PROTEIN ENERGY

MALNUTRITION (PEM)

MALNUTRITION
Results

from a lack of one or more essential

nutrients (nutritional deficiency) or from an
excessive nutrient supply to the point of
creating toxic or harmful effects
(obesity/adiposity)

FORMS OF MALNUTRITION
UNDERNUTRITION-results

from the consumption of an

inadequate quantity of food over an extended period of
time
OVERNUTRITION-results from the consumption of an
excessive quantity of food over an extended period of
time
SPECIFIC DEFICIENCY-results from a relative or
absolute lack of an individual nutrient
IMBALANCE- results from a disproportion among
essential nutrients, with or without the absolute
deficiency of any nutrient

TYPES OF MALNUTRITION
ACUTE-

relates to the present state of

nutrition; indicators for this include weight
for age, weight for height, MUAC, triceps
skin fold

CHRONIC-

relates to the past state of

nutrition; indicator for this is height for age

Effects of Malnutrition:
1. Increase mortality unless treated on time
2. Increased susceptibility to infection ( synergism between
malnutrition & infection)
3. Poor mental performance
4. Impaired national development
Health additional burden of medical services,
hospitalization
Education more school drop-outs, school absences,
leading to reduced manpower potential
Agriculture & industry - losses due to poor
performance, absenteeism, accidents
Socio-cultural greater unrest, disorders

Increased susceptibility to infection ( synergism between

malnutrition & infection)
Susceptibility to infection

Decreased nutritional level

infectious disease

Loss of appetite

SYNERGISM BETWEEN
MALNUTRITION & INFECTION
-Under most circumstances, malnutrition and infection

interact synergistically (one condition accentuates the

other). The end result is beyond the summed effect of 2
diseases acting alone.

Malnutrition tends to increase host susceptibility to

infection by facilitating both the entry & multiplication
of the infectious agent.
- The malnourished child tends to harbor infectious agents for

longer periods and often has more severe clinical

manifestations.

SYNERGISM

1. The integrity of the skin & mucous membranes may be affected.

2. Secretions of mucous & epithelial fluids may be reduced
(hypovitaminosis A)
3. The cell debris associated with edema provides a good medium for
microorganisms
4. Wound healing is slower
5. Malnutrition causes changes in the gut flora. Organisms not normally
pathogenic may cause diarrhea.
6. Cell-mediated immunity is depressed. The number of both the T-cells
and the macrophages and phagocytic activity are reduced.
7. Antibody formation is limited.

Infection/parasitic infestation may

precipitate or aggravate malnutrition:
1. Decreased dietary intake that may be due to:

Anorexia ex. Primary complex, influenza, common cold

Vomiting or coughing
Restricted diet prescribed by the family or health worker as in
diarrhea, hepatitis A etc.

2. Intake of drugs that may reduce intestinal absorption- - ex. Purgatives,

antibiotics
3. If accompanied by fever, increased metabolic rate & increased loss of
nutrients through the sweat

4. Stress reaction that causes increased loss of nitrogen in

urine
5. Reduced absorption of nutrients as in diarrhea
6. Some intestinal parasites compete with the host for
nutrition (ascariasis)
7. Loss of fluids & nutrients ex diarrhea

EFFECTS OF MENTAL
PERFORMANCE
-

direct association between deficiency in H & W

and the retardation in psychomotor, language and
social behavior

MECHANISM OF POOR MENTAL

PERFORMANCE
A.DIRECT- nutritional deficiency affects mental
performance directly by modifying the growth and
biochemical maturation of the brain

EFFECTS OF MENTAL
PERFORMANCE
B.INDIRECT- Loss of learning
- Interference with learning
- Motivation and personality changes

CLASSIFICATION OF DEGREES
OF MALNUTRTION
Gomez

Classification (according to
percentage of EBW)
> 110% - obesity
91-110% - normal
76-90% - first degree (mild)
61-75% - second degree (moderate)
</=60% - third degree (severe)

WATERLOW CLASSIFICATION
Uses

both weight for height (wasting) and

height for age (stunting)
% of ref. ABOVE
Ht.for
> 80
age

BELOW
<80

ABOVE
> 90

NORMAL

ACUTE OR
RECENT
MALNUTRITION

BELOW
< 90

NUTRITION
AL
DWARFISM

SEVERE
CHRONIC
MALNUTRIT
ION

WT.FOR
HT (80%
EBW)

WELLCOME CLASSIFICATION OF
SEVERE PEM
WEIGHT FOR EDEMA
AGE
PRESENT
% OF EBW
60-80%

EDEMA
ABSENT

KWASHIORKOR UNDERNOUR

ISHED
</= 60%

MARASMIC
KWASHIORKOR

MARASMUS

PROTEIN-ENERGY
MALNUTRITION (PEM)
-

A range of pathological conditions arising from a

deficiency of protein and energy commonly
associated with infections
Used to be PCM
Most widespread form of malnutrition in our
country
Occurs most frequently in infants and young
children and occasionally in adolescents and
adults

