Protein Energy Malnutrition (PEM) Robyn Smith Department of Physiotherapy UFS 2012

What is malnutrition ? The most common nutritional disorder in children is under nutrition due to a lack of adequate food intake Malnutrition is also associated with poor socio- economic conditions and neglect The condition results in failure to thrive and grow

Protein Energy Malnutrition (PEM) Protein energy malnutrition (PEM) Malnutrition implies inadequate food intake resulting in a protein deficiency, and inadequate energy is available to the child to grow and remain healthy. Morbidity and mortality from conditions such as gastroenteritis, TB, HIV is far higher in a malnourished child. These children also often present with chronic diarrhea and malabsorption

Kwashiorkor Severe form of PEM Occurs most frequently after child is weaned from breast/bottle – between ages of 9 months and 2 years The child's diet is void of milk and high protein foods The child presents with anorexia, diarrhea, wasting. Often also present with a significant infection e.g. pneumonia The child is irritable and apathetic. Pot bellies, oedema, dermatoses and thinning hair are characteristic.

Marasmus Equates to childhood starvation where the diet is void of energy and does not meet the protein requirements. In babies it occurs where overly diluted feeds are given and in children where no food is available to eat e.g. famine, poverty Often caused by prolonged diarrhea and malabsorption Usually occurs in the first year of life The child presents with anorexia, diarrhea, wasting. The child is irritable and apathetic.

Marasmic Kwashiorkor Most severe cases Combination of kwashiorkor and marasmus may occur in severe cases

Medical management Fluid resuscitation High protein diet Vitamin supplementation

Physiotherapy management During the acute period of hospital admission the child may be extremely miserable and irritable and apathetic. Give the child a chance to improve his nutritional and energy status before commencing physiotherapy (apart lung physio and basic stimulation) There are not hard and fast rules and time for commencement active therapy will vary from child to child. Initially the child may also be very apathetic and have very little endurance when coming to therapy Neurodevelopmental therapy and facilitation of age appropriate milestones aiming also at improving strength and endurance Play on a mat (Try and get the child out of bed in the hospital) Sensory stimulation e.g. cot mobile, toys, tactile stimulation etc. Long term follow up and nuerodevelopmental therapy.

Prognosis Often and unfortunately poor when the child has severe malnutrition, infection and collapses due to dehydrations and shock. Otherwise good Social circumstances need to be addressed (SW) Food aid/supplementation by DT

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References Images courtesy of GOOGLE Coovadia, H.M. & Wittenberg, D.F, 2006. Pediatrics and Child Health. A manual for professionals in developing countries (5th ed.)