Malnutritional Disorders

Prepared By

Dr. Sahar Farouk

Lecturer Of Pediatric Nursing

Out Lines
Introduction
Definitions
Prevalence of malnutrition
Etiology of malnutrition
Consequences of malnutrition
Comparison between marasmus and kwo in relation to: Definition
Incidence and etiology assessment of child and infant with
marasmus & kwo
Complications
Ivestigations
Treatment & prevention of marasmus &kwo
Nursing management

Out Lines (Cont.)

Rickets
Definition of rickets
Information about vit. D
Causes of rickets
Contributing factors of rickets
Clinical picture of rickets
Complication of rickets
Laboratory investigations
treatment of rickets
Nursing care
Infantile tetany
Definition
Etiology
Clinical Manifestations
Treatment
Nursing care

Introduction
Malnutrition means more than feeling hungry or not
having enough food to eat. It is a condition that
develops when the body does not get the proper
amount of protein, calories, vitamins and other
nutrients it needs to maintain healthy tissues and
organ function. It occurs in children who are either
undernourished or over nourished. Children who are
over nourished may become over weight or obese
and those who are under nourished are more likely
to have severe long term consequences.

Definition
Malnutrition includes: under nutrition and
over nutrition.
- Under nutrition: is a consequence of
consuming little energy and other
essential nutrients or using or excreting
them more.
Malnutrition: is a term referring to poor or
inadequate nutrition.

Prevalence of malnutrition
Malnutrition remains of the worlds highest
priority health issues not only because its effects are
so widespread and long lasting, but also because it
can be eradicated.
More than 35% of all preschool age children in
developing countries are under weight.
The unicef report found that 146 million children
under five years in the developing world are suffering
from insufficient food intake, repeated infections
diseases, muscle wasting and vitamin deficiencies.

Etiology
The cause of malnutrition may be due to: Poor food availability &preparation
Recurrent infections (GE)
Lack of nutritional education
Lack of sanitation
Erratic health care provision
Chronic diarrhea
Hook worm & malaria
Chronic infection by (T.B, otitis media)
Congenital mal formations as (pyloric stenosis)

Consequences of malnutrition
(long term effects)
1.
2.
3.
4.

Slowed growth & delayed development

Difficulty in school
High rates in illnesses
social stress

Protein energy malnutrition

Definition:

1- Marasmus

It is a clinical syndrome and a form of under nutrition characterized

by failure to gain weight due to inadequate caloric intake.

Incidence:
commonly in infants between the age of 6mo. - 2years (Infantile
atrophy).

Etiology

1- Dietary errors
2 Infection :Acute or chronic as T.B, otitis media pyelo nephritis
3- Gastroenteritis: (acute or chronic )
4- parasitic inf estuations as: Ascaris, ankylostoma ,giardia
5-Congenital anomalies as: Cardiac (P.D.A,V.S.D,F4) ,Renal (renal
agenesis, obstructive uropathy) ,G.I.T (pyloric stenosis , cleftlip or palat
6-Metabolic diseases.: Galactosemia, Fructose intolerance, Idiopathic
hypocalcaemia
7- Prematurety
8- Some cases of mental retardation
9- Low socio economic status
10-Endocrine causes ( DM.hyperthyroidism )

Assessment of Marasmic
Child/Infant

failure a to thrive ,loss of weight (weight < 60%of expected)

loss of subcutaneous fat : measured at many parts of the body
according to the degress:1 st degree : s.c fat in the abd. wall
2 nd degree : s.c fat in the abd. wall and limbs
3 rd degree : s.c fat in the abd. wall and limbs and face

Assessment of Marasmic
Child/Infant (Cont.)

Muscle wasting ( thin muscles and prominence of bony surfaces )

G.I.T disturbances as anorexia in advanced cases, hungry,
constipation or diarrhea or starvation diarrhea
liability to infection
Hypovolemia
Weak feeble pulse, subnormal temp, pulse rate
Senile face and pallor

Complications of Marasmus
1. Intercurrent
infection
:
Broncho
pneumonia . is the cause of death
2.
3.
4.
5.
6.

