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
Normal Grade I (mild malnutrition) Grade II (moderate malnutrition) Grade IIIa (severe malnutrition)

% of standard weight for age >90 75-89.9 60-74.9 <<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.

Waterlows Classification
When a childs 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 90-94% 85-89% <85%

Index: Weight for age

Level of stunting Mild Moderate Severe Level of wasting Mild Moderate Severe

% of NCHS reference 80-89% 70-79% <79%

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 weight for age 60-80 <60 Oedema present Kwashiorkor Marasmic kwashiorkor Oedema absent Undernourish ment Nutritional 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 childs 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 childhoodmeasles, 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
Growth failure Wasting Oedema Hair changes Mental changes

Kwashiorkor
Present Present Present (sometimes mild) Common Very common

Marasmus
Present Present, marked Absent Less common Uncommon

Dermatosis, flaky-paint
Appetite Anaemia Subcutaneous fat Face

Common
Poor Severe (sometimes) Reduced but present May be oedematous

Does not occur

Good Present, less severe Absent 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
Childs 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 buffalos milk contain 7.5% fat it must be diluted

 When fresh milk not available milk preparations may be used

Evaporated milk Full cream milk powder Skimmed milk power 500 ml 150 grams 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