Malnutrition: A Comprehensive Overview

1. Definition of Malnutrition

• Undernutrition - includes wasting, stunting, underweight, and micronutrient deficiencies
• Overnutrition - includes overweight, obesity, and diet-related non-communicable diseases

• Park's Textbook of Preventive and Social Medicine, p. 610

2. Classification of Malnutrition

A. Based on Nutrient Deficit

B. WHO/UNICEF Anthropometric Classification (Children)

• Park's Textbook of Preventive and Social Medicine, p. 736-737

C. PEM Sub-Classification (Wellcome Classification)

• Fitzpatrick's Dermatology, p. 2231

3. Causes of Malnutrition in India

A. Primary / Direct Causes

1. Inadequate food intake - both in quantity (insufficient calories) and quality (insufficient protein and micronutrients), particularly among rural poor and urban slum dwellers
2. Infections - diarrhoea, respiratory infections, measles, and intestinal worms increase nutrient requirements while decreasing absorption and utilization; malnutrition in turn worsens susceptibility to infection

B. Contributory Factors (Web of Causation)

• Poverty - insufficient purchasing power to acquire adequate food
• Poor maternal health - maternal depletion, anaemia; short maternal stature and very young age are associated factors
• High parity and close birth intervals - competition for limited household resources
• Failure of lactation and premature termination of breastfeeding
• Adverse cultural practices in weaning - use of over-diluted cow's milk, discarding cooking water from cereals (which contains water-soluble vitamins), delayed introduction of complementary foods
• Large family size
• Poor environmental sanitation - contaminated water, poor hygiene promoting diarrhoeal disease
• Lack of nutrition education - ignorance of correct feeding practices
• Smoking
• Inadequate health services - especially in rural and tribal areas

• Park's Textbook of Preventive and Social Medicine, p. 735-736

4. Prevention Strategies for Malnutrition

(a) Health Promotion

1. Measures directed at pregnant and lactating women - nutritional education, distribution of iron-folic acid and calcium supplements
2. Promotion of breastfeeding - exclusive breastfeeding for 6 months
3. Development of low-cost weaning foods - the child should eat more food at frequent intervals; timely introduction of complementary foods at 6 months
4. Measures to improve family diet - diversification of food sources, home gardening
5. Nutrition education - promotion of correct feeding practices at household and community level
6. Home economics - teaching food hygiene, storage, and preparation
7. Family planning and spacing of births - to reduce competition for nutritional resources
8. Improving family environment - socio-economic upliftment

(b) Specific Protection

1. The child's diet must contain protein and energy-rich foods - milk, eggs, fresh fruits and vegetables
2. Immunization against measles, diphtheria, pertussis, tetanus - reduces infection-driven malnutrition
3. Food fortification - iodized salt, vitamin A in vanaspati (dalda), iron in flour

(c) Early Diagnosis and Treatment

1. Periodic nutritional surveillance using growth charts and MUAC measurements
2. Early diagnosis of any lag in growth
3. Early diagnosis and treatment of infections and diarrhoea
4. Development of oral rehydration programmes for children with diarrhoea
5. Development of supplementary feeding programmes during epidemics and food crises
6. Deworming of heavily infested children

(d) Rehabilitation

1. Nutritional rehabilitation services (NRC - Nutritional Rehabilitation Centres)
2. Hospital treatment for severe cases
3. Follow-up care to prevent relapse

National Programmes in India

• Park's Textbook of Preventive and Social Medicine, p. 737

5. Responsibilities of a Health Worker in Preventing Protein Deficiency Disorders in Children

At the Community/Field Level

1. Nutritional surveillance - regular weighing of children at Anganwadi centres; maintenance and interpretation of growth charts (Road to Health cards) to identify children falling off their growth curve
2. MUAC measurement - arm circumference measurement to screen for malnutrition; values below 12.5 cm indicate severe malnutrition requiring referral
3. Health and nutrition education for mothers - promoting:
   • Exclusive breastfeeding for 6 months
   • Timely introduction of complementary foods (6 months onward)
   • Correct weaning practices (avoidance of over-diluted feeds)
   • High-protein foods (pulses, eggs, milk, soya) in the child's diet
   • Feeding frequency - small, frequent, energy-dense meals
4. Promotion of breastfeeding and counselling lactating mothers
5. Immunization - ensuring full immunization of all children (particularly measles, which triggers PEM)
6. ORS distribution and diarrhoea management education
7. Deworming children as per national guidelines
8. Distribution of micronutrient supplements - iron-folic acid, Vitamin A supplementation (large dose every 6 months for children 6 months - 5 years)
9. Early referral of malnourished children to PHC/NRC for management

At the Facility Level

1. Assist in nutritional assessment (anthropometric measurements, clinical examination)
2. Provide supplementary feeding at Anganwadi/NRC
3. Coordinate with ASHA, ANM, and Anganwadi worker for follow-up
4. Nutritional counselling of parents regarding dietary diversification and hygiene
5. Ensure indirect interventions - safe drinking water, sanitation promotion, family planning counselling

The primary health worker can play a vital role in improving the nutritional status of mothers and children. Nutritional surveillance is becoming increasingly important for identifying subclinical malnutrition, as it tends to be overlooked in both the mother and the child.

