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Protein-Energy Malnutrition

Updated : November 1, 2023





Background

Protein-energy malnutrition (PEM) is a critical and widespread nutritional disorder that affects millions of individuals, particularly in developing countries. It is a condition characterized by a severe deficiency in both protein and energy intake, leading to a range of physical and physiological abnormalities.

PEM encompasses a spectrum of conditions, from moderate malnutrition to severe forms, such as marasmus and kwashiorkor, each with distinct clinical features and implications for overall health.This condition primarily affects children and is a significant contributor to global morbidity and mortality, particularly in areas with limited access to adequate nutrition and healthcare resources.

Epidemiology

Prevalence:

PEM is most observed in children under the age of five, pregnant and lactating women, and the elderly.

The prevalence of PEM varies widely across different regions and is more prevalent in developing countries with limited access to nutritious food, healthcare, and sanitation.

In the year 2016, recent statistics revealed that over 18 million children worldwide, primarily in low-income environments, suffer from severe acute malnutrition, which includes conditions such as marasmus & kwashiorkor.

According to data from the World Health Organization in 2018, approximately 52 million children under the age of 5 experience wasting (insufficient weight-for-height), with 17 million of them classified as severely wasted. Moreover, a staggering 155 million children are affected by stunting (inadequate height-for-age).

Geographic Distribution:

PEM is more prevalent in sub-Saharan Africa, South Asia, and parts of Central and South America, where poverty and food insecurity are common.

Rural areas, where access to healthcare and nutritious foods is limited, tend to have higher rates of PEM.

Age and Gender:

Children, especially those under the age of two, are most vulnerable to acute forms of PEM, such as kwashiorkor and marasmus.

Gender disparities may exist, with boys and girls being affected differently in some regions, but overall, PEM affects both genders.

Socioeconomic Factors:

Poverty is a significant risk factor for PEM. Families with limited financial resources often struggle to afford nutritious food and healthcare, increasing the risk of malnutrition.

Lack of access to clean water, this can contribute to the development of PEM, as it can lead to infectious diseases and poor absorption of nutrients.

Cultural Practices:

Certain cultural practices, including early weaning and feeding patterns, can contribute to malnutrition in children.

Beliefs and customs related to food choices and dietary restrictions can also impact nutritional status.

Food Security:

Food security is a key determinant of PEM. In regions with food shortages, crop failures, or food price spikes, the risk of malnutrition increases.

Inadequate access to a variety of foods, including protein-rich sources, can lead to PEM.

Infectious Diseases:

Infections such as diarrhea, malaria, and respiratory infections can worsen PEM by reducing appetite, interfering with nutrient absorption, and increasing nutrient losses.

Maternal Nutrition:

Maternal malnutrition during pregnancy and lactation can contribute to the risk of PEM in infants and young children.

Adequate maternal nutrition is crucial for the healthy development of the child.

Anatomy

Pathophysiology

Inadequate Caloric Intake: The primary cause of PEM is an insufficient intake of calories, often resulting from inadequate dietary intake or chronic food shortages. A prolonged deficiency in caloric intake leads to a negative energy balance.

Protein Deficiency: In addition to inadequate calories, PEM also involves a lack of essential dietary proteins. This contributes to impaired growth, tissue repair, and the maintenance of vital bodily functions.

Imbalance in Macronutrients: The combination of calorie and protein deficiencies results in an imbalance of macronutrients, as carbohydrates and fats cannot fully compensate for the missing proteins in the diet.

Weight Loss and Muscle Atrophy: The body responds to the lack of calories by breaking down stored fat reserves for energy, resulting in weight loss. Concurrently, muscle protein is broken down for energy, leading to muscle wasting and reduced muscle mass.

Impaired Immune Function: PEM affects the immune system, making individuals more susceptible to infections. Protein deficiency can lead to a decreased production of immune cells, weakening the body’s ability to fight off pathogens.

Nutrient Deficiency: In addition to protein and calories, PEM often leads to deficiencies in essential micronutrients, such as vitamins and minerals. These deficiencies can further compromise overall health and contribute to various complications.

Etiology

Inadequate Dietary Intake:

  • Low overall calorie intake: Not consuming enough calories can lead to a deficiency in both energy and protein, which are essential for growth and maintenance.
  • Insufficient protein intake: A diet lacking in protein sources, such as lean meats, dairy, legumes, and nuts, can contribute to PEM.
  • Limited access to nutritious food: Poverty, food insecurity, and inadequate access to diverse, balanced meals can result in a lack of essential nutrients.

Infections and Illnesses:

Infections, especially repeated or chronic ones, can increase the body’s demand for nutrients and impair nutrient absorption.

Gastrointestinal infections or disorders may hinder the absorption of nutrients, including proteins and calories.

Socioeconomic Factors:

Poverty and low socioeconomic status can limit access to nutritious foods, healthcare, and education, increasing the risk of PEM.

