MALNUTRITION IN CHILDREN

PEDIATRIC NURSING
 INTRODUCTION
• Malnutrition a state of nutritional imbalance
• Arises when the supply of one or more nutrients is less or
in excess of the body’s need for such nutrient.
• Malnutrition essentially means ‘poor nutrition’ – when the
human body contains an insufficient, excessive or
imbalanced consumption of nutrients.
• Sub nutrition occurs when an individual does not consume
enough food. It may exist if the person has a poor diet that
gives them the wrong balance of basic food groups.
• Obese people, who consume more calories than they need,
may suffer from the sub nutrition aspect of malnutrition if
their diet lacks the nutrients their body needs for good
health
• Most vulnerable group
– Children under fives
– Pregnant and _ lactating mothers
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 Causative Factors of Malnutrition
The basic cause of malnutrition is under development, which bring
along;
• Social and economic problems
• Poverty
• Lack of hygiene
These lead to
• inadequate food intake
• Disease, especially infections like diarrhoea and malaria

• In adequate dietary intake alone or in combination with

infections can lead to malnutrition, depress immunity, make the
individual more susceptible to infections.

• The patients arrive at a vicious cycle of malnutrition and

infection.
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 Causative Factors of Malnutrition

However, the immediate cause of malnutrition can be

classified as follows:
• shortage of food
• consumption of a unbalanced diet
• methods of storage or preparation of food
• soil and water
• infections and infestations
• ignorance and superstitions
• poor environmental sanitation

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 Mechanisms by Which Infections
Causes Malnutrition
Different mechanisms may operate, often in conjunction:
• less food intake by loss of appetite (anorexia) and vomiting
• increase energy demand due to fever or inflammatory
process
• malabsorption of nutrients
• leakage of plasma (protein) from inflamed gut and
ulcerations
• catabolism, destruction metabolism: consumption of stored
fats, later of muscle protein, the breakdown of the body itself
• anaemia due to decreased production of blood cells, blood
loss, folic acid, etc

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 Different Mechanisms Through Which
Malabsorption is Produced
• digestion in gut - lumen is deficient in case of
pancreas disease
• bile salt deficiency - in case of liver disease
• abnormality of the mucous of the small intestine,
enzyme deficiency e.g. in bacterial and parasitic
infections
• obstruction of the venous and lymphatic ducts and
therefore interface with digestion and absorption of
nutrients, apart from disturbing the transport of
water and electrolytes.

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 Types of malnutrition
• Two types
– Under nutrition – due to inadequate intake
– Over nutrition – due to excess intake

• Under nutrition (sub nutrition) – When a person’s diet is

lacking in nutrients and does not provide them with an
adequate amount of calories, sustenance and protein for
maintenance and growth. Under nutrition can also occur if the
body cannot efficiently use food as a result of an illness.

• Over nutrition – When a person’s diet is getting far too many

nutrients for the body to cope with. Usually a result of people
choosing to eat more food than they need, but in rare cases
can be caused by excessive supplement intake.

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 COMMON FORMS OF UNDERNUTRITION
• Malnutrition is a serious condition occurred due to insufficient
intake of nutrients in the diet.
Kwashiorkor
• Kwashiorkor is also known by names like protein malnutrition,
protein-calorie malnutrition or malignant malnutrition.
• 1. This disease is caused by the deficiency of protein in the diet of
child.
• 2. Kwashiorkor occurs in children in the age group 1-5 years.
• 3. The disease is more common in villages where there is small gap
period between successive pregnancies.
• 4. In this disease, swelling of body is observed due to retention of
fluids.
• 5. Wasting of muscles is not evident.
• 6. Skin changes color and become broken and scaly.

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 KWASHIOR

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 UNDERNUTRITION CONT.
• Marasmus
• 1. This disease is caused by deficiency of protein as well as energy
nutrients (that is carbohydrates and fats) in the diet.
• 2. Marasmus occurs in children below the age of 1 year.
• 3. This disease is more common in towns and cities where breast-
feeding in discontinued quite early.
• 4. No swelling of body takes place in Marasmus.
• 5. In Marasmus, wasting of muscles is quite evident. The child is
reduced to skin and bones.
• 6. Skin does not change color and does not break.
• NB. Children with marasmus may rapidly deteriorate, especially if
they develop an infection, and present with oedema to become
marasmic kwashiorkor

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 MARASMUS

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 DIFFERENCES BETWEEN
KWASHIOKOR & MARASMUS
  Kwashiorkor Marasmus

Kwashiorkor is a kind of malnutrition. It is primarily caused due to Marasmus is a kind of malnutrition that occurs due to
Definition
insufficient intake of proteins. deficiency of proteins, carbohydrates and fats in the diet.

