Malnutrition

Definition
Malnutrition is globally the most important risk factor for
illness and death, contributing to more than half of deaths in children worldwide. The World Health Organization defines malnutrition as "the cellular imbalance between supply of nutrients and energy and the body's demand for them to ensure growth, maintenance, and specific functions."

Classification & Forms of Malnutrition

Common forms of malnutrition include: protein-energy malnutrition (PEM(: refers to inadequate availability or absorption of energy and proteins in the body . micronutrient malnutrition: refers to inadequate availability of some essential nutrients such as vitamins and trace elements that are required by the body in small quantities . Micronutrient deficiencies lead to a variety of diseases and impair normal functioning of the body. Deficiency in micronutrients such as Vitamin A reduces the capacity of the body to resist diseases .
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Protein Energy Malnutrition

Protein Energy Malnutrition is a major condition of nutritional disorders and defines as :-

A range of pathological conditions arising from coincident lack of proteins and calories in varying proportions, occurring most frequently in infants and young children and commonly associated with infections.

Classification
PEM is classified by many theories:-

1. 2. 3. 4.
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Water law classification. Gomez classification. Welcome classification . WHO classification.

Water law Classification

This classification was based on weight for height and height for age. This classification took into account the effect of past as well as present malnutrition. It is wasting code for present malnutrition and measured by loss of weight related to height, and past malnutrition (stunting), seen in retarded height for age.
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Gomez Classification
Wt to age %

It is used for field work, researches, population screening and public health evaluations. But it is not applied in sever malnutrition.

75 90 %

1st degree

Mild

60 74 %

2nd degree

Moderate

< 60 %

3rd degree

sever

Welcome classification
It is a simple and universally accepted one, depending on two main criteria :

PEM Form

Body weight % of standard

60 80%

Oedema

underweight

-ve

1.Weight loss. 2.Oedema.

kwashiorkor

60 80 %

+ve

Marasmus

< 60 %

-ve

Marasmic kuwashiorkor

< 60 %

+ve

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WHO Classification
It classifies malnutrition into moderate & sever depending on measuring: Wt for Ht ; and Ht for age
Moderate malnutrition Sever malnutrition

Symmetrical Oedema

No

Yes ( oedematous malnutrition) SD score < - 3 ( < 70% ) ( sever wasting) SD score < - 3 ( < 85%) ( sever stunting)

Weight for height

-3 < SD score < - 2 -(70 80 %)

Height for age

-3 < SD score < - 2 -( 85 90 %)

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Why Malnutrition is so Important?!

Incidence is app. 50% of population. Mortality rate is about 12 20% of childhood death. Morbidity ( predisposing to infections). It causes multisystem effect. Treatment is possible. Its is a controllable and preventable disease.
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Risk Factors & Causes

Malnutrition is associated with many disorders and circumstances, including poverty and social deprivation. Risk is also greater at certain times (i.e., during infancy, early childhood, adolescence, pregnancy, breastfeeding, and old age).

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In infancy and childhood:

Nutritional factors:1. Poverty ( inadequate or poor supplementations of food). 2. Poor breast feeding, late supplementation and poor quality or quantity or both. 3. Bad housing ( sanitation and environmental conditions). 4. Short spacing and large families. 5. Mother ignorance ( poor practicing, food taboos and believes). 6. Non or partially vaccinated. 7. Preterm, low birth weight and twins. 8. Sudden weaning and starvation therapy for diarrhoea.
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In infancy and childhood:

Precipitating Factors:1. Recurrent GE or sever infections: TB, UTI, Bronchiectasis, malaria ,HIV. 2. Metabolic diseases: galactosemia. 3. Malabsorption syndromes. 4. Congenital malformations: - GIT: pyloric stenosis. - CVS: cyanotic congenital heart diseases. - Kidney : obstructive uropathy. 1. Endocrinal : hyperthyroidism, DM. 2. Psychological disturbances : maternal deprivation syndrome. 3. Malignancy : neuroblastoma.
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Pathophysiology
1. 2. 3. 4. impairment of physical growth and of cognitive and other physiologic functions are as follows:Growth failure: Weight is markedly diminished. Retarded linear growth ( in long standing cases). Head circumference may be also affected. Bone age may be retarded. Water, electrolytes, vitamins & minerals:

1. Water : total body is increased ( ECF). 2. Sodium : total body sodium is higher than normal but serum sodium may be
low due to excessive amount of water in ECF ( dilutional hyponatreamia) .

