Prepared by:

Wilfredo Santos, MD.

Neonatology
Rebecca Abiog Castro, M.D.
Pediatric Gastroenterology & Nutrition
Faculty of Medicine & Surgery, UST

A pathological state resulting from a relative or

absolute deficiency or excess of one or more
essential nutrients.

This state being clinically manifested or detected

only by biochemical, anthropometric or
physiological tests.

Undernutrition:
pathological state resulting from the consumption
of an inadequate quantity of food over an
extended period of time
Specific Deficiency
absolute or relative lack of an individual nutrient
Overnutrition:
consumption of an excessive quantity of food for
an extended period of time
Imbalance:
disproportionate intake among essential nutrients

Diagnostic Criteria:

Anthropometric Measurements:
Weight

for age:
Underweight
Length/Height for age:
Stunted
Head circumference (until 3 years of age only)
Weight for length/height:
Wasted
Body mass index (BMI):
Overweight/Obese
WHO Standard Deviation Growth Curve

Z Score

Growth Indicators
Lt/Ht for age

Wt for age

2.
3.
4.
5.

BMI for age

Above 3

(See Note 1)

Obese

Obese

Above 2

Normal

Overweight

Overweight

Possible risk of
overweight
(See Note 3)

Possible risk of
overweight
(See Note 3)

(See Note 2)

1.

Wt for Lt or Ht

Above 1

Normal

0 (median)

Normal

Normal

Normal

Normal

Below - 1

Normal

Normal

Normal

Normal

Below - 2

Stunted
(See Note 4)

Underweight

Wasted

Wasted

Below - 3

Severely stunted
(See Note 4)

Severely underweight
(See Note 5)

Severely wasted

Severely wasted

A child in this range is very tall. This is rarely a problem unless the child is excessively
tall, in which case, he should be referred for possible endocrine work-up especially if both
his parents are not tall.
A child in this range may have a problem but this is better assessed with wt for Lt/Ht or BMI
for age.
A plotted point above 1 shows possible risk. A trend toward the 2 z-score shows definite risk.
It is possible for a stunted or severely stunted child to become overweight.
This is referred to as very low weight in IMCI training modules.

Marasmus (Infantile atrophy, balanced starvation,

old man face):

Due to severe deprivation of protein, energy, vitamins & minerals

Marasmic-Kwashiorkor:
Have

clinical findings of both marasmus & kwashiorkor

Have edema, gross wasting and stunting

Kwashiorkor (sugar baby):

Due

to a diet of a decreased protein but increased carbohydrate

intake with/without superimposed infection

Marasmus
Usual Age
Edema
generalized

Kwashiorkor
0-2 years
None

Wasting
of SubQ fat

Gross loss

1-3 years
lower legs, face or

sometimes hidden

Muscle Wasting

obvious

sometimes hidden

Growth retardation

obvious

sometimes hidden

Mental Changes
apathetic

apathetic, quiet

irritable, also

Marasmus
Appetite
Diarrhea
Skin Changes

good
often
seldom

Hair Changes

seldom

Moon face
Hepatic
enlargement

seldom
seldom

Kwashiorkor
poor
often
flaky-paint
dermatoses
sparse,
dyspigmentation
often
always

Serum albumin
Urea/creatinine
Hydroxyproline
Essential AA
Anemia
Liver biopsy

Marasmus

Kwashiorkor

N or low
N or low
low
normal
uncommon
normal or
atrophic

low
low
low
low
common
fatty change

A generalized excessive accumulation of fatty

subcutaneous tissue

May be due to overeating, genetic constitution,

psychic disturbances, insufficient exercise,
endocrine and metabolic disturbances

Z Score

Growth Indicators
Lt/Ht for age

Wt for age

2.
3.
4.
5.

BMI for age

Above 3

(See Note 1)

Obese

Obese

Above 2

Normal

Overweight

Overweight

Possible risk of
overweight
(See Note 3)

Possible risk of
overweight
(See Note 3)

(See Note 2)

1.

Wt for Lt or Ht

Above 1

Normal

0 (median)

Normal

Normal

Normal

Normal

Below - 1

Normal

Normal

Normal

Normal

Below - 2

Stunted
(See Note 4)

Underweight

Wasted

Wasted

Below - 3

Severely stunted
(See Note 4)

Severely underweight
(See Note 5)

Severely wasted

Severely wasted

A child in this range is very tall. This is rarely a problem unless the child is excessively
tall, in which case, he should be referred for possible endocrine work-up especially if both
his parents are not tall.
A child in this range may have a problem but this is better assessed with wt for Lt/Ht or BMI
for age.
A plotted point above 1 shows possible risk. A trend toward the 2 z-score shows definite risk.
It is possible for a stunted or severely stunted child to become overweight.
This is referred to as very low weight in IMCI training modules.

