Malnutrition in Pakistani Children

Dr. Nayyar Raza Kazmi M.B., B.S, D.H.P.M, M.Sc

Learning Objectives
To understand the burden of Malnutrition in Pakistan. To understand the etiology of Malnutrition. To know the factors useful in identifying Malnutrition in children. To know the treatment options available for Malnutrition. To know preventive strategies available for preventing Malnutrition.

Performance Objectives
By the end of the lecture, the students should be able to
Know the high risk groups for Malnutrition. Be able to diagnose Malnutrition and classify it. Be able to offer treatment for Malnutrition. Be able to understand and demonstrate the importance of Prevention of Malnutrition. Be able to demonstrate, how to make simple calorie rich foods.

What is Malnutrition
Malnutrition is defined as a pathological state resulting from relative or absolute deficiency of one or more essential nutrients. It is primary when there is deficiency of food available or secondary when food is available but the body cannot assimilate it for one or another reason. Malnutrition is common in children between age of 3 months and 3 years.

Anthropometric Indices in Malnutrition

Weight for age is the best screening tool. Weight for age below 2 Standard Deviation from median is taken as Malnutrition. It is used for mass screening of children to detect under nutrition. Weight for Height below the 5th Centile classifies the child as Wasted ( Acute Malnutrition). Height for age below the 5th centile classifies the child as Stunted (Chronic Malnutrition)

Malnutrition in Pakistan
38% of Children are Low Weight for Age. (Shakirullah et el. JCN, 1999,vol.xii) 14% of Children are Wasted 36% or Urban and 44% of rural Children are Stunted. Malnutrition is responsible as underlying factor for 55% of Deaths in Children under 5 years of age. (Nelson

textbook of Pediatrics, 16th Ed. Saunders, 2001)

Etiology of Primary Malnutrition

Failure of Lactation. Improper Weaning Practices Poverty Food Taboos 2 or more children under 5 years of age in same household Death of Mother Incompetent/ Ignorant Mother. Lack of Family Planning

Etiology of Secondary Malnutrition

Lack of Immunization Congenital Diseases: ASD, VSD, cleft palate etc. Malabsorption: Celiac Disease, Lactose intolerane, Giardiasis, Cystic Fibrosis Metabolic: Inborn errors of Metabolism, CRF, Renal tubular Acidosis etc. Infections: Tuberculosis ( very common in Pakistan)

Clinical features in Marasmus

Marked muscle wasting and loss of subcutaneous fat. Monkey Facies Skin becomes loose and hangs in folds Abdomen protuberant due to hypotonic muscles Temperature is usually sub-normal Child is alert

Clinical features of Kwashiorkor

Generalized Edema more marked in Lower Extremeties. Apathy and Irritability Fine, sparse and discoloured hair Anemia Usually Flaky Paint Dermatitis Enlarged Liver due to Fatty Changes

Lab Investigations in Malnutrition

Check Hemoglobin in all cases. It is usually low. Sometimes it may be normal despite severe pallor in child because of the associated dehydration and hemoconcentration, the Hb apparently seems to be normal. If there is no BCG Scar, do Diagnostic BCG and read after 72 hours. If more than 10 mm of induration, treat as Tuberculosis. Do Stool R/E and Urine R/E. Do Chest Xray in all cases of Malnutrition. Serum Pre-Albumin level. This is the most sensitive prognostic indicator in Kwashiorkor. Do on Day1, Day 5 and before discharge of the patient. Plasma Protiens and Serum Albumin level. These are usually very low in Kwashiorkor.

Complications of Malnutrition
Hypothermia Hypoglycemia Cardiac Failure Infections Vitamin A Deficiency Severe Anemia Dermatosis

Treatment of Malnutrition
Follow WHO Guidelines
1. Treat/prevent hypoglycaemia 2. Treat/prevent hypothermia 3. Treat/prevent dehydration 4. Correct electrolyte imbalance 5. Treat/prevent infection 6. Correct micronutrient deficiencies 7. Initiate refeeding 8. Facilitate catch-up growth 9. Provide sensory stimulation and emotional support

Therapeutic Nutrition in Malnutrition

Start slowly with F-75. If that is not available, give traditional easy to make, calorie rich foods. For those having severe anorexia, feed overnight with Milk given through NG tube, till appetite returns. Give Vitamin A, Vitamin D, Zinc, Magnesium, and folate to all children Treat Oral thrush, if present.

Prevention of Malnutrition
Primary Prevention
Health Education to mothers about good nutrition and food hygiene through Lady Health Workers Immunization of children. Growth monitoring on Growth Charts specially of all children under 3 years of age

Secondary Prevention
Mass Screening of high risk populations, using simple tools like Weight for age or MUAC.

Tertiary Prevention
Good Nutritional Care, supplementary feedings and rehabilitation, counselling of mothers.