Nutritional disorders range from overweigh, obesity, protein calorie malnutrition to starvations. it ie sthe is the end result of chronic nutritional and, frequently, emotional deprivation by caregivers who, because of poor understanding, poverty or family discord, are unable to provide the child with the nutrition and care he or she requires These disorders affect both the rich the poo and those in conflict zonesr

1. NUTRITIONAL
DISORDERS
FLORENCE F. A. OBONYO HAWA MPH, KRN, KRM, KRCHN

2. CONTENTS
1)Types of nutritional disorders
2)Obesity and overweight
3)Undernutrition
-Starvation
wasting,
 stunting,
Protein Energy Malnutrition
F.Hawa MPH
2

3. WHAT ARE NUTRITIONAL DISORDERS?
• Nutritional disorders are diseases that occur when a person's dietary intake does not
contain the right amount of nutrients for healthy functioning,
or
• when a person cannot correctly absorb nutrients from food.
(Kindly see the slide on basic nutrition)
https://www.nature.com/subjects/nutrition-disorders#:
F.Hawa MPH
3

4. MALNUTRITION
is the end result of chronic nutritional and, frequently, emotional
deprivation by caregivers who, because of poor understanding,
poverty or family problems, are unable to provide the child with the
nutrition and care he or she requires
F.Hawa MPH
4

5. NUTRITIONAL DISORDERS
There are 3 broad groups of malnutrition
 Ooverweight , obese
 undernutrition (wasting, stunting, underweight),
 micronutrient-related malnutrition- inadequate vitamins or minerals
F.Hawa MPH
5

6. KEY FACTS ( WORLD HEALTH ORGANIZATION)
 1.9 billion adults are overweight or obese, while 462 million are underweight.
 47 million children under 5 years of age are wasted, 14.3 million are severely
wasted and 144 million are stunted, while 38.3 million are overweight or obese.
Around 45% of deaths among children under 5 years of age are linked to
undernutrition. These mostly occur in low- and middle-income countries. At the
same time, in these same countries, rates of childhood overweight and obesity
are rising (WHO 2020 )
F.Hawa MPH
6

7. WHO IS AT RISK?
• Every country in the world is affected Combating malnutrition is one of the greatest
global health challenges.
• Women, infants, children, and adolescents are at particular risk of malnutrition.
• Good nutrition early in life—including the 1000 days from conception to a child’s second
birthday—has long-term benefits.
• . People who are poor are more likely to be affected by different forms of malnutrition.
• , malnutrition increases health care costs,
• reduces productivity, and
• slows economic growth, which can perpetuate a cycle of poverty and ill-health.
F.Hawa MPH
7

8. MALNUTRITION- INFECTION CYCLE
F.Hawa MPH
8
Inadequate diet
Undernutrition
lowered immunity
Weight loss, stunted growth,
wasting
Infection, incidence and severity
of disease increases
Malabsorption Syndrome,
loss of appetite, increased nutritional
requirements

9. ASSESSMENT OF NUTRITIONAL PROBLEMS
The assessment of the nutritional status of an individual involves various techniques:
1. Assessment of dietary intake through detailed dietary history taking pertaining to
specific food consumed its amount ,quality and adequacy in relation to nutrient value.
2. In young children head and chest circumference are important to assess for growth and
development or deviation from normal.
3. Anthropometric exam of the child including: weight, length, height, Middle Upper Arm
Circumference (MUAC),
F.Hawa MPH
9

10. MID-UPPER ARM CIRCUMFERENCE (MUAC)
is the circumference of the left upper arm,
measured at the mid-point between
the tip of the shoulder and the tip of the elbow
(olecranon process and the acromion).
MUAC is used for the assessment of nutritional
status.
• used for children between six and fifty-nine months
of age and for assessing acute energy deficiency
in adults during famine.
https://motherchildnutrition.org/early-malnutrition-detection/detection-referral-children-with-acute
F.Hawa MPH
10

11. ASSESSMENT OF NUTRITIONAL PROBLEMS
3.Clinical exam of the child to access deficiency signs and associated problems.
through head to toe exam to detect classical signs of various deficiency signs.
4.Assesment of associated problems e.g. socioeconomic or cultural food related
taboos e.g in some cultures children should not eat eggs they may become
chicken thieves
F.Hawa MPH
11

12. BODY MASS INDEX BMI
• is a measure for indicating nutritional status in adults. It is defined as a person’s weight
in kilograms divided by the square of the person’s height in meters (kg/m2). For
example, an adult who weighs 70 kg and whose height is 1.75 m will have a BMI of
22.9.
• 70 (kg)/1.752 (m2) = 22.9 BMI
• Body mass index z-scores, also called BMI standard deviation are measures of
relative weight adjusted for child age and sex.
F.Hawa MPH
12

