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Questions and Answers
Which nutrient is primarily responsible for the transport of nutrients and waste products in the body?
Which nutrient is primarily responsible for the transport of nutrients and waste products in the body?
Which of the following vitamins is associated with the control of calcium and phosphorus metabolism?
Which of the following vitamins is associated with the control of calcium and phosphorus metabolism?
What is the consequence of iron deficiency in children?
What is the consequence of iron deficiency in children?
Which nutrient is vital for aerobic metabolism and collagen synthesis?
Which nutrient is vital for aerobic metabolism and collagen synthesis?
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What is the role of Vitamin E in the body?
What is the role of Vitamin E in the body?
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Which mineral deficiency leads to hypotonia, apathy, and impaired cardiac function?
Which mineral deficiency leads to hypotonia, apathy, and impaired cardiac function?
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Which of the following is a requirement for protein intake in children?
Which of the following is a requirement for protein intake in children?
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What is one of the important roles of magnesium in the body?
What is one of the important roles of magnesium in the body?
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What is the expected average weight of a child at the age of 5 years?
What is the expected average weight of a child at the age of 5 years?
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At what age should a child's weight typically triple their birth weight?
At what age should a child's weight typically triple their birth weight?
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How much does the average head circumference increase during the first month of life?
How much does the average head circumference increase during the first month of life?
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Which form of malnutrition includes being too thin for height?
Which form of malnutrition includes being too thin for height?
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What percentage of deaths among children under 5 years is linked to undernutrition?
What percentage of deaths among children under 5 years is linked to undernutrition?
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By what age does a child's average height typically reach 40 inches?
By what age does a child's average height typically reach 40 inches?
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What is a global estimate for underweight children under 5 in 2020?
What is a global estimate for underweight children under 5 in 2020?
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What is considered a component of undernutrition?
What is considered a component of undernutrition?
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Study Notes
Malnutrition in Children
- Malnutrition encompasses undernutrition (wasting, stunting, underweight), inadequate vitamins/minerals, overweight, obesity, and diet-related noncommunicable diseases.
- In 2020, globally, 149 million children under 5 were stunted, 45 million wasted, and 38.9 million overweight or obese.
- About 45% of deaths in children under 5 are linked to undernutrition, mainly in low- and middle-income countries.
- Malnutrition is defined as an imbalance between nutrient supply and the body's demand for growth, maintenance, and function.
- Malnutrition includes deficiencies, excesses, or imbalances in energy and/or nutrient intake.
- There are three major malnutrition groups: undernutrition (wasting, stunting, underweight), micronutrient-related malnutrition (deficiencies or excesses), and overweight/obesity/diet-related noncommunicable diseases.
- Weight loss in the first few days after birth is normal (5-10% of birth weight). Children should regain birth weight within 7-10 days.
- An average child doubles their birth weight by 4-5 months and triples it by one year and quadruples by two years.
- Average weight at birth is 3.5 kg, 10 kg at one year, 20 kg at 5 years and 30 kg at 10 years.
- Average length at birth is 20 inches, 30 inches at one year and 40 inches at 4 years.
Objectives
- Define and classify malnutrition.
- Identify risk factors and causes of malnutrition.
- Describe management for PEM.
- Explain complications of malnutrition.
Food Pyramid for Kids
- Emphasizes balanced intake of various food groups.
- Fats, oils and sweets are to be used sparingly.
- Milk, yogurt and cheese (2-3 servings).
- Vegetables (3-5 servings).
- Meat, poultry, fish, eggs, beans and nuts (2-3 servings).
- Fruits (2-4 servings).
- Bread, cereals, rice and pasta (6-11 servings).
Important Biological Roles of Various Nutrients
- Proteins: 45-55g for growth and repair of tissue cells. Plasma proteins and enzymes are crucial.
- Carbohydrates (CHO): 31-35 Kcal/kg Weight. Source for energy.
- Fats: 5% of total calories, structure of cell membranes and nuclei, help absorb fat-soluble vitamins.
- Water: Transports nutrients and waste products, homeostatic function.
Minerals and Trace Elements
- Calcium: Skeletal rigidity, muscle function, and cellular metabolism.
- Potassium: Crucial for muscle function and cardiac function; deficiency leads to hypotonia, apathy and cardiac issues.
- Copper: Involved in aerobic metabolism, iron handling and collagen synthesis.
- Fluoride: Important for dental health.
- Iodine: Essential for thyroid hormone synthesis.
- Iron: Necessary for cellular respiration; deficiency leads to hypochromic microcytic anaemia.
- Magnesium: Crucial for growth, muscle function and neurological function.
- Phosphorus: Vital for bone metabolism and neurological function, and respiratory function.
- Selenium: An antioxidant.
- Zinc: Important for nucleic acid and membrane metabolism; deficiency causes growth retardation and dermatosis.
Vitamins
- Vitamin A: Visual integrity, cell differentiation. Deficiency leads to vision problems.
