HND 313|Clinical Nutrition

Protein energy malnutrition

Definition

Bangladesh, a very densely populated country, is one of the poorest developing countries in the
world; more than three-fifths of its population is living below the poverty line. As a result of
overcrowding, unemployment, poverty and poor access to adequate food as well as health
services, infectious diseases and malnutrition are common in this society. It is noted that,
increased morbidity among children living in poverty is strongly linked to malnutrition and an
inadequate diet. PEM leads to disturbance in growth and increases morbidity and mortality rate
and also decreases psychological and intellectual development.

Protein–energy malnutrition (PEM) is a form of malnutrition that is defined as a range of

pathological conditions arising from coincident lack of dietary protein and/or energy (calories) in
varying proportions. The condition has mild, moderate, and severe degrees. PEM is fairly
common worldwide in both children and adults and accounts for 6 million deaths annually. In the
industrialized world, PEM is predominantly seen in hospitals, is associated with disease, or is
often found in the elderly. Protein–energy malnutrition affects children the most because they
have less protein intake. The few rare cases found in the developed world are almost entirely
found in small children as a result of fad diets, or ignorance of the nutritional needs of children,
particularly in cases of milk allergy.

Epidemiology
Although protein energy malnutrition is more common in low-income countries, children from
higher-income countries are also affected, including children from large urban areas in low
socioeconomic neighborhoods. This may also occur in children with chronic diseases, and
children who are institutionalized or hospitalized for a different diagnosis. Risk factors include a
primary diagnosis of intellectual disability, cystic fibrosis, malignancy, cardiovascular disease,
end stage renal diseases, genetic disease, neurological disease, multiple diagnoses, or prolonged
hospitalization. In these conditions, the challenging nutritional management may get overlooked
and underestimated, resulting in an impairment of the chances for recovery and the worsening of
the situation.

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Causes and Pathogenesis

Causes
Causes of protein energy malnutrition are multi-factorial having a number of interwoven factors
operating simultaneously. The causes could be categorized as immediate, underlying and basic.
The following diagram depicts the causes operating at different levels.

Hierarchical Model of the Causes of PEM

At the level of the individual child one or more of the following factors may operate:-

➢ Lack of knowledge -People do not understand the nutritional nature of their Child‘s
health problem
➢ Poverty - lack of means to obtain and provide food to their child (as in the case of war)
➢ Famine and vulnerability- destitution, being orphan (Example HIV taking away parents
Lives)
➢ Infections - there is a reciprocal relationship between malnutrition and infection. During
infection, the requirement for nutrients increases, there will be increased loss of nutrients

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due to diarrhea; genesis of fever and other acute phase reactants is at the expense of
nutrients.
➢ Emotional deprivation- In orphan children and in children whose parents are negligent
in giving care to their children, due to different reasons, children will lose appetite for
feeding and hence end up in state of malnutrition
➢ Cultural factors- Different biases as to who should take the lion‘s share of the family‗s
food (Example, age bias—older children are given more food than the smaller ones,
➢ Sex bias—male children are more favored in getting nutritious food than female children
in some families, etc.)
➢ Mal-distribution of foodstuffs - within the family, it occurs between the different ages
and sexes due to biases, food prejudices and taboos. It also occurs between the different
regions of a country because of inappropriate food and nutrition policy, poor marketing
and distribution system due to different reasons like embargo, country under-siege, etc.

Pathogenesis
Marasmus and Kwashiorkor in their extreme forms have basically different pathogenesis. The
initiation of the pathogenesis of both problems can be traced back to the time of weaning.
Kwashiorkor develops following the additional demand levied on the body‘s already
marginalized nitrogen balance due to infection of a child that is on monotonous starchy family
diet. As a result of fragile nitrogen balance that the child has, negative nitrogen balance sets in
when the available nitrogen is used to produce antibodies or other acute phase reactants in the
face of infection, this will lead to kwashiorkor. On the other hand Marasmus develops due to
negative energy balance as a result of ―starvation therapy‖ that follows the bouts of diarrhea.
The following diagram depicts the scenario.

