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MUÑOZ, CJ | TALENTO, AC
Pediatrics

Nutrition 2: Nutritional Disorders

July 31, 2014

Liberiza M. Orseno-Ferrer, MD
, MD

WHO Definition
 Malnutrition usually refers to a number of
diseases, each with a specific cause related to
one or more nutrients, for example protein,
iodine, vitamin A or iron.
 In the present context, malnutrition is
synonymous with protein-energy malnutrition,
which signifies an imbalance between the supply
of protein and energy and the body's demand for
them to ensure optimal growth and function.
10% genes, 90% nutrition = role of
nourishment, environment, to achieve optimal
growth and function
 This imbalance includes both inadequate and
excessive energy intake; the former leading to
malnutrition in the form of wasting, stunting and
underweight, and the latter resulting in
overweight and obesity.

Malnutrition
 Pathologic state
 Relative or absolute deficiency of nutrients
 Excess nutrients


Global Burden of Malnutrition
99 million of the underweight children live in
Asia, 39 million in Africa and the other 10 million is
distributed around the globe.
*93% of underweight children around the world live in
Asia and Africa. The remaining 7% are dispersed
throughout Caribbean countries, Central America, etc.

Contributors of Malnutrition
 Malnutrition in children is the consequence of a
range of factors, that are often related to poor
food quality, insufficient food intake, and
severe and repeated infectious diseases, or
frequently some combinations of the three.
These conditions, in turn, are closely linked to
overall standard of living and whether a
population can meet its basic needs, such as
access to food, housing and health care.
 not only about the quantity but also
about the quality of food taken in.
 Growth assessment thus not only serves as a
means for evaluating the health and nutritional
status of children but also provides an indirect
measurement of the quality of life of an entire
population
Malnutrition in the Philippines
Malnutrition Prevalent among Filipino Children
0-4 years old 5-10 years old
33.6% - height stunted 33.6 - height stunted
20.2% - underweight 32% - underweight
7.2% - malnutrition 8.5% - malnutrition

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MUÑOZ, CJ | TALENTO, AC
 public health concern: how to assess the
nutritional status?
Why is there malnutrition in this age group? What is
the characteristic of this age group? How will you
improve the nutritional status of the whole
community?
 different feeding advocacies:
0-4: breastfeeding, 5-10: highly active, shorter
period for eating, additional stress: physical activity

 infant mortality rate is very high
0 - 1 yr old (neonatal [0-28 d] + >30 d to 1 yr old)
>>> Infant death during the 0 to 30 days
DOH: changed intervention from vaccine-based
strategy to lowering the IMR of under 0-28 days
Nutrition Situation
Undernutrition Overnutrition
Preschool (0-5 yrs) 24.6 2.0
School-age (6-10 yrs) 22.8 1.6
Adolescents (11-19 yrs) 15.5 3.3
Adults (20 yrs & above) 12.4 23.9

Double Burden of Malnutrition: Unhealthy Diets
 High fat, high sugar, refined carbohydrates, processed
meat products, low in fruits and vegetables
 Urban dwellers
 Higher income groups

 Low in protein, energy, macronutrients
 Lower income groups

Types of Malnutrition
 Undernutrition - consumption of inadequate
food over prolonged period
 Specific deficiency - lack of individual nutrient
 Overnutrition - chronic consumption of excess
food
 Obesity does not happen overnight.
 Imbalance - disproportion among essential
nutrients
Major nutritional deficiency in the Philippines -
Undernutrition, Overnutrition
Nutritional Deficiency States in the Philippines
 PROTEIN-ENERGY MALNUTRITION (PEM) -
deficient intake of proteins and energy
 Major Severe Syndrome:
 Marasmus
 Kwashiorkor


Marasmus
 Child is not getting enough energy and protein
from his regular diet to meet his nutritional
needs
 Balanced starvation - board exam question
 Severely wasted child and gross loss of
subcutaneous fat, skin becomes loose and
wrinkled (old man's faced)
 Poor appetite
 Miserable but alert

Kwashiorkor
 Malnutrition results from a low protein diet but
contains calories in the form of carbohydrates
 'Am' - rice water rich in calories but no protein
content
 Presence of bipedal edema is a cardinal sign
 Apathetic, drowsy
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MUÑOZ, CJ | TALENTO, AC
 Common signs:
 Hair changes (sparse, straight,
dyspigmentation, flag sign - different
discoloration/color)
 Scaly skin
 Puffy and moon face
 Del Mundo - described Kwashiorkor as a child
who is weaned immediately from breastfeeding
because there is another child in the family
Why do children become Undernourished?
 Causes:
 PRIMARY: no food, inadequate diet
 SECONDARY
 Ingestion (congenital anomalies)
 Absorption (malabsorption syndromes)
 Increased requirements (during surgery;
stressful activities)
 Increased excretion (diarrhea)

