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Clinical Manifestations of PEM

Clinical manifestations of undernutrition depends on the severity and duration of nutritional deprivation.



Marasmus: means wasting ; good adaptation to poor diet.

  1. Characterized by gross wasting of muscle and subcutaneous tissue resulting in emaciation, marked stunting and no edema
  2. Loose folds of skin are prominent
  3. The bucca pad of fat is preserved till malnutrition becomes extreme (higher proportion of saturated fatty acids is stored there and saturated fat is the last to be depleted)
  4. Baby is alert * but often irritable
  5. Voracious appetite * 

KWASHIORKOR: means deposed child; adaptation failure.

Essential features 

  1. Markedly retarded growth (Wt 60-80% of expected)
  2. Psychomotor changes
  3. Muscle wasting but preservation of fat
  4. Edema 

Edema caused by:

  1. Hypoalbuminemia
  2. Retention of fluid and water due to increased capillary permeability
  3. Free radical induced damage to cell membrane. It starts in the lower extremities.

Mental changes: lethargic,. listless, and apathetic


* Appetite is Impaired and it is difficult to feed orally                


Other clinical features: (Non essential)

  1. Hepatomegaly: 1/3 of cases due to fatty infiltration
  2. Hair changes; The hair is thin dry, brittle and easily pluck able, sparse, It becomes straight and hypopigmented.
  3. Flag sign (alternate pigmented and hypopigmented) related to the duration of under nutrition and are absent in acute PEM
  4. Skin changes:
    1. Hyperpigmented patches may desquamate to expose raw-hypopigmented skin.
    2. Flaky paint dermatosis.
    3. Petechiae or ecchymosis appear in severe cases.
    4. Follicular keratosis and sores may be also observed.                      
  5. Changes in the body composition:
    1. Total body water is increased Q
    2. Basal metabolic rate is reduced
    3. Synthesis of all proteins is reduced
    4. GFR and renal plasma flow are reduced
    5. Insulin levels are reduced
    6. Cortisol and growth hormone levels are increased
  6. Nutrition and Resistance to Infection:
    1. Impaired chemotaxis
    2. Normal phagocytosis
    3. Impaired cell mediated immunity
    4. Circulating immunoglobulin levels are usually normal or elevated but secretory IgA is generally elevated due to associated respiratory & GIT infection

Differences between kwashiorkor and marasmus

Clinical finding







Liver enlargement




More common





Less than kwashiorkor

Recover early

Less prone

Less common





High in early stage

Long to recover

More prone


Early death can occur due to:

  1. Hypothermia                                        
  2. Hypoglycemia              
  3. Infections
  4. Fluids and electrolytic imbalance  
  5. Severe anemia            
  6. Cardiac failure

Age Independent Indices


Name Of Index


Normal value

Value in malnutrition


Mid arm circumference/ head circumference (cm)

0.32- 0.33

Severely malnourished: < 0.25


( weight in kg / height² in cm x 100


0.12 – 0.14


Weight in kg / height¹· 6 (in cm)

0.88- 0.97

< 0.79





Jeliffe’s ratio

Hc/ cc

Ratio < 1 in a child> 1 yr: malnourished



Biochemical indices in children with malnutrition


Status in malnutrition


, <0.45 mg/ml indicative of severe malnutrition.


; Albumin concentration < 3 g/ dl is associated with early illness; between 2.5 and 2.9 are low and below 2.5 g/ dl are pathological.

Serum prealbumin, transthyretin and retinol binding protein

; Have short t1/2. Sensitive indicators of protein status; return to normal at beginning of nutritional therapy, therefore cannot be used as endpoint for terminating nutritional therapy.

Pattern of circulating amino acids in blood

Essential amino acids ; non essential amino acids are normal or ; therefore their ratio is. Mean value 1.5; subclinical illness 2-4; frank kwashiorkor> 3.5


              Glycine + serine + taurine + glutamine

Ratio =  ---------------------------------------------

              Valine + leucine + taurine + methionine

24 hr urinary

3-methylhitidine excretion

Present exclusively in skeletal muscle and white muscle fibres; released when actin and myosin catabolized; excreted in urine; reflects muscle mass. 24 hr excretion in malnutrition

Urinary creatinine height index (CHI)

Breakdown product of creatine; reflects muscle mass

           24 hour urine creatinine

CHI = ------------------------------------------------------------

           24 hour urine creatinine (normal child of same height)

Ranges 0.25 - 0.75 in kwashiorkor & 0.33-0.85 in marasmus; recovered child ~1




ORS in malnutrition:


WHO recommends ReSoMal (Rehydration Solution for severely Malnourished child)




















ORS (mmol /1)


90 Q

20 Q







Imp:. New improved low OSMOLAR WHO ORS can be now directly used in malnourished children, so no need to prepare Re somal.


It is given 70-100 ml / kg to restore normal hydration over a period of 12 hrs. If Hb < 4 gm / dl packed cell transfusions .




