Malnutrition in Children 2019

1. Malnutrition
in Children
of Pakistan
Prof. Imran Iqbal
Prof of Paediatrics (2003-2018)
Prof of Pediatrics Emeritus, CHICH
Multan, Pakistan

2. In the name of Allah,
the most gracious, the most merciful.

4. MALNUTRITION
IS A PATHALOGICAL STATE
RESULTING FROM
DEFICIENCY OF
ONE OR MORE
ESSENTIAL NUTRIENTS.

5. Nutritional status
Nutritional status is determined by balance of
Nutritional Intake and
Nutritional Expenditure
NUTRITIONAL INTAKE NUTRITIONAL EXPENDITURE
NUTRITIONAL STATUS

6. Clinical Types of Malnutrition
Previous terminology
• Marasmus
• Kwashiorkor
• Marasmic
Kwashiorkor
New terminology
• Low weight
• Stunting
• Wasting
• MAM (moderate acute
malnutrition)
• SAM (severe acute
malnutrition)

7. Clinical types of Malnutrition
• Underweight child – Weight for age
• Wasting – Weight for Height
• Stunting – Ht for age
• Micronutrient deficiency

11. Malnourished – Weight for age
• Moderate - 2 SD to - 3 SD or 60 - 80%
• Severe < - 3SD or < 60 % Wt for age

12. Stunting – Height for age
• Mild - 1 SD to - 2 SD or 90 – 95 %
• Moderate - 2 SD to -3 SD or 85 - 90%
• Severe < -3 SD or < 85 % Ht for age

13. Wasting - Weight for Height
• Mild - 1 SD to - 2 SD or 80 – 90 %
• Moderate - 2 SD to -3 SD or 70 - 80%
• Severe < -3 SD or < 70 % Wt for Ht

14. SEVERE ACUTE MALNUTRITION

16. Severe Acute Malnutrition (SAM)
(Presence of any of the following)
• Weight for Height < -3 SD (< 70 %)
• MUAC < 11.5 cm
• Edema

17. What is the condition of
Children in Pakistan
Prof Imran Iqbal

18. Statistics for Pakistan
• Under-five mortality rate (2012) = 85
• Infant mortality rate = 62
• Neonatal mortality rate = 49
per 1,000 live births

19. PAKISTAN

20. PAKISTAN

21. Why are the children dying ?

22. Pneumonia - 11%
Diarrhea - 14%
Other - 11%
Injuries - 2%

23. In Pakistan 61% of deaths occur during neonatal period. Main
causes being
Infections – 31%
Preterm – 27%
Asphyxia – 24%
Congenital – 10%
Diarrhea – 3%
Tetanus – 2%
Other – 4%

24. Causes of Death in children < 5
in 2012
• Prematurity 20 %
• Pneumonia 19 %
• Others 18 %
• Asphyxia 13 %
• Diarrhoea 11 %
• Neonatal sepsis 9 %
• Cong anomalies 5 %
• Injuries 5 %
• Measles 1 %

25. Contribution of undernutrition to
under-five mortality by cause, 2000
0%
20%
40%
60%
80%
100%
Diarrhoea Malaria Pneumonia Measles All-cause
Proportion of deaths associated with undernutrition All Deaths
Sources:
• For cause-specific mortality: EIP/WHO.
• For deaths associated with malnutrition: Caulfield LE, Black RE. Malnutrition and the
global burden of disease: underweight and cause-specific mortality.

27. RISK OF DEATH IN A CHILD IN
RELATION TO NUTRITIONAL STATUS
• NORMAL = 1
• MILD MALNUTRITION = 2
• MODERATE MALNUTRITION = 4
• SEVERE MALNUTRITION = 8
0
1
2
3
4
5
6
7
8
Norm Mild Mod Severe
Normal
Mild
Moderate
Severe

28. Health Indicators in Pakistan

29. • Low birth wt =25 – 33 %
• Exclusive Mother Feeding = 25 %
• Mod and Severe Malnutrition = 40 %

30. How Many children are
Malnourished ?

31. PAKISTAN - NNS 2011

32. Malnutrition
in Pakistan
Stunted 41 %
Wasted 14%
Underweight 31%

33. Anemia in children = 62%

34. Iron deficiency in children = 44%

35. Vitamin A deficiency = 53 %

36. Vitamin A deficiency = 53 %
KeratomalaciaBitot spot

37. Zinc deficiency = 39%

38. Vitamin D deficiency = 67%

39. Rickets

40. Iodine deficiency = 30 %

41. Congenital Hypothyroidism

42. What are the
causes of Malnutrition
in children ?

43. Breast Feeding = 63 %

44. Introduction of semisolids = 51 %

45. Inadequate diet = 93 %

46. Current ARI = 22 %

47. Diarrhea in last 2 weeks = 34%

48. Nutritional Status and
Mother Education

49. Micronutrient
Deficiency in
Mothers

50. Micronutrient Deficiency in Mothers
• Anemia = 51 %
• Iron Deficiency = 37 %
• Vitamin A deficiency = 44 %
• Vitamin D deficiency = 68 %
• Zinc deficiency = 47 %

