problem solving approach in management of pem ppt

Protein-Energy Malnutrition Treatment & Management

• Author: Hadi Atassi, DO; Chief Editor: Romesh Khardori, MD, PhD, FACP  more...
• Sections Protein-Energy Malnutrition
• Pathophysiology
• Epidemiology
• Patient Education
• Physical Examination
• Approach Considerations
• Laboratory Studies
• Other Tests
• Histologic Findings
• Imaging Studies
• Medical Care
• Diet and Activity
• Consultations
• Complications
• Media Gallery

Severe acute malnutrition is managed in health facilities and therapeutic feeding centers in developing countries. However, limited coverage and impact, cost, cross infections, and high mortality rate have been observed.

In Ethiopia, mixed results were reported from implementation of a community-based outpatient management program of children with severe acute malnutrition and without medical complications. [ 52 ] Although the recovery rate was 64.9%, the likelihood of recovery was 2.6 times higher for children with kwashiorkor than for those with marasmus. Children residing in areas with less than 25 minutes of travel from the program site had a 1.53 times higher odds of recovery than those residing in regions with travel of 25 minutes or longer. [ 52 ]

Surgical care

In general, malnutrition is managed medically. However, some infections, particularly of the skin, may require surgical intervention for debridement and infection stabilization.

Children who are unable to obtain their nutritional requirements via oral intake may be candidates for enteral nutrition, which may require surgical placement of a feeding tube or other method of nutrition.

In both children and adults, the first step in the treatment of protein-energy malnutrition (PEM) is to correct fluid and electrolyte abnormalities and to treat any infections. The most common electrolyte abnormalities are hypokalemia, hypocalcemia, hypophosphatemia, and hypomagnesemia. Macronutrient repletion should be commenced within 48 hours under the supervision of nutrition specialists.

A 1980 double-blind study of eight children with kwashiorkor and skin ulceration found that topical zinc paste was more effective than placebo in healing areas of skin breakdown. Oral zinc supplements were also found to be effective.

The second step in the treatment of protein-energy malnutrition (which may be delayed 24-48 h in children) is to supply macronutrients by dietary therapy. Milk-based formulas are the treatment of choice. At the beginning of dietary treatment, patients should be fed ad libitum. After 1 week, intake rates should approach 175 kcal/kg and 4 g/kg of protein for children and 60 kcal/kg and 2 g/kg of protein for adults. A daily multivitamin should also be added.

For most of the cutaneous manifestations of inflammatory bowel disease, the primary therapy remains treatment of the bowel.

In a study of patients undergoing chemotherapy for advanced hepatic cancer, those who received a late-evening snack enhanced with branched-chain amino acids had improvements in energy metabolism parameters compared with control subjects. [ 45 ]

In discussing that protein-energy malnutrition is highly prevalent among peritoneal dialysis patients, Chung et al noted that although nutritional status assessments had improved over the decade from 1997 to 2007, no definitive single test was available to assess nutritional status. [ 53 ] Instead, they proposed that several different markers of nutrition must be used to understand nutritional status. For example, the treatment for peritoneal dialysis patients with malnutrition must be multifaceted, and they suggested using nontraditional strategies such as appetite stimulants, anti-inflammatory diets, and anti-inflammatory pharmacologic agents combined with more traditional forms of nutritional support to abate the protein-energy malnutrition. [ 53 ]

An intervention that brought "buddies" to the homes of the elderly who were at risk for protein-energy malnutrition was successful at decreasing such malnutrition. [ 54 ]

Long-term care

Patients should receive follow-up care with nutrition professionals and social services, and their growth and development should be monitored.

Nutritional support guidelines are available in the National Institute for Health and Clinical Excellence  Nutrition Support in Adults  quick reference guide.

Dietary Guidelines for Americans, 2015-2020, 8th edition , are available from the US Department of Health and Human Services and US Department of Agriculture. [ 55 ]

It is recommended that children who suffer from malnutrition be started early with exercises and physical therapy, as well as resources to encourage stimulation. Also, parents should be educated on the importance of activity.  [ 56 ]

Any patient at risk for nutritional deficiency should be referred to a registered dietitian or other nutrition professional for a complete nutritional assessment and dietary counseling.

Other subspecialty referrals should be considered if findings from the initial evaluation indicate that the underlying cause is not poor nutritional intake. If signs indicate malabsorption, a gastroenterologist should be consulted. Further, in pediatric cases, a pediatrician, preferably one with experience in the management of protein-energy malnutrition, should oversee care of the patient. Any patient with significant laboratory abnormalities, as discussed previously, may benefit from consultation with the appropriate subspecialty (eg, endocrinology, hematology).

Children with poor nutrition secondary to inadequate intake and/or neglect should be referred to the appropriate social agencies to assist the family in obtaining resources and providing ongoing care for the child.

In the setting of malnutrition, the risk of refeeding syndrome represents an additional clinical challenge. Prolonged starvation followed by rapid feeding leads to this condition, [ 57 ]  in which there is resultant biochemical disturbance and physical symptoms/signs. Insulin release leads to the anabolic activity that underlies the pathophysiology of refeeing syndrome, and feeding overwhelms the dearth of electrolytes and micronutrients, which disrupts cellular function. Tissue edema, hypophosphatemia, and pathologic fluid shifts define refeeding syndrome.

Refeeding syndrome remains underrecognized, and patients on parenteral nutrition are considered to be at high risk. In a United Kingdom study, although refeeding syndrome was identified in 4% of cases of patients on parenteral nutrition, ​physicians only recognized it in half the cases. [ 57 ]  Using protocols with slower and lower rates of refeeding reduces deaths attributable to this syndrome. [ 57 ]

Death can be avoided if refeeding syndrome is recognized and patients are treated with dietary adjustment and clinical guidelines are followed.  A 13-month-old Kuwaiti male with marasmic kwashiorkor presented initially with normal levels of blood sugar and serum electrolytes. [ 58 ] However, by admission day 3, refeeding syndrome occurred with severe hypomagnesemia, hypokalemia, hypophosphatemia, and hypocalcemia, and the child then was given a lower calorie intake. The child survived following a gradual increase of caloric intake with vitamins, thiamine, and electrolyte supplementation. [ 58 ]

Refeeding syndrome guidelines are available in the National Institute for Health and Clinical Excellence  Nutrition Support in Adults  quick reference guide.

Refeeding syndrome can also occur in patients with anorexia nervosa who are replenished with food, vitamins, and electrolytes, [ 59 ]  although some investigators have argued that hypophosphatemia is not a problem in refeeding this patient population. [ 60 ]

Protein in 1 gram of food provides approximately 15 mg of phosphorus. [ 61 ]  Marasmic kwashiorkor is marked by phosphorus deficiency. Chronic phosphorus deficiency in humans causes proximal myopathy, and acute hypophosphatemia can precipitate rhabdomyolysis. Low blood phosphorus impedes the concentration of red blood cell synthesis as well as depletes stored levels of 2,3-diphosphoglycerate, which in turn affects hemoglobin's affinity for oxygen. Moreover, nervous system dysfunction (eg, apathy, weakness, intention tremors, a bedridden state) may occur in severe cases of phosphorus deficiency. [ 61 ]

Other groups at risk for refeeding syndrome include alcoholic individuals undergoing detoxification, extremely-low-birth-weight neonates who were intrauterine growth-restricted, cancer patients who have suffered from cachexia, and adults with kwashiorkor who receive enteral rather than parenteral feeding.

Prevention of protein-energy malnutrition begins with addressing the underlying cause. Economic and social factors are a major contributor to malnutrition. Extreme poverty leads to poor living conditions and often inadequate hygiene, as well as limited access to food and water. Children often do not receive the care they need. All of these can also lead to an increased risk of infections. In addition, diarrhea and vomiting can exacerbate the malnutrition due to water losses.

Prevention of malnutrition also must involve education. Educate mothers on the importance of breastfeeding and on how to adequately nourish their child. These women should also receive education regarding access to immunizations and the importance of fortification of food with necessary nutrients and vitamins.

