MALNUTRITION IN
CHILDREN
Dr. Deniz Ertem
Dr. Engin Tutar
OBJECTIVES OF THE LECTURE
□ Definition
□ Classification of malnutrition
□ Etiology and consequences
□ Nutritional assessment
MALNUTRITION
Nutrition is the provision of adequate energy and
nutrients to the cells to enable them perform their
physiological function (i.e. growth, defense, repair etc.)
□Malnutritionis the result of a lack or an excess in
supply of energy + nutrients to the body.
□ Malnutrition is one the most common causes of
death in children under 5 yr of age.
TYPES OF MALNUTRITION
□ Undernutrition
■ Protein-energy malnutrition
■ Micronutrient deficiency
□ Overnutrition
■ Overweight / obesity
■ Health consequences
□ Acute malnutrition
□ Chronic malnutrition
Akutproblemlerde K lo
kron k problemlerde k lo ve Boy Ik len r
T
Bodur
Wasting means that Stunting means that the Underweight
the child is thin: child is short in means that
she/he has lost fat stature: she/he did not she/he weighs
and muscle mass grow in height as less than
he/she should have she/he should
be
A child can be both wasted and stunted
Chronic malnutrition
Wasting means that Stunting means that the Underweight
the child is thin: child is short in means that
she/he has lost fat stature: she/he did not she/he weighs
and muscle mass grow in height as less than
he/she should have she/he should
be
A child can be both wasted and stunted
CLASSIFICATION OF MALNUTRITION
o Acute malnourished child is wasted, which
is characterised by rapid loss of fat & muscle
o Weight for age is low
o Height for age is normal
o Weight for height is low
o Chronic malnutrition develops over time
and results in stunting
o Weight for age is low
o Height for age is low
o Weight for hight is normal
PROTEIN ENERGY MALNUTRITION
□ PEM is associated with poor weight gain,
diminished height and deficit in lean body
mass and adipose tissue
■ Decreased physical activity
■ Mental apathy
■ Psychomotor and mental retardation
□ Severe PEM (depending on the presence or
absence of edema)
■ Marasmus (wasting syndrome)
■ Kwashiorkor
■ Combination of both
MARASMUS (wasting)
□ Most common form, PEM without edema
□ Caused by inadequate intake of all nutrients
particularly energy sources
□ Characterized by wasting of muscle mass
and depletion of fat stores
□ Body utilizes all fat stores before using muscle
proteins as a source of energy
□ Marasmic children are very hungry with gross
muscle wasting (very thin extremities)
MARASMUS (wasting)
FEATURES
□Diminished weight for age
□Severe wasting of muscle & s/c fats
■ Shrunken arms and thighs and buttocks with
redundant skin folds secondary to loss of sc fat tissue
□Apparently large head with staring eyes
□Emaciated and weak
□Irritable, alert
□Bradycardia, hypotension, hypothermia
□Thin, dry skin, sparse hair
Wr nklesaroundgluteal area
β
KWASHIORKOR (PEM with edema)
□ Characterized by marked muscle atrophy
with normal or increased fat tissue and the
presence of generalised edema (anasarca)
□ Inadequate protein and fair energy intake
may contribute to the clinical features
□ Pathogenesis --- not known
□ Considered as a lack of physiological
adaptation to unbalanced deficiency
□ Mortality --- high
KWASHIORKOR (PEM with edema)
CLINICAL FEATURES
□ Normal or nearly normal weight for age
□ Generalized edema
□ Pitting edema in lower extremities,
presacral area and scrotal area
□ Pursed appearence of mouth
□ Dry, atrophic and peeling skin
□ Hyperkeratosis and pigmentation of
skin
□ Hepatomegaly (fatty liver)
□ Distended abdomen, dilated bowel loops (due to edema)
□ Cardiomyopathy
17
Mixed marasmus-kwashiorkor
□ May occur in children with inadequate intake
of all nutrients and triggered by a common
infection / inflammation
■ Chronic wasting is aggravated by acute loss
nutrients during inflammation / infection
□ Usually assoc. with a high morbidity, mortality
FEATURES
□ Anorexia, dermatitis
□ Neurological abnormalities
□ Hepatic steatosis
Zinc
deficiency
Anguler
cheilitis
Copyrights apply
PROTEIN ENERGY MALNUTRITION
□ Primary (inadequate intake of energy and protein)
■ Common in developing countries
■ Poverty, lack of sanitation 🡪 frequent infections,
neglect, uneducated mother
■ PEM Infections
■ Important cause of death in children
□ < 5 yr of age --- 300.000 deaths/yr
□ Secondary (an underlying disease/pathology)
■ Malabsorption syndromes (i.e chr. Giardiasis / celiac disease)
■ Chronic diseases causing loss of appetite hence
inadequate oral food intake and increased energy
demand (catabolic condition)
PEM affects many organ systems
Cardiovascular System Gastrointestinal System
□Gastric acid decreased
□ Cardiac output decreased
□Atrophy of pancreas
□ Stroke volume decreased
□Intestinal atrophy
□ Instable fluid balance
□GIS motility impaired
■ I.V. fluids -- congestive HF
□Absorption impaired
LIVER
Immune SystemATSINAN
□ Hypoalbuminemia
□Cellular
and humoral
□ Hepatic detoxif. impaired immune funtions and
□ Gluconeogenesis reduced complement levels decr.
