Malnutrition

Malnutrition is a disease caused by not eating enough quantity of food or by eating a wrong quality of food.

Children are particularly exposed to malnutrition (their growing body has high protein and energy requirement, but they are fully dependant from adults).

The mortality risk of a malnourished child is high. Moreover there are long-term effects on cognitive and social development. Therefore, it is very important to identify children with malnutrition and treat them as quickly as possible.

Different types of malnutrition can occur when there is not enough energy-giving and/or growth-promoting foods (i.e. foods rich in carbohydrates and fats and/or proteins respectively), the so called:

PROTEIN – ENERGY MALNUTRITION (PEM)

PEM is a spectrum ranging from mild under nutrition resulting in some decrease in height and/or weight for age through severe forms of under nutrition resulting in more marked deficits in weight and height for age as well as wasting (i.e. a low weight for height) or stunting (i.e. a low height for age).

PEM is almost always accompanied by deficiencies of other nutrients such as vitamins and minerals.

The most severe forms of PEM are classified into 3 different CLINICAL TYPES:

1.     MARASMUS

2.     KWASHIORKOR

3.     MARASMIC – KWASHIORKOR

MARASMUS

Marasmic children have:

Low weight

Gross loss of muscle mass and subcutaneous fat (“skin and bone children”)

Hypotonia

A wrinkled face (looking like a “little old man”)

Usually subnormal temperature and slow pulse

Usually constipation but sometimes a so called “starvation diarrhea” (frequent small stools containing mucus)

They usually are hungry and worried.

Hair and skin modifications are uncommon.

Marasmus is frequent in children <1 year old. Some difficulty with breast-feeding usually causes it. A child's mother may have died, or she may have too little breast-milk or breast-feed inadequately.

Older children can also get marasmus if they do not eat enough food.

KWASHIORKOR or oedemaotous pem

Children with kwashiorkor have:

Bilateral edema, starting from feet, legs and hands

but finally involving also the face (“moon face”)

Failure to gain weight (initially it may be masked by edema)

Loss of muscle mass

Enlarged liver and steatosis

Dermatitis and sparse, thin, pale or slightly red hair 

Commonly vomiting, diarrhea and anemia

Secondary immunodeficiency with consequent infections

They usually are not interested in anything (apathy),

and do not move. Although malnourished they usually

do not want to eat (anorexia).

Sometimes hypoglycemia can lead them to drowsiness, coma or fits.

Kwashiorkor usually affects children aged 1-5 years of age.

“Kwashiorkor” is a ghanese word that describes the condition of an infant who has to be weaned away after a year to make room for the next baby. The weaning food, which is mainly sugar and water or a starchy gruel lacks proteins or has a poor quality of proteins.

The weaning diet for these young children can also lead to other nutrient deficiency diseases as well.

MARASMIC KWASHIORKOR

In some intermediate cases children are presenting with features of both kwashiorkor and marasmus (both edema and wasting).

PATHOPHYSIOLOGY of PEM

In the face of inadequate energy and/or protein intakes, activity and energy expenditure decrease.

However, despite this adaptive response, fat stores are mobilized to meet the ongoing, albeit lower, energy requirement. Once these stores are depleted, protein catabolism must provide the ongoing substrates for maintaining basal metabolism.

In some cases blood proteins decrease significantly. Hypoalbuminemia causes a decrease in the plasma oncotic pressure and consequent transudation of fluid from the intravascular compartment to the interstitial space → edema.

Why some children develop edematous PEM and others develop non-edematous PEM is poorly understood.

A number of factors have been suggested such as:

variability among infants (in body composition and nutrient requirements) at the time the dietary deficit has occurred

CONSEQUENCES

Prospective studies suggest that even mildly underweight children have a two- to three-fold greater risk for mortality than normally nourished children. About half of child deaths may be caused directly or indirectly by under nutrition, the major factor being the potentiation of infectious diseases by under nutrition.

Survivors of childhood under nutrition frequently have deficits in height and weight that persist beyond adolescence into adulthood. These deficits are often accompanied by reduced muscle mass and strength, with consequences on the work capacity of both men and women and on women's reproductive performance.

