk diet at a ratio of 125 ml/kg/day -Prevent hypoglycemia -NG tube feeding -Gradually increase feed -Schedule 8 feeds per day -Supplement minerals and vitamin -Treat infections

Complications of PEM

• Acute:
  • Systemic local infections
  • Severe dehydration
  • Shock
  • Dyselectrolytemia
  • Hypoglycemia
  • Hypothermia
  • CCF (congestive cardiac failure)
  • Bleeding disorders
  • Hepatic dysfunction
  • SIDS (sudden infant death syndrome)
  • Convulsions
• Long term:
  • Cachexia
  • Growth retardation
  • Mental subnormalities
  • Visual and learning disabilities

Prevention of PEM

• Health promotion
• Specific protection
• Early diagnosis and treatment
• Rehabilitation

Nursing Management of PEM

• Assessment:
  • History
  • Physical examination
  • Assessment of growth and development
  • Nutritional assessment
  • Lab investigations

Nursing Diagnosis

• Imbalanced nutrition: Less than body requirement
• Fluid and electrolyte imbalance
• Risk for infection
• Potential for complications
• Knowledge deficit
• Parental anxiety
• Body image disturbances

Evaluation

• The child regains weight as expected
• No infection and edema