51. Why Malnutrition ?

52. Causes of Malnutrition
• Primary causes – inadequate feeding
• Secondary causes -- diseases
 Repeated infections
 Genetic causes - syndromes
 Chronic diseases – CLD, CKD
 Celiac disease
 Diabetes mellitus
 Metabolic disorders

53. Determinants of Malnutrition
• Poor maternal health
• Lactation failure
• Restriction of food during illness
• Unequal distribution of food
• Unhealthy feeding habits
• Repeated infections
• Overcrowding
• Unhygienic environment
• Poor literacy rate
• Poverty (30% of population lives below poverty line)

54. How malnutrition occours in the community

55. Nutrition Causal Framework
Adapted from Unicef
Outcome Under-Nutrition
Immediate
Causes
Inadequate
Dietary Intake
Disease
Underlying
Health /
Nutrition
Causes
Inadequate
Care for Mothers
and Children
Insufficient
Access to Food
Lack of health services
unhealthy environment

56. The Impact of Malnutrition
Malnutrition-Infection Cycle
Inadequate dietary
intake
Weight loss
Growth faltering
Lowered immunity
Mucosal damage
Disease
Appetite loss
Nutrient loss
Mal-absorption
Altered metabolism

57. MALNUTRITION and INFECTION
- Immunoglobulins ↓
- T-CELL FUNCTION ↓
- POLYs FUNCTION ↓
- Complement levels ↓
- Transferrin levels ↓
- Macrophage function ↓
- Intestinal commensel flora-altered
↓
INFECTIONS

58. INDEQUATE DIET /DISEASE CYCLE
INFECTIONS
LOW
IMMUNITY
MALNUTRITION
INADEQUATE
DIETARY
INTAKE

59. Main cause of Malnutrition
LOW INTAKE (underfeeding)
+
RECURRENT INFECTIONS

60. Pathophysiology

61. Reductive adaptation
• Smaller size
• Thinness
• Smaller organs
• Reduced immunity

62. Physiological Effects of
Malnutrition
• Cardiovascular
• GI
• GU
• Immune
• Liver
• Endocrine
• Cellular function
• Circulatory/Temperature regulation
• Skin, muscles, glands

63. Cardiovascular System
Effects:
• ↓ cardiac output and stroke volume
• ↓ blood pressure
• ↓ renal perfusion
Concerns:
• An increase in blood volume can produce acute heart
failure
• A further decrease in blood volume will compromise
tissue perfusion
Management:
• If dehydrated, give ReSoMal or F-75
• Do not give IV fluids unless child is in shock
• If blood transfusion is necessary, restrict to 10 ml/kg
and give a diuretic

64. Gastrointestinal System
Effects:
• ↓ production of gastric acid
• ↓ intestinal motility
• ↓ production of digestive enzymes secondary
to pancreatic atrophy
• ↓ secretion of digestive enzymes secondary to
small intestinal mucosa atrophy
• ↓ absorption of nutrients when large amounts
of food ingested
Management:
• Give small, frequent feeds

65. Genitourinary System
Effects:
• ↓ glomerular filtration
• ↓ ability for renal excretion of acid or water load
• ↓ sodium excretion
• ↓ urinary phosphate output
• ↑ incidence of UTI
Concerns:
• A large protein load may not be well tolerated by the
kidneys
• Further protein deprivation will lead to continued
tissue breakdown
Management:
• Caloric intake should be targeted at 80-100 kcal/kg/day
• Restrict sodium intake

66. Immune System
Effects:
• ↓ cell-mediated immunity
• ↓ secretion of IgA
• ↓ levels of complement components
• ↓ efficacy of phagocytes
Concerns:
• Typical signs of infection (↑ WBC count, fever) are
often absent
• Hypoglycemia and hypothermia are signs of severe
infection
Management:
• Treat all inpatients with broad-spectrum antibiotics
• Protect against infection

67. Liver
Effects:
• ↓ synthesis of all proteins
• ↓ gluconeogenesis
Concerns:
• Risk of hypoglycemia is high, particularly with
infection
Management:
• Protein intake should be 1-2 g/kg/day
• Ensure sufficient carbohydrate intake
• Do not give iron supplements

68. Endocrine System
Effects:
• ↓ insulin levels, leading to glucose intolerance
• ↓ levels of IGF-1
• ↑ levels of growth hormone
• ↑ levels of cortisol
Management:
• Do not give steroids

69. Cellular Function
Effects:
• ↓ synthesis of proteins
• ↓ activity of sodium pump
• ↑ permeability of cell membranes
Concerns:
• This leads to an increase in intracellular sodium and a
decrease in intracellular potassium and magnesium
Management:
• Restrict sodium intake
• Give potassium and magnesium to all children

