By

Dr Saima Ali

"Most of the seven billion people in this world suffer from malnutrition.
Half do not have enough to eat and
the rest of us eat too much."
DEFINITION

A pathological state resulting from relative or absolute

deficiency of one or more essential nutrients.
Prevalence
 98% of the world's undernourished people live in
developing countries.

 1 out of 4 infants are born with a low birth weight

in developing countries

 The prevalence of malnutrition is 43% in

Pakistan.(2011)
Prevalence
 The Statistics report of October 2007 shows that

“A malnourished child dies every ----?--”

Every 7th second
Hidden hunger
 “Subclinical deficiency” is micronutrient malnutrition
without visible signs of deficiency, also termed as the
“hidden hunger”
 ETIOLOGY
 PRIMARY MALNUTRITION

 Failure of lactation

 Ignorance of weaning

 Poverty

 Food patterns

 Lack of immunization

 Socio-economic factors
ETIOLOGY (contd)
 SECONDARY MALNUTRIYION

 Infections( worms, TB, UTI)

 Congenital anomalies (VSD, obstructive uropathy, cong

lung anomalies)

 Malabsorption (giardiasis, celiac disease, CF)

 Metabolic (DM, DI, Galactesemia)

Classification
The Gomez classification of malnutrition based on weight-
for-age standards

 It is used to assess the magnitude of problem in

community.

 Normal >90%
 Grade I (mild malnutrition) 75-89.9%
 Grade II (moderate malnutrition) 60-74.9%
 Grade III (severe malnutrition) <<60%
GOMEZ CLASSIFICATION
 For example; Actual wt / expected wt
If 1 year child is ×100
weighing 5 kg then he
will be on which degree
of malnutrition ?
5/10 × 100 = 50%
Seoane and Lantham’classification
Malnutrition Wt for age Ht for age Wt for Ht

Acute (short Low Normal Low

term) Wasted

Chronic (long Low Low Low

term)
Wasted&
stunted
Past Low Low Normal
(stunted)
WELLCOME CLASSIFICATION
Standard Wt for Edema present Edema absent
age

Wt for age kwashiorkor under nutrition

60%-80%

Wt for age Marasmic marasmic

≤60% kwashiorkor
Mid arm circumference
Mid arm circumference Degree of malnutrition

16.5-14cm No malnutrition

13.9-12cm 1st and 2nd malnutrition

<12cm 3rd degree malnutrition

MUAC strip
 Up to Green color-------Normal(14cm)

 Yellow color--------Borderline malnutrition

(14-12cm)

 Red color--------Malnourished(≤ 12cm)

Skin fold
 Assessed by Herpenden caliper

Normal = 9-11mm
KWASHIORKOR
(Infantile pallegra, nutritional pallegra)

 First introduced by Cicely Williams in 1935.

 Used as local term by African means “Sickness of

weanling”

 Kwashiorkor is characterized by edema, apathy and

low body weight.
MARASMUS

 The cardinal features are severe growth retardation, loss of S/C

fats, muscle wasting and absence of edema.

 Growth retardation is one of the earliest manifestation. When

this process is prolonged, the body is forced to utilize its own
tissues.
 It is 20 times more common than kwashiorkor and usually
occur in children below 2 years.
Pathological changes in PEM
Liver: fatty infiltration is characteristics of kwashiorkor.

Malnutrition during childhood may lead to cirrhosis of liver in

later life.

Pancreas: PEM shows marked atrophy.

Kidney: Renal atrophy with scarring of medulla.

GIT: villous atrophy with decrease in absorption area.

Pathological changes in PEM
Thymolymphatic system: size of thymus, spleen and tonsil
reduced.

Heart: size is reduced in kwashiorkor. ECG shows ST segment

and T wave changes.

Endocrine system: Decrease in iodine uptake, impaired glucose

tolerance( impaired utilization)
Comparison of the features of kwashiorkor and
marasmus
Feature Kwashiorkor Marasmus
Age of incidence 12-36mths 6-12mths
Growth retardation less severe
wasting less obvious Gross,
Edema Present Absent
Hair changes common less Common
Mental changes Very common Uncommon
Skin changes, flaky-paint common infrequent
Moon face present Wise-man
look
Appetite Poor Good

S/C fat Reduced but present Absent

Phases of treatment

 Initial phase (2-7days)

 Rehabilitation phase (2-6 weeks)

 Follow-up phase (7-25 weeks)

Initial treatment
THINGS TO DO IN INITIAL PHASE

 To identify the life threatening problems


 To treat or prevent hypoglycemia

 To treat or prevent hypothermia

 To treat or prevent dehydration

 To treat infection

 To start to feed the child

Rehabilitation phase
“When child’s appetite has returned”
PRINCIPLES OF MANAGEMENT

 To encourage the child to eat as much as possible.

 To re-initiate and/or encourage breastfeeding.
 To prepare the mother to continue to look after the child after
discharge.
 To stimulate emotional and physical development.
Follow up plan
 Follow-up visits are important to prevent relapse
 Follow up visit should be at one week, 2 weeks, 1 month, 3
months, 6 months.
 After 6 months visit should be twice yearly until the child is at
least 3 years old.
 At each visit mother should be asked about the child health,
feeding and activities.
 The child should be examined, weighed and measured plotted
"A hungry man can't
see right or wrong.
He just sees food."