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1. NUTRITIONAL DEFICIENCY DISORDERS
INTRODUCTION
During childhood, the body needs a diversity of nutrients (carbohydrates, protein,
fat, vitamins and minerals) in appropriate amounts to ensure optimal growth, proper physical
and cognitive development, and appropriate physical fitness. Nutritional deficiencies can be
very significant to the overall health of infants and children because growth and development
can be seriously hindered by shortages in vitamins and nutrients.
DEFINITION OF MALNUTRITION
Malnutrition is a general term for a medical condition caused by an improper or
insufficient diet. It must often refer to under nutrition resulting from inadequate consumption,
poor absorption or excessive loss of nutrition but the term can also encompass over nutrition
resulting from overeating or excessive intake of specific nutrients.
INCIDENCE
1. In 2014, approximately 462 million adults worldwide were underweight, while 1.9
billion were either overweight or obese.
2. In 2016, an estimated 155 million children under the age of 5 years were suffering
from stunting, while 41 million were overweight or obese.
3. Around 45% of deaths among children under 5 years of age are linked to under
nutrition. 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.
4. 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.
https://www.who.int/news-room/fact-sheets/detail/malnutrition
fact-sheet:- 1April, 2020 WHO
% of children of :
 Stunting: 36%
 Severe stunting : 12%
 Wasting : 10%
 Severely wasting: 2%
 Underweight: 27%
 Severely underweight: 5%
 Overweight: 1%
-2016 (NDHS).

2. CAUSES/RISK FACTORS
● Poverty:
The poor family cannot purchase adequate amount of food of the desired
quality of meeting their and their family’s nutritional requirements. This deprivation
adversely affects their capacity for physical work resulting in low earning and
poverty.
● Low Birth Weight:
Malnourished mothers have a high incidence of low birth weight and growth
retarded babied with poor nutritional reserve.
● Infections:
Infections such as diarrhea, pneumonia, malaria, measles, whooping cough
and tuberculosis precipitate acute malnutrition and aggravate the existing nutritional
deficit. Because child’s appetite is impaired during infection result lack of food for
energy and body start to catabolize his own tissue to procedure energy. During
catabolism tissue breakdown causes loss of protein result low immunity keep child in
high to developing infections.
● Population Growth:
Increase in the birth rate leads over population growth in the country is
disproportionate to the increase in food production. Similarly large families and
higher birth order result in higher incidence of malnutrition.
● Feeding habits:
Lack of exclusive breast feeding for first 6 months makes the child prone to
early onset malnutrition. Similarly late initiation of weaning, diluted milk formula use
of improper weaning food early, stoppage of breast feeding, habit of withhold food
supplements during episodes of diarrhea, prevailing dietary practices and cultural
taboos on consumption of certain types of foods are the conditioning factors
developing malnutrition.
● Education:
In the context of Nepal, education is a vital cause of malnutrition because lack of
awareness and knowledge regarding food preparation preservation, family planning,
maintaining food hygiene and way of feeding child are seen as the major causes of
malnutrition.
● Geography:
Certain types of geographical territory such as high hill areas may contribute for
malnutrition indirectly. In high hill areas the soil is not good and it’s hard to cultivate
croups. This ultimately leads low production of food and low production leads low
consumption result malnutrition.
 Others:
High pressure advertising of baby foods, chronic disease (malabsorption), starvation,
twin baby, short interval between birth, large family size etc.

3. ASSESSMENT OF NUTRITIONAL STATUS
In infants and children under five years of age assessment of growth has been the
single most important measurement that best defines their nutritional status. Assessment of
the nutritional status of the child by the use of nutritional anthropometric indicators of growth
has thus been used not only to provide information on the nutritional and health status of
children but also as an indirect measure of the quality of life of the entire community or
population, and thereby as an indicator of the nutritional status and adequacy of food of all
members of community.
ANTHROPOMETRIC measurements such as weight and height and the associated
indicators, for example, height-for-age, weight-for-age, and weight-for-height, are among the
principal tools used by researchers, public health workers and clinicians to assess the health
and nutritional well-being of individuals and population groups at nearly all life stages.
Various references have been used for the various age groups have been made available by
WHO:
● Length/height-for-age
● Weight-for-age
● Weight-for-length
● Weight-for-height
● Body mass index-for-age
● Head-circumference-for-age
● Arm-circumference-for-age
● Subscapular skinfold-for-age
● Triceps skin fold-for-age
● Motor development milestones
Classification
Malnutrition is classified in different class, some of them are:
1. Welcome Trust Classification
This is based on weight for age of the child and presence or absence of edema:
Range of weight for age Edema +/- Nutritional status
>80% Absent Normal
60-80% Absent Undernutrition
60-80% Present Kwashiorkor
<60% Absent Marasmus
<60% Present Marasmus kwashiorkor
2. Water low’s classification
Based on age of the child and the measurement of weight and height:

