Protein energy malnutrition (PEM) refers to inadequate intake of protein and energy, commonly seen in infants and children. It ranges from marasmus characterized by weight loss to kwashiorkor with edema. Risk factors include social, economic, biological and environmental causes like poverty, infections, improper feeding. Free radicals and aflatoxins may damage liver cells and cause kwashiorkor. PEM results from direct causes like inadequate food intake and disease or indirect causes like food insecurity, poor sanitation and inadequate healthcare. Theories on the pathophysiology include adaptation and maladaptation, acute versus chronic effects, and free radical injury. PEM causes changes in body composition, metabolism, and anatomy.

1. Cristi Francis
PROTEIN ENERGY MALNUTRITION

2. DEFINITION
• Inadequate intake of protein and energy either
because the dietary intakes of these 2 nutrients are
less than required for normal growth are greater
than can be by what would otherwise be adequate
intake [Nelson 18E]
• Range of pathological conditions arising from
coincident lack in varying proportions of protein
and calories occurring mostly in infants and
young children commonly associated with
infections (WHO 2014)

3. WHO Spectrum of PEM
Marasmus :
weight for age
<60% expected
Kwashiorkor :
weight for age
<80% + edema
Marasmic
Kwashiorkor :
Wt/Age <60% +
edema

4. RISK FACTORS
• Different combinations of
many aetiological factors
can lead to PEM in
children.They are:
• Social & Economic factors
• Biological factors
• Environmental factors
• Role of Free Radicals &
Aflatoxin
• Age of the Host

5. Amongst the Social,Economic ,Biological &
Environmental Factors the common causes are:
Lack of breastfeeding and giving diluted formula
Improper complementary feeding
Ignorance
Illiteracy
Lack of health education
Poverty
Infection
Familial Disharmony

6. Role of Free Radicals & Aflatoxins:
o Two new theories have been postulated
recently to explain the pathogenesis of
kwashiorkor.These include Free Radical
Damage & Aflatoxin Piosoning.These may
damage liver cells giving rise to kwashiorkor.

7. • Age Of Host
• Frequent in Infants & young children whose
rapid growth increases nutritional
requirement.

8. AETIOLOGY
• The causes of PEM can either be direct or
indirect.
• Direct causes
• The direct factors, which are commonly
referred to as immediate factors include:
• (i) Inadequate food intake
• (ii) Diseases

9. Direct Causes
• (i) Inadequate food intake
• Inadequate food intake is the result of limited
access to food in terms of quality and quantity.
• (ii) Diseases
• Diseases notably malaria and measles lead to loss
of appetite, increased rate of metabolism due to
fevers thereby increasing the body’s nutrient
demands. Diarrhoea reduces the absorption of
food nutrients, whereas vomiting decreases food
intake. Intestinal parasites compete for nutrients
with the body e.g. hookworm competes for iron.

10. Indirect causes
• Indirect causes of PEM include:
• (i) Food insecurity and limited access to
foodstuffs
• (ii) Poor water / sanitation and inadequate
health services
• (iii) Inadequate maternal and childcare practice

13. PATHOPHYSIOLOGY - Theories
• Gopalan’s theory of adaptation and
maladaptation
• Viteri’s theory – acute Vs chronic
• Free radical injury theory – Golden’s

16. • Pathophysiological changes associated with
nutritional and energy deficits can be
described as
• (1) body composition changes,
• (2) metabolic changes, and
• (3) anatomic changes.