Onis M de, Monteiro C, Clugston G. The worldwide magnitude of protein-energy malnutrition: an overview from the WHO Global Database on Child Growth. Bulletin of the World Health Organization . 1993. 71(6):

Di Giovanni V, Bourdon C, Wang DX, et al. Metabolomic changes in serum of children with different clinical diagnoses of malnutrition. J Nutr . 2016 Dec. 146 (12):2436-44. [QxMD MEDLINE Link] . [Full Text] .

Levels and trends in child malnutrition: UNICEF – WHO – World Bank Group joint child malnutrition estimates. Key findings of the 2016 edition. Available at https://www.who.int/nutgrowthdb/jme_brochure2016.pdf?ua=1 . 2016; Accessed: August 27, 2018.

Bergen DC. Effects of poverty on cognitive function: a hidden neurologic epidemic. Neurology . 2008. 71:447-451. [QxMD MEDLINE Link] .

Horta BL, Victora CG, de Mola CL, et al. Associations of linear growth and relative weight gain in early life with human capital at 30 years of age. J Pediatr . 2017 Mar. 182:85-91.e3. [QxMD MEDLINE Link] . [Full Text] .

Golden BE, Golden MH. Plasma zinc and the clinical features of malnutrition. Am J Clin Nutr . 1979 Dec. 32 (12):2490-4. [QxMD MEDLINE Link] .

Lin CA, Boslaugh S, Ciliberto HM, et al. A prospective assessment of food and nutrient intake in a population of Malawian children at risk for kwashiorkor. J Pediatr Gastroenterol Nutr . 2007 Apr. 44 (4):487-93. [QxMD MEDLINE Link] .

Spoelstra MN, Mari A, Mendel M, et al. Kwashiorkor and marasmus are both associated with impaired glucose clearance related to pancreatic beta-cell dysfunction. Metabolism . 2012 Mar 2. [QxMD MEDLINE Link] .

Forrester TE, Badaloo AV, Boyne MS, et al. Prenatal factors contribute to the emergence of kwashiorkor or marasmus in severe undernutrition: evidence for the predictive adaptation model. PLoS One . 2012. 7(4):e35907. [QxMD MEDLINE Link] .

Ma L, Savory S, Agim NG. Acquired protein energy malnutrition in glutaric acidemia. Pediatr Dermatol . 2013 Jul-Aug. 30(4):502-4. [QxMD MEDLINE Link] .

Hyacinth HI, Adekeye OA, Yilgwan CS. Malnutrition in sickle cell anemia: implications for infection, growth, and maturation. J Soc Behav Health Sci . 2013 Jan 1. 7(1):7(1). [QxMD MEDLINE Link] .

Corware K, Yardley V, Mack C, et al. Protein energy malnutrition increases arginase activity in monocytes and macrophages. Nutr Metab (Lond) . 11(1). 2014 Oct 24:51. [QxMD MEDLINE Link] .

Velly H, Britton RA, Preidis GA. Mechanisms of cross-talk between the diet, the intestinal microbiome, and the undernourished host. Gut Microbes . 2017 Mar 4. 8 (2):98-112. [QxMD MEDLINE Link] .

Demling RH. The incidence and impact of pre-existing protein energy malnutrition on outcome in the elderly burn patient population. J Burn Care Rehabil . 2005 Jan-Feb. 26(1):94-100. [QxMD MEDLINE Link] .

Landi F, Calvani R, Tosato M, et al. Anorexia of aging: risk factors, consequences, and potential treatments. Nutrients . 2016 Jan 27. 8 (2):69. [QxMD MEDLINE Link] . [Full Text] .

William JH, Tapper EB, Yee EU, Robson SC. Secondary kwashiorkor: a rare complication of gastric bypass surgery. Am J Med . 2015 May. 128(5):e1-2. [QxMD MEDLINE Link] .

Ghorbel HH, Broussard JF, Lacour JP, Passeron T. Iatrogenic kwashiorkor developing after bypass surgery. Clin Exp Dermatol . 2014 Jan;. 39(1):113-4. [QxMD MEDLINE Link] .

Barker LA, Gout BS, Crowe TC. Hospital malnutrition: prevalence, identification and impact on patients and the healthcare system. Int J Environ Res Public Health . 2011 Feb. 8 (2):514-27. [QxMD MEDLINE Link] .

McCarthy A, Delvin E, Marcil V, et al. Prevalence of malnutrition in pediatric hospitals in developed and in-transition countries: the impact of hospital practices. Nutrients . 2019 Jan 22. 11 (2): [QxMD MEDLINE Link] .

Tierney EP, Sage RJ, Shwayder T. Kwashiorkor from a severe dietary restriction in an 8-month infant in suburban Detroit, Michigan: case report and review of the literature. Int J Dermatol . 2010 May. 49(5):500-6. [QxMD MEDLINE Link] .

Boyd KP, Andea A, Hughey LC. Acute inpatient presentation of kwashiorkor: not just a diagnosis of the developing world. Pediatr Dermatol . 2013 Nov-Dec. 30(6):e240-1. [QxMD MEDLINE Link] .

World Health Organization. Nutrition for Health and Development: A Global Agenda for Combating Malnutrition . WHO/NHD/00.6. Geneva, Switzerland: WHO; 2000. [Full Text] .

World Health Organization. Malnutrition fact sheet. Available at https://www.who.int/news-room/fact-sheets/detail/malnutrition . February 16, 2018; Accessed: March 8, 2019.

Moradi Y, Shadmani FK, Mansori K, Hanis SM, Khateri R, Mirzaei H. Prevalence of underweight and wasting in Iranian children aged below 5 years: a systematic review and meta-analysis. Korean J Pediatr . 2018 Aug. 61 (8):231-8. [QxMD MEDLINE Link] .

Jildeh C, Papandreou C, Abu Mourad T, et al. Assessing the nutritional status of Palestinian adolescents from East Jerusalem: a school-based study 2002-03. J Trop Pediatr . 2011 Feb. 57(1):51-8. [QxMD MEDLINE Link] .

Crichton M, Craven D, Mackay H, Marx W, de van der Schueren M, Marshall S. A systematic review, meta-analysis and meta-regression of the prevalence of protein-energy malnutrition: associations with geographical region and sex. Age Ageing . 2019 Jan 1. 48 (1):38-48. [QxMD MEDLINE Link] .

Rosenberger C, Rechsteiner M, Dietsche R, Breidert M. Energy and protein intake in 330 geriatric orthopaedic patients: Are the current nutrition guidelines applicable?. Clin Nutr ESPEN . 2019 Feb. 29:86-91. [QxMD MEDLINE Link] .

Adejumo AC, Adejumo KL, Adegbala OM, et al. Protein-energy malnutrition and outcomes of hospitalizations for heart failure in the USA. Am J Cardiol . 2019 Mar 15. 123 (6):929-35. [QxMD MEDLINE Link] .

Landi F, Lattanzio F, Dell'Aquila G, et al. Prevalence and potentially reversible factors associated with anorexia among older nursing home residents: results from the ULISSE project. J Am Med Dir Assoc . 2013 Feb. 14 (2):119-24. [QxMD MEDLINE Link] .

Shergill R, Syed W, Rizvi SA, Singh I. Nutritional support in chronic liver disease and cirrhotics. World J Hepatol . 2018 Oct 27. 10 (10):685-94. [QxMD MEDLINE Link] .

Yao CK, Fung J, Chu NHS, Tan VPY. Dietary interventions in liver cirrhosis. J Clin Gastroenterol . 2018 Sep. 52 (8):663-73. [QxMD MEDLINE Link] .

Nishikawa H, Yoh K, Enomoto H, et al. Factors associated with protein-energy malnutrition in chronic liver disease: analysis using indirect calorimetry. Medicine (Baltimore) . 2016 Jan. 95 (2):e2442. [QxMD MEDLINE Link] . [Full Text] .

Wharton B. Protein energy malnutrition: problems and priorities. Acta Paediatr Scand Suppl . 1991. 374:5-14. [QxMD MEDLINE Link] .

Jen M, Yan AC. Syndromes associated with nutritional deficiency and excess. Clin Dermatol . 2010 Nov-Dec. 28(6):669-85. [QxMD MEDLINE Link] .

