Dr Bianghunlang Nongsiej
Protein energy malnutrition (PEM) is a form of malnutrition due to inadequate feeding or poverty or due to lack of proper food/diet adequate in nutrients, energy and/or protein intakes. PEM is measured in terms of Wasting (weight for height is reduced), whereas Stunting (height for age is reduced), Underweight (weight for age is reduced). The main goals for management are to minimize weight loss, to maintain body mass and to encourage body mass repletion or growth. Homoeopathy offers an indivualized approach for the treatment of the various manifestations of PEM. This article reviews about protein energy malnutrition, classification, clinical features, general management and its homeopathic management.
KEYWORDS: Protein energy malnutrition, WHO, Marasmus, Kwashiokor.
According to the United Nations Children’s Fund (UNICEF), PEM is an invisible emergency much like the tip of an iceberg, where its deadly consequences are hidden from view. In 2005, 20% of children younger than 5 years in low-to-middle income countries were estimated to be underweight (weight for age z-score <2).
In 1959, Jelliffe coined the term protein calorie malnutrition (PCM) to include all clinical types of malnutrition. The International System of Units proposed the replacement of the term calorie by Joule (1 calorie= 4.184 Joule) as a unit and the term energy for general use.
- According to WHO definition, malnutrition involves a cellular imbalance between supply of nutrients and energy and the body’s demand for them to ensure normal growth, maintenance and specific tissue functions.
- The most common form of malnutrition in children is Protein energy Malnutrition (PEM) which earlier was called protein calorie malnutrition (PCM)
- WHO defined the term PEM as a range of pathological conditions arising from coincidental lack in varying proportions of protein and calories, occurring most frequently in infants and young children and commonly associated with infection.
ECOLOGY AND ETIOLOGY OF MALNUTRITION
PEM is the result of
- A complex interplay of interacting and related factors in the individual, family and community.
- Faulty feeding.
- Infections especially diarrhea during weaning period.
- Low birth weight.
- Inequitable food distribution.
- Lack of awareness in economically advantaged families.
- Maternal malnutrition.
- Food taboos and myths: These have an impact on maternal diet during pregnancy, during breastfeeding and also because of such facts and myths there is discarding of colostrum due to different beliefs.
- Ignorance: Many rural and urban mothers are quite ignorant of their infant’s need for adequate nutrition. It is a common belief that milk is the best and only food for a child even after 6 months of his life and so continue breastfeeding without other food supplements and may even dilute milk with just biscuits to feed the child without other cereals or pulse-based food.
- Many PEM manifestation represents adaptive responses to inadequate energy and/or protein intakes and decreased activity and energy expenditures.
The biochemical changes in prolonged starvation involve complex metabolic, hormonal, and glucoregulatory mechanisms. Metabolic changes progress from the early phase, where there is rapid gluconeogenesis with resultant loss of skeletal muscle caused by use of amino acids, pyruvate and lactate, to the later protein conservation phase, with fat mobilization leading to lipolysis and ketogenesis. Major electrolyte changes including sodium retention and intracellular potassium depletion can be explained by decreased activity of glycoside-sensitive energy-dependent sodium pump to increased permeability of cell membranes in Kwashiorkor.
- Gopalan’s theory on adaptation/ dysadaptation, in 1968, he stated that Kwashiokor was a failure of adaptation and this was explained on biochemical and hormonal factors. The malnourished child adapts himself to the unfavorable circumstances and to the calorie and protein gap, reducing activity curtail their growth thereby bringing down basal metabolic rate and save energy for survival. This reduction in BMR and lack of insulating fat leads to hypothermia may prove fatal.
High level of catabolic hormones including cortisol causes muscle and fat breakdown. The anabolic hormones like insulin and insulin like growth factors maintain near normal anabolism to prevent edema and fatty liver by enabling synthesis of albumin and beta lipoproteins from available pool of Amino Acid thus absence of edema or fatty liver in Marasmus.
- Srikantia’s theory on antidiuretic effect of ferritin, loss of edema without changes in serum albumin, noxious insults producing reactive oxidative free radicals, decreased sodium, potassium, ATPase activity, depressed cellular protein synthesis, etc.