Pathogenesis of Malnutrition (Must Know)
 Nutrient reserves (i.e. fatty acids, glycogen)
utilized during period of inadequacy
 With depletion of nutrient reserves (usage
without replenishment) = manifestations of
MALNUTRITION
 Biochemical lesions (i.e. electrolyte
imbalance, hypoglycemia)
 Anatomic lesions (i.e. villous atropy, muscle
wasting)
 Functional lesions (i.e. depressed immune
system, malabsorption)

Undernutrition throughout the life cycle





















Inadequate
catch up
growth
Inadequate
fetal
nutrition
BABY
Low birthweight
CHILD
Stunted
ADOLESCENT
Stunted
ELDERLY
Malnourished
Inadequate
food, health,
and care
Higher maternal
mortality
Higher mortality
rate
Impaired
mental
development
Increased risk of adult
chronic disease
Inadequate
food, health,
and care
Higher maternal
mortality
Reduced mental
capacity
Reduced mental
capacity
Inadequate
food, health,
and care
Frequent
infections
Untimely/inadequate
complementary
feeding
PREGNANCY
Low weight gain
WOUND
Malnourished
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MUÑOZ, CJ | TALENTO, AC
We start with a low birth weight baby. The baby has untimely/inadequate complementary feeding leading to inadequate catch up growth resulting to
frequent infections and inadequate food, health and care. Soon the baby will become a child, and it will become stunted with reduced mental capacity.
The adolescent is still stunted with reduced mental capacity eventually becomes pregnant, but is thinned and malnourished with a high risk of maternal
mortality. If the woman didn't die, she will eventually give birth to a low birth weight baby and will become an elderly who is malnourished. The cycle did
not stop because of the continued inadequacy of food, health and care.

Short and Long-term effects of early undernutrition














Classification of Malnutrition
 The international reference population - this
is where you compare your patient or the
population you are working on
 The designation of a child as having impaired
growth implies some means of comparison with
a "reference" child of the same age and sex.
Thus, in practical terms, anthropometric values
need to be compared across individuals or
populations in relation to an acceptable set of
reference values
 growth chart is the tool used. One value does
nogt mean anything, what we want is a seties.
So everytime a child comes into your clinic, plot
the progress in their height to check if they are
following the natural growth based on the
reference








 The database uses as a basis for comparison
across countries the National Center for Health
Statistics (NCHS) growth reference, the so-
called NCHS/WHO international reference
population
 del mundo: 2 years old patient, 12 kilgrams
You do not have the chart. Use the formula:
age (months/years)×2 +8 for a quick assessment
4 months old
Age (months <6 months) × 600 (20g/30 days) +
3000* (if birth weight is unknown)
7 months:
after 6 months, slower growth (plateau), age >6
months × 500 + BW

Weight in pediatrics is used to compute for dosage.
Use formula and knowledge for expected weight. Do
not give the dosage if you do not know the weight.
Expected weight, expected height

Early undernutrition
in utero &
childhood
Brain
development
Growth &
muscle mass
body composition
Metabolic
programming
of glucose, lipids,
protein

Cognitive &
educational
performance
Immunity
Work capacity
Diabetes
Obesity
Heart conditions
High fat

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MUÑOZ, CJ | TALENTO, AC
Measuring Malnutrition: Anthropometrics
 Health or nutritional status of a child is usually
assessed in three ways:
 anthropometric indicators
 biochemical indicators
 clinical indicators
 Among the three method of assessment,
anthropometric measurement is a common
and easy way to assess health and nutrition
status. The other two methods are less practical
because of the logistical difficulties and because
data collection and analysis is expensive and
time consuming.
Anthropometric Indices
 In children, the three most commonly used
anthropometric indices to assess their growth
status are:
 weight-for-height
 height-for-age
 weight-for-age

Anthropometric Interpretation
 Underweight (Weight for age) [Must Know]
 most common assessment of child nutrition
status
 routinely collected in growth promotion
programs
 good indicator for children under 24 months
because of the need to do precise
measurements of weight for these age
groups
 It is a simple index, but it does not take
height into account
 Children who are taller would be expected to
weigh more than other children
 Children who are shorter would be expected
to weigh a little less
 Stunting (Height for age) [Must Know]
 a measure of linear growth
 Stunting refers to shortness, and reflects
linear growth achieved pre- and postnatal;
with its deficits it is generally assumed to
indicate long-term, cumulative effects of
inadequate nutrition and poor health status
 It is considered a measure of past nutrition,
because a child who is short today, maybe
did not have adequate nutritional intake at
some point in the past

