AUTHOR INFORMATION

Section 1 of 8

Authored by Donna G Grigsby, MD, Associate Professor, Department of Pediatrics, University of Kentucky College of Medicine

Coauthored by Harohalli R Shashidhar, Associate Professor, Department of Pediatrics, Chief, Division of Pediatric Gastroenterology and Nutrition, University of Kentucky Medical Center

Donna G Grigsby, MD, is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Kentucky Pediatric Society

Edited by Maria Rebello Mascarenhas, MBBS, Associate Professor of Pediatrics, University of Pennsylvania School of Medicine; Section Chief, Division of Gastroenterology and Nutrition, Director, Nutrition Support Service, Children's Hospital of Philadelphia; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc; Jatinder Bhatia, MD, Professor of Pediatrics, Chief, Section of Neonatology, Vice Chairman for Clinical Research, Department of Pediatrics, Medical College of Georgia; Merrily P M Poth, MD, Professor, Department of Pediatrics and Neuroscience, Uniformed Services University of the Health Sciences; and Jatinder Bhatia, MD, Professor of Pediatrics, Chief, Section of Neonatology, Vice Chairman for Clinical Research, Department of Pediatrics, Medical College of Georgia

Author's Email:	Donna G Grigsby, MD
Editor's Email:	Maria Rebello Mascarenhas, MBBS

eMedicine Journal, June 30 2006, VOLUME 7, Number 6

INTRODUCTION

Section 2 of 8

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." Malnutrition is globally the most important risk factor for illness and death, contributing to more than half of deaths in children worldwide. 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.

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 (kwashiorkor) or absence (marasmus) of edema. 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 exist, some studies suggest that marasmus represents an adaptation to starvation whereas kwashiorkor represents a dysadaptation to starvation.

In 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, while 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.

Pathophysiology: Malnutrition affects virtually every organ system. Dietary protein is needed to provide amino acids for synthesis of body proteins and other compounds that have a variety of 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.

In 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 (AIDS). Loss of delayed hypersensitivity, fewer T lymphocytes, impaired lymphocyte response, impaired phagocytosis secondary to decreased complement and certain cytokines, and decreased secretory immunoglobulin A (IgA) 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.

Other pathologic changes include fatty degeneration of the liver and heart, atrophy of the small bowel, and decreased intravascular volume leading to secondary hyperaldosteronism.

Frequency:

• In the US: Fewer than 1% of all children in the United States have chronic malnutrition.

  Incidence 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.

• Internationally: 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.

  In 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.

Mortality/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. Impairment of immunologic functions in these children mimics those observed in children with AIDS, predisposing them to opportunistic and other typical childhood infections.

• Children who are chronically malnourished exhibit behavioral changes, including irritability, apathy and decreased social responsiveness, anxiety, and attention deficits. In addition, infants and young children who have malnutrition frequently demonstrate developmental delay or 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. In general, nutritional insults at younger ages will have worse outcomes.

• 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.

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.

CLINICAL

Section 3 of 8

History:

• Clinical signs and symptoms of PEM include the following:


• • Poor weight gain
  
  
  
  • Slowing of linear growth
  
  
  
  • Behavioral changes - Irritability, apathy, decreased social responsiveness, anxiety, and attention deficits
  
  
  
• Clinical signs and symptoms of micronutrient deficiencies: Some of the clinical signs and symptoms of specific micronutrient deficiencies may closely resemble those observed in PEM. Deficiencies of micronutrients, including vitamins, minerals, and trace elements have been well described. The most common and clinically significant deficiencies include the following:


• • Iron - Fatigue, anemia, decreased cognitive function, headache, glossitis, and nail changes
  
  
  
  • Iodine - Goiter, developmental delay, and mental retardation
  
  
  
  • Vitamin D - Poor growth, rickets, and hypocalcemia
  
  
  
  • Vitamin A - Night blindness, xerophthalmia, poor growth, and hair changes
  
  
  
  • Folate - Glossitis, anemia (megaloblastic), and neural tube defects (in fetuses of women without folate supplementation)
  
  
  
  • Zinc - Anemia, dwarfism, hepatosplenomegaly, hyperpigmentation and hypogonadism, acrodermatitis enteropathica, diminished immune response, poor wound healing
  
  
  

Physical: Physical findings that are associated with PEM include the following:

• Decreased subcutaneous tissue: Areas that are most affected are the legs, arms, buttocks, and face.