- The latest theory postulated by Golden suggests deficiency of type I (functional) nutrients like Zinc, and type II nutrients like Phosphorous, Manganese, Magnesium, Copper and Vitamin D and C in the diets of malnourished children due to decreased in appetite.
- Another theory postulated that of free radicals which are assumed to play a role in oedema, skin changes and fatty liver in the malnourished child deficiency of nutrients like Vit A, C and E and Selenium which are anti-oxidants result in accumulations of toxic free oxygen radicals which further damage liver cells resulting in Kwashiorkor
- Protein energy malnutrition is a generalized syndrome complex and it is very difficult to classify it using a single parameter.
- A large no. of classifications using anthropometric, clinical and biochemical parameters have been proposed.
- Among the most studied are weight, length or height, arm circumference, skinfold thickness and head circumference.
- In 1956, Gomez introduced a classification based on weight below a specified percentage of median weight for age.
- Seoane and Latham then proposed calculating weight for height and height for age as a means to distinguish between wasting and stunting.
- Wasting, where weight for height is reduced, is indicative of acute growth disturbance from malnutrition, whereas stunting, where height for age is reduced is more suggestive of chronic malnutrition with faltering of long-term growth.
- In 1977, Waterlow recommended the use of z-scores and SDs below the median to define underweight, wasting, and stunting.
- These definitions continue to be used widely with subsequent WHO modifications. WHO adopted the US National Center for Health Statistics (NCHS) classification in 1983 as the international reference for weight and height in children.
- It has since been used to classify children as underweight, wasted, or stunted based on Z-scores.
- An alternative proposed approach to assessing malnutrition is to measure mid-upper arm circumference (MUAC) as a proxy for weight, and head circumference as a proxy for height.
- This may be useful when accurate measures of height and weight are unavailable, particularly in children younger than 3 years and also in small regional centers.
- The degree of malnutrition is calculated by dividing the MUAC by occipitofrontal head circumference. The use of MUAC and presence of edema have been reported to be better indicators than weight for height (either NCHS or WHO) for case definition of severe acute malnutrition.
- There is significant evidence indicating that using MUAC less than 110 mm as a definition for severe malnutrition may be the best method to assess nutrition in terms of age independence, simplicity, accuracy, specificity, and sensitivity. Additionally, it is a good anthropometric predictor of mortality related to malnutrition.
CLASSIFICATION OF MALNUTRITION:
Weight below percentage of median value WFA (Weight for age)
Mild (grade 1)
Moderate (grade 2)
Severe (grade 3)
Z-scores SD (Standard Deviation) below median WFH (weight for height)
Z-scores (SD) below median WFH
Z-score < -2
Z-scores (SD) below median WFA
Z-score < -2
MUAC (mid and upper arm circumference) divided by occipitofrontal head circumference
Z-scores of BMI (Body Mass Index) for age
BMI for age Z score <-1
BMI for age Z score <-2
BMI for age Z score <-3
Percentage of standard weight for age (50th centile of Harvard standard)
Presence or absence of edema
Weight or age percentage of expected
Edema absent (underweight)
Edema present (Kwashiokor)
Edema absent (Marasmus)
Edema present (Marasmic Kwashiokor)
The term marasmus is derived from the Greek ‘marasms’ which means wasting. There is gross wasting of muscles and subcutaneous tissues, marked stunting but no edema.
It is an adaptive response to starvation. The body utilizes all fat stores before using muscles.
- It can develop in the first few months of life, commonly from birth to 2years.
- It is due to a result of feeding baby with diluted milk from buffalo, cow, goat or even tin milk without offering breast milk or any other food.
- Failure to gain weight and irritability, followed by weight loss and listlessness until emaciation results.
- Diagnosed by loss of subcutaneous fat and the infant seems to have only skin and bones, ribs become visible and costochondral junction looks prominent.
- Absence of edema.
- Baggy pants the loose skin of the buttocks hanging down, large head with sunken eyes.
- There is marked deficit in weight but not much in height.
- Growth retardation severe and obvious.
- Head appears disproportionately large with very little hair.
