Protein energy malnutrition (PEM) is one of the most important public health problems in many developing countries including India, South East Asia and Africa. It is a wide-spread deficiency disease among children of low socio-economic groups. In many areas nearly half the children do not survive to the age of five years on account of protein calorie malnutrition; those who survive may suffer from impaired growth and perhaps mental retardation.

The diseases known as ‘kwashiorkor’ and ‘marasmus’ represent extreme forms of protein calorie malnutrition. In 1933, a paediatri­cian, Cicelly William, working in West Africa used the local term Kwashiorkor which means ‘displaced child’ meaning “the sickness which a child develops when the next baby is born and the older one gets deprived of breast milk”. Kwashiorkor occurs due to the imbal­ance between proteins and carbohydrates. The term marasmus is derived from a Greek word meaning “to waste”. ‘Marasmus’ is also the result of a continued deficiency of calories, protein and other nutrients.

Protein energy malnutrition is characteristic of children under five years whenever the diet is poor in protein and calories, though no age is immune. The effect of protein deficiency in adults may show itself in the form of loss of weight, reduced subcutaneous fat, anaemia, great susceptibility to infection, frequent loose stools, general lethargy, inability to do sustained hard work, delay in healing of wounds and oedema.

The acute form of protein energy malnutrition is often precipitated due to inability on the part of the mother to supply proper nutrients to the foetus and later inability on her part to lactate. Marasmus is most common in infants found in twins; whereas kwashiorkor occurs most often among children beyond this age.


The degree of severity of protein calorie malnutrition is related to the extent of growth failure. It is expressed by the weight loss per age as compared to the weight of normal children. Loss of weight by 11-­25% is classified as Grade I, weight loss by 26-40% as Grade II and weight loss by more than 40% as Grade III in protein-calorie mal­nutrition.

Causes of Protein Energy Malnutrition

The following are the most important factors responsible:

i. Inadequate diet.


Inadequacy of dietary intake may be due to several reasons such as:

a. Low purchasing power; inappropriate choice of foods; non-availability of foods.

b. Prolonged breastfeeding, late introduction of supplementary foods.

c. Diarrhea and intestinal parasitism in children due to unhy­gienic feeding habits.


d. Shortening the period of breastfeeding without satisfactory supplements.

ii. Lack of knowledge.

Ignorance of the requirements of a growing child and the improper use of available resources.

iii. Traditions, Customs-and-Beliefs


Aare often responsible for certain food habits. Even child-rearing practices in the rural areas (ignorant older girls in the family are given charge of looking after the young infant) are responsible for this deficiency.