Malnutrition

Presented By:
Dr. Chandah Bilal
Dr. Bilal Jalil
Dr. Arif
Pediatrics Department
Capital Hospital
Islamabad
 Definition

The cellular imbalance

between supply of
World Health
nutrients and energy and
Organization (WHO)
bodys demand to ensure
defines Malnutrition as;
growth, maintenance and
specific functions.
 Malnutrition is having the inappropriate level of a
micro- or macro- nutrient;
Malnutrition can be associated with being grossly

overweight;
In most of the world, malnutrition is defined as a

LACK of nutrients
 Malnutrition

Under-nutrition Over-nutrition

Obesity
kwashiorkor Marasmas
The hungry child should be fed
1924: Declaration of the Rights of the Child (also
known as the Declaration of Geneva).
Adopted after World War I by the League of
Nations.
Affirms that "the child must be given the means
needed for its normal development, both
materially and spiritually"
 Epidemiology

Nearly half of all deaths in children under 5 are

attributable to undernutrition.
In 2015 globally, 50 million children under 5 were
wasted and 17 million were severely wasted.
23.2 per cent, or just under one in four children under
age 5 worldwide had stunted growth.
The prevalence of wasting in South Asia is so severe,
at just under 15 per cent, that it is approaching the
level of a critical public health problem.
Worldwide, in 2015, 42 million children under age 5
were overweight.
Percentage of children under 5 who are stunted, 20102016
Percentage of children under 5 who are wasted, by region, 2015
 Pakistani Scenario
In Pakistan, the nutritional status of children
under five years of age is extremely poor.
At a national level almost 40% of these children

are underweight.
Malnutrition is responsible as underlying factor

for 55% of Deaths in Children under 5 years of

age
Prevalence of Malnutrition in Pakistan
Death from malnutrition
*

*At least 70%

* of childhood
diseases are
related with
one of these
conditions
*
*
 Malnutrition resulting from increased Malnutrition
nutrient needs, decreased nutrient
absorption, and/or increased nutrient
Secondary
losses.
Malnutrition
Malnutrition resulting from inadequate food
intake.
Primary
Etiology of Malnutrition
 Primary
Malnutrition

Lack of family Failure of

planning lactation

Lack of
immunization Ignorance of
and primary weaning
care

Cultural
patterns and Poverty
food fads
 Secondary
Malnutrition

Inborn errors of Parasitic

metabolism, infestations,
galactosemia Measles, whooping
cough, Primary
tuberculosis, Urinary
tract infection

Cystic fibrosis

Congenital heart
disease, Urinary tract
Giardiasis, Lactose anomalies
intolerance, Celiac
disease, Tuberculosis
of the intestine
 Malnutrition rarely exists in isolation, and many
other factors contribute to its detrimental
impact.

Malnutrition has repercussions throughout the

life cycle and is thus multi-generational
(diagram with lots of arrows)
 Higher Impaired
mortality rate mental
development
Reduced Increased risk of
capacity adult chronic disease
Baby
to care
Low Birth Untimely/inadequate
Elderly for baby
Weight weaning
Malnourished
Frequent
Infections
Inadequate Inadequate
catch up food, health
Inadequate
Inadequate growth & care
fetal Child
food, nutrition
health Stunted
& care Reduced
mental
Woman capacity
Malnourished
Adolescent
Start here Pregnancy Inadequate
Stunted
Low Weight food, health
Gain & care

Reduced
Inadequate mental
Higher
food, health capacity
maternal
& care
mortality
Classification
 GOMEZ Classification
If the weight is > 90 % of the expected weight no
malnutrition
1st degree- weight is 75-90% of the expected weight
2nd degree- weight is 60-75% of the expected weight
3rd degree- weight is < 60 % of the expected weight
Modified 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
HARVARD CLASSIFICATION
If the weight falls on 50th percentile- healthy child
Grade I- if weight is 71-80% of 50th percentile
Grade II- if weight is 61-70% of 50th percentile
Grade III- if weight is 51-60% of 50th percentile
Grade IV- if weight is 50% of 50th percentile
 WATER LOW CLASSIFICATION