• Edema: Areas that are most affected are the distal extremities and anasarca [generalized edema].



• Oral changes


• • Cheilosis
  
  
  
  • Angular stomatitis
  
  
  
  • Papillar atrophy
  
  
  
• Abdominal findings


• • Abdominal distension secondary to poor abdominal musculature
  
  
  
  • Hepatomegaly secondary to fatty infiltration
  
  
  
• Skin changes


• • Dry peeling skin with raw exposed areas
  
  
  
  • Hyperpigmented plaques over areas of trauma
  
  
  
• Nail changes: Nails become fissured or ridged.



• Hair changes: Hair is thin, sparse, brittle, easily pulled out, and turns a dull brown or reddish color.

Causes:

• Inadequate food intake is the most common cause of malnutrition worldwide. In developing countries, inadequate food intake is secondary to insufficient or inappropriate food supplies or early cessation of breastfeeding. In some areas, cultural and religious food customs may play a role. Inadequate sanitation further endangers children by increasing the risk of infectious diseases that increase nutritional losses and alters metabolic demands.



• In developed countries, inadequate food intake is a less common cause of malnutrition. Instead, diseases and, in particular, chronic illnesses play an important role in the etiology of malnutrition. Children with chronic illness are at risk for nutritional problems for several reasons, including the following:


• • Children with chronic illnesses frequently have anorexia, which leads to inadequate food intake.
  
  
  
  • Increased inflammatory burden and increased metabolic demands can increase caloric need.
  
  
  
  • Any chronic illness that involves the liver or small bowel affects nutrition adversely by impairing digestive and absorptive functions.
  
  
  
• Chronic illnesses that commonly are associated with nutritional deficiencies include the following:


• • Cystic fibrosis
  
  
  
  • Chronic renal failure
  
  
  
  • Childhood malignancies
  
  
  
  • Congenital heart disease
  
  
  
  • Neuromuscular diseases
  
  
  
  • Chronic inflammatory bowel diseases
  
  
  
• In addition, the following conditions place children at significant risk for the development of nutritional deficiencies:


• • Prematurity
  
  
  
  • Developmental delay
  
  
  
  • In utero toxin exposure (ie, fetal alcohol exposure)
  
  
  
• Children with multiple food allergies present a special nutritional challenge because of severe dietary restrictions. Patients with active allergic symptoms may have increased calorie and protein needs.

WORKUP

Section 4 of 8

Lab Studies:

• The most helpful laboratory studies in assessing the nutritional status of a child are hematological studies and laboratory studies evaluating protein status.


• • Hematological studies should include a complete blood count (CBC) with red blood cell indices and a peripheral smear. This could also help exclude anemias from nutritional deficiencies such as iron, folate, and vitamin B-12 deficiencies.
  
  
  
  • Measures of protein nutritional status include serum albumin, retinol-binding protein, prealbumin, transferrin, creatinine, and BUN levels. Retinol-binding protein, prealbumin, and transferrin determinations are much better short-term indicators of protein status than albumin. However, in the field, a better measure of long-term malnutrition is serum albumin because of its longer half-life.
  
  
  
• Additional diagnostic evaluation


• • In children who have a history of adequate food intake and signs/symptoms of malnutrition, focus on identifying the cause of malnutrition. Perform laboratory studies based on information from a complete history and physical examination.
  
