Malnutrition

Malnutrition Dr.Anita Lamichhane

MD resident (Pediatrics)

Shaikh Zayed hospital , Lahore

• > 3.5 million/year , mothers & children die due to

the underlying cause of under nutrition

• > 55 million (10%) of children are wasted

• < 19 million are severely wasted.

South Asia and sub-Saharan Africa Have the South Asia and sub-Saharan Africa Have the Highest Shares of Young Children who Are Highest Shares of Young Children who Are

Underweight.Underweight.

Source: Carl Haub, 2007 World Population Data Sheet.

Prevalence of Underweight Children Under Age 5, by Country

Vitamin A and Iron Deficiencies Are Also Vitamin A and Iron Deficiencies Are Also Prevalent Among Children < 5 years . Prevalent Among Children < 5 years .

Percent of Children Under Age 5 with Vitamin A and Iron Deficiencies, Selected Regions

Data from PakistanData from Pakistan

• 36 % of children -- underweight before the current

floods.

• Researchers claim that up to 44 % of children of rural

area stunted.

• A survey by the World Health Organization -the

number of underweight pre-school children (0-5

years of age) is 40 %

Malnutrition Malnutrition

• Derived from malus (bad) and nutrire (to nourish)

• Includes both

Under nutrition (deficiency of one or more

essential nutrients)

Over nutrition (an excess of a nutrient or

nutrients)

• Macronutrients (carbohydrates, lipids, proteins &

water) - needed for energy, cell multiplication &

repair

• Micronutrients are trace elements, vitamins &

nutrients - essential for metabolic processes

Adaptation to Starvation Adaptation to Starvation energy sourceenergy source

• Depletion of glycogen stores

gluconeogenesis ( glucose / insulin)

(Glycerol, amino acids, lactate/ pyruvate)

• Fatty acid oxidation and ketone bodies

Utilization

• Reduced protein catabolism & gluconeogenesis

Adaptation to StarvationAdaptation to StarvationFluid & ElectrolyteFluid & Electrolyte

• Inhibition of sodium pump

intracellular Na

total body water

• urinary loss of K, calcium, phosphate, magnesium

& zinc

• total body K+ : hypotonia, apathy, impaired cardiac

function

Refeeding syndromeRefeeding syndrome• Metabolic disturbances occur at this point• Starvation- loss of lean muscle mass, water and minerals phosphorus• Carbohydrate refeeding, insulin release• glucose uptake• Hyphosphatemia- red cell ATP • K,Mg, glucose,thiamine

