MALNUTRITION

Introduction

Malnutrition is a condition created by inadequate intake of essential calories, macro-nutrients

(proteins, carbohydrates and fats) and micro-nutrients (vitamins and minerals). Children under 5
are the most vulnerable group because their metabolic needs are great and their reserves are low.
Breastfeeding, especially in the first six months of life, is an essential part of preventing/treating
malnutrition. However, lactation puts additional nutritional stress on women, who may also be
malnourished, especially when it overlaps the next pregnancy. Not meeting the increased
metabolic needs of pregnant and lactating women may result in increased risk of malnutrition in
the fetus or young child. Malnourished pregnant women can’t pass adequate nutrients to a
growing fetus. Poor nutrition may produce poor breast milk which can’t sustain a growing child.
The physical and neurological consequences of early life malnutrition may be irreversible.

Malnutrition can also is defined as “a state when the body does not have enough of the required
Nutrients (under-nutrition) or has excess of the required nutrients (over-nutrition). It also
includes deficiency of micro-nutrients such as mineral and vitamins.

In order for the body to run properly, it requires the macronutrients fats, carbohydrates and
proteins in large amounts. These nutrients provide calories, which in turn, provide the body with
energy. When the body does not receive enough calories, it begins to use its fat stores as a
primary energy source. When the fat stores are depleted, the body turns to muscles and other
body tissues for energy and begins to break those down. Initially, this leads to severe weight loss.
As the muscles and tissues become depleted, it can lead to severe problems, including death.

Assessment of malnutrition

Malnutrition is assessed using the following;

Clinical evaluation: This involves physical evidence of nutritional problems such as signs of
malnutrition. Symptoms are also determined during clinical evaluation

Anthropometry: This is the measurement of body dimensions such as age, weight, height and
the mid upper arm circumference.

Dietary assessment: This includes doing survey of food eaten. Methods of determining dietary
assessment include 24 hour recall and food frequency questionnaires among others

Biochemical assessment: This involves measuring levels of nutrients and other components of
body tissues and fluids
Causes of malnutritionon One

The UNICEF conceptual framework, developed in the 1990s and shown below, summarizes the
causes of malnutrition.

Immediate Causes of Malnutrition

Lack of food intake and disease are immediate cause of malnutrition and create a vicious cycle in
which disease and malnutrition exacerbate each other.
Inadequate food intake: If an individual doesn’t get an adequate diet they will become
malnourished. The poor diet might be due to not enough food, or a lack of variety of foods in
meals; low concentrations of energy and nutrients in meals; infrequent meals; insufficient breast
milk; and early weaning.
Disease: The most common disease suffered by children in both stable and emergency situations
is infectious disease (diarrhea, acute respiratory infections, malaria and measles). These
conditions can affect food intake through loss of appetite, nutrient mal-absorption or loss, altered
metabolism or increased nutrient needs. Poor food intake and malnutrition affects susceptibility
to, and the severity and duration of, disease.

Underlying Causes of Malnutrition

Three major underlying causes of malnutrition include:
Food security: Household food security incorporates food ‘access’ and ‘availability’, largely
determined by livelihoods. Emergencies usually imply livelihoods erosion and failure of food
security. E.g., natural disasters affect food access by destroying crops, food, fuel and water
stocks, and disrupting market access. Displacement or forced migration causes loss of traditional
food and income sources, and of social networks that would normally support household caring
mechanisms.

Health: Public health is a key determinant of nutritional wellbeing. Access to good quality
health services, safe water, adequate sanitation and good housing are pre-conditions for adequate
nutrition. Disaster-affected populations are often exposed to public health risks.

Care: Inadequate social and care environment in the household and local community, especially
with regard to women and children. Caring practices can determine malnutrition even when
adequate food is accessible. Caring practices include feeding, hygiene, psychological and health
behaviors.
They include direct practices and wider social determinants such as social networks. These may
be severely altered during an emergency (e.g., women may become more vulnerable when forced
to leave their families in search of food, or infant formula may become freely available during an
emergency, disrupting breastfeeding).

