Malnutrition in children in resource-limited countries: Clinical assessment
- Praveen S Goday, MBBS
Praveen S Goday, MBBS
- Professor, Pediatric Gastroenterology and Nutrition
- Medical College of Wisconsin, Milwaukee, WI
- Section Editors
- Kathleen J Motil, MD, PhD
Kathleen J Motil, MD, PhD
- Section Editor — Pediatric Nutrition
- Professor of Pediatric Nutrition
- Baylor College of Medicine
- B UK Li, MD
B UK Li, MD
- Section Editor — Pediatric Gastroenterology
- Professor of Pediatrics
- Medical College of Wisconsin
Undernutrition is a critical determinant of mortality and morbidity in young children worldwide; it is associated with 45 percent of all deaths in children under five years of age [1,2]. Severe undernutrition is primarily a problem in resource-limited countries. Globally, childhood stunting decreased from 39.7 percent in 1990 to 23.2 percent in 2015, and is expected to decline further . However, the trends vary by region: stunting rates in Asia have shown dramatic declines but have continued to increase in Africa . Severe undernutrition is uncommon in the United States.
In this topic review we use the term "malnutrition" in its traditional sense, referring to undernutrition (wasting, stunting, or micronutrient deficiencies), although some authors use the term more broadly, to encompass overnutrition/obesity.
The major forms of malnutrition are marasmus (wasting) and kwashiorkor (edematous malnutrition), with or without associated stunting. The clinical assessment of the child with malnutrition includes distinguishing between these types, assessing their severity, and identifying acute life-threatening complications, including sepsis and acute dehydration. These children are at risk for micronutrient deficiencies, as detailed in a separate topic review. (See "Micronutrient deficiencies associated with malnutrition in children".)
Treatment of severe malnutrition is discussed separately. (See "Severe malnutrition in children in resource-limited countries: Treatment".)
Clinical findings in children with chronic undernutrition usually include diminished height (stunting), as well as poor weight gain and deficits in both lean body mass and adipose tissue. Other features include reduced physical activity, mental apathy, and retarded psychomotor and mental development [4-6].
- Black RE, Victora CG, Walker SP, et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet 2013; 382:427.
- GBD 2015 Child Mortality Collaborators. Global, regional, national, and selected subnational levels of stillbirths, neonatal, infant, and under-5 mortality, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016; 388:1725.
- Levels and trends in child malnutrition: UNICEF – WHO – World Bank Group joint child malnutrition estimates. Key findings of the 2016 edition. Available at: http://www.who.int/nutgrowthdb/jme_brochure2016.pdf?ua=1 (Accessed on March 14, 2017).
- Bergen DC. Effects of poverty on cognitive function: a hidden neurologic epidemic. Neurology 2008; 71:447.
- Prado EL, Dewey KG. Nutrition and brain development in early life. Nutr Rev 2014; 72:267.
- Horta BL, Victora CG, de Mola CL, et al. Associations of Linear Growth and Relative Weight Gain in Early Life with Human Capital at 30 Years of Age. J Pediatr 2017; 182:85.
- Kabalo MY, Seifu CN. Treatment outcomes of severe acute malnutrition in children treated within Outpatient Therapeutic Program (OTP) at Wolaita Zone, Southern Ethiopia: retrospective cross-sectional study. J Health Popul Nutr 2017; 36:7.
- Mengesha MM, Deyessa N, Tegegne BS, Dessie Y. Treatment outcome and factors affecting time to recovery in children with severe acute malnutrition treated at outpatient therapeutic care program. Glob Health Action 2016; 9:30704.
- Trehan I, Goldbach HS, LaGrone LN, et al. Antibiotics as part of the management of severe acute malnutrition. N Engl J Med 2013; 368:425.
- Trehan I, Manary MJ. Management of severe acute malnutrition in low-income and middle-income countries. Arch Dis Child 2015; 100:283.
- Silverman JA, Chimalizeni Y, Hawes SE, et al. The effects of malnutrition on cardiac function in African children. Arch Dis Child 2016; 101:166.
- Doherty JF, Adam EJ, Griffin GE, Golden MH. Ultrasonographic assessment of the extent of hepatic steatosis in severe malnutrition. Arch Dis Child 1992; 67:1348.
- Bagga A, Tripathi P, Jatana V, et al. Bacteriuria and urinary tract infections in malnourished children. Pediatr Nephrol 2003; 18:366.
