Micronutrient deficiencies associated with malnutrition in children
- Sarah M Phillips, MS, RD, LD
Sarah M Phillips, MS, RD, LD
- Instructor of Pediatric Gastroenterology
- Baylor College of Medicine
- Craig Jensen, MD
Craig Jensen, MD
- Section Editor — Pediatric Gastroenterology
- Associate Professor
- Baylor College of Medicine
Severely malnourished children typically are brought to medical attention when a health crisis, such as an infection, precipitates the transition between marasmus (a state of nutritional adaptation) and kwashiorkor, in which adaptation is no longer adequate. The World Health Organization (WHO) classifies malnutrition based upon the degree of wasting or stunting and the presence of edema, as described in a separate topic review. (See "Malnutrition in children in resource-limited countries: Clinical assessment".)
Evaluation and management of the malnutrition depends on the clinical setting and cause of malnutrition. Although the principles of assessment and management of malnourished children from resource-rich countries are similar to those from resource-limited countries, the specific details may vary based on local customs and resources. (See "Laboratory and radiologic evaluation of nutritional status in children" and "Failure to thrive (undernutrition) in children younger than two years: Etiology and evaluation".)
The micronutrient deficiencies that are most commonly associated with protein-energy malnutrition (PEM) in children are discussed here. Deficiencies of fat-soluble vitamins, iron, and zinc are particularly common, but deficiencies of other water-soluble vitamins, minerals, and trace elements also may be found, varying with the region and chronicity of the malnutrition . More detailed information about the biochemistry of these micronutrients and their deficiency states is discussed in separate topic reviews. The clinical assessment and treatment of these children, including definitions and anthropometric measurements is discussed separately. (See "Malnutrition in children in resource-limited countries: Clinical assessment".)
ESSENTIAL FATTY ACID DEFICIENCY
Children with protein-energy malnutrition (PEM) may have deficiencies of the two primary essential fatty acids (EFA), linoleic and linolenic acid. EFA levels may be altered by diet, disease, or prematurity. The biochemical effects of deficiency are an increased triene/tetraene ratio and will be evident prior to any physical changes. Physical signs include scaly dermatitis, alopecia, and thrombocytopenia. Deficiency of EFA can affect growth, and cognitive and visual function in infants .
FAT-SOLUBLE VITAMIN DEFICIENCIES
Children with protein-energy malnutrition (PEM) also may have deficiencies of the fat-soluble vitamins: A, D, E, and K (table 1). (See "Laboratory and radiologic evaluation of nutritional status in children".)
- Bailey RL, West KP Jr, Black RE. The epidemiology of global micronutrient deficiencies. Ann Nutr Metab 2015; 66 Suppl 2:22.
- Foote KD, MacKinnon MJ, Innis SM. Effect of early introduction of formula vs fat-free parenteral nutrition on essential fatty acid status of preterm infants. Am J Clin Nutr 1991; 54:93.
- World Health Organization Global Database on Vitamin A Deficiency, Global prevalence of vitamin A deficiency in populations at risk, 1995-2005. Available at: http://www.who.int/vmnis/database/vitamina/en/ (Accessed on May 29, 2015).
- Donnen P, Brasseur D, Dramaix M, et al. Vitamin A deficiency and protein-energy malnutrition in a sample of pre-school age children in the Kivu Province in Zaire. Eur J Clin Nutr 1996; 50:456.
- Hussain A, Lindtjørn B, Kvåle G. Protein energy malnutrition, vitamin A deficiency and night blindness in Bangladeshi children. Ann Trop Paediatr 1996; 16:319.
- Schaumberg DA, O'Connor J, Semba RD. Risk factors for xerophthalmia in the Republic of Kiribati. Eur J Clin Nutr 1996; 50:761.
- Donnen P, Dramaix M, Brasseur D, et al. Randomized placebo-controlled clinical trial of the effect of a single high dose or daily low doses of vitamin A on the morbidity of hospitalized, malnourished children. Am J Clin Nutr 1998; 68:1254.
- Donnen P, Brasseur D, Dramaix M, et al. Vitamin A supplementation but not deworming improves growth of malnourished preschool children in eastern Zaire. J Nutr 1998; 128:1320.
- 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 August 02, 2017).
- Lulseged S, Fitwi G. Vitamin D deficiency rickets: socio-demographic and clinical risk factors in children seen at a referral hospital in Addis Ababa. East Afr Med J 1999; 76:457.
- Walter EA, Scariano JK, Easington CR, et al. Rickets and protein malnutrition in northern Nigeria. J Trop Pediatr 1997; 43:98.
- Kalra V, Grover J, Ahuja GK, et al. Vitamin E deficiency and associated neurological deficits in children with protein-energy malnutrition. J Trop Pediatr 1998; 44:291.
