PEM

A.AARADHANAIst MSc. Food Technology and

Management1619101

PROTEIN-ENERGY MALNUTRITION

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DEFINITIONIs defined as a range of pathological conditions arising from coincident lack of varying proportions of protein and calorie, occurring most frequently in infants and young children and often associated with infection (WHO)

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The worldwide magnitude of protein-energy malnutrition: an overview from the WHO Global Database on Child Growth

World More than 1/3 of the world’s population. For all indicators of PEM, a total of 80% of

the children affected live in Asia (mainly in southern Asia).

43% of children in developing countries are stunted. 50% of child deaths in developing countries are related to malnutrition

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National family health survey-NFHS reports

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Types of PEMThe five forms of PEM are :

1. Kwashiorkor2. Marasmus 3. Nutritional dwarfing4. Underweight child

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KWASHIORKOR• The term kwashiorkor is taken from the Ga language of Ghana and means

"the sickness of the weaning”

• Williams first used the term in 1933, and it refers to an inadequate protein intake with reasonable caloric (energy) intake.

• Kwashiorkor, also called wet protein-energy malnutrition, is a form of PEM characterized primarily by protein deficiency.

• This condition usually appears at the age of about 12 months when breastfeeding is discontinued, but it can develop at any time during a child's formative years.

• It causes fluid retention (edema); dry, peeling skin; and hair discoloration.

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• Kwashiorkor was thought to be caused by insufficient protein consumption but with sufficient calorie intake, distinguishing it from marasmus

• More recently, micronutrient and antioxidant deficiencies have come to be recognized as contributory

• Victims of kwashiorkor fail to produce antibodies following vaccination against diseases, including diphtheria and typhoid

• Generally, the disease can be treated by adding food energy and protein to the diet; however, it can have a long-term impact on a child's physical and mental development, and in severe cases may lead to death.

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SYMPTOMS• Changes in skin pigment.• Decreased muscle mass• Diarrhea• Failure to gain weight and grow• Fatigue• Hair changes (change in color or texture)• Increased and more severe infections due

to damaged immune system• Irritability• Large belly that sticks out (protrudes)• Lethargy or apathy• Loss of muscle mass• Rash (dermatitis)• Shock (late stage)• Swelling (edema)

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MARASMUS• The term marasmus is derived from the Greek word marasmos,

which means withering or wasting.

• Marasmus is a form of severe protein-energy malnutrition characterized by energy deficiency and emaciation.

• Primarily caused by energy deficiency, marasmus is characterized by stunted growth and wasting of muscle and tissue.

• Marasmus usually develops between the ages of six months and one year in children who have been weaned from breast milk or who suffer from weakening conditions like chronic diarrhea.

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SYMPTOMS• Severe growth retardation• Loss of subcutaneous fat• Severe muscle wasting• The child looks appallingly thin and limbs

appear as skin and bone• Shriveled body• Wrinkled skin• Bony prominence• Associated vitamin deficiencies• Failure to thrive• Irritability, fretfulness and apathy• Frequent watery diarrhoea and acid stools• Mostly hungry but some are anorectic• Dehydration• Temperature is subnormal• Muscles are weak• Edema and fatty infiltration are absent

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NUTRITIONAL DWARFING OR STUNTING

• Some children adapt to prolonged insufficiency of food-energy and protein by a marked retardation of growth

• Weight and height are both reduced and in the same proportion, so they appear superficially normal.

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UNDERWEIGHT CHILD

• Children with sub-clinical PEM can be detected by their weight for age or weight for height, which are significantly below normal. They may have reduced plasma albumin. They are at risk for respiratory and gastric infections

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Different factors lead to PEM in childrenETIOLOGY/CAUSES

1. Socioeconomic2. Biological 3. Environmental4. Role of free radical and aflatoxin5. Age of host• Among the socioeconomic, biological and environmental factors the common causes are• Lack of breast feeding and giving diluted formula, Overcrowding in the family, Ignorance, Illiteracy,

Lack of health education, Poverty, Infection

• Role of free radicals and aflatoxin- two new theories have been postulated recently to explain the pathogenis of kwashiorkor. These include free radical damage and aflatoxin poisoning. These may damage liver cells causing kwashiorkor.