Inadequate Breastfeeding:

Insufficient breastfeeding in infants, or early weaning from breast milk, can lead to inadequate protein and energy intake, especially in resource-limited settings.

Food Security and Agricultural Practices:

Issues related to food availability, distribution, and agricultural practices can impact the overall quality and quantity of food in each region, potentially leading to PEM in affected populations.

Cultural Practices and Beliefs:

Cultural or religious dietary restrictions or practices may limit the types of foods consumed and contribute to inadequate protein and energy intake.

Lack of Nutrition Education:

A lack of knowledge about balanced nutrition and its importance can lead to poor dietary choices and increase the risk of PEM.

Environmental Factors:

Natural disasters like floods or droughts can cause production of food to be disrupted, resulting in food shortages and nutritional deficiencies.

Genetics

Prognostic Factors

Age: Young children and the elderly are more vulnerable to the effects of PEM, and the prognosis can be worse in these age groups.

Severity of Malnutrition: The degree of malnutrition is a critical factor. Severe acute malnutrition has a poorer prognosis compared to moderate acute malnutrition.

Duration of Malnutrition: The longer someone has been malnourished, the worse the prognosis tends to be. Chronic malnutrition can lead to more serious health complications.

Underlying Health Conditions: The presence of other illnesses or health conditions can worsen the prognosis for PEM. Infections, such as pneumonia or diarrhea, are common complicating factors.

Nutritional Rehabilitation: The effectiveness of nutritional rehabilitation programs and interventions is crucial. Adequate and timely nutritional support can greatly influence the prognosis.

Clinical History

Age group

Infants and Young Children:

Infants and young children are particularly vulnerable to PEM, with severe consequences for growth and development.

Common forms of PEM in this age group include marasmus (protein and calorie deficiency) and kwashiorkor (protein deficiency with some calorie intake).

School-Age Children and Adolescents:

School-age children and adolescents can also experience PEM, which can hinder their growth and cognitive development.

Poor nutrition during these years can have long-term effects on physical and mental health.

Adults:

Adults, especially in low-income and resource-constrained regions, can be affected by PEM, which can lead to muscle wasting, weakness, and susceptibility to infections.

In adults, PEM can be associated with chronic diseases or a lack of access to adequate nutrition.

Pregnant Women:

Pregnant women are at risk of developing PEM if they do not receive proper nutrition during pregnancy.

PEM during pregnancy can have negative effects on the growing foetus as well as the mother.

Elderly Individuals:

Elderly individuals may also be susceptible to PEM due to age-related changes in metabolism, reduced appetite, or medical conditions.

PEM in the elderly can lead to muscle wasting and impaired immune function.

Associated Comorbidity or Activity:

Growth Stunting: PEM, especially in children, can lead to growth retardation, resulting in reduced height and weight for age. This can have long-term implications for physical and cognitive development.

Immune System Impairment: A weakened immune system is a common consequence of PEM. This makes individuals more susceptible to infections, which can further exacerbate malnutrition and lead to a vicious cycle of illness and poor nutrition.

Muscle Wasting: Protein deficiency can lead to muscle wasting, weakness, and decreased muscle mass. This can impair physical strength and functionality.

Edema (Swelling): Severe forms of PEM, such as kwashiorkor, can result in edema, which is the accumulation of fluid in body tissues. This leads to swelling, particularly in the extremities and the abdomen.

Anemia: PEM can contribute to anemia due to a deficiency of essential nutrients, including iron and vitamins necessary for red blood cell production. Anemia can lead to fatigue and reduced oxygen-carrying capacity of the blood.

Mental Health Issues: PEM can also be associated with psychological distress, including depression and anxiety. The physical and social consequences of malnutrition can contribute to mental health problems.

Physical Examination

General Appearance:

Emaciation: Obvious wasting and loss of body fat and muscle mass.

Growth retardation: Stunted growth in children.

Listlessness and apathy: Lack of energy and interest in the surroundings.

General weakness: Lack of muscle strength and tone.

Anthropometric Measurements:

Weight: A significant weight loss compared to the expected weight for age and height.

Height or length: Short stature or stunted growth in children.

Mid-upper arm circumference (MUAC): A MUAC measurement may be used to assess muscle wasting.

Skin Changes:

Dry, flaky, and scaly skin.

Loss of subcutaneous fat, leading to a wrinkled appearance.

Patchy hyperpigmentation (kwashiorkor).

Hair changes: Brittle, dry, and easily pluckable hair.

Edema: Swelling of the feet, legs, and sometimes the face (kwashiorkor).

Muscle Changes:

Muscle wasting and loss of muscle mass, especially in the limbs.

Weakness and poor muscle tone.

Face and Head:

Apathetic expression.

Sunken cheeks and eyes.

Enlarged parotid glands (bilateral parotid swelling may be a sign of kwashiorkor).