•

CLASSIFICATION CLASSIFICATION

WHO classificationWHO classification

• Defined as the presence of edema of both feet

or severe wasting {70% weight for

height/length or (<-3SD)} or clinical signs of

severe malnutrition

Gomez classificationGomez classification

• If the wt is > 90 % of the expected weight –no

malnutrition

• 1st degree- wt is 75-90% of the expected weight

• 2nd degree- wt is 60-75% of the expected weight

• 3rd degree- wt is < 60 % of the expected weight

Modified Gomez classificationModified Gomez classification

• If the wt is > 80 % of the expected wt –no

malnutrition

• 1st degree- wt is 70-80% of the expected wt

• 2nd degree- weight is 60-70% of the expected wt

• 3rd degree- wt is < 60 % of the expected wt

Water low classificationWater low classification

Height for age

Weight for age expressed as percentage

<80 80-120 >120

<90% Chronic malnutrition

Stunted but no malnutrition

Stunted and obese

> 90% Acute malnutrition

Normal Obese

Welcome classificationWelcome classification

Edema present

Edema absent

Weight for age 80-60 % of standard

Kwashiorkor Ponderal Retardation

Weight for age < 60 % of standard

Marasmic kwashiorkor

Marasmus

Harvard classificationHarvard classification

• If the wt falls 50th percentile- healthy child

• Grade I- if wt is 71-80% of 50th percentile

• Grade II- if wt is 61-70% of 50th percentile

• Grade III- if wt is 51-60% of 50th percentile

• Grade IV- if wt is 50% of 50th percentile

General classificationGeneral classification

Mid arm circumference – measured with a measuring

tape

• At 12 months- 16.5 cm

• Between 12-48 months= 12.5-16.5 cm

• Cut off point- 75 % of the expected mid arm

circumference

• If less than the cut off point (<14 cm)= malnourished

Skin fold thickness

• Herpeden caliper

• Triceps/back of shoulder

• Normal= 9-11 mm

• If < 9 mm- malnourished

Quac strip

• Special tape having colors on it

Up to green colour

Normal

Yellow colour Borderline malnutrition(14-12 cm)

Red colour Malnourished (< 12 cm)

• Body mass index (BMI) weight in kg

height in m²

<16 Malnourished

>25 Obese

16-25 Normal

Etiology Etiology

Primary malnutrition Secondary malnutritionFailure of lactation Parasitic infestations, Measles, whooping

cough, Primary tuberculosis, Urinary tract infection

Ignorance of weaning Congenital heart disease, Urinary tract anomalies

Poverty Giardiasis,Lactose intolerance, Celiac disease, Tuberculosis of the intestineCystic fibrosis

Cultural patterns and food fads

Inborn errors of metabolism,galactosemia

Lack of immunization and primary careLack of family planning

kwashiorkor marasmus

Derived from Ghanian dialect Ghanian dialect meaning first second- after birth of the second baby, the first baby is deprived from the breast feeding, which is the only source of protein

derived from the Greek the Greek marasmos,marasmos, which means wastingDue to dietary deficiency /severely restricted food intake

Underweight Extremely underweight below < 60%

Edema is always present Edema is always absent Thin lean muscles, fat is present Muscle wasting with loss of

subcutaneous fatHair changes are present-fine, straight,sparse,discolored

No hair changes

kwashiorkor marasmus

Poor appetite and anorexic Good appetitie

Flaky paint dermatitis, ulcers, hypo/hyperpigmentation

Normal skin

Miserable looking and apathetic Appearance of monkey face or little old man face,alert facies

Liver enlarged (fatty infiltration) No hepatomegaly

Initial assessment of the severely malnourished child

History

• Recent intake of fluids & foods

• Usual diet (before the current illness)

• Breast feeding

• When was weaning started

• Duration & frequency of diarrhea & vomiting

• Type of diarrhea (bloody/watery)

• Loss of appetite

• Time when urine was last passed

• Family circumstances-literacy level, socioeconomic

status, housing, family members, vaccination

• Chronic cough

• Contact with tuberculosis

• Recent contact with measles

• Milestones reached

Examination

• Proper exposure of the child

• General look /appearance:

Stunted,wasted,edematous, alert, apathetic,

emaciated

• Anthropoetic measurements: weight, height, head

circumference, mid arm circumference- plot in the

centile chart

• Signs of dehydration & shock – cold hands, absent

tears, slow capillary refill, weak & rapid pulse

• Hypo/hyper thermia

• Head- depressed and open fontanelle,fine sparse hair,

hypo/ hyper pigmented, easily pluckable

• Hands –severe palmar pallor, clubbing, pulse,

widening of wrist

• Eyes- signs of vitamin A deficiency

• Ear – discharge from the ear, (serosanguneous or

purulent)

• Neck-Goitre, lymph nodes

• Mouth- angular stomatits,Oral hygiene, gum

(bleeding/hyperplasia),dentition, tongue( flat , loss of

papilla, red and beefy), ulcer, oral thrush

• SkinSkin – colour, whether dry and lusterless, any

exudative changes (resembling severe burn) often

exist with secondary infecttion (including

Candida),petechiae and bruises

• ChestChest- shape, prominent costochondral junction,

ricket rosary, crowding of ribs, Harrison's sulcus

• CVSCVS- signs of heart failure

• Edema , jaundice

• Skin changes of Kwashiorkor

• Abdomen - distended, protuberant, tone of the

muscles, bowel sounds, tender hepatomegaly

Investigations

• Full blood counts, peripheral smear for MP

• Blood glucose level

• Septic screening

• Stool for cysts, ova, and C/S, fat globules

(Malabsorption)