- Weight less than 60% of expected weight, muscles atrophied leading to hypotonia.
- Child is conscious alert but apathetic and in extreme cases is disinterested in surroundings.
- Muscle wasting often starts in the axilla and groin, then thigh and buttocks, followed by chest and abdomen, and finally the facial muscles, which are metabolically less active. The loss of buccal fat pads commonly gives the child an appearance of monkey-like or aged facies or a wizened old man in severe cases.
- Anemia is moderate and may be associated with Vitamin deficiencies infections and infestations and electrolyte imbalance.
- Early stages child’s appetite is good and accepts what is offered.
- Loss of appetite in later stages and lots of patience is needed to coax child to eat.
- Constipated but may have starvation diarrhea with frequent small mucoid stools.
- Abdomen distended or flat with intestinal pattern readily visible.
- The temperature usually becomes subnormal and pulse slows.
- Child usually becomes quiet.
- African word suggested by Cicley Williams in early 1930s meaning “the disease that occurs when the child is displaced from the breast by another child”
- Uncommon under age of 1 year.
- Vague manifestations lethargy, apathy and/or irritability.
- When advanced there is lack of growth, lack of stamina, loss of muscle tissue, increased susceptibility to infections, vomiting, diarrhea, anorexia, flabby subcutaneous tissues and edema i.e., pitting.
- The edema is usually early and may mast the failure to gain weight, it is often present in internal organs before it is recognized in the face and limb.
- Edema occurs first around the eyes then above ankles and above dorsum of feet, in the later stages the whole face, hands and body may be edematous but ascites is usually rare due to kwashiorkor alone, edema is due to tissue wasting, with low plasma osmotic pressure caused by low serum albumin levels.
- Child is listless, lethargic, apathetic and miserable, her/his moaning cry is characteristic.
- Flag sign of hair growing part of hair becomes pigmented and gives appearance of flag.
- Dermatosis is present and becomes darkened in irritated areas but in contrast to pellagra does not occur in areas exposed to sunlight.
- Depigmentation may occur after desquamation in these areas or it may be generalised.
- Skin lesions appear as large areas of erythema followed by hyperkeratosis.
- The epidermis peels off in large scales exposing a raw area underneath prone to infection, it resembles old paint flaking off the surface of the wood called “flaky paint dermatosis”.
- Lesions are moist and common on areas exposed to continuous presence and irritation. In severe cases petechia or ecchymoses may appear.
- Alternate areas of hypopigmentation and hyperpigmentation gives a resemblance to pavement and this is “pavement dermatosis” or when skin changes are seen in a particular mosaic form it is “mosaic dermatosis”.
- Liver may be enlarged and fatty.
- Associated infections in form of diarrhoea, respiratory infections, urinary tract infection and vitamin deficiency, especially vitamin A, thiamine, riboflavin and niacin, eventually there is stupor coma and death.
- Children with severe muscle and fat wasting, but with presence of edema
- Seen in kids who have marasmus but suddenly develop edema due to increased deficiency of protein than before
- Anemia may be moderate and one or more vitamins deficiencies may be evident.
- The clinical features are those of both marasmus and kwashiorkor.
MANAGEMENT OF PROTEIN-ENERGY MALNUTRITION
Treatment of severe malnutrition is a challenging task and involves multi-prolonged approach. Most of the cases of severe malnutrition are not without complications on presentation. Non-complicated cases can be managed on outpatient basis in a hospital or primary health centre. But children presenting with complications can be managed in a hospital setting alone.
- Treatment depends on Nutritional status, degree of hypermetabolism, expected duration of illness and associated complications.
- Goals are to minimize weight loss, to maintain body mass and to encourage body mass repletion or growth
THE MANAGEMENT OF SEVERE ACUTE MALNUTRITION CAN BE ACHIEVED IN 3 WAYS:
1. Traditional nutrition therapy.
2. Hospital based therapy using F-75 and F-100 diets.
3. Initial stabilization in hosp. Using F-75 diet and rehabilitation in home, using RUTF (Ready-to-use Therapeutic Food).
