MALNUTRITION & PROTEIN-ENERGY MALNUTRITION (PEM)

1. DEFINITION OF MALNUTRITION

2. CLASSIFICATION OF PEM

A. WHO/Wellcome Trust Classification (based on weight-for-age as % of standard and presence of oedema)

B. IAP (Indian Academy of Pediatrics) Classification (based on weight-for-age)

C. Gomez Classification

• Grade I (mild): 76-90% of standard weight
• Grade II (moderate): 61-75% of standard
• Grade III (severe): <60% of standard

D. Waterlow Classification (used for wasting and stunting)

• Based on weight-for-height (wasting = acute malnutrition) and height-for-age (stunting = chronic malnutrition)

3. SEVERE FORMS OF MALNUTRITION

A. KWASHIORKOR

Definition

Causes

1. Primary cause: Inadequate protein intake - low protein/energy ratio in diet
2. Predominantly cereal/starch-based weaning foods devoid of protein
3. Abrupt cessation of breastfeeding
4. Large family size with poor purchasing power
5. Infections and diarrhoea precipitating protein loss
6. Traditional beliefs and food taboos restricting protein-rich foods for children
7. Ignorance about appropriate complementary foods

Clinical Features of Kwashiorkor

1. Oedema - the hallmark sign; bilateral pitting oedema starting in the feet and legs, giving a "moon face" appearance
2. Wasting - muscle wasting, though masked by oedema
3. Liver enlargement (hepatomegaly) - due to fatty infiltration (steatosis)
4. Hypoalbuminaemia - low serum albumin (contributes to oedema)
5. Skin changes - "flaky paint" dermatosis; hyperpigmentation followed by desquamation; raw weeping areas
6. Hair changes - depigmentation (reddish or brownish discolouration), sparse, easily pluckable hair ("flag sign" - alternating bands of pigmented and depigmented hair)
7. Mental changes - apathy, misery, irritability, anorexia, child does not want to move
8. Anaemia - normocytic or macrocytic
9. Diarrhoea - frequent
10. Moon face - rounded face due to oedema
11. Weight is 60-80% of standard (with oedema masking true weight loss)

B. MARASMUS

Definition

Causes

1. Early cessation or failure of breastfeeding
2. Inadequate feeding - overall calorie and protein deficiency
3. Poverty and food insecurity
4. Repeated infections (diarrhoea, respiratory infections) increasing metabolic demands
5. Poverty and low birth weight
6. Large family size
7. Ignorance and faulty feeding practices

Clinical Features of Marasmus

1. Severe wasting - the cardinal feature; extreme loss of muscle and subcutaneous fat
2. Little or no oedema (distinguishes from kwashiorkor)
3. "Old man's face" or "monkey facies" - wizened, aged appearance
4. Skin and bones appearance - "bag of bones"
5. Minimal subcutaneous fat - skin hangs in loose folds, especially over the buttocks ("baggy pants" sign)
6. Severe muscle wasting - ribs prominent, limbs emaciated
7. Weight below 60% of expected for age
8. Serum albumin - non-normal (may be borderline or low)
9. Child is alert, hungry, and irritable (unlike the apathetic kwashiorkor child)
10. Stunted growth
11. Frequent infections - diarrhoea, respiratory infections
12. Anaemia

C. MARASMIC KWASHIORKOR

4. INDICATORS OF MALNUTRITION

Anthropometric Indicators

Clinical Indicators

• Presence of oedema (kwashiorkor)
• Skin and hair changes
• Signs of specific deficiency diseases (xerophthalmia, rickets, scurvy, anaemia)

Biochemical Indicators

• Serum albumin (<3.5 g/dL = malnutrition)
• Serum transferrin
• Haemoglobin level
• Urinary creatinine-height index
• Serum total proteins
• Blood urea nitrogen

Dietary/Food Consumption Indicators

• 24-hour dietary recall
• Food frequency questionnaire
• Food consumption score

Vital Statistics / Ecological Indicators

• Infant mortality rate
• Under-5 mortality rate
• Low birth weight rate
• Morbidity rates (diarrhoea, respiratory infections)
• Per capita food availability and intake

Growth Monitoring

• Growth charts (Road-to-Health chart) - the first and most practical indicator of PEM is underweight-for-age; growth faltering detected early by weight monitoring

5. PREVENTIVE MEASURES TO REDUCE PEM IN INDIA

(a) Health Promotion

1. Measures directed to pregnant and lactating women - nutrition education, distribution of food supplements
2. Promotion of breastfeeding - exclusive breastfeeding for the first 6 months of life is essential
3. Development of low-cost weaning foods - the child should be made to eat more food at frequent intervals; locally available nutritious foods for weaning (6 months onwards)
4. Measures to improve family diet - dietary diversification, use of locally available protein-rich foods (pulses, eggs, milk)
5. Nutrition education - promotion of correct feeding practices; community nutrition workers play a key role
6. Home economics - food preparation, storage, hygiene
7. Family planning and spacing of births - fewer children means better nutrition; birth spacing of at least 2-3 years
8. Improving family environment - literacy, especially maternal education

