Malnutrition in Pakistani Children

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Malnutrition in Pakistani Children

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

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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.

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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.

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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.

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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)

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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)

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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

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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)

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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

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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

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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.

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Complications of Malnutrition

• Hypothermia
• Hypoglycemia
• Cardiac Failure
• Infections
• Vitamin A Deficiency
• Severe Anemia
• Dermatosis

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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
• 10. Prepare for follow-up after recovery

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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.

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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.