Large belly sticking out, diarrhea, change in skin pigment, decreased

muscle mass, diarrhea, failure to gain weight and grow, fatigue, hair
changes, easy hair pluckability, poor wound healing, skin Peeling and alternately pigmented skin, hair loss, edema or
Symptoms
swelling, skin folds are formed, etc.
breakdown, or pressure ulcers.

Affecting Generally children of age 1-5 years Generally children under the age 1

Failed breastfeeding, feeding inadequate infant formula or

Main causes Weaned from mother’s milk to a diet low in protein
suffering from some disease like diarrhea

Wasting of muscles Not evident Quite evident

Bloated belly Yes, due to retention of fluids No

Providing a nutritious, well-balanced diet with lots of fresh

Providing carbohydrates followed by high protein foods. Dried milk
Treatment fruits and vegetables, grains, and protein. Especially
specially.
adding Vitamin B to the diet.
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 MARASMIC KWASHIORKOR
• Marasmic kwashiorkor is a form of malnutrition
that lies in between kwashiorkor and marasmus,
as is clear by its name
• Marasmic-kwashiorkor is a mixed form of both
marasmus and kwashiorkor and is characterized by
the presence of both wasting and bilateral pitting
edema.
• marasmic kwashiorkor is The most severe form of
protein-energy malnutrition in children, with
weight for height less than 60% of that expected,
and with edema and other symptoms of
kwashiorkor.

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 MARASMIC KWASHIOKOR

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Protein-energy malnutrition

There are three types of protein-energy malnutrition in children:

Type Appearance Cause

Acute malnutrition Wasting or Acute inadequate nutrition leading to rapid weight loss or
thinness failure to gain weight normally

Chronic malnutrition Stunting or Inadequate nutrition over long period of time leading to
shortness failure of linear growth

Acute and chronic Underweight A combination measure, therefore, it could occur as a result
malnutrition of wasting, stunting, or both

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 These forms of protein-energy malnutrition in
children can be pictured like this:

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 WASTING
• Means low weight for height (WHO)
• Wasting or thinness indicates in most cases, a
recent and severe process of weight loss
which is often associated with acute
starvation

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 STUNTING
• Means inadequate height for age (WHO).
• 2. It is low Ht. for age or Ht. more than two
standard deviations below the WHO child
standard s median
• Stunting reflects chronic under nutrition during
the most critical period of growth and
development in early life.(child hood)
• Typically those with stunted growth have a
short Ht. and low body masses for their age
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 Cont.
• It is the most prevalent form of under
nutrition, yet it goes largely unrecognized
• Stunting usually does not pose an immediate
threat to life and is relatively common in many
populations in less-developed countries.
• is not to say that it is unimportant, just less
important than wasting in humanitarian
emergencies.

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 Cont.
• Stunting is chronic and its causative factors are
poorly understood.
• Wasting and stunting are very different forms of
malnutrition.
• The difference between stunting and wasting :
• Stunting is caused by long term insufficient
nutrient intake and frequent infections while
• Wasting is a strong predictor of mortality among
children under five. It is usually the result of
acute significant food shortage and / disease

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 Cont.
• Because Wasting results from an acute
shortage of food, it is reversible with
refeeding, and has a relatively high
mortality rate.
• For these reasons, wasting is the highest
priority form of malnutrition in
humanitarian emergencies.

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 SYMPTOMS OF MALNUTRITION

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 Timeliness: Early versus Late
Presentation

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 SIGNS OF UNDERNUTRITION 
The common signs of under nutrition are: 
•loss of body fat and muscle mass
•sunken cheeks
•white fungal growth on the tongue
•poor memory
•chewing and/or swallowing problems
•hollow eyes
•abdominal swelling and constant bloating
•protruding bones
•thinning, dry, cold and pale skin
•dry and sparse hair that falls out easily
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 Mgt of PEM includes the following
• Provision of enough and safe drinking water
• Immunizations
• Improved hygiene
• Early diagnosis and treatment of infection
• Prevention or treatment of dehydration
• Continued feeding should be stressed

All measures will finally be successful only if the problems of

under development at the international, national and
community level is solved.
• Improved nutrition i.e. uninterrupted breastfeeding for the
first 2 years of life and proper weaning practices
• Use of safer water, i.e. collecting an ample of quantity safe
drinking water and protecting the water from contamination
• Good personal and domestic hygiene i.e. hygienic disposal of
faeces
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 Mgt of PEM includes the following
Because these strategies are mainly aimed at the mothers and
care takers, it is therefore vital to find out to what extent
these messages are understood and accepted.