13. OVERWEIGHT AND OBESITY
are defined as abnormal or excessive fat accumulation that may impair health
• For adults, WHO defines overweight and obesity as follows:
• overweight is a BMI greater than or equal to 25; and
• obesity is a BMI greater than or equal to 30.
For children under 5 years of age:
• overweight is weight-for-height greater than 2 standard deviations above WHO Child Growth
Standards median; and
• obesity is weight-for-height greater than 3 standard deviations above the WHO Child Growth
Standards median.
•
F.Hawa MPH
13

14. CLASSIFICATION OF OVERWEIGHT AND OBESITY
for children aged between 5–19 years:
• overweight is BMI-for-age greater than 1 standard deviation above the WHO
Growth Reference median; and
• obesity is greater than 2 standard deviations above the WHO Growth Reference
median.
F.Hawa MPH
14

15. PATHOPHYSIOLOGY
OF OBESITY
 genetic predisposition
 diets largely derived from carbohydrates and fats
than protein rich food.
 Conditions e.g. hypothyroidism, crushing's
syndrome, insulinoma, Bulimia nervosa and
hypothalamic disorders
 fatty liver is common in obese individuals.
 There is increase in size, number of adipocytes
and there is hypertrophy
as well as hyperplasia.
F.Hawa MPH 15 This Photo by Unknown Author is licensed under CC BY-ND

16. CHALLENGES IN OVERWEIGHT AND OBESITY
• Obesity in children is an important issue because if not monitored may become a problem
in adult life.
• Over nutrition increases the growth and onset of puberty.
• The child may be teased and develops poor body image which affects their self
confidence particularly when it comes in to establishing relationships with the opposite
sex.
• Obese children need psychological support to overcome their problems.
F.Hawa MPH
16

17. METABOLIC CHANGES IN OVERWEIGHT AND
OBESE INDIVIDUALS
One can develop:
 Hyper insulineamia
 Non- Insulin dependent diabetes
 Benign intracranial hyper tension which
manifests with headaches and blurred optic
disk margins.
 Hyper lipoproteinaemia:
 Daytime somnolence/sleep.
 Snoring
 hypercapnia.(high concentration of CO2 in
blood)
 Coronary artery disease
 Cholelithiasis
 Cancer
 Atherosclerosis
 Osteoarthritis
 It causes complications of the heart thereby
reducing life expectancy
 Psychological consequences.
F.Hawa MPH
17

18. MANAGEMENT OF OVERWEIGHT AND OBESITY
• Behavior modification
• Support groups
• MEDICAL MANAGEMENT Drug therapy {appetite suppressing drugs}
Phentermine, diethylpropion etc.
• SURGICAL MANAGEMENT Vertical banded gastroplasty, Adjustable gastric
banding
• Parents should reduce inactivity in children by limiting television and computer games,
encourage children to walk instead of being driven to and from school and to actively play
with their friends for 30 min to 1hr daily .
F.Hawa MPH
18

19. UNDERNUTRITION
• There are 4 broad sub-forms of undernutrition: wasting, stunting, underweight, and deficiencies in
vitamins and minerals
Low weight-for-height is known as wasting. It usually indicates recent and severe weight loss,
because a person has not had enough food to eat or may have suffered diseases such as diarrhoea.
They are at an increased risk of death.
• Low height-for-age is known as stunting. It is the result of chronic or recurrent undernutrition,
usually associated with poor socioeconomic conditions, poor maternal health and nutrition, frequent
illness, and/or inappropriate infant and young child feeding and care in early life.
• Children with low weight-for-age are known as underweight. A child who is underweight may be
stunted, wasted, or both
F.Hawa MPH
19

20. F.Hawa MPH
20
http://conflict.lshtm.ac.uk/page_115.
htm

21. TRIAGE OF CHILDREN WITH MALNUTRITION
F.Hawa MPH
21

22. WASTING OR STARVATION
• it is a state of overall deprivation of nutrients.
Etiology
• deliberate fasting eg Anorexia nervosa
• famine conditions in a country or community.
• secondary under nutrition such as chronic wasting diseases, cancers etc.
F.Hawa MPH
22

23. WASTING OR STARVATION- SIGNS AND
SYMPTOMS
• Dry and scaly skin
• muscular weakness
• Aneamia
• Increased susceptibility to infections
• Loss of appetite
• delayed Wound healing
• Brittle nails
• Loss of hair
• Depression
• Decreased Blood Pressure , low pulse
rate, slight cyanosis.
F.Hawa MPH
23

