MALNUTRITION

Malnutrition
• Malnutrition is a general term that includes many
conditions, including undernutrition, overnutrition
and micronutrient deficiency diseases (like vitamin A
deficiency, iron deficiency anaemia, iodine deficiency
disorders and scurvy).
 Protein-energy malnutrition
• Currently the most important nutritional problem in
most countries in Asia, Latin America, the Near East and
Africa.
• A major health & nutrition problem in India
• Failure to grow adequately- the first and most important
manifestation
• Results from consuming too little food, especially energy,
and is frequently aggravated by infections
• Child may be shorter in length or height or lighter in
weight than expected for a child of his or her age, or may
be thinner than expected for height
• PEM is the result of inadequate intake or poor
utilization of food and energy, not a deficiency of one
nutrient and not usually simply a lack of dietary
protein
• At one end of the spectrum, mild PEM manifests itself
mainly as poor physical growth in children;
• At the other end of the spectrum, kwashiorkor
(characterized by the presence of oedema) and
nutritional marasmus (characterized by severe
wasting) have high case fatality rates.
 Factors contributing to PEM
• Lack of knowledge, ignorance
• Poverty
• Famine, vulnerability
• Infections
– Vicious cycle
• Emotional deprivation
• Gender bias
• Intra-familial mal-distribution of food stuffs
 Classification of PEM
• Gomez classification
• Waterlow classification
• Wellcome classification
 Gomez Classification
• Gomez classification is based on weight retardation
• It locates the child on the basis of his or her weight
in comparison with a normal child of the same age.
• In this system, the normal reference child is in the
50th centile of the Boston standards.
• The cut off values were set during a study of risk of
death based on weight for age at admission to a
hospital unit.
• The classification therefore has a prognostic value for
hospitalized children.
 The Gomez classification of
malnutrition
• Weight for age (%) = Weight of the child x 100
Weight of a normal child of same age

Classification % of standard
weight for age
Normal >90
Grade I (mild malnutrition) 75-89.9
Grade II (moderate malnutrition) 60-74.9
Grade IIIa (severe malnutrition) <<60
 Disadvantages of Gomez Classification

• A cut off point of 90 percent of reference is high (80

percent being approximately equivalent to 2SD or
the 3rd percentile), thus some normal children may
be classified as 1st degree malnourished
• By measuring only weight for age it is difficult to
know if the low weight is due to a sudden acute
episode of malnutrition or to long-standing chronic
undermalnutrition.
 Waterlow’s Classification
• When a child’s age is known, measurement of weight
enables almost instant monitoring of growth :
measurements of height assess the effect of
nutritional status on long-term growth.
• Index: Height for age
% of NCHS reference Level of stunting
90-94% Mild
85-89% Moderate
<85% Severe
• Index: Weight for age
% of NCHS reference Level of wasting
80-89% Mild
70-79% Moderate
<79% Severe
 Wasting (thinness)
• Malnutrition with a low weight for a normal height,
in which the weight for height ratio is indicative of an
acute condition of rapid weight loss or wasting.
• An indicator of acute (short-term) malnutrition.
• Usually the result of recent food insecurity, infection
or acute illness such as diarrhoea.
• Measurement of wasting or thinness is often used to
assess the severity of an emergency situation, with
severe wasting being highly linked with the death of
a child.
 Stunting (shortness)
• Malnutrition with retarded growth, in which a drop
in the height/age ratio points to a chronic condition
shortness, or stunting
• An indicator of chronic (long-term) malnutrition.
• Often associated with poor development during
childhood and is one of the harmful effects of
poverty.
• Commonly used as an indicator for development, as
it is highly related with poverty.
 Wellcome classification of severe
forms of protein-energy malnutrition

