PEDIATRIC

UNDERNUTRITION
Dr Mohamed sheikh
Kwashkor
Marasmus
 Definition
• WHO defines Malnutrition as

– "the cellular imbalance between the supply of

nutrients and energy and the body’s demand for
them to ensure growth, maintenance, and specific
functions.“

Somalia situation:
1.2 million Children under-5 acutely malnourished in 2017
 Causes of malnutrition
• Protein-energy malnutrition (PEM) is a spectrum of conditions caused by
varying levels of protein and calorie deficiencies.

Primary PEM is caused Secondary PEM is due to

by social or economic • Increased caloric requirements
factors that result in a lack (infection, trauma, cancer)
• Increased caloric loss
of food, e.g.
(malabsorption),
• Early weaning with no •
Reduced caloric intake
proper replacement (anorexia, cancer, oral intake
• Early or sudden restriction, social factors),
separation of the child • Or combination of all the three
from the mother
• Poverty
 Malnutrition
Etiology
 The underlying causes of protein energy malnutrition
[PEM] are:
• Social and economic factors such as poverty and ignorance.
• Social factors such as food taboos
• Biologic factors such as maternal malnutrition, inadequate
intakes of breast milk and other foods.
• Environmental factors such as overcrowded and unsanitary
living condition.

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 Assessment of malnutrition
• height and weight for age,
• weight for height,
• mid-upper arm circumference
 Classification of under-nutrition

1. Marasmus
2. Kwashiorkor
3. Marasimic kwashiorkor (presents with a
combination of the above two)
4. Underweight
 Marasmus
• Marasmus results from the body’s physiologic
response to inadequate calories and nutrients.
• There are loss of muscle mass and subcutaneous fat
stores.
• Edema usually is absent.
• The skin is dry and thin, and the hair may be thin,
sparse, and easily pulled out.
• Marasmic children may be apathetic, weak, and may
be irritable when touched.
• Bradycardia and hypothermia signify severe and life-
threatening malnutrition.
Marasmus

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 Kwashiorkor
• Kwashiorkor results from inadequate protein intake in
the presence of fair to good caloric intake.
• Pitting lower limb edema that ascends to the upper part
of the body e.g moon face
• Apathy and lethargic
• The body weight is near normal for age because of
edema
• There are marked atrophy of muscle mass
• The hair is sparse; is easily plucked; and appears dull
brown, red, or yellow-white
• Skin changes e.g. hyperpigmentation, desquamation,
erythematous macular rash
 Creteria of admistion
• Severe acute malnutrition is defined as the
presence of any of the following:
• weight for height – more than 3 standard
deviations (more than −3 z-score) below the
median on the standard WHO growth chart.
• mid-upper-arm circumference (MUAC) – less
than 11.5 mm in children 6 months – 5 years old.
• bilateral oedema.
• Any complication
MUAC
 Management
• Most children with severe acute malnutrition
have an appetite and are alert and can be
managed within the community with ready-to-
use therapeutic food (RUTF), which has
revolutionized its treatment. It is based on
peanut butter mixed with dried skimmed milk
and vitamins and minerals and is consumed
directly by the child.
• Children with no appetite, severe oedema, a medical
complication or are less than 6 months old have
complicated
• severe acute malnutrition require hospital
• in-patient care; it has a high mortality, up to 30%. In
addition to protein and energy deficiency, there is
electrolyte and mineral deficiency (potassium, zinc and
magnesium) as well as micronutrient and vitamin
deficiency (vitamin A).
Medical complication that needs special care and
admission
 Acute management comprises the WHO’s 10
essential steps. Stabilization is to:
1. Treat or prevent hypoglycemia urgently
2. Treat or prevent hypothermia
3. Treat or prevent dehydration – but avoid
fluid overload as it may lead to heart failure.
The standard WHO oral rehydration solution
contains too much sodium (Na+ 75 mmol/l)
and too little.
 Con………
• potassium for severe acute malnutrition; they
should be given a special rehydration solution
• (ReSoMal). Rehydration should be provided
orally, by nasogastric tube if necessary.
Intravenous fluids are given only for shock
 Cont…………..
4. Correct electrolyte imbalance – especially
potassium and magnesium. Although plasma sodium
may be low, they have excess body sodium
5. Treat/prevent infection – give broad-spectrum
antibiotics; fever and other signs may be absent.
Treat oral Candida if present
6. Correct micronutrient deficiency – vitamin A and
other vitamins; contained specialized feeds.
Introduction of iron is delayed to 2nd week
 Cont………..
7. Initiate feeding – small volumes, frequently,
including through the night. Too rapid
feeding may result in diarrhoea. Specialized
feeds are widely available: initially Formula
75 (75 kcal/100 ml) which is low in protein
and sodium and high in carbohydrate is used,
subsequently Formula 100 (100 kcal/100 ml)
or ready-to-use therapeutic food.
 Cont…………….
• The remaining three steps are provided during
rehabilitation:
8. Achieve catch-up growth
9. Provide sensory stimulation and emotional
support
10.Provide for follow-up after recovery.
Management
 Underweight

Characterized by FTT (failure to thrive) in

addition to signs of infections and anemia may
be present.
• C/F;
– Growth failure
– Infection; G E, pneumonia, measles, malaria,
hookworms and schistosoma.
– Anemia [iron+ folic acid)
– Regression of developmental mileston
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 Complication of malnutrition
• Infection e.g. sepsis, pneumonia, and
gastroenteritis.
• Hypothermia and hypoglycemia
• Bradycardia and poor cardiac output
• Micronutrient deficiencies
• Anemia
• Growth stunting and delayed development
• Social deprivation and cognitive impairment
 Summary
Malnutrition
• Worldwide – contributes to about a third of all childhood deaths;
often a consequence of war and social disruption, as well as famine
and natural disasters.
• In developing countries – results from poverty, parental neglect or
poor education, restrictive diets, and in children with feeding
disorders, chronic illness.
• Can be identified by anthropometric measurement.
• • Marasmus – wasted, wizened appearance, apathetic.
• • Kwashiorkor – generalized oedema, sparse and depigmented hair,
skin rash, angular stomatitis, distended abdomen, enlarged liver,
and diarrhoea.
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