4. Weight for height Height for age Nutritional status
>80% >90% Normal
<80% >90% Wasted
>80% <90% Stunted
<80% <90% Wasted and Stunted
WHO classification
a. Stunting: Low height- for- age indicator of chronic malnutrition that is result
of prolonged food deprivation, or disease.
b. Wasting: Low weight- for- height indicate or suggest acute malnutrition, the
result of more recent food deficit or illness
c. Underweight: Low weight- for- age. It is the combined indicator to reflect
both acute and chronic malnutrition
Protein Energy Malnutrition (PEM)
It can be defined as a group of clinical conditions that may result from varying degree of
protein deficiency and energy (calories) inadequacy. Previously it was known as protein
calorie malnutrition. PEM is a potentially fatal body depletion disorder. It is the leading cause
of death in children in developing countries.
Protein calorie malnutrition is defined as a range of pathological condition arising out of co-
incident lack of protein and energy in varying proportions most frequently seen in infant and
young children and usually associated with infection. (WHO)
PEM is categorized into:
1. Mild PEM
2. Moderate PEM
3. Severe PEM: Kwashiorkor, Marasmus, Kwashiorkor Marasmus
Mild PEM: This is common in children between 9 months to3 years (according to kamala
uperty child book) or It is most common between the ages of 9 months and 2 yr.( according
to ghai book). It's main a cause is deficit dietary intake for a short period. Main features are
as follows:
(i) Growth failure: This is manifested by slowing or cessation of linear growth; static or
decline in weight; decrease in mid-arm circumference; delayed bone maturation;
normal or diminished weight for height Z scores; and normal or diminished skin fold
thickness.
(ii) Infection: A high rate of infection involving various organ systems may be seen, e.g.
gastroenteritis, pneumonia and tuberculosis.
(iii)Anaemia: May be mild to moderate and any morphological type may be seen.
(iv)Activity: This may be diminished
(v) Skin and hair changes: These may occur rarely.
Moderate PEM: If the food deficit persists for a longer period, the child will develop
moderate PEM. This is also known as Runche (the local language of moderate PEM) which
mean crying children. Common age for moderate PEM is between 1 to 4 years. The
presentation of moderate PEM are similar to mild PEM but it is more easily recognizable
forms which includes children appear more slow and less energetic, growth failure, (more in

5. weight), thin limbs flattened buttock with wrinkling of skin over the front of thighs, winged
scapula, distended abdomen, repeated infection and loss of subcutaneous fat beneath skin.
Severe PEM: Severe form of PEM is associated with one of classical syndromes, namely,
marasmus, kwashiorkor, or Marasmus kwashiorkor
Kwashiorkor
Kwashiorkor was first described by Dr. Cicely Williams in 1933, but the particular term
“kwashiorkor” was introduced in 1935, according to local name for the disease in Ghana. It
usually affects children aged 1-4 yr. The main sign is pitting edema, usually starting in the
legs and feet and spreading, in more advanced cases, to the hands and face. Because of
edema, children with kwashiorkor may look healthy so that their parents view them as well
fed. Dietary history revels deficient intake of both protein and calories but protein lack is
more predominant. The presenting features can be divided into two group i.e. essential and
nonessential features.
● Essential features of kwashiorkor.
 Marked growth retardation with low weight and height gain.
 Muscle wasting with retention of some subcutaneous fat.
 Psychomotor changes characterized by mental apathy with listless, inertness, lack of
interest about the surrounding lethargy, dullness and loss of appetite.
 Pitting edema, especially over the pretibial region, due to hypoalbuminemia and
increased capillary permeability with damage cell membrane.
● Non essential features of kwashiorkor:
 Hair changes (alopecia)
 Skin changes (flaky- paint dermatitis )
 Superadded infection.
Marasmus
It is a common in infant and many found in toddlers and even in later life. It results from
rapid deterioration in nutritional status. Acute starvation or acute illness over a borderline
nutritional status could precipitate this form of undernutrition. It is characterized by marked
wasting of fat and muscle as these tissues are consumed to make energy. The child looks like
old person with wizened and shriveled face due to loss of buccal pad of fat. Initially the child
is irritable, Hungary and craves for food, but in later stages may become miserable apathetic
and refusal to take anything orally. The clinical features are subdivided into essential and non
essential features.
● Essential features of nutritional marasmus
 Marked growth retardation with less than 60 % of expected weight for age and
subnormal height /length.
 Gross wasting of muscle and subcutaneous tissue.
 Marked stunting and absence of edema.
 Non essential features of nutritional marasmus

