81  Malnutrition

Published

July 3, 2025

81.1 Introduction

Malnutrition remains one of the most significant health challenges affecting children globally, especially in low- and middle-income countries such as Ghana. It contributes substantially to morbidity and mortality, being an underlying factor in nearly half of all under-five deaths. Malnutrition includes both undernutrition (deficiencies in energy, protein, or micronutrients) and overnutrition (overweight and obesity).

Childhood malnutrition results from an interplay between inadequate dietary intake, infections, and social determinants such as poverty and poor sanitation. It affects physical growth, cognitive development, and immune competence, leading to long-term consequences in adulthood.

81.2 Definition

Malnutrition is a pathological state resulting from an imbalance between nutrient intake and the body’s requirements. It may result in:

  1. Undernutrition — deficiency of energy, protein, or micronutrients.
  2. Overnutrition — excess intake of energy and nutrients.

In children, protein–energy malnutrition (PEM) is the most severe form of undernutrition.

81.3 Classification

81.3.1 1. Based on Type

  • Undernutrition: Wasting, stunting, underweight.
  • Overnutrition: Overweight, obesity.
  • Micronutrient deficiencies: e.g., vitamin A, iron, iodine, zinc.

81.3.2 2. Based on Clinical Form (PEM)

Type Description Key Features
Marasmus Deficiency of energy (calories) Severe wasting, no oedema
Kwashiorkor Deficiency of protein with adequate calories Oedema, dermatosis, fatty liver
Marasmic–Kwashiorkor Combined energy and protein deficiency Wasting plus oedema

81.3.3 3. Based on Anthropometric Indices (WHO)

Indicator Definition Category
Weight-for-height (WFH) < -2 SD of WHO median Wasting (acute malnutrition)
Height-for-age (HFA) < -2 SD Stunting (chronic malnutrition)
Weight-for-age (WFA) < -2 SD Underweight
BMI-for-age > +2 SD Overweight
BMI-for-age >+3 SD Obesity

81.4 Epidemiology

  • Global burden: About 149 million children under 5 are stunted, 45 million wasted, and 37 million overweight (UNICEF 2023).
  • Sub-Saharan Africa: Persistent high rates of undernutrition; emerging overweight trends in urban areas.
  • Ghana: Stunting ~17%, wasting ~6%, overweight ~3% (GDHS 2022).

Malnutrition often clusters with poverty, low maternal education, poor sanitation, and infectious diseases such as diarrhoea and malaria.

81.5 Aetiology

The causes of malnutrition are multifactorial and interrelated. The UNICEF conceptual framework divides them into immediate, underlying, and basic causes.

81.5.1 1. Immediate Causes

  • Inadequate dietary intake — insufficient energy, protein, or micronutrients.
  • Disease burden — infections increase nutrient losses and metabolic demands.

81.5.2 2. Underlying Causes

  • Household food insecurity — lack of access to adequate food.
  • Poor care and feeding practices — inappropriate breastfeeding or complementary feeding.
  • Unhealthy environment and inadequate health services — infections and lack of preventive care.

81.5.3 3. Basic Causes

  • Poverty, low education, unemployment.
  • Political instability, poor governance, and social inequality.

81.6 Pathophysiology

Malnutrition disrupts multiple physiological systems:

  1. Energy deficiency → muscle wasting, loss of subcutaneous fat.
  2. Protein deficiency → impaired synthesis of enzymes, albumin, and immune factors.
  3. Micronutrient deficiency → anaemia, impaired growth, increased susceptibility to infection.
  4. Metabolic adaptation: Reduced basal metabolic rate and altered hormonal responses (insulin, cortisol).
  5. Immune dysfunction: Atrophy of lymphoid tissue leading to immunosuppression.

81.6.0.1 In Kwashiorkor:

  • Low plasma albumin → oedema.
  • Fatty liver due to defective lipoprotein synthesis.
  • Oxidative stress and free radical damage contribute to cellular injury.

81.7 Clinical Features

81.7.1 General Presentation

  • Poor growth and weight loss.
  • Wasting or oedema.
  • Recurrent infections (respiratory, diarrhoeal).
  • Lethargy, irritability, apathy.
  • Developmental delay.

