Babitha's Notes on Nutritional disorders

Mrs. Babitha K Devu
Assistant Professor
SMVD College of Nursing

Introduction
• Malnutrition is a condition that results from
eating a diet in which one or more nutrients
are either not enough or are too much such
that the diet causes health problems. It may
involve calories, protein, carbohydrates,
vitamins or minerals.
• Not enough nutrients is called under
nutrition or undernourishment while too
much is called over nutrition.
• Malnutrition is often used to specifically refer
to under nutrition where an individual is not
getting enough calories, protein,
or micronutrients.

Introduction
• The World Health Organization (WHO) defines
malnutrition as "the cellular imbalance between the
supply of nutrients and energy and the body's
demand for them to ensure growth, maintenance, and
specific functions."
• Malnutrition is the leading cause of the global burden
for disease.
• In 2016, an estimated 155 million children under the age of 5
years were suffering from stunting, while 41 million were
overweight or obese.
• Around 45% of deaths among children <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.

Introduction
• There are two main types of under
nutrition: protein - energy malnutrition and dietary
deficiencies.
• Protein - energy malnutrition has two severe
forms: marasmus (a lack of protein and calories)
and kwashiorkor (a lack of just protein).
• Common micronutrient deficiencies include: a
lack of iron, iodine, and vitamin A.
• In some developing countries, over nutrition in
the form of obesity is beginning to present within
the same communities as under nutrition.

• PEM was earlier attributed to the concept
of ‘protein gap’ (deficiency of proteins in
diet). ‘Food gap’ is the chief cause of PEM.
• It is not only the deficiency of proteins but
inappropriate food (low in energy density,
protein and micronutrients ‐ Vitamin A, Iron,
Zinc) and poor in both quantitatively and
qualitatively.
• Sometimes the terms malnutrition and PEM
are used interchangeably with under
nutrition.

The term protein energy malnutrition has been
adopted by WHO in 1976.
Highly prevalent in developing countries among <5
years children; severe forms 1-10% & underweight
20-40%.
All children with PEM have micronutrient
deficiency.
In developing countries, almost 65% of children
under the age of five years are underweight and
50% of these children die as a result of PEM.
The term "severe malnutrition" or "severe
undernutrition" is also refered specifically to PEM.

According to the NFHS – 4, carried out in the
year 2015 – 2016, 38% of India’s children <5
years are stunded and 36% are underweight.
India facts NFHS - 4 2015 - 2016.pdf
JK_FactSheet.pdf
Protein–energy malnutrition (PEM) or
protein–calorie malnutrition refers to a form
of malnutrition where there is inadequate
calorie or protein intake.

Indicator Interpretation Comment
Stunting
Low height -
for- age
Indicator of chronic
malnutrition, the result of
prolonged food
deprivation and/or
disease or illness.
Wasting
Low weight –
for - height
Suggests acute
malnutrition, the result of
more recent food deficit
or illness.

Indicator Interpretation Comment
Underwe
ight
Low weight -
for- age
Combined indicator to
reflect both acute and
chronic malnutrition.

The assessment of nutritional status is done
according to weight-for-height, height-for-age and
presence of edema. The WHO recommends the
use of Z scores or standard deviation scores
(SDS) for evaluating anthropometric data.
The score of -2 to -3 indicates moderate
malnutrition and a score of +2 to +3 SDS
indicates overweight. A score of less than -3 SDS
indicates severe malnutrition and a score of more
than +3 indicate obesity.

Grade of Malnutrition
Weight-for-age of the
standard (%)
Normal >80
Grade I 71-80 (mild)
Grade II 61-70 (moderate)
Grade III 51-60 (severe)
Grade IV <50 (very severe)

Degree of PEM
% of desired body
weight for age and sex
Normal 90–100%
Mild: Grade I (1st
degree)
75–89%
Moderate: Grade II (2nd
degree)
60–74%
Severe: Grade III (3rd
degree)
<60%

Degree of PEM
Stunting (%)
Height for age
Wasting (%)
Weight for height
Normal: Grade 0 >95% >90%
Mild: Grade I 87.5–95% 80–90%
Moderate: Grade II 80–87.5% 70–80%
Severe: Grade III <80% <70%
These classifications of malnutrition are commonly
used with some modifications by WHO.

