UNIT 22 MANAGEMENT OF CHILD WITH MALNUTRITION Structure 22.0 Objectives 22.1 Introduction 222 Epidemiology . 223 Etiology 22.4 Identifiing Malnutrition 22.4.1 Recognition of a Malnourished Child 22.4.2 Age dependent parameters 22.4.3 Age Independent Parameters 22.4.4 Early detection 22.4.5 Criteria for Admission in Hospital 22.5 Assessment 22.6 Management at Domiciliary Level 22.6.1 Nutritional Education 22.6.2 Rehabilitation 22.7 Let Us Sum Up 22.8 Key Words 22.9 Answers to Check Your Progress 22.10 Further Readings 22.0 OBJECTIVES After going through this unit, you should be able to: describe the epidemiology, etiology, clinical features and grading of protein energy malnutrition (PEM); enumerate steps in the management of cases of mild and moderate malnutrition at domiciliary level; enumerate the indications of hospitalizing a child with malnutrition and steps in the management of cases of severe maltlutrition at the hospital facilities; and enumerate the steps in nutritional counseling and rehabilitation in PEM. 22.1 INTRODUCTION Nutrition is important for proper growth and development of child . PEM and growth retardation are probably the most wide spread health and nutritional problem of developing countries including India. It is estimated that 57 million children are underweight. More than 50% of deaths in 0-4 yrs are associated with malnutrition. The median case fatality rate is approx. 23.5% in severe malnutrition reaching to 50% in edematous malnutrition. In the previous unit you learnt about complementary feeding and feeding counseling. If breastfeeding and supplementary feeding are not lookea after it results in malnutrition (under nutrition). In this unit you will learn about Protein Energy Malnutrition- its . definition, causative factors, clinical features, management of a child referred with severe malnutrition along with steps involved in nutritional education and rehabilitation.
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Structure
22.4.2 Age dependent parameters
22.4.3 Age Independent Parameters
22.5 Assessment
22.6.1 Nutritional Education
22.8 Key Words
22.10 Further Readings
After going through this unit, you should be able to:
describe the epidemiology, etiology, clinical features and grading of protein energy malnutrition (PEM);
enumerate steps in the management of cases of mild and moderate malnutrition at domiciliary level;
enumerate the indications of hospitalizing a child with malnutrition and steps in the management of cases of severe maltlutrition at the hospital facilities; and
enumerate the steps in nutritional counseling and rehabilitation in PEM.
22.1 INTRODUCTION
Nutrition is important for proper growth and development of child . PEM and growth retardation are probably the most wide spread health and nutritional problem of developing countries including India. It is estimated that 57 million children are underweight. More than 50% of deaths in 0-4 yrs are associated with malnutrition. The median case fatality rate is approx. 23.5% in severe malnutrition reaching to 50% in edematous malnutrition. In the previous unit you learnt about complementary feeding and feeding counseling. If breastfeeding and supplementary feeding are not lookea after it results in malnutrition (under nutrition). In this unit you will learn about Protein Energy Malnutrition-its .
definition, causative factors, clinical features, management of a child referred with severe malnutrition along with steps involved in nutritional education and rehabilitation.
- 22.2 EPIDEMIOLOGY
Management o f Child with Malnutrition
Let us begin with trying to understand as to what do we mean by term Protein Energy Malnutrition (PEM). You are well aware that proteins are needed for tissue building and energy is required to perform any activity by an individual. The term malnutrition is defined as insufficient nutrition, a condition where diet is deficient in some foods necessary for health. Severe malnutrition is both a medlcal and social disorder i.e., the medical problem of child results partly from the social problem of the house in which the child lives. PEM covers a range of nutritional disorders, which include growth failure, marasmus and kwashiorkor.
The prevalence of malnutrition varies from country to country. Various studies from India report prevalence of malnutrition ranging from 48-8 1.5% with severe ranging from 3.1 - 10%. According to National Family Health Survey (NFHS-2) 47% of children under age 3 are underweight (weight for age), 45.5% are stunted (height for age) and 15.5% are wasted (weig,ht for height).
In defeloping countries PEM may start even in fetal life. A malnourished mother gives birth to a low birth weight baby, which may in turn remain malnourished and the cycle thus goes on. For most children growth faltering starts at 4-6 months of age and critical perio~d is 6 months to 2 years. About 50-60% of children are malnourished by the age of 2 years.
PEM has high prevalence in families with low socio-economic status: Countries with large population have more illiterate people with low per capita income and thus have large number of malnourished people.
PEM may occur without any associated disease but in majority it is part of other disease and most common infections which form a vicious circle of infection-malnutrition- infecl ion.