Hon KL, Nip SY, Cheung KL. A tragic case of atopic eczema: malnutrition and infections despite multivitamins and supplements. Iran J Allergy Asthma Immunol . 2012 Sep. 11 (3):267-70. [QxMD MEDLINE Link] .

Mori F, Serranti D, Barni S, et al. A kwashiorkor case due to the use of an exclusive rice milk diet to treat atopic dermatitis. Nutr J . 2015 Aug 21. 14:83. [QxMD MEDLINE Link] .

Henrique de S B Xavier M, De Magalhaes E, Ferraz Oliveira G, Keltke Magalhaes M, Prates de Almeida E Oliveira C, Braganca Oliveira N. A child with kwashiorkor misdiagnosed as atopic dermatitis. Dermatol Online J . 2017 May 15. 23 (5): [QxMD MEDLINE Link] .

Lewandowski H, Breen TL, Huang EY. Kwashiorkor and an acrodermatitis enteropathica-like eruption after a distal gastric bypass surgical procedure. Endocr Pract . 2007 May-Jun. 13(3):277-82. [QxMD MEDLINE Link] .

Al-Mubarak L, Al-Khenaizan S, Al Goufi T. Cutaneous presentation of kwashiorkor due to infantile Crohn's disease. Eur J Pediatr . 2010 Jan. 169(1):117-9. [QxMD MEDLINE Link] .

Sander CS, Hertecant J, Abdulrazzaq YM, Berger TG. Severe exfoliative erythema of malnutrition in a child with coexisting coeliac and Hartnup's disease. Clin Exp Dermatol . 2009 Mar. 34(2):178-82. [QxMD MEDLINE Link] .

Franco G, Calcaterra R, Valenzano M, Padovese V, Fazio R, Morrone A. Cupping-related skin lesions. Skinmed . 2012 Sep-Oct. 10(5):315-8. [QxMD MEDLINE Link] .

Nafzger S, Fleury LA, Uehlinger DE, Plüss P, Scura N, Kurmann S. Detection of malnutrition in patients undergoing maintenance haemodialysis: a quantitative data analysis on 12 parameters. J Ren Care . 2015 Sep. 41 (3):168-76. [QxMD MEDLINE Link] .

Katalinic L, Premuzic V, Basic-Jukic N, Barisic I, Jelakovic B. Hypoproteinemia as a factor in assessing malnutrition and predicting survival on hemodialysis. J Artif Organs . 2019 Mar 9. [QxMD MEDLINE Link] .

Tavarela Veloso F. Review article: skin complications associated with inflammatory bowel disease. Aliment Pharmacol Ther . 2004 Oct. 20 Suppl 4:50-3. [QxMD MEDLINE Link] .

Harima Y, Yamasaki T, Hamabe S, et al. Effect of a late evening snack using branched-chain amino acid-enriched nutrients in patients undergoing hepatic arterial infusion chemotherapy for advanced hepatocellular carcinoma. Hepatol Res . 2010 Jun. 40(6):574-84. [QxMD MEDLINE Link] .

World Health Organization, United Nations Children's Fund. WHO child growth standards and the identification of severe acute malnutrition in infants and children. Available at https://apps.who.int/iris/bitstream/handle/10665/44129/9789241598163_eng.pdf?sequence=1 . 2009; Accessed: August 29, 2018.

Thavaraj V, Sesikeran B. Histopathological changes in skin of children with clinical protein energy malnutrition before and after recovery. J Trop Pediatr . 1989 Jun. 35(3):105-8. [QxMD MEDLINE Link] .

McKenzie CA, Wakamatsu K, Hanchard NA, Forrester T, Ito S. Childhood malnutrition is associated with a reduction in the total melanin content of scalp hair. Br J Nutr . 2007 Jul. 98(1):159-64. [QxMD MEDLINE Link] .

Odabas D, Caksen H, Sar S, Unal O, Tuncer O, Atas B, et al. Cranial MRI findings in children with protein energy malnutrition. Int J Neurosci . 2005 Jun. 115 (6):829-37. [QxMD MEDLINE Link] .

Writing Group for the ISCD Position Development Conference. Diagnosis of osteoporosis in men, premenopausal women, and children. J Clin Densitom . 2004 Spring. 7 (1):17-26. [QxMD MEDLINE Link] .

[Guideline] World Health Organization. Updates on the Management of Severe Acute Malnutrition in Infants and Children. Available at https://apps.who.int/iris/bitstream/handle/10665/95584/9789241506328_eng.pdf?sequence=1 . 2013; Accessed: September 6, 2018.

Kabalo MY, Seifu CN. Treatment outcomes of severe acute malnutrition in children treated within Outpatient Therapeutic Program (OTP) at Wolaita Zone, Southern Ethiopia: retrospective cross-sectional study. J Health Popul Nutr . 2017 Mar 9. 36 (1):7. [QxMD MEDLINE Link] . [Full Text] .

Chung SH, Stenvinkel P, Lindholm B, Avesani CM. Identifying and managing malnutrition stemming from different causes. Perit Dial Int . 2007 Jun. 27 suppl 2:S239-44. [QxMD MEDLINE Link] .

Dorner TE, Lackinger C, Haider S, et al. Nutritional intervention and physical training in malnourished frail community-dwelling elderly persons carried out by trained lay "buddies": study protocol of a randomized controlled trial. BMC Public Health . 2013 Dec. 13(1):1232. [QxMD MEDLINE Link] .

[Guideline] US Department of Health and Human Services, US Department of Agriculture. Dietary Guidelines for Americans: 2015-2020 . 8th ed. Washington, DC: HHS, USDA; December 2015. [Full Text] .

Bekele A, Janakiraman B. Physical therapy guideline for children with malnutrition in low income countries: clinical commentary. J Exerc Rehabil . 2016 Aug. 12 (4):266-75. [QxMD MEDLINE Link] .

Walmsley RS. Refeeding syndrome: screening, incidence, and treatment during parenteral nutrition. J Gastroenterol Hepatol . 2013 Dec. 28 Suppl 4:113-7. [QxMD MEDLINE Link] .

Al Sharkawy I, Ramadan D, El-Tantawy A. 'Refeeding syndrome' in a Kuwaiti child: clinical diagnosis and management. Med Princ Pract . 2010. 19 (3):240-3. [QxMD MEDLINE Link] .

Melchior JC. From malnutrition to refeeding during anorexia nervosa. Curr Opin Clin Nutr Metab Care . 1998 Nov. 1(6):481-5. [QxMD MEDLINE Link] .

Garber AK, Mauldin K, Michihata N, Buckelew SM, Shafer MA, Moscicki AB. Higher calorie diets increase rate of weight gain and shorten hospital stay in hospitalized adolescents with anorexia nervosa. J Adolesc Health . 2013 Nov. 53 (5):579-84. [QxMD MEDLINE Link] .

Takeda E, Ikeda S, Nakahashi O. [Lack of phosphorus intake and nutrition] [Japanese]. Clin Calcium . 2012 Oct. 22 (10):1487-91. [QxMD MEDLINE Link] .

Williams PCM, Berkley JA. Guidelines for the treatment of severe acute malnutrition: a systematic review of the evidence for antimicrobial therapy. Paediatr Int Child Health . 2018 Nov. 38 (sup1):S32-S49. [QxMD MEDLINE Link] .

[Guideline] US Health and Human Services, US Department of Agriculture. Dietary Guidelines for Americans: 2015-2020 [Executive summary]. Available at https://health.gov/dietaryguidelines/2015/guidelines/executive-summary/ . December 2015; Accessed: March 11, 2019.

[Guideline] Piercy KL, Troiano RP, Ballard RM, et al. The physical activity guidelines for Americans. JAMA . 2018 Nov 20. 320 (19):2020-8. [QxMD MEDLINE Link] .

2018 Physical Activity Guidelines Advisory Committee. 2018 Physical Activity Guidelines Advisory Committee Scientific Report . Washington, DC: US Department of Health and Human Services; November 2018. [Full Text] .

Balint JP. Physical findings in nutritional deficiencies. Pediatr Clin North Am . 1998 Feb. 45(1):245-60. [QxMD MEDLINE Link] .