6.  Hair changes usually not present or may be hypo pigmented.
 Skin looks dry, scaly with prominent loose folds and having reduced mid- upper arm
circumference.
 Superadded infections are common skin infections and diarrhea with vomiting and
abdominal distention usually occurs.
 Liver usually shrunk and the child is having craving for food and hunger.
 Psychomotor changes usually present with irritability. Apathy and miserable
appearance.
 Features of mineral deficiencies (anemia) and vitamin deficiencies are usually found.
Grading of nutritional marasmus is done depending upon the area of loss of fat.
● Grading I : is considered when there is loss of fat from axilla
● Grade II : for loss of fat from abdominal wall and gluteal region
● Grade III: for loss of fat from chest and back.
● Grade IV: for loss of buccal pad of fat.
Marasmus kwashiorkor:
It is condition where the child manifested both the features of marasmus and kwashiorkor.
The presence of edema is essential for the diagnosis and other features of kwashiorkor may or
may not be present.
Clinical finding Marasmus kwashiorkor
Occurrence More common Less common
Edema Absent Present
Activity Active apathetic
Liver enlargement Absent Present
Mortality Less than kwashiorkor High in early stage
Recovery Recovery early Slow recovery
Infection Less prone More prone
Appetite Good hungry Poor
Weight Grossly Underweight Underweight
Vitamin absorption Normal Markedly reduced
Diagnosis
(i) History: It includes dietary history, child health history and history of family, etc
(ii) Physical examination: overall appearance, skin, muscles, and amount of body far they
have, eating habit, etc.
(iii)Assessment of nutrition status:
Growth chart
Weight and height measurement
Measurement of mid upper arm circumference
(iv)Lab tests may include lipid profile, complete blood count, albumin, total protein, iron
tests (iron, ferritin), vitamin and minerals (vitamin B12, folate, vitamin D,K, ca, mg)
(v) Non laboratory test: X-rays, CT-scan, MRI. This helps evaluate the health of internal
organ and the normal growth and development of muscles and bones.
,

7. Treatment and Management of PEM
Depending upon the severity of condition can be done at home (mild), nutritional
rehabilitation center (NRC) (moderate) or in hospital (severe).
The child with severe PEM need hospitalization for initial treatment of associated life
threatening problems, correction of metabolic abnormalities and beginning of
intensive feeding with follow up.
Ten essential steps of management
1. Treatment or prevent hypoglycemia
Blood glucose level <54 mg/dl or 3 mmol/1. If blood glucose cannot be measured,
assume hypoglycemia. Hypoglycemia, hypothermia and infection generally occur as
a triad
Treatment
(i) If the child is conscious and glucose level is less than 54 mg/al then 50ml bolus of
10% dextrose orally or by NG tube. Start feeding every 30 min for 2 hours.
(ii) If unconscious: IV 10% glucose (5ml/kg) followed by 50 ml of 20% glucose and
feeding as above
(iii)Monitor blood glucose level
(iv)Start appropriate antibiotics
2. Treat /prevent hypothermia
If axillary temperature is less than 35degree Celsius
Prevention
(i) Feed 2 hourly starting immediately
(ii) Prevent hypothermia
(iii)Rectal temperature less than <35.5°C or 95.5°F or axillary temperature less than
35°C or 95°F
(iv)Always measure blood glucose and screen for infections in the presence of
hypothermia
Treatment
(i) Clothes the child with warm clothes; ensure that the head is also covered with
a scarf or cap
(ii) Provide heat using overhead warmer, skin contact or heat convector
(iii)Avoid rapid rewarming as this may lead to disequilibrium
(iv)Feed the child immediately
(v) Give appropriate antibiotics
3. Treat/ prevent dehydration
Do not use the IV route for rehydration except in case of shock. Give special
rehydration solution for malnutrition.
Resomal 5 ml/kg every 30 min for 2 hours, orally or by NG them 5-10 ml/kg/hour for
next 4-10 hours.
Amount depends on stool loss and how much child wants to drink
Continue feeding or breastfeeding
Watch for pulse, respiration and urine frequency.
4. Correct electrolyte imbalance
(i) All malnourished children have deficiency of potassium and magnesium which
may take 2 weeks or more to correct. Edema should not be treated with
diuretics, excess serum sodium is present
(ii) Give reduced osmolarity ORS at 5-10 ml/kg after each watery stool, to replace
stool losses.