The recent trend of urbanization is also a contributing factor to increased prevalence of malnutrition. Here also low socio-economic status, slum habitation, broken homes or overcrowded families have very high prevalence. The rapid growth of slums and these shanty towns are associated with problems of sanitaticn, water supply and other demands leading to rapid increase of children with malnutrition.
In rural areas of developing countriss malnutrition is endemic and is often seasonal related to a period of year when food for the whole family is in short supply and child is most deprived and gets infections like measles. Ignorance about nutrition is also an impoltant factor in rural areas.
.22.21 AETIOLOGY
As yc~u know now that India and other developing countries have great load of malnourished children. Malnutrition is not a disease of single etiological factor. All the factors are interrelated and form a vicious cycle.
As the name suggest, PEM is the deficiency of protein and energy as the major cause but there is much more to the syndrome. The calorie and protein requirement of young children are larger, relative to their size than in older children and adults. Malnutrition is result of a complex interplay of interacting and related factors in the individual family and comn~unity. Inadequate dietary intake and disease are immediate determinants of PEM. Disease may affect PEM by various mechanisms. Conversely PEM may increase susceptibility to and severity of infections. Thus malnutrition is both medical and social prob11:m. Malnutrition is the end result of chronic nutritional and frequently emotional deprivation by care providers who because.of poor understanding, poverty or family prob11:ms are unable to provide the child with nutrition and care that s h e requires. Successhl management of the severely malnourished child requires that both medical and social problems be recognized and corrected. If the illness is viewed as being only a medic a1 disorder, the child is likely to relapse when she returns home and other children will remain at risk of developing the same problem.
As there is high incidence of low birth weight babies in developing countries, these may remain malnourished and contribute to high incidence of under five under nutrition. So now we shall look into the various causes leading to PEM.
Poverty
One of the most common causes of malnutrition is poverty. The purchasing power of poor person is low and with increasing prices for food, adequate amount of food of desired quality can not be purchased for the family. This deprivation adversely affects their working capacity for physical work which leads to decreased earning and again poverty. With the industrialization and new social milieu there is more expenditure on housing, clothing and entertainment etc. at the cost of expenditure on food.
Feeding Habits
It is not only the lack of food but also lack of knowledge about nutrients, which may lead to PEM in rich families who have enough resources to purchase the food. Ignorance about proper feeding is an equally important factor contributing to malnutrition. Various factors are:
a) Bottle feeding
b) Delayed introduction of complementary food.
c) Diluted supplementary food (diluted milk)
d) Complementary food is too thin and lacks in energy density and protein.
e) Withholding the feeds during infections like diarrhea, fever etc.
f) Irrational beliefs and taboos about food.
Usually there is more than one factor leading to malnutrition in a child.
Marketing of Baby Foods
rhere is very attractive advertising by baby food manufacturers encouraging early discontinuation of breast-feeding. There is social pressure also on urban educated working women. Unfortunately, dry milk products are expensive and thus lead to excessive dilution and decreased energylprotein feeding to children. There is high risk of infection due to unhygienic preparation of food. Invariably slum mothers try to emulate the elite group and cause damage to their child.
Large Families
Short birth intervals result in large number of children in the family. When the mother remains preoccupied with large number of children, she is more prone to neglect her own health and ante natal check-up during pregnancy. Episodes of infection and under nutrition during pregnancy predispose her to complications of pregnancy and there are increased chances of low birth weight baby in the family.
Unequal Distribution of Food in the Family
Poor family has less available food and even the little available food is distributed unequally among different members of family. Share of women and pre-school child get reduced in favor of working adult males. Even a female child may get less food in comparison to male child.
Infections
There is strong correlation between infections and malnutrition. Malaria and Measles precipitate acute malnutrition and may aggravate existing nutritional deficit. Malnutrition adversely affects the immune system and makes the malnourished child more vulnerable to infections and even an infection, which would have passed as sub-clinical may become severe in the malnourished child. This sets up a vicious cycle of malnutrition-infection- malnutrition. Measles was the commonest cause of this vicious cycle before immunization became available against measles. Recurrent attacks of diarrhea in pre-school children are. major contributing factors. During infection child appetite is impaired. There may be
iatrogenic restriction of foods by pxents.
Infection may initiate several metabolic changes in the host and hence adversely affect the nutritional status. There is:
Inc~.ease in resting metabolic expenditure
Changes in energy, protein and mineral metabolism
Impaired utilization of lipid store.
Besides 1:his depending upon the infection there may be different nutritional deficit resulting due to malabsorption.
Maternal Malnutrition
Malnourished mothers have a high incidence of low birth weight babies with poor nutrition(a1 reserve. These mothers also show poor lactational performance.
