MALNUTRITION

PRESENTED BY:
Ms. Janet Chaudhary
M. Sc nursing 2nd year
1909719
 INTRODUCTION
• Undernutrition is widely recognized as a major
health problem in the developing countries like
India.

• Severe PEM often associated with infection

contributes to high child mortality in
underprivileged communities.

• Early malnutrition can have lasting effects on

growth and functional status.
 INTRODUCTION
• The frequency of undernutrition cannot be easily
estimated from the prevalence of commonly
recognized clinical syndromes of malnutrition
such as marasmus and kwashiorkor.

• Cases with mild to moderate undernutrition are

likely to remain unrecognized because clinical
criteria for their diagnosis are imprecise and
difficult to interpret accurately.
 DEFINITION
• Protein-energy malnutrition (PEM) is a potentially fatal body-
depletion disorder. It is the leading cause of death in children
in developing countries.

• Acute Malnutrition results in wasting (decrease in weight for

height) and occurs when food consumption is suddenly
severely reduced.

• Chronic under nutrition occurs when long term food

consumption is insufficient to cover the requirements for daily
energy expenditure. It results in stunting (decrease in height
for age).
 CLASSIFICATION
There are several classifications of PEM; known as
syndromal classification, Claasification by IAP, WHO
classification, WELLCOME Trust Classification,
Midarm Circumference Classification.
 SYNDROMAL CLASSIFICATION:
• Kwashiorkor
• Nutritional Marasmus
• Prekwashiorkor
• Nutritional Dwarfing
 CLASSIFICATION
• CLASSIFICATION BY IAP:

When the child is having weight more than 80 percent of expected

weight for age, considered normal. The grade of malnutrition is
described as follows:

•GRADE I: Between 71-80 % of expected weight for the age.

•GRADE II: Between 61-70 % of expected weight for that age.

•GRADE III: Between 51-60 %of expected weight for that age.

•GRADE IV: 50 %or less of weight expected for that age.

 CLASSIFICATION
• WHO CLASSIFICATION : This is based on all four
parameters i.e. weight for age, height for age, weight
for height and edema. WHO recommends three terms
i.e. stunting, underweight and wasting for assessing
the magnitude of malnutrition in under five children.
• STUNTING is defined as a child having a weight of less
than 90 percent from the median height for age of
WHO reference standards.
• WASTING is defined as a child having a less than 80
percent weight for height from the median of WHO
reference standards.
 WHO classification
This classification is used for assessing the
magnitude of malnutrition amongst under – five
children in national health programmes.
• Moderate undernutrition: No edema is present.
It also has wasting of muscles and stunting of
the growth.
• Severe undernutrition: It is edematous
malnutrition and has severe muscle wasting and
severe stunting of the height.
 CLASSIFICATION
• WELLCOME TRUST CLASSIFICATIONS: This is based on deficit in body
weight for age and presence or absence of edema.

• Children weighing between 60-80 percent of their expected weight for

age with edema are classified as Kwashiorkor.

• Those weighing between 60-80 percent of expected without edema

are known as having undernutrition.

• Those without edema ad weighing less than 60 percent of their

expected weight for age are considered to be having marasmus.

• Children with edema and body weight less than 60 percent of

expected are labelled as having marasmic kwashiorkor.
 CLASSIFICATION
• MIDARM CIRCUMFERENCE (MAC): This is known as an
age independent anthropometric between the ages of 1
and 5 years.

• MAC between the ages of 1-5 years should be more

than 13.5 cm.

• Those with a MAC of less than 12.5 cm are considered

malnourished.

• Children with MAC between 12.5 and 13.5 cm are

termed borderline.
 ETIOLOGY
IMMEDIATE DETERMINANTS:

• The immediate determinants of a child

nutritional status work at the individual level.
• They include inadequate dietary intake and
illness.
• These two often work synergistically and have an
immediate effect on the nutritional status of the
individual.
 ETIOLOGY
UNDERLYING DETERMINANTS:
• The immediate determinants are in turn influenced by three household
level underlying determinants namely food, health and care.

• This in turn depends on having financial, physical and social access as

distinct from mere availability.

• The factors that determine adequate household food security, care and
health are related to the resource, their control and a host of political,
cultural and social factors that affect their utilization.

• Resources include human, economic and organization resource.

Embedded in human resources are skills, motivation and knowledge
which is also influenced by education.
 ETILOGY
• BASIC DETREMINANTS: the underlying
determinants are influenced by the basic
determinants.
 CLINICAL MANIFESTATION
MILD MALNUTRITION:It is most common between the ages of 9 months to 2
years. Main features are:

• Growth failure: This is manifested by slowing or cessation of linear growth,

static or decline in weight, decrease in mid arm circumference, delayed bone
maturation, normal or diminished weight for height Z scores and normal or
diminished skin fold thickness.

• Infection: A high rate of infection involving various organ systems may seen
e.g. gastroenteritis .

• Anemia: May be mild to moderate and any morphological type may be seen

• Activity: This may be diminished.

• Skin and hair changes: These may occur rarely.

