Malnutrition

HUMAN NUTRITION

 Nutrients are substances that are crucial for human

life, growth & well-being.
 Macronutrients (carbohydrates, lipids, proteins &
water) are needed for energy and cell multiplication
& repair.
 Micronutrients: are trace elements & vitamins,
which are essential for metabolic processes.
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Types of Malnutrition

 Under nutrition: too little

 Protein Energy Malnutrition(PEM)
 Micronutrient deficiencies
 Overnutrition: too much
 Obesity
 Chronic diseases (diabetes, hypertension,..

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 Cont...

 Micronutrient malnutrition -- arises from inadequate

vitamin and mineral supply to cells in body to satisfy
physiological requirements
– Vitamin A, Iron & Iodine

– Others: Zinc, vitamin D

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Assessment of Nutritional status
 Direct method
 Clinical
 Anthropometric
 Dietary
 Laboratory
 Indirect method
 Health statistics
 Ecological variables

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 Clinical Assessment
 Useful in severe forms of PEM
 Based on physical examination for features of PEM & vitamin deficiencies.
 Focuses on skin, eye, hair, mouth & bones.
 Deficiency signs such as hair changes, anemia, xerosis, cheilosis, angular
stomatitis, bleeding spongy gums, dental caries, etc. should be actively looked for.
 ADVANTAGES - Fast & Easy to perform
- Inexpensive, - Non-invasive LIMITATIONS -
Did not detect early cases
- Trained staff needed

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 ANTHROPOMETRY
 Anthropometry is a very valuable index for evaluation of
nutritional status.
 Objective with high specificity & sensitivity
 Measuring Ht, Wt, MUAC, HC, skin fold thickness & BMI
 Reading are numerical & readable on standard growth charts
 Non-expensive & need minimal training

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ANTHROPOMETRY

 LIMITATIONS
 Inter-observers’ errors in measurement
 Limited nutritional diagnosis
 Problems with reference standards
 Arbitrary statistical cut-off levels for abnormality

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LAB ASSESSMENT

Biochemical


 Serum proteins,

Hematological


 CBC, iron, vitamin levels

Microbiology


 Parasites/infection

DIETARY ASSESSMENT
Breast & complementary feeding details


24 hr dietary recall


Home visits


Calculation of protein & Calorie content of children foods.



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 Terms/Acronyms
 F75 -Therapeutic milk used only in Phase 1 of treatment for SAM
 F100 -Therapeutic milk used in Transition Phase and Phase 2 of treatment of
SAM (for inpatients only)
 IU -International Units
 MUAC- Mid Upper Arm Circumference
 OTP -Out-patient Therapeutic Programme (treatment of SAM at home)
 ReSoMal -Oral REhydration SOlution for severely MALnourished patients
 RUTF- Ready-to-Use Therapeutic Food
 SAM -Severe Acute Malnutrition (wasting and/or nutritional oedema)
 SFP- Supplementary Feeding Programme
 TFU- Therapeutic Feeding Unit (in hospital, health centre or other facility)
 TFP- Therapeutic Feeding Programme
 Causes

 Immediate: At individual level( inadequate food intake &

Disease…)
 Underlying causes: At house hold level or community (House
Hold food insecurity, Care & social env’t (drought, war) , poor
access to health & the health env't…)
 Basic causes: at county level or society at large (Formal &
Informal Infrastructure, education, Political Ideology &
Resources…)
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 PROTEIN-ENERGY MALNUTRITION (PEM)
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• PEM results when the body's needs for protein and

energy fuels are not satisfied by the diet.
• It is accompanied by deficiency of several
micronutrients
• Severity ranges from milder forms weight loss or
growth retardation to distinct clinical features
marasmus, kwashiorkor or marasmic kwashiorkor
 Cont..
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 Primary PEM due to inadequate food intake

 Secondary PEM other disease lead to
 low food ingestion,
 inadequate nutrient absorption or
 utilization,

 increased nutritional requirements,

 increased nutrient losses
PATHOPHYSIOLOGY AND ADAPTIVE RESPONSES
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 The exact pathophysiology of PEM Is unknown.

