This document discusses malnutrition in pediatrics. It defines various types of malnutrition including protein energy malnutrition, marasmus, and kwashiorkor. Marasmus is characterized by energy deficiency and wasting, while kwashiorkor involves protein deficiency and can cause edema. Symptoms, assessment measures, treatment, prevention, and the roles of nutrition and occupational therapy are described for managing malnutrition in children.

1. Pediatrics Lecture 1 : Malnutrition
Definitions:
 Protein energy malnutrition - It is a group of body depletion
disorders which include kwashiorkor, marasmus and the
intermediate stages
 Malnutrition- is the condition that develops when the body
does not get the right amount of the vitamins, minerals, and
other nutrients it needs to maintain healthy tissues and organ
function.
 MARASMUS - Represents simple starvation . The body adapts
to a chronic state of insufficient caloric intake
 KWASHIORKOR - It is the body’s response to insufficient
protein intake but usually sufficient calories for energy
Etiology
MEALS ON WHEELS
 Medications
 Emotional problems
 Anorexia
 Late-life paranoia
 Swallowing disorders
 Oral problems
 Nosocomial infections
 Wandering/dementia
related activity
 Hyperthyroid/Hypoadren
alism
 Enteric disorders
 Eating problems
 Low-salt/Stones

2. Risk Factors
 Lack of breast
feeding and giving
diluted formula
 Improper
complementary
feeding
 Over crowding in
family
 Ignorance
 Illiteracy
 Lack of health
education
 Poverty
 Infection
 Familial disharmony
A) Kwashiorkor,
also called wet protein-energy malnutrition, characterized
primarily by protein deficiency.
 appears at the age of about 12 months when breastfeeding is
discontinued, but it can develop at any time during a child's
formative years.
 It causes fluid retention (edema); dry, peeling skin; and hair
discoloration.
Symptoms
• Severe growth
retardation
• Loss of subcutaneous fat
• Severe muscle wasting
• The child looks appallingly
thin and limbs appear as
skin and bone
• Shriveled body
• Wrinkled skin
• Bony prominence

3. • Associated vitamin
deficiencies
• Failure to thrive
• Irritability, fretfulness and
apathy
• Frequent watery
diarrhoea and acid stools
• Mostly hungry but some
are anoretic
• Dehydration
• Temperature is
subnormal
• Muscles are weak
• Oedema and fatty infiltration are absent
B) Marasmus
is a form of severe protein-energy malnutrition characterized
by energy deficiency and emaciation.
 Primarily caused by energy deficiency, marasmus is
characterized by stunted growth and wasting of muscle and
tissue.
 develops between the ages of six months and one year in
children who have been weaned from breast milk or who suffer
from weakening conditions like chronic diarrhea.
Symptoms
• Severe growth
retardation
• Loss of subcutaneous fat
• Severe muscle wasting
• The child looks appallingly
thin and limbs appear as
skin and bone
• Shriveled body
• Wrinkled skin
• Bony prominence
• Associated vitamin
deficiencies
• Failure to thrive
• Irritability, fretfulness and
apathy

4. • Frequent watery
diarrhoea and acid stools
• Mostly hungry but some
are anoretic
• Dehydration
• Temperature is
subnormal
• Muscles are weak
• Oedema and fatty
infiltration are absent
Difference Between Marasmus and Kwashiorkor
CLINICAL
FEATURES
- MUSCLE
WASTING
- FAT WASTING
- EDEMA
- WEIGHT FOR
HEIGHT
- MENTAL CHANGES
MARASMUS
Obvious
Severe loss of
subcutaneousfat
None
Very low
Sometimes quite and
apathetic
KWASHIORKOR
Sometimes
hiddenby edema and
fat
Fat often retainedbut
not firm
Present in lower legs,
and usually in face and
lower arms
May be masked by
edema
Irritable, moaning,
apathetic

