How Do You Treat Protein Energy Malnutrition in Nursing?

January 6, 2026 •

4 min read

According to the World Health Organization, severe malnutrition affects millions of children globally, making effective intervention a critical nursing responsibility. A nurse's role is to manage and monitor a patient's nutritional recovery, especially for those suffering from protein-energy malnutrition (PEM), through careful planning and implementation of therapeutic strategies.

Quick Summary

An effective nursing approach to protein-energy malnutrition involves a multiphase strategy, focusing on initial stabilization, refeeding, and rehabilitation while actively monitoring for complications like refeeding syndrome. Education for patients and families is also key for long-term recovery and prevention.

Key Points

Phased Approach: Treatment for PEM follows distinct stages—stabilization, rehabilitation, and long-term management—with nurses leading the implementation of care at each step.
Refeeding Syndrome Risk: Nurses must carefully initiate feeding in malnourished patients to prevent the dangerous fluid and electrolyte shifts of refeeding syndrome, requiring close monitoring and gradual reintroduction of calories.
Micronutrient Supplementation: Beyond protein and calories, nurses oversee the administration of vital vitamins and minerals like Vitamin A, zinc, and folic acid to correct deficiencies, often delaying iron until appetite returns.
Multiple Feeding Methods: Depending on the patient’s condition, nurses utilize various feeding methods, including oral intake, enteral tubes, or parenteral (IV) nutrition, each with specific nursing responsibilities and risks.
Holistic Care: Nursing care extends beyond physical interventions to include sensory stimulation and emotional support, addressing the developmental impacts of malnutrition, especially in pediatric cases.
Education for Long-Term Recovery: Patient and family education is essential for discharge planning, helping ensure the patient maintains nutritional gains and preventing relapse with proper feeding and hygiene practices at home.

The Nurse's Foundational Role in Managing PEM

For patients suffering from protein-energy malnutrition (PEM), nurses are at the frontline of assessment, planning, intervention, and evaluation. Successful treatment begins with a thorough nutritional assessment and identification of the specific type of PEM, such as marasmus or kwashiorkor. The nursing care plan is structured around the patient's individual needs, following a phased approach to restore nutritional status safely and effectively. This includes addressing both macronutrient and micronutrient deficiencies, managing underlying complications, and educating patients and families.

Phase 1: Initial Stabilization (Days 1–7)

The first and most critical phase focuses on addressing life-threatening complications that often accompany severe PEM, such as hypoglycemia, hypothermia, severe dehydration, and infection. The patient's metabolic state is unstable, requiring cautious management to prevent complications like refeeding syndrome.

Preventing Hypoglycemia and Hypothermia: Malnourished patients, especially children, are prone to low blood sugar and body temperature. Nurses must monitor blood glucose and body temperature every few hours. Interventions include immediate feeding, providing warmed blankets, or using the kangaroo technique (skin-to-skin contact) for infants.
Managing Dehydration: Dehydration in malnourished patients requires a cautious approach, as they have electrolyte imbalances. Oral rehydration salts (ORS) specially formulated for malnutrition (ReSoMal) are used over standard ORS, which has a high sodium content. Intravenous fluids are reserved for shock.
Treating Infection: PEM compromises the immune system, so broad-spectrum antibiotics are given routinely, as signs of infection may be masked. Nurses administer medications and monitor for therapeutic effects and potential side effects.
Initial Cautious Feeding: Feeding is started early but with low-osmolality, low-lactose starter formulas like F-75, in small, frequent amounts. The goal is to provide enough nutrients for maintenance without overwhelming the system. Continuous breastfeeding is encouraged for infants.

Phase 2: Rehabilitation (Weeks 2–6)

Once the patient is stabilized and complications are under control, the focus shifts to intensive feeding to achieve rapid catch-up growth. Appetite often returns during this phase, marking a turning point in recovery.

Intensive Nutritional Support: The starter formula is gradually replaced with a higher-calorie, higher-protein catch-up formula like F-100, which supports rapid weight gain. Nurses increase feed volumes and frequency based on the patient's tolerance and weight gain.
Micronutrient Supplementation: Deficiencies are addressed with specific supplements, including vitamin A, folic acid, zinc, and copper. Iron supplementation is typically deferred until the catch-up growth phase begins to avoid exacerbating infections.
Monitoring and Documentation: Regular monitoring of weight, intake/output, and vital signs is crucial. Accurate documentation helps the healthcare team track progress and adjust the plan of care as needed.

Phase 3: Long-Term Management and Follow-Up

Before discharge, nurses play a pivotal role in ensuring the patient and family are prepared for continued nutritional rehabilitation and follow-up care at home.