% of standard Oedema Oedema

weight for age present absent
60-80 Kwashiorkor Undernourish
ment
<60 Marasmic Nutritional
kwashiorkor marasmus
 Kwashiorkor
• One of the serious forms of PEM.
• Cicely Williams introduced the word in 1931
• It is a word from Ghana means “the disease that the first child
gets when the new child comes”
• From birth an infant is usually breast feed - By the time child
reaches 1 to 1.5 years mother is probably pregnant or already
given birth again; Breast feeding is no more possible for the
first child
• This child’s diet abruptly changes from nutritious human milk
to native starchy roots which have low protein content
• Often associated with, or even precipitated by, infectious
diseases
 Clinical signs of kwashiorkor
• Oedema.
– usually starts with a slight swelling of the feet and often
spreads up the legs.
– later, the hands and face may also swell.
• Poor growth.
– the child will be found to be shorter than normal and,
except in cases of gross oedema, lighter in weight than
normal (usually 60 to 80 percent of standard or below 2 SD).
– may be obscured by oedema or ignorance of the child's age.
• Fatty infiltration of the liver.
– may cause palpable enlargement of the liver
• Wasting.
– Wasting of muscles is also typical but may not be evident
because of oedema.
– The child's arms and legs are thin because of muscle
wasting.
• Mental changes.
– child is usually apathetic about his or her surroundings
and irritable when moved or disturbed
• Hair changes.
– lacks lustre, is dull and lifeless and may change in colour to
brown or reddish brown.
– bands of discoloured hair are reported as a sign of
kwashiorkor. These reddish-brown stripes have been
termed the "flag sign”
• Skin changes.
– Darkly pigmented patches appear, which may peel off or
desquamate- "flaky-paint dermatosis"
• Anaemia
• Diarrhoea.
– Stools are frequently loose and contain undigested particles of
food.
• Moonface.
– The cheeks may appear to be swollen with either fatty tissue or
fluid,
• Signs of other deficiencies.
– of vitamin B deficiency are common.
– Xerosis or xerophthalmia resulting from vitamin A deficiency
– Deficiencies of zinc and other micronutrients
Characteristics of kwashiorkor
 Marasmus
• More prevalent than kwashiorkor.
• The word Marasmus means “to waste away”
• The main deficiency is one of food in general, and
therefore also of energy.
• May occur at any age, most commonly up to about
three and a half years, but in contrast to kwashiorkor
it is more common during the first year of life.
• Is in fact a form of starvation, and the possible
underlying causes are numerous.
 Precipitating causes of marasmus
• Infectious and parasitic diseases of childhood-
measles, whooping cough, diarrhoea, malaria and
other parasitic diseases.
• Chronic infections - tuberculosis
• Other common causes - premature birth, mental
deficiency and digestive upsets such as
malabsorption or vomiting.
• A very common cause is early cessation of
breastfeeding.
 Clinical features of marasmus
• Poor growth.
– the weight of the child found extremely low by normal
standards (below 60 percent or -3 SD of the standard).
– In severe cases, the loss of flesh is obvious
• Wasting.
– The muscles are always extremely wasted; little, if any
subcutaneous fat left.
– The skin hangs in wrinkles, especially around the buttocks
and thighs.
• Alertness.
– The child may be less miserable and less irritable.
• Appetite.
– The child often has a good appetite.
• Anorexia.
• Diarrhoea.
– Stools may be loose, but this is not a constant feature of
the disease.
– Diarrhoea of an infective nature, as mentioned above, may
commonly have been a precipitating factor.
• Anaemia.
• Skin sores.
– There may be pressure sores, but these are usually over
bony prominences, not in areas of friction.
• Hair changes.
– Changes similar to those in kwashiorkor can occur
• Dehydration.
– a frequent accompaniment of the disease; it results from
severe diarrhoea (and sometimes vomiting).
 Comparison of the features of
kwashiorkor and marasmus
Feature Kwashiorkor Marasmus
Growth failure Present Present
Wasting Present Present, marked
Oedema Present (sometimes Absent
mild)
Hair changes Common Less common
Mental changes Very common Uncommon
Dermatosis, flaky-paint Common Does not occur
Appetite Poor Good
Anaemia Severe (sometimes) Present, less severe
Subcutaneous fat Reduced but present Absent
Face May be oedematous Drawn in, monkey-like
Fatty infiltration of liver Present Absent
 Marasmic kwashiorkor
• Children with features of both nutritional marasmus
and kwashiorkor are diagnosed as having marasmic
kwashiorkor.
• In the Wellcome classification, this diagnosis is given
for a child with severe malnutrition who is found to
have both oedema and a weight for age below 60
percent of that expected for his or her age.
 Clinical features
• Features of nutritional marasmus:
– severe wasting, lack of subcutaneous fat and poor growth,
and in addition to oedema, which is always present, they
may also have any of the features of kwashiorkor
described above.
• Feature of kwashiorkar:
– There may be skin changes including flaky-paint
dermatosis, hair changes, mental changes and
hepatomegaly.
• Many of these children have diarrhoea.
 Underweight
• An indicator of both acute and chronic malnutrition.
• Highly useful indicator when examining nutritional
trends.
• It is the indicator used to monitor the Millennium
Development Goal (MDG) of ending hunger, and
targets of halving the prevalence of underweight
children and adults by 2015.
 Laboratory tests
• Serum albumin concentrations below 3 g/dl are low
and that those below 2.5 g/dl are seriously deficient
• Fasting serum insulin levels, which are elevated in
kwashiorkor and low in marasmus;
• Ratio of serum essential amino acids to non-essential
amino acids - low in kwashiorkor;
• Low hydroxyproline and creatinine levels in urine,
may indicate nutritional marasmus
 Severe Acute Malnutrition (SAM)