Gastrointestinal Signs:

A distended abdomen, often due to hepatomegaly (enlarged liver) in kwashiorkor.

Prominent ribcage and visible abdominal distension in marasmus.

Hair changes: Brittle, dry, and easily pluckable hair.

Edema: Swelling of the feet, legs, and sometimes the face (kwashiorkor).

Dermatological Findings:

Dry, flaky, and scaly skin.

Patchy hyperpigmentation, often referred to as “flag sign” or “flaky paint dermatosis” (kwashiorkor).

Ulcers or skin lesions in severe cases.

Oral and Dental Signs:

Glossitis (inflammation of the tongue).

Cheilosis (cracks and scaling at the corners of the mouth).

Dental caries and poor oral hygiene (kwashiorkor).

Age group

Associated comorbidity

Associated activity

Acuity of presentation

Mild PEM:

This stage may not have obvious physical signs and symptoms.

Children with mild PEM might appear slightly underweight and have subtle growth delays.

Fatigue, lethargy, and reduced physical activity may be observed.

Nutritional deficiencies can often be detected through laboratory tests.

Moderate PEM:

Weight loss and muscle wasting become more noticeable.

Children may exhibit decreased appetite and increased irritability.

Growth retardation becomes more apparent, with a noticeable delay in height and weight compared to age-matched peers.

Reduced muscle mass, thinning hair, and dry skin are common physical signs.

Severe PEM:

Severe wasting of body tissues, especially muscle and fat, is evident.

The child appears emaciated, with a protruding ribcage and visible skeletal features.

Severe lethargy, apathy, and a weakened immune system are characteristic.

Edema (swelling of the extremities) may be present, particularly in cases of kwashiorkor, a severe form of PEM.

Severe complications can arise, including organ dysfunction, infections, and the risk of death.

Differential Diagnoses

Kwashiorkor: A type of severe PEM characterized by edema (swelling), dermatosis, hepatomegaly, and other signs of protein deficiency. It is often seen in children and can be distinguished from marasmus based on the presence of edema.

Marasmus: Another type of severe PEM, which is characterized by severe wasting and emaciation. Unlike kwashiorkor, marasmus is primarily a deficiency of calories and is associated with severe weight loss.

Celiac disease: A chronic autoimmune disorder that results in malabsorption of nutrients, including protein and energy. It can present with symptoms such as diarrhea, weight loss, and nutrient deficiencies.

Crohn’s disease: An inflammatory bowel condition that results in malabsorption, chronic diarrhea, weight loss, and nutrient deficiencies, resembling the symptoms of PEM.

Gastrointestinal disorders: Conditions such as chronic diarrhea, malabsorption syndromes, and inflammatory bowel diseases can lead to malnutrition by impairing nutrient absorption and digestion.

Food allergies: Severe allergies or intolerances to specific foods can lead to inadequate intake of essential nutrients, including protein and energy.

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

Screening and Diagnosis:

Early identification and diagnosis are essential. Healthcare providers should use anthropometric measurements, clinical assessment, and medical history to determine the severity of PEM.

Stabilization and Medical Management:

In severe cases, individuals may require hospitalization for stabilization and medical care.

Address and treat any underlying medical conditions or complications, such as infections, electrolyte imbalances, or organ dysfunction.

Administer appropriate medications and therapies based on individual needs.

Nutritional Rehabilitation:

Initiate nutritional rehabilitation with careful monitoring by a healthcare team, including a dietitian or nutritionist.

Gradual refeeding is crucial to prevent refeeding syndrome, characterized by electrolyte imbalances when nutrients are reintroduced too quickly.

Provide balanced macronutrients, micronutrients, and essential vitamins and minerals.

Enteral or Parenteral Nutrition:

In cases where oral intake is insufficient or not possible, consider enteral nutrition (e.g., nasogastric or gastrostomy tube feeding) or parenteral nutrition (intravenous) as appropriate.

Monitoring and Assessment:

Continuously monitor and assess the patient’s progress, including weight gain, growth in children, and improvements in clinical signs and symptoms.

Adjust the nutritional plan as needed to ensure adequate energy and protein intake.

Psychological and Social Support:

Offer psychological support to both the patient and their caregivers, as PEM often has psychosocial implications.

Encourage family involvement and education on proper nutrition and care.

Education:

Provide guidance on preventing relapse and maintaining good nutritional status.

Long-Term Follow-Up:

Continue to monitor and support the patient’s nutritional status and growth over the long term.

Address any recurring or persistent issues, such as dietary preferences, food security, and access to healthcare.

Community-Based Interventions:

Implement community-based programs to raise awareness and provide support for individuals at risk of or recovering from PEM.

Collaborate with local organizations and authorities to improve access to nutritious food and clean water.

Prevention:

Promote breastfeeding and appropriate complementary feeding for infants.

