CHAPTER II

LITERATURE REVIEW

1. UNDERNUTRITION
A. DEFINITION
Undernutrition is caused primarily by an inadequate intake of dietary energy,
regardless of whether any other specific nutrient is a limiting factor.(malnutrisi and
under) The WHO defines ‘‘undernutrition,’’ from a conceptual point of view, as the
imbalance between the intake of nutrients and energy and the bodily requirements to
live, grow, and carry out specific functions, especially before reaching the age of 5.
Undernutrition commonly affects all groups in a community, but infants and
young children are the most vulnerable because of their high nutritional requirements
for growth and development. In children, undernutrition manifests as underweight and
stunting (short stature), while severely undernourished children present with the
symptoms and signs that characterize conditions known as kwashiorkor, marasmus or
marasmic-kwashiorkar. The classical picture is dominated by muscle wasting,
peripheral oedema and skin and hair changes. The aetiopathogenesis depends both on
concurrent complications, such as infections, and the body’s endocrine response.
Immediate consequences include high morbidity and mortality. Weakened mucosal
barriers and an immunocompromised state predispose undernourished children to
infections, especially those of the gastrointestinal and respiratory systems.4 12-15 such
as diarrhoeal disease are often the underlying cause of malnutrition in infants and
children.
In 2013, child undernutrition accounted for 1.3 million child deaths and 120
million disability adjusted life years(DALYs).16 Compared with well nourished
children, children with moderate acute malnutrition have a threefold increased risk of
mortality and impaired physical and cognitive development.17 Children with severe
acute malnutrition have a ninefold increased risk of mortality.6 18 Long term
consequences include cognitive deficits, poor school performance, poor motor
development, compromised productivity, and high incidence of noncommunicable
diseases.19-22 (undernutrition). Undernutrition is both a medical and social
disorder.10. Lack of sanitation and hygiene, inadequate care, economic deprivation,
and food insecurity are contributory factors. Social, cultural, political, and legal factors
 that influence availability and use of resources further contribute to child
undernutrition.11 Any interventions must address these factors as well.