- Vitamin D: Regulates calcium and phosphorus metabolism; deficiency can lead to rickets.
- Vitamin E: Antioxidant.
- Vitamin K: Crucial for coagulation cascade; deficiencies cause bleeding disorders.
- Vitamin B1: ATP synthesis, cell membrane integrity.
- Vitamin B2: Redox reaction co-factor (important for energy production).
- Vitamin B6: Important in amino acid and lipid metabolism.
- Vitamin B12: Essential for DNA synthesis.
- Vitamin C: Antioxidant and important in collagen synthesis; deficiencies cause scurvy.
- Folate: Essential for DNA synthesis.
Rules of Thumb for Growth
- Weight loss in the first few days is normal.
- Return to birth weight by 7-10 days.
- Triple birth weight by one year.
- Quadruple birth weight by two years.
- Average weights at birth, 1 year, 5 years and 10 years.
- Average Length at birth, 1 year and 4 years.
- Average head circumference at birth and in first months, increase by 1 cm/month for the first 3 months. 0.5 cm/month for the last 6 months of infancy, further increase happens at the age of 12.
Definition of Malnutrition
- Inappropriate intake of essential nutrients for normal body growth and development.
- Defined by a deficiency (relative or absolute) of one or more essential nutrients, significant enough to cause illness.
Classifications of PEM
- Many classifications exist, varying by weight-for-age, height-for-age, weight-for-height, the presence of oedema and body mass index.
- WHO, Welcomme, Gomez, Waterloo Classification.
Marasmus
- Severe PEM characterized by severe wasting and loss of subcutaneous fat, without oedema.
- May occur at any age but most common in early infancy.
- Weight less than 80% of expected for age, and absence of oedema.
Kwashiorkor
- Severe PEM specifically associated with protein deficiency during the weaning and post-weaning period.
- Characterized by oedema, often in the lower limbs and face, and some degree of fatty infiltration of liver. Hair changes and skin changes are frequent signs.
Etiology of Marasmus
- Inadequate diet deficient in both protein and calories e.g. Breastfeeding failure, inadequate amount of formula milk, use of contaminated utensils and feeding difficulties.
- Chronic severe infections (TB, UTI).
- Chronich diarrhea and/ or vomiting.
- Malabsorption syndromes.
- Congenital malformations (e.g., pyloric stenosis, congenital heart defects).
- Metabolic disorders (e.g., galactosaemia).
- Endocrinal disease (hyperthyroidism, DM).
- Psychological disturbance (e.g., maternal deprivation syndrome).
- Starvation therapy for prolonged diarrhea.
Etiology of Kwashiorkor
- Dietary inadequacy during weaning and post-weaning, when the diet switches from breast milk or balanced diet to an unbalanced or protein-deficient diet.
- Impaired absorption of proteins (e.g., chronic diarrheal states).
- Abnormal protein loss (e.g., nephrosis, infections, burns).
- Failure of protein synthesis (e.g., chronic liver disease).
- Acute infections (e.g., measles, acute diarrhea).
- Malaria, and severe helminthic infections.
Clinical Manifestations of Marasmus
- Growth failure.
- Loss of subcutaneous fat from limbs, face and buttocks.
- Muscle wasting with stick-like limbs and scaphoid abdomen.
- Other symptoms include: anxiety, irritability, excessive crying, sleeplessness, while anorexia is rare and if present less commonly, Hypothermia, chronic diarrhea with/ without vomiting, Recurrent infections, and deficiencies of Iron, Vit. A & D.
- No oedema, dermatosis and fatty liver infiltration.
Clinical Manifestations of Kwashiorkor
- Edema (initially in feet/legs, then generalized).
- Bulky, pale and waxy cheeks.
- Potentially unusual ascites (abdominal swelling).
- Growth failure with weight being 60 - 80% of expected weight for age.
- The length, head circumference, and bone age show retardation.
- Disturbed muscle-fat ratio characterised by generalized muscle wasting and preservation of some subcutaneous fat.
- Characterized by apathetic, irritable, weak and inactive children who show poor interest in the surrounding and lack interest in play and activities.
Usual Manifestations of Kwashiorkor
- Hair changes: sparse, easily plucked hair with darker or lighter bands (flag sign).
- Gastrointestinal (GIT) manifestations: anorexia (loss of appetite), vomiting, diarrhea (common), infections with intestinal pathogens or parasites.
- Digestion of food and passage of loose stools.
- Malabsorption of fat, CHO, and minerals.
- Disaccharidase deficiency.
- Defect in conjugation of bile salts.
- Malabsorption of lipids.
- Skin changes: dermatosis, perioral dermatitis (skin rash that looks like burns)
- Hyperpigmentation, skin ulcers, and hypopigmentation.
Additional Clinical Findings in Kwashiorkor
- Hepatomegaly or enlarged liver.
