Malnutrition

Introduction

Malnutrition occurs when there is a deficiency in intake of essential nutrients (i.e. proteins, carbohydrates, fats, vitamins and minerals).
It is most commonly seen in children less than five years, particularly after weaning.
Malnutrition reduces the individual’s ability to fight disease and infection thereby increasing the likelihood of the patient presenting with diarrhoea, vomiting, fever, worm infestation, pneumonia, tuberculosis, otitis media, urinary tract infection etc.
In adults, malnutrition frequently occurs in association with chronic alcoholism.
Protein energy malnutrition (PEM), when severe, presents in different forms such as marasmus, kwashiorkor or marasmic-kwashiokor.
Birth-spacing, through family planning, as well as exclusive breast feeding for up to 6 months, followed by introduction of a weaning diet at 6 months and continuation with complimentary foods for up to 2 years, may be helpful measures in preventing malnutrition in young children.
Encouraging a balanced diet for the family, including pregnant and lactating women, and nutrition education in schools and villages may help reduce the prevalence of malnutrition in the community.

Causes of malnutrition

The following are established known causes of malnutrition:

  1. Poverty
  2. Inadequate quality and/or quantity of food intake
  3. Social neglect
  4. Repeated or chronic infections
  5. Repeated diarhoeal illness
  6. Worm infestations
  7. HIV, pulmonary tuberculosis, measles, pertussis
  8. Chronic illness and cancers
  9. Alcoholism (adults)

Symptoms of malnutrition

The symptoms of malnutrition are:

  1. Poor weight gain
  2. Weight loss (drop or flattening in weight on the child health record)
  3. Body swelling (kwashiorkor)
  4. Child plays less because of lack of energy
  5. Disinterest in food and surroundings

Signs of malnutrition

1. Marasmus

  • Thin (reduced muscle bulk)
  • Prominent bones
  • Hanging skin folds especially over the buttocks
  • Unusually alert Looks like an old man

2. Kwashiorkor

  • Thin and wasted arms
  • Puffy face and legs due to oedema
  • Brownish or reddish hair
  • Flaky skin rash especially on the legs
  • Sores on the oedematous parts of the body in severe cases
  • Miserable and disinterested appearance
  • Disinterest in food
  • Anthropometric measurements

3. Moderate Acute Malnutrition

  • Mid Upper Arm Circumference: 11.5 – < 12.5 cm
  • Weight for Age: <-2 Z-Score but > -3 Z Score
  • Weight for Height: <-2 Z-Score but > -3 Z Score

4. Severe Acute Malnutrition

  • Mid Upper Arm Circumference: < 11.5 cm (Age 6-59 months)
  • Weight for Age:<-3 Z-Score:
  • Weight for Height: <-3 Z – Score

Investigations

  • FBC
  • Urea and electrolytes
  • Serum albumin
  • Urine culture and sensitivity
  • Blood culture and sensitivity
  • Chest X-ray HIV testing
  • Gastric lavage for acid fast bacilli
  • Screen for common infections such as tuberculosis, pneumonia, urinary tract infections, etc.

Treatment for malnutrition

Objectives

  1. To identify and treat associated infections and complications
  2. To correct fluid and electrolyte imbalance and other complications
  3. To correct the nutritional deficiency including Vitamin A
  4. To prevent recurrence by educating caregivers
  5. To adequately manage chronic illnesses

Non-pharmacological treatment

Nutritional rehabilitation
Out-patient Care

  • Malnourished children who have appetite, and do not have any overt medical condition, which requires admission, should be managed as outpatients with Ready-to-Use Therapeutic Food (RUTF)

In-patient Care

  • Admit all severely malnourished children who have medical conditions requiring inpatient care

Stabilisation Phase

  • Frequent feeding with F75
  • Introduce Ready-To-Use Therapeutic Food – RUTF
  • Progressively return to acceptable balanced family meals
  • Participation of parents and caregivers in nutrition education

Pharmacological treatment

A. Vitamin A supplementation (children)

Evidence Rating: [A]
Vitamin A, oral,
Children

  • > 1 year; 200,000 units daily for 2 days
  • 6-11 months; 100,000 units daily for 2 days
  • < 6 months; 50,000 units daily for 2 days

Note

Vitamin A supplementation should be given to replace body stores, EXCEPT if the child is on RUTF made according to WHO specifications, which already contains adequate vitamin A.

B. Treatment of underlying infections (children)

Inpatients 
Evidence Rating: [B]
Cefuroxime, IV, 20 mg/kg 8 hourly for 48-72 hours

Then

Cefuroxime, oral,

  • 3 months-12 years; 15 mg/kg 12 hourly for 5-7 days

Outpatients
Evidence Rating: [B]
Amoxicillin, oral,

  • 5-18 years; 500 mg 8 hourly for 10 days
  • 1-5 years; 250 mg 8 hourly for 10 days
  • 1 month-1 year; 125 mg 8 hourly for 10 days

C. Immunization (children)

(See ‘Immunisation‘)

D. Treatment of worm infestations

(See ‘Worm Infestations’)

Referral Criteria

Refer to appropriate specialist for management of the underlying cause.
Also refer to Reproductive and Child Health (RCH) unit for family planning services and Social welfare department.