• Urine microscopy and C/S

• Electrolytes, Ca, Ph & ALP, Serum albumin & total

proteins

• CXR & Mantoux test

• Exclude HIV

ComplicationsComplications

• Hypoglycemia

• Hypothermia

• Hypokalemia

• Hyponatremia

• Heart failure

• Dehydration & shock

• Infections (bacterial, viral & thrush)

Management Management

• INITIAL TREATMENT (emergency treatment)

• REHABILITATION

• FOLLOW UP

• Stabilization Rehabilitation• 1 week 2-6 weeks• Hypoglycemia • Hypothermia • Dehydration • Electrolytes • Infections • micronutrients No iron Add iron• Initiate feeding • Catch up growth • Sensory stimulation • Follow up

Initial treatment ( First phase)(usually 2-7 days)

Fluids and electrolyte balanceFluids and electrolyte balance

• Iv infusion - indicated in a severely malnourished

child with circulatory collapse (otherwise N/G

feeding)

• ½ strength Darrow’s solution with 5% dextrose

• Half normal saline(0.45%) with 5% dextrose

• Give i/v fluid 15 ml/kg over 1 hour

• Measure the vital signs( pulse rate, respiratory rate) at the

start & every 5-10 minutes

• If signs of improvement, then repeat i/v 15 ml /kg over 1

hour, then switch to oral /NG rehydration with ReSoMal 10

ml/kg/hour up to 10 hour

• Initiate refeeding with starter F-75 ( 75 calories/100 ml)

• If the child fails to improve, assume the child has septic shock

• Give maintenance i/v fluid (4ml/kg/hr) while waiting for blood

• Transfuse fresh whole blood 10 ml/kg slowly over 3 hours

(packed cells used if in failure)

• Start antibiotics

• If the child comes out of shock, then start 70 ml/kg of RL(if not

available, NS) over 5 hours in infants (<12 months) and over

2/12 hours in children (aged 12 months to 5 years)

• Reassess the child every 1-2 hours

• As soon as the child can drink, give ORS solution

• Reassess after 6 hours(in infants) and 3 hours(in

children)

• Classify dehydration and then choose the

appropriate plan (A,B,or C) to continue treatment

• If available, add selenium & iodine

• Solution stored in sterilized bottles in fridge

• Discards if it turns cloudy

• Add 20 ml of the concentrated electrolyte/mineral

solution to each 1000 ml of milk feed

How to make ReSoMal???How to make ReSoMal???

• ORS 1 packet

• Water 2 litres

• Sugar 40 gram

• Mineral mix 33 ml ( Zn given as syrup zincate, Mg

given as I/V, K= 100 gm of KCl in 1 litre of water

(take 40 ml of KCl)

CORRECTION OF CORRECTION OF HYPOGLYCEMIAHYPOGLYCEMIA

PREVENTION:

By feeding every 2 -3 hours/day

TREATMENT:

o Conscious child- 50ml of 10% glucose/sucrose PO

o Unconscious child- 5ml/kg of 10% glucose I/V followed

by 50ml of 10% glucose/sucrose by N/G Tube

HYPOTHERMIAHYPOTHERMIA

Marasmic infants and children are more at risk of

hypothermia

if underarm temperature < 350C (950F)

The child is rewarmed by:

Kangaroo Method

Warm Blanket & Lamp method

CONTROL OF INFECTION

o MILD INFECTIONS: Cotrimoxazole BD x 5 days

o SEVERE INFECTIONS WITH COMPLICATIONS:

Ampicillin:50mg/kg I/M, I/V 6hr x 2days

Amoxicillin:15mg/kg oral 8hr x 5 days

Gentamicin:7.5mg/kg I/M,I/V O.D x 7days

• Measles vaccination if the child is 6 months old &

not immunized or if the child is > 9 months old & has

been vaccinated before

• Mebendazole 100 mg PO OD x 5 days

ORS solution for severely malnourished children

• Malnourished children- deficient in K+ & abnormally

high Na+

• ORS soln should contain high K and low Na than the

standard WHO- recommended solution

• Mg, Zn & Cu should also be given

•

Composition of ReSoMal

Component Concentration (mmol/l)Glucose 125Na 45K 40Cl 70Citrate 7Mg 3Zn 0.3Cu 0.045

Osmolarity 300 mosmol

• ReSoMal available commercially• Can also be made by diluting one packet of the standard

WHO-recommended ORS in 2 litres of water; 50 g of sucrose (25g/l) and 40 ml (20 ml/l) of mineral mix

• Mineral mix supplies K+ - affects cardiac function & gastric emptying Mg2+ - essential for K+ to enter the cells and be retained does not contain iron

• Mineral mix is stored at room temp and added to ReSoMal or liquid feed at a conc. Of 20 ml/l

Mineral mix solutionSubstance grams

KCl 89.5 Tripotassium citrate 32.4MgCl2.6H2O 30.5Zinc acetate.2 H2O 3.3CuSO4.5 H2O 0.56Sodium selenate 0.01Potassium iodide 0.005Water make upto 2500 ml

Vitamins Amount per litre of liquid diet

Water soluble

B1 0.7 mg

B2 2 mg

Nicotinic acid 10 mg

B6 0.7 mg

B12 1µg

B5 3 mg

C 100 mg

Biotin 0.1 mg

Folic acid 0.35 mg

Fat soluble

Vit A 1.5 mg

Vit D 30 µg

Vit E 22 mg

Vit K 40 mg

Types of formula feed

• F-75 (75 Kcal/ 3215kJ/100 ml)-used during the initial

phase

• F-100 (100 Kcal/420kJ/100 ml)-used during the

rehabilitation phase

F-75 (starter) F-100 (catch-up)Dried skimmed milk (g) 25 80Sugar (g) 70 50Cereal flour (g) 35 -Vegetable oil (g) 27 60Electrolyte/mineral solution (ml)

20 60

Vitamin mix (mg) 140 140

Water, make up to (ml) 1000 1000

Constituent Amount per 100 ml

F-75 F-100

Energy (kCal) 75 100

Protein (g) 0.9 2.9

Lactose(g) 1.3 4.2

Potassium (mmol/l) 3.6 5.9

Sodium (mmol/l) 0.6 1.9

Magnesium (mmol/l) 0.43 0.73

Zinc (mmol/l) 2 2.3

Copper (mmol/l) 0.25 0.25

%age of energy from• protein • fat

5%32%

12%33%

Osmolarity (mOsmol)

333 419

How to prepare??

• F-75/F-100• Add the dried skimmed milk,, sugar, cereal flour and

oil to some water and mix• Boil for 5-7 mins• Allow to cool• Add the mineral mix and vitamin mix and mix it again• Make up the volume to 1000ml with water• If dried skimmed milk not available, then 300 ml of

fresh cow’s milk can also be used

• F-75 diet should be given to all children during the initial

phase of treatment

• At least 80 kcal/kg should be given but not > 100 kcal/kg

• If < 80 kcal/kg given- the tissues continue to break down

& the condition will deteorate

• If >100 kcal/kg be given- serious metabolic imbalance will

develop

Feeding after the appetite improves

• The initial phase of Tx ends when the child becomes

hungry

• Now transfer to F-100 diet with an equal amount of

F-100 for 2 days before increasing volume offered at

each meal

Recording the food intake

• Type of feed given

• Amounts offered and taken must be recorded

accurately after each feed and deducted from the

total intake

• Once a day the energy intake for the last 24 hours

should be determined & compared with the child’s

weight

DIETARY MANAGEMENT

o 2-3 weeks

o Calorie : 120 -140 cal/kg/day

o Protein :3- 5 gm/kg/day

o Elemental iron: 3-6 mg/kg/day (ferrous sulphate)