Level 1: home /village: hygiene health education

• diversification of food production
• promotion, protection and support of breastfeeding
• prevention: under five vaccination of preventable diseases
and early treatment of infections.

Level 2: Health Centre/Hospital: diagnosis and treatment

• support all level training
• Level 3: Inter-sectoral approach
• Encourage inter sectoral collaboration
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 OVERNUTRITION IN CHILDREN
• Childhood obesity is associated with significant comorbidities
which, if untreated, are likely to persist into adulthood.
• Over nutrition caused by an overdose of vitamins usually causes
digestive problems such as stomach cramps, diarrhoea, and
persistent nausea.
• The probability of obesity persisting into adulthood has been
estimated to increase from 20% at 4 years to 80% by adolescence.
• Obesity is a medical condition in which excess of body fat has
accumulated to the extent that it may have a negative effect on
health
• Obesity is associated with cardiovascular and endocrine
abnormalities (e.g., dyslipidemia, insulin resistance, and type 2
diabetes), orthopedic problems, pulmonary complications (e.g.,
obstructive sleep apnea), and mental health problems.
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 CONT.
• Obese is defined as BMI at or above 95% and is
associated with increased risk of secondary
complications.

• Severe obesity is characterized by BMI for age

and sex at or above the 99th percentile.

• An upward change in BMI percentiles in any

range should prompt evaluation and possible
treatment.

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 SIGNS OF OVERNUTRITION 

• The main sign of over nutrition is

obesity, however people with under
nutrition can also be overweight if their
diet is high in calories but low in
essential nutrients.

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 RISK FACTORS
• There are multiple risk factors for developing obesity,
reflecting the complex relationships between genetic
and environmental factors.
• Family history is a strong risk factor. If one parent is
obese, the odds ratio is approximately 3 for obesity in
adulthood, but if both parents are obese, the odds ratio
increases to greater than 10 compared to children with
two none obese parents
• The home environment factors e.g. Consumption of
sugar-sweetened beverages, large portion sizes, foods
prepared outside the home, television viewing, video
gaming, and lack of activity are all associated with risk of
excessive weight gain
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 Cont.
• Essentials of Diagnosis and Typical Features

• Excessive rate of weight gain; upward change in

BMI percentiles.
• BMI for age between the 85th and 95th
percentiles indicates overweight.
• BMI for age > 95th percentile indicates obesity and
is associated with increased risk of secondary
complications.
• BMI for age > 99th percentile indicates severe
obesity and a higher risk of complications
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 TREATMENT
• Treatment should be based on risk factors, including age,
severity of obesity, and comorbidities, as well as family
history and support.
• For all children with uncomplicated obesity, the primary
goal is to achieve healthy eating and activity patterns, not
necessarily to achieve ideal body weight.
• For children with a secondary complication, improvement
of the complication is an important goal. In general, weight
loss goals for obese children range from 1 lb/mo for those
younger than 12 years to 2 lb/wk for those older than 12
years.
• More rapid weight loss should be monitored for pathologic
causes that may be associated with nutrient deficiencies
and linear growth stunting

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 CONT.
• Treatment is focused on behavior changes in
the context of family involvement has been
associated with sustained weight loss and
decreases in BMI
• Improving dietary habits and activity levels
concurrently is desirable for successful weight
management.
• The entire family should adopt healthy eating
patterns, with parents modeling healthy food
choices, controlling foods brought into the
home, and guiding appropriate portion sizes.

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 Suggested areas for assessment of diet and
activity patterns.
Suggested areas for assessment of diet and activity patterns.

Diet

   Portion sizes: adult portions for young children

   Frequency of meals away from home (restaurants or take out)

   Frequency/amounts of sugar-sweetened beverages (soda, juice drinks)

   Meal and snack pattern: structured vs. grazing, skipping meals

   Frequency of eating fruits and vegetables

   Frequency of family meals

Activity

   Time spent in sedentary activity: television, video games, computer

   Time spent in vigorous activity: organized sports, physical education, free play

   Activities of daily living: walking to school, chores, yard work

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 PRESENTLY PROPOSED TREATMENT
• A "staged approach" for treatment has been proposed, with the initial
level depending on the severity of overweight, the age of the child,
the readiness of the family to implement changes, the preferences of
the parents and child, and the skills of the health care provider.
• Prevention Plus: Counseling regarding problem areas identified by
screening questions; emphasis on lifestyle changes, including healthy
eating and physical activity patterns.
• Structured weight management: Provide more specific and structured
dietary pattern, such as meal planning, exercise prescription, behavior
change goals. This may be done in the primary care setting.
• Generally referral to at least one ancillary health professional will be
required: dietitian, behavior specialist, and/or physical therapist.
Monitoring is monthly or tailored to patient and family's needs.

