MALNUTRITION

dr. Purwoadi Sujatno, SpPD-FINASIM, MPH

 Malnutri?on
World Health Organiza?on deni?on:

The term is used to refer to a number of diseases, each
with a specic cause related to one or more
nutrients (for example, protein, iodine or iron) and
each characterized by cellular imbalance between
the supply of nutrients and energy on the one hand,
and the body's demand for them to ensure growth,
maintenance, and specic func>ons, on the other.

 WHAT IS MALNUTRITION?
Malnutrition is:

poor nutrition due to an insufficient, poorly

balanced diet, faulty digestion or poor utilization
of foods. (This can result in the inability to
absorb foods.)

Malnutrition is not only insufficient intake of

nutrients. It can occur when an individual is
getting excessive nutrients as well.
 Macro vs micro nutrients
Macro-nutrients
Protein (amino acids)
Energy (carbohydrates)
Fat (faQy acids)
Micro-nutrients
Water soluble vitamins
Fat soluble vitamins
Minerals
 Macro-nutrients
Energy
Necessary for all bodily func?on
Protein
Necessary for structural development (muscle and
bone)
Fat
Necessary for cell membrane and skin cell
development

 Thiamin B1
Water s oluble vitamins
nervous system func?on, enzyma?c energy release of carbohydrates
Riboavin B2
Par?cipants in enzyma?c energy release of carbs, fat & protein
Niacin
Par?cipates in enzyma?c energy release of energy nutrients
Folate
Red blood cell forma?on, new cell division
Vitamin B12 (Cobalamin)
Red blood cell forma?on, nervous system maintainance
Pantothenic Acid
BioBn (Vitamin H, CoEnzyme R)
Vitamin B6 (Pyridoxine)
Vitamin C
 Vitamin A
Fat soluble vitamins
Essen?al to vision, fetal development, immune response
Found in dairy products, sh liver oils; as B-carotene found in many
plants (e.g. carrots, mango)
Vitamin D
Bone forma?on, calcium metabolism and absorp?on
Found in sunlight, egg yolk, dairy products and sh liver oil
Vitamin E
Cell membrane construc?on and maintenance
In fats and oils, green leafy vegetables, poultry, sh
Vitamin K
Blood cloYng, protein synthesis
In green leafy vegetables, liver, cabbage
 Minerals
Major Bone Minerals Trace Minerals

Calcium (bones) Iodine (thyroid func?on)
Phosphorus (DNA) Iron (hemoglobin)
Magnesium (bones) Zinc (enzyme, hormone)
Sodium (nerve impulse) Copper (abs. of iron)
Chloride (uid balance) Flouride (bone & teeth)
Potassium (prot. syn) Chromium (energy rel.)
Sulfur (some a.a.s) Molybdenum (enzymes)
Manganese (enzymes)
Selenium (an?oxidant)
Cobalt (part of B12)
WHAT CAUSES MALNUTRITION?

Deficient nutrients in a person's diet

Malnutrition also occurs when there is an
imbalance of energy and protein in an
individuals diet. The body may become
unable to absorb the nutrients it requires
to function properly.
*For example, if a child is suffering from energy
and protein malnutrition, they will most likely
have deficiencies in iron, calcium, and other
vitamins and minerals.
 Causes of malnutri?on
Child malnutrition
death and disability

Inadequate Disease
Diet

Poor water/ sanitation Inadequate

Insufficient
inadequate health maternal and
access to food
services child care
 Causes/correlates
Malnutri?on rarely exists in isola?on, and many
other factors contribute to its detrimental impact;
Poor physical resources, and overcrowded homes
Poor sanita?on and water supply
Low income
Parents with liQle educa?on
Minimal interac?on/s?mula?on in the home
 Higher Impaired
mortality rate mental
development
Reduced Increased risk of
capacity adult chronic disease
Baby
to care
Low Birth Untimely/inadequate
Elderly for baby
Weight weaning
Malnourished
Frequent
Infections
Inadequate Inadequate
catch up food, health
Inadequate
Inadequate growth & care
fetal Child
food, nutrition
health Stunted
& care Reduced
mental
Woman capacity
Malnourished
Adolescent
Start here Pregnancy Inadequate
Stunted
Low Weight food, health
Gain & care

Reduced
Inadequate mental
Higher capacity
food, health
maternal
& care
mortality
 Types of malnutri?on
Severe Protein-Energy Malnutri?on
Kwashiorkor (low protein)
Marasmus (low calories)
Mild/moderate undernutri?on
Stun?ng
Underweight
Was?ng
Micro-nutrient deciency
Iodine
Iron
Vitamin A
Vitamin D
 SEVERE MALNUTRITION
WHO denes severe malnutri?on as the presence of
Oedema of both feet, or
Severe was?ng (<70% weight for height or
Clinical signs of severe malnutri?on.