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Pathophysiology
1. Potassium : is low due to cellular destruction and losses in diarrhoea. 2. Magnesium : total amount may be decreased but in serum is normal due
to shift from tissue to vascular compartment.

3. 4. 5. 6. 7. 8.
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Iron : low serum iron leading to microcytic hypochromic anaemia. Follic acids & vit B12 : low leads to megaloplastic anaemia. Riboflavin, niacin, copper and zinc : will results in dermatosis. Vit A deficiency : leads to night blindness. Vit C and K : results in bleeding. Manganese deficiency : results in mental status changes ( irritability
and apathy).

Pathophysiology
Metabolic changes :

1. Protein :

- reduced total plasma protein (< 4g/dl). - reduced serum albumin ( < 2g/dl)). - reduced serum amino acid ( essential amino acids). - Enzymes: amylase, esterase , alkaline phosphatase are low but hepatic enzymes are released like transaminase and isocitric dehydrogenase tend to increase with hepatic injury. Pancreatic and duodenal enzymes are diminished.
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Pathophysiology
- Blood Urea and urine is markedly reduced because of deficient intake of endogenous proteins.
- ( hypoproteineamia will results in decreased colloid oncotic pressure affecting the circulating blood volume leading stimulation of osmoreceptors ( ADH) and activation of renin angiotensin system leading to Na and water retention resulting in soft pitting oedema in dependant parts)
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2. Carbohydrates: hypoglycaemia due to 3. Lipids : - reduced level of serum triglycerides. - reduced serum cholesterol level. - reduced serum lipo protein.

deficiency of the enzymes involved in gluconeogenesis.

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Pathophysiology
GIT : 1. Reduction of intestinal and pancreatic enzymes will lead to inadequate digestion of food and passage of loose stool. 2. Malabsorption of nitrogen, fat, CHO and mineral due to atrophy of villi. 3. Disaccharadiase deficiency leads to fermentative diarrhoea accompanied by abnormal distension and flatulence.
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 Liver : is enlarged due to fatty infiltration resulting from :1. Increased mobilization of free fatty acids from adipose tissue to the liver. 2. Increase fatty acid synthesis from glucose. 3. Decreased oxidation of fatty acid in the liver. 4. Decrease synthesis of apolipoprotein, leading to decrease release of fat from the liver.
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 CNS:
1. 2. 3. 4. slowed rate of growth of the brain, lower brain weight, thinner cerebral cortex, decreased number of neurons, insufficient myelinization, and changes in the dendritic spines.

More recently, neuroimaging studies have found severe alterations in the dendritic spine apparatus of cortical neurons in infants with severe protein-calorie malnutrition.
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Pathophysiology
Immune system:

1. Loss of delayed hypersensitivity, 2. fewer T lymphocytes, 3. impaired lymphocyte response, 4. impaired phagocytosis secondary to decreased complement and certain cytokines, 5. decreased secretory immunoglobulin A (IgA).
These immune changes predispose children to severe and chronic infections, most commonly, infectious diarrhoea
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Symptoms:Symptoms of moderate PEM:

1. Apathy and irritability are common. 2. The patient is weak, and activities decreases. 3. Cognition and sometimes consciousness are impaired. 4. Temporary lactose deficiency . 5. Diarrhea is common and can be aggravated by deficiency of intestinal disaccharidases, especially lactase.
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Symptoms of sever PEM:

1. Signs of anemia. 2. Hypothermia. 3. Edema. 4. Symptoms of associated disease due to low cellular immunity ( i.e. chest infection, UTI, GE, sepsis). 5. Wasting (called cachexia in adults) is most obvious in areas where prominent fat depots normally exist. Muscles shrink and bones protrude. The skin becomes thin, dry, inelastic, pale, and cold. The hair is dry and falls out easily, becoming sparse. Wound healing is impaired.
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Signs of malnutrition
On examination :

Generally: pt looks ill,severly wasted, may be oedematous, pale, irritable or apathetic, and may be unconscious. vital signs: febrile, tachycardia, tachypnic,

hypotensive.

Anthropometric : retarded growth. Hair : sparse over temples and occipital regions,

dyspigmentation, dry and easily pickable.