WHO has formulated a three-phase management approach, where the patient initially is resuscitated and stabilized (phase 1), before starting nutritional rehabilitation (phase 2), and eventual follow-up and recurrence prevention (phase 3).
PHASE I: PHASE OF RESUSCITATION (0-7DAYS).
- Child here is being treated for complications; dietary therapy is being started simultaneously.
- The main aim during this phase is to resuscitate, rehydrate, treat infections, prevent sepsis, and monitor closely to avoid developing complications of treatment. Patients are most vulnerable during this period, which usually lasts about 1 week. Feeding should be instituted carefully and slowly, with restriction of caloric intake to 60% to 80% of caloric requirement for age. This is to avoid refeeding syndrome, but many severely malnourished children also have some degree of malabsorption because of disaccharidase deficiencies, villous atrophy, and relative pancreatic insufficiency. Continuous nasogastric feeding or small frequent meals including at night may be necessary to avoid hypoglycaemia. Vitamins, especially Thiamine and oral phosphate, also are administered, in addition to supplemental feeds to prevent the potentially fatal hypophosphatemia with refeeding. Refeeding syndrome is thought to be explained by the sudden availability of glucose, leading to inhibition of gluconeogenesis and an insulin surge. This causes rapid influx of potassium, magnesium, and phosphate intracellularly and thus low serum levels and poor myocardial contractility. This clinical syndrome, which can manifest with excessive sweatiness, muscle weakness, tachycardia, and heart failure, may be prevented by avoiding rapid carbohydrate feeding, supplementing phosphate and thiamine during the initial increase in nutritional intake, and monitoring the patient carefully for alterations in serum phosphate, potassium, and magnesium. During this phase, patients also should be kept warm, as they are often hypothermic and may need restriction of physical activities because of decreased cardiac output.
PHASE II: PHASE OF RESTORATION OR RECOVERY (1-2 WEEKS)
- Child increase intake and gain weight. The rehabilitation phase starts once acute complications have been addressed adequately with gradual return of appetite, resolution of diarrhoea and sepsis, and correction of electrolyte imbalances. The main goals of this phase are to increase dietary caloric intake, treat occult infections, complete vaccination, improve family involvement, and stimulate psychomotor activity. Weight loss is common initially in children with kwashiorkor as their edema resolves. Most children will need 120% to 140% of their estimated caloric requirements to achieve desired weight gain and maintain catch-up growth. WHO recommends delaying iron therapy until rehabilitation occurs because of concerns about increased infection risk, although a recent review does not support this practice. Elemental iron 2 to 6 mg/kg should be prescribed for 3 months.
PHASE III: PHASE OF REHABILITATION AND FOLLOW UP (2-26 WEEKS) which maybe after discharge. Discharge planning and follow-up are recommended, as these patients have tendency to relapse. Interventions that have been reported to be helpful in preventing undernutrition in children include promoting breast-feeding, complementary and supplemental feeding, zinc and vitamin A supplementation, universal salt iodization, and handwashing and other hygiene measures. Universal provision of iodized salt could reduce stunting by 36% and mortality for children younger than 3 years by 25%.
Nutrition recovery syndrome is a condition encountered generally during the rehabilitation phase of a child with severe PEM. It is marked by hepatomegaly, gynaecomastia, abdominal distension, ascites, splenomegaly, etc. this is attributed to sudden increase in energy and protein intake by these children. It is mostly self-limiting and might also be associated with tremors (kwashi shake) during treatment. Protein restriction during this period was generally advocated.
No amount of additional energy as lipids or carbohydrates would enhance convalescence of PEM unless the deficient specific nutrients are supplied in the balanced form.
Homoeopathy advocates that when there is an imbalance in nutritional requirement and its supply, the deficient nutrients should be supplied in adequate quantity through natural food, provided the body can assimilate and absorb the same. In cases where there is deficiency of supply or the body is so weakened to absorb the natural nutrients, then it is needed to be supplied artificially.
Hahnemann in § 94 of Organon of Medicine says that “While inquiring into the state of chronic diseases, the particular circumstances of the patient with regard to his ordinary occupations his usual mode of living and diet, his domestic situation, and so forth, must be well considered and scrutinized, to ascertain what there is in them that may tend to produce or to maintain disease, in order that by their removal the recovery may by prompted.”