The causes of malnutrition could be

– this determinants
work at the individual level. They include LBW,
illnesses (infectious), and inadequate dietary
intake.
– the immediate
determinants are in turn influenced by three
household factors namely food, health and care.
o Food: refers to food security at the household
level. This depends on having financial,
physical & social access as distinct from mere
availability.

o Health: includes access to curative & preventive
health services as well as a hygienic and
sanitary environment and access to water.
o Care: refers to a process taking place between
caregiver and the receiver of care. It includes
care of women, BF and complementary feeding,
home health practices, hygienic practices,
psychosocial care & food preparation. It is also
influenced by adequate resources, their control &
social factors that affects their utilization.

– these include the
socioeconomic status and educational level
of the families, women’s empowerment,
cultural taboos regarding food and health,
access to water and sanitation, etc.

It results from rapid deterioration in nutritional
status. Marasmus (also called the dry form of
PEU) causes weight loss and depletion of fat
and muscle. In developing countries, marasmus
is the most common form of PEU in children.
Marasmus results from the body’s physiologic
response to inadequate calories and nutrients
where body weight is reduced to less than 60%
of the normal (expected) body weight for the
age.
Marasmus occurrence increases prior to age 1
and is more common.

marked wasting of fat and
muscle as these tissues are consumed to make
energy.
The main sign is severe wasting. The child
Appears very thin (skin & bones) &
have no fats. Severe wasting of the
shoulders, arms, buttocks and thighs.
Aged or wrinkled appearance due to
lose of buccal pads of fats referred to
monkey facies. Baggy pants
appearance due to loose skin in
buttocks.

Affected children may appear to be alert in spite
of their condition.
There is no edema
Growth retardation
Variation in vital signs.
Hunger
Skin dry & thin, and the hair may be thin, sparse
& easily pulled out.
Children are apathetic, weak and may be irritable
when touched.

(also called the wet, swollen, or oedematous
form) is a risk after premature abandonment of
breastfeeding.
It usually affects children aged 1 – 4 yr. And is
less common in occurrence.
It tends to be confined to specific parts of the
world, such as rural Africa, the Caribbean, and
the Pacific islands where staple foods are low in
protein and high in carbohydrates.
In kwashiorkor, cell membranes leak, causing
extravasation of intravascular fluid and protein,
resulting in peripheral edema.

Hence kwashiorkor is protein deficiency with
adequate energy intake.
The main sign is pitting edema, usually starting in
the legs and feet and spreading, in more
advanced cases, to the hands and face.

General appearance: Fat sugar baby appearance
Edema: it ranges from mild to gross and may
represent up to 5 – 20% of the body weight
Muscle wasting: it is always present. The child is
often weak, hypotonic and unable to stand or
walk.
Skin changes: lesions are increased
pigmentation, desquamation and
dyspigmentation. Pigmentation resembles flaky
paint (dermatosis).

Mucous membrane lesions: smooth
tongue, cheilosis and angular stomatitis
are common. Herpes simplex stomatitis
are also seen.
Hair: dyspigmentation, flag sign, curls
and sparseness, dry and lustreless and
may turn reddish yellow to white in
colour. It become brittle and can be
pulled out easily.

Mental changes: unhappiness, apathy or irritability
with sad, intermittent cry. No signs of hunger and
its difficult to feed them.
GI system: Anorexia with or without vomiting.
Abdominal distension. Stool may be watery or semi
solid, bulky with low pH and contain unabsorbed
sugars. Fatty liver
Anemia:
CV system: cold, pale extremities. Variation in vital
signs
Renal function: Diminished GFR

It is mixed form of PEM and manifests as
edema occurring in children who may or
may not have other signs of kwashiorkor
and have varied manifestations of
marasmus.
These children often have concurrent
wasting and edema in addition to
stunting. These children exhibit features
of dermatitis, neurologic abnormalities
and fatty liver.

