Malnutrition

Malnutrition
Focusing on Protein energy

under nutrition
01/13/2024 BHU midwifery 1

Outline
• Definition
• Cause
• Type
• Management of SAM

• Malnutrition refers to deficiencies, excesses, or
imbalances in a person’s intake of energy and/or
nutrients.
1. undernutrition, which includes
• wasting (low weight-for-height)
• stunting (low height-for-age) and
• underweight (low weight-for-age);

2. micronutrient-related malnutrition, which includes
micronutrient deficiencies (a lack of important vitamins
and mineral
3. overweight, obesity and diet-related
noncommunicable diseases (such as heart disease,
stroke, diabetes and some cancers).

Globally in 2020,
• 149 million children under 5 were estimated

to be stunted (too short for age),
• 45 million were estimated to be wasted (too
thin for height), and
• 38.9 million were overweight or obese.

• Around 45% of deaths among children under 5
years of age are linked to under-nutrition.
• These mostly occur in low- and middle-income
countries.
 At the same time, in these same countries,
rates of childhood overweight and obesity are
rising

Global Targets 2025
• Stunting TARGET: 40% reduction in the
number of children under-5 who are stunted
• Wasting
• TARGET: Reduce and maintain childhood
wasting to less than 5%

Types of Malnutrition
• Undernutrition: too little

– Protein Energy Malnutriton(PEM)
– Micronutrient deficiencies
• Overnutrition: too much
– Obesity
– Chronic diseases (diabetes, hypertension,..

Cont...
• Micronutrient malnutrition -- arises from

inadequate vitamin and mineral supply to cells in
body to satisfy physiological requirements
– Vitamin A, Iron & Iodine
– Others: Zinc, vitamin D

Clinical Assessment
• Useful in severe forms of PEM
• Based on thorough physical examination for features of PEM

& vitamin deficiencies.
• Focuses on skin, eye, hair, mouth & bones.
• Deficiency signs such as hair changes, anemia, xerosis,

cheilosis, angular stomatitis, rachitic rosary, bleeding spongy
gums, dental caries, etc. should be actively looked for

SEVER MALNUTRITION
• Malnutrition is defined as chronic inadequacy in food

instances combined with high levels of illness
• Is a long term year round phenomena
• More than half of the deaths in children have stunting
and wasting as the underling cause.
 Occurs more frequently when infections impose
additional demands, induce greater loss of nutrients .
Sever Malnutrition….
• Most deaths in children have some form of malnutrition

as the background .
• Stunting is due to chronic malnutrition
• Wasting and edema are due to acute malnutrition .
• Is both medical and social disorder so management

includes both medical and social problems identified and
managed—this prevents relapse of the problem.
Cause
• There are two types
– Primary – nutritional insufficiency

• Inadequate protein, calorie and nutrient intake
– Secondary – malnutrition following infections, injury,

chronic disease, excessive nutrient loss as occurs in
chronic diarrhea, HIV, malabsorption syndrome etc…
• Social, economic, biologic, and environmental factors
underlying severe malnutrition
PROTEIN-ENERGY MALNUTRITION
• The term, protein-energy malnutrition, refers

to a class of clinical conditions that may result
from varying degree of protein lack and
energy (calorie) inadequacy.
• Lack of food & clean water, poor sanitation,
infection & social unrest lead to LBW & PEM
EPIDEMIOLOGY
• The term protein energy malnutrition has been

adopted by WHO in 1976.
• Highly prevalent in developing countries
among <5 children; severe forms 1-10% &
underweight 20-40%.
• All children with PEM have micronutrient
deficiency.
PEM in Sub-Saharan Africa
• PEM in Africa is related to:
– The high birth rate
– Subsistence farming
– Overused soil, draught & desertification
– Poverty
– Low protein diet
– Political instability (war & displacement)

PRECIPITATING FACTORS
· Lack of food (famine, poverty)
· Inadequate breast feeding
· Wrong concepts about nutrition
· Diarrhoea & malabsorption
· Infections (worms, measles, T.B)

CLASSIFICATION OF PEM
1. Syndromal Classification
• Kwashiorkor
• Nutritional marasmus
• Marasmic kwashiorkor
• Nutritional dwarfing (Stunting

MARASMUS
• The term marasmus is derived from the Greek

marasmos, which means wasting.
• Marasmus involves inadequate intake of protein and
calories and is characterized by emaciation.
• Marasmus represents the end result of starvation
where both proteins and calories are deficient.