81.7.2 A. Marasmus

  • Severe wasting, “skin and bones” appearance.
  • Loss of subcutaneous fat and muscle.
  • Alert but irritable.
  • No oedema.
  • Wrinkled skin, sunken eyes, sparse dry hair.

81.7.3 B. Kwashiorkor

  • Generalized or dependent oedema (starting from feet).
  • Moon face, flaky paint dermatosis.
  • Sparse, easily pluckable hair with flag sign.
  • Enlarged fatty liver.
  • Apathy, poor appetite.
  • Anaemia and susceptibility to infection.

81.7.4 C. Marasmic–Kwashiorkor

  • Features of both wasting and oedema.

81.8 Complications of Severe Acute Malnutrition (SAM)

  1. Hypoglycaemia
  2. Hypothermia
  3. Dehydration (often masked by oedema)
  4. Electrolyte imbalance (low potassium, magnesium)
  5. Infections (often with subtle signs)
  6. Anaemia
  7. Heart failure

81.9 Assessment and Diagnosis

81.9.1 1. Anthropometric Measurements

Indicator Tool Interpretation
Weight-for-height Salter scale, WHO chart < -3 SD = severe wasting
MUAC (6–59 months) MUAC tape < 11.5 cm = SAM
Oedema Clinical exam Presence indicates SAM regardless of weight

81.9.2 2. Laboratory Investigations

  • Blood glucose: detect hypoglycaemia.
  • Haemoglobin: assess for anaemia.
  • Electrolytes: Na⁺, K⁺, Mg²⁺.
  • Urinalysis: infection or proteinuria.
  • Malaria test: especially in endemic areas.
  • Stool examination: parasites.
  • HIV testing: as indicated.

81.10 Management of Severe Acute Malnutrition (SAM)

Management is guided by WHO protocols and Ghana Health Service guidelines.

81.10.1 Objectives

  • Treat or prevent complications.
  • Correct nutritional deficiencies.
  • Achieve catch-up growth.
  • Promote caregiver education.

81.10.2 Phases of Management

81.10.2.1 1. Stabilization Phase (Days 1–2)

  • Manage life-threatening problems.
  • Avoid excess protein and sodium.
  • Feed with F-75 (75 kcal/100 mL, 0.9 g protein/100 mL) every 2–3 hours.
  • Prevent hypoglycaemia and hypothermia.
81.10.2.1.1 a) Hypoglycaemia
  • Feed immediately.
  • If unable to feed: 10% dextrose 5 mL/kg IV or via NG tube.
81.10.2.1.2 b) Hypothermia
  • Keep child warm (skin-to-skin, warm room, clothing).
81.10.2.1.3 c) Dehydration
  • Use ReSoMal (Rehydration Solution for Malnutrition) orally or via NG.
  • Avoid standard ORS due to high sodium.
81.10.2.1.4 d) Infections
  • Empiric antibiotics (ampicillin + gentamicin, or ceftriaxone if indicated).
81.10.2.1.5 e) Micronutrient supplementation
  • Vitamin A (not if given within last month), multivitamins, folic acid, zinc, copper, magnesium.

81.10.2.2 2. Transition Phase (Days 2–7)

  • Introduce higher-calorie feeds: F-100 (100 kcal/100 mL, 2.9 g protein/100 mL).
  • Gradually increase intake to meet energy needs.

81.10.2.3 3. Rehabilitation Phase (Day 7 onwards)

  • Catch-up growth with F-100 or locally fortified feeds.
  • Encourage play and stimulation.
  • Treat underlying causes (e.g., poor feeding, infection).

81.10.3 Discharge Criteria

  • Weight-for-height > -2 SD for 2 consecutive weeks.
  • No oedema for at least 2 weeks.
  • Good appetite and clinical recovery.

81.11 Management of Moderate Acute Malnutrition (MAM)

  • Managed as outpatient.
  • Supplementary feeding with ready-to-use foods (RUFs).
  • Nutrition counselling for caregivers.
  • Monitor growth weekly.

