Maitree 2022

PEM in Children (Protein Energy
Malnutrition in Children)

Dr. Rakesh Kumar Sharma Protein energy malnutrition happens when a child does not receive protein as
Factory Medical Officer – HSE, MCPI per the physiological demand of the body. It is causing poor development of the
Brain, weak learning, low immunity, increased chances of infections and even
death.

Definition- Patient with a manifestation of nutritional deficiencies that ranges
from mild to severe, in whom low protein intake is a common denominator
but consumption of carbohydrates and fat as a source of energy remains
variable are called suffering from protein-energy malnutrition.

It is great problem for a developing country. Growing children are most vulnerable
to effects.

In the case of male children, it requires 0.9g/kg body wt per day from 3 years
to 18 years and for females, it requires the same amount up to 15 years of age
than 0.8 gram/kg/day for female children from 15 to 18 years of age. (Data from
WHO-FAO)

Nervous system Role of Immune power
development protein development

Clotting system Development of Development of
development muscles (Body building various enzymes
material) and early
healing of wounds 97

Prevalence B. SECONDARY CAUSE
The birth of a healthy baby required a healthy mother.
But just try to reflect on a few facts about our country. - Presence of systemic infections like AIDS
- Epidemiological factors
44% of children under the age of 5 - Poor Hygiene
years are underweight - Lack of education about adequate diet
- Gastrointestinal infection that interfere with protein
72% of Infants are anemia
absorption
52% of married women have anemia - Illness like Cancer, Kidney diseases, heart

diseases

Diagnosis

Measure following anthropometrics measures of
patient and compare with standard data-
- Weight
- Height
- Midarm circumference

Protein deficiency in about 70% CLASSIFICATION of PEM
population
Several classifications are present. Two important
classifications are-

1. Weight for Age classification
2. Height for Age Classification

About 85% do not know about WEIGHT FOR AGE CLASSIFICATION
Protein energy malnutrition
As per Gomez’s international classification-
About 60% of children between
6 months to 2 years do not get TYPES GRADE
proper protein in nutrition
Weight for more than 90% Normal
of expected Age
Grade- I
Weight for 76-90% of Age

CHILDREN PERCENTAGE Weight of 61-75% of Age Grade-II
Severely wasted 7.7% Grade-III
19.3% Weight of less than or equal
Wasted 35.5% to 60% of Age
Stunted
HEIGHT FOR AGE CLASSIFICATION
Note- Data received from NFHS-2020-21
According to WATERLOW classification-

1. 44% CHILDREN under the age of 5 years are TYPES GRADE
underweight.
Children with a height of more Normal
2. Causes- than 95% expected to Age Marginal
Moderate
A. PRIMARY CAUSE - Major primary cause is inadequate Children with a height 90-95%
intake of nutrition as per demand. expected for Age Severe

In developing countries undernutrition is major Children with a height 85-90
causing factor for this disease in children. Inadequate % expected to Age
nutrition for mother during pregnancy is also one of
major cause that cause malnourished or underweight Children with a height of less
baby. than 85% are expected to
Age

It can also be classified as

- Acute PEM
- Chronic PEM
- Acute on Chronic

In acute case weight get primarily affected. Proportional reduction in weight and height points towards Chronic cases.
A greater or disproportionate reduction in weight as compare to reduction in height indicate acute on chronic PEM.

Severity of CLINICAL Duration of
Deprivation MANIFESTATION-It deprivation

Age of depends on Deprivation
undernourished of associated
nutritional
factors

Presence of any
associated infections

Mild to Moderate undernutrition
If dietary intake is a deficit for a short period than the body modifies as per metabolic deficit. Nitrogen excretion in stool
and urine gets reduced.
If it persists for a longer period, then malnourished children conserve energy by reducing their physical activities.
Moderately affected children appeared slower and less energetic. Weight gain gets more affected than the length. But
with prolonged, deprivation height got also affected. Reduction of Head circumference in a significant way. Normally
by age of 1-year chest circumference exceed the head circumference, but in the case of PEM, it may get exceed.
Weight is less in comparison to height. Limbs are thin with an unduly large head. Buttocks are flattened.Wrinkling of
skin with winging of scapula.The abdomen appears distended.
With further exaggeration of deficit, the child develops two conditions-
1 MARASMUS
2 KAWASHORKER
MARASMUS - Features are
1. Markedly emaciated
2. Body weight is less than 60% of expected
3. Fat in adipose tissue gets severely depleted

99

4. Loose folds of skin with wrinkling. Contour of muscles get appeared.
5. Loss of buccal pad of fat
6. Hair is hypopigmented
7. Abdomen get distended. Reduction in mid arm circumferences
8. Bony points are prominent
9. Children are irritable with a voracious appetite

KAWASHORKER - Features are

1. Markedly restarted growth
2. Edema in dependent part. It startsin the lower extremities than involvesthe upper limbs and face
3. Muscles of upper extremities are waisted but of lower limbs got swollen
4. Face is moon shape and puffy. Trunk got affected less
5. Children are lethargic with no interest in playing
6. Hair is thin, dry, brittle, Hypopigmented, straight, and without sheen

Chances of Infections- Such children are having an extensive chance to be affected by

• Gastrointestinal tract infections like Diarrhea
• Respiratory tract infections like Pneumonia
• Skin infections
• Chances of other nutritional deficiencies diseases like Anemia, Rickets, Night blindness, etc.

Management of PEM-

First Child should be evaluated for

• Severity of protein malnutrition
• Deficiency of associated nutrition factors
• Associated infections
• Epidemiological factors contribute to malnutrition

For mild and moderate cases dietary advice becomes sufficient. Children should be advised to take all substances in
a proportionate manner. Such children should be kept under regular surveillance. The mother should ask about fresh
and locally available nutrition. Home-cooked meal should be preferred. Special attention is needed while rearing food.

Severely malnourished children require care in hospital. Otherwise, there will bechances of mortality or chances of
irreversible impairing of some systems. It requires prompt and vigorous management

It requires 160-200 C/kg /day with about 10% of total calories from protein. It also requires adding a proportionate
amount of minerals like- Mg, K, Ca. Attention should also be provided to supplement Vitamins like-A & D.

In the meantime, proper treatment of dehydration and associated infectious diseases.

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