From the Guidelines
Protein-Energy Malnutrition (PEM) diagnosis and treatment should be guided by the Global Leadership Initiative on Malnutrition (GLIM) criteria, which involves a two-step approach for malnutrition diagnosis, including a validated screening and a detailed assessment with phenotypic and etiologic criteria for diagnosis and grading the severity of malnutrition 1.
Diagnosis
Diagnosis of PEM involves evaluating weight-for-height ratios, mid-upper arm circumference, serum albumin levels, and checking for physical signs like edema, muscle wasting, and skin changes. The GLIM criteria consist of a two-step model for risk screening and diagnostic assessment, including five criteria: three phenotypic criteria (non-volitional weight loss, low BMI, and reduced muscle mass) and two etiological criteria (reduced food intake or assimilation, and disease burden/inflammation) 1.
Treatment
Treatment focuses on careful nutritional rehabilitation with a phased approach. Initially, life-threatening problems like hypoglycemia, hypothermia, dehydration, and electrolyte imbalances must be addressed. For malnourished non-critically ill hospitalized patients with AKI/AKD or CKD with or without KF, oral nutritional supplements (ONS) should be offered to facilitate the achievement of nutritional targets 1. The use of ONS, especially those with higher energy and protein content, can add up to 10-12 kcal/kg and 0.3-0.5 g of protein/kg daily over the spontaneous intake in a 70 kg patient if provided two times a day at least 1 h after a meal 1.
Key Considerations
- The first phase of treatment involves providing small, frequent feedings of easily digestible, low-protein, low-sodium formulas.
- Micronutrient supplementation is essential, including vitamin A, zinc, iron, folate, and multivitamins.
- Infections must be treated with appropriate antibiotics.
- For severe cases, hospitalization may be necessary, while moderate cases can often be managed with ready-to-use therapeutic foods (RUTF) in outpatient settings.
- Long-term management includes gradual introduction of balanced local foods, nutrition education for caregivers, and regular follow-up to monitor growth and development.
- Aggressive refeeding can cause dangerous metabolic complications like refeeding syndrome, characterized by fluid and electrolyte shifts that can lead to cardiac failure.
From the Research
Diagnosis of Protein-Energy Malnutrition (PEM)
- The diagnosis of PEM can be made using the criteria of the "Global Leadership Initiative on Malnutrition" (GLIM), which comprises 3 phenotypic and 3 etiologic criteria 2.
- A study published in 1984 proposed a new approach to the classification of PEM in adults, using three widely accepted measurements: triceps skinfold (TSF), mid-arm muscle circumference (MAMC), and serum albumin (SA) 3.
- The prevalence of PEM can be assessed in different populations, such as GI in-patients and out-patients, and can vary depending on the underlying disease and other factors 3.
Treatment of Protein-Energy Malnutrition (PEM)
- Nutritional therapy can be effective in treating PEM, and various approaches can be used alone or in combination, depending on the situation and disease of each individual patient 2, 4.
- Dietary supplements, either alone or in combination with hormonal treatment, may have positive effects in patients with manifest PEM or at risk of developing PEM 4.
- Ready-to-use therapeutic foods (RUTFs) have been developed for the treatment of severe acute malnutrition (SAM) and can be effective in promoting weight gain in both severely and moderately wasted children and adults 5, 6.
- Community-based therapeutic care, which treats the majority of severely malnourished children at home, has improved the management of acute malnutrition in emergencies 6.
- Rapid rehydration and careful management can help avoid death in severely malnourished children, even in the presence of risk factors for mortality 6.