 However the following possible explanations are
considered based on

1. Aflatoxin poisoning theory Reading assignment

2. Free radical theory

 effects of malnutrition on d/t organs
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 Body composition
 Total body water increases(ECF)
 Increased Na+
 Decreased K+ and Mg++
 Muscle and fat loss
 GIT
 Villus atrophy
 Reduced enzymes
 Bacterial over growth
End organ effects of malnutrition
 Liver
 Reduced synthesis of protein
 Impaired gluconeogenesis
 Decreased metabolism of toxins and substances
 Cardiac
 Myocardial atrophy, reduced cardiac out put , decreased
BP
 Hematology :anemia
 Metabolic
 Hypoglycemia
 Reduced metabolic rate
End organ effects of malnutrition
 Immunity
 Impaired especially the Cell mediated
 Reduced IgA
 Reduced phagocytosis
 Inflammatory response
 Impaired acute phase response
 Reduced chemotaxis of WBC to site of infection/
inflammation
 Prone to infectious agents/subtle signs
 Classification of PEM
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 Welcome: Welcome uses the weight for age

measured by Harvard curve. It differentiate b/n the
types of malnutrition but not whether acute or
chronic
Weight for age Edema- Edema +

60-80% Underweight Kwashaikor

<60% Marasmic Marasmickwash

 Water low classification

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 Water low is better in understanding the type of malnutrition and
its duration. Wasting showing acute malnutrition and stunting
showing chronic malnutrition

Grade of Wt/ht (Wasting ) Ht /age (Stunting )

malnutrition
Normal > or=90% > or=95%

Mild 80-89% 90-94%

Moderate 70-79% 85-89%

severe <70% <85%

Gomez
 Gomez : wt for age=wt of subject/wt of normal
child of same ageX100
 Short comings
 Did not differentiate b/n acute vs chronic and types of
malnutrition.
 Age may not be known in developing countries
Wt for age Degree of malnutrition
90-109% normal
75-89% mild
60-74 moderate
<60 severe
 Clinical manifestations
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Marasmus = Greek term means to waste

 It is an adaptive process
 Generalized muscle wasting and absence of subcutaneous
fat “bone and skin appearance” or old man’s face
 Hair sparse, thin, dry & easily pulled out
 Skin is dry, thin with little elasticity, and wrinkles easily
 Cont…
23

 Patients are apathetic but usually aware and have a look

of anxiety on their face
 Some are anorexic, whereas others are ravenously
hungry
 Diarrhea, vomiting, abdominal distension
 Heart rate, blood pressure, and body temperature may
be low
 Hypoglycemia
 Kwashiorkor
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 Edema
◦ bilateral pitting ,painless of the feet and legs in severe
cases may involve the upper extremities and face
 Skin lesions are usually present
◦ include Hyperpigmentation, hypopigmentation
desquamation and ulceration (flaky paint dermatosis)
◦ affected site areas of edema, continuous pressure
( buttocks and back), or frequent irritation (perineum
and thighs).
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  The extent of dermatosis can be described in the
following way:
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+ mild: discoloration or a few rough patches of skin

+ + moderate: multiple patches on arms and/or legs

+ + + severe: flaking skin, raw skin, fissures

(openings in the skin)
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 Hair
29 

 dry, fine, straight, without its normal sheen, and can

be pulled out easily
 Color usually changes to brown, red, or even
yellowish white
 “Flag sign” Alternating periods of poor and
relatively good protein intake can produce
alternating bands of depigmented and normal hair
 Flag sign
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  Mental status
31

 apathetic and irritable, cry easily, and expression of

misery and sadness
 Gastrointestinal
 Anorexia, postprandial vomiting, and diarrhea
 Hepatomegaly
 abdomen distention.
  Marasmic- kwashiorkor
32

 combines clinical characteristics of kwashiorkor and

marasmus
 edema of kwashiorkor, with or without its skin
lesions, and the muscle wasting and decreased
subcutaneous fat of marasmus
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Management
The criteria to classify severe acute malnutrition for 6
month
36
-5years