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Clinical Features

The severest clinical forms of PEM are Marasmus, kwashiorkor and features of both called
Marasmic- kwashiorkor. The following symptoms and signs clinically characterize them: -

Marasmus
Marasmic children have retarded growth with specific clinical manifestations including:-Wasting
of subcutaneous fat and muscles (flabby muscles), Wizened monkey (old man face), Increased
appetite, sunken eye balls, mood change (always irritable) and mild skin and hair changes.

Figure. A child with marasmus manifesting with old man’s

face and bone and skin appearance

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Kwashiorkor
Children with the kwashiorkor syndrome may have the following clinical manifestations; -
Growth failure, wasting of muscles and preservation of subcutaneous fat, edema (pitting type),
fatty liver (hepatomegaly), psychomotor retardation (difficulty of walking), moon face due to
hanging cheeks as a result of edema and preserved subcutaneous fat, loss of appetite, lack of
interest in the surrounding (apathy) and miserable, skins changes (ulceration and depigmentation
or hyper pigmentation), and hair changes (de-pigmentation, straightening of hair and presence of
different color bands of the hair indicating periods of malnourishment and well nourishment
(flag sign) Straightening of hair at the bottom and curling on the top giving an impression of a
forest (Forest sign) and easily pluckable hair. Marasmic kwashiorkor can have the clinical
features of both Marasmus and kwashiorkor.

Figure: Child with kwashiorkor manifesting with

edematous swollen legs and apathy

In children with PEM, there are usually deficiencies of micronutrients like: - riboflavin, vitamin
A, Iron and Vitamin D. Therefore, it is advisable to have high index of suspicion and look for the
signs and symptoms of deficiencies of these nutrients.

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Differences between Kwashiorkor and Marasmus

Kwashiorkor Marasmus

Causes

Deficiency of proteins. Deficiency of both proteins and calories.

Age factors

Between the age of 6 months and 3 years of age. Between the age of 6 months and 1 year of age.

Oedema

Present. Absent.

Subcutaneous fat

Present. Absent.

Weight loss

There is some weight loss. There is severe weight loss.

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Symptoms

The thinning of muscles and limbs. The thinning of limbs.

Fatty liver cells

There is an enlargement in the fatty liver cells. There is no enlargement in the fatty liver cells.

Appetite

Voracious feeder. Poor appetite.

The texture of the skin

Flaky paint appearance on the skin. Dry and wrinkled skin.

Requirement of Nutrition

Adequate amounts of proteins. Adequate amounts of proteins, carbohydrates and fats.

Diagnosis

▪ PEM can be diagnosed by identifying the dietary history of the patient. The measurement
of height and weight, fat distribution, anthropometric measurements of lean body mass
should be examined.
▪ The Body Mass Index or BMI is calculated to measure the severity of PEM.

▪ Laboratory tests such as measurement of serum albumin, total lymphocyte count,

transferrin and response to skin antigens can help to detect the severity of Protein Energy
Malnutrition.

▪ The decreased level of hormones, lipids, fats, cholesterol, prealbumin, insulin-like growth
factor, fibronectin, calcium, magnesium, and phosphate can also help to diagnose PEM.

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Complications of Protein-Energy Malnutrition

Acute Chronic
• Electrolyte imbalance • Insult to the brain development leading
• Diarrhea, dehydration and shock to low school performance
• Hypoglycemia • Stunting and ending up in short adult
• Hypothermia with low fitness for physical activity

Case Management
Management of a case of PEM focuses on the correction of specific nutrient deficiencies (dietary
management), treatment of complications and supper imposed infections. The treatment
approach is classified into two phases—the acute stabilization phase in which the main focus is
treatment of infection and other complications like dehydration, hypoglycemia, hypothermia and
other electrolyte imbalances. The rehabilitation phase focuses on the restoration of the lost tissue
and promotion of catch up growth.