□ Risk of hypoglycemia □Typical findings of infection
(fever, increase in CRP) 🡪
usually absent
PEM affects many organ systems
Endocrine System Genitourinary System
□Insulin level decreased □ GFR decreased
□ Excreation funct. impaired
□Glucose tolerance low
□ UTI is common
□GH increased
□IGF-1 level decresed
Skin and Glands
Metabolism
□ Skin and subcutaneous
□Decreased by 30% tissues atrophied – loose skin
□Heat balance impaired ■ difficult to assess dehydration
□Endogenous glucose
production is impaired in
kwashiorkor
CONSEQUENCES OF CHRONIC MALNUTRITION
□ Poor weight gain and slow lineer growth
□ Impaired neurological and cognitive development
□ Increased susceptibility to infections
□ Poor wound healing
□ Micronutritent (vitamin, trace element) deficiencies
■ Iron, vitamin D, vitamin A, zinc
CONSEQUENCES OF CHRONIC MALNUTRITION
□ Poor weight gain and slow lineer growth
□ Impaired neurological and cognitive development
□ Increased susceptibility to infections
□ Poor wound healing
□ Micronutritent (vitamin, trace element) deficiencies
■ Iron, vitamin D, vitamin A, zinc
malnourished children showed changes in developing brain
- slowed rate of growth of the brain
- lower brain weight
- thinner cerebral cortex (decreased number of neurons)
- insufficient myelinization
OBESITY IS THE OTHER EXTREME END
OF MALNUTRITION
□ Overnutrition
■ Obesity
■ Atherosclerotic heart disease
■ Hypertension
■ Metabolic syndrome
Obesity
□ ~ 30.3% of adults in Turkey (female 41%, male 20.5%)
□ ~ 8-8.5% of children and adolescents
<5 yr 18% and 6-18 yr --- 14% overweight
Hacettepe Üniv. Sağlık Bilimleri Fak. Beslenme ve Diyetetik Bölümü
Ankara Numune Eğitim ve Araştırma Hast. 2010 yılı Raporu
METHODS FOR
NUTRITIONAL
ASSESSMENT
The purpose of nutritional assessment
□ Identify individuals or population groups at risk
of becoming malnourished
□ Identify individuals or population groups who
are already malnourished
□ Measure the effectiveness of the nutritional
programs & intervention once initiated
Methods of Nutritional Assessment
These are summarized as ABCD
□ Anthropometric methods
□ Biochemical, laboratory methods
□ Clinical methods
□ Dietary evaluation methods
NUTRITIONAL ASSESSMENT
Anthropometric Methods
❑ Anthropometric measurements
❑ body height, weight & head circumference
❑ MAC (musscle mass) and TST (sc fat tissue)
❑ Essential component of clinical examination of infants
and children
❑ Advantages:
■ Objective, reproducible
■ Readings are gradable on standard growth charts
■ Non-expensive & need minimal training
Growth charts GROWTH CHART
are designed
for 1-18 YRS
according to age
and sex
HEIGHT
97th percentile
90th percentile
75th percentile
50th percentile
25th percentile
10th percentile
3rd percentile
WEIGHT
AGE
GROWTH CHART
for 0-36 months
97th percentile
LENGHT 50th percentile
3rd percentile
WEIGHT
97th percentile
measured
values
50th percentile
reflects
current
nutritional • 3rd percentile
status
It is possible to
differentiate between
acute & chronic
changes by using the
same chart and
putting a mark at each
measurement
Methods of Nutritional Assessment
These are summarized as ABCD
□ Anthropometric methods
□ Biochemical, laboratory methods
■ Measurement of serum level proteins with a short half
life (prealbumin, RBP, transferrin)
■ Total lymphocyte count
■ Impaired DHR to antigens (i.e. impaired T cell function)
□ Clinical methods
□ Dietary evaluation methods
Nutritional Assessment
❖ Clinical Evaluation:
• Beneficial in severe PEM
• A comprehensive physical examination in terms of PEM and vitamin
deficiencies
• Findings related to skin, eyes, hair, mouth, and bones are important
• Advantages: Fast and easy, non-invasive
• Limitations: Difficulty in diagnosing early cases, need for experienced
personnel
• Anthropometry
Weight, height, body mass index (BMI), mid-upper arm circumference
(MUAC), triceps skinfold thickness (TST), mid-upper arm muscle area
(MAMA), head circumference (up to 2 years old) measurements.
• Advantage: Objective (use of standard growth curves or SD scores)
• Limitations: Inter-observer variability, issues with the methods and
37
reference standards used, problems such as the use of different
statistical cutoff values.
❖ Laboratory and Imaging
• Hematological: Complete blood count, iron, vitamin levels
• Biochemical: Blood sugar, electrolytes, serum proteins, creatinine,
metabolic tests, urine creatinine, urine creatinine/height index
• Microbiology: Infection markers, bacteriological tests, parasites, etc.
