Malnutrition

Ph.D, Nune Baghdasaryan, Yerevan

2024 September
CHILDREN ARE THE WORLD’S MOST IMPORTANT RESOURCE
 I. undernutrition

stunting (low height for age)

wasting (low weight for height)
underweight (low weight for age)
micronutrient deficiencies or insufficiencies (a
lack of important vitamins and minerals)
 II. Overnutrition
overweight
obesity and diet-related noncommunicable
diseases (such as heart disease, stroke,
diabetes, and cancer)
 NUTRITION
Nutrition is provision of adequate energy, nutrients, essential
microelements to meet metabolic demands of the body
Essential nutrients cannot be synthesized of the body and
must be derived from diet: vitamins, minerals, fatty acids,
carbohydrates, amino acids
Non-essential nutrients can be synthesized from other
compounds or may be derived from diet
Macronutrients supply energy and essential nutrients for
growth and development, disease prevention and activity.
 DEFINITION
WHO defines as "the cellular imbalance between supply
of nutrients and energy and the body's demand for them
to ensure growth, maintenance, and specific functions."
American Society for Parenteral and Enteral Nutrition
workgroup defined pediatric malnutrition [undernutrition]
as "an imbalance between nutrient requirement and
intake, resulting in cumulative deficits of energy, protein,
or micronutrients that may negatively affect growth,
development, and other relevant outcomes."
[Link]/read/23528324/defining-pediatric-malnutrition-a-paradigm-shift-toward-etiology-related-definitions?redirected=slu
 EPIDEMIOLOGY
890 million adults worldwide are living with
obesity
390 million are underweight
37 million children under the age of 5 years are
overweigh
149 million are stunted
571 million or 30% of women of reproductive
age around the world affected by anemia, for
which approximately half would be amenable to
iron supplementation.
 EPIDEMIOLOGY
Fewer than 1% of all children in the US have chronic malnutrition.
WHO-the prevalence of malnutrition will have decreased to 17.6%
globally, with 113.4 million children younger than 5 years affected
as measured by low weight for age. The overwhelming majority of
these children, 112.8 million, will live in developing countries with
70% of these children.
Paradoxically, a massive global epidemic of obesity, especially in
countries in rapid economic transition, is simultaneously emerging
in children and adolescents. The concurrent manifestation of both
undernutrition and overweight/obesity has been termed the double
burden of malnutrition (DBM). The greatest concentration of the
DBM is found in sub-Saharan Africa, South Asia, and East Asia and
the Pacific region.
 TYPES OF MALNUTRITION
Undernutrition
Protein-energy malnutrition/ PEM
Micronutrient deficiencies
Overnutrition
overweigh
obesity
Co-existance
obesity and PEM
obesity and micronutrient deficiencies
Acute and chronic malnutrition
 UNDERNUTRITION
There is inadequate consumption, poor absorption
and excessive loss of nutrients
The terms PEM and malnutrition sometimes used
interchangeable for undernutrition
Undernutrition is lack of the macronutrients/
energy/ and micronutrients/vit, min/
They are susceptible for infection, sepsis,
pneumonia, gastroenteritis
 UNDERNUTRITION TYPES

1. Protein-energy malnutrition/ PEM:

Kwashiorkor lack of proteins and
marasmus lack of proteins and calories
2. Micronutrient deficiencies: iron, iodine and
vitamin A
 ETIOLOGY

Inadequate food intake is the most common cause of

malnutrition worldwide. In developing countries, inadequate
food intake is secondary to insufficient or inappropriate food
supplies or early cessation of breastfeeding. In some areas,
cultural and religious food customs may play a role.
Inadequate sanitation further endangers children by
increasing the risk of infectious diseases that increase
nutritional losses and alters metabolic demands.
In developed countries, inadequate food intake is a less
common cause of malnutrition. Instead, diseases and, in
particular, chronic illnesses play an important role in the
etiology of malnutrition.
Chronic illness are at risk for nutritional problems

Children with chronic illnesses frequently have

anorexia, which leads to inadequate food
intake.
Increased inflammatory burden and increased
metabolic demands can increase caloric need.
Any chronic illness that involves the liver or
small bowel affects nutrition adversely by
impairing digestive and absorptive functions.
Chronic illness are at risk for nutritional problems