• Age of host- frequent in infants and young children whose rapid growth increases the nutritional requirement. PEM in pregnant mothers can affect the nutritional status and survival of foetus, new born and infants. Elderly can also suffer from PEM due to alteration of GI systems.

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ECOLOGY OF PEM

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Early weaning from breast

Increased intestinal loss,

anorexia

Inadequate interfamilial food distribution Low birth

weight

Late weaning

High birth rate

Material malnutrition

Poverty and ignorance illiteracyInadequate medical

facilities

Poor hygiene sanitation water

supply

Large NO of % children

Social modes of feeding and cultural

practices

Occurrence of infectious diseases

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THEORY OF ADAPTATION

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 NUTRITIONAL REQUIRMENT:

NUTRIENT AMOUNT NEEDED

ENERGY 150-200Kcal/kg/BW for existing weight

Older children-150kcal/kg/BW

Important to produce calories otherwise protein will be utilized for providing energy instead of building tissues. 50% calories can be from carbohydrate

PROTEINS 5g/kg/BW for existing weight

Calorie derived form protein should be 10% of total calculated calories per day if the main source is animal protein

FAT 40% of total calorie from fat

Saturated fats like butter are preferred over unsaturated fats like oil as unsaturated fatty acid worsens diahorrea.

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COMPLICATIONS OF PEM

Hypoglycemia Hypothermia Dehydration and shock Electrolyte imbalance - hypokalaemia -

hyponatremia Infections (bacterial, viral and thrush) Micronutrient deficiencies

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TREATMENTThere are three stages of treatment.

1. Hospital TreatmentThe following conditions should be corrected. Hypothermia, hypoglycemia, infection, dehydration, electrolyte imbalance, anemia and other vitamin and mineral deficiencies.

2. Dietary ManagementThe diet should be from locally available staple foods - inexpensive, easily digestible, evenly distributed throughout the day and increased number of feedings to increase the quantity of food.

3. RehabilitationThe concept of nutritional rehabilitation is based on practical nutritional training for mothers in which they learn by feeding their children back to health under supervision and using local foods.

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HOSPITAL TREATMENTS

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DIETARY MANAGEMENT Energy dense feeding-established daily, graduated intake of 4-5g protein per kg/BW 200 Kcal of energy/kg/BW Breast milk Liquid feeds of skimmed milk, oil, sugar, Soft cereal gruels with milk, Soft ripe fruit, cooked vegetables Fortify oil with ghee to make it energy dense Micronutrient supplementation- to treat clinical conditions and to

prevent further deficiencies Route oral or nasogastric in small amount, more frequent small feeds

better than large meals

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REHABILITATION• Residential units- the mothers are admitted along with their children. Under the guidance of

the nutrition demonstrator they work as a group and prepare suitable therapeutic diet with available focus and feed their children

• Day care centers- in these centers mothers help in cooking and feeding in one or two days a week, though the children attend daily. It therefore takes longer for mothers to appreciate the essential message about better feeding.

• Domiciliary rehabilitation- it is done at home is more personal as nutritional advice and help is given in one to one basis by a nutrition demonstrator.

• Successful nutritional rehabilitation requires detailed knowledge about local foods, cooking and feeding practices. Based on knowledge diet should be prepared and can be practiced by poor families. Mothers who take active part in preparation of food and feeding their children and watching them recover to their health and vitality are more likely to retain idea and continue with a similar regime at home.

 

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PREVENTION

Promotion of breast feedingDevelopment of low cost weaningNutrition education and promotion of correct

feeding practicesFamily planning and spacing of birthsImmunizationFood fortificationEarly diagnosis and treatment

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REFERENCE• www.medecine.ups-tlse.fr/anglais/docs/DCEM1-

Malnutrition.pdf• gmch.gov.in/e-study/e%20lectures/Community

%20Medicine/PEM.pdf• ocw.jhsph.edu/courses/International

Nutrition/PDFs/Lecture2.pdf• www.oxfordjournals.org/tropej/online/mcnts_chap7.pdf• www.who.int/nutrition/publications/en/childgrowth_dat

abase_overview.pdf• Nutrition and dietetics by Shrilakshmi- vol V

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THANK YOU!