History and examination
Anthropometric
WHO classification
IAP classification
Age – independent indices – MUAC, bangle
test, Shakir tape, Quac stick
Biochemical investigation on admission
Clinical assessment of type
Dietary audit
Functional assessment

The management depends upon its severity. While
mild to moderate can be managed on ambulatory
basis, severe is preferably managed in hospital.
Treatment of mild to moderate malnutrition
Most patients with severe PEM and mild to
moderate dehydration can be treated by oral or
nasogastric administration of fluids.
• Oral rehydration
(a) What fluid to give? The" oral rehydration salts"
(ORS) solution is recommended.

(b) How much fluid to give?
Between 50 and 100 ml of ORS solution per kg of
body weight. This amount should be given in the
first 4-6 hours of treatment, in small quantities
every few minutes.
If the signs of dehydration are still present after 4 -
6 hours but the condition is improving, the same
amount of ORS solution can be given again over
the next 4-6 hours.

(c) Assessment of the patient's condition
After 4-6 hours of oral rehydration, reassess the
patient's condition. When the patient is fully
rehydrated (i.e., the signs of dehydration have
gone), maintenance therapy with ORS solution
should be started and continued until the
diarrhoea stops.

Assessment of patient's condition following oral
rehydration
AFTER 6 HOURS ORAL REHYORATION
IMPROVEMENT CONDITION UNCHANGED CONDITION WORSENS
BREAST MILK OR
HALF·STRENGTH
MILK FORMULA
CONTINUE
ORAL
ELECTROLYT
E AT SAME
RATE
REASSESS
FREQUENTLY
NG ADMINISTRATION
OF FLUIDS, OR
PREFERABLY
INTRAVENOUS
ADMINISTRATION OF
RINGER'S LACTATE
UNTIL SIGNS ARE
ABSENT

• Nasogastric administration of fluids
Nasogastric tube feeding should be started
immediately in children who vomit constantly or
who cannot be fed orally.
The volume of fluid to be given by nasogastric tube
is:
– 120 ml/kg body weight for the first 6 hours,
divided into 12 portions, with one portion given
every half-hour.

• Maintenance therapy
If diarrhoea continues after complete rehydration
has been achieved, the amount of water and salt
lost by the body owing to the diarrhoea should be
replaced by ORS solution-this is maintenance
therapy. For mild diarrhoea, 100 ml/kg body
weight per day should be adequate; for severe
diarrhoea, 2-4 times this amount may be
required.

• Maintenance therapy
it is important to give other fluids in addition to ORS
solution. A breast-fed infant should be given
breast milk as often as he desires it. A non-
breast-fed infant should be given clean drinking-
water in a volume equal to half the volume of
ORS solution taken by the infant.

Treatment of Severe malnutrition
• Patients with severe dehydration and patients
who do not respond after oral or nasogastric
fluids must be treated by intravenous fluid.
• WHO recommends exclusive inpatient
management of children with SAM.
• In SAM, due to physiologic changes and
coexisting infections put severely malnourished
children at particular risk of death from
hypoglycemia, hypothermia, electrolyte
imbalance, heart failure and untreated infections.

• The general treatment involves ten steps in two
phases:
– The initial stabilization phase focuses on
restoring homeostasis and treating medical
complications and usually takes 2 – 7 days of
inpatient treatment.
– The rehabilitation phase focuses on rebuilding
wasted tissues and may take several weeks.

Step 1: Treat/Prevent Hypoglycemia
Blood glucose level <54mg/dl or 3mmol/l
If blood glucose level cannot be measured,
assume hypoglycemia
Hypoglycemia, hypothermia and infection
generally occurs as a triad
Treatment
Asymptomatic hypoglycemia: Give 50ml of 10%
glucose or sucrose solution orally or NG tube followed
by 1st feed. Feed with starter F-75 every 2 hourly (D&N)

Step 1: Treat/Prevent Hypoglycemia
Treatment
Symptomatic hypoglycemia: Give 10%
dextrose IV 5ml/kg. Feed with starter F-75
every 2 hourly (D&N). Start appropriate
antibiotics.
Prevention
Feed 2 hourly starting immediately
Prevent hypothermia

Step 2: Treat/Prevent Hypothermia
Rectal temperature <35.5°C or 95.5°F or axillary
<35°C or 95°F
Always measure glucose and screen for infection
Treatment
Warm clothes; ensure head is covered. Provide
heat using overhead warmer, skin contact or
heat convector. Avoid rapid rewarming. Feed
immediately and give proper antibiotics.

