Malnutrition in children manifests in four main forms: wasting, stunting, underweight, and micronutrient deficiencies. Wasting is low weight-for-height and indicates recent severe weight loss. Stunting is low height-for-age and results from chronic undernutrition impairing physical and cognitive potential. Underweight refers to low weight-for-age. Micronutrient deficiencies lack vitamins and minerals essential for growth. The main types of severe acute malnutrition are kwashiorkor characterized by edema, and marasmus characterized by emaciation. Treatment involves correcting medical issues, providing nutrient-dense therapeutic foods, and addressing the social causes of malnutrition.

1. MALNUTRITION IN CHILDREN
DIVYESH R. KANGAD
NURSING TUTOR
GNS – JUNAGADH
CHILD HEALTH NURSING

2. MALNUTRITION
• Malnutrition refers to deficiencies or excesses in
nutrient intake, imbalance of essential nutrients or
impaired nutrient utilization.
• The double burden of malnutrition consists of both
under nutrition and overweight and obesity, as well
as diet-related no communicable diseases.
• Under nutrition manifests in four broad forms:
wasting, stunting, underweight, and
micronutrient deficiencies.

3. Definition:
• 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”
-WHO
Wasting:
• Wasting is defined as low weight-for-height. It
often indicates recent and severe weight loss,
although it can also persist for a long time. It usually
occurs when a person has not had food of adequate
quality and quantity and/or they have had frequent
or prolonged illnesses. Wasting in children is
associated with a higher risk of death if not treated
properly.

4. Stunting:
• Stunting is defined as low height-for-age. It is the result
of chronic or recurrent under nutrition, usually associated
with poverty, poor maternal health and nutrition, frequent
illness and/or inappropriate feeding and care in early life.
Stunting prevents children from reaching their physical and
cognitive potential.
Underweight:
• Underweight is defined as low weight-for-age. A child
who is underweight may be stunted, wasted or both.
Micronutrient deficiencies:
• These are a lack of vitamins and minerals that are
essential for body functions such as producing enzymes,
hormones and other substances needed for growth and
development.

5. Classification according to severity
• According to WHO, these can be
classified in to two categories
 Moderate Acute Malnutrition (MAM)
 Severe Acute Malnutrition (SAM)

6. Moderate Acute Malnutrition
• A child with 70-80% of median weight-for- height
(Z score of <-3SD to <-2 SD), or a Mid Upper Arm
Circumference of 115-125 cms and no edema is
classified as a case of Moderate Acute
Malnutrition.
• In addition the child should have appetite, be alert
and clinically well. Children with moderate acute
malnutrition can be managed in the Outpatients
setting where there is a provision for
supplementary feeding.

7. Severe Acute Malnutrition (SAM)
• Severe acute malnutrition is defined by very low
weight-for-height/length (Z- score below -3 SD of
the median WHO child growth standards), or a
mid-upper arm circumference < 115 mm, or by the
presence of nutritional edema.
• Severe Acute Malnutrition is both a medical and
social disorder.
• Lack of exclusive breast feeding, late introduction of
complementary feeds, feeding diluted feeds
containing less amount of nutrients, repeated
enteric and respiratory tract infections, ignorance,
and poverty are some of the factors responsible for
Severe Acute Malnutrition (SAM).

8. Severe Acute Malnutrition (SAM)
• SAM significantly increases the risk of death in
children under five years of age.
• It can be a direct or indirect cause of child death
by increasing the case fatality rate in children
suffering from such common illnesses as
diarrhea, acute respiratory infections, malaria
and measles.
• According to National Family Health Survey 3
(2005-06), 6.4% of children below 60 months of
age or nearly 8 .1 million were estimated as
having severe acute malnutrition

9. Assessment
of
Malnourished child

10. Take a history concerning
• Recent intake of food and fluids ™
• Usual diet (before the current illness) ™
• Breastfeeding
• Duration and frequency of diarrhea and vomiting ™
• Type of diarrhea (watery/bloody) ™
• Chronic cough ™
• Loss of appetite ™
• Family circumstances (to understand the child’s
social background) ™
• Contact with tuberculosis ™
• Recent contact with measles ™
• Known or suspected HIV infection. ™
• Immunizations

11. On examination, look for
Anthropometry- weight,
height/ length, mid arm
circumference ™
Edema ™
Pulse, heart rate, respiratory
rate ™
Signs of dehydration ™
Shock
(cold hands, slow capillary
refill, weak and rapid pulse) ™
Palmar pallor ™
Eye signs of vitamin A
deficiency: ‹
• Dry conjunctiva or cornea, ‹
• Bitot’s spots ‹
• Corneal ulceration ‹
• Keratomalacia ™
• secondary infection (including
Candida).
Localizing signs of infection,
including ear and throat
infections, skin infection or
pneumonia ™
Fever (temperature ≥ 37.5° C
or ≥ 99.5° F) or hypothermia
Mouth ulcers ™
Skin changes of kwashiorkor: ‹
Hypo or hyperpigmentation ‹
Desquamation ‹
Ulceration (spreading over
limbs, thighs, genitalia, groin,
and behind the ears) ‹
Exudative lesions (resembling
severe burns) often with

