Protein Energy Malnutrition, also known as Severe Acute Malnutrition (SAM), is a range of pathological conditions arising from coincidental lack of protein, and/or energy, in varying proportions in infant and young children, usually with associated infections.
It is at the end of the spectrum of malnutrition, which comprises of over-nutrition at one end and under-nutrition at the other. To understand what malnutrition entails, it is important to have a background understanding of nutrition, nutrients and their importance to individuals, especially children.
Nutrition is the science that interprets the nutrients and other substances in food, in relation to maintenance, growth, reproduction, health and disease of an individual. It is also the study of food production, distribution, marketing, preparation, its egestion as well as its fate and utilization in the body. It comprises of ingestion, digestion, absorption, assimilation, and biosynthesis, catabolism of nutrients and excretion of wastes products.
Nutrition promotes a stronger immune system, safer pregnancy and childbirth, low risk of non-communicable diseases and longevity. Nutrients are substances that are crucial for human life, growth and well-being. They are classified into macro and micronutrients. Macronutrients are carbohydrates, proteins, fats and oils; while micronutrients are vitamins and minerals.
A good understanding of nutrition and nutrients help to make better food choices and this is a critical part of health and development. It is also related to the improved infant, child and maternal health and well-being. A healthy diet provides balanced nutrients that satisfy the body’s needs without excess or shortage. This dietary requirements in children vary according to age, sex and development.
Malnutrition refers to deficiencies, excesses or imbalances in a person’s intake of energy and nutrients. It is also defined as a group of conditions in children and adults related to poor quality or insufficient quantity and quality of nutrients intake, absorption or utilization.
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The World Health Organisation (WHO) defines malnutrition as “cellular imbalances between the supply of nutrients and energy and the body’s demand for them, to ensure growth, maintenance and specific functions”. It results from eating an unbalanced diet where certain nutrients are lacking, or in excess, or the wrong proportion.
There are different types of malnutrition and they are classified broadly into under-nutrition and over-nutrition. Over-nutrition is divided into overweight, obesity and diet-related non-communicable diseases.
Under-nutrition on the other hand is divided into underweight, micronutrient deficiency and macro-nutrient deficiency. The latter is further subdivided into mild, moderate and severe acute malnutrition. The most severe and life-threatening is Severe Acute Malnutrition.
Severe Acute Malnutrition (SAM) is defined by two distinct clinical entities, namely severe wasting and nutritional edema. It is grouped into kwashiorkor, marasmus and marasmic kwashiorkor. Kwashiorkor is largely linked to protein deficiency as it is the number one indicator of protein deficiency in children.
Protein deficiency is quite prevalent across the country. There are different classification criteria used for this grouping and the most popular is the Welcome Classification. Parameters used for this classification include a weight-for-age with, or without, edema and the reference standard is the 50th percentile.
80-60 per cent of expected weight without edema is underweight.
80-60 per cent of expected weight with edema is kwashiorkor.
Less than 60 per cent of expected weight without edema is marasmus.
Less than 60 per cent of expected weight with edema is marasmic kwashiorkor.
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The general appearance and symptoms of SAM are wasting, underweight, growth retardation, muscle wasting, swollen feet and hands, swollen face, protruding abdomen, reduced physical activity, apathy, sunken eyes, wizen appearance and skin depigmentation. Children with these features need immediate hospitalization where adequate care is administered. SAM affects nearly 20 million children annually under the age of 5 years worldwide, causing up to one million deaths by increasing susceptibility to death from severe infections.
The most affected are children aged between six and 18 months, although it is increasingly recognized that it may occur in children less than six months old. Approximately 27 per cent of children under five years in developing countries worldwide are malnourished. In 2006, more than 36 million died of hunger due to under-nutrition. About six million die yearly directly or indirectly related to malnutrition in developing countries. According to WHO, in 2020, 47 million under-5 children are malnourished, while about 14.3 million are severely wasted and 14.4 million are stunted.
One-third of these are from Africa and two-thirds from Asia.
There are certain risk factors associated with malnutrition and SAM. They include socio-economic factors, political, religious, cultural, environmental, gender and medical factors. There is a cyclical relationship between poverty, malnutrition, food insecurity, unemployment, poor physical with cognitive development and low productivity.
According to World Food Summit (1996), food security exists when all people at all times have physical and economic access to sufficient, safe and nutritious food that meets their daily need for an active, healthy life. It is discussed at both national and household levels. Food security is the foundation for a healthy well-nourished population.
There are three important requisites of household food security, namely: adequate food supply at the local level, food accessibility and stability in food availability.