Treatment
In case of severe hypothermia, warm
humidified O2 should be given followed
immediately by 5ml/kg of 10% D Iv or 50 ml of
10% D by NG tube.
If there is a feed intolerance or contraindication
for NG, maintenance IV fluids (prewarmed)
should be started.
Frequently monitor temperature

Prevention
Feed 2 hourly starting immediately after
admission
Place bed in a draught free area
Always keep well covered including head
Skin-to-skin contact (KMC)

Step 3: Treat/Prevent Dehydration
Its difficult to estimate dehydration accurately in
severely malnourished children
Assume that all severely malnourished children
with watery diarrhoea have some dehydration
Hypovolemia can coexist with edema

Treatment
IAP recommends new reduced osmolarity ORS
with potassium supplements, given additionally
Should be corrected slowly over a period of 12hrs.
Some dehydration can be corrected with ORS. IV
only for sever and shock or if enteral route cannot
be used.
ORS is given orally/ NG at 5ml/kg every 30 min for
1st 2 hr and then 5 - 10ml/kg every hour for next 4 -
10 hr.

Treatment
BF should be continued during the rehydration
phase
Refeeding with starter F-75 within 2-3 hr of
starting rehydration. The feeds must be given
on alternative hours with reduced osmolarity
ORS. Continue the feed even after rehydration
Monitor progress and be alert for signs of over
hydration

Prevention
Give reduced osmolarity ORS at 5 – 10ml/kg to
replace stool losses
If breast fed continue BF
Initiate refeeding with starter F – 75 formula
Severe dehydration with shock is treated with IV
fluids. RL with 5% D or ½ NS with 5% D or RL
alone can be used after O2 administration at slow
rate of 15ml/kg.

Step 4: Correct Electrolyte Imbalance
Body sodium is high though plasma sodium is
low. Hence restrict sodium intake.
If Sr. K is <2mEq/l or <3.5mEq/l with ECG
changes, correction at 0.3-0.5 mEq/kg/hr of KCl
in IV fluids. Once severe hypokalemia is
corrected children need supplemental K at 3-4
mEq/kg/day for at least 2 weeks.
On day 1, 50% MgSO4 (4mEq/ml) should be
given at 0.3 ml/kg to a maximum of 2 ml IM.
Thereafter, 0.8-1.2 mEq/kg orally.

Step 5: Treat/Prevent Infection
Multiple infections are common; assume serious
infections and treat
But common signs such as fever are often
absent. Instead hypoglycemia and hypothermia
are markers of infection
Commonly due to gram-negative organisms
Lab investigations should be done to rule out
infections.

Treatment
Suspected infection should be treated with broad
spectrum antibiotics (parenteral)
Ampicillin 50mg/kg/dose 6 hrly for atleast 2 days
followed by oral amoxicillin 15 mg/kg 8 hrly for 5
days and gentamycin and amikacin IM or IV once
daily for 7 days
If no improvement change to cefotaxime IV
If other specific infections are identified give
appropriate antibiotics

Prevention
Follow standard precautions like hand hygiene
Prevent HAI
Give measles vaccine if the child is >6 month and
not immunized, or if the child is > 9 month and had
vaccinated before the age of 9 months.