• Weight-for-height of 70% (extreme wasting)

• Presence of bilateral pitting edema of nutritional
origin, “edematous malnutrition
• Mid-upper-arm circumference of less than 110 mm
in children age 1-5 years old
 Complications of SAM
• ARI
• Diarrhea
• Gram negative septicemia
• Poor feeding
• Electrolyte abnormalities
 Preventive measures
• Health promotion
• Specific protection
• Early diagnosis and treatment
• Rehabilitation
• Health promotion
– Health education for pregnant and lactating women.
– Promotion of breast feeding
– Low cost weaning foods
– Correct feeding practices
– Family planning
• Specific protection
– Child’s diet must contain protein and high energy foods
– Immunization
– Food fortification
• Early diagnosis and treatment
– Periodic surveillance
– Early diagnosis and treatment of infections and diarrhoea
– Development of programmes for early rehydration of
children with diarrhoea
– Development of supplementary feeding programmes
during epidemics
– Deworming
• Rehabilitation
– Nutritional rehabilitation services
– Hospital treatment
– Follow-up care
MANAGEMENT
 Management of PEM
• Resuscitation
– Oral / intravenous rehydration
– Small infusion of plasma is beneficial when there is severe
peripheral circulatory failure
– Blood transfusion when anaemia
– Slow infusions
– Antibiotics to counter infections
– Hypothermia
– Hypoglycemia
• Feeding
– From 1st or 2nd day dilute milk feed with added sugar
– When this is accepted strength can be increased vegetable
oil added to give extra energy
– Fats are poorly tolerated by malnurished children
– Specially buffalo’s milk contain 7.5% fat it must be diluted
– When fresh milk not available milk preparations may
be used
– Evaporated milk 500 ml
– Full cream milk powder 150 grams
– Skimmed milk power 75 grams
– K – MIX2 UNICEF formula for initiation of treatment of
severe PEM
– Calcium caseinate 3 parts
– Skim milk powder 5 parts
– Sucrose 10 parts
– With added retinol palmitate
– The fluid need of children 150 ml / kg body weight / day
– 12 feeds are given every 2 hours
– When this well tolerated, 8 feeds can be given every 3
hours
– Later 6 feeds every 4 hour
– For rapid replacement of lost tissues and catch up growth,
children need a high energy diet.
• 200 kcal / kg body weight
– If child is very weak nasograstic tube may be used
– All children should receive daily supplement of vitamins
and minerals
• Rehabilitation
– Residential Units- NRC
– Day Care Centres
– Domicilliary Rehabilitation
 NUTRITIONAL REHABILITATION
CENTRE
• After treating the life-threatening problems in a
hospital or in a residential care facility, the child with
acute malnutrition will be transferred to NRC for
– intensive feeding to recover lost weight,
– development of emotional & physical stimulation,
– capacity building of the primary caregivers of the child
with acute malnutrition through sustained counselling and
– continuous behavioural change activities.
 Services to be provided at NRC
• Treatment &Patient management.
• Nutritional support to inmates.
• Nutrition education to his/her family members.
• Other counselling services viz. Family planning, Better
hygiene practices, Psycho-social care & development.
• Capacity building of the primary caregivers on
Preparation of low cost nutritious diet from locally
available food ingredients, Developing Feeding habits &
time management in mothers, imparting knowledge of
developing kitchen garden etc.
• Follow up Services