12. CAUSES
OF
MALNUTRITION

13. DISORDERS DUE TO MAL-NUTRITION
 Protein-energy malnutrition
 Kwashiorkor
 Marasmus
 Deficiencies of Vitamins
 Thiamine (Vit B1) Deficiency - Beriberi
 Niacin (Vit B3) Deficiency - Pellagra
 Vitamin C Deficiency - Scurvy
 Vitamin D Deficiency - Rickets
 Vitamin A deficiency - Eye disorders
 Deficiencies of Minerals
 Calcium deficiency - Rickets
 Iodine deficiency - Goiter
 Iron deficiency - Anemia
 Zinc deficiency - Growth retardation
 Obesity.

14. Kwashiorkor
• Kwashiorkor is a form of severe protein malnutrition
characterized by edema and an enlarged liver with fatty
infiltrates. It is caused by sufficient calorie intake, but
with insufficient protein consumption. (Between 1-
3 years old children)
• Kwashiorkor is a serious condition that can happen
when a person does not consume enough protein. Severe
protein deficiency can lead to fluid retention, which can
make the stomach look bloated.
• Protein malnutrition, or kwashiorkor, is mostly found in
people living in geographical areas that have limited food
resources. It's most commonly seen in children whose
diets are low in protein and calories

15. Epidemiology
• Close to 50 million children younger than 5 years have
PEM Approximately 80% of these malnourished children
live in Asia, 15% in Africa, and 5% in Latin America.
Mortality/Morbidity
• 5 million children younger than 5 years die every year of
malnutrition.
• 70 million present with wasting, and 230 million present
with some stunting
Indian scenario
• Childhood malnutrition is underling cause of death in
35% of all death under five.
• During first six month due to unsuccessful exclusive
breast feeding 20-30% babies are already mal nourished
• By 18-23 month, during weaning, 30% are severely
stunted and 1/5 are under weight.

16. Symptoms
• Changes in skin pigment.
• Swelling (edema)
• Decreased muscle mass
• Diarrhea
• Failure to gain weight
and grow
• Fatigue
• Hair changes (change in
color or texture)
• Increased and more
severe infections due to
damaged immune system
• Irritability
• Large belly that sticks out
(protrudes)
• Lethargy or apathy
• Loss of muscle mass
• Rash (dermatitis)
• Shock (late stage)
• Moon face

17. Nursing care of Kwashiorkor
• Support the infant and parents
• Proper diet intake proteins and CHO vitamins
• Nursing care for vomiting, diarrhea or dehydration
• Skin care for child for edema, injuries.
• Avoid any infection and follow hygienic measures
for child.
• Frequent assessment of growth and development
• Safety measures to avoid injuries.
• Nutritional counseling
• Record intake and out put
• Health education about medications and follow up
• Frequent monitoring for any complications

18. Common nursing diagnoses
• Body image disturbance related to bone
deformities
• Altered nutritional requirements related to
deficiency of calcium
• High risk for infection related to low of
immunity.
• High risk for injury related to weakness of bones
and deformities.

19. Marasmus
• The term marasmus is derived from the Greek word
Marasmos, which means "withering" or "wasting".
• Marasmus is a form of severe protein-energy
malnutrition characterized by energy deficiency
and emaciation (abnormally thin or weak)
• Primarily caused by Energy deficiency, Marasmus is
characterized by stunted growth and wasting of
muscle and tissue.
• Marasmus usually develops between the ages of 6
months and 1 year in children who have been
weaned from breast milk or who suffer from
weakening conditions like chronic diarrhea.

20. Causes
• Poor feeding habits due to improper training
• Lack of breast feeding and the use of dilute
animal milk.
• A physical defect e.g. cleft lip or cleft palate or
cardiac abnormalities, which prevent the infant
from taking an adequate diet.
• Diseases, which interfere with the assimilation
of food e.g. cystic fibrosis
• Infections, which produce anorexia
• Loss of food through vomiting and diarrhea
• Emotional problems e.g. Disturbed mother-
child relationship.

21. Laboratory findings
• Blood glucose level
• Hemoglobin level
• Urine analysis
• Stool test
• Electrolyte tests

22. Complications of Marasmus
• Lack of proper growth in children
• Joint deformities
• Severe weakness
• Permanent vision loss
• Organ failure
• Coma.