Nutritional disorders: malnutrition. Beers MH, Berkow R, eds. The Merck Manual . 17th ed. Whitehouse Station, NJ: Merck Co; 1999. 28-32.

Caksen H, Kendirci M, Kandemir O, Patiroglu T. A case of malignant histiocytosis associated with skin involvement mimicking kwashiorkor. Pediatr Dermatol . 2001 Nov-Dec. 18(6):545-6. [QxMD MEDLINE Link] .

Collins N. Protein-energy malnutrition and involuntary weight loss: nutritional and pharmacological strategies to enhance wound healing. Expert Opin Pharmacother . 2003 Jul. 4(7):1121-40. [QxMD MEDLINE Link] .

Constans T, Alix E, Dardaine V. [Protein-energy malnutrition. Diagnostic methods and epidemiology] [French]. Presse Med . 2000 Dec 16. 29 (39):2171-6. [QxMD MEDLINE Link] .

De Caprio C, Alfano A, Senatore I, Zarrella L, Pasanisi F, Contaldo F. Severe acute liver damage in anorexia nervosa: two case reports. Nutrition . 2006 May. 22(5):572-5. [QxMD MEDLINE Link] .

Delahoussaye AR, Jorizzo JL. Cutaneous manifestations of nutritional disorders. Dermatol Clin . 1989 Jul. 7(3):559-70. [QxMD MEDLINE Link] .

Golden MHN. Severe malnutrition. In: Weatherall DJ, Ledingham JGG, Warrell DA, eds. Oxford Textbook of Medicine . 3rd ed. Oxford, UK: Oxford University Press; 1996. 1278-96.

Goskowicz M, Eichenfield LF. Cutaneous findings of nutritional deficiencies in children. Curr Opin Pediatr . 1993 Aug. 5(4):441-5. [QxMD MEDLINE Link] .

Gupta MA, Gupta AK, Haberman HF. Dermatologic signs in anorexia nervosa and bulimia nervosa. Arch Dermatol . 1987 Oct. 123(10):1386-90. [QxMD MEDLINE Link] .

Gurski RR, Schirmer CC, Rosa AR, Brentano L. Nutritional assessment in patients with squamous cell carcinoma of the esophagus. Hepatogastroenterology . 2003 Nov-Dec. 50(54):1943-7. [QxMD MEDLINE Link] .

Harris CL, Fraser C. Malnutrition in the institutionalized elderly: the effects on wound healing. Ostomy Wound Manage . 2004 Oct. 50 (10):54-63. [QxMD MEDLINE Link] .

Hendricks KM, Duggan C, Gallagher L, et al. Malnutrition in hospitalized pediatric patients. Current prevalence. Arch Pediatr Adolesc Med . 1995 Oct. 149(10):1118-22. [QxMD MEDLINE Link] .

Jilcott SB, Masso KL, Ickes SB, Myhre SD, Myhre JA. Surviving but not quite thriving: anthropometric survey of children aged 6 to 59 months in a rural Western Uganda district. J Am Diet Assoc . 2007 Nov. 107(11):1983-8. [QxMD MEDLINE Link] .

Kuhl J, Davis MD, Kalaaji AN, Kamath PS, Hand JL, Peine CJ. Skin signs as the presenting manifestation of severe nutritional deficiency: report of 2 cases. Arch Dermatol . 2004 May. 140(5):521-4. [QxMD MEDLINE Link] .

Lyder CH. Assessing risk and preventing pressure ulcers in patients with cancer. Semin Oncol Nurs . 2006 Aug. 22(3):178-84. [QxMD MEDLINE Link] .

Manguso F, D'Ambra G, Menchise A, Sollazzo R, D'Agostino L. Effects of an appropriate oral diet on the nutritional status of patients with HCV-related liver cirrhosis: a prospective study. Clin Nutr . 2005 Oct. 24(5):751-9. [QxMD MEDLINE Link] .

McLaren DS. Skin in protein energy malnutrition. Arch Dermatol . 1987 Dec. 123(12):1674-1676a. [QxMD MEDLINE Link] .

Miller SJ. Nutritional deficiency and the skin. J Am Acad Dermatol . 1989 Jul. 21(1):1-30. [QxMD MEDLINE Link] .

Neldner KH. Nutrition, aging and the skin. Geriatrics . 1984 Feb. 39(2):69-82, 87-8. [QxMD MEDLINE Link] .

Pelly TF, Santillan CF, Gilman RH, et al. Tuberculosis skin testing, anergy and protein malnutrition in Peru. Int J Tuberc Lung Dis . 2005 Sep. 9(9):977-84. [QxMD MEDLINE Link] .

Prendiville JS, Manfredi LN. Skin signs of nutritional disorders. Semin Dermatol . 1992 Mar. 11(1):88-97. [QxMD MEDLINE Link] .

Roongpisuthipong C, Sobhonslidsuk A, Nantiruj K, Songchitsomboon S. Nutritional assessment in various stages of liver cirrhosis. Nutrition . 2001 Sep. 17(9):761-5. [QxMD MEDLINE Link] .

Ryan AS, Goldsmith LA. Nutrition and the skin. Clin Dermatol . 1996 Jul-Aug. 14(4):389-406. [QxMD MEDLINE Link] .

Schneider JB, Norman RA. Cutaneous manifestations of endocrine-metabolic disease and nutritional deficiency in the elderly. Dermatol Clin . 2004 Jan. 22(1):23-31, vi. [QxMD MEDLINE Link] .

Shah S, Kannikeswaran N, Kamat D. A rash. Clin Pediatr (Phila) . 2007 Sep. 46 (7):650-4. [QxMD MEDLINE Link] .

Soni BP, McLaren DS, Sherertz EF. Skin lesions in nutritional, metabolic and heritable disorders: cutaneous changes in nutritional disease. In: Freedberg IM, Eisen AZ, Wolff K, Austen KF, Goldsmith LA, Katz S, eds. Fitzpatrick's Dermatology in General Medicine . 5th ed. New York, NY: McGraw-Hill; 1999. Vol 2: 1725-37.

Tirmentajn-Jankovic B, Dimkovic N. [Simple methods for nutritional status assessment in patients treated with repeated hemodialysis] [Serbian]. Med Pregl . 2004 Sep-Oct. 57 (9-10):439-44. [QxMD MEDLINE Link] .

Wilmer WA, Magro CM. Calciphylaxis: emerging concepts in prevention, diagnosis, and treatment. Semin Dial . 2002 May-Jun. 15(3):172-86. [QxMD MEDLINE Link] .

Wong MMY, Thijssen S, Wang Y, et al. Prediction of mortality and hospitalization risk using nutritional indicators and their changes over time in a large prevalent hemodialysis cohort. J Ren Nutr . 2019 Mar 6. [QxMD MEDLINE Link] .

• This photograph shows children and a nurse attendant at a Nigerian orphanage in the late 1960s. Note that four of the children have gray-blond hair, a symptom of the protein-deficiency disease kwashiorkor. Image courtesy of Dr Lyle Conrad and the Centers for Disease Control and Prevention Public Health Image Library.
• This late 1960s photograph shows a seated, listless child who was among many individuals found with kwashiorkor in Nigerian relief camps during the Nigerian-Biafran war. Kwashiorkor is a disease that develops due to a severe dietary protein deficiency. This child, whose diet fit such a deficiency profile, presented with symptoms including edema of the legs and feet; light-colored, thinning hair; anemia; a pot-belly; and shiny skin. Image courtesy of Dr Lyle Conrad and the Centers for Disease Control and Prevention Public Health Image Library.

Contributor Information and Disclosures

Hadi Atassi, DO Resident Physician, Department of Internal Medicine, University of Louisville Hospital Hadi Atassi, DO is a member of the following medical societies: American College of Physicians , American Gastroenterological Association , Greater Louisville Medical Society Disclosure: Nothing to disclose.