  
  
  • Initial diagnostic laboratory studies include a CBC, sedimentation rate, serum electrolytes, and urinalysis and culture. Stool specimens should be obtained if the child has a history of abnormal stools or stooling patterns or if the family uses an unreliable or questionable source of water.
  
  
  
  • Additional studies may focus on thyroid functions or sweat chloride tests, particularly if height velocity is abnormal. Further diagnostic studies should be determined as dictated by the history and physical examination. For example, lab tests evaluating renal function, such as phosphorus and calcium, should be obtained in the presence of renal symptoms. Children with suspected liver disease should have triglyceride and vitamin levels obtained, while zinc levels should be obtained in patients with chronic diarrhea.
  
  
  
• Celiac serology is a useful screening test and should be considered, especially if there is a family history of celiac disease or if other autoimmune diseases, such as type I diabetes mellitus, are present.

Other Tests:

• Practical nutritional assessment


• • Complete history, including a detailed dietary history
  
  
  
  • Growth measurements, including weight and length/height; head circumference in children younger than 3 years
  
  
  
  • Complete physical examination
  
  
  
• Sensitive measures of nutritional status


• • Height-for-age or weight-for-height measurements greater than 2 standard deviations below the mean for age
  
  
  
  • Height-for-age or weight-for-height measurements more than 2 standard deviations less than the mean for age

    Height-for-age measurements less than 95% of expected value

  
  
  
  • Weight-for-height measurements less than 90% of expected value
  
  
  
  • Less than 5 cm/y of growth in children older than 2 years
  
  
  
  • Body mass index (BMI) (although not established by the CDC as a criteria for failure to thrive)
  
  
  

TREATMENT

Section 5 of 8

Medical Care:

• Following evaluation of the child’s nutritional status and identification of the underlying etiology of the malnutrition, dietary intervention in collaboration with a dietitian or other nutritional professionals should be initiated. Children with edema must be assessed carefully for actual nutritional status because edema may mask the severity of malnutrition. Children with chronic malnutrition may require caloric intakes more than 120-150 kcal/kg/d to achieve appropriate weight gain. The formula for determining adequate caloric intake is:

  kcal/kg = (RDA for age X ideal weight)/actual weight




• Additionally, any micronutrient deficiencies must be corrected for the child to attain appropriate growth and development. Most children with mild malnutrition respond to increased oral caloric intake and supplementation with vitamin, iron, and folate supplements. The requirement for increased protein is met typically by increasing the food intake, which, in turn, increases both protein and caloric intake. Adequacy of intake is determined by monitoring weight gain.



• In mild-to-moderate cases of malnutrition, initial assessment and nutritional intervention may be done in the outpatient setting. A patient with malnutrition may require hospitalization based on the severity and instability of the clinical situation. Hospitalization of patients with suspected malnutrition secondary to neglect allows observation of the interactions between parent/caregiver and child and documentation of actual intake and feeding difficulties. It may also be warranted in cases where dehydration and acidosis complicate the clinical picture. In moderate-to-severe cases of malnutrition, enteral supplementation via tube feedings may be necessary.

Consultations:

• Any child at risk for nutritional deficiency should be referred to a registered dietitian or other nutritional professional for a complete nutritional assessment and dietary counseling.



• In the United States, children with poor nutrition secondary to inadequate intake should be referred to the appropriate social agencies to assist the family in obtaining resources and providing ongoing care for the child.



• Other subspecialty referrals are based on findings in the initial evaluation that may indicate a specific cause of inadequate nutrition other than inadequate food intake.

Diet:

• Protein, energy, and other nutrient requirements vary with age, sex, and activity levels.



• Following careful assessment of the child’s nutritional status, initiate nutritional intervention in collaboration with nutrition support personnel.



• Children with chronic malnutrition may require caloric intakes in excess of 120-150 kcal/kg/d to achieve appropriate weight gain. The diet must include adequate amounts of protein and other macronutrients.



