Protein-energy malnutrition

Last updated: August 25, 2021

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Malnutrition is a significant cause of morbidity and mortality worldwide, leading to ∼ 45% of all deaths in children under the age of five. Approximately 52 million children have wasting with one-third (17 million) suffering from severe acute malnutrition. Even more children (∼ 154.8 million) have stunted growth, indicating widespread chronic malnutrition. In severe cases, primary protein-energy malnutrition (PEM) can develop, which has two major clinical forms: kwashiorkor and marasmus. Kwashiorkor is characterized by muscle atrophy, pitting edema, and distended abdomen with an enlarged fatty liver. It is caused by a deficiency of dietary protein despite sufficient calorie intake (e.g., from carbohydrates). Marasmus is the diffuse loss of muscle and fat tissue (without edema or distended abdomen) due to a severe state of total calorie deficiency of all macronutrients. Secondary PEM occurs due to illnesses affecting appetite, digestion, absorption, metabolism, and/or increased energy/protein demand. In addition to muscle atrophy, it is possible for patients to have clinical features of either marasmus or kwashiorkor. All forms of PEM are primarily clinical diagnoses; for primary PEM, WHO diagnostic criteria involve a child's weight-for-length/height and mid-upper arm circumference. Thorough laboratory testing should also be conducted to evaluate for severity and complications. Treatment involves managing complications, rehydration, and careful nutritional rehabilitation to avoid refeeding syndrome. In the case of secondary PEM, underlying conditions should also be treated, as well.

Main types of PEM
Marasmus Kwashiorkor
  • Primarily protein, e.g.:
    • Premature ceasing of breastfeeding
    • Chronic GI infectious diseases
    • Inadequate preparation of food with use of staple foods without necessary amounts of proteins (e.g., sweet potatoes, cassava)
Calorie intake
  • Deficient
  • Variable (can be normal or even high)
  • Severe energy deficiency leads to a catabolic state → breakdown of adipose tissue, muscle, and eventually organ tissue for energy

Epidemiology [3]

  • Widespread in children living in resource-limited countries in Sub-Saharan Africa, South-East Asia, and Central America.
  • Marasmus is most common
  • ∼ 45% of children's deaths < 5 years of age are associated with undernutrition
  • Growth stunting affects 144 million children < 5 years of age worldwide
Key clinical features

Marasmic kwashiorkor

Protein-deficient KWick MEALS lead to Kwashiorkor: Malnutrition, Edema, Anemia, fatty Liver, Skin lesions.

Marasmus causes Muscle wasting but no edema.

PEM is primarily a clinical diagnosis. Laboratory testing should be conducted to assess the severity and complications. Additional testing may be required to determine the underlying condition for secondary PEM.

Clinical diagnosis [4]

Primary PEM

Secondary PEM

Laboratory tests

Refeeding syndrome is a frequent complication if nutritional rehabilitation occurs too rapidly (sudden shift from a catabolic to an anabolic state): It is characterized by fluid retention, hypophosphatemia, hypomagnesemia, and hypokalemia.

We list the most important complications. The selection is not exhaustive.

  1. Manary MJ, Leeuwenburgh C, Heinecke JW. Increased oxidative stress in kwashiorkor. J Pediatr. 2000; 137 (3): p.421-424. doi: 10.1067/mpd.2000.107512 . | Open in Read by QxMD
  2. Smith MI, Yatsunenko T, Manary MJ, et al. Gut Microbiomes of Malawian Twin Pairs Discordant for Kwashiorkor. Science (80- ). 2013; 339 (6119): p.548-554. doi: 10.1126/science.1229000 . | Open in Read by QxMD
  3. Levels and trends in child malnutrition: Key Findings of the 2020 Edition of the Joint Child Malnutrition Estimates.
  4. Protein-Energy Undernutrition (PEU). Updated: January 31, 2020. Accessed: September 1, 2020.
  5. WHO child growth standards and the identification of severe acute malnutrition in infants and children. . Accessed: September 1, 2020.
  6. Kumar V, Abbas AK, Aster JC. Robbins & Cotran Pathologic Basis of Disease. Elsevier Saunders ; 2014
  7. Kliegman R, Stanton B, St. Geme J, Schor N. Nelson Textbook of Pediatrics. Elsevier ; 2015

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 Evidence-based content, created and peer-reviewed by physicians. Read the disclaimer