KWASHIORKOR
• Cecilly Williams, a British nurse, had

introduced the word Kwashiorkor to the
medical literature in 1933.
• The word is taken from the Ga language in
Ghana & used to describe the sickness of
weaning.
Clinical features
• PEM can affect all ages but common among infants

and young children
• Marasmus – before 1 year of age
• Kwashiorkor – after 18 months of age
• Diagnosis is principally based on dietary history and
clinical features

Clinical Features of Marasmus
• Severe wasting of muscle & s/c fats
• Severe growth retardation
• Child looks older than his age (monkey’s or old man’s face)
• No edema or hair changes
• Alert but miserable
• Hungry
• Diarrhoea & Dehydration

Features of Marasmus

Muscle wasting in a child with marasmus
• Severe degree
of atrophy of
muscle and
subcutaneous
fat in a
malnourished
infant with
marasmus

Clinical Features of Kwashiorkor
• soft, pitting, painless edema, usually in the feet and leg
• Skin lesions – flaky paint dermatosis
• Subcutaneous fat is preserved
• Weight deficit is not as severe as marasmus
• Height may be normal or retarded
• Rounded prominence of the cheeks ("moon-face")

Continued…
• The hair is dry, brittle, easily pulled out without pain, pigment
changed to brown, red, or even yellow white
• ‘Flag sign’ – due to alternating period of poor and good protein intake
• Apathetic and irritable, cry easily, and have an expression of misery

and sadness
• Anorexic and diarrhea is common
• Hepatomegaly
• Protuberant abdomen and peristalsis is slow
• Muscle tone and strength is reduced

Dermatosis of Kwashiorkor

Skin and Hair changes in Kwashakor

Flag sign

Marasmic kwashiorkor
• Combines clinical feature of both kwashiorkor and

marasmus
• Edema
• Muscle wasting and decreased subcutaneous fat
• When edema subsides, the patient appearance

resembles that of marasmus
• Wt less that 60%and edema
Peripheral signs of malnutrition
Clinical presentation Edematous Non edematous
Peak age 12 – 36 months 6 – 12months
Growth retardation Absent Present
Mental changes Apathy Irritable
Appetite Poor Good
Kwash – dermatosis Present Absent
Hair color and skin change Common Infrequent
Moon face Present Absent
Hepatomegaly Present Absent
Long and curled eye lash Present Present
Anemia Present Present
Pot belly abdomen Present Present
Diarrhea Present Present
Classification
• Several methods have been suggested for the
classification of PEM.
– Wellcome classification
– Gomez classification
– Water low classification

Wellcome classification based on the
Harvard standard
malnutrition Body weight for age based on Edema
Harvard curve
Underweight 60 – 80 _
Marasmus <60 _
Kwashiorkor 60 – 80 +
Marasmic
kwashiorkor
<60 +
It is used for clinical purpose

Drawback of wellcome classification
• It does not indicate the duration of
malnutrition.
• Moreover, difficulties may be encountered in
some communities where the precise ages of
the children are not known.

Gomez classification based on the Harvard
standard
Malnutrition Body weight for age based
on the Harvard standards.
First degree (mild) 75 – 90
Second degree (moderate) 60 – 75
Third degree (severe) <60
It is used for community purpose

Drawbacks of Gomez classification
• It does not indicate the duration and type of
malnutrition.
• Moreover, difficulties may be encountered in
some communities where the precise ages of
the children are not known.

Water low classification
Malnutrition Weight for length Length for age
Mild 80 – 90% 90 – 95%
Moderate 70 – 80% 85 – 90%
Severe <70% <85%
It is well accepted one .

Classification of malnutrition according to the World
Health Organization (WHO
Classification
Severe malnutrition
Moderate malnutrition
(type)*
Symmetrical Yes (edematous
No
edema malnutrition) •
SD-score <-3 Δ (ie, more

than 3 SD below the
Weight-for-height -3 ≤ SD-score <-2 Δ
median)
(severe wasting) ◊
SD-score <-3 Δ
Height-for-age -3 ≤ SD-score <-2 Δ
(severe stunting)
Cont...
• The child's weight for his or her height and the height for his or her
age are expressed as Z-scores (also known as the standard
deviation [SD] score.
• Charts — The degree of malnutrition can be determined by
plotting the height and weight on Z-score charts.
– Charts based on recumbent length are used for children up to two years
of age and
– charts based on standing height are used for those between two and
five years.