Patient and Family Education: Nurses educate families on nutritional requirements, proper feeding techniques, food preparation, and hygiene. This includes teaching them to prepare energy-dense, nutrient-rich foods at home.
Sensory and Emotional Support: Malnutrition can cause developmental and psychological delays. Nurses provide emotional support and encourage play therapy and physical activity to aid in psychological and physical recovery.
Discharge Planning: Coordination with social services and nutrition professionals is essential to ensure a safe transition home and ongoing support. Follow-up appointments are scheduled to monitor the patient's continued progress.

Comparison of Feeding Methods

Nurses must be aware of different feeding methods and when to use them based on a patient's condition.


Feature	Oral Feeding	Enteral (Tube) Feeding	Parenteral (IV) Nutrition
Indication	Mild-to-moderate malnutrition, functioning GI tract, good appetite.	Inability to consume adequate oral intake due to swallowing issues, anorexia, or medical conditions.	Severe malabsorption, non-functional GI tract, bowel obstructions.
Nurse's Role	Encourage frequent, small, nutrient-dense meals. Monitor intake and tolerance. Patient education.	Administer feeds via nasogastric or gastrostomy tube. Check tube placement, manage residuals, and monitor for tolerance (bloating, nausea).	Administer IV solutions containing nutrients. Monitor for infection, hyperglycemia, and electrolyte imbalances. High-risk, typically reserved for severe cases.
Refeeding Risk	Lower, as intake is more gradual.	Present, requires cautious initiation and monitoring.	High, requires extremely cautious and slow initiation with close monitoring.
Complications	Non-adherence, insufficient intake.	Aspiration, tube displacement, gastrointestinal intolerance (diarrhea), clogging.	Infection, hyperglycemia, electrolyte abnormalities, liver complications.

Refeeding Syndrome: A Major Nursing Consideration

Refeeding syndrome is a potentially fatal shift in fluid and electrolytes that occurs when a severely malnourished patient is refed too quickly. This metabolic disturbance can lead to heart failure, respiratory failure, and death. Nurses are crucial in preventing this syndrome through careful assessment and a protocolized approach.

Nursing Management of Refeeding Syndrome

Identify At-Risk Patients: Screen all malnourished patients, especially those with little or no intake for over 5 days, those with low BMI, or those with pre-existing electrolyte issues.
Monitor Closely: Monitor vital signs, cardiac rhythm, and laboratory values (especially potassium, phosphate, and magnesium) during the initial refeeding phase.
Start Low and Go Slow: Initiate nutritional support at a low caloric intake (e.g., 5-10 kcal/kg/day) and gradually increase it over several days as tolerated.
Supplement Proactively: Administer thiamine and other B-vitamins before starting feeding, along with magnesium, potassium, and phosphate as needed.
Address Fluid Balance: Monitor for fluid shifts and edema. Intake and output measurements and daily weights are essential.

Conclusion

Treating protein energy malnutrition requires a detailed, phased approach with a high degree of nursing vigilance and expertise. From the initial stabilization of life-threatening complications to the careful progression of nutritional rehabilitation and the prevention of refeeding syndrome, the nurse's role is central to patient recovery. Comprehensive patient and family education during discharge is critical for preventing relapse and ensuring long-term health. By following established clinical guidelines and collaborating with a multidisciplinary team, nurses can significantly improve outcomes for individuals suffering from PEM.

An example of a trusted source for further reading on clinical nutritional guidelines is the National Institutes of Health (NIH), which often hosts books and documents from authoritative bodies like the World Health Organization (WHO) and professional societies. For instance, a nurse can consult publications like the Pocket Book of Hospital Care for Children for detailed management protocols.

Frequently Asked Questions

The first step is the stabilization phase, which involves treating immediate, life-threatening complications such as hypoglycemia (low blood sugar), hypothermia (low body temperature), dehydration, and infection.

Nurses manage dehydration cautiously using a special rehydration solution (ReSoMal) designed for malnourished patients. This is administered slowly, either orally or via a nasogastric tube, and intravenous fluids are typically reserved for cases of shock.

Refeeding syndrome is a dangerous metabolic shift caused by reintroducing nutrition too quickly to a severely malnourished person. It is prevented by starting feeding at a very low caloric rate, gradually increasing it, and closely monitoring for electrolyte imbalances.

Enteral nutrition is indicated when a patient cannot consume enough nutrients orally to meet their metabolic needs, often due to issues like dysphagia or anorexia. The nurse manages the tube, formula administration, and monitors for complications.

Iron supplementation is often delayed until the rehabilitation phase, after the patient's infection is controlled and weight gain has begun. Giving iron too early can promote bacterial growth and worsen infection.

Emotional and sensory support is a vital part of rehabilitation, especially in pediatric cases, as PEM can cause developmental and psychological delays. Nurses provide reassurance, encouragement, and incorporate play therapy to help with recovery.

Nurses educate families on maintaining a nutritious diet, preparing high-calorie foods, proper hygiene, and the importance of follow-up appointments. They also help connect families with social services if needed.