History
Clinical signs and symptoms of protein-energy malnutrition (PEM) include the following:
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Poor weight gain
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Slowing of linear growth
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Behavioral changes - Irritability, apathy, decreased social responsiveness, anxiety, and attention deficits
Some of the clinical signs and symptoms of specific micronutrient deficiencies may closely resemble those observed in PEM. Deficiencies of micronutrients, including vitamins, minerals, and trace elements have been well described. The most common and clinically significant deficiencies include the following:
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Iron - Fatigue, anemia, decreased cognitive function, headache, glossitis, and nail changes
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Iodine - Goiter, developmental delay, and mental retardation
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Vitamin D - Poor growth, rickets, and hypocalcemia
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Vitamin A - Night blindness, xerophthalmia, poor growth, and hair changes
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Folate - Glossitis, anemia (megaloblastic), and neural tube defects (in fetuses of women without folate supplementation)
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Zinc - Anemia, dwarfism, hepatosplenomegaly, hyperpigmentation and hypogonadism, acrodermatitis enteropathica, diminished immune response, poor wound healing
Physical Examination
Physical findings that are associated with PEM include the following: [2]
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Decreased subcutaneous tissue: Areas that are most affected are the legs, arms, buttocks, and face.
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Edema: Areas that are most affected are the distal extremities and anasarca (generalized edema). See the image below.
This infant presented with symptoms indicative of a dietary protein deficiency, including edema and ridging of the toenails. Image courtesy of the Centers for Disease Control and Prevention.
Other physical findings associated with PEM are as follows:
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Oral changes
Cheilosis
Angular stomatitis
Papillar atrophy
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Abdominal findings
Abdominal distension secondary to poor abdominal musculature
Hepatomegaly secondary to fatty infiltration
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Skin changes
Dry peeling skin with raw exposed areas
Hyperpigmented plaques over areas of trauma
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Nail changes: Nails become fissured or ridged.
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Hair changes: Hair is thin, sparse, brittle, easily pulled out, and turns a dull brown or reddish color.
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Hormonal adaptation to the stress of malnutrition: The evolution of marasmus.
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A classic example of a weight chart for a severely malnourished child.
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This infant presented with symptoms indicative of a dietary protein deficiency, including edema and ridging of the toenails. Image courtesy of the Centers for Disease Control and Prevention.
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This infant presented with symptoms indicative of Kwashiorkor, a dietary protein deficiency. Note the angular stomatitis indicative of an accompanying Vitamin B deficiency as well. Image courtesy of the Centers for Disease Control and Prevention.