 CLINICAL MANIFESTATION
• MODERATE TO SEVER MALNUTRITION:
Moderate to severe malnutrition is associated with one of
classical syndromes namely marasmus, kwashiorkor or with
manifestation of both.

• KWASHIORKOR: Kwashiorkor was introduced in 1935

according to local name for the disease in Ghana. The term
was said to mean “red boy” due to characteristic
pigmentary changes.

• Kwashiorkor means deficiency of only protein. The

presenting features can be divided into two groups, i.e.
essential and non-essential features.
 KWASHIORKAR
ESSENTIAL FEATURES:
• Edema starts in the lower extremities and later involves upper
limbs and the face. Muscles of the upper limbs are wasted, but the
lower extremities appear swollen. The face appears moon shaped
and puffy. The trunk is affected to a lesser extent. Debilitating
illnesses such as measles or diarrhea can precipitate edema.

• Marked growth retardation with low weight and low height

gain.Muscles wasting with retention of some subcutaneous fat.

• Psychomotor changes characterized by mental apathy with listless,

inertness, lack of interest about the surrounding, lethargy, dullness
and loss of appetite. Pitting edema, especially over the pretibial
region due to hypoalbunemia .
 KWASHIORKAR
NON-ESSENTIAL FEATURES:

• Hair changes: Hair changes are found as light colored hair or reddish brown hair
which becomes thin, dry, coarse. The affected child may have alopecia with
alternate band of light and dark color hair as ‘flag sign’ which indicates period
of inadequate, adequate and inadequate nutrition over a prolonged period.

• Skin changes: It is found initially with erythema and hyperpigmented skin

patches. The skin becomes dry and hyperkeratotic. The epidermis peels off in
large scales, exposing tender raw area underneath. It gives appearance of old
faint flaking off the surface of the wood. Petechiae or ecchymosis appear in
severe cases.

• Superadded infections: These children usually suffer from repeated infections

of GI tract with diarrhea, vomiting, anorexia and dehydration. Respiratory
infections, skin infections and septicaemia are common and difficult to manage
in these patients.
 NUTRITIONAL MARASMUS
• It results from prolonged starvation. It may also result from chronic or
recurring infections with marginal food intake.

• The main sign is a severe wasting.

• The child appears very thin and has no fat. Most of the fat and muscle mass
having been expended to provide energy.

• There is severe wasting of the shoulders, arms buttocks and thighs. The loss
of buccal pad of fat creates the aged or wrinkled appearance that has been
referred to as “monkey facies”.

• “Baggy pants appearance” refers to loose skin of the buttocks hanging down.
Affected children may appear to be alert in spite of their condition.

• There is no edema.
 NUTRITIONAL MARASMUS
ESSENTIAL FEATURES:

• Marked growth retardation with less than 60

percent of expected weight for age and
subnormal height/length.

• Gross wasting of muscle and subcutaneous

tissues.

• Marked stunting and absence of edema.

 NUTRITIONAL MARASMUS
NON-ESSENTIAL FEATURES:
• Hair changes usually not present or may be hypopigmented.

• Skin looks dry, scaly with prominent loose folds and having reduced mid upper
arm circumference.

• Superadded infections are common. Skin infections and diarrhoea with

vomiting and abdominal distension usually occur.

• Liver usually shrunk and child having craving for food and hunger.

• Psychomotor changes usually present with irritability and apathy.

• Features of mineral deficiencies and vitamin deficiencies are usually found.

 MARASMIC KWASHIORKOR:
• It is a condition where the child
manifested both the features of
marasmus and kwashiorkor. The
presence of edema is essential for the
diagnosis and other signs of
kwashiorkor may or may not be present.
 PREKWASHIORKOR
• It is a condition when the child is having
features of kwashiorkor without the edema.
If the early management is initiated by early
diagnosis of the condition, the child may be
protected from the full blown kwashiorkor.
 NUTRITIONAL DWARFING
• It is a condition when the child is having
significant low weight and height for the age
without any overt features of kwashiorkor or
marasmus. It is usually seen when the PEM
continue over a number of years.
 MANAGEMENT OF PEM
MILD AND MODERATE MALNUTRITION:
• The mainstay of treatment is provision of adequate
amounts of protein and energy. Experience has shown that
at least 150kcal/kg/day should be given.

• A protein intake of 3 g/kg/day is sufficient. Milk is the most

frequent source of the protein used in therapeutic diets
through other sources including vegetable protein mixtures
have been used successfully.

• Adequate minerals and vitamins should be provided for the

appropriate duration.
 MANAGEMENT
SEVERE MALNUTRITION:
• The WHO has developed guidelines for the management of severe
malnutrition based on sound pathophysiological principles and
extensive research and these have been adapted for Indian scenarios
by the Indian academy of paediatrics (IAP).

• At the community level, the presence of severe wasting or edema or

a mid upper arm circumgference (MUAC) of < 11.5 cm are suitable
criteria to identify severely wasted children aged 6 – 59 months.

• For children < 6 months, in place of using antropometric criteria

visible severe wasting or bilateral edema should be used for
determining severe malnutrition.
 THERAPEUTIC DIET
• Therapeutic diet should provide 150 kcal/kg/day for
moderately undernourished and about
200kcal/kg/day for severely malnourished children.
About 10-15 percent of total calories should be
obtained from proteins.