Thomas L Abell, MD Professor and Arthur M Shoen MD Chair in Gastroenterology, Division of Gastroenterology, Hepatology and Nutrition, Faculty, Uro-Gynecology Fellowship, University of Louisville School of Medicine; Director of GI Motility Clinic at Jewish Hospital/U of Louisville Physicians; Former Director of Nutritional Support, Medical Staff, University of Mississippi Medical Center; Former Medical Staff, Mississippi Methodist Rehabilitation Center Thomas L Abell, MD is a member of the following medical societies: American College of Gastroenterology , American College of Physicians , American Gastroenterological Association , American Medical Association , American Neurogastroenterology and Motility Society , American Society for Gastrointestinal Endoscopy , International Society for Quality-of-Life Studies Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: ADEPT-GI<br/>Received research grant from: Theravance; Vanda; Allergan<br/>Have a 5% or greater equity interest in: ADEPT-GI<br/>Received income in an amount equal to or greater than $250 from: Theravance<br/>GI Editor for MedStudy for: Reviewer for UpToDate.

David F Butler, MD Former Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha , American Academy of Dermatology , Association of Military Dermatologists , Phi Beta Kappa , Texas Dermatological Society Disclosure: Nothing to disclose.

Jeffrey J Miller, MD Associate Professor of Dermatology, Pennsylvania State University College of Medicine; Staff Dermatologist, Pennsylvania State Milton S Hershey Medical Center Jeffrey J Miller, MD is a member of the following medical societies: Alpha Omega Alpha , American Academy of Dermatology , Society for Investigative Dermatology , Association of Professors of Dermatology , North American Hair Research Society Disclosure: Nothing to disclose.

Romesh Khardori, MD, PhD, FACP (Retired) Professor, Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, Eastern Virginia Medical School Romesh Khardori, MD, PhD, FACP is a member of the following medical societies: American Association of Clinical Endocrinologists , American College of Physicians , American Diabetes Association , Endocrine Society Disclosure: Nothing to disclose.

Noah S Scheinfeld, JD, MD, FAAD † Assistant Clinical Professor, Department of Dermatology, Weil Cornell Medical College; Consulting Staff, Department of Dermatology, St Luke's Roosevelt Hospital Center, Beth Israel Medical Center, New York Eye and Ear Infirmary; Assistant Attending Dermatologist, New York Presbyterian Hospital; Assistant Attending Dermatologist, Lenox Hill Hospital, North Shore-LIJ Health System; Private Practice Noah S Scheinfeld, JD, MD, FAAD is a member of the following medical societies: American Academy of Dermatology Disclosure: Nothing to disclose.

Anusuya Mokashi, MD, MS Resident Physician, Department of Radiology, Staten Island University Hospital Disclosure: Nothing to disclose.

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Dr. Dino Santoro, to the development and writing of this article.

What would you like to print?

• Print this section
• Print the entire contents of
• Print the entire contents of article

• Nutrition in the Pediatric Surgical Patient
• Nutritional Requirements of Children Prior to Transplantation
• Thermal Burns
• Alcoholic Hepatitis
• Necrotizing Fasciitis
• Acute Respiratory Distress Syndrome (ARDS)
• Diet, Nutritional Therapies in IBD: Update Offers Practical Advice
• More Support for Tenecteplase in Ischemic Stroke
• Liberal Democrats and Labour Make Bids to Support the NHS

• Drug Interaction Checker
• Pill Identifier
• Calculators

• 2002938975-overviewDiseases & Conditions Diseases & Conditions Nutrition in the Pediatric Surgical Patient

Type your tag names separated by a space and hit enter

Protein-Energy Malnutrition

Protein-energy malnutrition (PEM) is classically described as 1 of 2 syndromes, marasmus and kwashiorkor, depending on the presence or absence of edema. Each type may be classified as acute or chronic. Additionally, marasmus can precede kwashiorkor. Many patients exhibit symptoms of both disease states.

Marasmus , or PEM without edema , is defined as inadequate intake of all nutrients, but especially energy. Its extreme form is characterized by muscle wasting and depletion of body fat stores. Other findings may include hypothermia, bradycardia, hypotension, decreased metabolic rate, loss of skin turgor, and constipation.

Kwashiorkor , or PEM with edema , is characterized by muscle atrophy, maintenance or gain of body fat, and peripheral edema. Other characteristics include anasarca (generalized edema), hepatomegaly, dry and peeling skin, anorexia, hypothermia, and apathy.

The exact pathogenesis of kwashiorkor is unknown. [1] Derived from an African term meaning “the disease that occurs when the next baby is born,” kwashiorkor was initially thought to result from a diet high in calories (mainly carbohydrates, such as maize) yet deficient in protein; however, recent evidence points away from dietary protein deficiency as the primary cause. While many of these patients exhibit hypoalbuminemia, this is thought to be a consequence of the disease and not a trigger. Aflatoxin poisoning, oxidative stress, immune system dysfunction, and the gut microbiota may play causative roles. [2] [3] [4] [5]

Mixed marasmus-kwashiorkor (edematous malnutrition) can occur in those who have inadequate dietary intake of all nutrients. This condition is typically triggered by an infection or inflammatory state.

PEM affects multiple organ systems and therefore places affected individuals at increased risk of severe illness and death by increasing the likelihood of micronutrient deficiencies, dehydration, infection, and sepsis.

PEM is primarily a problem in resource-limited countries. Worldwide, PEM is a leading cause of death in children under the age of 5, with the highest prevalence in Africa and Southeast Asia. [6] PEM is also found in developed countries under various circumstances, including anorexia nervosa, cancer, hemodialysis, dementia, and severe chronic disease states. The condition has also been found in infants placed on severely restricted diets and in 5% of a population of patients who underwent Roux-en-Y gastric bypass surgery to control obesity. [7] [8] [9]

Diagnosis of PEM is based on a variety of factors. While it was once thought that serum albumin levels were indicative of nutrition status, new guidelines indicate this measure does not take into account the complexity of hepatic protein synthesis. Altered serum albumin and pre-albumin levels can be accounted for by a number of factors, including the acute-phase response, hydration status, disease state, clinical condition, albumin leakage from intra- to extra-vascular spaces, and severe zinc deficiency. [10]

In lieu of albumin levels, the Academy of Nutrition and Dietetics and the American Society of Parenteral and Enteral Nutrition have established new standards to diagnose malnutrition in adults. Rather than a single parameter, the recommendations are based on a set of measurable characteristics indicative of nutrition status. To be diagnosed with PEM, patients must meet at least 2 out of the following 6 characteristics: insufficient energy intake, significant weight loss, loss of muscle, loss of subcutaneous fat, fluid accumulation unrelated to hypervolemia, and reduced hand-grip strength. [9]

Treatment for PEM varies based on the severity and etiology of the problem. Patients suffering from eating disorders will need an appropriate dietary intervention in conjunction with mental health support. Malnutrition due to social/environmental reasons or food insecurity may require a case-management consultation to help the patient connect with resources. For hospitalized patients, a team approach that includes the doctor, nurse, dietitian, and other clinicians is recommended to implement an appropriate nutrition care plan. Patients with malnutrition may benefit from oral nutrition supplements and, in some cases, parenteral or enteral nutrition to help improve nutrition status. Lastly, regardless of etiology, nutrition education is essential for long-term health of a patient with malnutrition. [11]

Some individuals treated for PEM are at risk for refeeding syndrome, in which hypophosphatemia, hypokalemia, and hypomagnesemia may lead to disturbances in the cardiac, neurologic, gastrointestinal, respiratory, hematologic, skeletal, and endocrine systems. The World Health Organization has developed guidelines to help prevent these complications and to establish a transition to normalcy. Treatment consists of 3 phases: stabilization, rehabilitation, and follow-up. [12]

The initial (stabilization) phase proceeds from days 1-7. It consists of treatment and prevention of hypoglycemia, hypothermia, dehydration, and infection; correction of electrolyte imbalance and micronutrient deficiencies; and a cautious feeding regimen. A rehabilitation phase proceeds from weeks 2-6, and consists of achievement of catch-up growth, provision of sensory stimulation, and emotional support.