(b) Specific Protection

1. Protein and energy-rich diet - the child's diet must contain protein and energy-rich foods: milk, eggs, fresh fruits, pulses should be given
2. Immunization - against the 9 childhood infections (TB, diphtheria, whooping cough, tetanus, Hepatitis B, Hib, Japanese encephalitis in endemic areas, measles, polio) under the Expanded Programme on Immunization (EPI)
3. Food fortification - fortification of staple foods with micronutrients (iodized salt, vitamin A fortified oil/dalda, iron-fortified flour)

(c) Early Diagnosis and Treatment

1. Periodic nutritional surveillance - routine growth monitoring at anganwadis and sub-centres
2. Early diagnosis of growth lag - using growth charts, MUAC measurement
3. Early diagnosis and treatment of infections and diarrhoea - ORS, antibiotics, deworming
4. Development of early rehydration programmes for diarrhoeal disease
5. Supplementary feeding programmes during epidemics or disasters
6. Deworming of heavily infested children (intestinal parasites compete for nutrients)

(d) Rehabilitation

1. Nutritional Rehabilitation Centres (NRCs) - for management of severe acute malnutrition (SAM); F-75 and F-100 therapeutic feeds, RUTF (Ready-to-Use Therapeutic Food)
2. Hospital treatment for complicated SAM (with medical complications)
3. Follow-up care - to prevent relapse

6. PREVENTION AND SOCIAL MEASURES AT FAMILY AND COMMUNITY LEVEL

A. AT THE FAMILY LEVEL

• Adequate nutrition of the mother during pregnancy and lactation
• Prevention of low birth weight (LBW) - LBW is associated with 80% of neonatal mortality
• Risk factors for malnutrition starting even before birth: mother under 18 or over 35 years, last child born <2 years ago, more than 4 previous births, deprived of basic antenatal care

• Exclusive breastfeeding for the first 6 months - provides complete nutrition and immunological protection
• Initiation of complementary feeding at 6 months while continuing breastfeeding up to 2 years
• Appropriate, adequate, and safe complementary foods

• Balanced family meals using locally available foods
• Adequate intake of protein-rich foods (pulses, milk, eggs, fish)
• Regular meal frequency - children need 5-6 small meals per day
• Avoidance of harmful food taboos

• Family planning - studies show prevalence of malnutrition increases in families with >4 children
• Birth spacing reduces maternal depletion and competition for food resources
• Fewer children = better nutrition, better health care, lower infant mortality

• Safe drinking water
• Safe disposal of human excreta
• Personal and food hygiene
• Prevention of diarrhoea and intestinal parasites - malnutrition and infection form a vicious cycle

• Mother's education is the single most important factor influencing child nutrition
• Educated mothers practice better feeding, hygiene, and health-seeking behaviour
• Poverty, illiteracy (especially mothers'), and sickness create a vicious cycle spanning generations

• Maintaining growth charts at home and sub-centre level
• Mothers educated to recognise growth faltering early

B. AT THE COMMUNITY LEVEL

• Supplementary nutrition (hot cooked meals/take-home rations) to children 6 months - 6 years and pregnant/lactating mothers
• Nutrition and health education
• Immunization
• Health check-up and referral
• Pre-school non-formal education
• Delivered through Anganwadi Workers (AWW) at the community level

• Monthly community-level event at the anganwadi
• Growth monitoring, immunization, health check-ups, counselling on nutrition and feeding practices

• Free cooked meals to school children (Classes I-VIII) in government schools
• Addresses school hunger, improves attendance, and addresses chronic undernutrition

• Subsidized food grains to below-poverty-line (BPL) families
• Addresses household food insecurity

• Iron and Folic Acid (IFA) supplementation to children, adolescent girls, pregnant and lactating mothers
• Vitamin A supplementation programme - biannual doses to children 9 months to 5 years
• Iodine Deficiency Disorder (IDD) control programme - iodized salt
• Rajiv Gandhi Scheme for Empowerment of Adolescent Girls (SABLA) - nutrition, health, life skills for girls 11-18 years

• Immunization (EPI/UIP)
• Environmental sanitation - safe water supply, sanitation, reduction of open defecation (Swachh Bharat Mission)
• ORS and zinc supplementation for diarrhoea management

• Nutritional awareness through ASHA workers, AWW, and PHC staff
• Promotion of locally available, low-cost, nutrient-dense foods
• Addressing myths, taboos, and cultural barriers to appropriate feeding

• Poverty alleviation as the fundamental long-term solution
• Women's empowerment, education, income generation
• Reduction of health inequity between privileged and underprivileged groups

• Regular monitoring of nutritional status at population level
• Growth faltering detection through National Family Health Survey (NFHS) and District Level Household Survey (DLHS)
• Identification of subclinical malnutrition which tends to be overlooked

• Not specifically nutrition-related but with wide ramifications:
  • Control of communicable diseases through immunization
  • Improvement of environmental sanitation
  • Provision of clean drinking water
  • Family planning
  • Food hygiene
  • Education
  • Primary health care

SUMMARY TABLE: Direct vs. Indirect Nutrition Interventions