Dietary Management
1. Acute Phase
Children are most at risk of dying during the acute phase. Dehydration, infection and severe
anemia are the main dangers. In PEM, cardiac and renal functions are impaired and in particular
malnourished children have a reduced capacity to excrete excess water and a marked inability to
excrete Sodium. The amount of fluid given and the Sodium load must be carefully controlled to
avoid cardiac failure. A cautious approach is required; aiming at administration of about
100kcal/kg/day and 1-1.15g of protein/kg/day. Small frequent feeds (as much as 12 times in 24
hours for the first two days and gradually tapering the number of feeds to be 6 in 24 hours after a
week) are ideal as they reduce the risks of diarrhea, vomiting, hypoglycemia and hypothermia.
Do NOT give iron early before infection is controlled. High dose vitamin A should be given
even if there are no eye signs of deficiency.
On this regimen, edema will disappear and the general condition will improve. High energy or
high protein diets should not be introduced too early or too rapidly. Such action may precipitate
the recovery syndrome' which can prove fatal. Return of a good appetite is a sign that a child is
ready to progress to the next phase (rehabilitation phase).

2. Rehabilitation Phase
The aim of this phase is to restore wasted tissues and promote a rapid rate of catch-up growth
through administration of high energy and protein. A vigorous approach is required. In this phase
there is no danger of recovery syndrome.
The synthesis of new tissue requires protein and other nutrients. Synthesis also requires a
considerable amount of energy. The aim is to provide all necessary nutrients so that none limits
the rate of recovery. Normal rate of growth of children is such that they gain a weight of
1gram/kg/day by taking 105 kcal/kg/d and 0.78gram of protein /kg/d. To increase this rate of
growth by 20 times the normal, the energy and protein intakes need to be increased to
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200kcal/kg/day and 5kcal/kg/day, respectively.

Assessing Progress:
Patients should be weighed at least weekly, preferably daily, and the weights plotted. Failure
to maintain rapid catch-up may signal an undiagnosed infection and/or inadequate intake.
Keeping a record of the child's food intake helps to elucidate the cause of poor weight gain.
Almost all malnourished children have diarrhea, but it is rarely due to lactose intolerance.
Chronic diarrhea may result from gut parasites (e.g. Giardia) or bacterial overgrowth of the small
bowel. The introduction of the high-energy formula may cause mild diarrhea initially, but this is
not a cause for concern unless stool frequency exceeds 8 per 24 hours.

Role of the Family Diet:

Transfer to a family-type of diet is important in rehabilitation. Introducing a family type diet at
an early stage of treatment is unlikely to permit catch-up growth because the traditional diet
usually does not provide enough energy and protein.
There are two options:
1. Feed a high-energy formula until the child reaches his normal weight-for height and then
transfer to a family-type diet as experienced in Jamaica.
2. Make an early transition to a modified family diet having a high energy and protein
concentration to support catch-up growth as evidenced in Bangladesh.
Local circumstances will influence which option is chosen. In the first option weight deficits
should be corrected in 4-6 weeks even in the most severe cases. The second option provides an
opportunity for catch-up growth and for demonstrating improved feeding practices. This has
been successful in India and Bangladesh for the home management of PEM.

Where to Rehabilitate
1. In Hospital: -
In many hospitals, treatment of PEM is unsatisfactory due to cross infection and frequent
relapses. Moreover, it is expensive and does not give a chance for parental education. Therefore,
not all children with protein energy malnutrition are admitted to hospitals merely for the purpose
of feeding. Admission of children to a hospital be targeted to those children with severe protein
energy malnutrition plus other admission criteria

2. At Home: -
As experienced in Bangladesh, even severe cases have been successfully rehabilitated at home.
But, this was successful only after one week of medical care to treat infections and other
complications. This method was also proved to be the most cost-effective, and parents prefer
the method, even though no food supplements were provided.

Prevention of Protein Energy Malnutrition

Many children attending outpatient clinics are malnourished. Prevalence of mild forms of
malnutrition like stunting and wasting is 40-50% while those severe cases are 5-10% in most of
the developing countries. If these cases of PEM can be recognized early enough by routine
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weight and height measurements (growth monitoring in under five clinics) and relevant action
taken, then severe malnutrition can often be prevented easily.