The clinical manifestations of malnutrition depend on the severity and duration of nutritionial deprivation and age of undernourished subject. Malnutrition can be compared to an icelxrg, where only tip of the iceberg ie the severe forms is seen above the surface of water. Those hidden under the surface constitute a vast majority of children suffering from mild and moderate forms of PEM. Mild degree of protein and calorie deficiency leads to growth n:tardation rather than frank malnutrition. This is associated with some degree of retardation in mental development.
As per latest definition, severe malnutrition is defined as the presence of severe wasting weight fca height (<70% or < 3SD) and 1 or edema. Mid upper arm circumference (MUAC) criteria niay also be used for identifying severe wasting. It is obvious that along with clinical examination and medical history it is required to assess the assessment of nutritionid status. Here we shall not go into the details of dietary intake assessment except mentioning various methods, which are being used in surveys.
precise weighing of food eaten
Chemical analysis of replicate diets
Dietary recall
Dietary recording.
In routine practice one can only use the dietary recall of an average day.
Now we will focus our attention on the methods used for classifying the child in a nutritionill category.
22.4.1 Recognition and Initial Assessment of a Malnourished Child
The initial assessment of a severely malnourished child involves a good history taking and physical examination. The key points to be covered, include history of recent intake of food and fluids, usual diet before onset of current illness, breast feeding, any history of dikrhea ,vomiting etc, fever or any symptoms suggestive of infection, family circumst;mces to understand the child's social back ground, chronic cough and contact with tuberculosis, recent contact with measles and known or suspected HIV infection Although the assessment of nutritional status is very important there is no universally acceptable system. Various methods are available but in routine practice regular weighing coupled with construction of a weight chart provides the most revealing information. Single weight plot on a chart may be fallacious. Various methods can be divided into two groups
Age Dependent Criteria
Age Independent Criteria
Management of Child with M a l n u t r i t i o ~ ~
Nutrition 22.4.2 Age Dependent Criteria
These include weight for age. For this measurement various classifications are available, but most acceptable and recommended classification in use are-
WHO CLASSrnCATION
IAP Classification-It has been proposed by nutritional sub committee of Indian academy of pediatrics using the standard value (100%) as 50th percentile of Harvard growth standard-
Add ( K) for presence of edema.
22.4.3 Age Independent Criteria
If exact date of birth is not known then there is disadvantage with the age dependent parameters. Under these circumstances certain age independent parameters have been developed which do not require the knowledge of exact age of child. These parameters are:
Weight for Height
Mid arm circumference
Triceps skin fold thickness.
Mid - arm Circumference It is useful for quick survey in community. The left arm is used for this purpose. The mid arm circumference is measured by Shakirs tape. The tape has 3 colors, which indicate the presence or absence of malnutrition.
22.4.4 Early Detection
Growin<: is a normal physiological phenomenon and child grows continuously right from birth to adolescence. The initial growth curvetchart was developed by David Morley and the growth should be measured on a growth curve. Morley used weight for age as a tool for assessing the nutritional status, but this is useful when regular sequential weighing is carried out. If recorded carefully the early growth faltering can be recognized and proper action can be taken before the child has lost weight.
22.4.5 Criteria for Admission in Hospital
Management of Child with Malnutrition
The indications for hospitalization of a child with malnutrition include the following:
Weight-for-length (or height) <70% or -3SD (marasmus)
~ d e m a of both feet (kwashiorkor or marasmic kwashiorkor).
Jf wdm-001-belght or weight-for-length cannot be measured, use the clinical signs for ~~ OF visible severe wasting. A child with visible severe wasting appears very thin md bas no fat. There is severe wasting of the shoulders, arms, buttocks and thighs, with VIS/M,P rib uqttlines.
Qllldrep. a%% weight-for-age may be stunted and not severely wasted. Stunted ch&b.ea de not require bmpital admission unless they have a serious illness. ChiIdren refenled d y on the basis of low weight-for-age should be reassessed to determine if
&agnostic feature of severe malnutrition is present.
Nutrit ion ASSESSMENT
Once a patient is referred to hospital, history should be taken and patient examined so as to decide quickly about the treatment to be given. Details of history and examination should be recorded later. Very sick children respond badly to frequent handling. They should not be taken for x-ray immediately and should remain in bed while clinical specimens are taken.
Following is the checklist of points for taking history:
Medical History
Acute Problem-Duration and frequency of vomiting or diarrhea, fever etc.
Usual diet befure current episode of illness
Food and fluids taken in past few days
Type of diarrhea (waterylbloody)
Breastfeeding history
Any death of sibling.