 Wasting (Weight for Height) [Must Know]
 measure of acute or short-term exposure of
a negative environment
 sensitive to changes in calorie intake or the
effects of disease
 can be calculated without knowing the age
of a child
 measure of current body mass
 best index to use to reflect wasting
malnutrition, when it is difficult to determine
the exact ages of the children being
measured
 A child is considered malnourished if any of
these indexes fall below two standard deviations
(<-2SD) of the median value of the National
Center for Health Statistics/World Health
Organization (NCHS/WHO) international
reference (WHO, 1995)
 Severe malnutrition is when the
indexes fall below 3 SD of the
median value



can still be
healthy
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MUÑOZ, CJ | TALENTO, AC
Classification of Malnutrition
Revised Waterlow Classification (Memorize!) - always go for the higher
Normal Mild Moderate Severe
Height-for-Age (stunting)
%
>95 90-95 80-90 <80
Weight-for-Age
(wasting) %
>90 80-90 70-79 <70

% Stunting Actual Height (or length)
Ideal height for age
% Wasting Actual weight
Ideal weight-for-height

Micronutrient Deficiencies
 Micronutrients (such as vitamins and minerals)
are nutrients needed throughout life in small
quantities. Though micronutrients are needed in
tiny amounts, a diverse diet is needed to obtain
the required amounts
 During emergencies, diets often lack essential
micronutrients and deficiencies arise.
Populations that are entirely dependent on a
general ration (food aid/relief) have suffered
from micronutrient deficiency disease outbreaks.
Micronutrient Deficiencies Diseases (MDDs) are
therefore an important concern in emergencies

Vitamin A Deficiency
 Affects preschool-aged children (under 5 years),
school age children and pregnant women.
WHO/UNICEF estimate that 280 million pre-
school children are affected by clinical Vitamin A
Deficiency (VAD)
 Predisposing Factors
 Poor birth scores
 Milk and supplement food low in Vitamin A
 High growth requirements
 Poor hepatic storage
 Causes xerophthalmia, impairs immune system
and increases the severity and mortality risk of
measles and diarrheal disease
 The signs of xerophthalmia in order of severity
and clinical presentation are: (MUST KNOW)
 Night blindness
 Bitot's spots (Dryness and foamy
accumulations on the inner eyelids)
 Keratomalacia (Softening and ulceration of
the cornea. This is sometimes followed by
perforation of the cornea, which leads to
permanent blindness)
 Corneal xerosis (Dullness or clouding of the
cornea) - irreversible

Vitamin A Supplementation (Must Know)
 Children: 200,000 IU Vitamin A on Day 1 and
Day 2; repeat after 2 weeks or if necessary
before discharge (if patient is hospitalized)
 del mundo:
 Patient who developed measles and diarrhea
need to be admitted to the hospital and is given
Vitamin A
 For infants <1 yr and malnourished: half the
dose


X 100
X 100
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Vitamin A Prevention
 DIET rich in Vitamin A (green leafy and yellow
vegetables and fruits)
 Adequate intake of Vitamin A of pregnant
mothers
 Annual prophylaxis in children

Iron Deficiency (MUST KNOW)
 Affects 3.5 billion people worldwide. The most
affected groups are pregnant women, 5-14 year
old children (because of eating habits,
menarche, very active individuals), older adults
and preschool-aged children (under 5 years)
 Iron is essential for the production of blood
hemoglobin. Lack of iron eventually results in
iron-deficiency anemia
 good sources of iron: bitter gourd, camote tops,
malunggay, liver
 doesnt happen overnight, clinical manifestations
show only when stores in the bone marrow are
depleted
 Stages (Nice to Know)
 Prelatent
 Reduction in iron stores without reduced
serum iron levels
 Hb (N), MCV (N), iron absorption (↑),
transferrin saturation (N), serum ferritin
(↓), marrow iron (↓)

 Latent
 Iron stores are exhausted, but the blood
hemoglobin level remains normal
 Hb (N), MCV (N), TIBC (↑), serum
ferritin (↓), transferrin saturation (↓),
marrow iron (absent)
 Iron deficiency anemia
 Blood hemoglobin concentration falls
below the lower third of normal
 Hb (↓), MCV (↓), Serum ferritin (↓),
transferrin saturation (↓), marrow iron
(absent)
 Diagnosis - iron studies:
 Decreased serum ferritin - most reliable test
available
 Increased TIBC (total iron binding
capacity)/transferrin
 Decreased serum iron
 Microcytic, hypochromic (RBCs on blood
smear)
 RDW (Red Cell Distribution Width) is usually
abnormal
 Typical signs of iron-deficiency anemia are
paleness, tiredness, headaches and
breathlessness
 A blood hemoglobin level of <7.0g/dl is an
indicator of severe anemia
 In children, pale conjunctivae, palms and
tongue are typical signs of anemia