In the absence of any of these, under-nutrition is inevitable. Evidence shows that under-nutrition is not simply a result of household insecurity. Many children in food-secure households are still underweight or stunted because of various reasons, including inappropriate infant feeding and care practices, poor sanitation, poor access to health facilities, harmful practices and illiteracy.
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SAM is both a medical and social disorder and it could be the result of chronic nutritional and emotional deprivation by carers, who because of poor understanding, poverty or family problems fail to provide the adequate nutrition and care that children need. Children diagnosed with Severe Acute Malnutrition grow up with worse health conditions which arise as complications from SAM and lower educational achievements. This condition also exacerbates diseases such as measles, pneumonia and diarrhoea – diseases which can be fatal.
Stunting is the impaired growth and development that children experience from under-nutrition, repeated infection and inadequate psychosocial stimulation. Stunted children are those whose height is lower than average for their age. Stunted growth is a reduced growth rate in human development. It is a primary manifestation of under-nutrition in early childhood, including fetal underdevelopment brought on by the undernourished mother.
Children suffering from Severe Acute Malnutrition should be taken to health facilities that are equipped to handle such cases, as they will require hospitalization. Note that it is important that dieticians are involved to ensure proper administration. A multi-disciplinary approach method of management is what is required. It is important to note that active and overzealous administration of food does not improve the condition, but worsens it. Instead, the focus should be on the introduction of protein-rich foods such as cowpea, beans, cashew nuts, mushrooms, oil bean seeds, guinea corn, milk, egg and soybeans.
History taking, examination, clinical assessment, dietary evaluation, laboratory investigations, definitive and supportive treatment, nursing care and social welfare intervention, are all included in the management. Treatment is administered for about six weeks duration in different phases, which include acute resuscitation, stabilization, rehabilitation, repair-recuperation, the discharge and follow up.
The discharge phase includes nutritional education, immunization, home visit, follow-up and serial weight monitoring. Nutritional education is paramount to prevent relapse and mothers are empowered to support the home in the best way they can.
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Some instances may not require hospitalization and as such, children need regular and community weight monitoring to detect children that need adequate care. Kwashiorkor and marasmic kwashiorkor have a greater risk of morbidity and mortality, compared to marasmus. Prognosis is influenced by the severity of the disease and it is poor if there are co-morbidities and associated complications.
Factors that influence prognosis are food preparation methods, feeding techniques, inappropriate amounts of food, persisting mal-absorption state, underlying infections and morbidities, poorly equipped and underfunded health facilities and poorly trained health professionals.
There are poor prognostic signs which include persistent low blood sugar, subnormal temperature, jaundice, severe edema, severe dermatitis, altered level of consciousness. Children with these signs have a lesser chance of survival. Complications of SAM include immobility, stunting, defective immune system, organ failure, neurological deficits and deaths.
Prevention of malnutrition globally is a huge challenge. They are often numerous and complex approaches and there is no single universal method. There are cheap and sustainable strategies that can be applied everywhere to reduce the severity of SAM.
However, growth in national income is an extremely potent force to reduce malnutrition, together with national food availability programs to ensure food security e.g. distribution of free soybeans powder and other derivates to children in IDP Camps, orphanages and slums. There should be policies that will ensure poverty alleviation, improve environmental sanitation and sustainability. Other factors like job creation, women education and empowerment, political stability devoid of wars and unrest, will also provide an enabling atmosphere for growth and development.
Working on the Sustainable Development Goals (SDGs) is another strategy that can provide ways of tackling hunger and malnutrition. According to WHO, Sustainable Development Goal 2 is Zero Hunger which includes end hunger, achieve food security and improved nutrition, and promote sustainable agriculture.
Under-nutrition, which includes fetal growth restriction, stunting, wasting and deficiencies of Vitamin A and Zinc, along with suboptimal breastfeeding, is the underlying cause of death in an estimated 45 per cent of all deaths among children under five years of age. The proportion of underweight children in developing countries has declined from 28 per cent to 17 per cent between 1990 and 2013. This rate of progress is close to the rate required to meet the SDG target; however, improvements have been unevenly distributed between, and within, different regions.
In conclusion, protein-energy malnutrition, also known as Severe Acute Malnutrition is a medico-social disorder that needs a multi-disciplinary approach to manage. The government has a lot to do to provide an adequate environment for the food stability and food security of the citizens.
A proper Nutritional Policy, perhaps a protein-centred national nutrition policy, will further facilitate quick results in the management and treatment of children with PEM. Children managed for PEM generally do well except those that have underlying morbidities and exhibit poor prognostic features.
By Dr. Monica Edeghonghon Omo-Irefo (MBBS) – a Principal Medical Officer at the Asokoro District Hospital, Abuja, Nigeria.
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