Follow-up is necessary, as some patients relapse. Provision of nutritional supplements is recommended for those of all ages affected by PEM to prevent malnutrition from recurring. Furthermore, education on the benefits of breastfeeding and hygiene have also been found to be helpful interventions in the pediatric population. [5]

• Fuhrman MP, Charney P, Mueller CM. Hepatic proteins and nutrition assessment. J Am Diet Assoc . 2004;104(8):1258-64.   [PMID:15281044]
• Hendrickse RG. Of sick turkeys, kwashiorkor, malaria, perinatal mortality, heroin addicts and food poisoning: research on the influence of aflatoxins on child health in the tropics. Ann Trop Med Parasitol . 1997;91(7):787-93.   [PMID:9625935]
• Sive AA, Dempster WS, Malan H, et al. Plasma free iron: a possible cause of oedema in kwashiorkor. Arch Dis Child . 1997;76(1):54-6.   [PMID:9059163]
• GBD 2019 Diseases and Injuries Collaborators. Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet . 2020;396(10258):1204-1222.   [PMID:33069326]
• Kuhl J, Davis MD, Kalaaji AN, et al. Skin signs as the presenting manifestation of severe nutritional deficiency: report of 2 cases. Arch Dermatol . 2004;140(5):521-4.   [PMID:15148094]
• Carvalho NF, Kenney RD, Carrington PH, et al. Severe nutritional deficiencies in toddlers resulting from health food milk alternatives. Pediatrics . 2001;107(4):E46.   [PMID:11335767]
• Faintuch J, Matsuda M, Cruz ME, et al. Severe protein-calorie malnutrition after bariatric procedures. Obes Surg . 2004;14(2):175-81.   [PMID:15018745]
• Marcason W. Should Albumin and Prealbumin Be Used as Indicators for Malnutrition? J Acad Nutr Diet . 2017;117(7):1144.   [PMID:28648265]
• Tappenden KA, Quatrara B, Parkhurst ML, et al. Critical role of nutrition in improving quality of care: an interdisciplinary call to action to address adult hospital malnutrition. J Acad Nutr Diet . 2013;113(9):1219-37.   [PMID:23871528]

1. Download the Nutrition Guide for Clinicians app by Unbound Medicine

2. Select Try/Buy and follow instructions to begin your free 30-day trial

Want to regain access to Nutrition Guide for Clinicians?

Renew my subscription

Not now - I'd like more time to decide

Log in to Nutrition Guide for Clinicians

Forgot your password, forgot your username, contact support.

• unboundmedicine.com/support
• [email protected]
• 610-627-9090 (Monday - Friday, 9 AM - 5 PM EST.)

Protein-Energy Malnutrition(PEM) PPT: Definition, Classification and Causes

Protein-Energy Malnutrition(PEM) PPT: Definition, Classification and Causes Free Download: Protein-energy malnutrition, or PEM, is a condition when a person lacks energy because they are not getting enough of many micronutrients and all of the macronutrients. It could happen quickly or gradually. Its severity might range from minor to severe. It affects youngsters in poor nations who aren’t given enough calories and proteins. The older generation is affected in developed nations.

PEM can be divided into two categories:

Primary PEM: Children often suffer from this kind of protein-energy malnutrition. Elderly people rarely develop it, and depression is the main contributing factor.

Secondary PEM is brought on by gastrointestinal tract issues. Infections, hyperthyroidism, trauma, and burns can all contribute to its development.

Table of Content

• Introduction
• Symptoms of PEM
• Classification of PEM
• Causes of PEM
• Complications of PEM
• Prevention of PEM
• Diagnosis of PEM
• Treatment of PEM

Related Posts

Social media marketing ppt presentation seminar free, biomedical waste management ppt presentation free, monkey and the cap seller story ppt presentation free download, 1210 electrical engineering(eee) seminar topics 2024, 112 iot seminar topics-internet of thing presentation topics 2024.

330 Latest AI (Artificial Intelligence Seminar Topics) 2024

No comments yet, leave a reply cancel reply.

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed .

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• J Family Med Prim Care
• v.3(1); Jan-Mar 2014

Protein Energy Malnutrition in India: The Plight of Our Under Five Children

Dechenla tshering bhutia.

Department of Community Medicine, Sikkim-Manipal Institute of Medical Sciences, Gangtok, Sikkim, India

Protein energy malnutrition (PEM) is a major public health problem in India. This affects the child at the most crucial period of time of development, which can lead to permanent impairment in later life. PEM is measured in terms of underweight (low weight for age), stunting (low height for age) and wasting (low weight for height). The prevalence of stunting among under five is 48% and wasting is 19.8% and with an underweight prevalence of 42.5%, it is the highest in the world. Undernutrition predisposes the child to infection and complements its effect in contributing to child mortality. Lalonde model (1974) is used to look into the various determinants of PEM in under five children and its interrelation in causation of PEM. The determinants of PEM are broadly classified under four distinct categories: Environmental factors including the physical and social environment, behavioral factors, health-care service related and biological factors. The socio-cultural factors play an important role wherein, it affects the attitude of the care giver in feeding and care practices. Faulty feeding practice in addition to poor nutritional status of the mother further worsens the situation. The vicious cycle of poor nutritional status of the mother leading to low birth weight child further exposes the child to susceptibility to infections which aggravates the situation. However, it is seen that percapita income of the family did not have much bearing on the poor nutritional status of the child rather lack of proper health-care services adversely contributed to poor nutritional status of the child. PEM is a critical problem with many determinants playing a role in causing this vicious cycle of undernutrition. With almost half of under five children undernourished in India, the Millennium Development Goal (MDG) of halving the prevalence of underweight by 2015 seems a distant dream.

Introduction

According to World Health Organization, protein energy malnutrition (PEM) refers to “an imbalance between the supply of protein and energy and the body's demand for them to ensure optimal growth and function”.[ 1 ] It is a major public health problem in India. It affects particularly the preschool children (<6 years) with its dire consequences ranging from physical to cognitive growth and susceptibility to infection. This affects the child at the most crucial period of time of development which can lead to permanent impairment in later life.[ 2 , 3 ]

PEM is measured in terms of underweight (low weight for age), stunting (low height for age) and wasting (low weight for height). The prevalence of stunting among under five is 48% (moderate and severe) and wasting is 20% (moderate and severe) and with an underweight prevalence of 43% (moderate and severe),[ 4 ] it is the highest in the world. The majority of children suffering from undernutrition (80%) are the mild and the moderate forms which go unnoticed[ 3 ] and the early ages are affected more which makes the process irreversible. In comparison to the global reference standards, the weight for age distribution of Indian children falls to the left of the curve [ Figure 1 ].

Weight-for-age distribution: Children under three in India compared to the global reference population

Undernutrition makes the child susceptible to infection and complements its effect in contributing to child mortality. This accounts for 22% of the burden of disease in India and adversely affects the economic growth of the country with an estimated adult productivity loss of 1.4% of gross domestic product (GDP).[ 2 ]

In order to ensure that adequate amount of food is available to the household, it is necessary for the family to be food secure.[ 5 ] The National Food Security Bill, 2010 Launched by the Government of India is a step forward in sustaining food availability to marginalized groups who are at a vulnerable position to be worst hit by food insecurity. According to the bill, “legal entitlement to subsidized food grains to be extended to at least 75% of the country's population 90% in rural areas and 50% in urban areas”.[ 6 ] It is seen that food unavailability, inadequate purchasing power or inappropriate utilization at household level contributes to food insecurity.[ 7 ] However, though the per capita food production increased by 75% in the past two decades, ironically this has not reflected in nutrition and food security, which still remains high.[ 8 ] The disturbing fact is that income, poverty and nutritional deprivation is not moving in the same direction. Despite an increase in per capita food production and decline in poverty, India continues to feature increased rates of undernutrition.[ 8 ] Therefore, it becomes necessary to distinguish the determinants responsible for persisting high undernutrition in the light of improvement in poverty status and food availability.

With an annual per capita growth rate of 3% (1990-2002), the reduction in underweight prevalence to 39% among children under three is estimated by the year 2015, but is “still short of the MDG” and even if India achieves the MDG goal, the prevalence will still be higher than the Sub Saharan African region.[ 2 ] PEM is a critical problem with many determinants playing a role in causing this vicious cycle of undernutrition.

This paper looks into the various determinants of PEM in under five children and its interrelation in causation of PEM using the Lalonde model[ 9 ] [ Figure 2 ].