• Park's Textbook of Preventive and Social Medicine, p. 610

6. Treatment of Marasmic Kwashiorkor

Pathophysiology Reminder

• Fitzpatrick's Dermatology, p. 2231; Robbins & Kumar Basic Pathology, p. 289

WHO 10-Step Management Protocol

Phase 1: Stabilisation (Days 1-7)

• Blood glucose < 3 mmol/L (54 mg/dL): give 50 ml of 10% glucose or 10% sucrose solution orally or via nasogastric tube (NG tube)
• Then feed F-75 formula (starter diet: 75 kcal/100 ml) every 2-3 hours, day and night

• Keep child clothed and covered, including the head
• Keep ambient temperature 25-30°C; avoid drafts
• Feed at least every 2 hours (prevents hypoglycaemia which worsens hypothermia)

• Use ReSoMal (Rehydration Solution for Malnourished children) - not standard ORS, as standard ORS has too much sodium and too little potassium for severely malnourished children
• Give 5 ml/kg every 30 minutes for 2 hours orally, then 5-10 ml/kg/hour for 4-10 hours
• Caution: IV fluids only if signs of circulatory collapse; use with extreme caution to avoid fluid overload/cardiac failure
• In marasmic kwashiorkor, the edema fluid may mask the true fluid deficit

• Give extra potassium (3-4 mmol/kg/day) and magnesium (0.4-0.6 mmol/kg/day)
• Avoid high sodium - do NOT treat edema with diuretics
• Use a low-sodium F-75 starter formula
• Edema should resolve spontaneously with treatment; do not attempt to diurese

• Even without obvious signs of infection, assume bacterial infection and treat
• Give broad-spectrum antibiotics: amoxicillin (first choice) or ampicillin + gentamicin for severe cases
• Screen for tuberculosis, malaria, urinary infection, and intestinal parasites
• Skin testing for TB; blood smear for malaria; stool for ova and parasites

• Give Vitamin A on day 1: 200,000 IU orally for children > 1 year; 100,000 IU for 6-12 months; 50,000 IU for < 6 months
• Folic acid 5 mg on day 1, then 1 mg/day
• Zinc 2 mg/kg/day
• Copper 0.3 mg/kg/day
• Multivitamin supplements daily
• Iron: do NOT give iron during stabilisation phase - it can worsen infections (free iron promotes bacterial growth and worsens oxidative stress); introduce only during rehabilitation phase

• F-75 formula (75 kcal/100 ml, 0.9 g protein/100 ml) - the low energy, low protein, low sodium starter diet
• Give small, frequent feeds (every 2-3 hours, including at night) - total 100 ml/kg/day in first 24 hours
• In kwashiorkor: initial lactose intolerance may be present due to mucosal atrophy and disaccharidase deficiency; use lactose-free or low-lactose formula if diarrhoea worsens
• Oral or nasogastric route preferred; IV hyperalimentation (TPN) only if child is unconscious or unresponsive (risk of CHF with rapid IV refeeding)

Phase 2: Rehabilitation (Weeks 2-6)

• Once edema starts resolving and appetite returns, transition to F-100 formula (100 kcal/100 ml, 2.9 g protein/100 ml)
• Start at the same volume as F-75, then increase by 10 ml per feed every 24 hours until child takes ad libitum (150-220 ml/kg/day)
• This is the phase of rapid catch-up growth - aim for weight gain > 10 g/kg/day
• Introduce ready-to-use therapeutic food (RUTF) if available - e.g. Plumpy'Nut (peanut-based, 500 kcal/sachet)
• Introduce iron supplementation now (not earlier)

• Structured play therapy for 15-30 minutes daily
• Cheerful, stimulating environment
• Mother/caregiver involvement in feeding and care
• This step addresses the developmental delay associated with SAM

• The child is ready for discharge when:
  • Edema has resolved
  • Weight-for-height > -2 SD (or weight gain for at least 3 consecutive days)
  • No medical complications
  • Mother/caregiver is trained in feeding and home care
• Follow-up visits at 1, 2, and 4 weeks post-discharge
• Continue RUTF or high-energy, high-protein home foods
• Immunization update, vitamin A, deworming
• Address underlying causes (poverty, poor sanitation, hygiene education)

Special Considerations in Marasmic Kwashiorkor

• Do not use diuretics to treat edema - the edema resolves with nutritional repletion
• Refeeding syndrome risk - sudden increase in calories stimulates insulin, causing intracellular shifts of phosphate, magnesium, potassium, and glucose, leading to hypophosphatemia, cardiac arrhythmias, cardiac failure; hence the slow, phased introduction of feeds
• Infections are the leading cause of death - maintain low threshold for starting antibiotics
• Gut mucosal atrophy in kwashiorkor means reduced absorption; start with diluted or low-lactose feeds
• Liver: fatty liver present in kwashiorkor (due to reduced apolipoprotein synthesis); resolves with treatment
• Monitor blood glucose every 30 minutes initially (risk of hypoglycaemia)
• Fitzpatrick's Dermatology, pp. 2232-2233; Robbins & Kumar (Basic Pathology) p. 289-290; Robbins, Cotran & Kumar (Pathologic Basis of Disease)

Summary Comparison: Marasmus vs. Kwashiorkor vs. Marasmic Kwashiorkor

• Park's Textbook of Preventive and Social Medicine - for India-specific epidemiology, causes, prevention, and health worker roles
• Robbins & Kumar Basic Pathology (Robbins Pathology) - for SAM pathophysiology and morphology
• Robbins, Cotran & Kumar Pathologic Basis of Disease - for kwashiorkor pathology
• Fitzpatrick's Dermatology (Volumes 1 & 2) - for clinical features, treatment protocol