Three most common nutrients, of public health

concern, that afflicts Filipino children:
Vitamin

A Deficiency (VAD)

Anemia

(Iron Deficiency Anemia {IDA})

Goiter

(Iodine Deficiency Disoder {IDD})

Carotenoids, the precursors of Vit. A is 60% lacking in the

diet of most developing countries

Stores of vitamin A are indicated by the serum retinol

level

1000 IU or 300 mcg are needed daily by children

Deficiency is frequently associated with diarrhea,

measles, protein-energy deficiency and ascariasis

Major nutritional concern in poor societies,

especially in developing countries

Assessed by measuring the prevalence of deficiency

in a population, represented by:
specific
clinical

biochemical markers (low serum retinol)

indicators of status (xerophthalmia)

Global prevalence of vitamin A deficiency in populations at risk 19952005

WHO Global Database on Vitamin A Deficiency

4 in every 10 children or 38%, of 0-5 years of age;

2 out of every 10 or 22% of pregnant and 16% of

lactating mothers, had deficient to low plasma
retinol levels in 1998;

Considering the economic situation from 1998 to

the present, the vitamin A deficiency problem is not
expected to decline, and may be getting worse.

6th National Nutrition Survey FNRI, DOST

Vision
Epithelial differentiation
Growth
Reproduction
Pattern formation during embryogenesis
Bone development
Hematopoiesis
Brain development
Immune system function

Nyctalopia or night blindness

Photophobia
Xerosis conjunctivae
Bitots spot
Corneal xerosis
Xeropthalmia
Skin signs: branny desquamation, follicular
hyperkeratois, defective teeth enamel

Clinical manifestations:
Night

blindness

Xeropthalmia

(Bitots spot, keratomalacia)

Dark adaptation tests assess early-stage vitamin A

deficiency

Vitamin A levels (NV:2060 g/dL)

Bitot spot

xerophthalmia

NO sign of vitamin A deficiency: Prophylaxis

50,000 IU single dose (< 6month)

100,000 IU single dose (6-12 month)
200,000 IU single dose (>12 month)

Given every 6 months until risk factor disappears

Sign of vitamin A deficiency Treatment:

< 6 months: 150,000 IU

6-12 months: 100,000 IU
> 12 months: 200,000 IU

Given on day 1, day 2 and 2 weeks from first dose

The prevalence of anemia among 6 months to < 1 year

has remained unabated since 1993, and increased from
49.2% to an alarming rate of 66 %.
Anemia among 1-5 y/o remained at 29.1%.

1. Iron depletion
Storage iron is absent or decreased
Normal serum iron conc and Hgb levels
2. Iron deficiency without anemia
Decreased or absent iron storage
Low serum iron concentration
Low transferrin
No frank anemia
3. Iron deficiency anemia
Low Hgb/Hct value

A significant body of causal evidence exists for:

1. Iron-deficiency anemia and work productivity
2. Severe anemia and child mortality
3. Severe anemia and maternal mortality
4. Iron-deficiency anemia and child development

Tissue effects of IDA:

1. GIT: anorexia, pica, atrophic glossitis, leaky-gut
syndrome (exudative enteropathy)
2.

CNS: irritability, conduct disorder, cognitive

function

3.

CVS: HR & CO, cardiac hypertrophy, plasma

volume

Regular response to adequate amounts of iron is an

important diagnostic and therapeutic feature.
Oral administration of simple ferrous salts (e.g.,
sulfate, gluconate, fumarate) provides inexpensive
and satisfactory therapy.

Therapeutic dose
46 mg/kg of elemental iron in 3 divided doses
Ferrous sulfate - 20% elemental iron by weight.

Therapeutic dose
46 mg/kg of elemental iron in 3 divided
doses
Ferrous sulfate - 20% elemental iron by
weight.

1.

Unpleasant taste - can be camouflaged by mixing with

flavored syrup

2. Older children and adolescents sometimes have GI

complaints
Constipation can be minimized by water &
fiber intake
Abdominal discomfort can be minimized by
administering iron with food, but may
decrease iron absorption to some extent.

Iodine is an essential trace element; the thyroid hormones

thyroxine and triiodotyronine contain iodine.

Lack of IODINE intake gives rise to the following

conditions:

goiter (so-called endemic goiter)

Cretinism
Iodine deficiency

The Lancet , to WHO, in 2007, nearly 2billion individuals had insufficient iodine
intake, a third being of school age. ... Thus iodine deficiency, as the single greatest
preventable cause of mental retardation, is an important public-health problem."[1]

Inadequate intake or metabolism of iodine. It directly

affects thyroid secretions, which influence heart
action, nerve response, growth rate, and metabolism

Simple goitre, the most frequent result, is most common in

areas without access to salt water and is rare along seacoasts.

Severe, prolonged deficiency can cause hypothyroidism.

Eating seafood regularly or using iodized table salt will
prevent iodine deficiency. Some countries have made dietary
iodine additives mandatory.

A few salient facts

Iodine deficiency is one of the main cause of impaired

cognitive development in children.

The number of countries where iodine deficiency is a

public health problem has halved over the past The
number of countries where iodine deficiency is a
public health problem has halved over the past decade
according to a new global report on iodine status.

