Protein energy malnutrition natural history, complications and prognosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Omodamola Aje B.Sc, M.D. [2]


If left untreated, all children with protein energy malnutrition will progress to develop a failure to thrive, poorly developed immune system which causes overwhelming bacteremia and sepsis which is the cause of death in most malnourished individuals.

Natural history, Complications, and Prognosis

Natural history

The symptoms of protein energy malnutrition usually develop between the first and fifth year of life, and start with symptoms such as lethargy, irritability, failure to thrive, decreased muscle mass, diarrhea, and recurrent infections due to decreased immunity. Without treatment patients with protein energy malnutrition which comprises of kwashiorkor and marasmus present with changes in their facial appearance with children with kwashiorkor having moon faces while those with marasmus develop monkey-like face due to loss of subcutaneous fat pad in the cheeks. There is generalized edema, hepatomegaly, changes in skin, hair color and texture, recurrent infections like diarrhea with kwashiorkor which will eventually lead to overwhelming shock and sepsis and death.[1][2][3]


Complications that can develop as a result of protein energy malnutrition are:[4][5][6][7][8]


The presence of severe of hypoproteinemia, hypoalbuminemia, electrolyte imbalance or an underlying HIV infection is associated with poorer prognosis among patients with protein energy malnutrition.[9]


  1. Bourke CD, Berkley JA, Prendergast AJ (2016). "Immune Dysfunction as a Cause and Consequence of Malnutrition". Trends Immunol. doi:10.1016/ PMC 4889773. PMID 27237815.
  2. Rytter MJ, Kolte L, Briend A, Friis H, Christensen VB (2014). "The immune system in children with malnutrition--a systematic review". PLoS ONE. 9 (8): e105017. doi:10.1371/journal.pone.0105017. PMC 4143239. PMID 25153531.
  3. Scrimshaw NS (2003). "Historical concepts of interactions, synergism and antagonism between nutrition and infection". J. Nutr. 133 (1): 316S–321S. PMID 12514318.
  4. Bagga A, Tripathi P, Jatana V, Hari P, Kapil A, Srivastava RN, Bhan MK (2003). "Bacteriuria and urinary tract infections in malnourished children". Pediatr. Nephrol. 18 (4): 366–70. doi:10.1007/s00467-003-1118-0. PMID 12700964.
  5. Jones KD, Berkley JA (2014). "Severe acute malnutrition and infection". Paediatr Int Child Health. 34 Suppl 1: S1–S29. doi:10.1179/2046904714Z.000000000218. PMC 4266374. PMID 25475887.
  6. Ahmed M, Moremi N, Mirambo MM, Hokororo A, Mushi MF, Seni J, Kamugisha E, Mshana SE (2015). "Multi-resistant gram negative enteric bacteria causing urinary tract infection among malnourished underfives admitted at a tertiary hospital, northwestern, Tanzania". Ital J Pediatr. 41: 44. doi:10.1186/s13052-015-0151-5. PMC 4472394. PMID 26084628.
  7. Doherty JF, Adam EJ, Griffin GE, Golden MH (1992). "Ultrasonographic assessment of the extent of hepatic steatosis in severe malnutrition". Arch. Dis. Child. 67 (11): 1348–52. PMC 1793750. PMID 1471885.
  8. Silverman JA, Chimalizeni Y, Hawes SE, Wolf ER, Batra M, Khofi H, Molyneux EM (2016). "The effects of malnutrition on cardiac function in African children". Arch. Dis. Child. 101 (2): 166–71. doi:10.1136/archdischild-2015-309188. PMID 26553908.
  9. Munthali T, Jacobs C, Sitali L, Dambe R, Michelo C (2015). "Mortality and morbidity patterns in under-five children with severe acute malnutrition (SAM) in Zambia: a five-year retrospective review of hospital-based records (2009-2013)". Arch Public Health. 73 (1): 23. doi:10.1186/s13690-015-0072-1. PMC 4416273. PMID 25937927.

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