Protein Energy Malnutrition(PEM)

According to who ,malnutrition is defined as" the cellular imbalance between the supply of nutrition and the body 's demand for them to ensure growth ,maintenance ,and specific function ".The term protein energy malnutrition (PEM) or protein calorie malnutrition include marasmus, kwashiorkor and intermediate state .in the India, about 20%to30% of the population is under -nourished. they are endemic in certain parts of south Africa, middle east ,Asia Central and South America.

PEM can be classified as normal ,mild ,moderate and severe; clinical presentation of PEM varies with its degree and duration .protein energy malnutrition affects usually every organ system . it depends upon the age of the child and associated vitamin, essential fatty acids and minerals deficiencies failure to thrive with retarded physical growth and development is the main clinical presentation of mild (PEM).it is also associated with a high rate of infection.

in the subsection below we shall study the primary cause and identifying features of marasmus and kwashiorkor. they represent two extremes of the spectrum of condition that fall within the preview of (PEM). some researchers are of the opinion that marasmus and kwashiorkor are two stages of the same disease. different countries have a different type of (PEM)with a different cause such as underlying organic disease and child abuse etc.

Present treatment  can be divided into three phases 'viz., resuscitation , stabilization ,and rehabilitation. The immediate causes of death in severe PEM are dehydration ,electrolyte imbalance ,infection; hypoglycemia and hypothermia. these pathophysiological condition should be rescued immediately. stabilization phase is the initiation of recovery and its maintenance for this energy and protein are gradually introduced at a steady state (0.6g of protein and 95cals/kg/day) in order to avoid liver failure, coma, and cardiac failure .After stabilization adequate amount of energy ,protein , vitamin (A,B,C.D and folic acid ), minerals  are given for normal repair and growth of children.

Marasmus

marasmus is due to prolonged restriction not only of protein but all kinds of food(chronic PEM) including inadequate vitamins and minerals. the child looks emaciated (dehydrated) and the skin easily wrinkles(old man 's face ) due to loss of subcutaneous fat. growth retardation is severe. it usually occurs in children from 6 to18months of age generally their appetite is good these children need to be wrapped up to keep them warm as there is little fat under the skin to insulate against cold

it is characterized by serve muscle wasting and absence of fatty liver. low calorie intake leads to low insulin and high cortisol levels favors catabolism of muscle.

Hypoalbuminemia is mild. these children have no detectable oedema. in marasmus patients, high level of plasma cortisol(free) might contribute abnormal glucose tolerance.

The child has reduced ability to digest and assimilation the limited food available as the supply of digestive enzymes is less and GI tract lining deteriorates. diarrhea is often vary common.

Hair texture may be modified. it can be thin, dry easily pulled out. inadequate nutrition in easily life leaves a permanent effect on brain size and cell number. this impair brain development and learning abilities. the suffering children engage in minimal activity ;usually a quiet child (not even crying food ). children with PEM have poor immune defense. 

kwashiorkor

the term kwashiorkor is used by members of the GA tribe in Ghana to describe "the sickness the older gets when the next child is born ".the older child is weaned from breast milk onto a starchy diet low  in protein. in this case the child has sufficient calorie intake, but insufficient amount and /or quality of protein. the hallmarks of kwashiorkor are hypoalbuminemia ,generalized Oedema and fatty liver.

the intake of high carbohydrate and low protein stimulates the release of insulin while the levels of epinephrine and cortisol are low. this will result in relatively less muscle wasting and fat mobilization

than marasmus.

An inadequate supply of amino acids derived from proteins results in decreased synthesis of plasma protein such as albumin and transferrin by the liver albumin account for almost 80% of the osmotic pressure(OP) due to plasma protein which is the main force  that derives the interstitial fluid into the capillaries  low OP is partly responsible  for oedema. the export of triglycerides , cholesterol and abdomen gets distended with enlarged liver. 

The children are susceptible to infections and frequent diarrhoea their t- cell function is particularly impaired. the incidence of dental caries  is high. they are anemic.

generally children are rest less and irritable they have loss of appetite (anorexia ),fever and stunted growth. skin may be reddish orange colored due to insufficient tyrosine needed for melanin synthesis. kwashiorkor is preventable if children are fed balanced diet containing adequate amount and quality of proteins.