( flag sign: its a sign of improvement: means part of hair is dyspigmented and parts has normal black colour)
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Signs of malnutrition
Fontanelles: is depressed due to dehydration. Eyes: 1. Sunken eyes ( dehydration and wasting). 2. Pus and inflammation ( eye infection). 3. Pallor, jaundice 4. Keratitis, vascularization of cornea with photophobia + tears ( riboflavin deficiency). 5. Lack of tears.
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Signs of malnutrition
6. Signs of vit A deficiency, which are: - night blindness. - conjunctival xerosis. - bitot spots. - corneal xerosis. - corneal ulceration. - keratomalacia. - corneal scar. - xeropthalmia fundus. - blindness.
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 Nose & Ears: discharges denote rhinitis or otitis media. Cheeks: loss of buccal bad of fat ( old man face). In kuwash they appear full, doll like cheeks.

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Mouth: look for: pallor. ( anaemia) Angular stomatitis. Glazed tongue : iron deficiency anaemia Magenta coloured tongue( riboflavin def ). Oral thrush. Dry tongue. Delayed teething.

 Neck : Lymph nodes enlargement ( TB, Lymphoma). Goiter. Back and extremities: Oedema Muscle wasting + loss of subcutaneous fat = sticky like limbs. Skin rash, arthritis if present. Cold cyanotic extremities : shock complicating diarrhoea.
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Forms of oedema:classification
Mild
Moderate

description
Both feet
Both legs, lower legs, hands and lower arms. Is character of kwash,the whole body is oedematus but term of kwash will not be 36 used

Sever

Skin : Inelastic skin ( slow skin pinch). Loss of subcutaneous fat. Dermatosis, hyper/hypopigmeneted areas Shedding and ulceration of skin of perineum, inguinal, limbs and axilla. petechiae.
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Forms of Dermatosis:classification
Mild Moderate sever

description
Discoloration or few rough patches.

Multiple patches on arms and/or leg.

Flaking skin, raw skin, fissures.
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 Chest: for crepitations, wheezes, or signs of pleural effusion. For chest infection. Heart : to exclude possibility of congenital heart disease. Abdomen: for :-

Hepatomegally. Hepatosplenomegally. Masses ( neuroblastoma) Ascitis. Abdominal distension.

CNS: psychic changes, exclude meningitis,

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The most helpful laboratory studies in assessing the nutritional status of a child are Haematological studies and lab. studies evaluating protein status.

Full investigations should includes:1. BFFM. 2. CBC ( low heamatocrite and leucocytosis). 3. Blood culture ( septicaemia). 4. Blood glucose ( hypoglycaemia). 5. Plasma proteins (hypoproteineamia) 6. Blood urea & electrolytes ( hypocaleamia). 7. Urine analysis & culture ( UTI). 8. Stool analysis & culture ( diarrhoeal diseases) 9. CXR for hidden T or pneumonia.. 10.Mantoux Test & sputum stain and culture. 11.Liver function test. 12.Ultrasonography for obstructive uropathy and pyloric stenosis.
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Severely malnourished child is likely to have many serious health problem in addition to malnutrition.
Serious health problems includes:

1. 2. 3. 4. 5. 6. 7. 8. 9.
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Hypothermia. Hypoglycaemia. Electrolytes and acid base disturbances. Septicaemia. Sever infection ( Pneumonia, malaria, TB, etc..). Heart failure. Jaundice. Dehydration. Blindness.

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Criteria for admission

1. Wt/ ht less than 3 SD ( < 70 % of the stanard wt and/or oedema of the both feet) or MUAC <110mm. 2. Malnourished children presented with complications eg: Diarrhoea Respiratory infection. Septicaemia. Dehydration and shocked child.
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Guidelines and principles of management flowing the 10 --steps:1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Treat / prevent hypoglycaemia. Treat/ prevent hypothermia. Treat/ prevent dehydration. Correct electrolyte imbalance. Treat/ prevent infections. Correct micronutrient deficiencies. Start cautious feeding. Achieve catch up growth. Provide sensory stimulation and emotional support. Prepare for follow up after recovery.