Advocate for measures to reduce poverty, improve sanitation, and enhance food security to prevent PEM in communities.

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

Lifestyle modifications in treating protein energy malnutrition: Specialty

Nutrient-Rich Food Availability: Ensure that a wide variety of nutrient-rich foods are accessible and affordable to the affected population. This includes promoting the cultivation of diverse crops, such as fruits, vegetables, legumes, and grains, to improve local food availability. 

Food Security: Implement food security measures, such as food distribution programs, subsidies, or conditional cash transfers, to make sure that vulnerable populations have access to an adequate and balanced diet. 

Nutrition Education: Promote nutrition education and awareness campaigns to improve knowledge about balanced diets and the importance of protein and energy intake. This can be achieved through schools, community centers, and healthcare facilities. 

Breastfeeding Promotion: Encourage and support breastfeeding as it is the most nutritionally complete and cost-effective source of nutrition for infants. This can be achieved through education, workplace policies, and community support. 

Sanitation and Clean Water: Ensure access to clean drinking water and proper sanitation facilities to reduce the risk of waterborne diseases that can exacerbate malnutrition. Improved hygiene practices can also aid in nutrient absorption. 

Economic Empowerment: Empower communities through income-generating activities and livelihood programs to improve their economic stability, allowing them to afford nutritious foods. 

Food Fortification: Encourage or mandate the fortification of staple foods with essential nutrients, such as iron, folic acid, and vitamin A, to enhance the nutritional quality of commonly consumed foods. 

Healthcare Access: Ensure access to quality healthcare services, including routine check-ups and treatment for underlying medical conditions that can contribute to malnutrition. 

Role of Antibiotics for the treatment of metabolic derangements in protein energy malnutrition

ampicillin 

The dose for ampicillin is 50 mg/kg through IM/IV every six hours  

gentamicin 

 gentamicin recommended dose is 7.5 mg/kg IM/IV once daily for seven to ten days some clinicians recommend taking ceftriaxone in the dose 50 mg/kg through IM/IV once daily for sick child 

metronidazole 

The recommended dose to take 10 to 12 mg/kg by oral route every eight hours who are suffering from prolonged exposure of diarrhea 

Surgical care

In most cases, the treatment of malnutrition involves medical intervention. Nonetheless, certain infections, particularly those affecting the skin, might necessitate surgical procedures such as debridement and infection control. 

For children who cannot meet their nutritional needs through oral consumption, enteral nutrition could be a suitable option. This may involve surgical procedures for the placement of a feeding tube or other means of delivering nutrition. 

Phases of Management

Assessment and Diagnosis:  

Screening: Identifying individuals at risk for PEM through regular health check-ups, growth monitoring, and nutritional assessments.  

Clinical Evaluation: Assessing the patient’s medical history, physical examination, and signs of malnutrition, such as weight loss, muscle wasting, and edema.  

Laboratory Tests: Measuring essential parameters like serum albumin, hemoglobin, and micronutrient levels to evaluate the severity of malnutrition. 

Stabilization Phase:  

Immediate Care: Hospitalization and initial stabilization for severely malnourished individuals. Addressing life-threatening complications such as dehydration, electrolyte imbalances, and infections.  

Restoring Fluid Balance: Rehydration with appropriate intravenous or oral fluids.  

Correcting Electrolyte Imbalances: Managing electrolyte disturbances like hypokalemia and hypophosphatemia.  

 Nutritional Therapy: Providing initial nutritional support with cautious refeeding to prevent refeeding syndrome. This may involve using therapeutic milk formulas or ready-to-use therapeutic foods (RUTFs). 

Rehabilitation Phase: Continued Nutritional Support: Gradual introduction of therapeutic diets or therapeutic feeds to meet energy and protein requirements, often with micronutrient supplementation. Addressing Coexisting Conditions: Managing comorbid conditions, such as respiratory or cardiac issues, and providing appropriate medical treatment.   

Psychological Support: Offering counseling and psychological support for both the patient and their family to address the emotional and mental aspects of malnutrition.  

Education and Counseling: Teaching caregivers about proper nutrition, feeding practices, and hygiene to prevent relapse and promote sustained recovery. 

Maintenance and Follow-up Phase:  

Monitoring Progress: Regular follow-up appointments to track weight gain, growth, and overall health status.  

Adjusting Nutritional Support: Modifying the nutritional plan as the patient progresses and gains weight.  

Providing Continued Care: Long-term support and nutritional interventions to maintain the patient’s improved health and prevent relapse.  

Education: Ongoing education for the patient and caregivers on maintaining a balanced diet and preventing future malnutrition. 

Nutritional Rehabilitation Centers (in severe cases):  

For severely malnourished children, especially in resource-limited settings, Nutritional Rehabilitation Centers (NRCs) can provide intensive care, feeding, and medical support. 