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 CONT.
• Comprehensive multidisciplinary: This level further increases
structure of therapeutic interventions and support, employs a
multidisciplinary team, and may involve weekly group meetings.
• Tertiary care intervention: This level is for patients who have not
been successful at the other intervention levels or who are severely
obese. Interventions are prescribed by a multidisciplinary team,
and may include intensive behavior therapy, specialized diets,
medications, and surgery.
• Pharmacotherapy can be an adjunct to dietary, activity, and
behavioral treatment, but by itself it is unlikely to result in
significant or sustained weight loss. Two medications are approved
for obesity treatment in adolescents: sibutramine, a serotonin and
noradrenaline reuptake inhibitor, is approved for patients older
than 16 years

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 WEIGHT MANAGEMENT GOALS.

Weight management goals.

Age  BMI  Weight Change Goal to Achieve BMI <

85% 

2–5 y 85–94% Maintain weight

  95–98% Maintain weight, or if complications lose 1

lb/mo

  99% Lose 1 lb/mo

6–11y 85–94% Maintain weight

  95–98% Lose 1 lb/mo

  99% Lose 2 lb/wk

12–18 y 85–95% Maintain weight

  95–98% Lose 2 lb/wk

  99% Lose 2 lb/wk

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 CONSEQUENCES OF MALNUTRITION
• Malnutrition affects every system in the body and always
results in increased vulnerability to illness, increased
complications and in very extreme cases even death.
• Retarded growth and development
• Susceptibility to infections: children with severe malnutrition
are often sick and feel miserable. Their frequent illness gives
the family a lot of worry and expenses.
• Reduced productivity
• Diarrhoea: which increases the risk of death
• Hypoglycaemia (low blood sugar): can cause severe brain
damage and death
• Hypothermia (low body temperature): due to lack of nutrients
to burn to keep the body warm.

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 Cont.2 CONSEQUENCES
• High morbidity and mortality
• Mental and physical retardation
• Social unrest

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 Consequences of malnutrition in
children and adolescents
• Growth failure and stunting
• Delayed sexual development
• Reduced muscle mass and strength
• Impaired intellectual development
• Rickets
• Increased lifetime risk of osteoporosis

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 CONSEQUENCES OF SPECIFIC MICRONUTRIENT
DEFICIENCIES
•There are very many of these and so only the commonest
are given below:
•Iron deficiency can cause anemia
•Zinc deficiency causes skin rashes and decreased ability to
fight infection
•Vitamin B12 deficiency can cause anemia and problems
with nerves
•Vitamin D deficiency causes rickets in children and
osteomalacia in adults
•Vitamin C deficiency causes scurvy
•Vitamin A deficiency causes seeing poorly at night,
blindness, dry skin, respiratory infections and an impaired
immune system

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 Prevention of Malnutrition (1)
The following are some strategies that can be
used to prevent malnutrition.
• Regular growth monitoring
• Promotion, protection and support of
breastfeeding
• Optimal feeding practices including weaning
practices
• Dietary diversification
• Increased food production, appropriate food
processing /preservation
• Improved health care service delivery
• Immunization
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 Prevention of Malnutrition (2)
• Improved maternal nutrition
• Early and prompt treatment of infection
• Proper environmental sanitation and personal
hygiene
• Improved food hygiene and safety
• Reduced fertility rate
• Improved income level
• Poverty alleviation
• Improve care
• Provision of labour saving devices
• IEC to counter social barriers, taboos,
misconception's
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 WHAT IS FOOD

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 What is food
• Food is regarded as everything we normally eat and
drink. Things consumed as food differ from one
country to another and sometimes within different
regions of one country. The extension worker must
know:
• What types of food are consumed in his/her area?
• What items of food people like?
• What foods people do not eat even when they are
inexpensive and available?

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 Why do we eat?
Food has three important functions for the human body:
1. To give energy for all types of activity.
2. To help the body grow in size.
3. To protect the body from disease.

• Foods contain substances called nutrients. Nutrients are parts of

the food, which are digested, absorbed into the body, and are put to
use.
• The study of nutrients and of their ingestion, digestion, absorption,
metabolism (the set of processes by which nutrients are rearranged
into body structures or broken down to yield energy), interaction,
storage, and excretion is the science of nutrition.