B. ASSESSMENT OF UNDERNUTRITION
In communities with a high burden of child undernutrition, active case finding
by community health workers who screen children through home visits or other
outreach platforms helps with early detection. In addition, we recommend that
healthcare providers screen all children during routine visits to a health facility. There
are several indicators used to measure nutritional status. These include body
composition, clinical signs of deficiency, physical function, biochemical compounds,
metabolic processes or dietary intake. The choice of which of these indicators is used
is dependent on the question being asked. In clinical settings, it is common to use a
combination of qualitative and quantitative descriptions of undernutrition e.g.
marasmus and kwashiorkor while in community studies of protein-energy
undernutrition, body size is widely used because it is readily measurable and is a
sensitive indicator of nutritional status and health. However, for specific nutrient
deficiencies other indicators are used.
1) History
Explore the carer’s concerns about a child’s growth and any current illness.
The child may have cough, fever, diarrhoea, skin infections, eye or ear complaints,
which suggest an infection. Ask about changes in behaviour such as lethargy,
irritability, drowsiness, and loss of appetite.
A detailed diet history in terms of breastfeeding and complementary feeding
(that is, timely introduction of solids and semisolid foods) is important. Individuals
are well nourished or malnourished according to whether their food intake matches
their requirements for both macronutrients (energy, protein and fat) and
micronutrients.A nutritionist or trained health worker can help assess the child’s
current dietary intake pattern in terms of the frequency, portions, variety, and
composition of meals using validated tools. Understanding socioeconomic factors
such as housing, occupation, family size, and dietary or childcare practices may be
important, as discussed above.23 The data related to family food habits and how
meals areeaten is fundamental in cases of undernutrition. The following point is the
social situation: age and occupation of the parents, possible family stress, and the
economic situation in the home.
2) Examination
A number of classifications are available for assessing different degrees of
undernutrition. The anthropometric measurements usually include length or stature,
weight, skin-fold thickness of the triceps, subscapular region and circumference of
the head, upper arm, and upper thigh. Undernutrition is diagnosed using
anthropometric parameters that are compared with NCHS/WHO international
reference standards. WHO growth standards ussualy use for infants and children
ages 0 to 2 years of age and use the CDC growth charts to monitor growth for
children age 2 years and older. The reason use WHO growth standards for infants
and children ages 0 to 2 years of age is:
a) The WHO standards establish growth of the breastfed infant as the norm for growth.
Breastfeeding is the recommended standard for infant feeding. The WHO charts reflect
growth patterns among children who were predominantly breastfed for at least 4 months
and still breastfeeding at 12 months.
b) The WHO standards provide a better description of physiological growth in infancy.
Clinicians often use the CDC growth charts as standards on how young children should
grow. However the CDC growth charts are references; they identify how typical children
in the US did grow during a specific time period. Typical growth patterns may not be ideal
growth patterns. The WHO growth charts are standards; they identify how children should
grow when provided optimal conditions.
c) The WHO standards are based on a high-quality study designed explicitly for creating
growth charts.
The WHO standards were constructed using longitudinal length and weight data measured
at frequent intervals. For the CDC growth charts, weight data were not available between
birth and 3 months of age and the sample sizes were small for sex and age groups during
the first 6 months of age.()
These anthropometric measures are plotted in the WHO growth charts
as composite indicators of weight relative to age, height/length relative to age,
and weight relative . For the assessment WHO has provided charts for both boys
and girls based on:
o length/height-for-age
o weight-for-age
o weight-for-length/height
 BMI (body mass index)-for-age
 The WHO recommendation is to use the z score or standard deviation
(SD) system to grade undernutrition. Children who are more than 2 SD below
the reference median (ie, a z score of less than −2) are considered to be
undernourished: that is, to be stunted, wasted, or underweight. Children with
measurements below 3 SD (a z score of less than −3) are considered to be
severely undernourished.( Bandyopadhyay, 2014). Interpretation of the charts
is easy and is done based on the following table provided by WHO.
 In CDC, the clinical charts for infants and older children were published in two
sets. Set 1 has the outer limits of the curves at the 5th and 95th percentiles. These
are the charts that most users in the United States will find useful for the
majority of routine clinical assessments. Set 2 has the outer limits of the curves
at the 3rd and 97th percentiles for selected applications. Pediatric
endocrinologists and others who assess the growth of children with special
health care requirements may wish to use the format in set 2 for selected
applications.
 Mid-upper arm circumference is a simple measure of nutritional status in
children, used particularly for screening in emergency situations. Mid-upper arm
circumference reflects both muscle mass and subcutaneous fat. This simple
measurement has been found to adequately identify children with severe acute
malnutrition. A circumference of more than 14 cm is considered normal; less than
12.5 cm indicates severe undernutrition. Circumferences of 12.5–14 cm suggest
mild or moderate undernutrition.
3) Complementary tests:
This can be limited initially to a complete blood test, CPR, albumin, alkaline
phosphatase, total cholesterol with a urine analysis and culture. One must
remember that the markers are never too early and for caloric deficiency are the
serum reduction of albumin and total cholesterol. The classic malnutrition markers
(IGF 1, pre-albumin, RBP, test for immune responses, amino acid levels, essential
fatty acids, vitamins, and trace elements) are found to be altered in only 1% of the
cases which occur in the western world, while their determination in developing
areas is more complicated and resource consuming. At least one must make sure
that there is no lack of iodines, or of vitamins A and D, and specially iron. Cases
with an important malnutrition are also candidates to studies of endocrinology,
hepatology, cardiology, and especially for gastrointestinal tract disorders due to the
therapeutic implications and prognosis that they may have.

C. CLASSIFICATION OF UNDERNUTRITION
Undernutrition is caused primarily by an inadequate intake of dietary energy,
regardless of whether any other specific nutrient is a limiting factor. Protein-energy
undernutrition (also called protein-energy malnutrition) is a severe deficiency of protein
and calories that results when people do not consume enough protein and calories for a
long time.
In developing countries, protein-energy undernutrition often occurs in children.
It contributes to death in more than half of children who die (for example, by increasing
the risk of developing life-threatening infections and, if infections develop, by
increasing their severity). However, this disorder can affect anyone, regardless of age,
if food supplies are inadequate.Protein-energy undernutrition has two main forms:
1) Marasmus
When dietary energy is limited through chronic inadequate food intake, low
insulin and high plasma cortisol levels result in release of amino acids from muscle and
their subsequent availability for hepatic synthesis of protein (particularly albumin). The
result is severe muscle wasting with normal plasma albumin levels and, hence, no
oedema. Absence of oedema in the presence of severe muscle wasting in an infant or
1-year-old child is characteristic of marasmus.
2) Kwashiorkor
Kwashiorkor develops in those on diets with a low protein:energy ratio. Protein
may be a limiting factor in such diets. Free radical-induced and possibly other damage
to tissues caused by deficiencies of essential nutrients and coexisting infections may be
an important reason why some malnourished children develop oedema. Protein loss can
certainly contribute.