Community-Based Rehabilitation:  

 In some cases, community-based programs may be implemented to provide ongoing support, counseling, and nutritional supplements to individuals recovering from PEM. 

Medication

Media Gallary

References

https://www.sciencedirect.com/topics/food-science/protein-energy-malnutrition

Protein-Energy Malnutrition

Updated : November 1, 2023




Protein-energy malnutrition (PEM) is a critical and widespread nutritional disorder that affects millions of individuals, particularly in developing countries. It is a condition characterized by a severe deficiency in both protein and energy intake, leading to a range of physical and physiological abnormalities.

PEM encompasses a spectrum of conditions, from moderate malnutrition to severe forms, such as marasmus and kwashiorkor, each with distinct clinical features and implications for overall health.This condition primarily affects children and is a significant contributor to global morbidity and mortality, particularly in areas with limited access to adequate nutrition and healthcare resources.

Prevalence:

PEM is most observed in children under the age of five, pregnant and lactating women, and the elderly.

The prevalence of PEM varies widely across different regions and is more prevalent in developing countries with limited access to nutritious food, healthcare, and sanitation.

In the year 2016, recent statistics revealed that over 18 million children worldwide, primarily in low-income environments, suffer from severe acute malnutrition, which includes conditions such as marasmus & kwashiorkor.

According to data from the World Health Organization in 2018, approximately 52 million children under the age of 5 experience wasting (insufficient weight-for-height), with 17 million of them classified as severely wasted. Moreover, a staggering 155 million children are affected by stunting (inadequate height-for-age).

Geographic Distribution:

PEM is more prevalent in sub-Saharan Africa, South Asia, and parts of Central and South America, where poverty and food insecurity are common.

Rural areas, where access to healthcare and nutritious foods is limited, tend to have higher rates of PEM.

Age and Gender:

Children, especially those under the age of two, are most vulnerable to acute forms of PEM, such as kwashiorkor and marasmus.

Gender disparities may exist, with boys and girls being affected differently in some regions, but overall, PEM affects both genders.

Socioeconomic Factors:

Poverty is a significant risk factor for PEM. Families with limited financial resources often struggle to afford nutritious food and healthcare, increasing the risk of malnutrition.

Lack of access to clean water, this can contribute to the development of PEM, as it can lead to infectious diseases and poor absorption of nutrients.

Cultural Practices:

Certain cultural practices, including early weaning and feeding patterns, can contribute to malnutrition in children.

Beliefs and customs related to food choices and dietary restrictions can also impact nutritional status.

Food Security:

Food security is a key determinant of PEM. In regions with food shortages, crop failures, or food price spikes, the risk of malnutrition increases.

Inadequate access to a variety of foods, including protein-rich sources, can lead to PEM.

Infectious Diseases:

Infections such as diarrhea, malaria, and respiratory infections can worsen PEM by reducing appetite, interfering with nutrient absorption, and increasing nutrient losses.

Maternal Nutrition:

Maternal malnutrition during pregnancy and lactation can contribute to the risk of PEM in infants and young children.

Adequate maternal nutrition is crucial for the healthy development of the child.

Inadequate Caloric Intake: The primary cause of PEM is an insufficient intake of calories, often resulting from inadequate dietary intake or chronic food shortages. A prolonged deficiency in caloric intake leads to a negative energy balance.

Protein Deficiency: In addition to inadequate calories, PEM also involves a lack of essential dietary proteins. This contributes to impaired growth, tissue repair, and the maintenance of vital bodily functions.

Imbalance in Macronutrients: The combination of calorie and protein deficiencies results in an imbalance of macronutrients, as carbohydrates and fats cannot fully compensate for the missing proteins in the diet.

Weight Loss and Muscle Atrophy: The body responds to the lack of calories by breaking down stored fat reserves for energy, resulting in weight loss. Concurrently, muscle protein is broken down for energy, leading to muscle wasting and reduced muscle mass.

Impaired Immune Function: PEM affects the immune system, making individuals more susceptible to infections. Protein deficiency can lead to a decreased production of immune cells, weakening the body’s ability to fight off pathogens.

Nutrient Deficiency: In addition to protein and calories, PEM often leads to deficiencies in essential micronutrients, such as vitamins and minerals. These deficiencies can further compromise overall health and contribute to various complications.

Inadequate Dietary Intake:

  • Low overall calorie intake: Not consuming enough calories can lead to a deficiency in both energy and protein, which are essential for growth and maintenance.
  • Insufficient protein intake: A diet lacking in protein sources, such as lean meats, dairy, legumes, and nuts, can contribute to PEM.
  • Limited access to nutritious food: Poverty, food insecurity, and inadequate access to diverse, balanced meals can result in a lack of essential nutrients.

Infections and Illnesses:

Infections, especially repeated or chronic ones, can increase the body’s demand for nutrients and impair nutrient absorption.

