Malnutrition

By
Prof. Kassim Al-Dawood & Prof. Manal Koura
Family and Community Medicine Department

Malnutrition is a condition of over- or under-nutrition. Under-nutrition is more

common in developing countries. In countries in transition, e.g. KSA, the problem of
over-nutrition is increasing.

Protein Energy Malnutrition in Children:

It is considered a spectrum of disease:
 Sub-clinical forms of PEM (mild-moderate PEM) are characterized by growth and
development retardation.
 Severe forms manifest clinically as:
 Marasmus
 Kwashiorkor
 Marasmic-kwashiorkor (cases with mixed features)

Protein-energy malnutrition (PEM) affects every fourth child world-wide: 150 million
(26.7%) are underweight while 182 million (32.5%) are stunted. Geographically,
more than 70% of PEM children live in Asia, 26% in Africa and 4% in Latin America
and the Caribbean.
 Marasmus is real starvation. There is deficiency of energy and all nutrients. It’s
primarily a disease of infancy. It’s widespread among the low socio-economic
groups of most developing countries and is much more common than
kwashiorkor.
 Kwashiorkor results from deficiency of protein and to a less extent other nutrients
in the presence of adequate or even excess energy intake. It’s primarily a
condition of early life (2-3 years), but older children and adults may be affected.
Kwashiorkor in language of Ghana means: “the disease the first child gets when
the next one is on the way”.

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 Marasmus
This child was a low-birth-weight baby who remains chronically malnourished.
As a result, fat and muscle tissue are depleted, and the skin hangs in loose folds with the
bones clearly visible beneath. Hyper-alert and hungry. This child's severe wasting makes
him look like a wrinkled old man long before his time.

Growth retardation and wasting of subcutaneous fat and muscle are constant
features of marasmus. Weight is more affected than skeletal measurements, such as
length, head circumference and chest circumference. The wasting can be quantified
by measurement of the circumference of the mid-upper arm and skin folds in biceps,
triceps, sub-scapular and supra-iliac regions. It’s often evidenced by the old man or
monkey facies. Vitamin deficiencies, especially rickets (vit D) and xerophthalmia (vit
A) may be associated. The infant is often bright eyed, alert and hungry. Edema is
absent. Mild skin and hair changes and enlarged liver (common in kwashiorkor) are
occasionally present. Gastroenteritis, occurs especially in summer and leads to
dehydration. Respiratory infections are common precipitating factors in winter. TB,
severe parasitism & other chronic diseases frequently lead to emaciation.

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 Kwashiorkor

Constant features of kwashiorkor are growth retardation, preservation of sub-

cutaneous fat with wasting of muscles, edema and psycho-motor changes. As in
marasmus, weight is more affected than skeletal growth, but the extremes of weight
deficit seen in marasmus (up to 60%) do not occur, due to the presence of edema and
older age. Edema is usually dependent. Edema together with preservation of buccal
fat, gives the moon face appearance. The child is apathetic, anorexic, miserable,
withdrawn and has a weak, monotonous cry.
Skin lesions are characteristic. They are more frequent & severe in dark skinned races
with depigmentation as the basic change. Desquamation, in severe cases leads to the
characteristic “flaky paint” dermatosis. The most commonly observed appearance in
fair skinned children is a fine desquamation and hyper-pigmentation called “mosaic
skin”, especially prone to affect the forehead. Unlike the skin lesions of pellagra,
those of kwashiorkor are not prominent on the parts of the body exposed to sunlight.
Hair changes consist of depigmentation, straightening if the normal hair is curly,
fineness of texture and loose attachment of roots, flag sign with alternating light and
dark bands, recording periods of bad and good nutrition.

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 The liver is usually large and fatty. Iron deficiency anaemia is common, but
megaloblastosis is not rare, usually due to folic acid deficiency and Xerophthalmia
(vit. A defic.) is a frequent complication.

Reasons for Vulnerability of Children to Under-nutrition in Developing Countries:

 Maternal under-nutrition during pregnancy and lactation
 Children are in a growing stage, thus there is an increased demand for food intake
 In the young, tissues are labile and will develop dehydration, hypoglycemia and
other deficiencies rapidly.
 The young have high demands, but little reserves
 Immunologically the young child is out-growing the protection he received from
his mother. He has to built up his own immunity for which proper nutrition is
necessary, further increasing his demand.
 Lack of environmental sanitation and poor personal hygiene increase the risk of
infection during weaning.
 Lack of knowledge of types of foods to be introduced during weaning results in
under-nutrition as well as diarrhea.
 Diarrhea and other infectious diseases e.g. measles aggravate the malnutrition.
 Rapid urbanization leading to family disruption, cultural conflict, economic stress
& change in food habits etc. can lead to insufficient food intake.
 Poverty

The Vicious Circle of Diarrhea & Malnutrition:

Malnutrition causes villous atrophy of small intestinal mucosa, leading to mal-absorption
and diarrhea. It also causes reduction of body resistance, thus increased liability to
infection including diarrhea. On the other hand, diarrhea causes malnutrition, as it stops a
child from eating and causes mal-absorption and malnutrition.

Prevention of Malnutrition:
1. Primary Prevention:

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  Proper nutrition of mother during pregnancy and lactation
 Promotion of breast feeding
 Good weaning practice
 Early exposure to nutrition knowledge and desirable nutritional practice
 Control of infections
 Household hygiene and sanitation
 Al-zakah and Al-sadakah to eliminate poverty
 Emphasize the role of PHC & intersectoral cooperation for promotion of
nutrition
2. Secondary prevention:
 Screening of mothers and children for nutritional problems
 Early diagnosis of nutritional deficiencies
 Specific intervention & treatment of nutritional disorders
 Effective referral and follow-up system
 Supplementary feeding programs to selective groups
 Community participation