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1. Hypoglycaemia

Hypoglycaemia hypothermia usually occur together and they may be signs of infection

Hypoglycaemia is considered when blood glucose is less than 3 mmol/dl

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Hypoglycaemia
Treatment: If the child is conscious Give 50ml of 10 % glucose or 10 % sucrose solution Orally or by NG tube. Then star F-75 every 30 minutes for 2 hours Feeds two hourly day and night Give antibiotics If the child unconscious lethargic or convulsing Give IV sterile glucose 10 % Fallowed by 50ml of 10% glucose or sucrose by NG tube .
Then star feeding F-75 Two hourly feeds day and nigh Give antibiotic
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 Monitoring
1. 2. 3. 4. 5. Check blood glucose after 2 hours. If it is < 3 mmol/L, give further 50 ml bolous of 10% glucose or dextrose. Continue feeding every two hours till blood glucose become 3 mmol/L. If rectal temp is < 35.5 c, repeat the bolous. If level of consciousness is deteriorated, repeat the bolous.

PREVENTION
Feed every two hours Always give feeds through the day and night
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2. HYPOTHERMIA
If the axillary temperature is < 35 c or rectal temp is < 35.5 c: 1. Feed straight away ( or start rehydration). 2. Rewarm the child ( clothes, blankets, heater, or lamp nearby, bottles are dangerous). 3. Kangaroo technique: placing the child on the mothers bare chest & abdomen an covering both of them. 4. Give antibiotics
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 1. 2. 3. 1. 2. 3. 4.

Monitor : Body temp, rectally every 2 hrs till rises above 36.5 c. Child must be covered all time esp. at night. Blood glucose level whenever there is hypothermia. Prevention : Feed 2 hrly through out day and night. Keep the child dry. Avoid exposure ( bathing or prolonged medical examination). Let child sleep beside his mother esp. at night.

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3. Dehydration
Dehydration progresses from some to sever, reflecting 5 10% and > 10% wt loss, respectively, where as septic shock progresses from incipient to developed, as blood flow to the vital organs decreases. Dont use iv line for rehydration except in shock, with care and slowly to avoid fluid overload.

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Classification of Dehydration
Clinical signs Watery diarrhoea Some dehydration Sever dehydration yes yes

Thirst Hypothermia Sunken eyes Weak radial pulse Cold hands & feet Urine flow Mental state

Drinks eagerly NO yes no no yes Restless, irritable

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Drinks poorly NO yes yes yes No Lethargic, comatose

 Treatment :
1.

2.
3. 4.

composition Use Resomal ( Glucose rehydration solution for Sodium malnutrition). Potassium Give 5ml/kg every 30 min for first 2 hrs orally Chloride or by NG tube. Citrate Then 5 10ml/kg hrly in Magnesium the next 4 10 hrs. Zinc Start feeding F- 75. copper

Resomal 125 45 40 70 7 3 0.3 0.045

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ORS 111 90 20 80 10 -

 Monitor : 1. Observe the vital signs, urine frequency and stool vomiting, every hrly for 2 hrs then hrly for 6 12 hrs. 2. Stop to give fluid if continuous rapid breathing and pulse ( infection or over hydration) or oedema and puffyness of eyes. Prevention : 1. Keep feeding with F 75. 2. Replace the volume of stool losses with Resomal (50 100ml after each watery stool). 3. Encourage breast feeding.

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4. Electrolyte imbalance
Oedema is a result of electrolyte imbalance, thats why we dont treat it with diuretics. Give:1. Extra potassium ( 3 4 mmol/kg/day). 2. Extra magnesium ( 0.4 0.6 mmol/L/kg/day). 3. Give low sodium rehydration (Resomal). 4. Prepare food without salt. * 20 ml of combined electrolyte/ mineral solution or Resomal to 1 litre of feed will supply the requirement of K and Mg.

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5. infection
Give: 1. Broad spectrum antibiotics. 2. Measles vaccine if the child above 6 month of age and not immunized (delayed in shocked pt). 3. May give metronidazole ( 7.5 mg/kg/8hrly for 7 days) routinely in addition to antibiotics for: Hasten repair of intestinal mucosa. Reduce risk of oxidative damage. Reduce systemic infection arising of anaerobic bacterial infection in small intestine.
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 Drugs of choice:1. If no complications : cotrimoxazole (5ml = 40 mg TMP + 200 mg SMX) < 6month: 2.5 ml / BD / for 5 days. > 6 month : 5 ml / BD / for 5 days. 2. If the child is severely ill and has complications (hypoglycaemia, hypothermia, UTI..etc): ampicillin (50 mg/kg IM or IV / 6 hrly for 2 days) then orally amoxycillin (15 mg /kg/ 8hrly for next 5 days), After 48 hrs if child fail to improve : add chloramphinicol 25 mg/kg IM or IV 8 hrly for 5 days.

