Protein energy malnutrition is a disease of the poor , undernourished and chronically ill patient characterized by the imbalance between the supply of nutrient and energy and the body’s demand for them to ensure growth, maintenance of health and function of the body.

There are 3 types of PEM

• Marasmus – deficiency of both energy (carbohydrate) and protein
• Kwashiorkor – deficiency of only protein
• An intermediate state of Marasmus and Kwashiorkor 

Signs and Symptoms of Protein energy malnutrition

Most commonly occurs in children below 5 years and failure to thrive is a common presentation.

Marasmus

• Poor weight gain and weight loss
• Short in height for age – stunting
• Gross Muscle wasting and loss of subcutaneous fat
• Emaciated and looks like a baby monkey
• Irritable – doesnt allow to touch
• Apathy
• Anxiety
• Decreased responsiveness
• Behavioural changes
• No edema
• Wrinkled skin dry and loose – like tissue paper
• Loss of even buccal pad of fat. 

Kwashiorkor

Also called the disease of weaning as it appears during the period of weaning in a child when the mother fails to supplement the proteins required but feeds the cereals and malt which are rich in carbohydrate but poor in proteins

• Edema of the whole body especially belly – pot belly
• Moon facies
• Wasted muscles
• Retarded growth
• Psychomotor changes
• Hepatomegaly – fatty liver
• Hair changes – flag signs
• Skin changes – flaky paint appearance and mosaic skin appearance
• Nail plates are thin,soft and fissured

And in intermediate type both the features are seen.

Associated symptoms like Atrophy of the papillae on the tongue, angular stomatitis, xerophthalmia, and cheilosis can occur and vitamin C deficiency and zinc deficiency are also seen.

Diagnosis

Most of the time it is diagnosed clinically and in children with the standard growth chart. Along with it the lab investigation done are

• Hemoglobin
• Blood smear microscopy
• Blood glucose and total protein
• Urine examination and culture
• Electrolytes
• Stool for ova and parasites 

Treatment:

The treatment should be stared immediately after diagnosis.

The initial treatment depends on correcting the fluid and electrolytes imbalance for first 24-48 hrs and to start energy and protein rich food appropriate for the grade of malnutrition and given under a nutritionist guidance supplementing the macronutrient deficient orally as soon as possible.

After 1 week, intake rates should approach 175 kcal/kg and 4 g/kg for the children to be started and a multivitamin tablet also to be started with zinc paste for wounds to heal and child is monitored continuously with a growth chart the improvement and the necessary intervention.