GROUPS MOST SERIOUSLY

AFFECTED BY PEM:
Pregnant

& lactating mothers

Infants
Preschoolers
Those

engaged in heavy manual labor

 Vulnerable

age Pre-school children

Reasons:

higher needs than older children & adults

cultural reasons Filipinos give rice gruel
affected by childhood diseases
emotional factors anorexia, jealousy sibling

rivalry
In infants- usually due to inadequate
breastfeeding

CAUSES OF PEM:
The main cause - quantitatively insufficient &
qualitatively inadequate diet

1. Poverty - inadequate food intake, both in quality &

quantity; high CHO, low CHON
2. Faulty food intake inadequate intake of protective
foods (vegetables, milk, eggs, dried beans, etc)
3. Large family size true when the buying capacity of
family is low
4. Low level of education illiteracy, wrong habits and
beliefs, resistance to change

Causes of PEM.

5. Intra-familial food distribution

the growing child may be deprived of necessary nutrients
because the older family member , especially the
breadwinner is given a larger food share.

6. Poor environmental sanitation

widespread incidence of infectious diseases and intestinal
parasitism

7. Urbanization unemployment, low wages

8. Underdeveloped agriculture
9. Uneven distribution of wealth

TYPES OF PEM
KWASHIORKOR-

first used in

Ghana, Africa
-comes from the Ghan language
meaning red boy
- also means the sickness of the
older child when the next baby is
born
- a qualitative deficiency state

 NUTRITIONAL MARASMUS

gross muscle

wasting
- comes from a Greek word meaning wasting
- a quantitative deficiency state

MARASMIC

KWASHIORKOR- combination

Kwashiorkor and marasmus are accompanied by

deficiency in vitamins and minerals

 Marasmus
Calorie deficiency

(lack of protein,
vitamins, and
minerals)
Affects very young
children
Emaciated, no
edema, hair is dull
and dry, skin thin
and wrinkled.

PRINCIPAL FEATURES OF
SEVERE PEM
CLINICAL FEATURES
(always present)

MARASMUS

KWASHIORKOR

MUSCLE WASTING

Obvious

Sometimes hidden by
edema & fat

FAT WASTING

Severe loss of
Often retained but not firm
subcutaneous fats

EDEMA

Skin and bones;

old mans face

Present in lower legs and

usually in face and lower arms;
moon facies

WEIGHT FOR HEIGHT

Very low

Low but maybe mashed by

edema

MENTAL CHANGES

Sometimes quiet
and apathetic

Irritable, moaning, apathetic

VARIABLE
FEATURES
(sometimes
present)

MARASMUS

KWASHIORKOR

APPETITE

Usually good

Poor

DIARRHEA

Often

Often

SKIN CHANGES

Usually none

Diffuse pigmentation,
sometimes flaky paint
dermatosis

HAIR CHANGES

Seldom

Sparce, silky, easily

pulled out

HEPATIC
ENLARGEMENT

None

Sometimes due to
accumulation of fats

BIOCHEMICAL SERUM
ALBUMIN

Normal or slightly
decreased

Low-<3 gms/100 ml

MANAGEMENT OF PEM
PREVENTIVE
A. Maintenance of good nutritional status
with emphasis on the high risk
1. Breastfeeding
2. Supplementary feeding
3. Proper nutrition for all age group

B. Minimize morbidity and other stresses

1. Immunization
2. Environmental sanitation
3. Food habits
4. Early detection and prompt treatment
5. Feeding programs
6. Deworming

C. Nutrition Education
D. Multidisciplinary Approach
1. Family Planning

CURATIVE
MILD-

ambulatory- OPD/housecall
MODERATE- ambulatory
SEVERE- hospital

A. Case history and examinations particularly for:

1. Dehydration
2. Vitamin A deficiency
3. Edema
4. Infection
5. Hypothermia
6. Anemia

B. Treatment of dehydration
C. Treatment of Infection
D. Diet- high CHO
high CHON

E. Vitamins and mineral supplement

F. Nursing Care- keep child clean, warm, dry,
encourage to consume diet

Sample feeding schedule for a hospitalized child

1st DAY
-oral rehydration/IVF
2nd-3rd DAY
- half-strength MF (8-12 feedings/day;125
ml/k/BW/day)
4th-5th DAY
- full strength MF (8
feedings/day;125ml/k/BW/day)

From 6th DAY

- high energy MF (6 feedings/day; 160
ml/k/BW/day)
3rd WEEK
- solid + MF ( 5-6 feedings/day; 160
ml/k/BW/day)

REHABILITATION
1.
2.
3.
4.
5.

Intensive follow through

Continuous nutrition education
Income generating activities
Increase food production
Immunization and environmental sanitation

END OF
TOPIC