Basic Causes of Malnutrition

Political factors: Certain political factors, such as policy decisions and economic situations
caused by inflation or war, can cause under nutrition.
Cultural factors: Can you think of health beliefs that might contribute to nutritional problems in
your own community? There are many cultural beliefs that may affect the nutrition status of a
child. It can be hard to get people to realize that these beliefs have a negative impact on their
nutrition status. For example, abrupt weaning due to pregnancy, the belief that food should not
be given to a child who is suffering from measles or diarrhea, and sharing food from the same
bowl between different children, can result in the child getting less than their body requirements,
are examples of some of the cultural factors that may affect nutrition.
Other causes of malnutrition include: climate change and lack of safe drinking water.
Climate change: In the space of 30 years, the number of natural disasters — droughts, cyclones,
floods, etc. — linked to climate change has increased substantially. The effects of climate
change are often dramatic, devastating areas which are already vulnerable. Infrastructure is
damaged or destroyed; diseases spread quickly; people can no longer grow crops or raise
livestock.

Lack of safe drinking water: Water is synonymous with life. Lack of potable water, poor
sanitation and dangerous hygiene practices increase vulnerability to infectious and water-borne
diseases, which are direct causes of acute malnutrition.
Classification of Malnutrition
There are two categories of malnutrition: Acute Malnutrition and Chronic Malnutrition.
Children can have a combination of both acute and chronic. Acute malnutrition is categorized
into Moderate Acute Malnutrition (MAM) and Severe Acute Malnutrition (SAM), determined by
the patient’s degree of wasting. All cases of bi-lateral oedema are categorized as SAM.
Chronic malnutrition is determined by a patient’s degree of stunting, i.e. when a child has not
reached his or her expected height for a given age. To treat a patient with chronic malnutrition
requires a long-term focus that considers household food insecurity in the long run; home care
practices (feeding and hygiene practices); and issues related to public health.
SAM is further classified into two categories: Marasmus (non-oedematous malnutrition) and
Kwashiorkor (oedematous). Patients may present with a combination, known as Marasmic
Kwashiorkor.
Severe acute malnutrition (SAM)

SAM is categorized into oedematous and non-oedematous malnutrition

Signs and symptoms of non-oedematous malnutrition

Severe weight loss, muscle wasting especially of the limbs and around the buttocks, bone
prominence especially of the ribs and shoulder blades, Sunken eyes, good appetite and general
body weakness

Signs of oedematous malnutrition

Bi-lateral oedema, skin and hair changes, brittle thinning hair, loss of appetite, apathetic and
irritable, enlargement of the liver, muscle wasting and general body weakness.

Medical complications of acute malnutrition

Diarrhea, vomiting, dehydration, anemia, fever, hypoglycemia, cardiac failure, pneumonia and
high\low body temperature

Moderate Acute Malnutrition:

Individuals with moderate acute malnutrition (MAM) show signs of thinness and are managed in
the supplementary feeding programme (SFP). Oedema is absent. However patients with MAM
and also HIV positive or HIV exposed or have medical complications are managed similarly to
patients with severe acute malnutrition in either the OTC or the ITC.

Indices used for classification of malnutrition

Weight for age (WFA) indicates under weight i.e. when a child has not reached his or her
expected weight for a given age.
Height for age (HFA) indicates stunting i.e. when a child has not reached his or her expected
height for a given age.

Weight for height (WFH) indicates wasting i.e. when a child has not reached his or her expected
weight for a given height.

MUAC is also used to indicate wasting.