5. Assessment
• Full blood counts,
inflammatory markers;
• Blood glucose profile,
lipidic profile
• Iron, vitamin levels;
• Microbiology: septic
screening,stool & urine
for parasites & germs;
• Electrolytes, Ca, Ph & Mg;
• Serum proteins, protein
electrophoresis;
• immunological status:
cellular immunity -
decreased T cell,
interferon, IDR lack of
response to tuberculin;
humoral immunity - low
IgA (secretory IgA), IgM -
high, low IgG.
• Decrease complement
C3;
• Exclude HIV &
malabsorption.
CLINICAL FEATURES
-APPETITE
-DIARRHOEA
-SKIN CHANGES
-HAIR CHANGES
-HEPATIC ENLARGEMENT
MARASMUS
Usually good
Often
Usually none
Seldom
None
KWASHIORKOR
Poor
Often
Diffuse pigmentation,
sometimes ‘flaky paint
dermatitis’
Sparse, silky, easily pulled
out
Sometimes due to
accumulation of fat

6. PI = actual weight of the child / ideal weight (W of child of
the same age located on the 50th percentile of the growth
curve).
After the PI values : 3 degrees of PEM
 degree I (PI = 0.89 to 0.76)
 degree II (PI = 0.75 to 0.60)
 degree III ( PI = 0.60).
 degree I PI = 0.8-0.6 - KWASHIORKOR
 degree II PI= 0.6 – MARASMIC KWASHIORKOR
 PI = 0.90- underweight or child at risk of malnutrition.
Nutritional index (NI) - index diets.
• NI = actual weight / weight appropriate waist.
After this indicator there are 3 degrees of malnutrition:
• grade I (NI= 0.89 to 0.81);
• grade II (NI= 0.80 to 0.71);
• grade III (NI= 0.70).

7. OT Role
• Occupational therapy offers patients goal-directed activity to
increase their functional mobility and self-care abilities.
• Psychological problems may emerge during hospitalization;
pain, fear, and change in medical status will influence
motivation and activity tolerance. Patients may attempt to
avoid activity because they are generally deconditioned from
prolonged illness and bedrest.
• A program of individualized activity should be instituted if
nutritional intake is used appropriately, and it should result in
increased strength and endurance.
• Physical activity or exercise enhances the synthesis of protein
into skeletal muscle. Because the body does not store protein,
unused calories are stored only as fat or, to a lesser extent,
carbohydrates.
Complications
• Hypoglycemia
• Hypothermia
• Hypokalemia
• Hyponatremia
• Heart failure
• Dehydration & shock
• Infections (bacterial, viral
& thrush)
Treatment
I)Parenteral nutrition for 2-3 days → enteral nutrition with flow
probe using hyperproteic and hypercaloric solutions ;
II) Early initiation of oral nutrition :

8. – hypoallergenic preparations rich in proteins and calories,
low osmolarity: Alfare, PeptiJunior, Pregestimil,
Nutramigen, Pregomin or amino acid formulas, such as
Neocate .
– Keep in parallel parenteral intake of carbohydrates,
amino acids, lipids.
– Simultaneously treating infections, hypoproteinemia,
anemia, multivitamins deficiencies .
III) after fluid replacement and electrolyte - digestive tolerance :
- with carrot soup or rice mucilage (in various concentrations ) in
a dose of 150-200 ml / kg ( not exceeding 1000 ml / day)
- carbohydrates were obtained from glucose 5%, 7 %, 10 % and
chicken mixed proteins ( hypoallergenic, 100g , 17g protein).
- after normalization of the stools ( 7 days) :oil gradually (3-4 ml
/ day ) and after 10 days from the beginning of enteral diet
→hypoallergenic preparation can be inserted (!preparations
lactose free- can induce cow's milk protein intolerance ) .
- week 4 :sugar (restoring lactose tolerance is difficult , 3-4
months);
- flour products containing gluten will not enter until full
recovery;
- increases in protein - calorie intake by parenteral
administration of carbohydrates , amino acids and proteins;
- treat the infection , iron or vitamin deficiencies .

9. Education
• Patient
• Family
• Community
• WHO/World
Prevention
• Promotion of breast feeding
• Development of low cost weaning
• Nutrition education and promotion of correct feeding practices
• Family planning and spacing of births
• Immunization
• Food fortification
• Early diagnosis and treatment