Height for Weight for age expressed as percentage

age

<80 80-120 >120

<90% Chronic malnutrition Stunted but no Stunted and obese

malnutrition

> 90% Acute malnutrition Normal Obese

 Welcome Classification

Edema present Edema absent

Weight for age Kwashiorkor Ponderal

80-60 % of Retardation
standard

Weight for age Marasmic Marasmus

< 60 % of kwashiorkor
standard
 General 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; Skin fold thickness is assessed
by Herpenden Caliper at Triceps or back of
shoulder.
Normal= 9-11 mm
If < 9 mm- Malnourished
 Quac strip
Special tape having colors on it

Up to green Normal
colour
Yellow colour Borderline malnutrition(14-12
cm)
Red colour Malnourished (< 12 cm)
 Types of Malnutrition

Two broad categories of malnutrition

Protein Energy Malnutrition (PEM)

Micronutrient Deficiency Diseases
Protein Energy Malnutrition

Kwashiorkor

Protein
Energy
Malnutrition

Khashiorkar-
marasmus Marasmas
 Kwashiorkor

Derived from 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.
Supply of calories may be little less but proteins

are grossly deficient.

It usually occurs between 1-5 years.
 Signs always Present

Generalized Edema.
Growth failure (wasting masked by edema)
Weak and wasted but some subcutaneous fats.
Psychomotor changes, e.g. apathy and irritability.
 Signs usually present
Hair changes; straight , sparse and discolored and
easily detachable.
Anemia
Loose stools
 Signs occasionally present

Skin; flaky paint dermatitis , ulcers or open sores.

Liver; Enlarged due to fatty infiltration.
 Complications
Hypothermia
Hypoglycemia
Cardiac failure
Infections
Vitamin A deficiency
Severe anemia
Dermatosis
 Biochemical changes
Hypoproteinemia and reversal of albumin globin
ration
Ketonuria due to starvation.
Glucose tolerance curve is like diabetic patient
Aminoacids
Plasma amino acids are low.
Serum cholestrol
 Serum cholinesterase, lipase, alkaline phosphatase
and 17 ketosteroid are decreased.
Deficiency of vitamin k and tendency for bleeding.
Serum growth hormones are increased.
 Marasmus (low calories)
Deficit in calories marasmus comes from
Greek origin of word to waste
Due to dietary deficiency /severely restricted

food intake.
Gross weight loss
Hyper-alert and ravenously hungry
Children have no subcutaneous fat or muscle
 Mechanism
Energy intake is insufficient for bodys requirements
body has to draw on its own stores
Liver glycogen exhausted in a few hours skeletal
muscle protein used via gluconeogenesis to maintain
adequate plasma glucose
When near starvation is prolonged, fatty acids are
incompletely oxidized to ketone bodies, which can be
used by brain and other organs for energy
High cortisol and growth hormone levels

Mechanism is same as anorexia

 Etiology

Over Diluted milk is given to children

Weaning food are not started or started late.
Infections; diarrhea, measles, pertussis, primary

tuberculosis
 Signs always present

Extreme growth failure and weight below 60% of

expected weight.
Marked muscle wasting and loss of subcutaneous

fat.
Alert and good appetite.
Monkey face or shrived like little old man
 Signs occasionally present

Anemia
Diarrhea and signs of dehydration
Signs of vitamins deficiency, e.g. Cheilosis,

dermatosis and rickets.

Respiratory infections.
 Kwashiorkor Marasmus
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 fat
Hair changes are present-fine, No hair changes
straight, sparse, discolored.

