Chapter 33. Malnutrition

Malnutrition is a huge problem throughout the world, and it worsens in disaster situations. Estimates are that malnutrition contributes to more than half (54%) of all deaths of children <5 years old worldwide (Fig. 33-1). It usually occurs in resource-poor situations. The keys are both to recognize it and to treat it effectively.

Malnutrition can be identified using arm circumference or by comparing a child's height and weight with standard charts.

Arm Circumference

Measuring a child's arm circumference halfway between the point of the shoulder and the elbow can help to determine the degree of malnourishment. This technique is at least as good at predicting mortality from malnutrition as is a child's position on a weight/height growth chart. Arm circumference is measured, in centimeters, at the midpoint of the left upper arm. From 1 to 5 years of age, the mid-arm circumference remains fairly stable, because the increasing growth in muscle mass is balanced by a decrease in arm fat. The median value for this age group is 16.5 cm. In the first 12 months of life, arm circumference changes so rapidly that it is not a reliable indicator of malnutrition. And, while skin thickness over the scapula or triceps can be measured, this requires the use of calipers and provides little additional information.1

To make the measurement, have the child keep the arm hanging straight down by his side (Fig. 33-2). If the arm circumference of a child between the ages of 1 and 5 years is below 12.5 cm, he is severely malnourished. If it is between 12.5 and 14 cm, he is moderately malnourished. Above 14 cm is normal.2,3

If a measuring tape is not available, a marked piece of non-stretchable cloth or a string with knots at the appropriate distances can be used, although it may stretch a little. Another method is to use a strip of x-ray film. Scratch or paint the film at the 0-cm mark, and again at the 12.5-cm and 14-cm marks. For clarity, the area between the 0- and 12.5-cm marks can be colored red; the area between 12.5 and 14 cm, yellow; and the area above 14 cm, green.

The classification of malnutrition is based on the child's position on the standard weight-height-for-age charts, which can be accessed at the Centers for Disease Control and Prevention: Growth Charts (www.cdc.gov/growthcharts/). Height (length for a supine infant) and weight can be measured using standard means or by the improvised methods described in Chapter 7, Vital Signs, Measurements, and Triage. The results can be interpreted using the Welcome Classification system:

Severe malnutrition takes the form of either marasmus (wasting; Fig. 33-3) or kwashiorkor (edema; Fig. 33-4), or a combination of the two. The reasons for a progression of nutritional deficit into one rather than the other are unclear and cannot be explained solely by the composition of the deficient diet.4

Moderate Malnutrition

The child's weight is 60% to 80% of the expected weight, with a flat or falling position on the weight chart; there is no edema. Treat the child as an outpatient. Discuss one or two of the following "nutrition messages" with the child's parent(s).5

1. Start giving soft food as well as breast milk when your child is 4 months old. If you do not know the child's age, start this when he or she can roll over.

2. Add extra coconut cream, pan drippings, or margarine to the child's food.

3. Feed your child four to six times a day.

4. Feed your child cooked and mashed peanuts, beans, or fish every day.

5. Continue to feed your child when he or she is sick and give extra food after sickness.

6. Eat plenty of food when pregnant or breastfeeding.

Check and treat the child for diseases that cause malnutrition, such as worms, anemia, chronic diarrhea, other infections, resistant malaria, and tuberculosis (TB). Admit only if another illness is present or if there is no improvement after 1 month of outpatient treatment.

Severe Malnutrition

If the child's weight-for-height is <70% for the population and he or she has a flat or falling position on the standard weight chart, if there is obvious severe wasting, or if the child has edema of both feet, then he or she has severe malnutrition. Admit the child to the hospital and treat any infection and anemia. Rule out resistant malaria and TB.

Severely malnourished hospitalized children die primarily from hypoglycemia, hypothermia, cardiac failure (over-hydration and potassium deficiency), and missed or untreated infections. The basic steps, and a timeline, for treating severely malnourished children are described in Table 33-1.

Feeding Severely Malnourished Children8

Immediately give 50 mL of 10% glucose or sucrose solution (1 rounded teaspoon of sugar in 3½ teaspoons water) orally or by nasogastric (NG) tube. If it will be quicker, give starter formula (Table 33-2) or Formula-75 (F-75; see Table 33.3 for homemade F-75). Always use water that has been boiled.

1. Prepare the F-75 formula by adding the dried skimmed milk, sugar, cereal flour, and oil to some water and mix. Boil the mixture for 5 to 7 minutes. After the mixture cools, add the mineral mix and vitamin mix, and mix the solution again. Add enough boiled water to bring the volume up to 1000 mL.

2. Alternatively, make a similar formula with 35 g whole dried milk, 70 g sugar, 35 g cereal flour, 17 g oil, 20 mL mineral mix, 140 mg vitamin mix, and enough water to make 1000 mL. Another alternative is to use 300 mL fresh cows' milk, 70 g sugar, 35 g cereal flour, 17 g oil, 20 mL mineral mix, 140 mg vitamin mix, and enough water to make 1000 mL.

3. If cereal flour is not available or if there are no cooking facilities, make a comparable formula with 25 g dried skimmed milk, 100 g sugar, 27 g oil, 20 mL mineral mix, and 140 mg vitamin mix in enough water to make 1000 mL. Note that this formula has a high osmolarity (415 mOsmol/L) and may not be well tolerated by all children, especially those with diarrhea.