24. MANAGEMENT OF STARVATION
The aim is to maintain an optimal body weight through, Health promotion ,Acute
intervention and Health education
TYPES OF NUTRITIONAL THERAPY
• Oral feeding
• Nasogastric Tube feeding and
• gastrostomy and jejunostomy
• intravenously ( See management of Protein energy malnutrition in the next slide)
F.Hawa MPH
24

25. PROTEIN-ENERGY MALNUTRITION (PEM)
• World Health Organization defines , protein energy malnutrition as “an imbalance
between the supply of protein and energy and the body's demand for them to ensure
optimal growth and function”
• Also defined as an unintentional loss of 10% or more of body weight in a period of
six months or less and/or serum albumin levels of less than 3.5 grams per decilitre
(g/dl) (Hudson et al., 2000).
• referred to as protein calorie malnutrition
F.Hawa MPH
25

26. PCM CAN BE CLASSIFIED AS
1.Primary type-the nutrition needs are not meet as a result of poor eating habits.
2.Secondary type-malnutrition occurring due to an alternation in digestion, absorption and
metabolism.
• In such cases the tissues needs are not met even though the daily intake would be
satisfactory under normal circumstances e.g. in measles, TB, metabolic syndrome e.t.c.
F.Hawa MPH
26

27. CLINICAL SIGNS AND SYMPTOMS OF PROTEIN-ENERGY
MALNUTRITION (PEM)
include the following:
• Poor weight gain.
• Slowing of linear growth.
• Behavioral changes - Irritability, apathy, decreased social responsiveness,
anxiety, and attention deficits.
F.Hawa MPH
27

28. THREE CLINICAL SYNDROMES OF MALNUTRITION/TYPES
• Kwashiorkor (protein malnutrition predominant)
• Marasmus (deficiency in calorie intake)
• Marasmic kwashiorkor- (marked protein deficiency and marked calorie
insufficiency signs .It is the most severe form of malnutrition]
The classification of protein energy malnutrition (PEM) is primarily clinical
(anthropometry and other clinical changes).
some children fall in between the two forms and suffer growth failure but
exhibits no signs of either disease.
F.Hawa MPH
28

29. KWASHIORKOR
• Was first described by a Dr. Cecily William in 1933 but the particular term, kwashiorkor
was introduced in 1935 according to the local name for the disease in Ghana.
• The term was used to mean (red boy) due to characteristics pigmentary changes.
• The nutritional deficiency is mainly found the first year of life to primary school age.
F.Hawa MPH
29

30. CAUSES OF KWASHIORKOR
Caused by sudden change from breast milk to porridge consisting of
carbohydrates. may be prompted when the mother realizes she is pregnant while
still breast feeding.
The impaired absorption or loss of protein may occur in infants and children who
have nephrosis, hemorrhage, burns or infection such as malaria, Intestinal worms,
chronic diarrhoea ,measles accompanied by fever which tend to use up the
proteins
Anorexia due to other illnesses may also predispose to kwashiorkor because the
person is not consuming the diet provided.
F.Hawa MPH
30

31. KWASHIORKOR
CLINICAL FEATURES
 Marked growth retardation with low weight
and height
 apathetic, Mental apathy and lack of interest
to the environment
 Irritable and inactive; Dullness
 Face edema, hands, anus, bulging abdomen.
Pitting edema especially pre-tibia
 Muscle wasting with retention of some sub-
cutaneous fat.
 hepatomegaly,
CLINICAL FEATURES
 skin changes (desquamating
hyperpigmented patches exposing raw
areas of skin, fissures at flexures).
Dermatosis of kwashiorkor
 Very severe anaemia
 Congestive heart failure
 Decreased serum albumin,
 signs of vitamin A deficiency
F.Hawa MPH
31

32. MARASMIC
• They lack all nutrients
• Marasmic children are grossly emaciated due to wasting of muscles and subcutaneous fat,
having weight for age < 60% of reference median
• and may be stunted and have no edema.
• These children are often irritable and unlike children with kwashiorkor may have good
appetite for food. The skin and hair are usually dry and depigmented, and the hair is
usually sparse.
• When children with features of marasmus have edema they are classified as marasmic-
kwashiorkor.
F.Hawa MPH
32

33. CLINICAL FEATURES OF MARASMIC
• The weight of the a child drops to 60% below the expected weight for age
• Muscular atrophy /wasting especially visible in the arms and les with loss of
subcutaneous fats where the arms and legs are thin
• wrinkled thin and flaccid skin
• The face of the child looks old and anxious.
• The child may have diarrhea and constipation
• The child has very good appetite when fed with no increase in weight
• Hypothermia due to lack of subcutaneous fat
F.Hawa MPH
33