o Vitamin A: 300,000I.U then 1500I.U/day

o Vitamin D: 4000 I.U/day

o Vitamin k: 5mg I/M, I/V once only

o Folic acid: 5 mg on day 1, then 1 mg/day

o Copper: 0.3 mg/kg/day

Basic principle of dietary management

• Improve the nutritional level of the child as quickly as

possible by providing a diet with sufficient energy

producing foods & high quality proteins

Initial refeeding

o Frequent small feeds of low osmolarity & low lactose

o Oral/NG feeds (never parenteral preparation)

o 100 cal/kg/day

o Continue breast feeding if the child is breast fed

• Increase each successive feed by 10 ml until some feed remains

uneaten

• Assess progress: weigh the child every morning before being

fed, plot the weight

• Calculate weight gain every 3rd day

• If the weight gain is poor (<5 g/kg/day), check whether the

intake targets are being met

• good wt gain = (>10g/kg/day)

Sensory stimulationSensory stimulation

Provide

• Tender loving care

• A cheerful stimulating environment

• A structural play therapy for 15-30 mins / day

• Physical activity as soon as the child is well enough

• Maternal involvement as much as possible

Criteria for transfer to Criteria for transfer to nutritional rehabilitationnutritional rehabilitation

• Eating well

• Improvement of mental state

• Sits, crawls stands or walks

• Normal temperature

• No vomiting/diarhea/edema

• Gaining wt > 5 gm/kg body wt/day x 3 consecutive days

NUTRTIONAL REHABILITatION

o Infants <24 months fed

exclusively on liquid/ semi solid

food

o Older children given solid food

Feeding < 2 years• F-100 diet be given every 4 hours, night & day

• Increase the amount of diet at each feed by 10 ml

• When feed is not finished, the same amount should be

offered at the next feed

• process is continued until some feed is left after most feed

• Any feed not taken should be discarded, should never be

reused

• If the intake is <130 Kcal, the child is failing to

respond

• F-100 should be continued until the child achieves -

1SD (90%) of the media WHO reference values for

weight for height

Feeding children >2 years

• Introduce solid food, local foods should be fortified to increase their content of energy, mineral and vitamins

• Oil added to increase the energy content• The mineral & vitamin mixes used in F-100 should be

added after cooking• Other ingredients-dried skimmed milk may also be

added to increase the protein content• Supplementation of food with folic acid and iron

• Daily weight and plotted on a graph

• Mark the point that is equivalent too -1SD (90%) of

the median/WHO reference values for wt. for ht. on

the graph which is the target weight for children

• Usual weight gain is 10-15/kg/day

How to calculate the caloriesHow to calculate the calories

• Required calories = currently required for age + 25% calories

for catch up growth

o for e.g. calculation of calories for one year old child with weight 6.5 kg

o expected wt at one year = 10 kg

o So the required calorie should be = 1000 ( 100 cal/kg/day)+ 250 (25% of

1000 calories)

o Start with 625 cal/day or whatever the child is taking and if it is > 625

calories/day

• Then increase by 10% per day

liquid

solid

months

Calories required

1/3

0

18

12

6

24

2/3

1/21/2

2/31/2

Source of calorie supplySource of calorie supply

• Carbohydrate : 50-55%

• Fat: 30-35%

• Protein: 10-15%

• Daily increment

• < 6 months= 50 calories/day

• 6-9 months= 75 calories/day

• > 1 year=100 calories/day

• Iron & folic acid for anemia

• Iron dose : 3mg/kg/day in 2 divided doses

• Folic acid :5mg on day one then 1mg/day

• Zinc : 2-3 mg/kg/day

• Copper : 0.3 mg/kg/day

• Ferrous sulphate (3-6 mg/kg/day)