- Kishi T, Fujita N, Eguchi T, Ueda K. Mechanism for reduction of serum folate by antiepileptic drugs during prolonged therapy. J Neurol Sci 1997; 145:109.
- Seear M, Lockitch G, Jacobson B, et al. Thiamine, riboflavin, and pyridoxine deficiencies in a population of critically ill children. J Pediatr 1992; 121:533.
- Roe DA. Riboflavin deficiency: mucocutaneous signs of acute and chronic deficiency. Semin Dermatol 1991; 10:293.
- Centers for Disease Control and Prevention (CDC). Neurologic impairment in children associated with maternal dietary deficiency of cobalamin--Georgia, 2001. MMWR Morb Mortal Wkly Rep 2003; 52:61.
- Rasmussen SA, Fernhoff PM, Scanlon KS. Vitamin B12 deficiency in children and adolescents. J Pediatr 2001; 138:10.
- Strand TA, Taneja S, Kumar T, et al. Vitamin B-12, folic acid, and growth in 6- to 30-month-old children: a randomized controlled trial. Pediatrics 2015; 135:e918.
- Goraya JS, Kaur S, Mehra B. Neurology of Nutritional Vitamin B12 Deficiency in Infants: Case Series From India and Literature Review. J Child Neurol 2015; 30:1831.
- Yilmaz S, Serdaroglu G, Tekgul H, Gokben S. Different Neurologic Aspects of Nutritional B12 Deficiency in Infancy. J Child Neurol 2016; 31:565.
- Zengin E, Sarper N, Caki Kiliç S. Clinical manifestations of infants with nutritional vitamin B deficiency due to maternal dietary deficiency. Acta Paediatr 2009; 98:98.
- Hinton CF, Ojodu JA, Fernhoff PM, et al. Maternal and neonatal vitamin B12 deficiency detected through expanded newborn screening--United States, 2003-2007. J Pediatr 2010; 157:162.
- Pollitt E. Functional significance of the covariance between protein energy malnutrition and iron deficiency anemia. J Nutr 1995; 125:2272S.
- Pollitt E. Iron deficiency and educational deficiency. Nutr Rev 1997; 55:133.
- Brown WD, Dyment PG. Pagophagia and iron deficiency anemia in adolescent girls. Pediatrics 1972; 49:766.
- Doherty CP, Sarkar MA, Shakur MS, et al. Zinc and rehabilitation from severe protein-energy malnutrition: higher-dose regimens are associated with increased mortality. Am J Clin Nutr 1998; 68:742.
- Prasad AS. Zinc deficiency in women, infants and children. J Am Coll Nutr 1996; 15:113.
- Ninh NX, Thissen JP, Collette L, et al. Zinc supplementation increases growth and circulating insulin-like growth factor I (IGF-I) in growth-retarded Vietnamese children. Am J Clin Nutr 1996; 63:514.
- Hambidge M. Human zinc deficiency. J Nutr 2000; 130:1344S.
- Fraker PJ, King LE, Laakko T, Vollmer TL. The dynamic link between the integrity of the immune system and zinc status. J Nutr 2000; 130:1399S.
- Semrad CE. Zinc and intestinal function. Curr Gastroenterol Rep 1999; 1:398.
- Cordano A. Clinical manifestations of nutritional copper deficiency in infants and children. Am J Clin Nutr 1998; 67:1012S.
- Yang FY, Lin ZH, Li SG, et al. Keshan disease--an endemic mitochondrial cardiomyopathy in China. J Trace Elem Electrolytes Health Dis 1988; 2:157.
- Levy JB, Jones HW, Gordon AC. Selenium deficiency, reversible cardiomyopathy and short-term intravenous feeding. Postgrad Med J 1994; 70:235.
- Collipp PJ, Chen SY. Cardiomyopathy and selenium deficiency in a two-year-old girl. N Engl J Med 1981; 304:1304.
- Elnour A, Hambraeus L, Eltom M, et al. Endemic goiter with iodine sufficiency: a possible role for the consumption of pearl millet in the etiology of endemic goiter. Am J Clin Nutr 2000; 71:59.
- ESSENTIAL FATTY ACID DEFICIENCY
- FAT-SOLUBLE VITAMIN DEFICIENCIES
- Vitamin A
- Vitamin D
- Vitamin E
- Vitamin K
- WATER SOLUBLE VITAMIN DEFICIENCIES
- Vitamin B12
- Ascorbic acid
- MINERAL AND TRACE ELEMENT DEFICIENCIES
- Calcium, phosphate, and magnesium
- SOCIETY GUIDELINE LINKS