Protein energy malnutrition in children

  • Kwashiorkor : There is deficiency of protein with adequate energy intake.
  • Marasmus : is due to severe and prolonged restriction of all food (energy sources + protein + other nutrients). It is seen in infants usually under one year.


  • It is mostly occurs in age of 2 when the child is shifted from breast milk to low protein diet or to a cereal that is refined and disputed.

Clinical features :

  • Oedema generalised
  • Growth retardation
  • Poor appetite
  • Hair become thin and sparse
  • Hair colour changes from black to grey.
  • Diarrhoea
  • Liver is enlarged

Investigation :

Lab. finding is very low plasma albumin.


  • It is childhood version of starvation (Starvation in infants).
  • It usually occcurs after six months of age.

Cause :
Very Low diet in calories, protein and essential nutrients

Clinical Features :

  • Muscle wasting
  • Very thin child with no subcutaneous fat
  • Limbs look like sticks
  • Weight is reduced below 60% of standard weight
  • No oedema
  • No or mild skin and hair changes

Management :

Severe PEM both kwashiorkor and marasmus is dealt in three phases :-

I. Resuscitation :
Correction of dehydration, electrolyte imbalance, acidosis, hypoglycaemia and hypothermia.

II. Start of the cure :

  • This consists of refeeding, gradually giving calories to 150 Kcal/kg with protein about 1.5g/kg.
  • They are usually based on dried shimmed milk mixed with some flour or sugar and given 5-6 times a day.
  • Potassium, magnesium and a multi-vitamin mixture are also needed.

III. Nutritional rehabilitation :

  • After about 3 weeks, the child should be better.
  • After this, mother should be educated about nutrition and helped to obtain extra food.

Main features of kwashiorkor and Marasmus –

Kwashiorkor Marasmus
Growth retardation
Skin and hair changes
Poor appetite
Wasting (muscle)
Good appetite

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