• Any micronutrient deficiencies must be diagnosed and corrected to achieve adequate somatic growth and psychomotor development.

FOLLOW-UP

Section 6 of 8

Further Outpatient Care:

• Monitor patients closely for growth and resolution of clinical signs and symptoms of malnutrition. Follow-up should be based on the severity of the illness, age of the patient, and the patient's initial response to intervention. Minimal intervals between visits should give the patient sufficient time to show a change in the measured parameter. For example, in infants beyond the newborn stage, the time needed to show an appreciable change in weight is 7 days. A 4-week interval is needed to document changes in length, and an 8-week interval is needed to document a change in height.

Deterrence/Prevention:

• Prevention of malnutrition in children starts with an emphasis on prenatal nutrition and good prenatal care. Health care providers should emphasize the importance of breastfeeding in the first year of life. Promotion of breastfeeding is particularly crucial in developing countries where safe alternatives to human milk are unavailable. In addition to the promotion of breastfeeding, health care providers should counsel parents on the appropriate introduction of nutritious supplemental foods. Health care providers should continue to provide age-appropriate nutritional counseling at every opportunity.



• Programs addressing micronutrient supplementation and fortification have been successful at decreasing the incidence of specific micronutrient deficiencies (eg, iodine, vitamin D) in many countries. These programs should be promoted more in developing countries. Additional fortification programs should be developed to address other common nutritional deficiencies such as iron deficiency, which continues to be significant problem throughout the world.



• Improvement in hygiene practices and sanitation reduces the incidence of infectious diseases, which decreases the incidence of malnutrition in developing countries.

Prognosis:

• Children who have chronic malnutrition, especially those with intrauterine growth retardation and with onset at an early age, do not achieve their full growth potential or regain cognitive deficits. Although malnutrition is rare in the United States and other industrialized countries, over half of childhood mortality in developing countries is either directly or indirectly secondary to malnutrition.

TEST QUESTIONS

Section 7 of 8

CME Question 1: A 15-month-old boy presents to a clinic with poor growth and anasarca. His mother reports a decrease in activity and listlessness over the last week. His past medical history is significant for multiple allergies, including several foods for which he has been placed on a restricted diet consisting of rice water and a few vegetables. His mother reports no diarrhea or change in stools or urine output. On physical examination, irritability, wasting muscle mass, and diffuse edema are observed. Which of the following is the most likely etiology of this infant’s kwashiorkor?

A: Inadequate ingestion of protein
B: Protein malabsorption
C: Acute nephrotic syndrome
D: Protein-losing enteropathy
E: Protein allergy

The correct answer is A: This child is ingesting very little protein with his diet of rice water and vegetables. Malabsorption or enteropathy is unlikely with normal stools. Although normal urine output does not rule out nephrotic syndrome completely, he has wasting, which is unusual for acute nephrosis.

CME Question 2: The immunologic changes observed in children with malnutrition most closely resemble those changes found in which of the following disease processes?

A: B-cell deficiency
B: Agammaglobulinemia
C: Acquired immune deficiency syndrome (AIDS)
D: Isolated T-cell deficiency
E: Immunoglobulin subclass deficiency

The correct answer is C: The immune changes observed in children with malnutrition correlate with poor outcomes and mimic the changes observed in children with acquired immune deficiency syndrome (AIDS). They include loss of delayed hypersensitivity, fewer T lymphocytes, impaired lymphocyte response, impaired phagocytosis secondary to decreased complement and certain cytokines, and decreased secretory immunoglobulin A (IgA).

Pearl Question 1 (T/F): In 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.

The correct answer is True: These immune response changes correlate with poor outcomes and mimic the changes observed in children with acquired immune deficiency syndrome (AIDS).

Pearl Question 2 (T/F): Common micronutrient deficiencies include iron, zinc, and vitamin A deficiencies.

The correct answer is True: 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 2 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, while deficiencies of vitamin C, B, and D have improved in recent years.