Cystic fibrosis Celiac disease

Chronic renal failure Hyperthyroidism
Childhood malignancies Physical problems affecting
Congenital or acquired feeding
heart disease
Tuberculosis
Neuromuscular
diseases In newborns and infants:
UTI, cow’s milk allergy or
Inflammatory bowel
diseases other food allergies
HIV In adolescents: eating
disorders
The following conditions place at significant risk for the
development of nutritional deficiencies

Prematurity
Developmental delay
In utero toxin exposure (fetal alcohol
exposure)
Children with multiple food allergies
present a special nutritional challenge
because of severe dietary restrictions.
 PATHOPHYSIOLOGY
Malnutrition affects virtually every organ
system
In addition to the impairment of physical growth, cognitive and other
physiologic functions, immune response changes occur early in the
course of significant malnutrition. Immune response changes correlate
with poor outcomes and mimic the changes observed with acquired
immune deficiency syndrome: loss of delayed hypersensitivity, fewer T
lymphocytes, impaired lymphocyte response, phagocytosis secondary
to decreased complement and cytokines, and decreased secretory Ig A.
Immune changes predispose to severe and chronic infections, most
commonly diarrhea, which further compromises anorexia, decreased
nutrient absorption, increased metabolic needs, and direct nutrient
losses
Changes in the developing brain: a 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.
Pathophysiology.
 WHO CLASSIFICATION
Uses Weight for height Z score, mid
upper arm circumferences and
presence of edema

The WHO recommends to use Z

scores or Standard deviation scores
to evaluate anthropometric data
Growth charts
WHO CLASSIFICATION
CLASSIFICATION OF PEM/WHO
 Clinical Presentation

Poor weight gain, Slowing of linear growth, Behavioral

changes
The most common clinically significant deficiencies
include:
Iron - Fatigue, anemia, decreased cognitive function, headache, glossitis,
nail changes
Iodine - Goiter, developmental delay, and intellectual disability
Vitamin D - Poor growth, rickets and hypocalcemia
Vitamin A - Night blindness, xerophthalmia, poor growth, and hair changes
Folate - Glossitis, megaloblastic anemia, and neural tube defects
Zinc - Anemia, dwarfism, hepatosplenomegaly, hyperpigmentation and
hypogonadism, acrodermatitis, diminished immune response, poor wound
healing.
 Physical Examination
Physical findings that are associated with PEM
Decreased subcutaneous tissue: most affected are the legs, arms, buttocks,
and face.
Edema: most affected are the distal extremities and anasarca (generalized
edema).
Oral changes: Cheilosis, Angular stomatitis, Papillar atrophy
Abdominal finding: distension secondary to poor abdominal musculature,
hepatomegaly secondary to fatty infiltration
Skin changes: Dry peeling skin with raw exposed areas, hyperpigmented
plaques over areas of trauma
Nail changes: Nails become fissured or ridged.
Hair changes: Hair is thin, sparse, brittle, easily pulled out, and turns a dull
brown or reddish color.
Practical nutritional assessment

Complete history, including a detailed dietary

history
Growth measurements, including weight and
length/height; head circumference in children
younger than 3 years
Complete physical examination
 UNCOMLICATED VS COMPLICATED SAM

UNCOMLICATED SAM COMPLICATED SAM

Child > 6mo Child < 6mo
Child is alert not alert
Preserved appetites Having loss of
Clinically assessed to be appetites
well Not clinically well
Child is living in Hospital care is
conducive home
environment considered mandatory
Can be managed as
outpatient
 INVESTIGATION FOR PEM
In essence
Decrease serum albumin
edema
Decrease apoproteins/ lipoproteins carrier
Storage of fat in the liver /fatty infiltration
Clinical outcomes: edema, hepatomegaly,
changes in hair growth and skin changes,
diarrhea, predisposition to infection (humoral
and cellular immunity disturbed)
 FORMS OF SAM/PEM

Kwashiorkor: inadequate protein

intake

Marasmus: inadequate protein and

calories intake
 Kwashiorkor
Usually affects children 1-4 years
The main symptoms are: edema, vesting, liver
enlargement, hypoalbuminemia, steatosis, and
possibly depigmentation of skin and hair
General appearance: child may be have a fat sugar
baby appearance
Edema ranges from mild to gross and represented
5-20% of the body weight
Muscle wasting: always present, child is often weak,
hypotonic, enable to stand and walk
 MARASMUS
Results from rapid deterioration of nutritional status
Acute starvation or acute illness
It is marked are wasting fat, muscle as tissues are consumed
to make energy
The main sigh is the severe wasting. The child is appearing
very thin and has no fat.
The loss of buccal pad of fats creates the aged or wrinkled
appearance that has been referred to once as monkey facies
 MARASMUS
Baggy pants appears
refers to loss skin of
the buttocks hanging
down
Axillary pad of fat
may also be
diminished
Affected children may
appear to be alert in
spite of their
condition
There is no edema
CLINICAL FEATURES OF PEM
CLINICAL FEATURES OF PEM
 RECURRENT INFECTION

