6/25/12 Malnutrition

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MaInutrition
Author: Harohalli R Shashidhar; Chief Editor: Jatinder Bhatia, MBBS more...

Updated: Oct 25, 2011
Background
The World Health Organization defines malnutrition as "the cellular imbalance between supply of nutrients and
energy and the body's demand for them to ensure growth, maintenance, and specific functions."
[1]
Women and
young children are the most adversely affected groups; one quarter to one half of women of child-bearing age in
Africa and south Asia are underweight, which contributes to the number of low birth weight infants born
annually.
[2]
Malnutrition is globally the most important risk factor for illness and death, contributing to more than half of deaths
in children worldwide; child malnutrition was associated with 54% of deaths in children in developing countries in
2001.
[1, 2]
Protein-energy malnutrition (PEM), first described in the 1920s, is observed most frequently in
developing countries but has been described with increasing frequency in hospitalized and chronically ill children
in the United States.
[3]
The effects of changing environmental conditions in increasing malnutrition is multifactorial. Poor environmental
conditions may increase insect and protozoal infections and also contribute to environmental deficiencies in
micronutrients. Overpopulation, more commonly seen in developing countries, can reduce food production,
leading to inadequate food intake or intake of foods of poor nutritional quality. Conversely, the effects of
malnutrition on individuals can create and maintain poverty, which can further hamper economic and social
development.
[2]
Kwashiorkor and marasmus are 2 forms of PEM that have been described. The distinction between the 2 forms of
PEM is based on the presence of edema (kwashiorkor) or absence of edema (marasmus). Marasmus involves
inadequate intake of protein and calories, whereas a child with kwashiorkor has fair-to-normal calorie intake with
inadequate protein intake. Although significant clinical differences between kwashiorkor and marasmus are noted,
some studies suggest that marasmus represents an adaptation to starvation whereas kwashiorkor represents a
dysadaptation to starvation.
n addition to PEM, children may be affected by micronutrient deficiencies, which also have a detrimental effect
on growth and development. The most common and clinically significant micronutrient deficiencies in children and
childbearing women throughout the world include deficiencies of iron, iodine, zinc, and vitamin A and are
estimated to affect as many as two billion people. Although fortification programs have helped diminish
deficiencies of iodine and vitamin A in individuals in the United States, these deficiencies remain a significant
cause of morbidity in developing countries, whereas deficiencies of vitamin C, B, and D have improved in recent
years. Micronutrient deficiencies and protein and calorie deficiencies must be addressed for optimal growth and
development to be attained in these individuals.
PathophysioIogy

