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Malnutrition in developing
countries
Neonatal
37%
Emily Walton
Stephen Allen
Abstract
Over a third of
all deaths are
attributable to
undernutrition
Diarrhoea
17%
Pneumonia
19%
Based on data of the Child Mortality Estimation Group used in the UNICEF
report The State of the Worlds Children 2008
Box 1
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WHZ less than 2 and 9.4 for WHZ less than 3. Therefore,
severely wasted children are the focus of in-patient treatment
programmes.
In the resource limited settings where malnutrition is
common, accurate measurement of weight and height may not
be possible and calculation of age and access to, and correct use
of, the reference norms may also be difficult. MUAC (mid upper
arm circumference) may be more appropriate in these situations
as it can be measured more easily. MUAC is relatively constant
from 6 months to 5 years avoiding the requirement for accurate
calculation of age. MUAC of less than 11.5 cm and WHZ of
less 3 identify similar proportions of children and are associated with similar risks of mortality.
In the most basic settings where no measurements are
possible, diagnosis is based on the presence of visible signs of
severe wasting and nutritional oedema. There are two wellrecognized malnutrition syndromes. Children with marasmus
(see Figure 2) have severe muscle wasting and minimal adipose
tissue; they are often noted to be irritable. Children with
kwashiorkor (see Figure 3) present with oedema and may show
other classical features including dermatitis, sparse depigmented
hair and hepatomegaly; they are typically described as apathetic.
Nutritional oedema (i.e. pitting oedema of both feet with no
identifiable cause such as nephrosis) increases weight and,
therefore, may result in a misleadingly high WHZ score. Many
children present with clinical features of both syndromes.
Whichever diagnostic criteria are used, they must be applied
consistently. All children who present to a health facility, whatever the reason, should have their nutritional status assessed. If
treatment is prescribed for the presenting condition but there is
a failure to identify and address underlying malnutrition then an
opportunity to reduce long-term mortality has been lost.
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History
History of presenting complaint
Appetite e recent oral intake
C Recent weight change/swelling of feet
C Diarrhoea (frequency, consistency, presence of blood)
C Fever
C Cough (acute or chronic)
C
Box 2
Clinical evaluation
History
Aspects of the history to be covered in all malnourished children
are listed in Box 2. A thorough dietary history is necessary to
elicit inappropriate feeding practices such as supplementation of
breast milk with water, early or late weaning and withholding
feeds during diarrhoea. A detailed social history is also vital to
obtain background information on the family and the mothers
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these two groups is the appetite test. A good appetite is a reliable sign that the child does not have any serious hidden
complications. The child is encouraged to eat an appropriate
portion of ready-to-use therapeutic food (RUTF) over the course
of about an hour. The child who has appetite and no obvious
complications can embark immediately on an OTP.
RUTFs are high energy and protein foods enriched with
electrolytes, minerals and vitamins. They will keep for months at
ambient temperature in the packaging they are distributed in and
do not require cooking or the addition of water. This makes them
microbiologically safe even in the harsh environments of the
developing world. Plumpy Nut, the most widely used, is made
from peanut paste, milk powder, oil and sugar with added
potassium, magnesium, vitamins and minerals. Each 92 g sachet
provides 500 kcal.
OTPs are usually based in local health centres. At registration
the child will be given a course of broad spectrum oral antibiotics.
They then attend weekly for weighing and for the distribution of
quantities of RUTF appropriate to their current weight. OTPs are
generally popular with families but weight gain is usually not as
rapid as in in-patient programmes. RUTFs are very palatable and
in home based treatment there may be a temptation to share
rations with other children (and adults!) in the household.
OTPs are also the most appropriate setting to manage
moderate malnutrition. The aim is to provide nutritious food
rations, preferably based on locally available foods, and appropriate health education to promote recovery and, critically,
prevent progression to severe malnutrition.
Examination
C
C
C
C
C
C
C
C
Box 3
Investigations
Access to investigations is likely to be limited in the resource
limited settings where malnutrition is prevalent. If blood glucose
cannot be measured, then presumptive treatment for hypoglycaemia should be initiated. The presence and degree of
anaemia may need to be assessed clinically. In parts of the world
where malaria is endemic, a blood film should be examined for
malarial parasites.
Even if available, measurement of plasma electrolytes may be
misleading as they will not accurately reflect total body stores
and, therefore, empirical management may actually be safer than
using plasma levels to guide fluid therapy.
Other investigations include a chest X-ray (to screen for TB)
and HIV testing (discussed later). It is unlikely that a specific
pathogen will be identified in persistent diarrhoea but stool
culture is indicated in dysentery.
Management
Where should malnourished children be managed?
Current guidelines recommend integrated management involving
both in-patient and community services. Children with complications (severe infections or metabolic disturbances) should
begin treatment in an in-patient facility whereas those with no
complications can progress directly to an out-patient therapeutic
programme (OTP). A simple test to help discriminate between
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Stabilization
Days 12
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Hypoglycaemia
Hypothermia
Dehydration
Electrolytes
Infection
Micronutrients
Initiate feeding
Catch-up growth
Sensory stimulation
Prepare for follow-up
Days 37
NO IRON
Rehabilitation
Weeks 26
WITH IRON
Taken from the World Health Organizations Pocket book of Hospital care for children 2005.
Figure 4 Outline of priorities and time frame in the management of severe acute malnutrition.