81.12 Management of Chronic Malnutrition (Stunting)

  • Address long-term inadequate nutrition.
  • Promote maternal nutrition and antenatal care.
  • Early initiation of breastfeeding.
  • Timely complementary feeding and infection control.

81.13 Management of Micronutrient Deficiencies

81.13.1 1. Iron Deficiency Anaemia

  • Oral iron (3–6 mg/kg/day elemental iron) for 3 months.
  • Treat underlying infection (malaria, hookworm).

81.13.2 2. Vitamin A Deficiency

  • 200,000 IU single dose (>12 months), 100,000 IU (6–12 months), 50,000 IU (<6 months).
  • Encourage intake of carotene-rich foods (mango, palm oil, liver).

81.13.3 3. Iodine Deficiency

  • Universal salt iodization.

81.13.4 4. Zinc Deficiency

  • Zinc supplementation (10–20 mg/day) during diarrhoeal illness.

81.14 Prevention of Malnutrition

  1. Exclusive breastfeeding for the first 6 months.
  2. Timely and adequate complementary feeding from 6 months.
  3. Micronutrient supplementation and fortification (iron, vitamin A, zinc, iodine).
  4. Routine immunization to reduce infections.
  5. Nutrition education for caregivers.
  6. Deworming every 6 months after age 1.
  7. Food security interventions at household and community level.

81.15 Nutrition Rehabilitation Centres (NRCs)

These provide facility-based care for children with SAM who cannot be managed as outpatients. Activities include: - Stabilization and rehabilitation phases. - Nutrition education for caregivers. - Psychosocial stimulation. - Growth monitoring and follow-up.

81.16 Community Management of Acute Malnutrition (CMAM)

The CMAM strategy integrates facility and community-level interventions: - Screening: by MUAC or oedema. - Outpatient therapeutic care: for uncomplicated SAM using RUTF (e.g., Plumpy’Nut). - Inpatient care: for complicated SAM. - Community outreach: to promote early detection and referral.

81.17 Overnutrition and Childhood Obesity

81.17.1 Definition

Excessive fat accumulation due to imbalance between energy intake and expenditure.

81.17.2 Risk Factors

  • High-calorie, low-nutrient diets.
  • Sedentary lifestyle.
  • Urbanization.
  • Genetic predisposition.

81.17.3 Complications

  • Type 2 diabetes mellitus.
  • Hypertension, dyslipidaemia.
  • Non-alcoholic fatty liver disease.
  • Orthopaedic and psychosocial problems.

81.17.4 Management

  • Lifestyle modification: healthy diet, regular physical activity.
  • Family-based behavioural interventions.
  • Avoid restrictive diets in growing children.

81.18 Prognosis

  • Mild to moderate malnutrition: reversible with appropriate intervention.
  • Severe malnutrition: carries a mortality rate of 10–30% if untreated.
  • Early detection and management significantly improve outcomes.
  • Stunting has long-term impacts on cognition, school performance, and adult productivity.

81.19 Public Health and Policy Considerations

  • Integrated management of childhood illness (IMCI) includes nutrition counselling.
  • Ghana Health Service programs: CMAM, growth monitoring, vitamin A supplementation, and infant feeding promotion.
  • Sustainable Development Goals (SDG 2): End all forms of malnutrition by 2030.

81.20 Key Takeaways

  • Malnutrition encompasses both undernutrition and overnutrition.
  • Protein–energy malnutrition (marasmus and kwashiorkor) is preventable.
  • Early recognition, stabilization, and rehabilitation are critical in SAM management.
  • Micronutrient supplementation and infection control are essential.
  • Prevention through improved feeding practices and socioeconomic development remains the cornerstone.

81.21 Suggested References

  1. World Health Organization. Pocket Book of Hospital Care for Children, 3rd Edition, 2023.
  2. Ghana Health Service. Integrated Management of Acute Malnutrition Guidelines, 2021.
  3. UNICEF/WHO/World Bank. Levels and Trends in Child Malnutrition, 2023.
  4. Black RE, Victora CG, Walker SP et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet. 2021;397(10283):138–154.
  5. Ministry of Health, Ghana. Standard Treatment Guidelines, 2022.