• The diet prescribed for the child should be such,

which the family can afford to provide for the baby
within the its limited income, can be easily cooked
at home, is culturally acceptable and easily
available in the local market.
 THERAPEUTIC DIET
• Milk based diets may not be tolerated by some
malnourished infants in the first few days due to
transient lactose intolerance. If tolerated, milk based
diets are most suitable at the beginning of the treatment.

• Sugar and oil should be added to provide extra calories.

• It is necessary to introduce semisolid diet with high

calories and protein content, a week after the start of the
therapy.
LACTOSE MALABSORPTION:
• Some malnourished children do not tolerate
milk because of associated lactose intolerance.
This should be suspected if the pH of the stools
is lower than 5.5 on two separate occasions,
while the child is on milk diet.

• In such children it is desirable to substitute a

part of milk feeds by formulatebased on lactose
free milk protein, sugar and oil, soyabean, meat
or vegetable protein mixtures.
 TREATING ASSOCIATED CONDITIONS
• Concurrent nutritional deficiencies should be treated
promptly.
• Administer vitamin A immediately on admission,
otherwise the child may become blind.
• Also give packed cell transfusion, if there is severe
anemia.
• Immediately give vitamin K, folic acid and magnesium
sulphate.
• Provide all vitamin and mineral supplements.
• Start oral iron therapy after one week.
• These patients should also be treated with vitamin D.
 TREATMENT OF COMPLICATIONS
• Severely malnourished children have to be SHIELDED
(treated or prevented) against:

• S - Sugar deficiency i.e. hypoglycaemia

• H - Hypothermia
• I - Infection and septic shock
• EL - Electrolyte imbalance
• DE - Dehydration
• D - Deficiencies of iron, vitamins and other
micronutrients.
• HYPOGLYCEMIA: Intravenous infusion of 5-10 Ml/kg of
10 percent glucose solution should be given at start of
therapy to prevent hypoglycaemia deaths.

• HYPOTHERMIA: Use kangaroo mother care or cloths the

child well including the head. Cover with a warm
blanket, specially during the night.

• INFECTIONS: The child should be clinically examined for

the presence of infections and adequately treated.
Antibiotics should be chosen depending on body weight
rather than the age of the child. For empirical therapy
ampicillin is useful in combination with gentamicin. If
child does not respond, suspect tuberculosis.
• SEPTIC SHOCK: All such children should be first treated with IV
fluids for first 2 hours as for severe dehydration. If there is no
change in condition den broad spectrum antibiotics should be
initiated. Blood transfusion or plasma is infused slowly at the rate
of 10 Ml / kg slowly over a period of at least 3 hours.

• DEHYDRATION: Intavenous therapy should be given for severe

dehydration and shock, initially in the form of Ringer’s lactate or
N/2 saline in 5 percent dextrose followed by N/6 saline in 5
percent dextrose. This should be followed by administration of
the same solution at half rate for next 12 hours.

• ELECTROLYTE IMBALANCE: Sodium intake should be restricted to

prevent sodium overload and water retention during the initial
phases of treatment. Hypertonic saline should not be used even
in case of hyponatremia.
 EARLY DIAGNOSIS AND TREATMENT
• Periodic health check- up of all children for health supervision and
maintenance of growth chart.

• Detection of growth lag or growth failure as early as possible.

• Early diagnosis and management of infections, worm infestations

and common childhood illnesses.

• Promotion of early rehydration therapy in the child having

diarrhea, without restriction of feeding.

• Implementation of supplementary feeding programs and services.

 REHABILITATION
• Nutritional rehabilitation services.

• Hospital management of advanced PEM

cases.

• Follow-up care.
 NURSING RESPONSIBILITIES
• Assessment of nutritional status of the children with collection of appropriate
dietary history, including history of breastfeeding, weaning, food habits,
balanced diet, socio economic status, presence of illness etc.

• Assisting in diagnostic investigations whenever necessary.

• Maintenance of growth chart by regular health checkup at home, clinic or

health centers for early detection of growth failure.

• Participating in the hospital management in complications and life threatening

situations related to PEM and other related illnesses.

• Implementing nutritional rehabilitation activities.

 NURSING RESPONSIBILITIES
• Encouraging the parents for home care and follow-up at regular
interval.

• Nutrition education, demonstration and counselling according to

identified problems of particular child. Informing about breast feeding,
weaning, balanced diet, food hygiene, personal hygiene, quality of
common foods, food values and food preservations etc.

• Promoting preventive measures for individual, family and community

to overcome the problem of PEM.

• Co-operating with other team members and acting with different

sectors for the implementation of various nutritional services (e.g.
working with Anganwadi workers).
 NURSING RESPONSIBILITIES
• Maintaining records and reports related to nutritional
assessment of individual and community.

• Assisting in implementation of national nutritional

programs for prevention of various malnutrition.

• Participating in nutritional research project and

assisting in modification of nutritional behaviors by
creating awareness in individual, family and
community towards appropriate nutritional practices
for better nutritional status.
THANK YOU