Pediatric Malnutrition

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Pediatric Malnutrition:

Pediatric Malnutrition BY Minyahil Alebachew Bpharm ., MSc ., Clinical Pharmacy Mekelle University Department of Pharmacy

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According to the World Health Organization ( WHO ), 10.5 million children younger than 5 yr died in 1999 . Of these, 99% lived in developing countries. Causes of death were attributed to malnutrition (54%), perinatal conditions (20%), pneumonia (19%), diarrhea (15%), measles (8%), malaria (7%), HIV/AIDS (3%), and other (28%). One third of births in the developing world are not registered . Malnutrition among pregnant women leads to stunting of an estimated 182 million children .

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Breast-feeding is the ideal method of feeding an infant up to 1 year of age. When this is not feasible , a wide variety of infant formulas are available that provide appropriate nutrients for infants using the oral route. A pediatric patient who has a functioning intestinal tract , but is unable to achieve adequate oral intake , can be fed enterally using a tube inserted into the stomach or small intestine.

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Indications for providing specialized enteral nutrition include malnutrition , malabsorption , hypermetabolism , failure to thrive , prematurity , and disorders of absorption, digestion, excretion, or utilization of nutrients .

Severe Acute Malnutrition (SAM):

Severe Acute Malnutrition (SAM) Severe malnutrition is one of the most common causes of morbidity and mortality among children under the age of 5 years worldwide. Many children with SAM die at home without care, but even when there is no good hospital care, mortality rates may be high. With appropriate case management in hospitals and follow-up care, the lives of many children can be saved, and the facility case fatality rates can be reduced significantly, a mortality rate has been reduced from over 30% to less than 5%.

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Severe malnutrition is both a medical and a social disorder. Successful management of the severely malnourished patients requires that both medical and social problems be recognized and corrected . If the illness is viewed as being only a medical disorder , the patient is likely to relapse when he/she returns home and the rest of the family will remain at risk of developing the same problem. Therefore, successful management of severe malnutrition does not require sophisticated facilities and equipment neither highly qualified personnel. It does, however require that each child be treated with proper care and affection.


UNDERNUTRITION The problem of undernutrition is multifaceted, and solving it at a national level requires understanding , trust , and cooperation among diverse governmental agencies accustomed to dealing solely with health, agriculture, education, or finance issues.

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UNICEF has developed and is promoting an inclusive conceptual framework for organizing scientific knowledge and experience concerning undernutrition (or malnutrition), fostering a common understanding and developing coherent strategies for addressing the problem. A key feature of this framework is the recognition that undernutrition , or malnutrition , is a biologic manifestation of the combined effects of inadequate dietary intake and disease , both of which are closely related to social and economic development .

Diagnosis :

Diagnosis Key diagnostic features of SAM are: Infants less than six months: Weight –for- Length ( W/L ) less than 70% of the National Center for Health Statistics [ NCHS ] median, OR Presence of pitting Oedema of both feet, OR Visible Severe W asting if it is difficult to determine W/L

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Children 6 months to 5 years: Weight for Height (W/H) or Weight –for- Length (W/L) less than 70 % of NCHS median, OR Presence of pitting Oedema of both feet, OR If W/H or W/L cannot be measured, use the clinical signs for visible severe wasting A child with visible severe wasting appears very thin and has no fat. There is severe wasting of the shoulders, arms, buttocks and thighs, with visible rib outlines.


Consequences. The cumulative evidence suggests that undernutrition has pervasive effects on immediate health and survival as well as on subsequent performance . These include not only acute effects on morbidity and mortality but also longer-term effects on cognitive and social development, physical work capacity, productivity, and economic growth .

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Prospective studies suggest that severely underweight children (<60% of reference weight for age) have more than an eight-fold greater risk for mortality than normally nourished children, that moderately underweight children (60–69% of reference weight for age) have a four- to five-fold greater risk , and that even mildly underweight children (70–79% of reference weight for age) have a two- to three-fold greater risk .

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The fact that severely undernourished children, as assessed by low length-for-age, have greater deficits in cognitive performance than children with mild or moderate undernutrition strongly suggests that the intellectual deficits are related to the severity of undernutrition . But the extent to which intellectual deficits can be decreased by dietary intervention alone is not clear.


PROTEIN/ENERGY MALNUTRITION (PEM) PEM, is manifested primarily by inadequate dietary intakes of protein and energy , either because the dietary intakes of these two nutrients are less than required for normal growth or because the needs for growth are greater than can be supplied by what, otherwise, would be adequate intakes for growth. is almost always accompanied by deficiencies of other nutrients .