8. (iii)If breastfed, continue breastfeeding.
(iv)Give supplemental potassium at 3-4 mEq/kg/ day for at least 2 weeks.
(v) On day l, give 50% magnesium sulphate (equivalent to 4 mEq/ml) IM once (0.3
ml/kg; maximum of 2 ml). Thereafter, give extra magnesium (0.8-1.2 mEq/kg
daily).
(vi)Excess body sodium exists even though the plasma sodium may be low;
decrease salt in diet
5. Treat/ prevent infection
In severe malnutrition, the usual sign of infection is often absent but multiple infections are
common. Therefore all the malnourished children are assumed to be seriously infected and
treat. Usual signs of infection such as fever are often absent. Majority of bloodstream
infections are due to gram-negative bacteria. Hypoglycemia and hypothermia are markers of
severe infection
Treatment
(i) Treat with parenteral ampicillin 50 mg/kg/ dose 6 hourly for at least 2 days followed
by oral
(ii) amoxicillin 15 mg/kg 8 hourly for 5 days and gentamicin 7.5 mg/kg or amikacin 15-
20 mg/kg
(iii)IM or IV once daily for 7 days
(iv)If no improvement occurs within 48 hr, change to IV cefotaxime (100-150 mg/kg/day
6-8 hourly) or ceftriaxone (50-75 mg/kg/day 12 hourly)
(v) If other specific infections are identified, give appropriate antibiotics
Prevention
a) Follow standard precautions like hand hygiene
b) Give measles vaccine if the child is >6 mo and not immunized, or if the child is >9
month and had been vaccinated before the age of 9 months
6. Correct micronutrient deficiencies
Child may have vitamin and mineral deficiencies. Use up to twice the recommended
daily allowance of various vitamins and minerals. On the first day give vitamin A
orally (if age >1 yr give 2 lakh IU; age 6-12 mo give 1 lakh IU; age 0-5 month give
50,000 IU)
Folic acid 1 mg/ day (give 5 mg on first day1)
Zinc 2 mg/kg/ day
Copper 0.2-0.3 mg/kg/day
Iron 3 mg/ kg/ day, once child starts gaining weight; after the stabilization phase
7. Start caution feeding
Start feeding as soon as possible as frequent small feeds. If unable to take orally,
initiate nasogastric feeds.
Total fluid recommended is 130 ml/kg/ day; reduce to 100 ml/kg/ day if there is
severe edema.
Continue breastfeeding and Start with F-75 starter feeds every 2 hourly
If persistent diarrhoea, give a cereal based low lactose F-75 diet as starter diet
If diarrhoea continues on low lactose diets give, F-75 lactose free diets (rarely
needed)
Feeding pattern
Days Frequency Volume /kg/ feed Volume /kg /day
1-2 2 hourly 11ml 130ml
3-5 3 hourly 16ml 130ml
6-7+ 4 hourly 22ml 130ml
Monitor and note, amount left over, vomiting, stool pass, daily body weight

9. 8. Achieve for catch up growth
(i) Once appetite returns in 2-3 days, encourage higher intakes.
(ii) Increase volume offered at each feed and decreases the frequency of feeds to
6 feeds per day.
(iii)Continue breastfeeding.
(iv)Make a gradual transition from F-75 to F-100 diet
(v) Increase calories to 150-200 kcal/kg/ day, and proteins to 4-6 g/kg/ day
(vi)Add complementary foods as soon as possible to prepare the child for home
foods at discharge
9. Provide sensory stimulation and emotional support
A cheerful, stimulating environment
Age appropriate structured play therapy for at least 15-30 min/ day
Age appropriate physical activity as soon as the child is well enough
Tender loving care
10. Prepare for follow up visit:
a. Primary failure to respond is indicated by:
(i) Failure to regain appetite by day 4
(ii) Failure to start losing edema by day 4
(iii)Presence of edema on day 10
(iv)Failure to gain at least 5 g/kg/day-by-day 10
b. Secondary failure to respond is indicated by:
(i) Failure to gain at least 5 g/kg/day for consecutive days during the rehabilitation
phase
Preventive Management of PEM
Nutritional education is the high priority to prevent to prevent this problem. Other
preventive measures include the followings:
1. Health promotion
❏ Improvement of health of pre-pregnant state, pregnant mother and lactating women
towards healthy mother for healthy child.
❏ Promotion of exclusive breastfeeding upto 6 month of age to prepare firm base of
child health and promotes nutritional status.
❏ Appropriate weaning practices and necessary nutritional supplementation.
❏ Improvement of family dietary habit with locally available, low cost food items for
balanced diets.
❏ Nutrition education and nutrition counselling to promote correct feeding practices,
food habits, food hygiene, safe water, environment sanitation and to eliminate
misconception regarding food and feedings.
❏ Improvement of home economics, earning, income generating activities, adequate
dietary budget and diet planning for family members.
❏ Birth spacing and regulating family size.
❏ Promotion of educational status especially women literacy to improve the family
health.