Children with severe malnutri?on are at risk of several

life threatening problems like hypoglycaemia,
hypothermia, serious infec?on and severe electrolyte
imbalance.
Because of this vulnerability, they need careful
assessment, special treatment and management, with
regular feeding and monitoring
 Severe Malnutri?on: Consequences
Mental development
Lower IQ levels
Poorer school performance
Behaviors of recovered severely malnourished
children
shy, isolated, withdrawn
decreased aQen?on span
immature, emo?onally unstable
fewer peer rela?onships/reduced social skills
 Diagnosis
Key diagnos?c features are:
Weight for length(or height) <70% (Marasmus)
Oedema of both feet (kwashiorkor or marasmic-
kwashiorkor)
 Kwashiorkor (low protein)
Decreased muscle mass (failure to gain weight and of linear
growth)
Swollen belly (edema and lipid build-up around the liver)
Changes in skin pigment (pellagra); may lose pigment where
the skin has peeled away (desquamated) and the skin may
darken where it has been irritated or trauma?zed
Hair lightens and thins, or becomes reddish and briQle.
Increased infecBons and increased severity of normally mild
infec?on, diarrhea
Apathy, lethargy, irritability

Death does not occur from actual starvaBon but from
secondary infecBon
 Kwashiorkor mechanisms
Occurs in reac?on to emergency situa?ons
Kwashiorkor more likely in areas where
cassava, yam, plantain, rice and maize are
staples, not wheat
Increased carbohydrate intake with decreased
protein intake eventually leads to edema
(water) and faQy liver
 Marasmus
Decit in calories marasmus comes from
Greek origin of word to waste
Gross weight loss
Hyper-alert and ravenously hungry
Children have no subcutaneous fat or muscle

eventually starve to death (immediate cause

ohen is pneumonia)
 Marasmus mechanism
Energy intake is insucient for bodys requirements
body must draw on own stores
Liver glycogen exhausted in a few hours skeletal
muscle protein used via gluconeogenesis to maintain
adequate plasma glucose
When near starva?on is prolonged, faQy acids are
incompletely oxidized to ketone bodies, which can
be used by brain and other organs for energy
High cor?sol and growth hormone levels

Mechanism is same as anorexia

 Mild/moderate undernutri?on
STUNTING: Height for age
height compared to a reference popula?on of the
same age.
= represents long term growth retarda?on

UNDERWEIGHT: Weight for age

weight compared to age in a reference popula?on

WASTING: Weight for height

weight compared to a reference popula?on of the
same height.

 Micro-nutrient deciency
Iodine Deciency
Iron Deciency
Vitamin A
Vitamin D
 General Management
General treatment of severe malnutri?on involves two
phases:
An ini?al stabiliza?on phase
A longer rehabilita?on phase
Ini?al stabiliza?on phase:
addresses management of complica?ons, micronutrient
deciency and ini?a?on of the catch up growth.
Rehabilita?on phase:
strengthens what has been achieved in the ini?al phase
with the catch up growth, electrolyte balance and sensory
s?mula?on
 Management of complica?ons
Hypoglycaemia:
All severely malnourished are at risk of hypoglycaemia.
Where blood glucose results can be obtained quickly (eg with Dextros?x),
this should be measured quickly.
Hypoglycaemia is present when blood glucose is <3 mmol/l (<54 mg/dl)
Give 50mls of 10% glucose.
Give 2 hourly feeds, day and night at least for the rst day.
If the child is unconscious. Treat with IV glucose.

Hypothermia(<35C):
Is associated with increased mortality in severely malnourished children.
Feeding the child, ensuring adequate clothing and appropriate an?bio?cs
forms the management.
 Management of complica?ons
Electrolyte imbalance:
Extra potassium should be added to the feeds during their
prepara?on.
All severely malnourished children have deciencies of
potassium and magnesium which may take 2 weeks or more to
correct.

Infec?on:
In severe malnutri?on, the usual signs of infec?on such as fever
are ohen absent, yet mul?ple infec?ons are common.
Therefore, assume all malnourished children have an infection
on their arrival at the hospital and treat with broad spectrum
antibiotics straight away
 Eye problems
If the child has eye signs of vitamin A deciency
(dry conjunc?va or cornea, corneal ulcera?on,
keratomalacia):
Give vitamin A orally
If the eyes shows signs of inamma?on or
ulcera?on
Ins?ll Chloramphenicol or tetracycline eye drops,
Cover with saline-soaked eye pads
 SENSORY STIMULATION
AND EMOTIONAL SUPPORT
In severe malnutri?on there is delayed mental and
behavioral development. Malnourished child needs
interac?on with other children and adults during
rehabilita?on. Therefore provide:
Tender loving care
A cheerful s?mula?ng environment
Structured play therapy
Physical ac?vity as soon as the child is well
enough
Maternal involvement as much as possible
 Micronutrient deciencies
All severely malnourished children have vitamin and
mineral deciencies. Although anaemia is not
common, do not give iron ini?ally but wait un?l the
child has good appe?te and starts gaining
weight(usually in the 2nd week), because iron can make
the infec?on worse.
Give daily (for atleast 2 weeks)
Mul?vitamin supplement
Folic acid (5mg on day 1, then 1mg/day)
Zinc (2mg Zn/kg/day)
Copper (0.3mg Cu/kg/day)
Once gaining weight, ferrous sulphate (3mgFe/kg/day)