 W/H or W/L < 70%

or
 MUAC < 11.5cm
or
 Presence of bilateral pitting edema
 Admission to in patient
37

 SAM plus
 at least one Medical complication or
 Failed appetite test or
 Edema +++ or
 Wt/ht< 70% with edema or
 Medical complications

38

Unable to breast feed drink or feed or vomiting everything



 Convulsions
Very Weak, Lethargic or unconscious


Pneumonia/severe pneumonia


Hypothermia or Fever >39 0C



Shock, Severe DHN, Hypoglycaemia



Severe anemia, Jaundice, Bleeding Tendencies



Dermatosis +++


Dysentery, Persistent diarrhoea


 Treatment at a outpatient treating program
39

 WFL/H < 70% of median or

 MUAC <11.5cm or
 Edema of both feet (+, ++)

AND(give attention)
 No medical complication AND pass appetite test
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Infants less than 6 months

 WFL < 70% of median or
OR
 Visible severe wasting,
OR
 Edema of both feet
 Admit for inpatient treatment( with out
considering medical complication and appetite test)
 Apptite test
41
 Phase 1 nutritional management
42

Principles of phase 1 treatment

 Feed the patient F 75
 Routine medications
 Monitor the patient
 Prevent, diagnose and treat complications
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1. F75 =75 kcal per 100ml

 Has less Na, proteins, fats, lower osmolarity
and renal solute load
 Less energy dense
 75kcal/100ml and 0.9g protein / 100ml
 Is given 8 times per day
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 Use NG tube when

 Taking less than 75% of prescribed diet per 24 hours
in Phase 1
 Pneumonia with a rapid respiration rate
 Painful lesions of the mouth
 Cleft palate or other physical deformity
 Disturbances of consciousness
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2. Routine medicines
 Vitamin A for all children except those with edema
or those who received vitamin A in the past 6
months
 On the day of admission and on the day of
discharge
 6-11months 100,000IU
 >12months 200,000IU
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 Folic acid single dose of folic acid 5mg to children with

clinical signs of anemia
 Antibiotics:
 First line : amoxicillin
 Second line :chloramphenicol or gentamycin
 Measles vaccine: all children > 9 months without a
vaccination card on admission and discharge after
Phase 2
 3. Surveillance (monitoring)
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 Weight each day

 degree of edema each day
 Body temperature twice per day
 stool, vomiting, dehydration, cough, respiration and
liver size assessed each day
 MUAC is taken each week
 Length or Height is taken after 21 days
 4. Complications
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 Dehydration
-All signs of dehydration in normal child are present
in severe malnourished children with no
dehydration
-History of significant recent fluid loss and history of
a recent change in the child’s appearance
- Rx resomal solution 50-100ml over 12hrs
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 Replace ongoing loss with 30 ml of ReSoMal per

watery stool for oedematous children and with 50-
100 ml for non-oedematous children under 2 years
 If the child has already received IV fluids for shock
and is switching to ReSoMal, omit the first 2-hour
treatment and start with the amount for the next
period of up to 10 hours.
ReSoMal
 An oral rehydration solution developed for use in severely
malnourished children.
 It consists of the standard WHO rehydration oral solution
(ORS) that has been modified by decreasing sodium and
increasing potassium concentrations .
 This solution is used to correct the hypernatremia and
potassium deficiency that occur in severe malnutrition.
 ReSoMal is available commercially.
 This solution also can be made by diluting one packet of the
standard WHO-recommended ORS in two, instead of one,
liters of water and adding 50 g of sucrose (25 g/L) and 40
mL (20 ml/L) of mineral mix solution. 50 g of sucrose is
approximately 4 tablespoons.
 Congestive heart failure
51

 C/F weight gain, tachycardia, tachypenia, engorged neck

veins, gallop rhythm, increase in lived size and tender,
creptation
 Stop all fluids and feeds, small sugar in water solution
orally
 Furosemide 1mg/kg
 Digoxin in small doses 5microgram/kg
 Even if severely anemic don’t transfuse manage heart
failure first
 Anemia
52

