PEM is a common disorder which covers a wide spectrum of deficiency in nutrition ranging from mild or underweight to severe forms like marasmus and kwashiorkor. The first sign of PEM is poor weight gain.

Clinical Features

The clinical features of the two severe forms of malnutrition, kwashiorkor and marasmus, are itemized in the table below. Each of the features varies from mild to severe. A child may have combination of features for both kwashiorkor and
marasmus, and then be diagnosed to have marasmic kwashiorkor.

Clinical features of the two severe forms of malnutrition

Kwashiorkor Marasmus
  • Pedal oedema
  • Low weight
  • Apathy
  • Poor appetite
  • Muscle wasting
  • Flaky paint dermatosis
  • Hair changes (thin, sparse)
  • Very low weight for age
  • Gross loss of subcutaneous fat
  • Wise old man look
  • Good appetite (if no complications)
  • Severe muscle wasting


Weight for height rather than weight for age is now used for classifying malnutrition for the sake of deciding on management options because weight is affected by stunting. It is known that a child who is less than 60% for their “weight for age”
may be so mainly because of stunting and such a child does not need hospital treatment. Mid upper arm circumference (MUAC) can also add value.

Classifications are available for children with macronutrient malnutrition:

  • Mild malnutrition: Child <5 yrs who is failing to gain weight for 2 months.
  • Moderate malnutrition: Weight for height Z score between > -3SD and < -2SD, MUAC >11.0cm and < 12.5cm.
  • Severe malnutrition: Weight for height Z score < -3SD, MUAC <11.0cm with or without oedema.

If weight for height is not available, visible severe wasting is used to make a judgement.

Children with macronutrient malnutrition may have the following additional features or complications in varying degrees and combinations:

  • Anorexia
  • Lower respiratory infections
  • Fever
  • Hypothermia
  • Vomiting
  • Diarrhoea with or without dehydration
  • Altered consciousness
  • Severe anaemia


  • Mantoux test
  • HIV test
  • Blood sugar
  • Haemogram
  • Chest x-ray


  • If clinically well, that is has good appetite and is alert, treat as outpatient with
    ready to eat therapeutic food.
  • Advise mother to keep the child warm.
  • Teach her how to feed the child at home.
  • Review weekly until weight for height Z score is >- 2, MUAC >11.0cm, and there is no oedema.
  • If not well or if any of the complications listed above are present, admit urgently for inpatient care.

Specific management issues for the different classifications of malnutrition are given below.

Mild malnutrition:
  • Advise the mother to bring the child to the clinic fortnightly for nutrition counselling and growth monitoring.
  • Treat any intercurrent problem, e.g., diarrhoea, pneumonia, malaria.
  • Check HIV status.

Evaluate carefully if:

  • There is no change after 2 months. The child may have an underlying cause.
  • Admit if the child develops moderate to severe malnutrition.
Moderate malnutrition:

Patients with this degree of malnutrition can be treated as an outpatient with food supplementation and nutritional counselling.

Severe malnutrition:

Such children should be assessed for the presence of complications:

  • Dehydration
  • Shock
  • Severe anaemia
  • Hypoglycaemia
  • Hypothermia
  • Malaria,
  • Pneumonia
  • Septicaemia
  • Mouth ulcers.

If the children do not have any of these complications or problems, and have good appetite and are alert, they
should be treated as outpatients with ready to eat therapeutic food. They should be reviewed weekly until weight for height Z score is > -2, MUAC >11.0cm and no oedema.

If the children have the complications mentioned and/or have poor appetite and/or are not alert, look for other intercurrent problems like the presence of oedema that signifies kwashiorkor or marasmic kwashiorkor, and appropriately manage.

Plan of Care

  • Advise the mother to keep child warm.
  • Ensure sufficient staff to provide feeds during day and night. Death often occurs at night because of hypoglycaemia.
  • Initiate feeding within 2 hours of admission and feed every 2 or 3 hours throughout the 24-hour period until the child is out of danger. The child may need tube feeding in the first days of admission.
  • Give all children with severe PEM a broad spectrum antibiotic.
  • Update immunizations.
  • Keep any skin ulcers clean; you can use antiseptic washes.
  • Mouth ulcers: Clean mouth with normal saline (or salt water) and apply gentian violet.

Feeding Regime

  • Initial phase: 100kcal/kg/day; protein 1–1.5g/kg/day; liquid 130ml/kg/day OR 100ml/kg/day if severe oedema.
  • After stabilization: Gradually increase intake to 150–200kcal/kg/day; protein 2– 4g/kg/day.
  • Correct micronutrient deficiencies:
    • Multivitamins
      • Folic acid
      • Zinc
      • Vitamin A
      • Ferrous sulphate 3mg/kg/day after child has started gaining weight

Monitoring Response to Therapy

  • Weigh child daily:
    • Child with oedema: Weight loss initially, then weight gain of >10g/kg/day is expected. If weight gain is less than that, check feeding, re-examine for possible missed infection.
    • Child without oedema: Should gain weight as soon as good feeding is established.
    • Calculation of weight gain: Child’s weight 3 days ago 6,000g; current weight 6, 300g; weight gain = 300g; daily weight gain = 100g. Divide 100g by 6kg to  get g/kg/day.
  • Check for intercurrent problems daily.

Time frame for care of seriously malnourished child

Arrival at health facility: Triage for danger signs and initiate treatment then admit
Stabilization Rehabilitation
Days 1–2 Days 3–7 Weeks 2–6
1. Hypoglycaemia start
2. Hypothermia start
3. Dehydration start
4. Electrolytes start continue
5. Infection start continue continue
6. Micronutrients no iron with iron continue
7. Initiate feeding start continue
8. Catch up growth start
9. Sensory stimulation start continue continue
10. Counsel on feeding start start continue

Advice to Mothers

  • Explain the problems and involve the mother in the care of the child.
  • Show the mother how well the child is doing on the weight chart.
  • Nutrition counselling: Advise mother on how to mix nutritious food from the 3 food groups.
  • Show her how to provide sensory stimulation once child is over acute phase and takes interest in surroundings.


Preventive strategies for macronutrient malnutrition include the following:

  • Appropriate nutritional advice in the MCH clinic (breastfeeding and complementary feeding), with emphasis on how to mix nutritious food from the 3 food groups.
  • Showing mothers how to provide sensory stimulation to their children.
  • Use of growth chart in the MCH clinic for all children aged below 5 years.
  • Health education to parents attending all health facilities and in the community on appropriate child rearing and feeding practices.
  • Advocating for good hygiene in food preparation.
  • Advocating for environmental sanitation.

Admit to hospital if there is a history of illness and either of: Visible severe wasting (buttocks), or oedema and low weight for age and other signs of kwashiorkor (flaky paint skin/hair changes)