And : Gentamycine (7.5 mg/kg IM or IV once daily for 7 days) 3.

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 If specific infections are identified add the specific antibiotics. If anorexia persist after 5 days of antibiotics: treat a full complete 10 days course. If anorexia still persist :Reassess the child fully : 1. Site of infection. 2. If its resistant organism. 3. Ensure vitamin and minerals supplements.
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6.Correct micronutrient deficiency

1. Give : Vit A orally: day 1 , 2 & 7. 0 5 month = 50,000 IU 6 12 month = 100,000 IU above 12 month= 200,000 IU Give daily for at least 2 weeks:Multivitamin supplement or combined mineral vitamins (CMV). Follic acid 1 mg/ kg/ day. Copper 0.3/kg/day. Iron 3 mg /kg/day (but only after gaining wait)

2.

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7. Cautious feeding

Ingredient Dry skimmed milk Sugar Cereal flour Vegetable oil Mineral mix Vitamin mix Water to mix Amount in F75 25 g 70 g 35 g 27 g 20 mL 140 mg 1000 mL
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Formula used are: F-75 and F-100. On first day give child: Small amount of F-75 every 2 hrs, if pt hypoglycaemic give of 2 hrly amount ever hr an hr till blood glucose become at least 3 mmol/L.

Amount in F100 80 g 50 g 60 g 20 mL 140 mg 1000 mL

 1. 2. 3.

On 2nd day : increase the volume per fed gradually and decrease the frequency (every 3 4 hrs) Child feeding plan should be recorded in the 24 hrs food intake chart. The essential features are: Small frequent feeds of low osmolarity and low lactose. Orally or nasogastric tube is used for feeding never parentral. Total amount of F-75 which is given per day( 130 ml/kg which is appropriate until the child is stabilized equal to : 100 kcl/kg/day 1 1.5 g/kg/day of protein.

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 If the child continue watery diarrhoea, give Resomal: < 2 yrs = 50 100 ml > 2 yrs = 100 200 ml (after every loose stool) If the child vomits, estimate the amount of vomits and offer the amount of feed again or give half the amount every hr till vomit stop.
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Recommended volume which gradually increased:Days 12 35 6 7+ Frequency 2 hrly 3 hrly 4 hrly Vol/kg/feed 11 ml 16 ml 22 ml
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vol/kg/day 130 ml 130 ml 130 ml

 1. 2. 3. 4.

Monitor and note : Amount offered and left over. Vomiting Frequency of watery stool Daily body wt

During stabilization phase: 1. Diarrhoea should gradually diminish. 2. Oedematous children should lose wt.

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8. Achieve catch up growth

Catch up formula F-100 used to rebuild wasted tissues, contains: 1. 100 kcl and 2.9 kl/100 ml. 2. More calories and protein. 3. Start when the child is stabilized ( after 2 7 days). We change to F-100 when the child return his appetite and reduce oedema. Gradual transition is recommended to avoid heart failure.

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Transitional phase:

1. In first 48 hours: replace F-75 with same amount of catch up formula F-100 every 4 hrs. 2. In the next 24 hours: increase each successive feed by 10 ml until some feeds remains uneaten ( usually when intakes reach 30ml/kg/feed 200 ml/kg/day) Monitor for: 1. Respiratory rate.

2. Pulse rate.
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 If RR. Increased by > 5 breath/min or pulse by 25 or more / min for two successive 4 hourly: reduce the volume per feed :

1st 24 hrs: 4 hourly F-100 at 16 ml/kg/feed. 2nd 24 hrs: 19 ml/kg/feed . next 48 hrs: 22 ml/kg/feeds. Then increase each feed by 10 ml as above.
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Rehabilitation phase: The daily need is calculated by :wt x 150 (minimum) 220 (max) 6 (feeds per day) If wt gain is: 1. Poor ( < 5 g/kg/day) require full reassessment. 2. Moderate ( 5-10g/kg/day) check for intake or infection). 3. Good ( > 10g/kg/day).

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9. Provide sensory stimulation & emotional support: 1. 2. 3. Provide: Tender loving care. A cheerful, stimulating environment. Structural play therapy 15 30 minutes /day. 4. Physical activity as soon as the child well enough. 5. Maternal involvement when possible (feeding, bathing, play)
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