 Hgb <4g/dl or HCT <12% during the first 48hrs of

admission
 Give 10ml/kg of whole blood or packed RBC over 3
hr
 Hypoglycemia
53

 In severely malnourished children, the level

considered low is less than <54 mg/dl
 Clinical signs that occur in normal person doesn’t
occur in malnourished children
 Eye lead retraction is one important sign
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 If conscious -50 ml of 10%sugar in water or F75

diet by mouth
 If loosing consciousness -give 50 ml of 10% sugar-
water by naso-gastric tube
 If unconscious - 5ml/kg of 10% glucose solution IV,
followed by 50 ml of 10% sugar by NG tube
 Hypothermia
55

 Rectal temperature below 35.5oC or under arm

temperature below 35oC
 Commonest cause is due to environmental or lack of cover

-Use the “kangaroo technique” for children with a caretaker

-Put a hat on the child and wrap mother and child together
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-The room should be kept warm, especially at

night thermo-neutral temperature range for
malnourished patients is 28oC to 32oC

-Treat for hypoglycemia and give second-line

antibiotic treatment
 Transition phase
57

 The criteria to progress from Phase 1 to Transition Phase are :

1. Return of appetite and
2. Beginning of loss of edema and
3. No IV line, no NGT
 F100(100kcal/100ml) is given same amount as phase 1, 8times per
day
 Lasts 1 to 5 days
 Energy intake increases by 30%
 Expected wt gain is 6g/Kg/day
 Criteria to move back from Transition phase to Phase 1
58

 Rapid weight gain greater than 10g/kg/d

 Edema increasing or development of edema
 Rapid increase in the size of the liver
 Any signs of fluid overload develop
 Tense abdominal distension
 Cont….
59

 significant re-feeding diarrhea resulting weight los

 Naso-Gastric Tube is needed
 If patient takes less than 75% of the feeds in
Transition Phase
 Criteria to progress from Transition
phase to Phase 2
60

1. Good appetite
2. Complete loss of edema
3. No other medical problems
 Management of Phase 2
61

 F100 (100ml = 100 kcal): five feeds per day or

Ready to use therapeutic feeding(RUTF)
 One porridge may be given for patients who are
more than 8kg
 Phase 2 management can be done as out patient
at home or in therapeutic feeding center
 Wt gain 8g/kg/day
 Routine medications
62

 Iron: is added to the F100 in Phase 2

 De-worming: Albendazole or Mebendazole
is given at the start of the Phase 2
Age <1 year 1 to 2 years >= 2years

Albendazole 400mg Not given ½ tablet once 1 tablet once

Mebendazole 100mg Not given 2½ tablet once 5 tablets once

 Failure to respond to treatment
63
 Causes of treatment failure
64

 Problems with the treatment facility

1. Poor environment for malnourished children

2. Poorly trained staff

3. Inaccurate weighing machines

4. Food prepared or given incorrectly

 Problems of individual children
65

1. Insufficient food given

2. Malabsorption

3. Infection, especially: Diarrhoea, dysentery,

pneumonia, tuberculosis, urinary infection

4. Other serious underlying disease: congenital

abnormalities (e.g. Down’s syndrome)
 Discharge criteria
66

 W/L>=85% or W/H>=85% =(Two days for in-

patients, two weeks for out-patients)

and
 No edema for 10 days (In-patient)
 Vaccination updated
 Education to the mother is given
 Follow-up after discharge
67

 The patients should be enrolled in a

Supplementary Feeding Program and given
nutritional support for another 4 months
 Reference values for the main indicators
68
 Poor prognostic factors for PEM
69

1. Age <6 months

2. Deficit in wt/ht >30%, or in wt/ age >40%
3. Signs of circulatory collapse
4. Altered mental status
5. Infections
6. Bleeding tendencies
7. Dehydration and electrolyte disturbances
70
Cont..
8. Congestive heart failure

9. Total serum proteins <30 g/L

10. Severe anemia

11. Clinical jaundice or elevated serum bilirubin

12. Extensive exudative or exfoliative cutaneous

lesions or deep decubitus ulcerations

13. Hypoglycemia or Hypothermia

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