PROTEIN ENERGY MALNUTRITION (PEM)
The term protein energy malnutrition covers a wide spectrum of clinical stages ranging from the severe forms like kwashiorkar and marasmus to the milder forces in which the main detectable manifestation is growth retardation. It is widely prevalent among weaned infants and pre-school children in India and other developing countries.
1. Social and Economic Factors
Poverty that results in low food availability, overcrowded and unsanitary living conditions and improper child care are frequent causes of PEM. A decline in the practice and duration of breast feeding combined with inadequate weaning practices are the important causes of PEM.
2. Biological factors
Maternal malnutrition prior to and or during pregnancy is more likely to produce an underweight new born baby. Infectious diseases are major contributing and precipitating factors of PEM. Diarrhoea, measles and respiratory and other infections result in negative protein and energy balance.
3. Environmental factors
Overcrowded and or unsanitary conditions lead to frequent infections like diarrhoea. Agricultural patterns, droughts, floods, earthquakes, wars and forced migrations lead to cyclic, sudden or prolonged food scarcities. Post harvest losses of food can occur due to bad storage conditions and inadequate food distribution.
It mostly affects infants and young children whose rapid growth increases nutritional requirement. The long term intake of insufficient food can result in marasmus before one year. Kwashiorkar is common after 18 months.
The five forms of PEM are as follows :
The important Clinical signs and symptoms of kwashiorkor are:
Growth failure due to general lack of proteins and calories.
Mental changes such as apathy and irritability.
Oedema occurs at first in the feet and lower leg and then may involve the hands, thigh and face.
Fatty and enlarged liver
Loss of appetite, vomiting and diarrhoea
Characteristic skin changes which include dark pigmented brownish black areas of skin on buttocks and back of thighs called as crazy pavement dermatosis.
Vitamin A deficiency.
The following picture shows a child suffering from kwashiorkor showing oedema of legs, hands and crazy pavement dermatosis.
The signs and symptoms of marasmus are:
1. severe growth retardation
2. loss of subcutaneous fat
3. severe muscle wasting
The child looks appallingly thin with shrivelled body, wrinkled skin and bony prominence. A child suffering from marasmus is shown in the picture.
iii. Marasmic Kwashiorkar
The child shows a mixture of some of the features of marasmus and kwashiorkar.
iv. 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.
v. Under Weight 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.
Treatment strategy can be divided into three stages.
Resolving life threatening conditions Restoring nutritional status
Ensuring nutritional rehabilitation. There are three stages of treatment.
The following conditions should be corrected. Hypothermia, hypoglycemia, infection, dehydration, electrolyte imbalance, anaemia and other vitamin and mineral deficiencies.
2. Dietary Management
The 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.
The 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.
Promotion of breast feeding
Development of low cost weaning
Nutrition education and promotion of correct feeding practices
Family planning and spacing of births
Early diagnosis and treatment