Severe Malnourishment

Severe malnutrition can result in life-long consequences that include short-stature, susceptibility to disease, and poor cognition. No matter what the cause, poor growth caused by poor nutrition is the result of not eating adequate calories, not being offered adequate calories, or not being able to retain adequate calories.

Poor caloric intake can result from medical problems, such as prematurity, low birth weight, developmental delay, HIV, gastrointestinal diseases, food allergy, cystic fibrosis, lead poisoning, or others. It can also be the result of the environment in which the child is living or has lived. For instance, malnutrition can be seen in children who were not offered adequate calories as a result of high-stress situations, such as poverty or intentional abuse. This type of malnutrition is not caused from anything that is medically wrong with the child, but rather is caused by the environment in which the child is living.

To correctly assess whether or not a child is malnourished, anthropometric, biochemical and dietary patterns must be analyzed.

Learn more about how to address severe malnutrition:

Anthropometrics

A child’s weight, length (or height), and head circumference must be measured regularly and plotted on an appropriate growth chart. If a child is premature, it is important to mark their weight according to the age they would be had they been born full-term (corrected age), not their actual age. For example, if a child was born 2 months early (32 weeks gestational age) and they are now 6 months old, their measurements should be plotted at the 4month age marker. Weight should be plotted in this way until the child is 24 months corrected age and length should be plotted for corrected age until the child is 40 months.

Learn how to properly measure weight, length and head circumference and plot points on growth charts.

It is desirable that the child’s growth measurements fall between the 3rd and 97th percentiles. If a child has both low weight-for-age and height-for-age, their weight-for-length should at least be proportional (between the 3rd and 97th percentiles).

Learn about classifications associated with severe malnutrition:

Keeping a record of head circumference provides a record of brain growth. When a child is malnourished, the head circumference is usually the last measurement affected. This is the body’s way of sparing brain health above weight gain and length growth. When a child’s brain growth begins to lag, this can indicate chronic malnourishment.

Laboratory Testing

In order to correctly identify and treat malnutrition, certain laboratory tests can be conducted.

Blood tests:

  • Complete Blood Count: can indicate iron deficiency anemia (if Mean Corpuscular Volume is low and Red Cell Distribution Width is high)
  • Iron
    • Serum ferritin: low levels linked to iron deficiency
    • Serum transferrin receptor: high levels linked to iron deficiency
    • Blood zinc protoporphyrin: high levels linked to iron deficiency
  • Lead level
  • Vitamin D: low levels can indicate rickets
  • Alkaline Phosphatase: if high, can indicate rickets, if low, can indicate zinc deficiency
  • Serum Zinc: low zinc levels are linked to growth failure and can result from prematurity, diarrhea or a poor dietary intake

Stool tests:

  • Giardia
  • pH: acidic pH can indicate lactose intolerance or an infection, such as rotavirus
  • Reducing substances: if high can indicate carbohydrate malabsorption
  • Fat: if high can indicate fat malabsorption
  • Ova
  • Parasites
  • Blood: presence of blood in the stool can indicate cow’s milk protein allergy

Diet Analysis

A detailed diet history should be taken. This should include:

  • What foods/drinks are typically offered?
    • If a child drinks too much juice (>8oz/day) or milk (>24oz/day) this can result a decreased intake of solid foods.
  • What amount of food/drink are typically offered to and eaten by the infant or child?
  • Where do meals/snacks take place (table, floor, in a noisy or quiet room, in the presence of other children or adults, with a television on)?
    • It is helpful for children to eat all meals at a table or common eating area in the presence of other children and adults eating with them.
    • The stimulus of a television set can distract children from eating.
  • What is the feeding philosophy surrounding the child? Is force-feeding practiced, or is the child able to control what and how much he or she eats?
    • Force feeding is not recommended and can result to increased anxiety and resistance to eating.
    • Adults should determine what is served, when it is served and where it is served.
    • Children should determine if they eat the food, and how much of it they eat.
  • How does the child tolerate feeding? Is she able to finish meals in an appropriate time frame?
    • Meals should last no longer than 30 minutes, snacks no longer than 15 minutes.
  • Does the child tolerate a variety of textures? Is he/she able to chew and swallow without difficulty?
    • Some children have difficulty with the above, and this can result in decreased intake and possibly food aversions.

Treating Malnutrition

Once a thorough assessment has been made, a plan can be made to help to restore the child back into a healthy nutritional status. This plan will depend on the cause of the malnutrition, but in general, the main goals are the same.

  1. Restore patient to an appropriate weight for length/height.
  2. Make sure the child’s micro and macronutrient needs are provided for in order to support adequate growth.
  3. Provide clear instructions to the child’s caregivers on how to care for the child’s nutritional and feeding needs.

Catch-up growth

In order for normal growth and nutritional status to be restored, catch-up growth must occur. Catch-up growth is a faster-than-normal rate of weight and length gain that requires more calories, protein and vitamins than would usually be required by someone the same age/weight as the child. Treatment recommendations (e.g. supplements) to stimulate catch-up growth should be made by a health care professional after testing indicates a child’s specific nutritional needs.

Often, it is difficult for infants or children to meet the caloric needs necessary for catch-up growth. For this reason, high calorie/protein foods and drinks may be helpful. A list of such foods may be found here. For infants, concentrated infant formula may be beneficial. Routine infant formula, when prepared according to directions, is 20 calories/ounce. A pediatrician or pediatric dietitian can prescribe a higher calorie preparation (22-30 calories/ounce) that can help the infant meet their nutritional needs without having to drink very large volumes of formula. There are also higher protein and calorie infant formulas on the market for infants that require specialized nutrition. Children older than one year may do well with a pediatric nutritional drink. These drinks are 30 calories/ounce and also provide protein, vitamins and minerals.

Treatment for malnutrition should continue until the child achieves a normal weight-for-length percentile (at least 10%) and is able to maintain this for several months while continuing to gain weight at an appropriate rate. Length growth is slower to respond to nutritional therapy than weight, and so it is important to continue treatment nutrition even if the child begins to appear “chubby.” This extra fat can help to stimulate growth hormone necessary for length growth.

Refeeding Syndrome

For children who are severely malnourished, more caution must be used when stimulating catch-up growth. Refeeding syndrome occurs if malnourished children are fed too quickly and their cells require more minerals and electrolytes than available. Vomiting, diarrhea, cardiac arrhythmias, and low blood levels of phosphorus, potassium, magnesium and glucose can result. When feeding a malnourished child, extra calories/protein should not be given in the first week. Simply offer normal calories and protein for the child’s weight. Potassium, phosphorus, magnesium and glucose levels must be closely monitored. A multivitamin/mineral supplement containing iron and zinc should be given to prevent vitamin and mineral deficiencies. Over the next several days, the caloric density of food and formula, or amounts of food can be gradually increased by 20-30% to help stimulate catch-up growth.

Learn about the World Health Organization’s recommendations for the inpatient treatment of a severely malnourished child: http://www.who.int/nutrition/publications/guide_inpatient_text.pdf