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

2. 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

4. 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

5. 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.

6. 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.

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

8. Medical management Fluid resuscitation High protein diet
Vitamin supplementation

9. 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.

10. 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

11. End

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