70. Circulatory System and
Temperature Regulation
Effects:
• Heat generation as well as heat loss are impaired
• ↓ energy expenditure and basic metabolic rate
Concerns:
• Child becomes hypothermic in cold environment and
hyperthermic in hot environment
Management:
• Keep child dry and warm
• Room temperature should be at 25-30 °C
• If child has fever, cool with tepid water

71. Skin, Muscles, Glands
Effects:
• Skin and subcutaneous fat are atrophied
• Atrophy of sweat, tear, and salivary glands
• Respiratory muscles are fatigued easily
Concerns:
• Typical signs of dehydration (sunken eyes, abdominal
skin pinch) are unreliable due to the loss of
subcutaneous fat.
• No of stools, vomits, thirst, pulse, urine output can be
used
Management:
• Rehydrate with ReSoMal when necessary

72. Management of Malnutrition

73. Management of Malnutrition
• Adequate calories
• Micronutrients
• Growth monitoring
• Follow-up

74. PRINCIPLES of Management
Assessment
- Severity and type of malnutrition
- Any complications
- Associated deficiencies
- Epidemiological factors
Hospital treatment
- Severe and complicated malnutrition
Home treatment
- Severe malnutrition--uncomplicated cases
- Moderate malnutrition

75. Community-based Management of Acute Malnutrition (CMAM)
• Inpatient care or Stabilization Centre
(SC) to treat severe acute malnutrition
with
• Medical complications
• Anorexia
• Severe edema
• Severe wasting and edema

76. Time frame for the management of
a child with severe malnutrition
Stabilization Rehabilitation
Days 1-2 Days 3-7 Weeks 2-6
1. Hypoglycaemia
2. Hypothermia
3. Dehydration
4. Electrolytes
5. Infection
6. Micronutrients no iron with iron
7. Initiate feeding
8. Catch up growth
9. Sensory stimulation
10. Prepare for follow-up
Source: WHO

77. ReSoMal
(Rehydration Solution for Malnutrition)
• Sodium Chloride 1.75 gm
• Sodium Citrate 1.45 gm
• Potassium Chloride 2.54 gm
• Potassium Citrate 0.65 gm
• Magnesium Chloride 0.61 gm
• Zinc Acetate 0.0656 gm
• Copper Sulphate 0.0112 gm
• Glucose 10 gm
• Sucrose 25 gm

78. Recipe for F-75 and F-100
Alternatives Ingredient Amount for F-75 Amount for F-100
Dried whole Milk Dried whole milk
sugar
vegetable oil Mineral
mix* water to
make 1000ml
35 g
100 g
20 g
20 ml
1000 ml**
110 g
50 g
30 g
20 ml
1000 ml**
Fresh cow’s Milk Fresh Cow’s milk, or
full cream (whole)
long life milk
sugar
vegetable oil Mineral
mix* water to
make 1000 ml
300 ml
100 g
20 g
20 ml
1000 ml**
880 ml
75 g
20 g
20 ml
1000 ml**

79. RECOVERY
• WEIGHT GAIN should be 10 gm / kg /
day
• Child is considered to be recovered
when 90 % of expected weight for
length has been achieved

81. Hifsa’s journey from malnutrition to health

82. Prevention
of
Malnutrition
Prof Imran Iqbal

83. PREVENTION is
BETTER than CURE

84. Main cause of Malnutrition
LOW INTAKE (underfeeding)
+
RECURRENT INFECTIONS

85. FEEDING PRACTICES
LEADING TO MALNUTRITION
1. BOTTLE FEEDING
- DILUTED MILK
- UNHYGENIC PREPARATION
2. DELAYED WEANING
- INADEQUATE CALORIES
- IRON DEFICIENCY
3. FOOD RESTRICTIONS
- IN A NORMAL CHILD
- DURING DISEASE

86. PREVENTION OF
MALNUTRITION
1. Nutrition education
2. Adequate feeding and diet
3. Growth monitoring
4. Protection against
infections

87. Nutrition education
• Health care providers
• Parents
• Caregivers

88. Adequate feeding and diet
• Breast feeding for 2 Yrs.
• Weaning at 4 months
• Adequate diet
• Feeding during illness

89. During an illness
Prevent malnutrition by:
• Frequent small feeds
• Extra food after the child recovers

91. Strategies to prevent
Infections
• Vaccination
• Handwashing
• Avoid
overcrowding
• Unpolluted air
• Breastfeeding
• Nutrition
• Micronutrients
• Safe water
• Clean food

93. 31% of all child deaths can be prevented
through nutrition related interventions
Intervention Deaths (x 103) % deaths
Oral Rehydration Therapy* 1477 15
Breastfeeding 1301 13
Zinc (prophylaxis &
treatment*)
810 9
Insecticide-treated bednets 691 7
Complementary feeding 587 6
Antibiotics for sepsis* 583 6
Antibiotics for pneumonia* 577 6
Clean delivery 411 4
Vitamin A 233 3

94. What can I do ?
Give at least 1 - 5
Preventive Health care
message to
Parents of each child whom
I see in my
OPD, Ward, Clinic

95. ?

96. Thankyou