Lalonde basic health field model

Determinants of PEM

Environment, socio-cultural factors affecting feeding practices.

Appropriate child feeding behavior goes a long way in preventing and overcoming malnutrition and determining a child's growth.[ 2 ] As feeding practice changes with age, a fourfold increase in the prevalence of undernutrition is seen from 15.4% (0-6 months) to 52.6% (12-23 months).[ 10 ] This can be attributed to early initiation of complementary feeds in the earlier months and late weaning and inadequate amount of complementary feeds in the later months.[ 11 ] A delay in the initiation of breast feeding, lack of colostrum and inappropriate complementary feeding were significantly associated with underweight and stunting.[ 12 ]

Inappropriate feeding practices are closely related to cultures and beliefs. Mothers feed their children with prelacteal feeds to cleanse their intestines and did not initiate complementary feeds thinking that it will lead to infections.[ 13 ] Beliefs like considering colostrums as witch's milk and cultural practices of prelacteal feeds exposed the child to infections which contributes to undernutrition.[ 14 ] The feeding practices come up as a major concern in combating undernutrition with hidden cultural values and beliefs.

Maternal nutrition

Maternal nutritional status has a direct relation to the child's nutritional status.[ 15 ] An undernourished mother gives birth to a low birth weight baby who grows up with compromised feeding and infections to a stunted child and adolescent and carries this vicious life cycle approach by giving birth to an underweight child.[ 16 ] Women with height <145 cm and body mass index <18.5 are likely to give birth to low birth weight children.[ 15 ] With a low birth weight prevalence of 28%, these children are already compromised before birth.

The vicious cycle of infection and undernutrition go hand in hand. With inadequate dietary intake, the immune response gets weaker and increases susceptibility to infections. A single episode of infection is easy to regain but if the child suffers from repeated infections without adequate dietary intake, it becomes difficult to regain normal growth. Infection was commonly diagnosed in children suffering from undernutrition.[ 17 ] One of the first studies to associate infection and malnutrition was cited from India where children developed diarrhea during the weaning period which resulted in growth faltering (Gordon et al. , 1964; Scrimshaw et al. , 1968 cited in Gragnolati et al. [ 2 ]). 46.8% of infants suffering from acute diarrhea were underweight and it was worse for those children having persistent diarrhea (83.35%).[ 18 ] Respiratory infections were found to be the second common infection.[ 19 ] Measles and helminthic infections too contribute to undernutrition by increasing demand for proteins and calories but reducing its absorption and utilization.[ 3 ] It shows that infection and undernutrition complements the effect of each other and cannot be managed separately.

National Family Health Survey II (NFHS II) reported an underweight prevalence of 48.9% among girls compared with boys (45.5%). Even the proportion of severe underweight was higher for girls (18.9%) than boys (16.9%) (NFHS II, 1998-99 cited in Gragnolati et al. [ 2 ]). Similar findings were noticed in West Bengal where undernutrition among girls (54.8%) exceeded those of boys (46.8%) and the difference was higher for moderate and severe forms.[ 20 ] However, these differences are not merely biological but the care and feeding practices makes up for the difference. Timely feeding and continuation of breast feeding was seen more among boys than girls.[ 21 ] The median duration of breast feeding was 2 months longer for boys than girls. Early weaning of the girl child was done to increase chances of having a boy in the next pregnancy.[ 15 ] Therefore, the gender inequality of male preference over female among the care givers is responsible for the difference in prevalence of undernutrition.

Mother's literacy status

A decreasing trend in all forms of undernutrition is observed where the literacy status of mother increased.[ 22 ] Children of illiterate women were twice as likely to show signs of underweight and stunting as those who had at least completed high school. Children whose mothers were illiterate showed 3 times higher prevalence of wasting than literate mothers.[ 15 , 23 , 24 ] Increasing literacy status of a mother has a positive effect in reducing undernutrition since she is the first contact of care for the child and a more informed and literate mother is at a better position to take care of her child.

Poverty and income

Undernutrition is more common in the lower income groups and even if malnutrition is present in the upper income group, it is limited to the milder forms.[ 22 ] There is over representation of “backward” caste and socially excluded groups in the society among the poor people, which exposes them to further disadvantages of poverty, food insecurity and undernutrition.[ 25 ] NFHS II findings suggest a twofold increase in undernutrition among children belonging to households with low standard of living than with a high standard of living.[ 15 ] Though 26% of people live below the poverty line in India, 46% of under three children are suffering from undernutrition.[ 26 ] This shows that the prevalence of poverty solely cannot be responsible for undernutrition but is an underlying cause of factors like inadequate dietary intake, large family, infection, unhygienic environment and illiteracy which contributes to undernutrition among low income group.

Urban-rural difference

NFHS data shows that except Tripura, the prevalence of undernutrition is higher in rural than urban children in all states.[ 10 ] The urban and rural variations are large with prevalence of 50% in rural when compared with 38% in urban children.[ 2 ] Stunting was seen more among the rural children (74.5%), but undernutrition was lower among urban children, majority were wasted (30.3%).[ 27 ] It shows that rural undernutrition is related more towards food insecurity whereas the problem of undernutrition is more acute in urban areas.[ 28 ] However with 26% below the poverty line in urban areas, it is catching up with the rural areas (29%) and undernutrition might not remain only a rural problem.[ 29 ]

Life-style and behavior

The life-style and behavior of the child itself does not contribute to undernutrition, but the child feeding practices of the mother and care givers affect the dietary intake of the child. Since the care givers and mother belong to the environment of the child, the feeding practices have been discussed in the environment section.

Health-care services

The Integrated Child Development Services (ICDS) scheme has an empirical role in combating undernutrition whose services include supplementary nutrition, health checkups and growth monitoring. But even after 35 years of its initiation, the problem of undernutrition still persists and the decrease in the prevalence is relatively low.

The program has given more attention to coverage rather than quality-of-care. It has neglected aspect of educating parents on improving nutrition through proper child care and feeding behavior within the family budget, but focused more on food distribution. Even when the ICDS coverage is as high as 90% in few states, the utilization is limited to 28% among under six children.[ 23 ] In addition to it, inadequate skills of the staff, lack of logistics and poor supervision has added to the problem.[ 2 ]

However, there are examples of good implementation of services for e.g. States like Kerala and Tamil Nadu with a low per capita income still have low undernutrition prevalence (Kerala: 23% and Tamil Nadu: 30%) due to good health services. States where the ICDS enrolment is lower show a higher prevalence of undernutrition. Bihar with prevalence of 55% has very low ICDS beneficiaries of 1.5%, whereas the north eastern states with a fairer picture of undernutrition (20-30%) have the highest ICDS beneficiaries.[ 2 ] Therefore, access and quality-of-care are both important features of a good health-care service.

The prevalence of underweight rapidly increased from 11.9% (<6 months) to 37.5% (6-11 months) to 58.5% among 12-23 months old children. Stunting prevalence also rose from 15.4% (<6 months) to 57.5% among 12-23 months.[ 15 ] A study in Jhansi found an increase in undernutrition from 52.3% (0-1 years) to 80.9% among 1-3 years children.[ 30 ] These variations are not just due to increasing age, but the dietary changes have a positive role in affecting nutritional status.

Birth order and birth interval

The proportion of undernutrition in higher birth order (>3) was more at risk of undernutrition than those with first birth order.[ 22 ] NFHS II observed that lower birth orders were an advantage.[ 15 ] The prevalence of undernutrition declined from a birth order of 3 (48.5%) to 1 (20.38%). Severe undernutrition was not seen in children with first birth order.[ 22 ]

A decrease in the prevalence of underweight is seen when the birth interval widens from 24 months (52.2%) to 47 months (45.1%) as well as for stunting with an 8% decrease with increasing interval. Mothers belonging to households with many children did not have time to care and feed each one of them.[ 31 ] Frequent childbirth at short interval does not allow the mother to regain her heath for the next pregnancy resulting in a low birth weight child and short intervals of childbirth results in early weaning of the earlier child from breast milk.