Gastro enteritis
Hemorrhagic tendency, purpura
Hypothermia
Hypoglycemia
Edema(marasmic kwashiorkor )

Investigations for Marasmic Infant

1.Blood analysis : (W.B.C ,Electrolytes
Sugars, ketones,Plasma proteins , normal
or lowered )
2. Urire analysis: culture, sugar, ketones,
ca, phosphate, aminoacids
3.Stool analysis for parasites
4. X- ray for chest and heart
5. Tuberculin test for T.B
6. E.N.T examination for otitis media

Treatment
1- Prevention :

proper diet ( balanced nutritional diet )

encourage breast feeding up to weaning
proper weaning
proper vaccination as measles , T.B. whooping cough
Education regarding the cheap sources of balanced
diet, family planning.
Proper follow up of the growth rate
Early treatment of defects or associated diseases

Treatment (Cont.)

2 Curative treatment:-

A- Proper dietary management:

Adequate balanced feeding. teaching about nutritional
needs.preparation of diet, technique of administration of food

If there is vomiting or anorexia, give IV fluids or naso gastric tube

feeding.

Gradual increase the amount and concentration of formula (total

calories is120-200cal kg d)
B Treatment of the cause
C- Emergency treatment for complications
D Blood transfusion
E Vitamins and minerals supplementation

Kwashiorkor
Definition
It is a clinical syndrome and a form of
malnutrition characterized by slow rate of
growth due to deficient of protein intake,
high CHO diet and vitamins & minerals
deficiency (adequate supply of calories).
Incidence
Commonly in toddlers between the age
1-3years, following or with weaning

Etiology
1.
Un balanced diet (of protein, CHO.)
2. improper weaning (during and post
weaning period )
3. faulty management of marasmic baby
4. Ignorance poverty due to lack of basic
health education
5. precipitating factors as(acute infection with
measles, diarrhea and malaria, parasitic
infestations)

Assessment
1- Essential features
(cardinal manifestation):

Growth retardation :Weight is diminished (60-80%) of

expected

Edema :

It is due to hypo proteinemia. It is

starts in the feet and lower parts of the
legs) then becomes generalized
edema . The cheeks become bulky,
pale, waxy in appearance (doll-likecheeks)

Essential features- 1
- Diminished muscle fat ratio:
Generalized (muscle wasting) with
subcutaneous fat
- Fatty liver :
It is detected by liver biopsy

- Mental changes :
The infant has apathy never smile, looks
sad his cry is weak

2-Early features
(usual manifestation)

Hair changes : The hair is sparse , dys pigmentation( reddish or greyish),atrophic ,easily pickable.

G.I.T Manifestations: Anorexia ,vomiting in severe cases, diarrhea due to k

Occasional or variable features-3

- Vitamins and minerals defection and vit.D , A,C
minerals as iron, zinc, Mg,
Hepatomegaly.
Skin changes (dermatitis in areas due to pigmentation
,napkin dermatitis, petechiae over the abdomen,
fissures,ulceration
Poor resistance and liability to infections

Complication of kwashiorkor
1. Secondary infection ,fungal and
bacterial infection
2. Hemorrhagic tendency, purpura
3. Gastroenteritis
4. Hypoglycemia
5. Hypothermia
6. Heart failure due to anemia and
infection.

Investigations for kwashiorkor

1. Blood analysis: (Albumin < 2.5gmld) , total
protein, amino acids, Enzymes (amylase ,lipase,
alkaline phosphate, , Glucose (hypoglycemia) , k
( hypokalemia )
2. Low pancreatic and intestinal enzymes
3. Urine analysis, culture for infection
4. Stool analysis for parasites
5. Chest x-ray
6. Tuberculin test

Common Nursing Diagnoses

of Marasmus and KWO
1. Altered nutrition :less than body requirements related
to knowledge deficit, infection, emotional problems,
physical deficit
2. Body temperature alteration (hypothermia) related to
low subcutaneous fat and deficiency of food intake
3. Impaired skin integrity related to vitamins deficiency
4. Fluid volume deficit related to diarrhea
5. High risk for infection related to low body resistance.