Poor appetite and anorexic Good appetite

Flaky paint dermatitis, ulcers, hypo/ Normal skin
hyper pigmentation
Miserable looking and apathetic Appearance of monkey face or little old
man face , alert facies

Liver enlarged (fatty infiltration) No hepatomegaly

Micronutrient Deficiency
Diseases
 Micronutrient

Vitamins Minerals

Water soluble Fat soluble

 Water soluble vitamins
Vitamin B1Beriberi
Vitamin B2 Ariboflavinosis
Vitamin B3 Pellagra
Vitamin B5 Paresthesia
Vitamin B6 Anemia
Vitamin B7 Dermatitis, enteritis
Vitamin B9 & Vitamin B12 Megaloblastic

anemia
Vitamin C Scurvy, Swelling of Gums
Vitamin D Vitamin K
Vitamin E Vitamin A
Rickets & Non-Clotting of
Less Fertility Night blindness
Osteomalacia Blood
Fat soluble vitamins
 Minerals
Major Bone Minerals

Calcium (bones)
Phosphorus (DNA)
Magnesium (bones)
Sodium (nerve impulse)
Chloride (fluid balance)
 Minerals
Trace Minerals

Iodine (thyroid function)

Iron (hemoglobin)
Zinc (enzyme, hormone)
Copper (abs. of iron)
Flouride (bone & teeth)
Chromium (energy rel.)
Molybdenum (enzymes)
Manganese (enzymes)
Selenium (antioxidant)
Cobalt (part of B12)
Management
 Management

INITIAL TREATMENT (emergency treatment)

REHABILITATION
FOLLOW UP
 10 Initial steps

1.Treat/prevent hypoglycemia
2.Treat/prevent hypothermia
3.Treat/prevent dehydration
4.Correct electrolyte imbalance
5.Treat/prevent infection
6.Correct micronutrient deficiencies
7.Start cautious feeding
8.Achieve catch-up growth
9.Provide sensory stimulation and emotional
support
10. Prepare for follow-up after recovery
 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
 CORRECTION OF HYPOGLYCEMIA
PREVENTION:
By feeding every 2 -3 hours/day
TREATMENT:
Conscious child- 50ml of 10% glucose PO
Unconscious child- 5ml/kg of 10% glucose I/V
followed by 50ml of 10% glucose by N/G Tube.
 Start feeding F-75 half an hour after giving
glucose , during the first 2 hours.
If the childs blood glucose is not low, begin

feeding the child with F-75 right away. Feed the

child every 2 hours, even during the night.
Fluids and electrolyte balance
Iv infusion - indicated in a severely
malnourished child with circulatory collapse
(otherwise N/G feeding)
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).
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.
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 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
 Manage hypothermia
Actively re-warm the hypothermic
child:
keeping the child covered and
keeping the room warm,
Have the mother hold the child with his skin next