54 countries are still iodine-deficient.

Efforts are required to strengthen sustainable salt

iodization programmes.

Iodine deficiency is the worlds most prevalent, yet

easily preventable, cause of brain damage. Today we
are on the verge of eliminating it an achievement
that will be hailed as a major public health triumph
that ranks with getting rid of smallpox and
poliomyelitis

nearly 2billion individuals had insufficient

iodine intake, a third being of school age. ...

Thus iodine deficiency, as the single greatest

preventable cause of mental retardation, is an
important public-health problem.

The Lancet WHO, in 2007

Low dietary iodine

Selenium deficiency
Pregnancy
Exposure to radiation
Increased intake/plasma levels of goitrogens, such as calcium
Gender (higher occurrence in women)
Smoking tobacco
Alcohol (reduced prevalence in users)
Oral contraceptives (reduced prevalence in users)
Perchlorates
Thiocyanates

Signs and symptoms

Presence of possible risk factors

24-hour urine iodine collection (approximately

90% of ingested iodine is excreted in the urine)

Food supplements fortified with iodine

Mild cases may be treated by using iodized

salt in daily food consumption, or eating
more of milk, egg yolks, and saltwater fish

In an adult, 150 g/d is sufficient for normal

thyroid function.[2

Iodine supplementation results with shrinkage of

goiters caused by iodine deficiency in very young
children and pregnant women

Preventive Measures:
Use

of iodized salts:

Addition of small amounts of iodine to table salt in form

of sodium iodide, potassium iodide, and/or potassium
iodate,

Food

fortification such as flour, water and milk in

areas of deficiency.

Intake

of seafood, a good source thus, iodine

deficiency is more common in mountainous regions
where food is grown in soil poor in iodine.

Beri-beri

Types: Dry Beri-beri the infant may appear well

nourished but pale, listless, flabby, cyanotic and
dyspneic, tachycardic with enlarged liver

Wet Beri-beri- the infant is edematous, pale,

undernourished, dyspneic with vomiting and
tachycardia


1.

2.
3.

Other types:
Acute cardiac type occurs at age 2-4
months. With cyanosis, dyspnea, systolic
murmur, pulmonary edema
Aphonic type develops at age 5-7 months
with hoarseness, dysphonia or aphonia
Pseudomeningeal type develop at 8-10
months with apathy, drowsiness and signs of
meningeal irritation

Diagnosis: therapeutic test of parenteral

thiamine results in dramatic symptom and
sign improvement

Prevention: thiamine at 0.4 mg for infants

and 0.6 to 1.2 mg for older children

Treatment: 10 mg oral thiamine for several

weeks

Usually occurs with other deficiencies of

Vitamin B complex

Angular stomatitis, cheilosis, glossitis,

fissuring of the tongue

Scrotal or vulval dermatosis, nasolabial

seborrhea

Photophobia, blurred vision corneal

vascularization

Diagnosis: Urinary riboflavin determination and

RBC riboflavin load test

Prevention: < 10 years old 0.6 to 1.4 mg/day

> 10 years old 1.4 to 2 mg per day

Treatment: 2-5 mg of oral riboflavin daily

Cause:
A deficiency

disease caused by diets low in niacin

and/or tryptophan
Clinical manifestations:
Triad of diarrhea, dermatitis and dementia; also
depression, irritability, insomnia and delirium

Diagnosis:
signs

and symptoms

Prevention:
6-10

mg for infants and less than 10 years old. Older is

10-20 mg

Treatment: 50-300 mg of niacin daily

Cause:
Deficiency occurs due to losses of pyridoxine from
refining, processing, cooking and storing of food
Clinical Manifestations:
Convulsion, depression, seborrheic dermatitis,
intertrigo, angular stomatitis, glossitis, poor response to
infection
Diagnosis:
tryptophan load test; response of seizure to B6
treatment
Treatment:
IM pyridoxine injection 2-10 mg or 10-100 mg orally

Scurvy

Due to Vit C deficient diet

S/Sx: Pseudoparalysis, spongy gum bleeding, rosary

of scorbutic beads at the costochondral junctions,
petechiae, orbital or subdural hemorrhages

Diagnosis: X-ray of the long bones: atrophy of the

bone; Vit C blood levels

Treatment: 200-500 mg of ascorbic acid

Deficiency of Vit K dependent factors

(prothrombin, factors VII, IX, X), exclusively
breastfed infants, antibiotic adminstration

S/Sx: Bleeding from cord, GI bleeding, intracranial

bleeding, anemia, hematuria

Prevention and Treatment: Vit K administration at

birth. Transfusion of deficient factors

Lack of vitamin D in the diet and lack of access of

the skin from ultraviolet irradiation

S/Sx: rachitic rosary, craniotabes, growth

impairment, mental retardation, bowing of legs,
knock-knees

Diagnosis: X-ray of the involved bones

Treatment: 4000 IU or 100 mg Vit. D, fish-liver oil

sunbathing

Del Mundo, et.al Textbook of Pediatrics and

Child Health, 4th edition