Step 6: Correct Micronutrient Deficiencies
Up to twice the RDA of various vitamins and
minerals should be used.
Iron should not be given initially, should be added
only after a week of therapy. 3 mg/kg/day
Vitamin A should be given to all SAM. On day 1,
at 50,000 IU, 100,000 IU and 200, 000 IU for
infants 0-5 mo, 6-12 mo and >1 yr unless dose
was given last 1 month. Children >1yr but
weighing <8 kg should receive half dose
Vitamin A for 2 days

Step 6: Correct Micronutrient Deficiencies
Vitamin K single dose 2.5 mg IM at the time of
admission
Daily multivitamin supplements containing thiamine
0.5 mg/1000 kcal, riboflavin 0.6 mg/1000 kcal and
nicotinic acid 6.6 mg/1000 kcal should be given.
Folic acid 1 mg/day (5 mg on day 1)
Zinc 2 mg/kg/day and copper 0.2 – 0.3 mg/kg/day
daily
Emergency management of anemia with whole
blood transfusion with furosemide

Step 7: Initiate Refeeding
Start as soon as possible with small frequent feeds
If not able to take oral feed, initiate NG feeding
Bf continued ad libitum
Suggested starter F-75, older could start on cereal
based diets
Begin with 80 kcal/kg/day and gradually increased to
100 kcal/kg/day. Start with 2 hrly feeds of 11
ml/kg/feed. Night feeds are essential.
Volume increased gradually by decreasing the
frequency

Step 8: Achieve Catchup Growth
Once appetite returns, higher intakes are
encouraged. Starter F-75 can be replaced
gradually with F-100 diets. Each successive feed is
increased by 10 ml until some is left uneaten.
Bf continued ad libitum
Increase volume and decrease frequency to 6
feeds/day
Increase to 150-200 kcal/kg/day and 4-6 g/kg/day
protein
Add complementary foods as soon as possible

Step 8: Achieve Catch-up Growth
Ready-to-use Therapeutic Food (RUTF) A recently
developed home-based treatment for severe acute
malnutrition is improving the lives of hundreds of
thousands of children a year. RUTF has
revolutionized the treatment of severe malnutrition
– providing foods that are safe to use at home and
ensure rapid weight gain in severely malnourished
children.

Step 8: Achieve Catchup Growth
The advantage of RUTF is that it is a ready-to-use
paste which does not need to be mixed with water.
The product, which is based on peanut butter
mixed with dried skimmed milk and vitamins and
minerals, can be consumed directly by the child
and provides sufficient nutrient intake for complete
recovery. It can be stored for three to four months
without refrigeration, even at tropical temperatures.
Local production of RUTF paste is already under
way in several countries including Congo, Ethiopia,

Step 9: Provide Sensory Stimulation &
Emotional support
A cheerful, stimulating environment
Age appropriate play therapy
Age appropriate physical activity as soon
as the child is well enough
Tender loving care

Step 10: Prepare for Follow-up after
Recovery
Child is said to be recovered when his/her
weight for height is 90% of the median
Advised for regular follow-up checks,
immunizations, feed with energy and
nutrient dense foods and play therapy
Care at home should be educated

• The seriously ill malnourished child should be
handled gently and disturbed as little as possible.
• He should be kept clean, dry, and warm.
Vomiting and diarrhoea are common in such
children, and they should not be left in soiled
clothes or lying on soiled sheets.
• The tendency for malnourished children,
especially marasmic patients, to become
hypothermic is aggravated by cool surroundings,
and it is more common at night when sleep and
inactivity reduce heat output. Special care should

be taken at night to ensure that the children are
warm, even though the air temperature may
seem uncomfortably high to the nursing staff.
Frequent feeding and maternal warmth will also
help to prevent the development of hypothermia.
• Malnourished children, especially those with
extensive skin lesions, are also susceptible to
heat and may become feverish if exposed to high
temperatures. The most satisfactory temperature
range which to nurse the malnourished child is
around 25°C.

• Much care and patience are required to feed the
ailing malnourished child, who is weak and has a
poor appetite.
• Nurses and other attending staff should always
use malnourished children's given names and
talk to them even though they may not respond
initially.

• Imbalanced nutrition: Less than body
requirements, related to lack of knowledge and
inadequate food intake
• Risk for infection, related to protein-calorie
malnutrition
• Fluid Volume Deficit related to a decrease in oral
intake and increased loss due to diarrhea.
• Impaired social interaction, related to widowhood
and reduced social support group
• Impaired Growth and Development related to
caloric and protein intake is not adequate.