to her skin when possible (kangaroo technique),

and cover both of them.
Keep the childs head covered.
 CONTROL OF INFECTION
Give all severely malnourished children
antibiotics for presumed infection.
IF: GIVE:
Amoxil Oral
Mild infection/ NO
cotrimazole Oral (25 mg sulfamethoxazole + 5
COMPLICATIONS
mg trimethoprim / kg) every 12 hours for 5 days
COMPLlCATIONS
(shock, hypoglycaemia, Gentamicin IV or IM (7.5 mg/kg), once daily for
hypothermia, 7
dermatosis with raw days, plus:
skin/fissures,
respiratory or urinary
tract infections, or Ampicillin IV or IM (50 mg/kg), every 6 hours
for 2 days
lethargic/sickly
appearance) Followed by: Amoxicillin Oral (15 mg/kg),
every 8 hours for 5 days
 Manage Shock
The severely malnourished child is considered to
have shock if he/she:
is lethargic or unconscious and
has cold hands
plus either:
slow capillary refill (longer than 3 seconds),or
weak or fast pulse.
 Give oxygen, IV glucose, and IV fluids for
shock
Give 10% glucose 5 ml/kg by IV
then infuse IV fluid at 15ml/kg over 1 hour.
Use 0.45% (half-normal) saline with 5% glucose).
Observe the child and check respiratory and pulse
rates every 10 minutes.
 If respiratory rate and pulse rate are slower after 1
hour, the child is improving. stop the IV.
If the respiratory rate and pulse rate increase Repeat
the same amount of IV fluids for another hour.
Continue to check respiratory and pulse rates every
10 minutes.
After 2 hours of IV fluids, switch to oral or
nasogastric rehydration with ReSoMal (special
rehydration solution for children with severe
malnutrition).
 Manage watery diarrhea and/or vomiting
with ReSoMal
ReSoMal is Rehydration Solution for
Malnutrition. It is a modification of the standard
Oral Rehydration Solution (ORS) recommended
by WHO.
ReSoMal contains less sodium, more sugar, and
more potassium than standard ORS
For children < 2 years, give 50 100 ml after each loose
stool.
For children 2 years and older, give 100 200 ml after
each loose stool.
It should be given by mouth or by nasogastric tube.
Composition of ReSoMal vs. ORS
 Feeding
Types of formula feed;
F-75 (75 Kcal/100 ml)-used during the initial
phase
F-100 (100 Kcal/100 ml)-used during the
rehabilitation phase
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% 12%
32% 33%
Osmolarity (mOsmol) 333 419
 Determine frequency & Amount
of feeds
Feed orally .
Use an NG tube if the child does not take 80%

of the feed.
Remove the NG tube when the child takes: 80% of

the days amount orally; or two consecutive feeds

fully by mouth.
 Determine frequency of feeds

On the first day, feed the child a small amount of

F-75 every 2 hours.
After the first day, increase the volume per feed

gradually.
The child will gradually be able to take larger, less

frequent feeds (every 3 hours or every 4 hours).

 Criteria for increasing volume/decreasing
frequency of feeds:
If little or no vomiting and moderate diarrhea (e.g

less than 5 watery stools per day), change to 3-

hourly feeds.
After a day on 3-hourly feeds: If no vomiting and

less diarrhea, change to 4-hourly feeds.

Adjusting to F-100 during transition,
or feeding freely on F-100:
Look for the following signs of readiness usually
after 2 7 days:
Return of appetite (easily finishes 4-hourly feeds

of F 75)
Reduced edema or minimal edema
The child may also smile at this stage.
Begin giving F-100 slowly and gradually:
Transition takes 3 days.

First 48 hours (2 days): Give F-100 every 4 hours

in the same amount as you last gave F-75. Do not
increase this amount for 2 days.
Then, on the 3rd day: Increase each feed by 10 ml
as long as the child is finishing feeds.
Ifthe child is breastfeeding, encourage the mother
to breastfeed between feeds of F-100.
 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
 Micronutrient deficiencies
Folic acid: Each child should be given a large dose
(5mg) on Day 1 and a smaller dose (1mg) on subsequent
days.
Multivitamin: daily (not including iron).

Iron:

After two days on F-100 , give iron daily,

Calculate and administer the amount needed: Give 3

mg elemental Fe/kg/day in 2 divided doses. Always
give iron orally, never by injection. Preferably give
iron between meals using a liquid preparation.
 Zinc : 2-3 mg/kg/day
Copper : 0.3 mg/kg/day
Ferrous sulphate (3-6 mg/kg/day)
 All severely malnourished children need vitamin A
on Day 1.
Additional doses are given if:
the child has signs of eye infection, measles ,

clinical signs of vitamin A deficiency.

The additional doses are given on Day 2 and at

least 2 weeks later, preferably on Day 15.

Child's age Vitamin A Oral Dose

< 6 months 50 000 IU

100 000 IU

6 12 months
 Rehabilitation" phase

After transition, the child is in the "rehabilitation"

phase and can feed freely on F-100 to an upper
limit of 220 kcal/kg/day.
(This is equal to 220 ml/kg/day.)
 CRITERIA for DISCHARGE from
HOSPITAL
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
THANK YOU