38
❖ Dietary Assessment
• Details of breast milk and complementary feeding,
• 24-hour dietary record/calculation
• Evaluation of foods in terms of protein and caloric content
• Inquiry into eating techniques and behaviors
39
Clinical manifestations of PEM
□ Pallor, fatigue □ Rickets/osteoporosis
□ Glossitis □ Easy fractures
□ Angular cheliosis □ Peripheral neuropathy
□ Skin pigmentation □ Loss of balance
□ Thin and sparse hair □ Diarrhea
□ Spongy, bleeding gums □ Muscle cramps
□ Edema □ Abdominal distention
□ Easy bruisability □ Hepatomegaly
□ Enlarged epiphysis of □ Ascites
long bones
Methods of Nutritional Assessment
These are summarized as ABCD
□ Anthropometric methods
□ Biochemical, laboratory methods
□ Clinical methods
□ Dietary evaluation methods
■ List of nutrients for 3 dys, calculation of daily caloric intake
CLASSIFICATION OF MALNUTRITION
GOMEZ classification:
o Parameter: weight for age
o Reference standard (50th percentile) WHO charts
actual weight of the child
o Weight / Age = --------------------------------- - - - - - - - X 100
wt of a normal child at the same age
■ >90-110% = Normal
■ 75-89% = 1st degree, Mild
■ 60-74% = 2nd degree, Moderate
■ <60% = 3rd degree, Severe
GOMEZ CLASSIFICATION
13 years old male patient
Actual weight =35 kg (3-10 p.)
Nutritional status:
W/A -- 35/45 x 100 = 77.7%
MILD DEGREE MALNUTRITION
50th percentile = NORMAL
45 kg Ideal weight (50 p.)= 45 kg
Nutritional assessment
according to the Gomez does
not take the height of the
child into consideration
CLASSIFICATION OF MALNUTRITION
WATERLOW classification --- classify PEM in children
based on wasting and degree of stunting.
actual weight of the child
oExp.Weight / Height = --------------------------- x 100
(WASTING) wt of a normal child at the same Ht
actual height of the child
oExp.Height / Age = -------------------------------- x 100
(STUNTING) ht of a normal child at same age
Malnutrition Severity
Normal Mild Moderate Severe
Height for Age (perc) > 95 90-95 85-90 < 85
Weight for Height (perc) > 90 80-90 70-80 < 70
Table. Gomez Classification (1956) Table. Waterlow Classification (1972)
Malnütris
yon
Normal Hafif Orta Ağır
Yaşa Göre Boy > 95 90-95 85-90 < 85
(pers)
Boya Göre > 90 80-90 70-80 < 70
Ağırlık (pers)
Table. Wellcome Classification
Yaşa göre
ağırlık (YGA) Ödem var Ödem yok
%80-60 Kwashiorkor Beslenme
yetersizliği
<60 Marasmik Marasmus
kwashiorkor
45
WATERLOW CLASSIFICATION
What if the height of this
patient is
(normal height for 13 yrs of boy is 155
cm = 50p.)
- 165 cm (75-90p.)
13 years old male patient
whose weight =35 kg (3-10p.)
WATERLOW CLASSIFICATION (Ht for wt)
- >%90 normal
- %80-90 mild
- %70-80 moderate
- <%70 severe
164
Nutritional status = 67.3% SEVERE
cm
The height of 165 cm is normal (50th
percentile) height for a 14 yr old child
A healthy 14 yrs old boy’s normal
weight (50th percentile) should be 52
kg
13 years old male patient
Weight =35 kg (3-10 p.)
52
Height = 165 cm (75-90p)
13 years old male patient
actual wt / exp.wt for height
35 / 52 x 100 = 67.3%
Severe malnutrition
□ WHO:
❖ Three indices: a) height-for-age (HFA),
b) weight-for-height (WFH),
c) weight-for-age (WFA)
▪ Values less than or greater than 2 standard
deviations are used to define malnutrition
▪ Stunting (assessed via HFA): HFA z score < 2 SD
chronically undernourished (<-3 SD:
severely stunted)
▪ Wasting (assessed via WFH): WFF z score < 2 SD
thin (wasted), or acutely undernourished
▪ Underweight (assessed via WFA): HFA z score
< 2 SD
• WFA is a composite index of HFA and WFH
• It takes into account both acute and chronic
undernutrition
• WFA z score < 2 SD undernutrition
< 3 SD severe undernutrition
▪ Overweight (assessed via WFH)
• Children whose weight-for-height Z-score is more
than 2 standard deviations (+2 SD)
Anthropometry – Malnutrition Classification
Table. Evaluation of "Weight for Age" and "Height for Age" Criteria According to
Percentile Curves
Zayıf (orta) Kısa (orta)
(hafif) (hafif)
50
JPEN 2013
▪ ASPEN:
"Terminologies such as PEM, marasmus, and kwashiorkor describe
the effects/outcomes of malnutrition in contemporary contexts,
but they do not provide explanations for the various etiologies and
dynamic interactions involved."
51
Figure: Definition of Malnutrition in Hospitalized Patients
⮚Chronicity
52
⮚Etiology