Micronutrient Deficiency
Xerophthalmia
Xerophthalmia caused by a severe vitamin
A (Retinol) deficiency is described by
pathologic dryness of the conjunctiva and
cornea. The conjunctiva becomes dry,
thick and wrinkled. If untreated, it can lead
to corneal ulceration and ultimately to
blindness as a result of corneal damage.

Xerophthalmia
Symptoms
–Blindness from chronic eye infections,
–Poor growth,
–Dryness and keratinization of epithelial
tissues
–Night blindness is an early symptom.
This is an inability to see in dim light.
–lesions form on your cornea. These
deposits of tissue are called Bitot’s
spots.

Xerophthalmia
Foods rich in key nutrient
It’s a fat-soluble substance found in animal
products like: liver, fortified milk, sweet
potatoes, spinach, greens, carrots,
cantaloupe, apricots

Rickets
Definition
Rickets, disease of infancy and childhood
characterized by softening of the bones,
leading to abnormal bone growth and
caused by a lack of vitamin D in the body.
When the disorder occurs in adults, it is
known as osteomalacia.

Rickets
Symptoms
–weakened bones,
–bowed legs (genu valgum),
–other bone deformities like craniotabes,
spinal & pelvic deformities
–Greenstick fracture
–bone pain or tenderness

Rickets
Food source
–fortified milk,
–fish oils,
–sun exposure

Beriberi
Definition
Beriberi, nutritional disorder caused by a
deficiency of thiamine (vitamin B1) and
characterized by impairment of the nerves
and heart. General symptoms include loss
of appetite and overall lassitude, digestive
irregularities, and a feeling of numbness
and weakness in the limbs and
extremities.

Beriberi
Types
In dry (neurotic) beriberi, there is a gradual
degeneration of the long nerves, first of
the legs and then of the arms, with
associated atrophy of muscle and loss of
reflexes.
In wet (cardiac) beriberi, a more acute form,
there is edema (overabundance of fluid in
the tissues) resulting largely from cardiac
failure and poor circulation.

Beriberi
Unrefined or
fortified cereals
It is sensitive to
heat,
pasteurization
& sterilization

Pellagra
Definition
Pellagra, nutritional disorder caused by a
dietary deficiency of niacin (also called
nicotinic acid) or a failure of the body to
absorb this vitamin B3 or the amino
acid tryptophan, which is converted to
niacin in the body.

Pellagra
Signs & Symptoms
Pathognomonic skin changes. It is
characterized by 3 Ds – dermatitis,
diarrhoea and dementia.

Pellagra
Sources

Scurvy
Definition
Scurvy, also called vitamin C deficiency,
one of the oldest-known nutritional
disorders of humankind, caused by a
dietary lack of vitamin C (ascorbic acid), a
nutrient found in many fresh fruits and
vegetables, particularly the citrus fruits.

Scurvy
Signs & Symptoms
–delayed wound healing,
–internal bleeding,
–abnormal formation of bones and teeth
–In infancy, anorexia, diarrhoea, pallor,
irritability and increased susceptibility to
infection.

Scurvy
Sources

Iron-deficiency anaemia
Definition
Iron deficiency anemia, anemia that
develops due to a lack of the mineral iron,
the main function of which is in the
formation of hemoglobin,
the blood pigment that carries oxygen from
the blood to the tissues.

Signs & Symptoms
–weakness, fatigue, and sometimes
pallor,
–shortness of breath,
–coldness of extremities,
–changeable appetite,
–sore tongue,
–loss of hair,
–brittle fingernails, or dry skin.

Sources

Goitre
Definition
Goitre, enlargement of the thyroid gland,
resulting in a prominent swelling in the
front of the neck. The most common type
of goitre is endemic goitre, caused
by iodine deficiency.

Goitre
Signs & Symptoms
enlarged thyroid gland,
poor growth in infancy and childhood,
possible mental retardation,
Cretinism if iodine deficiency in the fetus

Goitre
Therapy
– Iodization of salt is the most practical option
– Administration of iodized oil capsules every 6-
10 months

Babitha's Notes on Nutritional disorders

Babitha's Notes on Nutritional disorders

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