Dietary Diversification and Nutrition Education

This approach focuses on educating mothers/care givers on the importance of having a balanced
diet through diversification of food. It also aims at the production foodstuffs at the backyard
garden and intensification of horticultural activities. The nutrition education should focus on:

▪ Cultural malpractice and beliefs in child feeding and weaning process, weaning foods,
exposure of children to sun light, time of weaning and food prejudices
▪ Intra household mal-distribution of food (age and sex bias)
▪ Effects of emotional deprivation and neglect on nutritional status of children and proper
child treatment practices
▪ Importance of breast feeding
▪ Hygiene (personal hygiene, food hygiene, environmental hygiene)
▪ Importance of immunization
▪ Importance of growing fruits and vegetables in the backyard garden and consumption by
the household members regardless of their age and sex. Importance taking their children
to health institutions for growth monitoring
▪ Monitoring of the growth of children is very important for the following reasons:
▪ Steady growth is the best indicator of child‘s health.
▪ Weight gain is the most sensitive measure of growth.
▪ Serial measurement of weight is simple, universally applicable tool for assessing growth.
▪ Weight gain monitoring is the best method for early detection of health problems
whether from malnutrition or infection.

Dietary Modification:-
This approach focuses on modifying the energy, protein and micronutrient content of the
weaning foods. In order to reduce dilution of the energy and protein contents of the weaning
foods and their level of contamination, we need to educate mothers and demonstrate to them the
benefits of sprouting (germination) and fermentation.
Fermentation renders the food less contaminated probably because of acid formation as result.
Using sprouted (germinated) flour otherwise known as ―power flour‖ or amylase rich flour
(ARF) makes the weaning food more liquid but less dilute. This is an attempt to reduce the
problem of bulky low -energy density weaning foods, which arise from the water holding
capacity of cereals, which makes them swell and become viscous upon cooking. This means that
large volume is required to satisfy their energy needs.
The upper limit of dry matter in a gruel made up of ordinary flour is 20 % (0.7-0.8 kcal/gram),
because beyond this level, the gruel would be too thick to stir. When germinated flour is used or
added to an already made thick gruel (up to even 30% solid concentration), the meal becomes
liquefied almost instantly. A meal prepared in this way with 25 to 30% dry matter would have an
energy density above 1 kcal/gram. This is an energy density recommended for the weaning food
on the basis that breast milk has an energy density of 0.7 Kcal/gram.
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On top of this, supplementation of micronutrient like vitamin A and iron to children below five
years of age and fortification of salt with iodine could also be considered based on the local
needs.

Economic Approach:
This approach aims at improving the incomes of the target community as a solution to their
nutritional problems. It is considered usually in areas where there are many poor people and if
their purchasing power is low as in the case of urban slums and people displaced because of war
and other natural calamities. There are different methods in this approach: -
✓ Food for work
✓ Food subsidy
✓ Income generating projects

Surveillance
Targets for surveillance:- Infants & child growth monitoring(GM) activities need to carried out
in an integrated manner with other PHC services.
Triple A cycle (assessment, analysis and action) be employed in effecting GM activities.
□ Assessment includes regular measurement of weight &heights of < 5 children
□ Analysis includes comparison of the growth performances of children with nutritional Status.
□ Action involves nutritional intervention to curb the problems.

Preparation Nutritious Food from Locally Available Food Staffs

Balanced diet can be prepared by mixing different locally available foodstuffs. For Example the
protein and energy requirements of children can be met by preparing the following diets: -

1. Quadri mix---staple+ animal protein + plant protein + leafy vegetable

2. Triple Mix---Staple +animal protein + plant protein or leafy vegetables
3. Double mix--- staple + animal protein or plant protein or leafy vegetable
Parents / care givers need to be instructed how to modify the protein, energy and other
nutrientcontents of the locally available foodstuffs used in weaning and child feeding.

Nutritional Surveys
Community based nutritional surveys including anthropocentric measurements and dietary
consumption surveys need to be carried out among under five children in order to early detect the
occurrence of nutritional problems in the community.

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