India stands at a very vulnerable position with one of the highest prevalence of undernutrition in the world in spite of improvement in food availability and poverty alleviation. In addition to it, numerous determinants play a role in its causation. The interplay of these determinants and their complementary effect makes it difficult to isolate one key factor in causing undernutrition.

For example, age cannot be dealt in isolation since faulty feeding practices have a complementary effect in causing undernutrition. The socio-cultural factors play an important role wherein, it affects the attitude of the care giver in feeding and care practices. The compromised nutritional status of the mother comes up as a direct determinant in producing a low birth weight baby, worse if the child is born to a large and poor family. This further worsens the condition with susceptibility to infections and lack of health care services. Evidence shows that states with low percapita income have better undernutrition figures as compared with the richer states due to better implementation of health care services, which shows that low income capability of the family is not always responsible for undernutrition.

The MDG goal of halving the prevalence of underweight by 2015 seems a distant target if the determinants are dealt in isolation. It requires a holistic approach due to the complex interrelation of factors in causation of PEM, which has continued to haunt India as a silent crisis.

Source of Support: Nil.

Conflict of Interest: None declared.

Newly Launched - AI Presentation Maker

AI PPT Maker

Powerpoint Templates

Icon Bundle

Kpi Dashboard

Professional

Business Plans

Swot Analysis

Gantt Chart

Business Proposal

Marketing Plan

Project Management

Business Case

Business Model

Cyber Security

Business PPT

Digital Marketing

Digital Transformation

Human Resources

Product Management

Artificial Intelligence

Company Profile

Acknowledgement PPT

PPT Presentation

Reports Brochures

One Page Pitch

Interview PPT

All Categories

Top 10 Creative Problem Solving PowerPoint Presentation Templates in 2024

Unlock your team's potential with our Creative Problem Solving PowerPoint presentations, designed to inspire innovative thinking and enhance collaborative efforts. Each slide is fully editable and customizable, allowing you to tailor the content to your specific needs and audience. Our presentations provide a structured approach to problem-solving, integrating techniques such as brainstorming, mind mapping, and design thinking. With visually engaging graphics and interactive elements, you can easily present complex ideas and foster an environment of creativity.Use cases for these presentations are vast and varied. Whether you're conducting a workshop, leading a team meeting, or delivering a training session, our Creative Problem Solving slides serve as the perfect foundation. They can be utilized in educational settings to teach students effective problem-solving strategies, or in corporate environments to drive innovation and enhance team collaboration. Additionally, they can support project kick-offs, strategy sessions, or any scenario where creative solutions are needed. Empower your audience to think outside the box and tackle challenges with confidence using our expertly crafted, customizable PowerPoint presentations. Transform your approach to problem-solving today and watch creativity flourish within your organization!

Multiple ideas of problem solving image graphics for powerpoint

We are proud to present our multiple ideas of problem solving image graphics for powerpoint. Graphic of puzzle has been used to design this power point template. This image slide contains the concept of problem solving . Use this PPT slide for your business and marketing related presentations.

There are countless ways to do any thing. Select the best with our Multiple Ideas Of Problem Solving Image Graphics For Powerpoint.

Nine circle arrow process for problem solving

Introducing our premium set of slides with Nine Circle Arrow Process For Problem Solving. Ellicudate the nine stages and present information using this PPT slide. This is a completely adaptable PowerPoint template design that can be used to interpret topics like Define The Problem, Generate New Ideas, Evaluate And Select Solutions, Implement And Evaluate. So download instantly and tailor it with your information.

Our Nine Circle Arrow Process For Problem Solving are topically designed to provide an attractive backdrop to any subject. Use them to look like a presentation pro.

• Define The Problem
• Generate New Ideas
• Evaluate And Select Solutions
• implement and evaluate

Creative problem solving process ppt powerpoint presentation model infographic template cpb

Presenting Creative Problem Solving Process Ppt Powerpoint Presentation Model Infographic Template Cpb slide which is completely adaptable. The graphics in this PowerPoint slide showcase five stages that will help you succinctly convey the information. In addition, you can alternate the color, font size, font type, and shapes of this PPT layout according to your content. This PPT presentation can be accessed with Google Slides and is available in both standard screen and widescreen aspect ratios. It is also a useful set to elucidate topics like Creative Problem Solving Process. This well structured design can be downloaded in different formats like PDF, JPG, and PNG. So, without any delay, click on the download button now.

Our Creative Problem Solving Process Ppt Powerpoint Presentation Model Infographic Template Cpb are topically designed to provide an attractive backdrop to any subject. Use them to look like a presentation pro.

• Creative Problem Solving Process

Analytical problem solving skills ppt powerpoint presentation ideas diagrams cpb

Presenting this set of slides with name Analytical Problem Solving Skills Ppt Powerpoint Presentation Ideas Diagrams Cpb. This is an editable Powerpoint four stages graphic that deals with topics like Analytical Problem Solving Skills to help convey your message better graphically. This product is a premium product available for immediate download and is 100 percent editable in Powerpoint. Download this now and use it in your presentations to impress your audience.

You may be a good communicator but can what are your presentations saying? When you come to us we use our Analytical Problem Solving Skills Ppt Powerpoint Presentation Ideas Diagrams Cpb to ensure you are giving a clear message in a structured manner.

Present a solution for a problem bulb and puzzle

Presenting this set of slides with name - Present A Solution For A Problem Bulb And Puzzle. This is a two stage process. The stages in this process are Present A Solution For A Problem, Challenges And Solutions, Problem And Solution.

End the jitters with our Present A Solution For A Problem Bulb And Puzzle. Don't give in to baseless apprehensions.

• Present A Solution For A Problem
• Challenges And Solutions
• problem and solution

Problem solving skills creative thinking concept idea generation

Presenting this set of slides with name - Problem Solving Skills Creative Thinking Concept Idea Generation. This is an editable six stages graphic that deals with topics like Problem Solving Skills, Creative Thinking, Concept Idea Generation to help convey your message better graphically. This product is a premium product available for immediate download and is 100 percent editable in Powerpoint. Download this now and use it in your presentations to impress your audience.

Highlight causes of injury with our Problem Solving Skills Creative Thinking Concept Idea Generation. Caution folks to avoid harmful conditions.

• Problem Solving Skills
• Creative Thinking
• Concept Idea Generation

Approach for key business problem solving process icon

Presenting our set of slides with Approach For Key Business Problem Solving Process Icon. This exhibits information on one stage of the process. This is an easy to edit and innovatively designed PowerPoint template. So download immediately and highlight information on Approach For Key Business Problem Solving Process Icon.

Our Approach For Key Business Problem Solving Process Icon are topically designed to provide an attractive backdrop to any subject. Use them to look like a presentation pro.

• Approach For Key Business Problem Solving Process Icon

Problem management flow powerpoint ideas

Presenting problem management flow powerpoint ideas. This is a problem management flow powerpoint ideas. This is a five stage process. The stages in this process are problem management, problem statement.

Entrepreneurial abilities evolve with our Problem Management Flow Powerpoint Ideas. Your business grows bigger by the day.

• Problem Management
• Problem Statement

Identify candidate technologies technology creativity imagination finance wealth management

Presenting this set of slides with name - Identify Candidate Technologies Technology Creativity Imagination Finance Wealth Management. This is an editable five graphic that deals with topics like Identify Candidate Technologies, Technology Creativity Imagination, Finance Wealth Management to help convey your message better graphically. This product is a premium product available for immediate download, and is 100 percent editable in Powerpoint. Download this now and use it in your presentations to impress your audience.

Increase the degree of enjoyment felt with our Identify Candidate Technologies Technology Creativity Imagination Finance Wealth Management. Be able to handle aspects that jar.

• Identify Candidate Technologies
• Technology Creativity Imagination
• Finance Wealth Management

Key solution for creative business problem solving

Presenting this set of slides with name Key Solution For Creative Business Problem Solving. This is a three stage process. The stages in this process are Key Solution For Creative Business Problem Solving. This is a completely editable PowerPoint presentation and is available for immediate download. Download now and impress your audience.

Our Key Solution For Creative Business Problem Solving are topically designed to provide an attractive backdrop to any subject. Use them to look like a presentation pro.

• Key Solution For Creative Business Problem Solving