Protein-Energy Malnutrition Treatment & Management

Updated: Sep 14, 2016
  • Author: Noah S Scheinfeld, JD, MD, FAAD; Chief Editor: Romesh Khardori, MD, PhD, FACP  more...
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Medical Care

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 8 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 one study, patients who were undergoing chemotherapy for advanced hepatic cancer who received a late-evening snack enhanced with branched-chain amino acids had improvements in energy metabolism parameters compared with controls. [21]

Chung et al, [27] in discussing that protein-energy malnutrition is highly prevalent among peritoneal dialysis patients, noted that although nutritional status assessments are better now than they were a decade ago, no definitive single test is available to assess nutritional status. Instead, they propose that several different markers of nutrition must be used to understand nutritional status. Thus, the treatment for peritoneal dialysis patients with malnutrition must be multifaceted, and they suggest 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.

An intervention that brought buddies to the homes of the elderly who were at risk for protein malnutrition was successful at decreasing such malnutrition. [28]

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

The clinical guideline summary, Dietary guidelines for Americans, 2010, from the US Department of Health and Human Services and US Department of Agriculture, may also be helpful. [29]

In the setting of malnutrition, risk of refeeding syndrome represents an additional clinical challenge.

Prolonged starvation followed by rapid feeding leads to refeeding syndrome (RS). [30] RS involves resultant biochemical disturbance, physical symptoms, and physical signs. Insulin release leading to anabolic activity underlies the pathophysiology of RS. Feeding overwhelms the dearth of electrolytes and micronutrients. This effect disrupts cellular function. Tissue edema, hypophosphatemia and pathological fluid shifts define RS. RS was identified in 4% of cases of parenteral nutrition (PN) in a UK study while physicians only recognized it half the time. A study in New Zealand also shows similar data. RS remains underrecognized. PN patients are considered to be at high risk and using protocols with slower and lower rates of refeeding reduces deaths attributable to RS. [30]

Using guidelines when treating children at risk for RS saves lives. Al Sharkawy et al in 2010 notes a Kuwaiti male aged 13 months who presented with marasmic Kwashiorkor. Blood sugar and serum electrolytes were normal initially. However, RS occurred by day 3 with severe hypomagnesemia, hypokalemia, hypophosphatemia, and hypocalcemia. The child then was given a lower calorie intake. Caloric intake was increased gradually with vitamins, thiamine, and electrolyte supplementation and survived. [31] This shows that death can be avoided if RS is recognized and treated with diet adjustments.

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

RS can also occur in patients who are replenished with food, vitamins and electrolytes after suffering from anorexia nervosa (AN), [32] although some have argued that hypophosphatemia is not a problem in refeeding patients with AN. [33]

Protein in 1 gram of food provides approximately 15 mg of phosphorus. [34] Marasmic Kwashiorkor is marked by phosphorus deficiency. Chronic phosphorus deficiency in humans causes proximal myopathy. Hypophosphatemia can precipitate rhabdomyolysis. Low blood phosphorus impedes concentration of red blood synthesis. Low blood phosphorus depletes stored levels. 2,3-diphosphoglycerate affects affinity of oxygen for hemoglobin. Nervous system dysfunction (eg, apathy, weakness, intention tremors, a bedridden state), are also characteristic of RS. [34]

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



Any patient at risk for nutritional deficiency should be referred to a registered dietitian or other nutritional 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 (PEM), should oversee care of the patient. Any patient with significant laboratory abnormalities, as discussed above, 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.



See Medical Care.


Long-Term Monitoring

Patients should receive follow-up care with nutrition professionals and social services. Patients should have their growth and development monitored as well.