PROTEIN ENERGY

MALNUTRITION

Dr G T Deepak
Junior Resident
III Semester

MALNUTRITION
Primary

Secondary

Malnutrition resulting from inadequate food intake

Malnutrition resulting from increased nutrient needs,

decreased nutrient absorption, and/or increased nutrient
losses.

Developing Countries

Developed Countries

DEFINITION
PEM may be defined as impaired growth primarily
due to inadequate intake of food
Both macronutrients and energy containing food and
micronutrients
WHO (1973) Range of pathological conditions
arising from coincidental lack in varying
proportions of proteins and calories, occurring most
frequently in infants and young children and

DETERMINANTS
Physical environment
Biological environment
Psycho socio cultural
environment
Microenvironment
Feeding Practices

DETERMINANTS
Physical environment
Biological environment
Psycho socio cultural
environment
Microenvironment
Feeding Practices

children living in families

who accessed drinking
water Similarly, the IMR
and U5 mortality rates
are consistently lower
among children living in
families with access to
an improved toilet as
compared to those who
do not have such an
access.

DETERMINANTS
Physical environment
Biological environment
Psycho socio cultural
environment
Microenvironment
Feeding Practices

Biological environment is the term to denote all the living

things which surround man, including human beings.
The microbes that are useful and harmful are included in this.

DETERMINANTS
Physical environment
Biological environment
Psycho socio cultural
environment
Microenvironment
Feeding Practices

Cultural values, customs, habits, benefits, attitudes, morals,

religion, education, lifestyle, and social and political organization.

Children born in lower social strata families have higher risk of dying
than others
Mortality among low SLI has declined

DETERMINANTS
Physical environment
Biological environment
Psycho socio cultural
environment
Microenvironment
Feeding Practices

The immediate home environment with special emphasis on the

mother and her psychosocial functions

DETERMINANTS
Physical environment
Biological environment
Psycho socio cultural
environment
Microenvironment
Feeding Practices

EPIDEMIOLOGY
U5MR WORLD

INDIA 248 48

INDIA 248
48

EPIDEMIOLOGY
IMR INDIA

CLASSICAL TYPES

PATHOPHYSIOLOGY
THE CLASSICAL THEORY
Marasmus to protein and
calorie deficiency
Marasmus was believed
to occur due to early
abrupt weaning followed
by starvation and
infection contributing to
the wasting.

Kwashiorkor to a highcarbohydrate low-protein

diet.
Kwashiorkor was
associated with late gradual
weaning and starchy family
diet and repeated infections
contributing to edematous
malnutrition.

PATHOPHYSIOLOGY
DYSADAPTATION THEORY
It was found that the diet of many children with
kwashiorkor was not necessarily protein deficient.
Marasmus adapted to the deficient protein calorie intake.
In these children there was loss of fat and degradation of
muscle protein secondary to hormonal responses,
characterised by high cortisol and low insulin levels.
The protein thus derived was used for production of
proteins including albumin; hence there was no
hypoalbuminemia and edema.
1973 Proceedings Nut . Soc. India N.I.N.,
Hyderabad.

PATHOPHYSIOLOGY
DYSADAPTATION THEORY
Kwashiorkor- this adaptation did not occur.
The dietary protein was used for energy production
and possibly for the production of acute phase
reactants in response to repeated infections.
Unlike in marasmus, there was no muscle protein
available-hence the hypoalbuminemia.

Physiologic Characteristics

Hypometaboli
c,
Nonstressed
Patient
(Cachectic,
Marasmic)
Decreased

Cytokines,
catecholamines,
glucagon, cortisol, insulin
Metabolic rate, O2
Decreased
consumption
Proteolysis,
Decreased
gluconeogenesis
Ureagenesis, urea
Decreased

Hypermetabolic,
Stressed Patient
(Kwashiorkor Risk)

Increased

Increased
Increased
Increased

PATHOPHYSIOLOGY
FREE RADICAL THEORYCURRENT
Imbalance between free radical production and elimination
by antioxidants and oxygen radical scavengers.
Free radical-induced injury to the cells causes leaky
membranes and results in edema.
Infection is believed to increase the oxidant stress in
children with kwashiorkor: proteins are used for the
manufacture of acute phase reactants and there is
inadequate substrate for albumin production, causing
hypoalbuminemia and edema.

ASSESSMENT

Dietary factors
Clinical features
Anthropometry
Biochemical parameters
Morphological parameters
Radiological parameters
Epidemiological data

ASSESSMENT

Dietary factors
Clinical features
Anthropometry
Biochemical parameters
Morphological parameters
Radiological parameters
Epidemiological data

24 hour recall method- accuracy

increased by taking average of 3 days
recall during midweek
Food frequency table records
frequency intake of each food item
after defining standard servings of
each
Weighing uncooked and cooked
food and assessing nutritive value
Breast feeding and bottle feeding
practices, diet during illness

ASSESSMENT

Dietary factors
Clinical features
Anthropometry
Biochemical parameters
Morphological parameters
Radiological parameters
Epidemiological data

CLINICAL FEATURES
SIGNS
ORGAN
Hair

Hypochromotrichia
Easily pluckable
Flag sign
Straightening
Altered texture

Skin

Flaky paint dermatosis

Crazy pavement
dermatosis
Secondary infections
Cutaneous diphtheria
Xerosis
Follicular hyperkeratosis
Pellagra

face

Depigmentation
Noma

CLINICAL FEATURES
SIGNS
ORGAN
eyes

lips

tongue

Teeth
Glands
nails

Pale conjunctiva
Bitot spots
Conjunctival /corneal
xerosis
Angular stomatitis
Angular scars
Cheilosis
Edema
Scarlet/ raw tongue
Bald tongue
Mottled enamel
Spongy, bleeding gums
Thyroid and parotid
swelling
Koilonychia,Platynychia,