Micronutrient deficiencies Micronutrient deficiencies

Treatment of the associated conditions

Eye problemEye problem

• Vit A supplement

• Chloramphenicol/tetracycline drops- 4 drops daily x 7-10

days

• Atropine drops 1 drop tds x 3-5 day

• Cover with saline soaked eye pad

• Bandage the eyes

• Severe anemia: blood transfusion

• Skin lesions in kwashiorkor: zinc supplementation,

barrier cream ( Zn and castor oil ointment), nystatin

cream to skin sores,oral nystatin(1000 IU QID)

• Bathe or soak the affected area for 10 mins/day in

0.01% KMnO4 solution

• Giardiasis: metronidazole

• Lactose intolerance: substitute with yogurt or lactose

free formula, reintroduce milk feeds in the

rehabilitation phase

• Treatment of tuberculosis

Congestive cardiac failure• usually a complication of overhydrationn,very severe

anemia, blood or plasma transfusion or giving a diet with high Na content

• When due to fluid overload: stop all oral intake and IV fluids Diuretic IV ( furosemide 1 mg/kg) Do not give digitalis unless the diagnosis of heart

failure is unequivocal & the plasma K level is normal

Drugs for the treatment of malaria in severely malnourished child

Drug Dosage

Plasmodium malaria,P.ovale & susceptible forms of P. malaria

Chloroquine Total dose: 25 mg of base/kg orally given over 3 days Day 1& 2= 10 mg og base/kg in a single doseDay 3: 5 mg of base/kg in a single dose

Plasmodium falciparum malaria

Chloroquine Same as above

Quinine 8 mg of base /kg orally TDS x 7 days

Primethamine+sulphadoxine 5-10 Kg: 12.5 mg+250 mg orally in a single dose11-20 kg:25 mg+500 mg orally in a single dose

NUTRTIONAL REHABILITIONNUTRTIONAL REHABILITION

Child should be weight daily

o Usual weight gain is 10 to 15Gm/kg/day

o Treatment failure: when the child doesn't gain wt at

least 5Gm/kg/day for 3 consecutive days

o target wt for discharge achieved after 2 to 4 wks

RECOVERYRECOVERY

• Takes place in 2 phases

INITIAL RECOVERY PHASE

It takes 2 -3 wks: edema & other signs improve

CONSOLIDATION PHASE

In next 2 to 3 months child regains normal weight

and is clinically recovered

CRITERIA for DISCHARGE from CRITERIA for DISCHARGE from HOSPITALHOSPITAL

1. CHILD

• Weight gain is adequate

• Eating an adequate amount of diet

• Vitamins & mineral deficiencies treated

• All infections & other conditions treated

• Full immunization programme started

2. MOTHER

• Able & willing to look after the child

• Knows how to prepare & feed balance diet

• Knows how to play with child

• Knows how to give home treatment for diarrhea,

fever and ARI. Warn for danger signs

FOLLOW UP

• Follow up at regular intervals after discharge

• Child should be seen after

every 2 days for 1 wk

once weekly for 2nd wk

at 15 days interval for 1 - 3 months

monthly for 3- 6 months

• More frequent visits if there is problem

• After 6 months, visits twice a year until the child is at least 3 years old

Prognostic factors in PEMPrognostic factors in PEM

• Grade of PEM & the type

• Grade III-IV marasmus & severe of Kwashiorkor are

associated with increased mortality

• Girls diagnosed as marasmus have been found to

have a higher death rate than boys

• Age: case fatality rate decrease with increase in age

• low weight for age is a sensitive indicator of mortality

• Presence of serious complications like septicemia, pneumonia

& severe diarrheal diseases with dehydration

• severe hypokalaemia & hyponatremia- poor prognosis

• hypoproteinemia & hypoalbuminemia- poor prognosis

PreventionPrevention

• Education of mother

• Counseling regarding family planning and spacing

between children

• Promotion of breast feeding

• Education of the parents regarding immunization of

the children

THANK YOU