4. Commercially available isotonic versions of F-75 (280 mOsmol/L) contain maltodextrins to replace cereal flour and some of the sugar.

If the child will eat, give him food and, if needed, start rehydration immediately. Feed every 2 to 3 hours, day and night, to prevent hypoglycemia and hypothermia.

For the first 1 to 7 days (stabilization phase), give small frequent feedings of commercial or homemade F-75 or milk-based starter formula. The norm is 130 mL/kg/d, or 100 mL/kg/d if the child has severe edema.

As the child's appetite returns, switch to Formula-100 (F-100) solution (see Table 33-3) or to catch-up formula (see Table 33-2). Add 10 mL to each feeding until some remains uneaten. This should provide about 200 mL/kg/d.

1. To prepare the F-100 diet, mix dried skimmed milk, sugar, and oil into warm water that has been boiled. Add the mineral mix and vitamin mix, and stir the solution. Add more boiled water to make 1000 mL.

2. Make a similar formula using 110 g whole dried milk, 50 g sugar, 30 g oil, 20 mL mineral mix, 140 mg vitamin mix, and boiled water to make 1000 mL. Alternatively, use 880 mL fresh cows' milk, 75 g sugar, 20 g oil, 20 mL mineral mix, 140 mg vitamin mix, and sufficient boiled water to make 1000 mL.

After 1 to 2 days, the child normally regains his appetite and should be given frequent feedings of unlimited amounts of either F-100 or the catch-up formula. If the child is still being breast-fed, continue this after providing the F-100, which has more protein. For children on solid foods, peanut butter (paste) or commercial ready-to-use therapeutic food (RUTF), such as Plumpy'nut, is used in place of some or all the formulas at this stage.12 Encourage the child to eat: good foods to give are mashed ripe banana, bread or wheat meal with margarine, ground-up roasted or boiled peanuts, sweet potato, rice, or similar local foods.5

Feedings can be supplemented with snacks: children love to eat snacks. That they are healthy is a side benefit. Available high-carbohydrate, high-protein snacks may include high-protein biscuits, peanut paste, peanut balls, banana, pawpaw, other appropriate local foods, and egg or milk balls.5

• Peanut balls: mix 2 cups mashed sweet potato (or taro, yam, or sago) and ¼ cup peanut paste. Roll into balls of about 1 teaspoonful and allow to dry.
• Milk balls: mix 6 tablespoons milk powder, 1 tablespoon sugar, and 1 tablespoon cocoa. Then mix in 3 tablespoons boiled water. Roll into balls of about 1 teaspoonful and let dry.

Treat hypothermia in infants and neonates as described under "Hyperthermia, Hypothermia, and Frostbite" in Chapter 21, Surgery/Trauma, or under "Neonatal Hypothermia" in Chapter 34, Pediatrics and Neonatal.

Do not overhydrate the child; confusing dehydration with malnutrition is a common problem. Use parenteral fluids only if necessary.

Give vitamin A (<6 months, 50,000 IU; 6-12 months, 100,000 IU; >12 months, 200,000 IU) immediately. Repeat if there is xerophthalmia. Give daily doses of multiple-vitamin liquid, folic acid (5 mg immediately, then 1 mg/d), zinc (2 mg/kg/d), and copper (0.3 mg/kg/d), or give an electrolyte mixture that contains these elements. Wait to give iron until the child has a good appetite, and then give 3 mg Fe/kg/d.8

Treat infections or presumed infections. Administer vaccines (if due or overdue), especially against measles.

Discharging the Patient

Both the child and the parent/caregiver must be ready before discharge. Do not discharge the child until he is stable and the parents/caregivers have been taught how to prevent a recurrence.

Discharge only if the child:

• has completed antibiotic treatment
• has no edema
• is eating very well
• shows good weight gain
• has had 2 weeks of potassium and vitamin supplements (or can continue them at home)

Discharge only if the parents/caregivers know:

• when and how to follow up with neighborhood clinics
• what to feed the child, and how much and how often, using foods that will support continued catch-up growth and are affordable and culturally acceptable
• how to keep their child healthy at home
• how to provide play and stimulation to promote development
• to take their child for follow-up at 1, 2, and 4 weeks, then monthly, and for booster immunizations and vitamin A (every 6 months)

Early recognition and innovation can overcome problems of nutritional deficiencies.

Vitamin A

Vitamin A deficiency is one of the most common vitamin deficiencies. The presence of any of the following vitamin A deficiency (xerophthalmia) indicators over the specified prevalence levels in children aged 6 to 71 months signifies a public health problem that must be addressed: night blindness present at 24 to 71 months (>1%); Bitot spots (>0.5%); corneal xerosis/ulceration/keratomalacia (>0.01%); or corneal scars (>0.05%).13 Vitamin A deficiency can be treated by providing oral or parenteral supplements. Since adequate vitamin A contributes to disease-fighting capability, it is given to every severely malnourished child.

Iodine Deficiency

Iodine is an essential element for thyroid function and is necessary for normal growth, development, and functioning. A diet deficient in iodine is associated with a wide spectrum of illnesses, collectively known as iodine deficiency disorders. The most obvious result is goiter. If a goiter is present in school-age children (6 to 12 years old), the severity level of the public health problem is high when ≥30% of population has goiter; moderate, if 20% to 29.9%; and mild, if 5% to 19.9%.13 To treat iodine deficiency, add iodized salt to the diet; eat milk, egg yolks, and saltwater fish; add iodine to the water source; or inject iodized oil.