Decreased immune response due to Immunosuppression is seems in

inability synthesize IL-6, IL-8, TNF-α malnutrion and changes are
due to lack of essential aminoacides correlated with poor outcomes
C3, C5 an b factors levels reduced- and mimic changing observed in
opsonization and phagocytosis children with AIDS
reduce This predispose to child in
Decreased phagocytic and severe and chronic infections
bactericidal activity of leucocytes such as infective diarrhea, which
Atrophy thymico-lymphatic glands further compromises nutrition
causes depletion T lymphocytes cases anorexia, decreased
and depressed cell-mediated nutrient absorption, increased
immunity thus infection like herpes, metabolic needs and direct
candidiasis are common
nutrient losses created vicious
cycles
 MICRONUTRIENT DEFICIENCIES
Iron- microcytic anemia: fatigue, anemia, decreased cognitive
functions, headache, glossitis, koilonychia
Folate-megaloblastic anemia, neural tube defects
Iodine- goiter, development delay and cognitive impairment
Zink- anemia, dwarfism, hepatosplenomegaly, hypo- and
hyperpigmentation, acrodermatitis enteropathica, diminished
immune response, poor wound healing> Zink important for during
rehydration and refeeding processes. Urinary zinc is proportional
for overall zinc status
Vitamin A- night blindness, xerophthalmia, keratinous changes of
cornea and conjunctiva, skin keratinization, poor growth and hair
changes
Vitamin D -poor growth, rickets and hypocalcemia
children < 5 y
 children ≥ 5y

Note that standard deviation (SD) and z-score have the same meaning.
Malnutrition, thinness and growth faltering

In children < 5 years

Moderate malnutrition is defined as weight-for-
length/height or BMI for-age between < -2 SD and
≥ -3 SD
Severe malnutrition is defined as weight-for-
length/height or BMI-forage < - 3SD
Consider measuring the mid-upper arm
circumference to identify young children with
severe or moderate acute malnutrition, particularly
in children with oedema.
Malnautrition, thinness and growth faltering

In children ≥ 5 years
Thinness is defined as BMI-for-age between < -2 SD and ≥ -
3 SD
Severe thinness is defined as BMI-for-age < -3 SD
Growth faltering is characterized by a slower rate of weight
or height gain than expected for age and sex. The child’s
growth when plotted on the growth chart will deviate below
the expected trajectories of the growth line over time.
Growth faltering may be due to a sequence of acute
illnesses or the onset of a nutritional problem.
 History
Feeding or eating history
Newborns and infants ­
Factors that may be associated — Breastfeeding or infant
with growth faltering: formula feeding
— Preterm birth — Frequency and amount of
— Other congenital problems or consumed milk or formula
perinatal illness — If formula-milk fed: type of
— Neurodevelopmental formula and preparation of milk
concerns (dilution)
— History of maternal postnatal — Complementary feeding, type
depression and anxiety of complementary food
— Recurrent infections
 Factors contributing to insufficient weight gain or
weight loss in infants:

— Ineffective suckling — Unfavorable parent

in breastfed infants — infant interactions
— Ineffective bottle — Insufficient response
feeding of caregivers to infant’s
— Inappropriate feeding feeding cues
patterns or routines — Physical conditions
used affecting feeding.
— Unfavorable feeding
environment
— Feeding aversion
 Toddlers and children
Feeding/eating history: number of meals per day, timing of
meals (breakfast, lunch and dinner), components of meals ­
History: diarrhea, frequent cough or airway infections, living
environment, social and family state condition.
Note: A difficult family situation or exposure to maltreatment
can influence eating and weight gain. ­ Contributing factors to
insufficient weight gain or weight loss: — Mealtime practices —
Types of food offered — Food aversion and avoidance — Difficult
parent–child interactions — Insufficient response of caregivers
to child’s mealtime cues — Lack of appetite — Physical
conditions affecting feeding ­Parents’ diet (vegan, vegetarian).
 Adolescents ­
Eating history
Living environment, social and family situation ­
medications ­
Signs of eating disorders
— Distorted body image and fear of gaining
weight
Weight control measures, e.g. self-induced
vomiting, dieting, use of laxatives, diuretics or
other medications, fasting or excessive exercise.
 Medical Care
Following evaluation of nutritional status, identification of the
underlying etiology, dietary intervention in collaboration with a
dietitian or other nutritional professionals should be initiated.
Children with edema must be assessed for nutritional status because
edema may mask the severity of malnutrition. Children with chronic
malnutrition may require caloric intakes more than 120-150 kcal/kg/d
to achieve appropriate weight gain.
kcal/kg = (RDA for age X ideal weight)/actual weight
Any micronutrient deficiencies must be corrected to attain appropriate
growth and development. Most children with mild malnutrition respond
to increased oral caloric intake and supplementation with vitamin, iron,
and folate supplements. The requirement for increased protein is met
typically by increasing the food intake, which, in turn, increases both
protein and caloric intake. Adequacy of intake is determined by
monitoring weight gain.
,
 Treatment
Children with moderate malnutrition or growth faltering and no other
medical conditions do not require immediate hospital admission.
However, they require regular follow-up.
Treat the underlying medical condition
Encourage and support the mother to continue breastfeeding, and
counsel on overcoming difficulties
Establish a management plan with specific goals including: —
Interventions, e.g. correction of breastfeeding technique,
introduction of complementary feeding, regular meals if previously
skipped
Follow-up appointments for reassessment including physical
examination and growth monitoring to review progress and
achievement of goals.
 Treatment
— Encourage relaxed and enjoyable feeding and mealtimes

— Eat together as a family or with other children

— Allow young children to eat by themselves and be “messy” with their

food

— Make sure that feeds and mealtimes are not too brief or too long

— Set reasonable boundaries for mealtime behavior and avoid

punishment

— Avoid coercive feeding

— Establish regular eating schedules, e.g. 3 meals and 2 healthy snacks

in a day.
 They are 3 strategies of treatment
1. Hospital treatment -the following
condition should be corrected
Hypoglycemia
Dehydration
Electrolyte imbalance
Infection
Anemia
Other vitamin and mineral deficiencies
They are 3 strategies of treatment
2. Dietary management
Should be from locally available staple
foods- inexpensive, easily digestible,
evenly distributed throughout the day
and increased number of feedings to
increase quantity of food
They are 3 strategies of treatment
3. Rehabilitation
The concept of nutritional
rehabilitation is based on practical
nutritional training for mothers in
which their learn by feeding their
children back to health under
supervision and using local foods
 TREATMENT
Parenteral nutrition for 2-3 d enteral nutrition with
flow probe using hyperproteic and hypercaloric solutions
Early initiation of oral nutrition
hypoallergenic preparation rich in proteins and calories,
low
osmolarity
Simultaneously treating infection, hypoproteinemia,
anemia, deficiencies
Keep in parallel parenteral intake of carbohydrates, amino
acids, lipides
This variant is also little used because it is required
specials dietetics and carefully monitorization of
nutritional therapy
 TREATMENT
After fluid replacement and electrolytes – digestive tolerance:
With Carrot soup or rice mucilage in various concentration in dose of 120-
200ml/kg, no exiting 1000ml/day
Carbohydrates were obtained from glucose 5%, 7%, 10 %, chicken mixed
proteins (hypoallergenic 100g, protein 17g)
After normalization of stool (7 days) oil gradually 3-4ml/d, and after 10 days
from beginning enteral diet hypoallergenic preparation can
be inserted (preparation lactose free can induce cow’s milk protein
intolerance)
Week 4 sugar (restoring lactose tolerance is difficult 3-4 mo )
Fluor products containing gluten will not enter until full recovery
Increase in proteins- calorie intake by parenteral administration of
carbohydrates, aminoacides and proteins
Treat the infection and iron or vitamin deficiencies
 EDUCATION
Patient
Family
Community
WHO
 PREVENTION
Promotion of breastfeeding
Development of low cost weaning
Nutrition education and promotion of
correct feeding practices
Family planning and spacing of birth
Immunization
Food fortification
Early diagnosis and treatment
 COMPLICATIONS
Hypoglycemia
Hypokalemia
Hypothermia
Hyponatremia
Hearth failure
Dehydration & shock
Infection
EVIDENCE - BASED PEDIATRICS

Analy
Appl

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Apprai
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Clinical
Practice
Guidelines
Aire
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Guyatt G. Evidence-based medicine. ACP J Club 1991; A-16:114.
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phenomenon!