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14 Malnutrition

Malnutrition is an impairment of physical or mental health (or both) resulting from failure to meet nutritional requirements characterized by inadequate or excess availability of calories, protein, and micronutrients. Despite the increasing problem of obesity in many parts of the world, nutritional deficiency remains the most prevalent form of malnutrition worldwide. Inadequate consumption of food, lack of essential dietary nutrients, and impaired absorption because of disease are the most common contributors to malnutrition in children. Worldwide, malnutrition is estimated to be a contributing factor in more than half of all childhood deaths. Children in low-income countries are most susceptible to malnutrition around the time of weaning.

Acute malnutrition is characterized by low weight for height, small mid-upper arm circumference (MUAC), or nutritional edema. A chronically malnourished child is stunted and has a low weight for age. The severity of malnutrition is typically defined as mild, moderate, or severe. Severe malnutrition has the highest case fatality rate, but mild malnutrition is responsible for the largest overall burden of nutritionally preventable illnesses. This chapter focuses on the manifestations and management of patients with severe acute malnutrition. Identification and management of mild and moderate malnutrition are also reviewed.

Clinical Presentation

Chronic malnutrition is identified by low height for age, also known as stunting. Chronically malnourished children are shorter than other children their age and may fail to meet their long-term growth potential. Acute malnutrition is characterized by low weight for height and low MUAC with or without symmetric edema. Severe acute malnutrition is defined as severe wasting, nutritional edema, or both. An acutely malnourished child has low body fat reserves and may also have limited protein stores. Children with severely low levels of serum protein often develop symmetric edema. Table 14-1 displays criteria used to define moderate and severe malnutrition. This chapter uses the World Health Organization (WHO) definitions to classify the severity of malnutrition. It is common for stunting and wasting to occur concomitantly. Children with combined chronic and acute malnutrition are both short for age and thin for height.

Table 14-1 World Health Organization Criteria for Defining Moderate and Severe Malnutrition

  Moderate Malnutrition Severe Malnutrition
Height for age −3 to −2 SD below the mean (85th to 89th percentile) <−3 SD below the mean (<85th percentile)
Weight for height −3 to −2 SD below the mean (70th to 79th percentile) <−3 SD below the mean (<70th percentile)
Symmetric edema No Yes

SD, standard deviation.

Scales for assessing weight, stadiometers for measuring height, and tape measures for evaluating MUAC are all essential tools in settings where severe malnutrition is diagnosed and managed. Growth charts (discussed in Chapter 13) are also necessary to allow for the quantification of the degree of malnutrition. In very low-resource settings when scales are not available, MUAC tapes alone may be used to screen for and follow up severe acute malnutrition (Figure 14-1).

The three common forms of protein-energy malnutrition are marasmus, kwashiorkor, and a mixed form called marasmic kwashiorkor. Whereas marasmus is typically considered to be a reflection of caloric deficiency, kwashiorkor is thought to be reflective primarily of a deficiency of protein. Marasmus can be recognized visually by decreased subcutaneous fat leading to prominent bones and the appearance of “loose skin,” especially around the buttocks. Kwashiorkor is characterized by bilateral pitting edema and a protuberant belly (Figure 14-2). Malnutrition is commonly associated with visible hair and skin changes. The hair is commonly thin, scanty, straight, and lightly pigmented. Skin changes are varied and commonly include xerosis, itchy rashes, and poor wound healing.

Other physical examination findings that are commonly seen with severe malnutrition are outlined in Table 14-2.

Table 14-2 Common Physical Examination Findings in Severe Acute Malnutrition

Physical Finding Significance
Low height for age

Low weight-for-height and low MUAC Edema Extreme pallor Sunken eyes Corneal and conjunctival lesions Weak pulses Hypothermia
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