Weight and length or height
Temperature for hypothermia or fever
Edema and severe pallor
Signs of dehydration or circulatory collapse-cold hand and feet, weak radial pulse, and diminished consciousness.
Thirst
Abdominal distension, bowl sounds, enlargement of liver and jaundice
Respiratory rate and type of respiration-signs of pneumonia or heart failure.
Eyes--corneal lesions indicative of vitamin A deficiency.
Ears, mouth, throat for evidence of infection.
Skin for evidence of infection or purpura.
Appearance of face.
Marasmus
Parentslgrand parents usually complaint that child is only skin and bone. In northern India the local term used is 'Sukha Rog' (drying disease). Marasmus can be diagnosed easily. The child gets very little to eat and is very thin. You can count bones in his body. The muscles are wasted and there is loss of subcutaneous fat. Adipose tissue is severely depleted. Skin is thin and wrinkled.
Clinically a marasmic child is described as a wise old man because of his typical face. His weight is less than 50% of expected weight for his age. His mid-arm circumference is less than 12.0 cm. He has anxious look and is hungry. These children may have skin infections; there is abdominal distension and intestinal loops are easily visible. Hair is hypo- pigmented.
History may reveal that there was problem with breastfeeding. Mother might have died or there was little output even if she was alive. Working mother might have tried bottle- feeding, milk must have been diluted and there might have been insufficient sterilization, poor hygiene and in recurrent illnesses like diarrhea and pneumonia and feeding was restrict~d.
Fig. 22.1: Child with marasmus
Kwashiorkor
This is most severe and fatal form of PEM. The baby is swollen and irritable. Child is nat getting :nough protein as compared to his energy intake. This is generally noticed between 8 months to 2 years of age. This is the period when weaning is completing. Clinically there is growth faltering, low weight for age and even height is less. Two classical features are:
Ed8:ma starts in lower limbs and then covers upper limb.
Muscles of upper limb are wasted and the lower limb is swollen.
Sometimes the face has moon face appearance. Usually there is history of acute episode of diarrhea.
Childre11 with Kwashiorkor are usually inactive, irritable, become listless and apathetic.
Skin changes are described as Flaky Paint dermatosis. Lesions are most common on buttock and perineum. There is fissuring on angles of mouth and atrophy of tongue. The hair is slmse, thin and easily pluckable. There is typical flag sign i.e. alternate pigmented and hypopigmented hair. These children are prone to various infections like meningitis, pneumonia.
Their immunity is lowered. There is enlargement of liver and they have anemia due to iron and folic: acid deficiency.
The mortality is due to inter current infection and majority of deaths occur in early days of being brought to health centrelhaspital.
The difi:rence in Marasmus and Kwashiorkor are given in Table 22.1.
Management of Child with Malnutritiam
Nutrition Table 22.1: Differences between Marasmus and Kwashiorkor
Fig. 22.2: Child with kwashiorkor
Associated Deficiencies
PEM is a not the result of deficiency of energy and proteins only, it is the syndrome which has associated multiple deficiencies. These deficiencies affect either directly or indirectly by affecting various metabolisms in the body. Most common deficiencies should be looked for are:
Signs of Vitamin A deficiency
Signs of Anemia
B-complex factor deficiency
Among the micronutrients Zinc is the most common deficiency responsible for various features of PEM.
Since rickets is the disease of growing bones its signs are not present initially but as soon as the nutritional management is started and child starts growing, the signsand symptoms of rickets get manifested.
Systemic Illness
Since these children of PEM and specially that of Kwashiorkor are very prone to infection, these children might have associated systemic illnesses like UTI, tuberculosis, pneumonia, and meningitis. Clinically a marasmus child may not show typical features of meningitis or
'respiratory signs of pneumonia; hence these should be specifically looked for. Patient should be investigated for tuberculosis and UTI to be ruled out as causal agent for development for malnutrition.
Laboratory Investigations
Before deciding about the laboratory tests required to be done let us look at the biocheinical alteration in PEM. A brief description of these changes is listed below.
Proteirr and Amino acid Metabolism
A chilcl with severe PEM has reduced total body protein and plasma protein particularly serum (dbumin is markedly decreased. The catabolic rate of albumin is reduced by about half and this change may be related to decreased intake. There is no reduction in serum globulin but plasma transferrin is found to be reduced.
Fasting, blood glucose is lowered in malnourished children. In certain cases life-threatening hypoglycemia can occur. This may be the result of unrecognized associated infection.
There :.s decreased liver glycogen store and also decreased glycogenolysis.
