Malnutrition

Author: Harohalli R Shashidhar, Associate Professor, Department of Pediatrics, Chief, Division of

Pediatric Gastroenterology and Nutrition, University of Kentucky Medical Center

Coauthor(s): Donna G Grigsby, MD, Associate Professor, Department of Pediatrics, University of

Kentucky College of Medicine

Contributor Information and Disclosures

Updated: Apr 9, 2009Print ThisEmail This

Overview

Differential Diagnoses & Workup

Treatment & Medication

Follow-up

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References

Keywords

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Introduction

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."1 Women and young children are the most adversely affected groups; one quarter to one half
of women of child-bearing age in Africa and south Asia are underweight, which contributes to the
number of low birth weight infants born annually.2

Malnutrition is globally the most important risk factor for illness and death, contributing to more than
half of deaths in children worldwide; child malnutrition was associated with 54% of deaths in children in
developing countries in 2001.1,2 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.3

The effects of changing environmental conditions in increasing malnutrition is multifactorial. Poor

environmental conditions may increase insect and protozoal infections and also contribute to
environmental deficiencies in micronutrients. Overpopulation, more commonly seen in developing
countries, can reduce food production, leading to inadequate food intake or intake of foods of poor
nutritional quality. Conversely, the effects of malnutrition on individuals can create and maintain
poverty, which can further hamper economic and social development.2

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 of edema (kwashiorkor) or absence of edema (marasmus).
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 are noted, 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, whereas 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 various 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.4

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

Hormonal adaptation to the stress of malnutrition. The evolution of marasmus.

A classic example of a weight chart for a severely malnourished child.

Frequency

United States

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.

International

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.1

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.
In developing countries, poor perinatal conditions account for 23% of deaths in children younger than
five. Malnourished women are at high risk of giving birth to low birth weight infants. Many low birth
weight infants (23.% of all births) face severe short-term and long-term health consequences, such as
growth failure in infancy and childhood, which increases risk of morbidity and early death.2

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 in delayed achievement of motor
skills, delayed mental development, and may have 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 have worse outcomes. Dose-
dependent relationships between impaired growth and poor school performance and decreased
intellectual achievement have been shown.2,5,6,7

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.1

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

History

Clinical signs and symptoms of protein-energy malnutrition (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:8

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.