Malnutrition

Malnutrition

Malnutrition is estimated to contribute to more than one third of all child deaths, although it is rarely listed as the direct cause. Lack of access to highly nutritious foods, especially in the present context of rising food prices, is a common cause of malnutrition. Poor feeding practices, such as inadequate breastfeeding, offering the wrong foods, and not ensuring that the child gets enough nutritious food, contribute to malnutrition.
Infection – particularly frequent or persistent diarrhoea, pneumonia, measles and
malaria – also undermines a child's nutritional status.

A recently developed home-based treatment for severe acute malnutrition is improving the lives of hundreds of thousands of children a year.

Ready-to-use Therapeutic Food (RUTF) has revolutionized the treatment of severe malnutrition – providing foods that are safe to use at home and ensure rapid weight gain in severely malnourished children.

The advantage of RUTF is that it is a ready-to-use paste which does not need to be mixed with water, thereby avoiding the risk of bacterial proliferation in case of accidental contamination. The product, which is based on peanut butter mixed with dried skimmed milk and vitamins and minerals, can be consumed directly by the child and provides sufficient nutrient intake for complete recovery. It can be stored for three to four months without refrigeration, even at tropical temperatures. Local production of RUTF paste is already under way in several countries including Congo, Ethiopia, Malawi and Niger.

Following the consensus on community-based management for severe malnutrition reached in a informal consultation in 2005, WHO has worked with UNICEF on the development of a field manual on community-based management of severe malnutrition, and the IMCI guidelines have been revised to take account of the new home-based treatment.

Malnutrition occurs when a person does not receive adequate nutrients from diet. This causes damage to the vital organs and functions of the body.
      Lack of food is the most cause of malnutrition in the poorer and developing countries.

However, in developed countries like UK or USA the cause may be more varied. For example, those with a high calorie diet deficient in vital vitamins and minerals are also considered malnourished. This includes the obese and the overweight.

The causes of malnutrition include:

Lack of food: this is common among the low income group as well as those who are homeless.

Those having difficulty eating due to painful teeth or other painful lesions of the mouth. Those with dysphagia or difficulty swallowing are also at risk of malnutrition. This could be due to a blockage in the throat or mouth or due to sores in the mouth.

Loss of appetite. Common causes of loss of appetite include cancers, tumours, depressive illness and other mental illnesses, liver or kidney disease, chronic infections etc.

Those with a limited knowledge about nutrition tend to follow an unhealthy diet with not enough nutrients, vitamins and minerals and are at risk of malnutrition.

Elderly living alone, disabled persons living alone or young students living on their own often have difficulty cooking healthy balanced meals for themselves and may be at risk of malnutrition.

The elderly (over 65 years of age are), especially those living in care facilities are at a higher risk of malnutrition. These individuals have long term illnesses that affect their appetite and ability to absorb nutrients from food and they may also have difficulty feeding themselves. In addition, there may be concomitant mental ailments like depression that affect appetite and food intake.

Those who abuse drugs or are chronic alcoholics.

Those with eating disorders like anorexia nervosa have difficulty maintaining adequate nutrition.

Those with digestive illnesses like ulcerative colitis or Crohn’s disease or malabsorption syndrome have difficulty in assimilating the nutrients from diet and may suffer from malnutrition.

Those with diarrhea or persistent nausea or vomiting.

Some medications tend to alter the body’s ability to absorb and break down nutrients and taking these may lead to malnutrition.

The demand for energy from food exceeds the amount of food taken. This includes those who have suffered a serious injury, burn or after major surgical procedures. This also includes pregnant women and children whose growth and needs for the unborn baby causes increased demand for nutrients and calories that may be deficient in a normal diet.

Among children lack of knowledge of adequate feeding among parents is the leading cause of malnutrition worldwide.

Premature babies are at a higher risk of malnutrition as are infants at the time of weaning.

Childhood cancers, heart defects from birth (congenital heart disease), cystic fibrosis and other major long term diseases in children are the leading cause of malnutrition.

Types of Malnutrition

Each form of malnutrition depends on what nutrients are missing in the diet, for how long and at what age. 

The most basic kind is called protein energy malnutrition . It results from a diet lacking in energy and protein because of a deficit in all major macronutrients, such as carbohydrates, fats and proteins. 

Marasmus is caused by a lack of protein and energy with sufferers appearing skeletally thin. In extreme cases, it can lead to kwashiorkor, in which malnutrition causes swelling including a so-called 'moon face'. 

Other forms of malnutrition are less visible - but no less deadly. They are usually the result of vitamin and mineral deficiencies (micronutrients), which can lead to anaemia, scurvy, pellagra, beriberi and xeropthalmia and, ultimately, death.

Deficiencies of iron, vitamin A and zinc are ranked among the World Health Organization's (WHO) top 10 leading causes of death through disease in developing countries:

Iron deficiency is the most prevalent form of malnutrition worldwide, affecting millions of people. Iron forms the molecules that carry oxygen in the blood, so symptoms of a deficiency include tiredness and lethargy. Lack of iron in large segments of the population severely damages a country's productivity. Iron deficiency also impedes cognitive development, affecting 40-60 percent of children aged 6-24 months in developing countries (source: Vitamin & Mineral Deficiency, a global damage assessment report, Unicef).
    Vitamin A deficiency weakens the immune systems of a large proportion of under-fives in poor countries, increasing their vulnerability to disease. A deficiency in vitamin A, for example, increases the risk of dying from diarrhoea, measles and malaria by 20-24 percent. Affecting 140 million preschool children in 118 countries and more than seven million pregnant women, it is also a leading cause of child blindness across developing countries (source: UN Standing Committee on Nutrition's 5th Report on the World Nutrition Situation, 2005).
Iodine deficiency affects 780 million people worldwide. The clearest symptom is a swelling of the thyroid gland called a goitre. But the most serious impact is on the brain, which cannot develop properly without iodine. According to UN research, some 20 million children (source: Vitamin & Mineral Deficiency, a global damage assessment report, Unicef) are born mentally impaired because their mothers did not consume enough iodine. The worst-hit suffer cretinism, associated with severe mental retardation and physical stunting.
    Zinc deficiency contributes to growth failure and weakened immunity in young children. It is linked to a higher risk of diarrhoea and pneumonia, resulting in nearly 800,000 deaths per year. 

Neglected children, orphans and those living in care homes are at risk of malnutrition.

Childhood acute malnutrition is high among HIV-infected children.

Severe wasting is a common clinical presentation of HIV infection in children. Generally despite of their HIV status, children with severe malnutrition are at risk for a number of life-threatening problems and require urgent and appropriate rehabilitation.
HIV-infected children with severe malnutrition have a higher risk of mortality than uninfected
children due to the frequency and severity of OIs including TB. After their recovery
from the initial rehabilitation, HIV infected children need urgent initiation of ART.
Children with an unknown HIV status, who present with severe malnutrition should
be tested for HIV and considered for ART.
Clinical presentation of severe malnutrition

Severe malnutrition is characterized by the presence of any of the following:
weight/height z score < -3, a MUAC of < 11.5cm in children of 6-59 months of age, visible wasting in infants of < 6 months of age, or bilateral pitting oedema.

Management of severe malnutrition
The treatment of severe malnutrition in HIV-infected children is the same as for
uninfected children.

Guidelines for Integrated Management of Severe Acute Malnutrition and Community based management of malnutrition for details.
In HIV-infected children, the initial period of stabilization may take longer due to
direct effects of HIV on the gut, appetite suppression or presence of OIs that may
be hard to diagnose, such as TB.