This document discusses several nutritional deficiencies that affect children. It begins with an introduction on malnutrition and its prevalence in India. It then covers protein energy malnutrition including kwashiorkor and marasmus. Symptoms, causes, diagnosis and treatment are described for each. Vitamin C deficiency and scurvy are also examined. The document concludes with sections on management principles, prevention strategies at national, community and family levels, and government initiatives to address malnutrition in India.

1. Presented By:-
Rashi
Bsc(Hons.) Nursing 3rd
year
Batch-2017
In Guidance Of:-
Mrs. Malar Kodi
Assistant professor,
AIIMS, Rishikesh

2. CONTENT
 Introduction
 Epidemiology
 Protein Energy Malnutrition
• Kwashiorkor
• Marasmus
 Vitamin C deficiency
• Scurvy
 Management
 Prevention

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Introduction
 An inadequate supply of essential
nutrients (as vitamins and minerals)
in the diet resulting in malnutrition or
disease.
 In India many children are suffering
with nutritional disorders. 2 million
children affected by nutritional
deficiency in every year.

4. FACTORS AFFECTING NUTRITIONAL
STATUS OF CHILD
 Nutritional intake of the child
 Health status
 Child feeding practice
 Food demand
 Family income/ Occupation
 Education of Mother etc.

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Epidemiology
 Global burden- more prevalent in
developing countries. "Often starts
in the womb and ends in the
tomb."

6.  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
WORLD SCENARIO

7. INDIAN SCENARIO
 Malnutrition caused 69 per cent of deaths of
children below the age of five in India,
according to a UNICEF
 The State of the World's Children 2019,
UNICEF said that every second child in that
age group is affected by some form of
malnutrition.

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Protein Energy Malnutrition
 Range of pathological conditions
arising from lack, in varying
proportions , of protein and calories.
• Marasmus: weight for age < 60%
expected
• Kwashiorkor: weight for age < 80% +
edema
• Marasmic kwashiorkor: wt/age <60%
+ edema

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• Only wt for age taken into account
• No comment about height
• All cases of edema in 3rd degree irrespective of wt for
age
Gomez Classification
Nutritional status Wt for Age(% Expected)
Normal > 90
1st Degree PEM 75-90
2nd Degree PEM 60-75
3rd Degree PEM < 60

11. RISK FACTORS
 LBW
 Multiple birth
 Closely spaced birth
 Early stoppage of breast
feeding
 Too early or late weaning
 Recurrent infections
 Illiteracy, poverty
 Secondary due to
malabsorption

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It refers as combination of
• Edema
• Lethargy
• Growth failure.
KWASHIORKOR

13. ETIOLOGY
 Non availability of suitable protein -rich
foods.
 Faulty feeding habits.
 Prolonged breast feeding.
 Infection and infestation
 Sudden loss of protein
 Seasonal incidence-July - august.
 Size of the family.

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CLINICAL FEATURES
Actually develops over a period of week or month.
 Growth retardation
 Apathy
 Diarrhea
 Edema.
 Hair changes
 Mental changes
 Wasting
 Anaemia
 Diarrhoea
 Dermatosis (flaky-paint)

15.  Skin Changes:- Dry & scaly skin,
Dermatosis
 Deep fissures- region of elbows, groins,
knees.
 Pinkish area over the legs.
 Hair Changes:-Scanty, Lusterless,
Brownish
 Hepatomegaly.
 Moon face
 Anemia
 Psycho motor changes
 Cardio vascular changes.

16.  Bio chemical changes:
• Reduced serum protein (less than 1.5g)
• Blood cholesterol reduced, low serum iron
and copper.
• Decreased water and electrolytes

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 Serum electrolytes
 Blood Urea Nitrogen
 Glucose, and
 Possibly levels of Ca, Mg, Phosphate,
Na should be measured.
 Urine culture,
 Blood cultures,
 Tuberculin testing, and
 A chest X-ray
DIAGNOSIS

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MARASMUS
There is loss of weight of more
than 50% or the expected
weight for given age.
Causes:
• Primary
• Secondary

19.  Primary:
• Artificial fed babies with over diluted
formula.
• Infection
• Poor socio economic background.
 Secondary:
• Chronic vomiting
• Chronic diarrhea
• Congenital disease Serious organic
disorders of heart, brain, kidney.
• Metabolic disorders.

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CLASSIFICATION
Grade 1: Wasting starts in axilla & groin
Grade 2: Wasting extended to thigh and buttocks
Grade 3: Chest and abdomen
Grade 4 : Wasting of buccal pad of fat also

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CLINICAL FEATURES
 Remarkable wasting of both muscles and
subcutaneous.
 Irritable
 In early stage Hungry and craving for food.
 In later stages apathetic, refusing to take anything
 Hair changes
 Face has prematurely aged look.
 Wrinkle skin with loss of elasticity
 Scaphoid abdomen.
 Visible intestinal peristalsis.

22. Biochemical changes:
 Plasma protein reduced
 Increases basal metabolic
rate.
Pathological changes:
 Decreased weight of many
organ.
 Reduced function of organ.