Pearl Question 3 (T/F): Childhood malignancies are associated with nutritional deficiencies in children.

The correct answer is True: Cystic fibrosis, chronic renal failure, childhood malignancies, neuromuscular diseases, congenital heart disease, and multiple food allergies are the most common chronic illnesses associated with nutritional deficiencies in children.

Pearl Question 4 (T/F): In the United States, children who have acute illness are at highest risk for malnutrition.

The correct answer is False: Children with lower socioeconomic status (SES), in shelters for the homeless, and in rural areas are at highest risk for malnutrition. Hospitalized children and children with chronic illnesses also are at high risk for malnutrition.

BIBLIOGRAPHY

Section 8 of 8

• Balint JP: Physical findings in nutritional deficiencies. Pediatr Clin North Am 1998 Feb; 45(1): 245-60[Medline].
• Benitez-Bribiesca L, De la Rosa-Alvarez I, Mansilla-Olivares A: Dendritic spine pathology in infants with severe protein-calorie malnutrition. Pediatrics 1999 Aug; 104(2): e21[Medline].
• Blecker U, Mehta DI, Davis R, et al: Nutritional problems in patients who have chronic disease. Pediatr Rev 2000 Jan; 21(1): 29-32[Medline].
• Caulfield LE, de Onis M, Blossner M: Undernutrition as an underlying cause of child deaths associated with diarrhea, pneumonia, malaria, and measles. Am J Clin Nutr 2004 Jul; 80(1): 193-8[Medline].
• Chandra RK: 1990 McCollum Award lecture. Nutrition and immunity: lessons from the past and new insights into the future. Am J Clin Nutr 1991 May; 53(5): 1087-101[Medline].
• de Onis M, Blossner M, Borghi E: Estimates of global prevalence of childhood underweight in 1990 and 2015. JAMA 2004 Jun 2; 291(21): 2600-6[Medline].
• de Onis M, Frongillo EA, Blossner M: Is malnutrition declining? An analysis of changes in levels of child malnutrition since 1980. Bull World Health Organ 2000; 78(10): 1222-33[Medline].
• Hay WW Jr, Lucas A, Heird WC, et al: Workshop summary: nutrition of the extremely low birth weight infant. Pediatrics 1999 Dec; 104(6): 1360-8[Medline].
• Hendricks KM, Duggan C, Gallagher L, et al: Malnutrition in hospitalized pediatric patients. Current prevalence. Arch Pediatr Adolesc Med 1995 Oct; 149(10): 1118-22[Medline].
• Islam S, Abely M, Alam NH, et al: Water and electrolyte salvage in an animal model of dehydration and malnutrition. J Pediatr Gastroenterol Nutr 2004 Jan; 38(1): 27-33[Medline].
• Kleinman RE, Murphy JM, Little M, et al: Hunger in children in the United States: potential behavioral and emotional correlates. Pediatrics 1998 Jan; 101(1): E3[Medline].
• Kleinmann R, Committee on Nutrition: Pediatric Nutrition Handbook. 4th ed. American Academy of Pediatrics; 1998.
• Koerner CB, Hays TL: Food allergy: current knowledge and future directions. Immunol Allergy Clin North Am 1999; 19.
• Müller O, Krawinkel M: Malnutrition and health in developing countries. CMAJ 2005 Aug 2; 173(3): 279-86[Medline].
• Rosenfield RL: Essentials of growth diagnosis. Endocrinol Metab Clin North Am 1996 Sep; 25(3): 743-58[Medline].
• World Health Organization: Malnutrition- The Global Picture. 2000; Available at: http://www.who.int/home-page/[Full Text].

eMedicine Journals > Pediatrics > Nutrition > Malnutrition

Please email us with any comments you have on our new chapter format.

Author Information | Introduction | Clinical | Workup | Treatment | Follow-up | Test Questions | Bibliography