- Jones KD, Berkley JA. Severe acute malnutrition and infection. Paediatr Int Child Health 2014; 34 Suppl 1:S1.
- Ahmed M, Moremi N, Mirambo MM, et al. Multi-resistant gram negative enteric bacteria causing urinary tract infection among malnourished underfives admitted at a tertiary hospital, northwestern, Tanzania. Ital J Pediatr 2015; 41:44.
- Bourke CD, Berkley JA, Prendergast AJ. Immune Dysfunction as a Cause and Consequence of Malnutrition. Trends Immunol 2016.
- Rytter MJ, Kolte L, Briend A, et al. The immune system in children with malnutrition--a systematic review. PLoS One 2014; 9:e105017.
- Scrimshaw NS. Historical concepts of interactions, synergism and antagonism between nutrition and infection. J Nutr 2003; 133:316S.
- Sauerwein RW, Mulder JA, Mulder L, et al. Inflammatory mediators in children with protein-energy malnutrition. Am J Clin Nutr 1997; 65:1534.
- Reid M, Badaloo A, Forrester T, et al. The acute-phase protein response to infection in edematous and nonedematous protein-energy malnutrition. Am J Clin Nutr 2002; 76:1409.
- Ashworth A. Energy balance and growth: experience in treating children with malnutrition. Kidney Int 1978; 14:301.
- Rao KS, Khan L. Basal energy metabolism in protein-calorie malnutrition and vitamin A deficiency. Am J Clin Nutr 1974; 27:892.
- Ashworth A. Treatment of severe malnutrition. J Pediatr Gastroenterol Nutr 2001; 32:516.
- Spoelstra MN, Mari A, Mendel M, et al. Kwashiorkor and marasmus are both associated with impaired glucose clearance related to pancreatic β-cell dysfunction. Metabolism 2012; 61:1224.
- Bandsma RH, Spoelstra MN, Mari A, et al. Impaired glucose absorption in children with severe malnutrition. J Pediatr 2011; 158:282.
- Bandsma RH, Mendel M, Spoelstra MN, et al. Mechanisms behind decreased endogenous glucose production in malnourished children. Pediatr Res 2010; 68:423.
- Coulthard MG. Oedema in kwashiorkor is caused by hypoalbuminaemia. Paediatr Int Child Health 2015; 35:83.
- Golden MH. Oedematous malnutrition. Br Med Bull 1998; 54:433.
- Manary MJ, Heikens GT, Golden M. Kwashiorkor: more hypothesis testing is needed to understand the aetiology of oedema. Malawi Med J 2009; 21:106.
- Golden MH. Nutritional and other types of oedema, albumin, complex carbohydrates and the interstitium - a response to Malcolm Coulthard's hypothesis: Oedema in kwashiorkor is caused by hypo-albuminaemia. Paediatr Int Child Health 2015; 35:90.
- Ciliberto H, Ciliberto M, Briend A, et al. Antioxidant supplementation for the prevention of kwashiorkor in Malawian children: randomised, double blind, placebo controlled trial. BMJ 2005; 330:1109.
- Smith MI, Yatsunenko T, Manary MJ, et al. Gut microbiomes of Malawian twin pairs discordant for kwashiorkor. Science 2013; 339:548.
- Prentice AM, Nabwera H, Kwambana B, et al. Microbes and the malnourished child. Sci Transl Med 2013; 5:180fs11.
- Kau AL, Planer JD, Liu J, et al. Functional characterization of IgA-targeted bacterial taxa from undernourished Malawian children that produce diet-dependent enteropathy. Sci Transl Med 2015; 7:276ra24.
- Reyes A, Blanton LV, Cao S, et al. Gut DNA viromes of Malawian twins discordant for severe acute malnutrition. Proc Natl Acad Sci U S A 2015; 112:11941.
- Subramanian S, Huq S, Yatsunenko T, et al. Persistent gut microbiota immaturity in malnourished Bangladeshi children. Nature 2014; 510:417.
- WHO child growth standards and the identification of severe acute malnutrition in infants and children. World Health Organization and UNICEF, 2009. Available at: http://apps.who.int/iris/bitstream/10665/44129/1/9789241598163_eng.pdf?ua=1 (Accessed on March 15, 2017).
- Li Y, Guo G, Shi A, et al. Prevalence and correlates of malnutrition among children in rural minority areas of China. Pediatr Int 1999; 41:549.
