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2025 ICD-10-CM code E45

Retarded development following protein-calorie malnutrition (PCM).

Code E45 should be used when the primary cause of the retarded development is protein-calorie malnutrition.If there are other underlying conditions contributing to the developmental delay, those conditions should also be coded.

Medical necessity for treatment is established by the presence of signs and symptoms of protein-calorie malnutrition and its impact on the child's development. The documentation should support the need for interventions such as nutritional support, treatment of complications, and rehabilitation.

PCM occurs primarily in developing countries and poverty-stricken areas due to severe protein deficiency immediately after weaning, parasites and infections, child abuse or severe neglect, and inadequate healthy food habits.Diagnosis is based on patient history, signs and symptoms, and physical examination, along with laboratory tests (blood and urine), imaging tests (abdominal ultrasound), BMI calculation, skin biopsy, and hair analysis. Treatment depends on symptom severity and may include a protein-rich diet, vitamin supplements, hospitalization for severe cases (dehydration, low blood glucose, anemia, infection), iron tablets for anemia, antibiotics for infection, and rehabilitation.

In simple words: Delayed development due to not enough protein and calories in the diet, mainly affecting babies and young children, leading to slow growth.

Retarded development following protein-calorie malnutrition (PCM) refers to a type of energy and nutrient deficiency which leads to slow or stunted growth. It mainly affects infants and young children.

Example 1: A 1-year-old child from a developing country presents with stunted growth, a protuberant belly, and muscle wasting after being weaned onto a diet primarily consisting of starchy foods., A 2-year-old child with a history of recurrent infections and inadequate food intake exhibits delayed developmental milestones and growth retardation., A neglected 3-year-old child displays signs of severe malnutrition, including edema, skin dryness, and changes in hair color, along with significant developmental delays.

Documentation should include evidence of protein-calorie deficiency, such as dietary history, anthropometric measurements (height, weight, BMI), physical exam findings (e.g., growth retardation, muscle wasting, edema), and laboratory results (e.g., low serum albumin, anemia). Developmental assessments should also be documented.

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