Cont…
Wasting and stunting are defined by the following
1. Wasting (indicates acute malnutrition):
– Moderate wasting — weight/height z-score <-2 to -3
– Severe wasting — weight/height z-score <-3
2. Stunting (indicates chronic malnutrition):
– Moderate stunting — height or length z-score <-2 to -3
Severe stunting — height or length z-score <-3

Length-for-age boys: birth to 2 years (z-scores)

Classification based on mid upper arm
circumference
Malnutrition MUAC
Mild 12 – 13.5cm
Moderate 11 – 12cm
Severe <11cm
It is well accepted one .

Diagnosis
• History – nutritional history
• Physical findings
• Anthropometric measurements
 WHO recommends NCHS as a reference
 wt for ht –index of current nutritional status
 ht for age –index of past nutritional history
 -Harvard status – for under 5th

INVESTIGATION
• Hct and Hgb
• WBC count and differential
• RBS
• Urinalysis and urine culture
• Chest X-ray
• Blood culture
• Total serum protein
• Reduced urinary creatinine clearance

Admission criteria
• Weight for height less than 70%

• Bilateral pitting edema
• Severe visible wasting (visible ribs, facial bones etc)
• The presence of complications (Sepsis, anemia,
hypoglycemia, hypothermia etc)
• Failed appetite test

• Admission criteria for age below 6mo and
weight below 3kg
– The infant is too weak or feeble to suckle
effectively (independently of his/her weight-for-
length)
– W/L (Weight-for-Length) less than 70%
– Presence of bilateral edema.

Cont...

Admission
procedure

Preparation of F75 and F100 Diets
F75(to prepare 100ml) F100(to prepare 100ml)
Dried skim milk 25 g 80 g
Sugar 70 g 50 g
Cereal flour 35 -
Vegetable oil 27 g 60 g
Mineral mix 20ml 20ml
Vitamin mix 140mg 140mg

Water to make 1000ml 1000ml
In patient management has 3phases
• Phase 1
– F-75 130ml/kg/24hrs divided in to 8doses
( * F-75 has 75kcal/100ml
* It is low in sodium, protein, energy)
– Antibiotics
• 1st line is Amoxicillin PO (or Ampicillin PO)
• 2nd line is add Gentamycin or CAF on the 1st line or give Augmentine.
• 3rd line is based on the clinician decision
– Vit. A for non edematous
– Folic acid
– Measles vaccine for age ≥9months and for those not
vaccinated for measles before.
Phase 1 conti…
Naso-gastric feeding
• Naso-gastric tube (NGT) feeding is used when a patient is not
taking sufficient diet by mouth. This is defined as an intake of less
than 75% of the prescribed diet (for children about 75 Kcal/ kg/
day).
• The reasons for use of an NG tube are:
 Taking less than 75% of prescribed diet per 24 hours in Phase 1
 Pneumonia with a rapid respiration rate
 Painful lesions of the mouth
 Cleft palate or other physical deformity
 Disturbances of consciousness.
• Every day, try patiently to give the F75 by mouth before using the
NGT. The use of the NGT should not normally exceed 3 days and
should only be used in Phase 1.
Criteria to change phase 1 to transition
phase
1. Gaining the appetite
2. Decreasing the edema
3. No medical complications
4. No IV line or NGT insitu

Transition phase
– Continue any medication not completed in phase 1

– F – 100, 130ml/kg/24hrs divided in to 8 doses
– RUTF can be given in a place of F – 100

Criteria to change transition phase to phase
2
1. Good appetite
2. No edema
3. No medical complication
4. No NGT or IV line insitu

Phase 2
– F – 100, 200ml/kg/24hrs divided in to 6doses
– RUTF can be given in a place of F – 100
– Albendazole or mebendazole
– Iron supplementation
– Advice and health education

Criteria to return from TP or phase 2 to
phase 1
• Diarrhea or vomiting
• Any medical complication
• Edema (new or exacerbation),
• Hepatomegaly
• abdominal distention or Sn of heart failure
• Loss of appetite