Nursing care of Marasmus

Support the infant and parents
1. provide nutrition rich in essential nutrients
2. Give small amounts of foods limited in proteins, carbohydrates and fats
3. Maintain body temperature
4. Provide periods of rest and appropriate activity and stimulation
5. Record intake and output
6. Weight daily
7. Change position frequently
8. Proper treatment is given for infection
9. Protection from infected persons and injuries
10. Refer family to social worker for financial support
11. Education for parents about proper nutrition

Nursing care of Kwashiorkor

Support the infant and parents
1. Proper diet intake proteins and CHO vitamins
2. Nursing care for vomiting, diarrhea or dehydration
3. Skin care for child for edema , injuries
4. Avoid any infection and follow hygienic measures for child
5. Frequent assessment of growth and development
6. Safety measures to avoid injuries
7. Nutritional counseling
8. Record intake and out put
9. Health education about medications and follow up
10. Frequent monitoring for any complications

3-Marasmic Kwashiorkor
Definition
Its a combination of caloric deficiency (marasmus ) and
protein deficiency (KWO) .

Clinical picture

The clinical picture of this disease represents

manifestations from both diseases as:
loss of subcutaneous fat as in marasmus
Edema, hair and skin changes as in KWO but there is
no moon face.

Rickets (Osteomalacia)
Definition: Its is a systemic metabolic disease due to of vit.D
results in inadequate deposition of calcium in developing
cartilage and bone leading to bone deformities, hypotonia
and some times affecting cns.

Vitamin D:- it is a group of steroid fat soluble

compounds

It affects the reabsorption of ca and phosphours by the

kidneys

It has two types: Biologically ,D2 and D3 which are present (in-active) form

and Trans formed to (active form) in the liver as (Calcitriol)

- D2 called (Calciferol.) and D3called (Chole calciferol.)

Causes of vitamin D. deficiency rickets

Dietary def of vit. D and Ca

lack of exposure to sun rays
Malabsorption of vit.D as in(obstructive jaundice )
Congenital rickets
Taking of anti convulsive drugs
poor utilization of vit.D by the tissues lead to rickets
as in :

hyper para thyroidism, renal disorders

hypo phosphatemia
recurrent attacks of diarrhea due to G.E
High proportion of phosphorous as in cows milk leads to
impaired absorp. of ca.

Contributing factors
1.
2.
3.
4.

Age
common in infants (6 months -2years)
Preterm babies and twins
season
more in winter than in summer
Diet
inadequate intake of vitamin D and calcium
and vitamin C in diet. and diet. the disease is
more common in artificial feed babies than breast
feed infants
5. Heredity factor
6. Atmospheric condition
more common in big
cities and heavy crowded areas with population no
common in tropics areas
7. Race
more common in dark races

Clinical picture
During assessment of the child / infant with
rickets, the chief complains are:
1.
2.
3.
4.

Delayed motor development specially walking

Delayed dentition
Deformities of the bones
presence of one of any complications

Physical examination
A-Early manifestations:

Craniotabes. (In the head) infant 3-8mo.

Rickety rosary beads (in the thorax)
Enlarged of the lower radio ulner epiphysis.
Sweating at fore head, irritability

Physical examination (Cont.)

B- Late manifestations:
1. Head
Enlargement of the head like (box shape skull)
due to frontal and parietal bossing)
Delayed closure of anterior fontanel
Delayed eruption of teeth

Physical examination (Cont.)

B- Late manifestations:
2-Thorax
Rickety rosary beads
Harrison sulcus (transverse groove at the
lower part of the chest at the costal insertion
of the diaphragm)
Longitudinal sulcus (lateral groove)
Pigeon chest

Physical examination (Cont.)