Gastrointestinal infections or disorders may hinder the absorption of nutrients, including proteins and calories.

Socioeconomic Factors:

Poverty and low socioeconomic status can limit access to nutritious foods, healthcare, and education, increasing the risk of PEM.

Inadequate Breastfeeding:

Insufficient breastfeeding in infants, or early weaning from breast milk, can lead to inadequate protein and energy intake, especially in resource-limited settings.

Food Security and Agricultural Practices:

Issues related to food availability, distribution, and agricultural practices can impact the overall quality and quantity of food in each region, potentially leading to PEM in affected populations.

Cultural Practices and Beliefs:

Cultural or religious dietary restrictions or practices may limit the types of foods consumed and contribute to inadequate protein and energy intake.

Lack of Nutrition Education:

A lack of knowledge about balanced nutrition and its importance can lead to poor dietary choices and increase the risk of PEM.

Environmental Factors:

Natural disasters like floods or droughts can cause production of food to be disrupted, resulting in food shortages and nutritional deficiencies.

Age: Young children and the elderly are more vulnerable to the effects of PEM, and the prognosis can be worse in these age groups.

Severity of Malnutrition: The degree of malnutrition is a critical factor. Severe acute malnutrition has a poorer prognosis compared to moderate acute malnutrition.

Duration of Malnutrition: The longer someone has been malnourished, the worse the prognosis tends to be. Chronic malnutrition can lead to more serious health complications.

Underlying Health Conditions: The presence of other illnesses or health conditions can worsen the prognosis for PEM. Infections, such as pneumonia or diarrhea, are common complicating factors.

Nutritional Rehabilitation: The effectiveness of nutritional rehabilitation programs and interventions is crucial. Adequate and timely nutritional support can greatly influence the prognosis.

Age group

Infants and Young Children:

Infants and young children are particularly vulnerable to PEM, with severe consequences for growth and development.

Common forms of PEM in this age group include marasmus (protein and calorie deficiency) and kwashiorkor (protein deficiency with some calorie intake).

School-Age Children and Adolescents:

School-age children and adolescents can also experience PEM, which can hinder their growth and cognitive development.

Poor nutrition during these years can have long-term effects on physical and mental health.

Adults:

Adults, especially in low-income and resource-constrained regions, can be affected by PEM, which can lead to muscle wasting, weakness, and susceptibility to infections.

In adults, PEM can be associated with chronic diseases or a lack of access to adequate nutrition.

Pregnant Women:

Pregnant women are at risk of developing PEM if they do not receive proper nutrition during pregnancy.

PEM during pregnancy can have negative effects on the growing foetus as well as the mother.

Elderly Individuals:

Elderly individuals may also be susceptible to PEM due to age-related changes in metabolism, reduced appetite, or medical conditions.

PEM in the elderly can lead to muscle wasting and impaired immune function.

Associated Comorbidity or Activity:

Growth Stunting: PEM, especially in children, can lead to growth retardation, resulting in reduced height and weight for age. This can have long-term implications for physical and cognitive development.

Immune System Impairment: A weakened immune system is a common consequence of PEM. This makes individuals more susceptible to infections, which can further exacerbate malnutrition and lead to a vicious cycle of illness and poor nutrition.

Muscle Wasting: Protein deficiency can lead to muscle wasting, weakness, and decreased muscle mass. This can impair physical strength and functionality.

Edema (Swelling): Severe forms of PEM, such as kwashiorkor, can result in edema, which is the accumulation of fluid in body tissues. This leads to swelling, particularly in the extremities and the abdomen.

Anemia: PEM can contribute to anemia due to a deficiency of essential nutrients, including iron and vitamins necessary for red blood cell production. Anemia can lead to fatigue and reduced oxygen-carrying capacity of the blood.

Mental Health Issues: PEM can also be associated with psychological distress, including depression and anxiety. The physical and social consequences of malnutrition can contribute to mental health problems.

General Appearance:

Emaciation: Obvious wasting and loss of body fat and muscle mass.

Growth retardation: Stunted growth in children.

Listlessness and apathy: Lack of energy and interest in the surroundings.

General weakness: Lack of muscle strength and tone.

Anthropometric Measurements:

Weight: A significant weight loss compared to the expected weight for age and height.

Height or length: Short stature or stunted growth in children.

Mid-upper arm circumference (MUAC): A MUAC measurement may be used to assess muscle wasting.

Skin Changes:

Dry, flaky, and scaly skin.

Loss of subcutaneous fat, leading to a wrinkled appearance.

Patchy hyperpigmentation (kwashiorkor).

Hair changes: Brittle, dry, and easily pluckable hair.

Edema: Swelling of the feet, legs, and sometimes the face (kwashiorkor).

Muscle Changes:

Muscle wasting and loss of muscle mass, especially in the limbs.

Weakness and poor muscle tone.

Face and Head:

Apathetic expression.