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the disease to ensure that families are not stigmatized and that
children do not receive inferior care due to a belief that their
demise is inevitable. HIV positive malnourished children should
follow the same protocol as HIV negative children with the
addition of prophylactic co-trimoxazole. Severe oral thrush can
inhibit feeding and may need treatment with fluconazole. When
to start antiretrovirals should be based on the level of immunosuppression (CD4 count) and stage of malnutrition treatment
according to local protocols.
Prevention
As detailed above, management of the severely malnourished
child presents a huge challenge, especially in inadequately staffed and resourced health facilities. Even when the WHO 10 steps
are applied rigorously, mortality often remains high. Therefore,
prevention of malnutrition is a priority for governments and
other organizations interested in reducing child mortality. As
malnutrition is both a medical and socioeconomic condition,
a range of interventions are necessary.
An essential component of any preventive strategy is the
promotion of breastfeeding. The WHO recommends exclusive
breastfeeding until 6 months of age with supplementary breast
milk forming an important part of the diet up to 2 years of age.
Currently only 24e32% of infants in developing countries are
exclusively breastfed up to 6 months. The WHO ranks suboptimal breastfeeding as the 7th most significant risk factor for
global burden of disease. The uncompromising guidelines of the
Baby Friendly Hospital Initiative e now familiar in many UK
maternity units e were originally intended for use in the developing world where breastfeeding is truly a life-saving intervention. Infant formula milks are inferior to breast milk both in
nutritional composition and lack of immunological protection
against infectious diseases, in particular gastroenteritis and
pneumonia. In poor societies where many mothers are illiterate
and innumerate, producing appropriately concentrated and
hygienic milk from instructions on a tin of powder is unlikely to
be achieved. Furthermore, the cost may result in a temptation to
over-dilute infant formula or to purchase a cheaper, nonmodified, animal milk.
Other health education approaches include the promotion of
nutrient rich weaning foods and discouraging the over-reliance
on carbohydrate dense staple foods. This is combined with an
active programme of routine child health surveillance with
regular weight monitoring to detect children at risk of severe
malnutrition and target interventions. Increasing coverage of
immunization and vitamin A supplementation should help
prevent the infectious diseases that can often trigger severe
malnutrition in an already undernourished child. Primary care
services must also be available to ensure the prompt treatment of
childhood illnesses that can precipitate or worsen malnutrition.
Improvement of a communitys sanitation and hygiene via the
provision of toilets (currently available to only 59% of the
worlds population) and the promotion of handwashing with
soap will also be crucial in improving childrens nutritional
status e particularly if tropical enteropathy is confirmed as a key
contributing factor to malnutrition.
The large family sizes common in many developing countries
make it difficult for mothers both to offer optimal breastfeeding
Special groups
Infants younger than 6 months: traditionally malnutrition has
been considered a condition that develops after the age of 6
months and management guidelines are aimed at children
greater than 6 months old. However, increasing numbers of
young infants are presenting with both non-oedematous and
oedematous malnutrition. Possible reasons for this include
increased survival of low birthweight and premature babies and
failure to exclusively breastfeed (for a variety of reasons
including increased prevalence of maternal HIV). The younger
the child the more likely an organic cause of malnutrition further
highlighting the importance of a thorough assessment to detect
any underlying medical conditions.
Breast milk is the ideal nutrition for these infants but is often
not available in sufficient quantities and the child may be too
unwell to suckle effectively by the time they reach the attention of
health services. There is currently no consensus on the optimum
nutritional management in the rehabilitation phase if breast milk,
or a commercial infant formula, are not available. F100 has a high
potential renal solute load and its use could result in hypernatraemic dehydration e particularly in hot, dry environments.
Some practitioners advocate the use of a diluted version of F100 as
a safer alternative. However, studies of its use have not shown it to
consistently support the rapid weight gain required. Additional
guidance on the management of infants less than 6 months is
anticipated in the next edition of the WHO treatment protocol.
HIV positive children: there is debate as to whether malnourished children should be routinely screened for HIV infection.
The increasing availability of antiretroviral medication, as well as
the opportunity to access prophylactic co-trimoxazole, suggest
that it will now be helpful to check HIV status. However, treatment facilities must ensure that nursing staff are educated about
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FURTHER READING
Amadi B, Fagbemi AO, Kelly P, et al. Reduced production of sulfated
glycosaminoglycans occurs in Zambian children with kwashiorkor but
not marasmus. Am J Clin Nutr 2009; 89: 592e600.
Ashworth A, Chopra M, McCoy D, et al. WHO guidelines for management
of severe malnutrition in rural South African hospitals: effect on case
fatality and the influence of operational factors. Lancet 2004; 363:
1110e5.
Berkley J, Mwangi I, Griffiths K, et al. Assessment of severe malnutrition
among hospitalized children in rural Kenya: comparison of weight for
height and mid upper arm circumference. J Am Med Assoc 2005; 294:
591e7.
Bhutta ZA, Chopra M, Axelson H, et al. Countdown to 2015 decade report
(2000e10): taking stock of maternal, newborn, and child survival.
Lancet 2010; 375: 2032e44.
Black RE, Allen LH, Bhutta ZA, et al. Maternal and child undernutrition:
global and regional exposures and health consequences. Lancet 2008;
371: 243e60.
Practice points
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