34. MARASMUS CLINICAL
FEATURES
Morphology
No fatty liver
Atrophy of different tissues and organs
including subcutaneous fat
Severe hypo chromic anemia
The plasma proteins level is low
Do Chest x ray for pneumonia
F.Hawa MPH
34

35. INVESTIGATIONS
• Take family and social history to identify the cause of the health problems. take
the MUAC, height , Weight and head circumference.
• Conduct a physical examination to find out if the child is suffering from another
condition.
• Blood test for full haemogram,check wbc count , if Hb <4g.l indicates severe
anaemia
• Blood slide for malaria parasites and stool test
F.Hawa MPH
35

36. CLINICAL FEATURES- COMPARISON
• KWASHIORKOR
• Occurs in children between 6 months 3 years of age
• Growth failure
• Wasting muscles but preserved adipose tissue
• Edema , localized or generalized, present
• Enlarged fatty liver
• Serum proteins low
• Anemia present
• Alternate bands of light and dark hair
• MARASMUS
• Growth failure
• Wasting of all tissues including muscles and adipose
tissue Edema present
• No hepatic enlargement
• Serum proteins low Anemia present
• old man like face, protuberant abdomen, thin limbs
F.Hawa MPH
36

37. MANAGEMENT OF THE CHILD WITH SEVERE MALNUTRITION IS DIVIDED
INTO THREE PHASES
These are:
• • Initial treatment: Day 1 to 7-life-threatening problems are identified and treated in a hospital
specific deficiencies are corrected, metabolic abnormalities are reversed and feeding is begun. All severely
malnourished children are at risk of developing hypoglycaemia (blood glucose <54 mg/dl or <3 mmol/l),
which is an important cause of death during the first 2 days of treatment.
• If the patient is conscious or can be roused and is able to drink, give 50 ml of 10% glucose or sucrose, or
give F-75 diet by mouth
F.Hawa MPH
37

38. 2ND AND 3RD PHASE OF MANAGEMENT
• Rehabilitation: week 2 to 6- intensive feeding is given to recover most
of the lost weight, emotional and physical stimulation are increased. The
mother or carer is trained to continue care at home, and preparations are
made for discharge of the child.
• • Follow-up: week 7-26- after discharge, the child and the child’s family
are followed to prevent relapse and assure the continued physical, mental
and emotional development of the child.
F.Hawa MPH
38

39. TIME-FRAME FOR THE MANAGEMENT OF A CHILD WITH SEVERE MALNUTRITION
Initial treatment: Rehabilitation: Follow-up:
days 1–7 weeks 2–6 weeks 7–26
Treat or prevent:
i. hypoglycemia –
ii. hypothermia - room temp 25-30 degrees C , if rectal temperature is <35 degrees C
iii. dehydration – – – – – – –
• Correct electrolyte imbalance– – – – – – – – – – – – – – –
• Treat infection – – – – – – – – – – – – – –
• Correct micronutrient deficiencies – – – – – – – – – – – – – – – – – –
• Begin feeding – – – – – – – – – – – – – –
• Increase feeding to recover lost weight (“catch-up growth– – – – – – –
• Stimulate emotional and sensorial development– – – – – –
• Prepare for discharge ************************************************
F.Hawa MPH
39

40. MANAGEMENT OF SEVERE PEM
• Administer parenteral fluids and give oral feedings,
• Keep the child warm .maintain the body temperature within normal range, provide rest , appropriate
activity and stimulation,
• record in feeding, fluid intake and output charts,
• daily weighing
• Frequent turning and preventing infection.
• carefully observe infants for infection of mouth, skin and respiratory and genitourinary tracts and
treat .
• The infant is protected from other patient and care givers who have infections since they have low
immunity
• infant may also have emotional deprivation, stimulate child and counel the care giver
F.Hawa MPH
40

41. FEEDING
• One should begin with milk products which may have to be diluted. Observe for milk
intolerance
• As the patient condition improves , undiluted milk, sugar oils and vitamin should be
given.
• A high calorie food should be commenced after 2-4days with solids being cautiously
and slowly introduced.
• As the child's condition gradually improves the nasogastric tube is removed and a
spoon and cup is introduced.
• The parent should be involved n the feeding under the instructions of the nurse
• Feeds should be given at 2-3 hours intervals and later as the child improves the feeds
can be increased and given 4hrly (See Table 1)
F.Hawa MPH
41