Sunken cheeks and eyes.

Enlarged parotid glands (bilateral parotid swelling may be a sign of kwashiorkor).

Gastrointestinal Signs:

A distended abdomen, often due to hepatomegaly (enlarged liver) in kwashiorkor.

Prominent ribcage and visible abdominal distension in marasmus.

Hair changes: Brittle, dry, and easily pluckable hair.

Edema: Swelling of the feet, legs, and sometimes the face (kwashiorkor).

Dermatological Findings:

Dry, flaky, and scaly skin.

Patchy hyperpigmentation, often referred to as “flag sign” or “flaky paint dermatosis” (kwashiorkor).

Ulcers or skin lesions in severe cases.

Oral and Dental Signs:

Glossitis (inflammation of the tongue).

Cheilosis (cracks and scaling at the corners of the mouth).

Dental caries and poor oral hygiene (kwashiorkor).

Mild PEM:

This stage may not have obvious physical signs and symptoms.

Children with mild PEM might appear slightly underweight and have subtle growth delays.

Fatigue, lethargy, and reduced physical activity may be observed.

Nutritional deficiencies can often be detected through laboratory tests.

Moderate PEM:

Weight loss and muscle wasting become more noticeable.

Children may exhibit decreased appetite and increased irritability.

Growth retardation becomes more apparent, with a noticeable delay in height and weight compared to age-matched peers.

Reduced muscle mass, thinning hair, and dry skin are common physical signs.

Severe PEM:

Severe wasting of body tissues, especially muscle and fat, is evident.

The child appears emaciated, with a protruding ribcage and visible skeletal features.

Severe lethargy, apathy, and a weakened immune system are characteristic.

Edema (swelling of the extremities) may be present, particularly in cases of kwashiorkor, a severe form of PEM.

Severe complications can arise, including organ dysfunction, infections, and the risk of death.

Kwashiorkor: A type of severe PEM characterized by edema (swelling), dermatosis, hepatomegaly, and other signs of protein deficiency. It is often seen in children and can be distinguished from marasmus based on the presence of edema.

Marasmus: Another type of severe PEM, which is characterized by severe wasting and emaciation. Unlike kwashiorkor, marasmus is primarily a deficiency of calories and is associated with severe weight loss.

Celiac disease: A chronic autoimmune disorder that results in malabsorption of nutrients, including protein and energy. It can present with symptoms such as diarrhea, weight loss, and nutrient deficiencies.

Crohn’s disease: An inflammatory bowel condition that results in malabsorption, chronic diarrhea, weight loss, and nutrient deficiencies, resembling the symptoms of PEM.

Gastrointestinal disorders: Conditions such as chronic diarrhea, malabsorption syndromes, and inflammatory bowel diseases can lead to malnutrition by impairing nutrient absorption and digestion.

Food allergies: Severe allergies or intolerances to specific foods can lead to inadequate intake of essential nutrients, including protein and energy.

Screening and Diagnosis:

Early identification and diagnosis are essential. Healthcare providers should use anthropometric measurements, clinical assessment, and medical history to determine the severity of PEM.

Stabilization and Medical Management:

In severe cases, individuals may require hospitalization for stabilization and medical care.

Address and treat any underlying medical conditions or complications, such as infections, electrolyte imbalances, or organ dysfunction.

Administer appropriate medications and therapies based on individual needs.

Nutritional Rehabilitation:

Initiate nutritional rehabilitation with careful monitoring by a healthcare team, including a dietitian or nutritionist.

Gradual refeeding is crucial to prevent refeeding syndrome, characterized by electrolyte imbalances when nutrients are reintroduced too quickly.

Provide balanced macronutrients, micronutrients, and essential vitamins and minerals.

Enteral or Parenteral Nutrition:

In cases where oral intake is insufficient or not possible, consider enteral nutrition (e.g., nasogastric or gastrostomy tube feeding) or parenteral nutrition (intravenous) as appropriate.

Monitoring and Assessment:

Continuously monitor and assess the patient’s progress, including weight gain, growth in children, and improvements in clinical signs and symptoms.

Adjust the nutritional plan as needed to ensure adequate energy and protein intake.

Psychological and Social Support:

Offer psychological support to both the patient and their caregivers, as PEM often has psychosocial implications.

Encourage family involvement and education on proper nutrition and care.

Education:

Provide guidance on preventing relapse and maintaining good nutritional status.

Long-Term Follow-Up:

Continue to monitor and support the patient’s nutritional status and growth over the long term.

Address any recurring or persistent issues, such as dietary preferences, food security, and access to healthcare.

Community-Based Interventions:

Implement community-based programs to raise awareness and provide support for individuals at risk of or recovering from PEM.

Collaborate with local organizations and authorities to improve access to nutritious food and clean water.

Prevention:

Promote breastfeeding and appropriate complementary feeding for infants.