Lipids
Chi1drt:n with Kwashiorkor have fatty liver. In Marasmus the liver lipids are not markedly increased as in Kwashiorkor. The levels of triglycerides, cholesterol and 0-lipoprotein are usually increased in Marasmus while in Kwashiorkor either these are reduced or are at lower 1,:vel of normal.
Thermo Regulation
Because of loss of subcutaneous fat and reduced skin fold thickness in Marasmus, the ability to maintain body temperature is lowered and these children suffer from hypothermia more often then those with Kwashiorkor.
Growth hormones Nonnal or increased
Insulin Levels decreased, impaired Glucose tolerance
Thyroi,d hormone Conflicting reports
In most cases only a few investigations are needed but where facility persist the tests given in Table 22.2 may help to diagnose specific problem. They are not needed however to guide or monitor treatment. The most important guide to treatment is frequent careful assessment of the child.
Table 22.2: Tests that are useful
Management of Child with Malnutrition
Nutrition
22.6…
22.4.2 Age dependent parameters
22.4.3 Age Independent Parameters
22.5 Assessment
22.6.1 Nutritional Education
22.8 Key Words
22.10 Further Readings
After going through this unit, you should be able to:
describe the epidemiology, etiology, clinical features and grading of protein energy malnutrition (PEM);
enumerate steps in the management of cases of mild and moderate malnutrition at domiciliary level;
enumerate the indications of hospitalizing a child with malnutrition and steps in the management of cases of severe maltlutrition at the hospital facilities; and
enumerate the steps in nutritional counseling and rehabilitation in PEM.
22.1 INTRODUCTION
Nutrition is important for proper growth and development of child . PEM and growth retardation are probably the most wide spread health and nutritional problem of developing countries including India. It is estimated that 57 million children are underweight. More than 50% of deaths in 0-4 yrs are associated with malnutrition. The median case fatality rate is approx. 23.5% in severe malnutrition reaching to 50% in edematous malnutrition. In the previous unit you learnt about complementary feeding and feeding counseling. If breastfeeding and supplementary feeding are not lookea after it results in malnutrition (under nutrition). In this unit you will learn about Protein Energy Malnutrition-its .
definition, causative factors, clinical features, management of a child referred with severe malnutrition along with steps involved in nutritional education and rehabilitation.
- 22.2 EPIDEMIOLOGY
Management o f Child with Malnutrition
Let us begin with trying to understand as to what do we mean by term Protein Energy Malnutrition (PEM). You are well aware that proteins are needed for tissue building and energy is required to perform any activity by an individual. The term malnutrition is defined as insufficient nutrition, a condition where diet is deficient in some foods necessary for health. Severe malnutrition is both a medlcal and social disorder i.e., the medical problem of child results partly from the social problem of the house in which the child lives. PEM covers a range of nutritional disorders, which include growth failure, marasmus and kwashiorkor.
The prevalence of malnutrition varies from country to country. Various studies from India report prevalence of malnutrition ranging from 48-8 1.5% with severe ranging from 3.1 - 10%. According to National Family Health Survey (NFHS-2) 47% of children under age 3 are underweight (weight for age), 45.5% are stunted (height for age) and 15.5% are wasted (weig,ht for height).
In defeloping countries PEM may start even in fetal life. A malnourished mother gives birth to a low birth weight baby, which may in turn remain malnourished and the cycle thus goes on. For most children growth faltering starts at 4-6 months of age and critical perio~d is 6 months to 2 years. About 50-60% of children are malnourished by the age of 2 years.
PEM has high prevalence in families with low socio-economic status: Countries with large population have more illiterate people with low per capita income and thus have large number of malnourished people.
PEM may occur without any associated disease but in majority it is part of other disease and most common infections which form a vicious circle of infection-malnutrition- infecl ion.
The recent trend of urbanization is also a contributing factor to increased prevalence of malnutrition. Here also low socio-economic status, slum habitation, broken homes or overcrowded families have very high prevalence. The rapid growth of slums and these shanty towns are associated with problems of sanitaticn, water supply and other demands leading to rapid increase of children with malnutrition.
In rural areas of developing countriss malnutrition is endemic and is often seasonal related to a period of year when food for the whole family is in short supply and child is most deprived and gets infections like measles. Ignorance about nutrition is also an impoltant factor in rural areas.
.22.21 AETIOLOGY
As yc~u know now that India and other developing countries have great load of malnourished children. Malnutrition is not a disease of single etiological factor. All the factors are interrelated and form a vicious cycle.