23. Enter titleDIAGNOSIS
 Care dietetic history of
the infant.
 Physical examination
 Lab investigation
 X-ray

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TREATMENT
Principles:
 Liberal protein must be offered.
 Carbohydrates and fat must also be supplied.
 Take care of their total calorie needs
 Treat underlying causes.

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LIBERAL PROTEIN
(MILD & MODERATE DEGREE)
 wheat-50gm
 Bengal gram-16.5gm
 Groundnuts-8.5gm
 Dry skimmed milk-8.5grams or
defatted soya-8.5gms
 In that total protein is-16.8grams
Calories-370 gms. total calories
requirement is - 120-150 cal/kg/day

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CONTINUED
(FOR SEVERE DEGREE)
 Hospitalization
 Parenteral therapy
 N.G tube feeding (2-3gms/kg)
 Control the infection
 Correction of metabolic derangement and
deficiencies

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MANAGEMENT
Mild and moderate malnutrition
 Mainstay of treatment is to give
adequate amounts of protein and
energy.
 At Least 150 kcal/kg/day, protein
intake of 3g/kg/day.
 Best measure of efficacy of the
treatment is weight gain.

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WHO Steps Of Recovery
STEP 1
Prevent/Treat Hypoglycemia
STEP 2
Prevent/Treat Hypothermia
STEP 3
Prevent/Treat Dehydration
STEP 4
Correct Electrolyte Imbalance
STEP 5
Prevent/Treat Infection

30. STEP 6
Correct Micronutrient Deficiency
STEP 7
Initiate Re-feeding
STEP 8
Achieve Catch-up Growth
STEP 9
Provide Sensory Stimulation And Emotional
Support
STEP 10
Prepare For Follow Up After Recovery

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VITAMIN C DEFICIENCY
Disease result from severe vitamin
C deficiency:
 Scurvy
 Cardiovascular Disease
 Stroke
 Cataract
 Lead toxicity

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SCURVY
ETIOLOGY:-
 Diet lacking in vitamin C-rich foods
 Destruction of vitamin C in foods by
overexposure to air or by overcooking
 PEM
 Malabsorption
 Artificial feeding
 Illness and infection
 Daily requirement 40 mg/ kg/day

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CLINICAL FEATURES
Infantile scurvy:
 Irritability
 Excessive crying
 Tenderness to touch
 Frog position
 Hemorrhages (skin and mucus membranes,
gums)
 Hemorrhages in gums (result in spongy,
swollen, bluish purple gums)

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CONTINUED
Childhood scurvy:
 Minute hemorrhages at the root of the hair
 Follicles.
 Bleeding to skin leads to petechiae or large
purpuric swelling, gums

35. Enter titleDIAGNOSIS
 History Collection
 Physical Examination
 Ascorbic Acid level in the serum usually less
than 0.1 mg/100 ml
 Excretion Ascorbic acid
 X ray

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TREATMENT
 Administer 500mg of single dose of
vit c Followed by daily dose of 100
to 300 mg for several week.
 Vitamin c rich diet

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SPECIAL CONSIDERATION
HOSPITAL
 Administer ascorbic acid orally or by slow I.V. infusion, as
ordered.
 Avoid moving the child unnecessarily, to avoid irritating
painful joints and muscles.
 Encourage child to drink orange juice.
 Explain the importance of supplemental ascorbic acid.
 Counsel the child and family about good dietary sources of
vitamin C.
 Advise against taking too much vitamin C.
 Explain that excessive doses of ascorbic acid may cause
nausea, diarrhea, and renal calculi formation and may also
interfere with anticoagulant therapy.

38. PREVENTION
At national level
1. Nutrition supplementation - Fortification,
iodination
2. Nutritional surveillance- define the character
and magnitude of nutritional problems and
strategies to tackle.
3. Nutritional planning- formulation of nutrition
policy, improve food production and supplies,
ensure distribution.

39. At community level
 Health and nutritional education
 Promotion of education and
literacy in the community
 Growth monitoring
 Integrated health package
 Vigorous promotion of family
planning programs
PREVENTION

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PREVENTION
At family level
 Exclusive breast feeding
 Complementary feeds at 6
months
 Vaccination
 Spacing between
pregnancies

41. GOVT INITIATIVE TO PREVENT
MALNUTRITION
 National Rural Health Mission Of India
 Mid-day meal Scheme
 Integrated Child Development Scheme
 National Children's Fund
 United Nations Children's Fund

42. REFERENCE
S
 1. Paul Vinod, Bagaa Arvind. Ghai Essential
Pediatrics: Nutrition.8th Edition.New Delhi:CBS
publishers,2013
 2. Datta Parul. Pediatric Nursing: Nutritionl
Deficiency Disorder. 3rd Edition. New
Delhi:Jaypee,2014
 3. Healthline. Nutritional Deficiencies: Symptoms
and Treatment[online].2018(cited 2020 May 28).
Available from:
www.healthline.com/health/malnutrition

43. THANK YOU