Management for those age <6mo or Wt
<3kg
• Diluted F – 100 if no edema (with supplementary
suckling technique if the infant is on breast feeding)
• Start with F – 75 if there is bilateral pitting edema
(with supplementary suckling technique if the infant
is on breast feeding) and then change to diluted F –
100 when edema resolves.
• Mother should be supplemented with vitamins and
mineral
• Other routine managements are the same

Monitoring of treatment response
• Weight gain >6gm/kg/day
• MUAC every week
• Height every three weeks
• Degree of edema daily
• The response of medical complications
• Frequency , amount and type of feeding
• Fill monitoring chart

Treat every new SAM child at entry to treatment
facility on emergency basis

Wasted infants need admission for
supplemental suckling technique (SST)

Playing and stimulation is important to avoid
cognition impairment and early recovery

Supplemental Suckling Technique

Avoid Hanging Pants

Discharge criteria
• Weight for length ≥85% on more than one
occasion.
• No edema for 10days
• No medical complication
• Good appetite

Discharge criteria for those age <6mo or Wt
<3kg
• If gaining weight with breast feeding alone
• No medical problem
• the mother has been adequately
supplemented with vitamins and minerals, so
that she has accumulated body stores of the
type 1 nutrients.?

Treatment failure
Criteria for failure to respond Time after admission
Primary failure to respond (phase 1)
Failure to regain appetite Day 4
Failure to start to loose edema Day 4
edema still present Day 10
Failure to enter phase 2 Day 10
Gain more than 5g/kg/d Day 10
Secondary failure to respond
Failure to gain more than 5g/kg/d for 3 During Phase 2
successive days

Complications
• Anemia
• Diarrhea with DHN or shock
• CHF
• Different kinds of infection that can leads to sepsis and
septic shock
• Hypoglycemia
• Hypothermia
• Absent bowel sounds, gastric dilatation and intestinal
splash ?with abdominal distension
• Long term sequelae
Thank you

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Malnutrition

Focusing on Protein energy

01/13/2024 BHU midwifery 1

01/13/2024 BHU midwifery 2

01/13/2024 BHU midwifery 3

01/13/2024 BHU midwifery 4

• 149 million children under 5 were estimated

01/13/2024 BHU midwifery 5

01/13/2024 BHU midwifery 6

01/13/2024 BHU midwifery 7

• Undernutrition: too little

01/13/2024 BHU midwifery 9

• Micronutrient malnutrition -- arises from

– Vitamin A, Iron & Iodine

– Others: Zinc, vitamin D

01/13/2024 BHU midwifery 10

• Based on thorough physical examination for features of PEM

• Deficiency signs such as hair changes, anemia, xerosis,

01/13/2024 BHU midwifery 11

• Malnutrition is defined as chronic inadequacy in food

• Most deaths in children have some form of malnutrition

• Wasting and edema are due to acute malnutrition .

• Is both medical and social disorder so management

• There are two types

– Primary – nutritional insufficiency

– Secondary – malnutrition following infections, injury,

• The term, protein-energy malnutrition, refers

• The term protein energy malnutrition has been

01/13/2024 BHU midwifery 17

· Lack of food (famine, poverty)

· Inadequate breast feeding

· Wrong concepts about nutrition

· Diarrhoea & malabsorption

· Infections (worms, measles, T.B)

01/13/2024 BHU midwifery 18

01/13/2024 BHU midwifery 19

• The term marasmus is derived from the Greek

01/13/2024 BHU midwifery 20

• Cecilly Williams, a British nurse, had

• PEM can affect all ages but common among infants

01/13/2024 BHU midwifery 22

• Severe growth retardation

• No edema or hair changes

• Alert but miserable

• Diarrhoea & Dehydration

01/13/2024 BHU midwifery 24

01/13/2024 BHU midwifery 26

• soft, pitting, painless edema, usually in the feet and leg

• Skin lesions – flaky paint dermatosis

• Subcutaneous fat is preserved

• Weight deficit is not as severe as marasmus

• Height may be normal or retarded

• Rounded prominence of the cheeks ("moon-face")

01/13/2024 BHU midwifery 27

• Apathetic and irritable, cry easily, and have an expression of misery

• Protuberant abdomen and peristalsis is slow

• Muscle tone and strength is reduced