- Anemia is a multifactorial problem due to deficiencies in proteins, iron, zinc, copper, folic acid, Vit. A, B1, B12 and/or C.
- Types of anemia seen: hypochromic microcytic (iron deficiency), megaloblastic (folic acid or vitamin B12 deficiency), and dimorphic (combination of the above).
- Aplastic anemia is seen in severe cases due to inhibition of bone marrow.
- Deficiencies of other vitamins, minerals, and trace elements.
- Impaired resistance to infections.
Complications of Malnutrition
- Dehydration and electrolyte imbalance.
- Infections (skin infections, respiratory infections, urinary tract infections, etc.).
- Bleeding disorders (purpura, due to deficiency of vitamin K).
- Hypoglycemia.
- Hypothermia.
- Mental sub-normality.
Causes of Death
- Severe dehydration and electrolyte imbalance.
- Infections, especially bronchopneumonia.
- Hypothermia (low body temperature).
- Severe hypoglycemia. (Low blood sugar)
Management of PEM
- Stabilization (Initial treatment): Stabilize the child (treating immediate life-threatening conditions, correcting deficiencies and deficiencies of vitamins and minerals, treating infections and starting enteral feeding).
- Rehabilitation: Encourage breastfeeding and initiate intensive feeding. Train the mother how to continue care at home. Physical and emotional stimulation for the child is critical.
- Follow-up: Monitor the child and mother; implement nutrition strategies for preventing reoccurrence of malnutrition.
How to manage this child
- Decide if the child needs an in-patient program or an out-patient one.
- If the child is 6-59 months old with SAM (Severe Acute Malnutrition) then conduct an appetite test.
- Follow guidelines on how to give IV fluids
- Children with no apparent signs or complications should administer Cotrimoxazole orally for 5 days.
- Children with complications should administer Ampicillin, amoxicillin, and Gentamicin.
- Correct and treat dehydration.
- Use IV solution (half-strength Darrow's solution with 5% dextrose, Ringer's lactate solution with 5% glucose, 0.45% (half-normal) saline with 5% glucose).
- If there is heart failure give blood transfusion(10 ml/kg).
- If there is liver failure give a single dose of 1 mg Vit. K IV.
- If there is a sign of congestive heart failure, administer a diuretic and slow down the rate of transfusion.
- Introduce high calorie diet.
- Provide a high biological value protein diet (liver, meat, etc.).
- Provide micronutrients (vitamin A (as listed), vit K(10mg injection), multivitamins, potassium (KCl), iron(6 mg/kg/day), and folic acid (5 mg orally for the first few days of treatment).
Criteria for Failure to Respond
- Primary: Failure to gain weight (non-oedematous), failure to reduce oedema, successive weight loss.
- Secondary: Failure of appetite test, weight loss over two consecutive visits, static weight below admission weight.
Growth Charts
- Assess growth (height and weight) using standard charts.
- Identify deviations and monitor trends.
Important Points in Clinical Examinations
- Measure MUAC and head/chest circumference ratio.
- Accurate height and length measurements.
- Examine the patient for signs and symptoms of malnutrition (including any oedema).
Micronutrients
- Folic acid: Glossits, anemia, neural tube defects in fetuses.
- Zinc: Anemia, dwarfism, hepatosplenomegaly, hyperpigmentation and hypogonadism, acrodermatitis enteropathica, decreased immune response and impaired wound healing.
- Vitamin A: Night blindness, xerophthalmia.
- Vitamin K: 10 mg IM injection.
Other Management Issues
- Treat conditions such as severe anaemia (requiring blood transfusions for Hb < 4g/dl or PCV <12%) or congestive heart failure (requiring diuretics and slower transfusion rates).
- Provide micronutrients like vitamin A (dosage based on age). Provide iron, folic acid and electrolytes as required - zinc, copper, selenium and iodine
- Use age-appropriate formulas (e.g., F75, F100, F135) for initial and catch-up periods, considering any lactose intolerance.
Rehabilitation Phase
- Begins when appetite returns.
- Continue feeding (increasing quantities gradually).
- Emotional and physical stimulation.
- Mother training for continued home care.
- Vaccination for the child (if needed).
Signs of Recovery
- Improved psychomotor development (social behavior, mood changes, irritability, smiling, reacting to surroundings).
- Improved appetite.
- Weight gain (marasmic patients) or weight stabilization (kwashiorkor patients as oedema subsides).
- Improvement in hepatomegaly.
Follow-up
- Regular monitoring of the child for growth, well-being and oedema.
- Immunizations.
- Referrals or rehabilitation programs.
Additional Considerations
- Specific dietary formulation, dosage and considerations.
- Criteria for discharge for both child and mother.
- Considerations for and complications from IV rehydration.
- Follow-up after discharge.
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Description
Test your knowledge on malnutrition in children, including its types, statistics, and effects. This quiz covers important aspects such as undernutrition, obesity, and nutrient imbalances that affect children's health globally.