42. F-75 AND F- 100 POWDERED INFANT FORMULA DIET
• Two formula diets, F-75 and F-100, are used for severely malnourished children.
• F-75 (75 k calth or 315 kJ/100 ml), is used during the initial phase of treatment, while F-100
• (100 k calth or 420 kJ/100 ml) is used during the rehabilitation phase, after the appetite has
returned.
• These formulas can easily be prepared from the basic ingredients:
dried skimmed milk, sugar, cereal flour, oil, mineral mix and vitamin mix
• They are also commercially available as powder formulations that are mixed with water.
F.Hawa MPH
42

43. • Ingredient Amount
F-75 F-100
• Dried skimmed milk 25 g 80 g
• Sugar 70 g 50 g
• Cereal flour 35 g —
• Vegetable oil 27 g 60 g
• Mineral mix 20 ml 20 ml
• Vitamin mix 140mg 140mg
• Water to make 1000 ml 1000 ml
Nb:To prepare the F-75 diet, add the dried skimmed milk, sugar, cereal flour and oil to
some water and mix. Boil for 5–7 minutes. Allow to cool, then add the mineral mix
and vitamin mix and mix again. Make up the volume to 1000 ml with water.
F.Hawa MPH
43
Table1- Preparation of F-75 and F-100 diets

44. TABLE 2-DETERMINING THE AMOUNT OF DIET TO GIVE AT EACH FEED TO
ACHIEVE A DAILY INTAKE OF 100 KCAL OR 420 KJ/KG
• Weight of child (kg) Volume of F-75 per feed (ml)a
Every 2 hours (12 feeds) 3 hourly (8 feeds) 4 hourly (6 feeds)
• 2.0 20 30 45
• 2.2 25 35 50
• 2.4 25 40 55
• 2.8 30 45 60
• 3.0 35 50 65
F.Hawa2 MPH
44

45. COMPLICATIONS OF PROTEIN ENERGY
MALNUTRITION - ACUTE
child is prone to systemic/local infections
• Severe dehydration
• Shock
• Hypoglaecemia
• Hypothermia
• Congestive cardiac failure
• Bleeding disorder
• Hepatic dysfunction
• Sudden infant death syndrome
F.Hawa MPH
45

46. LONG TERM COMPLICATIONS OF PEM
1. Cachexia
2. Growth retardation
3. Mental abnormality
4. Visual and hearing disability
• NB; prognoses depends upon good hospital and domiciliary care.
F.Hawa MPH
46

47. PREVENTION OF PROTEIN ENERGY MALNUTRITION
• Promotion of exclusive breast feeding up to six months of age where possible
• Appropriate weaning practices , give necessary nutritional supplements.
• Improvement of health of pre-pregnant mothers, pregnant mothers, and
lactating mothers
• Improvement of family dietary habit with locally available low cost food items for a
balanced diet.
• Nutritional education and counseling to promote correct feeding practices, food habits
hygiene, safe water, environmental sanitation , eliminate misconception regarding food
and feedings.
• Promotion of educational status of women to improve the family health.
F.Hawa MPH
47

48. PREVENTION OF UNDERNUTRITION
• Provision of balanced diet with adequate protein and energy ,Food fortification e g iodized salts
• Immunizing against vaccine preventable diseases.
• Periodic Health check up for all children for nutritional supervision Detection of growth failure .
• Early diagnosis and management of infections, and common childhood illness.
• Promotion of early rehydration therapy in the child with diarrhea without restriction of feeding.
• Nutritionists to provide food for the poor families
• Parent counseling and education on infant feeding and care
• Prompt treatment congenital defects
F.Hawa MPH
48

49. REFERENCES
• Medline plus (2020 )https://medlineplus.gov/definitions/nutritiondefinitions.html
• Science Direct ,(2020 )https://www.sciencedirect.com/topics/food-science/protein-energy-malnutrition
• Triage of children with acute malnutrition. Cited and modified from 'Community Based Therapeutic Care, A Field
Manual, First Edition, Valid International 2006 (available online at
http://www.fantaproject.org/downloads/pdfs/CTC_Manual_v1_Oct06.pdf).
• World Health Organization. Training Course on Child Growth Assessment. Geneva, WHO, 2008.
https://apps.who.int/iris/bitstream/handle/10665/43601/9789241595070_A_eng.pdf?sequence=1&isAllowed=y
• Worl Health Organization ( 2020 )https://www.who.int/news-room/fact-sheets/detail/malnutrition
• Washington state university(2020 ) https://mynutrition.wsu.edu/nutrition-basics#water
F.Hawa MPH
49