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6/25/12 Malnutrition
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Malnutrition affects virtually every organ system. Dietary protein is needed to provide amino acids for synthesis of
body proteins and other compounds that have various functional roles. Energy is essential for all biochemical and
physiologic functions in the body. Furthermore, micronutrients are essential in many metabolic functions in the
body as components and cofactors in enzymatic processes.
n addition to the impairment of physical growth and of cognitive and other physiologic functions, immune
response changes occur early in the course of significant malnutrition in a child. These immune response
changes correlate with poor outcomes and mimic the changes observed in children with acquired immune
deficiency syndrome (ADS). Loss of delayed hypersensitivity, fewer T lymphocytes, impaired lymphocyte
response, impaired phagocytosis secondary to decreased complement and certain cytokines, and decreased
secretory immunoglobulin A (gA) are some changes that may occur. These immune changes predispose children
to severe and chronic infections, most commonly, infectious diarrhea, which further compromises nutrition
causing anorexia, decreased nutrient absorption, increased metabolic needs, and direct nutrient losses.
Early studies of malnourished children showed changes in the developing brain, including, a slowed rate of growth
of the brain, lower brain weight, thinner cerebral cortex, decreased number of neurons, insufficient myelinization,
and changes in the dendritic spines. More recently, neuroimaging studies have found severe alterations in the
dendritic spine apparatus of cortical neurons in infants with severe protein-calorie malnutrition. These changes are
similar to those described in patients with mental retardation of different causes. There have not been definite
studies to show that these changes are causal rather than coincidental.
[4]
Other pathologic changes include fatty degeneration of the liver and heart, atrophy of the small bowel, and
decreased intravascular volume leading to secondary hyperaldosteronism.
Hormonal adaptation to the stress of malnutrition. The evolution of marasmus.
A classic example of a weight chart for a severely malnourished child.
EpidemioIogy
Frequency
United States
Fewer than 1% of all children in the United States have chronic malnutrition. ncidence of malnutrition is less than
10%, even in the highest risk group (children in shelters for the homeless). Some studies indicate that poor
growth secondary to inadequate nutrition occurs in as many as 10% of children in rural areas. Studies of
hospitalized children suggest that as many as one fourth of patients had some form of acute PEM and 27% had
chronic PEM.
InternationaI
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The World Health Organization estimates that by the year 2015, the prevalence of malnutrition will have
decreased to 17.6% globally, with 113.4 million children younger than 5 years affected as measured by low weight
for age. The overwhelming majority of these children, 112.8 million, will live in developing countries with 70% of
these children in Asia, particularly the southcentral region, and 26% in Africa. An additional 165 million (29.0%)
children will have stunted length/height secondary to poor nutrition.
Currently, more than half of young children in South Asia have PEM, which is 6.5 times the prevalence in the
western hemisphere. n sub-Saharan Africa, 30% of children have PEM. Despite marked improvements globally in
the prevalence of malnutrition, rates of undernutrition and stunting have continued to rise in Africa, where rates of
undernutrition and stunting have risen from 24% to 26.8% and 47.3% to 48%, respectively, since 1990, with the
worst increases occurring in the eastern region of Africa.
[1]
MortaIity/Morbidity
Malnutrition is directly responsible for 300,000 deaths per year in children younger than 5 years in developing
countries and contributes indirectly to over half the deaths in childhood worldwide.
The adverse effects of malnutrition include physical and developmental manifestations. Poor weight gain and
slowing of linear growth occur. mpairment of immunologic functions in these children mimics those observed in
children with ADS, predisposing them to opportunistic and other typical childhood infections.
n developing countries, poor perinatal conditions account for 23% of deaths in children younger than five.
Malnourished women are at high risk of giving birth to low birth weight infants. Many low birth weight infants (23.%
of all births) face severe short-term and long-term health consequences, such as growth failure in infancy and
childhood, which increases risk of morbidity and early death.
[2]
Children who are chronically malnourished exhibit behavioral changes, including irritability, apathy and decreased
social responsiveness, anxiety, and attention deficits. n addition, infants and young children who have
malnutrition frequently demonstrate developmental delay in delayed achievement of motor skills, delayed mental
development, and may have permanent cognitive deficits. The degree of delay and deficit depends on the
severity and duration of nutritional compromise and the age at which malnutrition occurs. n general, nutritional
insults at younger ages have worse outcomes. Dose-dependent relationships between impaired growth and poor
school performance and decreased intellectual achievement have been shown.
[2, 5, 6, 7]
Although death from malnutrition in the United States is rare, in developing countries, more than 50% of the 10
million deaths each year are either directly or indirectly secondary to malnutrition in children younger than 5
years.
[1]
Age
Children are most vulnerable to the effects of malnutrition in infancy and early childhood. Premature infants have
special nutritional needs that are not met with traditional feeding recommendations; they require fortified human
milk or specially designed preterm formula until later in infancy. Children are susceptible to malnutrition for
differing reasons. During adolescence, self-imposed dietary restrictions contribute to the incidence of nutritional
deficiencies.

Contributor Information and DiscIosures
Author
HarohaIIi R Shashidhar Associate Professor, Department of Pediatrics, Chief, Division of Pediatric
Gastroenterology and Nutrition, University of Kentucky Medical Center
Harohalli R Shashidhar is a member of the following medical societies: American Academy of Pediatrics,
Kentucky Medical Association, and North American Society for Pediatric Gastroenterology and Nutrition
Disclosure: Nothing to disclose.
Coauthor(s)
Donna G Grigsby, MD Associate Professor, Department of Pediatrics, University of Kentucky College of
Medicine
Donna G Grigsby, MD is a member of the following medical societies: American Academy of Pediatrics and
Kentucky Pediatric Society
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Disclosure: Nothing to disclose.
Specialty Editor Board
Maria RebeIIo Mascarenhas, MBBS Associate Professor of Pediatrics, University of Pennsylvania School of
Medicine; Section Chief of Nutrition, Division of Gastroenterology and Nutrition, Director, Nutrition Support
Service, Children's Hospital of Philadelphia
Maria Rebello Mascarenhas, MBBS is a member of the following medical societies: American
Gastroenterological Association, American Society for Parenteral and Enteral Nutrition, and North American
Society for Pediatric Gastroenterology and Nutrition
Disclosure: Nothing to disclose.
Mary L WindIe, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of
Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Nothing to disclose.
MerriIy P M Poth, MD Professor, Department of Pediatrics and Neuroscience, Uniformed Services University
of the Health Sciences
Merrily P M Poth, MD is a member of the following medical societies: American Academy of Pediatrics,
Endocrine Society, and Pediatric Endocrine Society
Disclosure: Nothing to disclose.
Chief Editor
Jatinder Bhatia, MBBS Professor of Pediatrics, Chief, Section of Neonatology, Department of Pediatrics,
Medical College of Georgia
Jatinder Bhatia, MBBS is a member of the following medical societies: American Academy of Pediatrics,
American Association for the Advancement of Science, American Dietetic Association, American Pediatric
Society, American Society for Clinical Nutrition, American Society for Parenteral and Enteral Nutrition, Society
for Pediatric Research, and Southern Society for Pediatric Research
Disclosure: Nothing to disclose.
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