B- Late manifestations:
3- Spine : kyphosis, scoliosis
4- Pelvis : contracted pelvis
5- Extremities : deformities , green stick ,
fractures
6- Muscles : weakness of muscles , hypotonic
laxity of ligaments as (In abdomen)
7- Constipation, enlarged spleen

COMPLICATIONS
1.

Bone fractures, limbs deformities as the following:

2- Tetany due to hypocalcaemia

3- Anemia
4- G.I.T disturbances as: G.E, constipation.
5- Respiratory complications as pneumonia,
broncho
-pneumonia
6- low resistance , liability to infection as urinary tract
infections

Treatment
Prevention Of rickets: Exposure of all infants to ultra violet rays.
Daily intake of diet rich with vit-D and
supplementation of vit.D (400-800 IU / d). The
infant need 400ivld .premature baby receives
800-1200 IU / d( 2nd -4th ) month of life
Pregnant and lactating mothers need vit.D
supplementation.

Treatment (Cont.)
2- Active treatment : Oral calcium with vit.D intake should be
increased.
Vit-D (1500-5000)IU/ d .for 2months or
shock therapy by vit-D (600-000) IU/d .by
IM injection deeply one dose every
2weeks (3doses)
After healing, give. vit.D (400-800) IU and
repeat blood analysis for calcium.
Surgical correction of deformities
Treatment of any complications

Treatment (Cont.)
2- Active treatment : Oral calcium with vit.D intake should be
increased.
Vit-D (1500-5000)IU/ d .for 2months or
shock therapy by vit-D (600-000) IU/d .by
IM injection deeply one dose every
2weeks (3doses)
After healing, give. vit.D (400-800) IU and
repeat blood analysis for calcium.
Surgical correction of deformities
Treatment of any complications

Common nursing diagnoses

1. Body image disturbance related to bone
deformities
2. Altered nutritional requirements related
to deficiency of calcium
3. High risk for infection related to low of
immunity.
4. High risk for injury related to weakness
of bones and deformities.

Infantile Nutritional Tetany

(Tetany of vit.D deficiency)
Definition:

It is a disease caused by decrease in

serum calcium level
( < 7mgldl) and by
a deficiency in the intake and absorption
of vitamin .D (not all infants with rickets
have tetany). This condition leads to
hyper excitability of the central and
peripheral nervous system

Etiology
1. Hypocalcemia as by (hypo parathyroid),
vit.D.
deficiency
intake
,
exchange
transfusion)
2. hypo magnesemia by (chronic diarrhea ,
malabsorption . of mg)
3. alkalosis (pH) due to (severe vomiting,
alkalotic therapy)
4. Severe rickets.
NB. Infantile tetany. has the some
predisposing factors as in rickets.

Clinical manifestations
1- Early manifestations as :

serum calcium - >7mg /dl

Carpo pedal spasm
laryngeal spasm
cyanosis
Generalized convulsions in infants and newborns
N.B: infantile tetany is due to rapid deposition of
serum Calcium so, spasms in hands, feet appear

2- late manifestations:

serum Ca (7-9)mg /dl, bone deformities

Treatment
A. Immediate:

Give the child infant Ca gluconate .10% solution (5-10) cc. IV

injection slowly.

If no response search for etiology and correct it as (Mg

deficiency ) by giving Mg solution sulface .50% (0.2 ml/kg )
IM

O2 therapy for convulsions and emergency intubation. for

laryngo spasm
B. Maintenance:
Diet rich in calcium

Ca chloride orally (1-3gm /d in milk) or Ca lactate.

Vit.D. for treatment of rickets daily

Common Nursing diagnoses

Nursing diagnoses:

High risk for injury related to convulsions

High risk for infection related to lack of immunity
Altered body image, related to bone deformities
Ineffective breathing pattern, related to laryngeal
spasm
Activity intolerance, related to weakness of bones
Altered parenting related to lack of knowledge
about the disease process and its management .

Thank You