In § 261: “The most appropriate regimen during the employment of medicine in chronic diseases consists in the removal of such obstacles to recovery, and in supplying where necessary the reverse: innocent moral and intellectual recreation, active exercise in the open air in almost all kinds of weather (daily walks, slight manual labour), suitable, nutritious, unmedicinal food and drink, etc”
Thus, we need to provide the deficient nutrients in the body through proper diet, food and regimen to the patient along with the medicine. The different manifesting symptoms of PEM are taken into account to frame the Totality of the Symptoms to select the most appropriate similimum for the treatment of PEM following homoeopathic principles.
In cases where the malnutrition is not due to the deficiency of nutrients alone, but the body’s inability to use the available nutrients, then it is identified as a constitutional error in the system and advised its correction through constitutional homoeopathic medication.
MURPHY –HOMOEOPATHIC MEDICAL REPERTORY
- CHILDREN: ABDOMEN, general- enlarged, in-emaciation with – CALC., sanic., sars., sil.
- CHILDREN: ANOREXIA, nervosa- ARS., calc., carc., CHIN., ign., lach., levo., merc., nat-m., perh., puls., rhus-t., staph., SULPH., tarent., verat
- CHILDREN: DEVELOPMENT, delayed or arrested- nutritional disturbances, due to: bac., bar-c., calc., calc-p., caust., kreos., lac-d., med., nat-m., pin-s., sil., thyr.
- CHILDREN: EMACIATION, children, nutritional, problems, from- bac., bar-c., calc., calc-p., caust., cina., kreos., lac-d., med., nat-m., ol-j., pin-s., sil., thyr.
- DISEASES: MARASMUS, abrot., acet-ac., AETH., alf., ant-c., apis., arg-n., ars., bac., bar-c., bell., CALC., calc-p., caps., cham., coca., con., ferr-m., hydr., iod., kreos., lac-d., lyc., mag-c., med., NAT-M., nux-m., nux-v., ol-j., op., petr., pin-s., podo., sars., SIL., sulph., thyr., tub.
- Abdomen large- calc
- Angina pectoris with- chin-s
- Belching, with sour, worse during night- con
- Bottle-fed, children who are- nat-p
- Buttocks, emaciated- nat-m
- Exercise, averse to, hollow, wrinkled face, hair dry- calc
- Incipient- cham
- Irritability, child will be approached by no one- iod
- Jerking hiccough after nursing, and belching without bringing up food- teucr
- Last stage, in- nuph
- Nervous., restlesss, weakly children- sul-ac
- Nourishment, from defective- nat-m
- Nutritional disturbances from- aeth., alum., bac., bar-c., calc., calc-p., caust., kreos., lac-d., med., nat-m., nat-p., pin-s., sil., thyr
- Old man, like an, had not grown, limbs lax, skin wrinkled, bones of skull had lapped over during birth- op., syph
- Reduced weight- hydr
- Skin dry and wrinkled- calc
- Tendency to- iod
- ABROTANUM: Marasmus, especially of the lower extremities, despite a good appetite emaciation progresses, occurring in weak children who are emaciated, wrinkled, pale, blue rings around dull looking eyes, gnawing hunger and whining and bloated abdomen. Cross, irritable, anxious depressed.
- ACETIC ACIDUM: Pale, lean people, with lax, flabby muscles. Wasting and debility. Irritable. face is pale, waxen, emaciated. Eyes sunken surrounded dark rings. Ascites, extremities emaciated oedema of feet and legs. Intense burning thirst
- AETHUSA CYNAPIUM: Restless anxious crying. Inability to think to fix the attention. Idiocy may alternate with furor and irritability. Photophobia, rolling of eyes on falling asleep. Dry mouth pustules in throat, intolerance of milk. undigested thin, greenish stool preceded by colic with tenesmus followed by exhaustion and drowsiness. Cholera infantum: child cold, clammy, stupid, with staring eyes and dilated pupils. Weakness of lower extremities, fingers and thumb clenched. Child is so exhausted it falls asleep at once, anasarca.