WHO reference tables are used to determine a child’s degree of wasting, stunting and under
weight

 WFA, HFA and WFA Z-scores of less than -3 indicate severe acute malnutrition
 WFA, HFA and WFA Z-scores of less than -2 indicate moderate acute malnutrition
 WFA, HFA and WFA Z-scores of less than -1 indicate mild acute malnutrition
 MUAC less than 11.5cm indicates SAM, MUAC between 11.6-12.5 indicates MAM,
MUAC greater than 12.6 indicates that the child is healthy

Management of malnutrition
Malnutrition is managed using Formula 75 (F75), Formula 100 (F100), Plumpy nut and corn soy
blend (CSB)

Inpatient management of malnutrition

Treatment Process
Severe acute malnutrition requires specialized treatment to ensure rapid recovery and reduce the
risk of mortality. The management of severe acute malnutrition in the in-patient setting is
divided into three phases: Phase 1, Transition Phase and Phase 2.

Phase 1: Nutrition and Medical Stabilization

Patients without an adequate appetite and/or a major medical complication are initially admitted
to an in-patient facility for Phase 1 treatment. The formula used during this phase (F75) promotes
recovery of normal metabolic function and nutrition-electrolytic balance. In Phase 1, the patient
receives F75 formula at 100kcal/ kg/day. Rapid weight gain at this stage is dangerous, that is
why the quantities and formula are formulated so that patients do not gain weight during this
stage. A routine, systematic medical treatment is commenced in Phase 1, and medical
complications are treated. It is important in Phase 1 that oedema, if present, reduces. When
oedema is reduced from +++ to ++, only then can these patients graduate from Phase 1 to
Transition Phase.

Nutrition Support: Diet and Frequency

A milk diet is given to clients in phase 1. This milk diet can either be F75 or an equivalent of
locally available produced milk product. The milk diet is given at regular intervals throughout
the day (approximately every two to three hours). The quantity required for each 24 hour period
is determined by the child’s weight. To determine the amount per feed, divide the 24-hour
required quantity by the number of feeds per day.
For severely malnourished patients with severe oedema (+++), reduce the quantity of F75 by up
to 20% until the oedema begins to subside.

Transition Phase: Increase Diet and Prevent Complications

Patients normally remain in Transition Phase for two to three days. This phase is designed to
slowly increase the diet and prevent complications of over-feeding for the stabilized, severely
acute malnourished patient. F75 is replaced with F100 or a locally made-up milk of the
equivalent nutritional value. The patient’s diet is increased from 100kcal/kg/day to
130kcal/kg/day for children. The quantity of milk remains the same, but the calorie content
changes by changing milk formulas from 75kcal to 100kcal per 100ml of milk. The patient in
Transition Phase receives around 30% more calories than when in Phase 1. For patients qualified
and willing to be discharged from Transition Phase to Outpatient Therapeutic Care for the
remainder of nutrition treatment, the equivalent calories are given to the patient in the form of
Ready-to-Use-Therapeutic Food (RUTF).

Phase 2: Catch-up Growth and Discharge

In the in-patient setting for the treatment of severe acute malnutrition, patients move from
Transition Phase into Phase 2 when they have a good appetite; are tolerating the diet given; have
no major medical complications; and oedema is resolved. This is usually after about two to three
days in Transition Phase. In Phase 2, the patient receives F100 at 200kcal/kg/day or the
equivalent in the form of RUTF. Those formulas are designed for patients to rapidly gain weight.
Recovered patients are discharged for supplementary feeding centre (SFC) or an out-patient
therapeutic centre (OTC) if available at the nearest health facility.

Preparation of F75
If F75 is available, add one packet (410g) of F75 to two (2) liters of water. (Water must be boiled
and cooled prior to mixing.) If five or less children are being treated for severe acute
malnutrition, a less quantity of F75 and F100 milk are necessary. Smaller volumes can be mixed
using the red scoop (4.1g) included with the F75 and F100 package (20 ml water per red
scoop/4.1g of F75/F100).

Preparation of F100
Prepare F100 by adding a sachet of F100 powdered milk (net weight 456gms) to two (2) liters of
boiled, cooled water. If small quantities of milk are required (few children in need of nutritional
rehabilitation), add one (1) red scoop (4.1g) powder milk to 18ml boiled and cooled water.
Note: For children who are still exclusively breastfeeding and premature babies diluted
therapeutic milk (DTM) is used when managing MAM or SAM.