PROTEIN ENERGY MALNUTRITION

Dr.Rittu Chandel
Second year resident
Grant Government Medical College
02 -01-2013

Rittu Chandel

The World Health Organization (WHO) 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.
WHO defines PEM as range of pathological conditions
arising from coincidental lack in varying proportions of
proteins and calories, occuring most frequently in infants,
young children
Protein-energy malnutrition - weight loss of greater than
10% of normal body weight
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Marasmus

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A global problem
First national nutritional disorder
Childhood mortality and morbidity
Physical impairment
Retardation of mental growth

Protein gap replaced by food gap

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CAUSES

Worldwide, the most common cause of is inadequate food

intake
ineffective weaning
poor hygiene, economic factors, and cultural factors
Gastrointestinal infections

malnutrition

infection

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Early detection
First indicator underweight for age

Method maintenance of growth charts

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CAUSES

by decreased absorption or abnormal metabolism

Burns
cystic fibrosis
chronic renal failure
childhood malignancies
congenital heart disease
neuromuscular diseases
psychiatric diseases, such as anorexia nervosa

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MARASMUS
insufficient energy intake to match the
body's requirements
Duration : months to years

Emaciation
loss

of subcutaneous fat
muscle wasting
an adaptive response to starvation
skin is xerotic, wrinkled, and loose
Monkey facies
fine, brittle hair; alopecia; impaired growth; and fissuring of the nails
Good appetite
Listless
Temperature - subnormal
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KWASHIORKAR

adequate carbohydrate consumption

decreased protein intake
Duration : weeks
edema, moon facies
a swollen abdomen (potbelly)
Poor appetite
Irritable, moaning cry

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Hypoalbuminemia

-Impaired synthesis of B-lipoprotein

produces a fatty liver
- Atrophy of pancreas,salivary gland
and intestine

hair-pull analysis

Flaky paint dermatosis

Pavement dermatosis
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elderly persons

indicative sign of malnutrition is delayed healing

decubitus ulcers
increased likelihood of calciphylaxis, a small vessel
vasculopathy involving mural calcification with intimal
proliferation, fibrosis, and thrombosis. As a result,
ischemia and necrosis of skin occurs. Other tissues
affected include subcutaneous fat, visceral organs, and
skeletal muscle
Noma

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Marasmic Kwashiorkar

Initially marasmic-------then oedema develops

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Laboratory Studies
The WHO recommends the following laboratory tests:
Blood glucose
Examination of blood smears
Hemoglobin
Urine examination and culture
Stool examination by microscopy for ova and parasites
Serum albumin
HIV test
Electrolytes

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Cellular reactions to protein deficiency

Decrease
cellular RNA

Decreased protein
catabolism

Decreased
DNA
synthesis
Decreased
formation of new
cells

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CNS delayed mental development

Immunologically competent cells deficient immune response
Decreased myeloid, monocytes susceptibility to infection
Decreased erythrocytes anemia
Endochondral bone growth - growth retardation
Hair follicle atrophy
Stomach and small intestine - malabsorption

Cellular reactions to protein calorie deficiency

Decrease
cellular RNA

Decreased protein
catabolism

Fall in tissue and

cellular proteins and
enzymes

Anatomical changes
Fatty liver
Atrophy of pancreas, salivary
glands

Delayed
mental
developmen
t

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Decreased
DNA
synthesis

Kwashiorkar
Proteins - decreases
hypoalbuminemia (< 2.8 g/dl)
Hypoglobulinemia
Amino acids
essential amino acids ( branched ones) decreases
Non essential - tyrosine, arginine, citrulline, - amino butyric
acid - decreases
Ratio branched essential amino acids

glycine, glutamic acid, serine

Incomplete metabolism of histidine, phenylalanine, tryptophan

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KWASHIORKAR
transferrin (<150 mg/dl)
Iron binding capacity < 200 mcg/dl
hypoglycemia
lymphopenia
growth hormone levels are high
insulin secretion and insulin like growth factor levels are
decreased.
percentage of body water and extracellular water is increased
potassium and magnesium depleted
iron deficiency anemia
lactase, amylase, lipase - reduced
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MARASMUS

Urinary excretion of hydroxyproline diminished, reflecting

impaired growth and wound healing
Increased urinary 3-methylhistidine is a reflection of muscle
breakdown
Creatinine height index low (< 60%)

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PREVENTIVE MEASURES
From WHO expert committee on nutrition
Health Promotion
1.Measures directed to pregnant and lactating women
2.Promotion of breast feeding
3.Meal given at frequent intervals
4.Improve family diet
5.Promotion of correct feeding practices
6.Family planning and spacing of births

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Specific Protection
1.Immunization
2.Food fortification
3.Diet must contain protein and energy rich foods milk, egg,
fresh fruit

Early Diagnosis and treatment

1.Early diagnosis of any lag of growth
2. Early diagnosis and treatment of infections and diarrhea
3.Rehydration
4.deworming
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treatment
PHASE

STABILISATION
Day 1-2

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Hypoglycaemia
Hypothermia
Dehydration
Electrolytes
Infection
Micronutrients
Cautious feeding
Rebuild tissues
Sensory stimulation
Prepare for follow-up

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Day 2-7+

no iron

REHABILITATION
Week 2-6

with iron

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Bibliography

Harrisons internal Medicine 17th edition

Nelsons Pediatrics
IAP pediatrics
Parks Preventive Social and Medicine
Talwar

THANK YOU

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