- CALCAREA CARBONICA: Impaired nutrition, children who grow fat, are large bellied with a large head, pale skin, chalky look. Children craves eggs, eat dirt and other indigestible things and are prone to diarrhoea. Forgetful, confused low spirited. Sensitive to light, lachrymation in open air ad early in the morning, eyes fatigue easily, spots and ulcers on the cornea. Distension of abdomen with hardness, children are late in learning to walk. Chilblains, nettle rash of skin.
- CALCAREA PHOSPHORICA: Anemic children who are peevish, flabby, have cold extremities and feeble digestion. Forgetfulness, great hunger with thirst, easy vomiting in children. Involuntary sighing. Sunken and flabby abdomen. Unable to support head.
- CINCHONA OFFICINALIS: debility from exhausting discharges, from loss of vital fluids. Night blindness and photophobia. Hungry without appetite, slow digestion, severe flatulent colic. Liver and spleen swollen. Anasarca and erysipelas.
- IODIUM: Rapid metabolism, loss of flesh great appetite. hungry with much thirst. Great weakness the slightest effort induces perspiration, loss flesh, yet hungry and eating well. liver and spleen sore and enlarged. Pain in the eyes, violent lachrymation.
- NATRUM MURIATICUM: Dropsy, edema, anemia. Great debility; maximum weakness is felt in the morning, in bed. Emaciation most notable on neck. Great weakness and weariness. Dry mucous membrane. irritable gets into a passion about trifles, awkward hasty, hungry yet loose flesh, unquenchable thirst, sweats while eating, craves for salt. Distended abdomen. Dry eruption on skin, eczema raw, red and inflamed.
- SILICEA: Imperfect assimilation and consequent defective nutrition. Scrofulous, rachitic children, with a large head, open fontanelles and sutures, distended abdomen, slow in walking, lack of vital heat. Photophobia. Eruptions on chin, hard bloated abdomen, yellow hands and blue nails. Much rumbling in bowels. Loss of power in legs. Felons, abscesses, boils, eruptions itch only during daytime and evening.
PEM is a worldwide problem especially in the developing countries. Various manifestations of PEM bring awareness and concern of child’s health. Proper counselling regarding diet for mother and infant/child is needed so as to prevent progression of complication. Counselling and raising awareness to avail the various health programs and schemes by the government can improve nutritional diet of the child. Homoeopathy offers an indivualized approach for the treatment of the various manifestations of PEM, by giving Homeopathic medicine on the basis of constitutional approach when the body is unable to use the available nutrients or when there is defect in the assimilation of food, we can improve the health of the person.
- Mehta MN, Malnutrition. In: Parthasarathy A, editor. IAP Textbook of Pediatrics. 6th ed. New Delhi: Jaypee Brothers Medical Publishers (P)Ltd; 2016.p.152-172
- Sharma M. Pediatric Nutrition in Health and Disease. 1st ed. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd; 2013.p.174-182
- Grover Z, Ee LC. Protein energy malnutrition. Pediatric Clinics. 2009 Oct 1;56(5):1055-68. https://www.researchgate.net/publication/40024492_Protein_Energy_Malnutrition [ Accessed on 07-06-2021]
- https://www.nhp.gov.in/Malnutrition-and-Homeopathic-Management_mtl#:~:text=Homoeopathic%20approach%20on%20Malnutrition,assimilate%20and%20absorb%20the%20same. [Accessed on 08-06-2021]
- Hahnemann S, Organon of Medicine,6th ed, New Delhi, Indian Books & Periodicals Publishers, Reprint edition 2008, §94, §261.
- Murphy R. Homoeopathic Medical Repertory. Revised 3rd ed. Noida: B Jain publishers (p) ltd; 2010: p. 327,331,332,443.
- Boericke W. Boericke’s new manual of Homoeopathic Materia Medica and repertory. 3rd revised and augmented ed. New Delhi: B Jain publishers (P) LTD; 2016
Dr. Bianghunlang Nongsiej
Department Of Practice Of Medicine
Government Homoeopathic Medical College Bengaluru, Karnataka-560079