As the name suggest, PEM is the deficiency of protein and energy as the major cause but there is much more to the syndrome. The calorie and protein requirement of young children are larger, relative to their size than in older children and adults. Malnutrition is result of a complex interplay of interacting and related factors in the individual family and comn~unity. Inadequate dietary intake and disease are immediate determinants of PEM. Disease may affect PEM by various mechanisms. Conversely PEM may increase susceptibility to and severity of infections. Thus malnutrition is both medical and social prob11:m. Malnutrition is the end result of chronic nutritional and frequently emotional deprivation by care providers who because.of poor understanding, poverty or family prob11:ms are unable to provide the child with nutrition and care that s h e requires. Successhl management of the severely malnourished child requires that both medical and social problems be recognized and corrected. If the illness is viewed as being only a medic a1 disorder, the child is likely to relapse when she returns home and other children will remain at risk of developing the same problem.
As there is high incidence of low birth weight babies in developing countries, these may remain malnourished and contribute to high incidence of under five under nutrition. So now we shall look into the various causes leading to PEM.
Poverty
One of the most common causes of malnutrition is poverty. The purchasing power of poor person is low and with increasing prices for food, adequate amount of food of desired quality can not be purchased for the family. This deprivation adversely affects their working capacity for physical work which leads to decreased earning and again poverty. With the industrialization and new social milieu there is more expenditure on housing, clothing and entertainment etc. at the cost of expenditure on food.
Feeding Habits
It is not only the lack of food but also lack of knowledge about nutrients, which may lead to PEM in rich families who have enough resources to purchase the food. Ignorance about proper feeding is an equally important factor contributing to malnutrition. Various factors are:
a) Bottle feeding
b) Delayed introduction of complementary food.
c) Diluted supplementary food (diluted milk)
d) Complementary food is too thin and lacks in energy density and protein.
e) Withholding the feeds during infections like diarrhea, fever etc.
f) Irrational beliefs and taboos about food.
Usually there is more than one factor leading to malnutrition in a child.
Marketing of Baby Foods
rhere is very attractive advertising by baby food manufacturers encouraging early discontinuation of breast-feeding. There is social pressure also on urban educated working women. Unfortunately, dry milk products are expensive and thus lead to excessive dilution and decreased energylprotein feeding to children. There is high risk of infection due to unhygienic preparation of food. Invariably slum mothers try to emulate the elite group and cause damage to their child.
Large Families
Short birth intervals result in large number of children in the family. When the mother remains preoccupied with large number of children, she is more prone to neglect her own health and ante natal check-up during pregnancy. Episodes of infection and under nutrition during pregnancy predispose her to complications of pregnancy and there are increased chances of low birth weight baby in the family.
Unequal Distribution of Food in the Family
Poor family has less available food and even the little available food is distributed unequally among different members of family. Share of women and pre-school child get reduced in favor of working adult males. Even a female child may get less food in comparison to male child.
Infections
There is strong correlation between infections and malnutrition. Malaria and Measles precipitate acute malnutrition and may aggravate existing nutritional deficit. Malnutrition adversely affects the immune system and makes the malnourished child more vulnerable to infections and even an infection, which would have passed as sub-clinical may become severe in the malnourished child. This sets up a vicious cycle of malnutrition-infection- malnutrition. Measles was the commonest cause of this vicious cycle before immunization became available against measles. Recurrent attacks of diarrhea in pre-school children are. major contributing factors. During infection child appetite is impaired. There may be
iatrogenic restriction of foods by pxents.
Infection may initiate several metabolic changes in the host and hence adversely affect the nutritional status. There is:
Inc~.ease in resting metabolic expenditure
Changes in energy, protein and mineral metabolism
Impaired utilization of lipid store.
Besides 1:his depending upon the infection there may be different nutritional deficit resulting due to malabsorption.
Maternal Malnutrition
Malnourished mothers have a high incidence of low birth weight babies with poor nutrition(a1 reserve. These mothers also show poor lactational performance.
The clinical manifestations of malnutrition depend on the severity and duration of nutritionial deprivation and age of undernourished subject. Malnutrition can be compared to an icelxrg, where only tip of the iceberg ie the severe forms is seen above the surface of water. Those hidden under the surface constitute a vast majority of children suffering from mild and moderate forms of PEM. Mild degree of protein and calorie deficiency leads to growth n:tardation rather than frank malnutrition. This is associated with some degree of retardation in mental development.
As per latest definition, severe malnutrition is defined as the presence of severe wasting weight fca height (<70% or < 3SD) and 1 or edema. Mid upper arm circumference (MUAC) criteria niay also be used for identifying severe wasting. It is obvious that along with clinical examination and medical history it is required to assess the assessment of nutritionid status. Here we shall not go into the details of dietary intake assessment except mentioning various methods, which are being used in surveys.
precise weighing of food eaten
Chemical analysis of replicate diets
Dietary recall
Dietary recording.
