1. Deficiency of proteins
Presented By:
Mr. Ajith K K
Asst. Professor
College of Nursing, Kishtwar

2. PROTEIN ENERGY MALNUTRITION (PEM)
Protein Energy Malnutrition (PEM) or Protein Caloric Malnutrition (PCM) has been identified as not only an important cause of children morbidity and mortality but also leads to permanent impairment of physical and mental growth.

3. CLINICAL FORMS OF PEM
Kwashiorkor is caused by the deficiency of proteins in diet. The main features are growth failure, edema, diarrhoea, anaemia, and changes in skin and hair.
Marasmus is caused by severe deficiency of both proteins and calories in the diet. This is characterized by growth failure, loss of fat, signs of dehydration, and mental changes.

4. CAUSES OF PEM An inadequate intake of food in quantity and quality.
Infections like diarrhoea, measles, respiratory infections and intestinal worms.
Poor environmental sanitation.
Large family size.
Poor maternal health.
Failure of lactation.
Premature termination of breast feeding.
Adverse cultural practices related to breast feeding and weaning.

5. CLINICAL FEATURES OF PEM
Signs and symptoms
Marasmus
Kwashiorkor
Muscle wasting
Obvious
Sometimes hidden by edema and fat
Fat loss
Severe loss of subcutaneous fat
No loss of fat
Edema
Not present
Usually present on lower limbs, lower arms and face.
Weight for height
Very low

6. Sometimes quiet and apathetic
Signs and symptoms
Marasmus
Kwashiorkor
Face look
Like monkey face
Moon face
Mental changes
Sometimes quiet and apathetic
Very rare
appetite
Usually good
Poor
Diarrhoea
Often

7. Signs and symptoms Marasmus Kwashiorkor
Skin changes
Usually none
Diffuse pigmentation, sometimes flaky pain, dermatoses.
Hair changes
Sparse, silky, and easily pulled out.
Liver enlargement
None
Sometimes present due to accumulation of fat.

8. DETECTION OF PEM
Underweight for age.
Road – to – health growth chart.

9. CLASSIFICATION OF PEM a) Gomez’s classification
Degree of PEM is classified as:
Weight between 90 – 110% = Normal nutritional status
Weight between 75 – 89% = 1st degree malnutrition (mild)
Weight between 60 – 74% = 2nd degree malnutrition (moderate)
Weight below 60% = 3rd degree malnutrition (severe)

10. Weight ∕ height Height ∕ age
b) Waterflow’s classification
Weight ∕ height Height ∕ age
˃ m – 2SD
˂ m – 2SD
Normal
Wasted
Stunted
Wasted and stunted

11. Stunting (% of Height ∕ Age) Wasting (% of Weight ∕ Height)
Grading according to Waterflow’s calculation
Nutritional Status
Stunting (% of Height ∕ Age)
Wasting (% of Weight ∕ Height)
Normal
˃ 95
˃ 90
Mildly impaired
87.5 – 95
80 – 90
Moderately impaired
80 – 87.5
70 – 80
Severely impaired
˂ 80
˂ 70

12. Arm Circumference Nutritional Status
˃ 13.5cm
Satisfactory nutritional status
12.5 – 13.5cm
Mild – moderate malnutrition
˂ 12.5 cm
Severe malnutrition

13. PREVENTIVE MEASURES Health Promotion
Measures are directed to pregnant and lactating women (education and nutritional supplements.)
Promotion of breast feeding.
Development of low cost weaning foods.
Improvement of family diet.
Nutrition education.
Home economics.
Family planning and spacing of birth.

14. PREVENTIVE MEASURES Specific Protection
Diet of the child must contain protein and energy rich foods such as milk, eggs, fresh fruits.
Immunization against diseases.
Food fortification.
Early detection and treatment.
Periodic surveillance.
Early diagnosis with degrees of malnutrition.
In case of PEM, good quality protein 3 – 4 g ∕ kg body weight∕day should be given.
ORS for children with diarrhoea.
Deworming of infested children.

15. PREVENTIVE MEASURES Rehabilitation Nutritional rehabilitation services
Hospital treatment in case of severe PEM.
Follow up care.

16. THANK YOU