Malnutrition ;
It is a primary cause of morbidity and mortality in developing countries.
Etiology
;
1
( unavailability of food or inadequate food supply ( faddism )
2 ) bad cultural food practice such as use of food with low protein and
calorie as weaning food.
3 ) early displacement of infant from breast feeding ( due often to belief
that infants should not be nursed if the mother is pregnant)
4 ) failure to initiate or early cessation of breast feeding
5 ) malabsorption state like chronic diarrhea and chronic parasitic
infestation.
6 ) abnormal loss of protein ; such as nephritis and burn.
7 ) failure of protein synthesis as in chronic liver disease
Classification
;
1) according to percentile ( on the growth chart)
a) below the 3
rd
centile = 2 SD below the mean
b) below the 10
th
centile
c) below the 25
th
centile
2) Z score ; by using the normal distribution curve of the population (
standard deviation )
3) international classification ; which is the most commonly used;
a) marasmus
; below 60% of the median wt for his age without edema
b) kwashiorkor
; below 80% and above 60% of the median wt with
oedema
c) marasmic kwashiorkor; below 60% of the median wt with oedema.
d) under weight
; below 80% and above 60% of the median wt without
edema.
Marasmus ( infantile atrophy(
It is due to inadequate caloric intake, common below 1 y. of life due to
failure of breast feeding, it is also common in area with insufficient food
(faddism), inadequate knowledge of feeding technique or poor hygiene
Clinical features
;
1) initially there is failure to gain wt, then there is loss of wt.
2) skin become wrinkled and loose as subcutaneous fat disappears
3) as fat is lost from the sucking pads of the cheek. The infant face give an
old appearance (wizen face(
4) generalized muscle wasting; this is the most characteristic sign of
marasmus ,the Infant looks very thin, his legs looks like sticks, muscle
wasting most obvious at the buttocks, then deltoids, arms and intercostals
muscles
5 ) the abdomen is distended because of abdominal muscle weakness
6) hypotonia because of muscle wasting
7 ) the temperature may be subnormal and the pulse is low.
8 ) infant 1
st
is fretful but later become listless and the appetite is
diminished
Kwashiorkor (Protein malnutrition)
Because the children are growing they must consume enough nitrogenous
food to maintain a positive nitrogen balance ,where is adult need only
maintain nitrogen equilibrium
Kwashiorkor is a clinical syndrome that result from severe deficiency of
protein and an inadequate caloric intake .Either from lack of protein intake
or excessive loss, or increase metabolic rate caused by infection,
kwashiorkor mean deposed child that is the child no longer suckled i.e
Weaned from breast feeding so it may become evident from early infancy
to about 5 y. of age
Clinical manifestation
;
1 ) early clinical features include lethargy, apathy or irritability
2 ) oedema which is the main sign of kwashiorkor which is noted 1
st
on the
legs then on the arm and face as the child condition is worse
3 ) moderately low wt not as severe as marasmus ,it mostly below 3
rd
centile
4 ) hypotonia due to muscle wasting ; some time patient unable to walk and
the abdomen is distended because of muscle wasting .
5 ) anorexia ; more severe than marasmus ,marasmus some time eagerly
6 ) dermatitis is common; darkening of the skin appear in irritated area but
not in those exposed to sun light, converse to that in pellagra (rough skin =
niacin deficiency)
7 ) the hair is often sparse and thin and losses it`s elasticity.
8) liver is enlarged due to fatty infiltration, due to internal organ oedema or
due to heart failure which occur as a result of severe anemia or deficiency
of trace element like selenium
9
) increased susceptibility to infection and parasite infestation.
Laboratory finding
;
1 -
decreased serum albumin which is the most characteristic finding
2 -
ketonuria is common in the early stage and disappear in the later stage.
3 -biood glucose is low
4 -anemia may be normocytic ,microcytic or macrocytic
Complication
;
1 -decreased immunity and increased susceptibility to infection like u.t.i ,.
pneumonia ,otitis media and
T.B
2 -diarrhea
; diarrhea lead to malnutrition and malnutrition lead to diarrhea
so it worse the condition
and it is vicious circle ,the diarrhea may be due to
infection (whether viral, bacterial or parasitic) or due to lactose intolerance
or bacterial over growth
3 -hypoglycemia
; which is dangerous as it lead to brain damage and death
4 -
dehydration and acid base disturbance
5 -hypothermia due to one or more of the fallowing factors
;
a) hypoglycemia; lack of energy source
b)when room temperature is low
c)during infection because the body need extra energy.
6 -anemia; due to lack of iron, foliate and copper
7 -other micronutrient and vitamin deficiency; lead to eye complication like
xerosis ,keratomalecia and blindness .Rickets and gum hypertrophy
8 -
long term complication; mental and physical retardation may be
permanent.
9 -
heart failure due to aneamia ,cardiac muscle change or selenium
deficiency.
Management of malnutrition
;
The aim of treatment
;
1) recover from any infection and complication
2 ) regain wt so that wt for ht return to normal range
3) grow at healthy rate
Assessment of patients
;
History and physical examination
;
nutritional history, history
of diarrhea and vomiting. Symptoms and signs of infections
Look for signs of malnutrition; wasting of muscle and edema ,
Look for signs of heart failure and when there is heart failure
look for the cause (anemia, fluid over loud, thiamin
deficiency, or selenium deficiency(
Look for sign of anemia (pallor); Fe ,foliate ,vit .E deficiency
or copper deficiency could be the causes.
Look for sign of micro nutrient deficiency;
a) when eye affected; can be caused by vit .A, zinc ,vit .E
deficiency.
b) dermatitis caused by
; vit .A, B2, B6, biotin, niacin, zinc, or
fatty acid deficiency.
C) angylo stomatitis
; caused by iron, B2, or niacin
deficiency.
D) glossitis
; B6, B2, B12, biotin, iron, foliate or niacin
deficiency.
E ) cheilosis
; B6 or B2 deficiency.
Do investigation
;
Like urinalysis ,c.B.p .and blood film (to show microcytic ,
macrocytic or normocytic anemia) also do infection screen ,
blood urea, s. electrolyte and bl .Sugar.
Treatment
;
a) measure to prevent and treat life threatening condition
like dehydration, renal failure, shock, severe anemia ,
hypothermia, hypoglycemia, eye sign and micro nutrient
deficiency.
b) treat infection ; effective antibiotic like penicillin for 5-10
days or according to the result of culture
c) feeding;
when dehydration is corrected, oral feeding started with
frequent small feeds of diluted milk, the strength and volume
are gradually increase and frequency decreased over the
next 5-6 days i.e. we start with amount of 125ml/kg/day or in
term of calorie 50 kcal/kg to reach at the end of 1
st
week to
150 ml/kg/day or 200-250 kcal/kg/day. In the recovery
period high energy food made with milk, oil, sugar are
needed .
when high calorie and high protein are given too early and
too rapidly, the liver become enlarged and the abdomen
become distended markedly and lead to diarrhea and
vomiting and the child improve more slowly .Vegetable fat is
absorbed better than cow`s milk fat ,vit .And minerals
especially vit .A, potassium and magnesium sulfate 0.2 ml/kg
for 3 days. Iron, folic acid and vit .B group should be given.
Causes of failure to response to treatment
;
1 -
feeding problem.
2 -
missed associated condition like u.t.i,T.B
3 -
psychological causes like emotional deprivation and if we
give him attention and affection he start to eat and increase
weight.
Treatment of mental and psychological impairment
;
The infant should be given love and affection by parent and
attending staff. He should be mentally stimulated by uses of
games, toys and book appropriate to age and social
background
.