23. Nursing intervention
• Support the infant and parents
• Provide nutrition rich in essential nutrients
• Give small amounts of foods limited in proteins,
carbohydrates and fats
• Maintain body temperature
• Provide periods of rest and appropriate activity and
stimulation
• Record intake and output
• Weight daily
• Change position frequently
• Proper treatment is given for infection
• Protection from infected persons and injuries
• Refer family to social worker for financial support
• Education for parents about proper nutrition

24. Nursing diagnosis
• Altered nutrition, less than body requirements
related to knowledge deficit, infection, emotional
problems, and physical deficit
• Body temperature alteration (hypothermia)
related to low subcutaneous fat and deficiency of
food intake
• Impaired skin integrity related to vitamins
deficiency
• Fluid volume deficit related to diarrhea
• High risk for infection related to low body
resistance.

26. Management of malnutrition (acc.WHO)
• Inpatient treatment takes between 2 to 6 weeks. However, if
the necessary community support is available close to where
the child lives, they may be discharged early (at step 8) to
continue recovery at home.
• Routine inpatient treatment is summarized in ’10 steps’:
1. Treat/ prevent hypoglycemia
• Treat hypoglycemia with glucose immediately. To prevent
hypoglycemia, feed malnourished children 2-3 hours day
and night. Start straightaway.
2. Treat/prevent hypothermia
• To treat hypothermia actively re-warm the child. To prevent
hypothermia, keep malnourished children warm day and
night.
3. Treat/prevent dehydration
• Too much fluid can kill. Rehydrate more slowly than usual.
Do not give IV fluids except in shock.

27. Continue…….
4. Correct electrolyte imbalance
• Give extra potassium and magnesium daily. Limit
sodium (salt).
5. Treat/prevent infection
• Give antibiotics routinely to all severely malnourished
children to treat hidden infections and prevent death.
Wash hands to prevent cross-infection.
6. Correct micronutrient deficiencies
• Give extra vitamin A, zinc, copper, folic acid and
multivitamins. Do not give iron until the child is in the
rehabilitation phase.
7. Start cautious feeding
• Give small amounts of F75 every 3 hours day and night.
F75 is a special formula designed to meet the needs of
malnourished children.

28. Continue…….
8. Achieve catch-up growth
• For rapid weight gain, give as much F100 or ready-
to-use therapeutic food (RUTF) as the child can eat,
8 times a day. F100 and RUTF are high in energy
and protein.
9. Provide sensory stimulation and emotional
support
• Provide loving care, play and stimulation to improve
mental development.
10. Prepare for follow-up after recovery
• Teach mothers what to feed at home to help the
child recover. Malnourished children need regular
follow-up to prevent relapse and death.

29. Vitamin deficiencies
• Vitamin A deficiency is common in the children
with malnutrition.
• Disorders due to vitamin A deficiency are as follow:
▫ Xeropthelmia: abnormal dryness of the
conjunctiva and cornea of the eye,
with inflammation, typically associated with vitamin
A deficiency.
▫ Night blindness:
▫ Conjunctivitis Xerosis
▫ Bitot spot:
▫ Corneal Xerosis
▫ Keretomalacia
▫ Frequent infections.

30.  Thiamine (Vit B1) Deficiency - Beriberi
 Niacin (Vit B3) Deficiency - Pellagra
 Vitamin C Deficiency - Scurvy
 Vitamin D Deficiency - Rickets
 Calcium deficiency - Rickets
 Iodine deficiency - Goiter
 Iron deficiency - Anemia
 Zinc deficiency - Growth retardation

31. Micronutrients
Give oral vitamin A in a single dose.
• Vitamin A orally in single dose as given below:
• < 6 months : 50,000 IU (if clinical signs of
deficiency are present).
• 6-12 months : 1 lakh IU.
• Older children: 2 lakh IU.
• Children < 8kg irrespective of age should
receive 1 lakh IU orally.
• Give half of the above dose if injectable
(intramuscular) vitamin A needs to be given.
• Give same dose on Day 0,1 and 14 if there is
clinical evidence of vitamin A deficiency.

32. Other micronutrients should be given daily
for at least 2 weeks:
• Multivitamin supplement (should contain
vitamin A, C, D, E and B12 & not just vitamin B-
complex): 2 Recommended Daily Allowance.
• Folic acid: 5mg on day 1, then 1mg/day.
• Zinc : 2mg/kg/day.
• Copper: 0.3mg/kg/day (if separate preparation
not available use commercial preparation
containing copper).
• When weight gain commences and there is no
diarrhea add 3mg of iron/kg/day.

33. Thank you………………………