- Mid upper arm circumference and weight-for-height Z-score as indicators of severe acute malnutrition: A consultation of operational agencies and academic specialists to understand the evidence, identify knowledge gaps, and to inform operational guidance, ENN, Geneva 2012. http://www.cmamforum.org/Pool/Resources/MUAC-WFH-Report-ENN-2013.pdf (Accessed on December 11, 2016).
- Fernández MA, Delchevalerie P, Van Herp M. Accuracy of MUAC in the detection of severe wasting with the new WHO growth standards. Pediatrics 2010; 126:e195.
- World Health Organization. Guideline: updates on the management of severe acute malnutrition in infants and children, 2013. Available at: http://apps.who.int/iris/bitstream/10665/95584/1/9789241506328_eng.pdf (Accessed on February 19, 2014).
- Physical status: The use and interpretation of anthropometry. Technical Report Series No. 854. World Health Organization (WHO), Geneva 1995. http://apps.who.int/iris/bitstream/10665/37003/1/WHO_TRS_854.pdf (Accessed on December 05, 2016).
- Myatt M, Khara T, Collins S. A review of methods to detect cases of severely malnourished children in the community for their admission into community-based therapeutic care programs. Food Nutr Bull 2006; 27:S7.
- Updates on the management of severe acute malnutrition in infants and children, World Health Organization, Geneva 2013. http://apps.who.int/iris/bitstream/10665/95584/1/9789241506328_eng.pdf?ua=1 (Accessed on December 11, 2016).
- Mwangome MK, Fegan G, Fulford T, et al. Mid-upper arm circumference at age of routine infant vaccination to identify infants at elevated risk of death: a retrospective cohort study in the Gambia. Bull World Health Organ 2012; 90:887.
- Berkley JA, Ngari M, Thitiri J, et al. Daily co-trimoxazole prophylaxis to prevent mortality in children with complicated severe acute malnutrition: a multicentre, double-blind, randomised placebo-controlled trial. Lancet Glob Health 2016; 4:e464.
- Mwangome M, Ngari M, Fegan G, et al. Diagnostic criteria for severe acute malnutrition among infants aged under 6 mo. Am J Clin Nutr 2017.
- World Health Organization (WHO). Management of severe malnutrition: A manual for physicians and other senior health workers, Geneva 1999. http://www.who.int/nutrition/publications/severemalnutrition/9241545119/en/ (Accessed on December 11, 2016).
- The treatment of diarrhea; A manual for physicians and other senior health workers, WHO, Geneva 2005. Available at: http://www.who.int/child_adolescent_health/documents/9241593180/en/index.html (Accessed on November 17, 2009).
- Nichols BL. Managing dietary carbohydrate intolerance. In: Nutrition During Infancy, Tsang RC, Zlotkin SH, Nichols BL, Hansen JW (Eds), Digital Educational Publications, Cincinnati 1997. p.105.
- Golden MH. The nature of nutritional deficiency in relation to growth failure and poverty. Acta Paediatr Scand Suppl 1991; 374:95.
- Gracey M. Nutritional effects and management of diarrhoea in infancy. Acta Paediatr Suppl 1999; 88:110.
- Management of severe malnutrition: a manual for physicians and other senior health workers, WHO, Geneva 1999. www.who.int/nutrition/publications/malnutrition/en/index.html (Accessed on November 17, 2009).
- Antwi A. Assessment and management of severe malnutrition in children. West Afr J Med 2011; 30:11.
- Heilskov S, Rytter MJ, Vestergaard C, et al. Dermatosis in children with oedematous malnutrition (Kwashiorkor): a review of the literature. J Eur Acad Dermatol Venereol 2014; 28:995.
- CHRONIC MALNUTRITION
- ACUTE MALNUTRITION
- Clinical subtypes
- - Marasmus
- - Kwashiorkor (edematous malnutrition)
- CLINICAL ASSESSMENT
- - Z-scores
- - Mid-upper arm circumference
- Diagnostic criteria
- Children 6 through 59 months
- - Infants <6 months
- ADMISSION AND DISCHARGE CRITERIA
- EVALUATION FOR COMORBID CONDITIONS
- Distinguishing sepsis from dehydration
- Diarrhea and dehydration
- - Definitions and types of diarrhea
- - Evaluation for dehydration
- Other infections
- Dermatosis of kwashiorkor
- SPECIFIC NUTRIENT DEFICIENCIES
- SUMMARY AND RECOMMENDATIONS