10. ❏ Provision of nutritional supplementation from ICDS centres' and schools (mid-day
meal).
❏ Maintenance of healthy environment congenial for physical, social and psychological
development of children.
2. Specific protection
❏ Provision of balanced diet with adequate proteins and energy for all children
according to the age.
❏ Immunization against vaccine preventable disease.
❏ Promotion and maintenance of hygiene measures (hand washing, food hygiene)
❏ Food fortification to enrich the food items.
3. Early diagnosis and treatment
❏ Periodic health check-up of all children for health supervision and maintenance of
growth chart.
❏ Detection of growth lag or growth failures as early as possible .
❏ Early diagnosis and management of infections, worm infestations and common
childhood illness (ART, diarrhoea, measles, malaria).
❏ Promotion of early rehydration therapy in the child having diarrhoea, without
restriction of feeding.
❏ Implementation of supplementary feeding programs and services.
4. Rehabilitation
❏ Nutritional rehabilitation services.
❏ Hospital management of advanced of PEM cases.
❏ Follow -up -care.
Complication
PEM has acute and long-term complication which influence the outcome.
1. Acute complication
➔ Systemic or local infections
➔ Severe dehydration
➔ Shock
➔ Dyselectrolytemia
➔ Hypoglycaemia
➔ Hypothermia
➔ CCF
➔ Bleeding disorder
➔ Hepatic dysfunction
➔ Sudden infant death syndrome (SIDS)

11. ➔ convulsion
2. Long term complication
➔ Growth retardation
➔ Mental sub normality
➔ Visual and learning disabilities
Nursing Management
1. Assessment
● Ask the nutritional history with the patient and their visitor.
● Monitor laboratory values that indicate well being or deterioration.
● Assess patients' ability to obtain and use essential nutrients.
● Assess the physical activity level and mobility of the patient.
2. Nursing Diagnosis
a. Imbalanced nutrition less than body requirements related to inadequate intake.
b. Delayed growth and development related to malnutrition.
c. Activity intolerance related to generalized weakness.
3. Nursing Intervention
a. Imbalanced nutrition
Provide good oral hygiene and dentition.
Provide a pleasant environment or as a child want.
Provide high protein supplements based on patient needs and capabilities.
If patient want own home food encourage family members to bring food from home
to the hospital.
b. Delayed growth and development
Promote adequate nutrition
Develop individualized teaching plan to instruct parents of child's dietary needs.
Specify type of diet, essential nutrients, serving quantity and method of preparation.
Provide a quiet, non stimulating environment for eating.
Demonstrate proper feeding techniques including details on how to hold and how long
to feed the child.
Administer multivitamin supplement as prescribed.
c. Activity intolerance
Establish guidelines and goals of activity with the patient.
Gradual increase activity with range of motion exercise in bed, increasing to sitting
and then standing.
If necessary assist the patient to perform activity more slowly, in a longer time with
more rest or pause.
Provide emotional support and positive attitude regarding abilities.
● REFERENCES
1) Paul VK, Bagga A, Ghai Essential Pediatrics, eighth Edition. CBS Publisher and
distributors Pvt Ltd, New Delhi, India: 2009. pg 95-107.

12. 2) Uprety K, Child Health Nursing, fourth Edition (2071 Bhadra), Tara Books and
Stationery, Chhetrapati, Kathmandu, pg 346- 352
3) Dahal K, Community Health Nursing –II, fifth Edition, Makalu Publication House,
Dillibazar, Kathmandu, Nepal, page 172- 175
4) Shrestha T, Nursing Care of Children, first Edition 2015 August, Medhavi
Publication Jamal, Kantipath, Kathmandu, Page 204-209
5) https://www.who.int/news-room/fact-sheets/detail/malnutrition
6) http://dohs.gov.np/wp-content/uploads/2020/11/DoHS-Annual-Report-FY-075-76-
.pdf