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The terms primary and secondary malnutrition refer, respectively, to malnutrition resulting from inadequate food intake and malnutrition resulting from increased nutrient needs , decreased nutrient absorption , and/or increased nutrient losses . Although both primary and secondary malnutrition occur in developing as well as developed countries , primary malnutrition accounts for the major percentage of malnourished children in developing countries , whereas secondary malnutrition accounts for a higher percentage in developed countries.

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Historically, the most severe forms of PEM, marasmus , and kwashiorkor , were considered distinct disorders. Marasmus was thought to result primarily from inadequate energy intake, whereas kwashiorkor was thought to result primarily from inadequate protein intake . Currently , a third disorder , marasmic kwashiorkor , which has features of both disorders, also is recognized.

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The three type of PEM have distinct clinical and metabolic features , but they also have a number of overlapping features . For example, a low plasma albumin concentration , often thought to be a manifestation of kwashiorkor, is common in children with both clinical marasmus and clinical kwashiorkor . In recognition of the overlapping features of these two clinically distinct conditions, the terms currently preferred are edematous (kwashiorkor) and nonedematous ( marasmus ) PEM.

Clinical Manifestations of nonedematous PEM (marasmus) :

Clinical Manifestations of nonedematous PEM (marasmus) initially there is failure to gain weight & irritability , followed by weight loss and listlessness until emaciation results. The skin loses turgor and becomes wrinkled and loose as subcutaneous fat disappears.

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Loss of fat from the sucking pads of the cheeks may occur late , and the infant's face may retain a relatively normal appearance , eventually becoming shrunken and wizened . The abdomen may be distended or flat with the intestinal pattern readily visible. There is muscle atrophy and resultant hypotonia . The temperature is usually subnormal and the pulse slow . Infants are usually constipated but may develop a starvation diarrhea with frequent small stools containing mucus.

Clinical Manifestations of Edematous PEM (kwashiorkor):

Clinical Manifestations of Edematous PEM (kwashiorkor) initially present as vague manifestations that include lethargy, apathy, or irritability. When well advanced, there is inadequate growth, lack of stamina, loss of muscle tissue , increased susceptibility to infections, vomiting, diarrhea , anorexia, flabby subcutaneous tissues, and edema . The edema usually develops early and may mask the failure to gain weight, but the liver may enlarge early or late.

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The edema is often present in internal organs before it is recognized in the face and limbs . Dermatitis is common, with darkening of the skin in irritated areas but not in areas exposed to sunlight , in contrast to pellagra . Depigmentation may occur after desquamation in these areas, or it may be generalized. The hair is sparse and thin and, in dark-haired children, may become streaky red or gray.

Note: No distinction has been made between the clinical conditions of kwashiorkor, marasmus, and marasmic kwashiorkor because the approach to their treatment is similar. :

Note: No distinction has been made between the clinical conditions of kwashiorkor, marasmus, and marasmic kwashiorkor because the approach to their treatment is similar.


Pathophysiology. it has been proposed that giving excess carbohydrate t o a child with clinical marasmus reverses the adaptive responses to low protein intake , resulting in mobilization of body protein stores . Eventually, albumin synthesis decreases , resulting in hypoalbuminemia with edema . Fatty liver also develops secondary, perhaps, to lipogenesis from the excess carbohydrate.

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Aflatoxin poisoning as a cause of edematous PEM also has been proposed. Finally, free radical damage has been proposed as an important factor in development of clinical kwashiorkor or edematous PEM . This concept is supported by low plasma concentrations of methionine , a dietary precursor of cysteine , one of the amino acids needed for synthesis of the major antioxidant factor, glutathione . methionine => cysteine => glutathione

Treatment. three phases:

Treatment. three phases

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Iron therapy usually is not started until this final phase of treatment so as to prevent binding of iron to already limited stores of transferrin , which, in turn, may interfere with the protein's host defense mechanisms . Also free iron during the early phase of treatment may exacerbate oxidant damage , precipitating clinical kwashiorkor or marasmic kwashiorkor in a child with clinical marasmus .


REFERENCES 1.Joseph T. Dipiro :Pharmacotherapy a pathophysiologic approach(2008),7 th edn. McGraw-Hill Companies,New York. 2.Harrison’s: The principle of internal medicine(2008),17 th edn. McGraw-Hill Companies,USA 3. Koda-Kimble: Applied Therapeutics: The Clinical Use Of Drugs, 9th Edition 28

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