D. RISK FACTOR OF UNDERNUTRITION

Based on scientific literature investigating the relationships among specific individual,
household, and environmental factors and the development of malnutrition in children,
the following are significant risk factors:
a. Inadequate dietary intake
b. Inappropriate feeding
c. Fetal growth restriction
d. Inadequate sanitation
e. Lack of parental education
 f. Family size
g. Incomplete vaccination
h. Poverty
i. Economic, political, and environmental instability and emergency situations
(Lenters et al., 2016)

E. MANAGEMENT
The WHO published a 10-step guide for inpatient management. The 10 steps are
divided into three phases (Lenters et al., 2016):
a. Initial treatment/stabilization phase:
During the initial treatment phase, frequent feeding is important to prevent both
hypoglycemia and hypothermia. Feeding during the initial treatment phase should
be approached cautiously because of the fragility of the child’s physiological state.
F75 should be given every 30 minutes for two hours, followed by F75 every two
hours, day and night. Breastfed children should be encouraged to continue
breastfeeding. Children with hypothermia should be rewarmed by being clothed,
covered with a warmed blanket, placed near a heater or lamp, or placed on the
mother’s chest (skin-to-skin) and covered.
Dehydration should be treated following the WHO’s 2013 guidelines; several key
updates have been included. For example, dehydrated children who are not in shock
should be rehydrated orally or by nasogastric tube using ReSoMal or half-strength
WHO low-osmolarity oral rehydration solution with added potassium and glucose.
If the child has profuse watery diarrhea or suspected cholera he or she should be
rehydrated with full-strength WHO low-osmolarity oral rehydration solution.
Children who are severely dehydrated or with signs of shock should be rehydrated
intravenously, using half-strength Darrow’s solution with 5 percent dextrose,
Ringer’s lactate solution with 5 percent dextrose, or, if neither is available, 0.45
percent saline with 5 percent dextrose.
Infections should be treated routinely upon admission by provision of a broad-
spectrum antibiotic, and measles vaccination should be given for unimmunized
children older than age six months.
Micronutrient deficiencies should be treated by giving vitamin A (200,000
international units [IU] for children older than age 12 months, 100,000 IU for
children ages 6–12 months, and 50,000 IU for children ages 0–5 months), coupled
 with daily multivitamin, folic acid, zinc, and copper supplementation for at least
two weeks. Iron supplementation should only be given once children have begun
gaining weight.
b. Rehabilitation phase
During the rehabilitation phase, F75 should be replaced with F100 in the same
amounts for 48 hours before increasing successive feeds by 10 milliliters until some
remains unconsumed. If available, children could be transitioned from F75 to RUTF
according to the updated WHO guidelines (WHO 2013). F75 and F100 are specially
formulated milks used in inpatient. Children are provided with approximately 80–
100 kilocalories per kilogram per day (kcal/kg/d) spread over 8–12 meals per day
for three to seven days. F75 is not designed for weight gain. F100 is given during
the rehabilitation phase of inpatient treatment, providing children with
approximately 100–200 kcal/kg/d for three to four. Because F75 and F100 require
preparation and have high moisture content, they cannot be stored for long at room
temperature for food safety reasons, and are not given to caretakers to prepare at
home.
Children’s respiratory and pulse rates should be monitored closely. After transition
to F100, children should receive feedings consisting of 100–200 kcal/kg/d and 4–6
g protein/kg/d at least every four hours. Breastfeeding should continue to be
encouraged.
c. Follow up
After recovery, parents should be taught to feed children frequently with energy-
and nutrient-dense foods and to continue to stimulate their children’s sensorial and
emotional development. Parents should be requested to bring children back for
regular follow-up checks. Vitamin A supplementation and booster immunizations
should be provided.

Criteria for patient discharged:

The parameters for defining recovery are Weight/Height or Weight/Length > -2 SD
and there is no clinical symptom. The patient can be discharged when:
a. Edema is reduced or disappear, children are aware and active
b. Weight/height or weight/length > -3 SD
c. Complications are resolved
d. Mother has got nutrition counseling
e. There is weight gain about 50 g/kg/week for 2 weeks in a row
f. Appetite is good