Nutrients are divided into two main types:

• 1. The major nutrients or macronutrients are carbohydrates,
proteins, and fats.
• 2. The minor nutrients or micronutrients are the vitamins and
minerals.
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 Macronutrients:
Carbohydrates
Sources
• Cereals: rice, corn, millet, findi, sorghum, and wheat
• Starchy roots and fruits: cassava, sweet potatoes, Irish
potatoes, yam, yam, breadfruit, and plantain
• Sugar: sugar, honey, and jam

Functions
• Carbohydrates provide the body with energy and may be
converted into fats.
• Carbohydrates provide most of the energy in the Gambian
diet.

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 Macronutrients
Proteins
Source
• Animal protein: meat and meat products (beef, mutton,
pork), chicken, fish and fish products, eggs, milk and milk
products.
• Vegetable protein: peas, beans, nuts, ogiri (melon seed),
ogiri (beeni seed), and netetou

Functions
• Proteins provide the body with material for growth, repair,
and reproduction.
• They can also be used for the production of heat and other
forms of energy, but their fundamental importance in the
diet is for growth and repair, of which no other nutrient can
be a substitute.
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 Macronutrients

Fats
Sources
• Fats: fatty meat (beef, mutton, pork), fatty fish,
lard, butter, margarine, whole milk, fenneh, palm
kernel
• Oils: groundnut oil, sesame oil, sunflower oil or any
other vegetable oils and palm oil

Functions
• Fats provide fuel or energy and can be stored as
body fat in the human body. Fats are the richest
source of energy.
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 Micronutrients
Minerals & Vitamins
Sources of vitamins and minerals
• Vegetables, especially the dark green leafy
types Yellow and orange coloured fruits and
vegetables like carrots, pumpkins, papaya,
mango, tomato, and oranges.
• Fruits with sour juice like orange, lime, lemon,
and grapefruit

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 Micronutrients
Functions of minerals
• Minerals are small elements, smaller than vitamins. Of the
dozens of minerals found in nature, 21 are essential in human
nutrition. Calcium, phosphorous, iron, sodium, chloride, and
iodine form the most important minerals.
• The four main functions of minerals are:
• As a constituent of bones and teeth (calcium, phosphorous,
magnesium)
• As constituent of body cells (iron, phosphorous, sulphur)
• As soluble salts (sodium, potassium, chloride)
• Serve in reactions concerned with the release of energy
during metabolism (phosphorous, magnesium)

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 Micronutrients
Functions of vitamins
• Vitamins are substances we need in small amounts, but
which the body cannot produce. These have to be
supplied daily by the diet.
• Vitamins are grouped into fat soluble vitamins which
include vitamins A, D,
• E, and K, usually found in fatty foods and oils; and water
soluble vitamins which include the B vitamins and
ascorbic acid or Vitamin C, usually found in non-fatty
foods.
• Vitamins are essential for the proper functioning of the
tissue cells.
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 Food Square: concept of a balanced diet

Carbohydrates: Protein:
Rice, Millet, Maize, Findi, Meat, poultry, Fish, Beans
“Netetou”
Potato & Cassava Breast
Milk

Fats/Oils: Vegetable/Fruit: ,
Palm oil G/nut oil, Sesame oil, Carrots, Pumpkin, greens,

Butter, Margarine Okra, Banana, Pawpaw, Citrus

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 Millet Benachin
CHO: Veg/Fruits Spices
Millet grits Fresh Tomatoes Pepper
Pumpkin Black pepper
Cabbage Garlic
Carrot Salt
Egg plant
Onions
Tomato Paste

Protein: Fats/Oils Water

Meat/Fish/Beans Vegetable/Cooking oil

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 Summary of the role of nutrients

• Carbohydrates and fats: energy sources

• Proteins: body building foods (growth,

maintenance, and repair of tissue cells)

• Minerals and vitamins: proper functioning

of body cells protection against disease)
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 Conclusion
• It is important to develop and maintain healthy
eating habits in order to keep a good nutritional
status
• This can be achieved by eating a well balanced diet
everyday

• A well balanced and/or healthy diet is one that

provides sufficient energy & nutrients to not only
prevent deficiency but also helps to optimize health
and reduce the risk of disease. This provides a
combination of all the essential nutrients

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 REFERENCE
• Barlow SE: Expert Committee recommendations
regarding the prevention, assessment, and
treatment of child and adolescent overweight
and obesity: Summary report. Pediatrics
2007;120(Suppl 4):S164. [PMID: 18055651]  [Full
Text]
• Daniels SR et al: Overweight in children and
adolescents. Patho-physiology, consequences,
prevention, and treatment. Circulation
2005;111:1999. [PMID: 15837955]  [Full Text]

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 THANK YOU

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