Vit A, Vit K, Magnesium sulphate, Folic acid, calcium , zinc


Initiation of Cure (first 7 days)

  1. All calculation according to the present weight
  2. To start with
    80 k cal / kg/ day of energy and 0.7 gm/ kg of protein / day
    gradually increased to 150 k cal and 2-3 gm/ kg 

Rehabilitative phase:

  1. For optimum catch up growth             
  2. Fluids : 150 ml/kg/day
  3. Energy : 175-200 Kcal/ Kg/ day
  4. Protein : 4-5 gm/ kg /day 

Criteria of discharge:

  1. The child should have at least 90% of his ideal weight for height
  2. Gaining weight at normal rate
  3. All infection, vitamins and mineral deficiency treated
  4. Immunization
  5. Education
  6. Serum albumin > 3.0 gm/dl 

Treatment failure:


Primary failure: Q

  1. Failure to regain appetite by day 4
  2. Failure to start losing edema by day 4
  3. Failure to disappearance of edema by day 10
  4. Failure to gain weight at least 5 mg / kg per day, by day 10 

Secondary failure;

  1. If the child does not gain > 5 gm / kg /day B.W. for 3 consecutive day during rehabilitative phase Q.
    a. Prevention at community level:
  2. K If the growth of the child is slowed or is arrested, the curve on the growth card is flattened –high risk.
  3. K Velocity of growth is more important then the actual weight of a child. 

Age independent anthropometric indices Q

  1. Mid arm circumference-Shakir tape
    (1-5 yrs)
    N->13.5 cm
    Malnutrition < 12.5 cm
  2. Kanawati index
  3. Rao's index
  4. Dugdale's index 

Certain Important Practical Aspects Regarding PEM

  1. D/D of Crazy pavement dermatosis:
    1. PEM
    2. Ichthyosis
    3. ​Pellagra
  2. Poor prognostic factors in PEM: 
    1. Gross edema
    2. Hypothermia
    3. Drowsiness
    4. Hypoglycemia
    5. Coma
    6. Severe infection
    7. Hepatomegaly (severe)

Imp. Poor prognostic markers

  1. Hyponatremia <12 mg/L Q
  2. S. Albuminic < 1 g/dL Q
  3. S. Bilirubin > 6 mg/dL Q 

3. Causes of Hypopigmented patches on skin Q

  1. Post-infectious (Pyoderma, Fungal infections) hypopigmentation
  2. Tyrosine deficiency
  3. Zinc deficiency
  4. Tyrosine & Zinc are required for melanin formation, Transport etc. 
4. Causes of Edema Q
  1. Hypoproteinemia
  2. Increased ADH secretion
  3. Increased Renin and angiotensin and aldosterone secretion
  4. Decreased Hepatic function (reduced degradation of aldosterone) Increased Ferritin
  5. Anemia with CCF. 

5. Causes of Hair changes. Q

  1. Protein deficiency          
  2. Relative Zinc deficiency & Copper Excess              
  3. Tyrosine deficiency 

6. CNS changes: Q

  1. Mental changes. Apathy, listlessness etc. of kwashiorkor
  2. Hypotonia - Reduced Potassium I Magnesium concentration and nutritional myopathy
  3. Hypertonia - Reduced Calcium Concentration 

7. In PEM the following anthropometric characteristics decrease in the following order.

  1. Weight                
  2. Skin fold thickness              
  3. Mid-arm circumference
  4. Calf circumference                
  5. Chest circumference            
  6. Height
  7. Head circumference 

8. Causes of Cardiomegaly in Kwashiorkor:

  1. CCF                      
  2. Nutritional recovery
  3. Anemia                        
  4. Pericardial effusion (due to hypoproteinemia)

Iron may not be given in the acute phase (1 week at least) in severe e/o Infection due to foil reasons:

  1. Increased levels of free Iron (due to low circulating proteins)
  2. Some organisms are dependent on iron for growth
  3. It worsens diarrhea in some cases. 

9. Conditions which precipitate Kwashiorkor:

  1. Acute gastroenteritis            
  2. Malaria        
  3. Measles
  4. Repeated LRTI                      
  5. Whooping cough  
  6. Tetanus        
  7. Koch's

10. Causes of Dysentery:


Acute bacillary dysentery due to Shigella, Salmonella, Yersinia & Campylobacter Organisms

  1. Amebiasis                            
  2. Acute ulcerative colitis                  
  3. Crohn's disease
  4. Intussusception                    
  5. Whipworm infections                    
  6. Milk allergy
  7. Pseudomembranous colitis          
  8. Tb ulcers in abdomen                  
  9. Meckel's diverticulitis 

11. Worms causing Diarrhea:

  1. Strongyloides stercoralis (Bloody diarrhea).
  2. Trichuris Trichiura - Causes prolapse of rectum and bloody diarrhea. 

12. Pica occurs when Iron deficiency has been for> 3 years. Bitot spots may disappear within 48 hrs of starting Treatment.


13. Differences between Kwashiorkor and Marasmus:

Tongue changes in Vit B deficiency:

  1. Riboflavin deficiency - Magenta-tongue
  2. Niacin deficiency       - Beefy red tongue (fiery red tongue)
  3. Folic acid deficiency   - Painful tongue

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