In routine practice one can only use the dietary recall of an average day.
Now we will focus our attention on the methods used for classifying the child in a nutritionill category.
22.4.1 Recognition and Initial Assessment of a Malnourished Child
The initial assessment of a severely malnourished child involves a good history taking and physical examination. The key points to be covered, include history of recent intake of food and fluids, usual diet before onset of current illness, breast feeding, any history of dikrhea ,vomiting etc, fever or any symptoms suggestive of infection, family circumst;mces to understand the child's social back ground, chronic cough and contact with tuberculosis, recent contact with measles and known or suspected HIV infection Although the assessment of nutritional status is very important there is no universally acceptable system. Various methods are available but in routine practice regular weighing coupled with construction of a weight chart provides the most revealing information. Single weight plot on a chart may be fallacious. Various methods can be divided into two groups
Age Dependent Criteria
Age Independent Criteria
Management of Child with M a l n u t r i t i o ~ ~
Nutrition 22.4.2 Age Dependent Criteria
These include weight for age. For this measurement various classifications are available, but most acceptable and recommended classification in use are-
WHO CLASSrnCATION
IAP Classification-It has been proposed by nutritional sub committee of Indian academy of pediatrics using the standard value (100%) as 50th percentile of Harvard growth standard-
Add ( K) for presence of edema.
22.4.3 Age Independent Criteria
If exact date of birth is not known then there is disadvantage with the age dependent parameters. Under these circumstances certain age independent parameters have been developed which do not require the knowledge of exact age of child. These parameters are:
Weight for Height
Mid arm circumference
Triceps skin fold thickness.
Mid - arm Circumference It is useful for quick survey in community. The left arm is used for this purpose. The mid arm circumference is measured by Shakirs tape. The tape has 3 colors, which indicate the presence or absence of malnutrition.
22.4.4 Early Detection
Growin<: is a normal physiological phenomenon and child grows continuously right from birth to adolescence. The initial growth curvetchart was developed by David Morley and the growth should be measured on a growth curve. Morley used weight for age as a tool for assessing the nutritional status, but this is useful when regular sequential weighing is carried out. If recorded carefully the early growth faltering can be recognized and proper action can be taken before the child has lost weight.
22.4.5 Criteria for Admission in Hospital
Management of Child with Malnutrition
The indications for hospitalization of a child with malnutrition include the following:
Weight-for-length (or height) <70% or -3SD (marasmus)
~ d e m a of both feet (kwashiorkor or marasmic kwashiorkor).
Jf wdm-001-belght or weight-for-length cannot be measured, use the clinical signs for ~~ OF visible severe wasting. A child with visible severe wasting appears very thin md bas no fat. There is severe wasting of the shoulders, arms, buttocks and thighs, with VIS/M,P rib uqttlines.
Qllldrep. a%% weight-for-age may be stunted and not severely wasted. Stunted ch&b.ea de not require bmpital admission unless they have a serious illness. ChiIdren refenled d y on the basis of low weight-for-age should be reassessed to determine if
&agnostic feature of severe malnutrition is present.
Nutrit ion ASSESSMENT
Once a patient is referred to hospital, history should be taken and patient examined so as to decide quickly about the treatment to be given. Details of history and examination should be recorded later. Very sick children respond badly to frequent handling. They should not be taken for x-ray immediately and should remain in bed while clinical specimens are taken.
Following is the checklist of points for taking history:
Medical History
Acute Problem-Duration and frequency of vomiting or diarrhea, fever etc.
Usual diet befure current episode of illness
Food and fluids taken in past few days
Type of diarrhea (waterylbloody)
Breastfeeding history
Any death of sibling.
Weight and length or height
Temperature for hypothermia or fever
Edema and severe pallor
Signs of dehydration or circulatory collapse-cold hand and feet, weak radial pulse, and diminished consciousness.
Thirst
Abdominal distension, bowl sounds, enlargement of liver and jaundice
Respiratory rate and type of respiration-signs of pneumonia or heart failure.
Eyes--corneal lesions indicative of vitamin A deficiency.
Ears, mouth, throat for evidence of infection.
Skin for evidence of infection or purpura.
Appearance of face.
Marasmus
Parentslgrand parents usually complaint that child is only skin and bone. In northern India the local term used is 'Sukha Rog' (drying disease). Marasmus can be diagnosed easily. The child gets very little to eat and is very thin. You can count bones in his body. The muscles are wasted and there is loss of subcutaneous fat. Adipose tissue is severely depleted. Skin is thin and wrinkled.
