Protein-Energy Malnutrition

PEM Basics - The Hunger Games

• Definition: A group of pathological conditions due to a deficiency of dietary protein and/or energy, typically in combination. Leads to impaired growth, reduced immunity, and compromised organ function.
• Etiology:
  • Primary: Insufficient food intake (socioeconomic factors, ignorance, poor feeding habits).
  • Secondary: Underlying diseases increasing demand or causing malabsorption/loss (e.g., chronic infections, GI disorders).
• Classification: Various systems grade PEM severity. Common methods:

⭐ IAP classification (using weight-for-age) is commonly used in India for grading PEM, alongside WHO z-score classifications.

Kwashiorkor - Puffy & Peeling

• Severe protein deficiency; energy intake often adequate.
• Age: 6 months - 3 years; post-abrupt weaning to low-protein diet.
• Key Features:
  • Edema: Generalized, pitting; hallmark. Starts in lower limbs. 📌 "Puffy"
  • Skin: "Flaky paint" dermatosis, desquamation, hypopigmentation. "Peeling"
  • Hair: Sparse, brittle, dyspigmented (flag sign).
  • Mental: Apathy, lethargy, irritability.
  • Growth failure.
  • Moon facies, enlarged fatty liver (hepatomegaly).
  • Subcutaneous fat often preserved; muscle wasting present.

⭐ The presence of edema is the hallmark of Kwashiorkor, often starting in the lower limbs and progressing upwards.

Marasmus - Wasted Away

• Severe deficiency of all nutrients, primarily calories; typically < 1 year old.
• Clinical Features:
  • Severe muscle & subcutaneous fat wasting (emaciation).
  • Weight for height < -3 SD or < 70% median.
  • "Old man" or "monkey" facies.
  • Alert, irritable, often hungry.
  • No edema.
  • Skin: dry, loose folds ("baggy pants").
  • Hair: sparse, thin; less change than Kwashiorkor.
  • Prominent ribs.
• 📌 Mnemonic: Marasmus = Muscle Wasting, Miserable (but alert).

⭐ In Marasmus, there is severe wasting of muscle and subcutaneous fat, but the child often remains alert and irritable, unlike the apathy seen in Kwashiorkor.

The PEM Spectrum - Mix & Match Malady

• PEM: Spectrum from protein deficiency (Kwashiorkor) to calorie deficiency (Marasmus).
• Marasmus: Severe wasting (weight/height < -3 SD), no edema. Alert, irritable. "Old man" face.
• Kwashiorkor: Edema essential. Apathetic, moon face, flaky paint dermatosis, flag sign hair, fatty liver.
• Marasmic-Kwashiorkor: Edema + severe wasting.

⭐ Marasmic-Kwashiorkor presents with features of both conditions, typically edema along with significant wasting.

PEM Management - Rescue & Rebuild

• WHO 10 Steps Framework:
  • Stabilization Phase (Days 1-7):
    • Treat: Hypoglycemia, Hypothermia, Dehydration (ReSoMal), Electrolytes (K+, Mg++, no initial Na+), Infection.
    • Micronutrients (Vit A, Folic Acid, Zn; NO Iron).
    • Cautious feeding: F-75.
  • Rehabilitation Phase (Weeks 2-6):
    • Catch-up growth: F-100, ↑ feeds. Start Iron.
    • Sensory stimulation, emotional support.
    • Discharge planning & follow-up.

⭐ The WHO 10 steps for management of severe malnutrition are crucial, with initial stabilization focusing on hypoglycemia, hypothermia, dehydration, and infection before aggressive nutritional rehabilitation.

High‑Yield Points - ⚡ Biggest Takeaways

• Kwashiorkor: Key features are edema, hypoalbuminemia, flaky-paint dermatosis, and apathy.
• Marasmus: Defined by severe wasting ("old man" face), no edema, and alert irritability.
• Severe Acute Malnutrition (SAM): Diagnosed by MUAC < 11.5 cm or Weight-for-Height Z-score < -3 SD.
• Management phases: Stabilization with F-75, rehabilitation with F-100; ReSoMal for dehydration.
• Critical complications: Hypoglycemia, hypothermia, infections, and electrolyte disturbances.
• Marasmic-Kwashiorkor presents with mixed features including both edema and wasting.