Iron Supplementation (Must Know)
 4-6 mg/kg/day elemental iron
 Iron-fortified milk
 Iron drops beginning 6 months of age (because
this is the start of complementary feeding and
the turnover of blood)
 A patient who is iron deficient at 4 months can
start receiving iron supplements already
(remember, rbc's life is for 120 days/ 4 months).
Common problem: stains the teeth

Iodine Deficiency
 The third most prevalent micronutrient deficiency
 It causes a range of abnormalities and is the
most common cause of preventable brain
damage and mental retardation
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 110 countries worldwide are affected by iodine
deficiency disorders
 The most common form of severe iodine
deficiency is goiter (bosyo), a swelling of the
thyroid gland. An estimated 750 million people
are affected by goiter.
 Cretinism (both mental and physical disability)
is the most severe form of iodine deficiency.
Cretinism affects over 11 million people
 Prevention is iodized salt

Vitamin C Deficiency
 Vitamin C (also called Ascorbic Acid) deficiency
leads to Scurvy. Populations with a low intake
of fresh fruit and vegetables are at risk of this
disease
 Typical signs include: swollen and bleeding
gums, minute hemorrhages (bleeding) in the
skin, and slow healing of wounds
 Combined with iron for faster absorption

Vitamin B Complex Deficiency
 Vitamin B3 or Niacin deficiency causes
Pellagra. Populations dependent on maize and
with a low dietary diversity are at risk of the
disease
 The disease affects the skin, gastro-
intestinal tract and nervous system. For this
reason, it is sometimes called the disease of
the 3Ds: Dermatitis, Dementia, Diarrhea
 If left untreated, it can also result in death
 Vitamin B1 or Thiamin deficiency causes
Beriberi. Populations dependent on polished
rice as their staple and with low diet diversity are
at risk of the disease
 There are 3 main types of the disease:
 Wet beriberi (adults)
 Dry beriberi (adults)
 Infantile beriberi (infants)
 Typical symptoms include:
 Dry beriberi - general dysfunction of the
nervous system, diminished touch
sensation, muscles become
progressively weak and wasted, and
walking becomes difficult
 Wet beriberi - cardiac abnormalities
and edema
 Infantile beriberi - loss of normal crying
voice

Zinc supplementation
 breakthrough: discovery of its function:
 shortens duration of diarrhea
 shortens frequency of cough and colds

Key Points
 Though micronutrients are needed in tiny
amounts, a diverse diet is needed to obtain the
required amounts
 Iron deficiency, Vitamin A, and iodine
deficiencies are endemic throughout many
countries in the world
 Vitamin A deficiency is associated with
increased clinical severity and risk of mortality
from measles and diarrheal disease. Vitamin A
deficiency affects pre-school children, school
age children and pregnant women (board exam
question)
 Iron deficiency affects 3.5 billion people
worldwide. The most affected groups are
pregnant women, children (53%), older adults,
and pre-school children
 Iodine deficiency disorders are the leading
cause of preventable brain damage and mental
retardation
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MUÑOZ, CJ | TALENTO, AC
 Thiamin, Niacin, and Vitamin C deficiencies
have been frequently found in emergency
affected populations
Emergence of Undernutrition in Disaster Areas
 Complex emergencies and natural disasters
increase the risk of undernutrition in a population
 Examples in areas affected by flooding,
tsunamis, earthquakes, etc.
 Children suffer the most in evacuation centers
 In order to design an effective emergency
response to nutrition crises, it is crucial that the
causes of undernutrition in vulnerable
populations are identified from the start
What is being done?
 Malnutrition is frequently part of a vicious cycle
that includes poverty and disease. These three
factors are interlinked in such a way that each
contributes to the presence and permanence of
the others. Socioeconomic and political changes
that improve health and nutrition can break the
cycle; as can specific nutrition and health
interventions
 The WHO Global Database on Child Growth and
Malnutrition seeks to contribute to the
transformation of this cycle of poverty,
malnutrition and disease into a virtuous one of
wealth, growth and health

Interventions with Sufficient Evidence to Implement in All countries
Maternal and Birth Outcomes Newborn Babies Infants and Children
 Iron folate supplementation
 Maternal supplements of multiple
micronutrients
 Maternal iodine through iodization of
salt
 Maternal calcium supplementation
 Interventions to reduce tobacco
consumption or indoor air pollution
 Promotion of breastfeeding
(individual and group counseling)
 Promotion of breastfeeding
(individual and group counseling)
 Behavior change communication for
improved complementary feeding
 Zinc supplementation
 Zinc in management of diarrhea
 Vitamin A fortification or
supplementation
 Universal salt iodization
 Handwashing or hygiene
interventions
 Treatment of SAM (subacute
malnutrition)


“You may have to fight a battle more than once to win it.” ~Margaret Thatcher