Clinically a marasmic child is described as a wise old man because of his typical face. His weight is less than 50% of expected weight for his age. His mid-arm circumference is less than 12.0 cm. He has anxious look and is hungry. These children may have skin infections; there is abdominal distension and intestinal loops are easily visible. Hair is hypo- pigmented.
History may reveal that there was problem with breastfeeding. Mother might have died or there was little output even if she was alive. Working mother might have tried bottle- feeding, milk must have been diluted and there might have been insufficient sterilization, poor hygiene and in recurrent illnesses like diarrhea and pneumonia and feeding was restrict~d.
Fig. 22.1: Child with marasmus
Kwashiorkor
This is most severe and fatal form of PEM. The baby is swollen and irritable. Child is nat getting :nough protein as compared to his energy intake. This is generally noticed between 8 months to 2 years of age. This is the period when weaning is completing. Clinically there is growth faltering, low weight for age and even height is less. Two classical features are:
Ed8:ma starts in lower limbs and then covers upper limb.
Muscles of upper limb are wasted and the lower limb is swollen.
Sometimes the face has moon face appearance. Usually there is history of acute episode of diarrhea.
Childre11 with Kwashiorkor are usually inactive, irritable, become listless and apathetic.
Skin changes are described as Flaky Paint dermatosis. Lesions are most common on buttock and perineum. There is fissuring on angles of mouth and atrophy of tongue. The hair is slmse, thin and easily pluckable. There is typical flag sign i.e. alternate pigmented and hypopigmented hair. These children are prone to various infections like meningitis, pneumonia.
Their immunity is lowered. There is enlargement of liver and they have anemia due to iron and folic: acid deficiency.
The mortality is due to inter current infection and majority of deaths occur in early days of being brought to health centrelhaspital.
The difi:rence in Marasmus and Kwashiorkor are given in Table 22.1.
Management of Child with Malnutritiam
Nutrition Table 22.1: Differences between Marasmus and Kwashiorkor
Fig. 22.2: Child with kwashiorkor
Associated Deficiencies
PEM is a not the result of deficiency of energy and proteins only, it is the syndrome which has associated multiple deficiencies. These deficiencies affect either directly or indirectly by affecting various metabolisms in the body. Most common deficiencies should be looked for are:
Signs of Vitamin A deficiency
Signs of Anemia
B-complex factor deficiency
Among the micronutrients Zinc is the most common deficiency responsible for various features of PEM.
Since rickets is the disease of growing bones its signs are not present initially but as soon as the nutritional management is started and child starts growing, the signsand symptoms of rickets get manifested.
Systemic Illness
Since these children of PEM and specially that of Kwashiorkor are very prone to infection, these children might have associated systemic illnesses like UTI, tuberculosis, pneumonia, and meningitis. Clinically a marasmus child may not show typical features of meningitis or
'respiratory signs of pneumonia; hence these should be specifically looked for. Patient should be investigated for tuberculosis and UTI to be ruled out as causal agent for development for malnutrition.
Laboratory Investigations
Before deciding about the laboratory tests required to be done let us look at the biocheinical alteration in PEM. A brief description of these changes is listed below.
Proteirr and Amino acid Metabolism
A chilcl with severe PEM has reduced total body protein and plasma protein particularly serum (dbumin is markedly decreased. The catabolic rate of albumin is reduced by about half and this change may be related to decreased intake. There is no reduction in serum globulin but plasma transferrin is found to be reduced.
Fasting, blood glucose is lowered in malnourished children. In certain cases life-threatening hypoglycemia can occur. This may be the result of unrecognized associated infection.
There :.s decreased liver glycogen store and also decreased glycogenolysis.
Lipids
Chi1drt:n with Kwashiorkor have fatty liver. In Marasmus the liver lipids are not markedly increased as in Kwashiorkor. The levels of triglycerides, cholesterol and 0-lipoprotein are usually increased in Marasmus while in Kwashiorkor either these are reduced or are at lower 1,:vel of normal.
Thermo Regulation
Because of loss of subcutaneous fat and reduced skin fold thickness in Marasmus, the ability to maintain body temperature is lowered and these children suffer from hypothermia more often then those with Kwashiorkor.
Growth hormones Nonnal or increased
Insulin Levels decreased, impaired Glucose tolerance
Thyroi,d hormone Conflicting reports
In most cases only a few investigations are needed but where facility persist the tests given in Table 22.2 may help to diagnose specific problem. They are not needed however to guide or monitor treatment. The most important guide to treatment is frequent careful assessment of the child.
Table 22.2: Tests that are useful
Management of Child with Malnutrition
Nutrition
22.6…
Related Documents