Advocate for measures to reduce poverty, improve sanitation, and enhance food security to prevent PEM in communities.

Nutrient-Rich Food Availability: Ensure that a wide variety of nutrient-rich foods are accessible and affordable to the affected population. This includes promoting the cultivation of diverse crops, such as fruits, vegetables, legumes, and grains, to improve local food availability. 

Food Security: Implement food security measures, such as food distribution programs, subsidies, or conditional cash transfers, to make sure that vulnerable populations have access to an adequate and balanced diet. 

Nutrition Education: Promote nutrition education and awareness campaigns to improve knowledge about balanced diets and the importance of protein and energy intake. This can be achieved through schools, community centers, and healthcare facilities. 

Breastfeeding Promotion: Encourage and support breastfeeding as it is the most nutritionally complete and cost-effective source of nutrition for infants. This can be achieved through education, workplace policies, and community support. 

Sanitation and Clean Water: Ensure access to clean drinking water and proper sanitation facilities to reduce the risk of waterborne diseases that can exacerbate malnutrition. Improved hygiene practices can also aid in nutrient absorption. 

Economic Empowerment: Empower communities through income-generating activities and livelihood programs to improve their economic stability, allowing them to afford nutritious foods. 

Food Fortification: Encourage or mandate the fortification of staple foods with essential nutrients, such as iron, folic acid, and vitamin A, to enhance the nutritional quality of commonly consumed foods. 

Healthcare Access: Ensure access to quality healthcare services, including routine check-ups and treatment for underlying medical conditions that can contribute to malnutrition. 

ampicillin 

The dose for ampicillin is 50 mg/kg through IM/IV every six hours  

gentamicin 

 gentamicin recommended dose is 7.5 mg/kg IM/IV once daily for seven to ten days some clinicians recommend taking ceftriaxone in the dose 50 mg/kg through IM/IV once daily for sick child 

metronidazole 

The recommended dose to take 10 to 12 mg/kg by oral route every eight hours who are suffering from prolonged exposure of diarrhea 

In most cases, the treatment of malnutrition involves medical intervention. Nonetheless, certain infections, particularly those affecting the skin, might necessitate surgical procedures such as debridement and infection control. 

For children who cannot meet their nutritional needs through oral consumption, enteral nutrition could be a suitable option. This may involve surgical procedures for the placement of a feeding tube or other means of delivering nutrition. 

Assessment and Diagnosis:  

Screening: Identifying individuals at risk for PEM through regular health check-ups, growth monitoring, and nutritional assessments.  

Clinical Evaluation: Assessing the patient’s medical history, physical examination, and signs of malnutrition, such as weight loss, muscle wasting, and edema.  

Laboratory Tests: Measuring essential parameters like serum albumin, hemoglobin, and micronutrient levels to evaluate the severity of malnutrition. 

Stabilization Phase:  

Immediate Care: Hospitalization and initial stabilization for severely malnourished individuals. Addressing life-threatening complications such as dehydration, electrolyte imbalances, and infections.  

Restoring Fluid Balance: Rehydration with appropriate intravenous or oral fluids.  

Correcting Electrolyte Imbalances: Managing electrolyte disturbances like hypokalemia and hypophosphatemia.  

 Nutritional Therapy: Providing initial nutritional support with cautious refeeding to prevent refeeding syndrome. This may involve using therapeutic milk formulas or ready-to-use therapeutic foods (RUTFs). 

Rehabilitation Phase: Continued Nutritional Support: Gradual introduction of therapeutic diets or therapeutic feeds to meet energy and protein requirements, often with micronutrient supplementation. Addressing Coexisting Conditions: Managing comorbid conditions, such as respiratory or cardiac issues, and providing appropriate medical treatment.   

Psychological Support: Offering counseling and psychological support for both the patient and their family to address the emotional and mental aspects of malnutrition.  

Education and Counseling: Teaching caregivers about proper nutrition, feeding practices, and hygiene to prevent relapse and promote sustained recovery. 

Maintenance and Follow-up Phase:  

Monitoring Progress: Regular follow-up appointments to track weight gain, growth, and overall health status.  

Adjusting Nutritional Support: Modifying the nutritional plan as the patient progresses and gains weight.  

Providing Continued Care: Long-term support and nutritional interventions to maintain the patient’s improved health and prevent relapse.  

Education: Ongoing education for the patient and caregivers on maintaining a balanced diet and preventing future malnutrition. 

Nutritional Rehabilitation Centers (in severe cases):  

For severely malnourished children, especially in resource-limited settings, Nutritional Rehabilitation Centers (NRCs) can provide intensive care, feeding, and medical support. 

Community-Based Rehabilitation:  

 In some cases, community-based programs may be implemented to provide ongoing support, counseling, and nutritional supplements to individuals recovering from PEM. 

https://www.sciencedirect.com/topics/food-science/protein-energy-malnutrition