Survivors of childhood malnutrition also have deficits in cognitive function and school performance. The intellectual deficits appear to be related to the severity of under nutrition.

DIAGNOSIS

Diagnosis of marasmus and kwashiorkor is merely clinical.

Anemia and hypoalbuminemia may be present, more frequently in edematous-PEM.

In children with severe oedema but without skin lesions a differential diagnosis with nephrotic syndrome or congestive heart failure should be made (Proteinuria? Tachycardia? Dyspnea? ...).

TREATMENT

The treatment of severe malnutrition is similar for marasmus and kwashiorkor. It requires hospitalization and is based on:

 Management of the associated conditions

(Treat / prevent):

1.     Hypoglycemia and hypothermia

2.     Infections

3.     Dehydration and electrolytes imbalance

4.     Diarrhoea

5.     Aanemia

6.     Institution of adequate diet

Stabilization phase (24-48 hours)

Hypoglycemia and hypothermia usually occur together and are signs of infection. Frequent feeding (2-hourly feeds, day and night) is important in treat and prevent both conditions. If destrostix shows <3 mmol/l (54 mg/dl) give first 50 ml bolus of 10% glucose (IV only if the patient is unconscious, lethargic or convulsing). Rewarm the child and ensure he is covered at all time, expecially at night.

Dehydration status is difficult to estimate in severely malnourished child, so assume all children with watery diarrhoea may have dehydration. Moreover all severely malnourished children have excess body sodium and deficiencies of potassium and magnesium. Give 5-10 ml/kg/h for 5-10 hours of an oral rehydration salts solution containing about 45 mmol Na, 40 mmol K and 3 mmol Mg/l. Because of the difficulty of estimating hydration (and the risk of over-hydration with heart overload), oral (or by naso-gastric tube) rehydration therapy is preferred and monitoring of respiratory and pulse rate is necessary.

Stabilization phase (1-7 days)

In severe malnutrition the usual signs of infection, such as fever, are often absent, therefore give routinely on admission broad-spectrum antibiotics (with or without associated metronidazole).

If the child appears to have no complications give oral cotrimoxazole.

If the child is severely ill (apathetic, lethargic) or has complications (hypoglycemia, hypotermia, broken skin, respiratoty tract or urinary tract infection) give ampicillin plus gentamicin.

Add antimalarial treatment if the child has a positive blood film.

The child's reduced homeostatic capacity requires a cautious approach to feeding. Feeding should be started as soon as possible after admission and should provide just sufficient energy and protein to maintain basic physiological processes (75-100 kcal/kg/d and 1-1,5 g/kg/d respectively). Milk-based starter formula containing 75 kca/100 ml and 0,9 g protein/100 ml will be satisfactory for most children. Give 130ml/kg/d 2-hourly in the first days and progressively 3- and 4-hourly (after 6-7 days). Give it from a cup; very weak children may be fed by spoon, dropper or syringe.

If moderate malnutrition (MM) is present, advice and support should be given to the caretakers on how to improve diets being given to the children at home and what foods should be added to provide nutrients that are missing in the diet.

Children with MM should receive most of the recommended nutrients from usual family foods. Fortified foods or food supplements could be used to provide nutrients missing in family foods.

Dietary advice given to mothers of underweight children

Age 6 months to 1 year

 To breastfeed as often as the baby wants

 To select nutrient-dense fluids (such as milk, soups) rather than drinks with low nutrient value (e.g. tea, coffee, diluted sweet juices...) that easily fill the baby up without providing many nutrients

Age 1 to 5 years

To add legumes and animal-source foods (milk, meat, eggs, fishes) to meals. This is especially important for the stunted child to promote growth in height without excess weight gain

If the diet is mainly cereal-based, to make the cereal thick, not dilute, and add some fat (e.g., oil) to increase energy density

To feed yellow-fleshed fruit and vegetables and dark-green leafy vegetables, to increase vitamins and minerals amount

To introduce gradually new foods

SOURCES

WHO Child growth training course

WHO Guidelines for the impatient treatment of severely malnourished children 2003

Dr Giuseppe Gaido

Dr Nadia Chiapello