ORGAN
Subcutaneous
tissue

SIGNS
Edema/ gross reduction

musculoskelet Wasting
al
Craniotabes
Frontoparietal bossing
Epiphyseal enlargement/
tenderness
Beading of ribs
Wide open AF
Knock knees / bow legs
Thoracospinal
deformities
bleeds
GIT

Fatty liver
Hepatomegaly
Lactose intolerance

CLINICAL FEATURES
ORGAN

neurological

CVS

Serous
cavities

SIGNS

Psychomotor changes
Confusion
Sensory loss
Motor weakness
Loss of position sense
Loss of ankle and knee jerks
Calf tenderness
Tremors

Cardiomegaly
Tachycardia

effusion

ASSESSMENT

Dietary factors
Clinical features
Anthropometry
Biochemical parameters
Morphological parameters
Radiological parameters
Epidemiological data

ANTHROPOMETRY
Weight for Age

(acute)

Height for Age

(chronic)

Weight for Height

chronic)
Head circumference
Chest circumference

(acute on

ANTHROPOMETRY
Gomez

Jelliffe's

ANTHROPOMETRY
WELLCOME

ANTHROPOMETRY IAP 1972

Status

Weight For Age

% Expected

Normal

>80

Grade 1

71 80

Grade 2

61 70

Grade 3

51 60

Grade 4

<50

Ref : 50th centile of Harvard standards

ANTHROPOMETRY

ANTHROPOMETRY

ANTHROPOMETRY- WHO

ANTHROPOMETRY MUAC

Increases rapidly in the first year (11 16cm)

and stabilizes between 1 to 5 years age

Age reference data used in 6 59 months age

group

1 5 years
> 13.5cm normal
12.5 13.5cm borderline
< 12.5cm wasted
< 11 cm
severe

ANTHROPOMETRY-AGE
INDEPENDENT INDICATORS
INDEX

NORMAL

MILD PEM

MOD PEM

SEVERE PEM

KANAWATI
MAC / HC

>= 0.315

0.28 - 0.314

0.25 - 0.279

<= 0.249

DUGHDALE
Wt / Ht^1.6

> 0.79

< 0.79

PONDERAL
Wt/ Ht^3

> 2.5

2 2.5

<2

RAO & SINGH

Wt/ Ht ^2

> 0.0015

0.0013 - 0.0015

< 0.0013

ASSESSMENT

Dietary factors
Clinical features
Anthropometry
Biochemical parameters
Morphological parameters
Radiological parameters
Epidemiological data

ASSESSMENT

Dietary factors
Clinical features
Anthropometry
Biochemical parameters
Morphological parameters
Radiological parameters
Epidemiological data

Mutilation of cells in buccal

smear (normally < 10%)
hair texture, shaft size
Bone Age, Rickets, Scurvy,
Osteoporosis
Vital statistics, under 5
mortality is used to rank
nations based on child
health and nutritional status

MANAGEMENT
Basic Principles
Careful initial evaluation
Anticipation of problems
Prevention of problems
Early detection &treatment of problems
Avoid intravenous infusions except when essential
Promotion of food intake by all available means

MANAGEMENT
Routine treatment
Emergency treatment
Associated Conditions
Treatment failure
Preparing Follow-up

MANAGEMENT
Routine treatment
Emergency treatment
Associated Conditions
Treatment failure
Preparing Follow-up

MANAGEMENT

The 10 Steps
1. Treat/prevent hypoglycemia S

Routine treatment

Emergency
treatment
Associated
Conditions
Treatment failure
Preparing Follow-up

2. Treat/prevent hypothermia
3. Treat/prevent infection
4. Correct electrolyte imbalance
5. Treat/prevent dehydration
6. Correct micronutrient deficiencies
7. Begin cautious feeding
8. Achieve catch-up growth E
9. Sensory Stimulation and emotional support
10. Prepare for follow-up T

MANAGEMENT
Routine treatment
Emergency treatment
Associated Conditions
Treatment failure

Anemia

Preparing Follow-up

Shock

MANAGEMENT
Vitamin A deficiency
Emergency treatment

Day 1, 2, 14
Antibiotic drops/Atropine in
ulcers

Associated Conditions

Dermatosis

Routine treatment

Treatment failure
Preparing Follow-up

Barrier creams (Zinc, petroleum

jelly)
Omit nappies

Worm infestations
Mebendazole 100mg BD x 3
days

Tuberculosis

MANAGEMENT
Primary Failure
Routine treatment

Failure to gain appetite by day 4

Failure to start losing edema by day 4

Emergency treatment

Presence of edema on day 10

Failure to gain at least 5g/kg/d by day 10

Associated Conditions
Treatment failure
Preparing Follow-up

Secondary Failure

Failure to gain at least 5g/kg/day for 3 consecutive days in rehabilitation

 Absence of infection

MANAGEMENT
Child eating at least 120-130
cal/kg/day

Routine treatment

Consistent weight gain of at least 5

Emergency treatment
Associated Conditionsg/kg/day for 3 consequent days
Treatment failure

WFH is 90% NCHS median

Preparing Follow-up

Absence of edema
Completed immunization for age
Caretakers sensitized to home care

REFERENCES
Nutrition and Child Development . K E Elizabeth
Nelson 20th Edition
Achar TB of Pediatrics 4th
WHO Manual for SAM

THANK YOU