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Protein-energy malnutrition (PEM) is a potentially fatal body-depletion disorder. It is the leading cause of death in children in developing countries.


PEM is also referred to as protein-calorie malnutrition. It develops in children and adults whose consumption of protein and energy (measured by calories) is insufficient to satisfy the body’s nutritional needs. While pure protein deficiency can occur when a person’s diet provides enough energy but lacks the protein minimum, in most cases the deficiency will be dual. PEM may also occur in persons who are unable to absorb vital nutrients or convert them to energy essential for healthy tissue formation and organ function.

Although PEM is not prevalent among the general population of the United States, it is often seen in elderly people who live in nursing homes and in children whose parents are poor. PEM occurs in one of every two surgical patients and in 48% of all other hospital patients.

Types of pem

Primary PEM results from a diet that lacks sufficient sources of protein and/or energy. Secondary PEM is more common in the United States, where it usually occurs as a complication of AIDS, cancer, chronic kidney failure, inflammatory bowel disease, and other illnesses that impair the body’s ability to absorb or use nutrients or to compensate for nutrient losses. PEM can develop gradually in a patient who has a chronic illness or experiences chronic semi-starvation. It may appear suddenly in a patient who has an acute illness.


Kwashiorkor, also called wet protein-energy malnutrition, is a form of PEM characterized primarily by protein deficiency. This condition usually appears at the age of about 12 months when breastfeeding is discontinued, but it can develop at any time during a child’s formative years. It causes fluid retention (edema); dry, peeling skin; and hair discoloration.


Primarily caused by energy deficiency, marasmus is characterized by stunted growth and wasting of muscle and tissue. Marasmus usually develops between the ages of six months and one year in children who have been weaned from breast milk or who suffer from weakening conditions like chronic diarrhea.

Causes and symptoms

Secondary PEM symptoms range from mild to severe, and can alter the form or function of almost every organ in the body. The type and intensity of symptoms depend on the patient’s prior nutritional status and on the nature of the underlying disease and the speed at which it is progressing.

Mild, moderate, and severe classifications have not been precisely defined, but patients who lose 10-20% of their body weight without trying are usually said to have moderate PEM. This condition is also characterized by a weakened grip and inability to perform high-energy tasks.

Losing 20% of body weight or more is generally classified as severe PEM. People with this condition can’t eat normal-sized meals. They have slow heart rates and low blood pressure and body temperatures. Other symptoms of severe secondary PEM include baggy, wrinkled skin; constipation; dry, thin, brittle hair; lethargy; pressure sores and other skin lesions.


People who have kwashiorkor often have extremely thin arms and legs, but liver enlargement and ascites (abnormal accumulation of fluid) can distend the abdomen and disguise weight loss. Hair may turn red or yellow. Anemia, diarrhea, and fluid and electrolyte disorders are common. The body’s immune system is often weakened, behavioral development is slow, and mental retardation may occur. Children may grow to normal height but are abnormally thin.

Kwashiorkor-like secondary PEM usually develops in patients who have been severely burned, suffered trauma, or had sepsis (tissue-destroying infection) or another life-threatening illness. The condition’s onset is so sudden that body fat and muscle mass of normal-weight people may not change. Some obese patients even gain weight.


Profound weakness accompanies severe marasmus. Since the body breaks down its own tissue to use as calories, people with this condition lose all their body fat and muscle strength, and acquire a skeletal appearance most noticeable in the hands and in the temporal muscle in front of and above each ear. Children with marasmus are small for their age. Since their immune systems are weakened, they suffer from frequent infections. Other symptoms include loss of appetite, diarrhea, skin that is dry and baggy, sparse hair that is dull brown or reddish yellow, mental retardation, behavioral retardation, low body temperature (hypothermia), and slow pulse and breathing rates.

The absence of edema distinguishes marasmuslike secondary PEM, a gradual wasting process that begins with weight loss and progresses to mild, moderate, or severe malnutrition (cachexia). It is usually associated with cancer, chronic obstructive pulmonary disease (COPD), or another chronic disease that is inactive or progressing very slowly.

Some individuals have both kwashiorkor and marasmus at the same time. This most often occurs when a person who has a chronic, inactive condition develops symptoms of an acute illness.

Hospitalized patients

Difficulty chewing, swallowing, and digesting food, pain, nausea, and lack of appetite are among the most common reasons that many hospital patients don’t consume enough nutrients. Nutrient loss can be accelerated by bleeding, diarrhea, abnormally high sugar levels (glycosuria), kidney disease, malabsorption disorders, and other factors. Fever, infection, surgery, and benign or malignant tumors increase the amount of nutrients hospitalized patients need. So do trauma, burns, and some medications.


A thorough physical examination and a health history that probes eating habits and weight changes, focuses on body-fat composition and muscle strength, and assesses gastrointestinal symptoms, underlying illness, and nutritional status is often as accurate as blood tests and urinalyses used to detect and document abnormalities.

Some doctors further quantify a patient’s nutritional status by:

  • comparing height and weight to standardized norms
  • calculating body mass index (BMI)
  • measuring skinfold thickness or the circumference of the upper arm


Treatment is designed to provide adequate nutrition, restore normal body composition, and cure the condition that caused the deficiency. Tube feeding or intravenous feeding is used to supply nutrients to patients who can’t or won’t eat protein-rich foods.

In patients with severe PEM, the first stage of treatment consists of correcting fluid and electrolyte imbalances, treating infection with antibiotics that don’t affect protein synthesis, and addressing related medical problems. The second phase involves replenishing essential nutrients slowly to prevent taxing the patient’s weakened system with more food than it can handle. Physical therapy may be beneficial to patients whose muscles have deteriorated significantly.


Most people can lose up to 10% of their body weight without side effects, but losing more than 40% is almost always fatal. Death usually results from heart failure, an electrolyte imbalance, or low body temperature. Patients with certain symptoms, including semiconsciousness, persistent diarrhea, jaundice, and low blood sodium levels, have a poorer prognosis than other patients. Recovery from marasmus usually takes longer than recovery from kwashiorkor. The long-term effects of childhood malnutrition are uncertain. Some children recover completely, while others may have a variety of lifelong impairments, including an inability to properly absorb nutrients in the intestines and mental retardation. The outcome appears to be related to the length and severity of the malnutrition, as well as to the age of the child when the malnutrition occurred.


Breastfeeding a baby for at least six months is considered the best way to prevent early-childhood malnutrition. Preventing malnutrition in developing countries is a complicated and challenging problem. Providing food directly during famine can help in the short-term, but more long-term solutions are needed, including agricultural development, public health programs (especially programs that monitor growth and development, as well as programs that provide nutritional information and supplements), and improved food distribution systems. Programs that distribute infant formula and discourage breastfeeding should be discontinued, except in areas where many mothers are infected with HIV.

Every patient being admitted to a hospital should be screened for the presence of illnesses and conditions that could lead to PEM. The nutritional status of patients at higher-than-average risk should be more thoroughly assessed and periodically reevaluated during extended hospital stays or nursing home residence.



American College of Nutrition. 722 Robert E. Lee Drive, Wilmington, NC 20412-0927. (919) 152-1222.

American Institute of Nutrition. 9650 Rockville Pike, Bethesda, MD 20814-3990. (301) 530-7050.

Food and Nutrition Information Center. 10301 Baltimore Boulevard, Room 304, Beltsville, MD 20705-2351.