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The problem of child deficiency-related
malnutrition
Even though the inalienable right of any human being not to starve
to death was reaffirmed over and over again at the meetings of UN
member countries in 1948( Universal Declaration of Human Rights),
in 1974(UN World Conference on Feeding) in 1978(International Pact
for Economic Rights and World Health Organization Declaration on
"Health for All in the 21st century"), in 1989 (Convention
on Children's Rights) (),
and recently regarded by the World Health Organization as a human
right (),
child malnutrition is still one of the major public health problems
today due to its magnitude and disastrous consequences on children's
development and survival. This article reviews the existing knowledge
about child malnutrition and the strategies used for its control.
The World Health Organization estimates that, every year, more than
20 million children present low weight at birth()
and that approximately 150 million children younger than 5 years
have low weight patterns for their age (),
and that 182 million (32.5%) have low height ().
Authors affirm that these values, however, may be underestimated
as it is difficult to calculate world prevalence rates accurately().
Relatively small changes in the limit cut-off points of anthropometric
indicators used for the classification of nutritional status, and
consequently, for the definition of the disease, may imply variations
amounting to millions of undernourished children who supposedly
suffer from malnutrition. (,).
Malnutrition is the second most frequent cause of death in children
under the age of 5 in developing countries ().
Pelletier et al.(),
attribute 56% of child mortality to malnutrition, due to the potential
effects of mild and moderate forms of the disease.
Around 20 to 30% of children with severe malnutrition die when submitted
to health services in developing countries().
These rates have remained unchanged for the last 5 decades, and
correspond to a percentage 4 to 6 times higher than 5%, rate regarded
as acceptable by the World Health Organization().
A recent survey carried out in 79 hospitals around the world revealed
that many health professionals have outdated ideas about or are
totally unaware of the procedures involved in the treatment of children
with severe malnutrition ().
Inadequate treatment often results from the incorrect perception
of altered physiological state and of the reduced homeostatic mechanisms
that characterize malnutrition(,).
Procedures include inadequate rehydration, causing heart strain
and failure; imperception of infections that lead to septicemia;
and lack of perception as to the vulnerability of children with
severe malnutrition to hypothermia and hypoglycemia. Rehabilitation
is too slow in most treatment centers or clinics().
In some health centers, professionals have the necessary knowledge
but the resources are limited().
In some others, the update on or the improvement of procedures through
some slight changes may bring substantial benefits. This was observed
in Bolivia, by adding zinc to the treatment of undernourished children().
In Brazil, decreased intake of lactose at the beginning of the treatment,
increased energy intake during the growth enhancement stage, and
supplementation with potassium, magnesium, zinc and copper reduced
the incidence of diarrhea, allowed a fourfold increase in weightl
index, and considerably reduced treatment costs().
In South Africa, the simple use of micronutrients reduced mortality
rate from 30 to 20%; however, when the intensity and quality of
child care were enhanced, mortality rate dropped to 6%().
In Brazil (),
as in most developing countries(),
the nutritional status of children under 5 years has changed for
the better in the last few years due to extraordinary economic development
and the expansion of health services and programs().
Between 1975 and 1989, the prevalence of malnutrition fell approximately
60%, which is equivalent to one million children. Nevertheless,
the fact that chronic child malnutrition nowadays is extremely frequent,
shown mainly by reduced height for age standards, the percentage
of children with severe malnutrition (although not very high), in
addition to a high concentration of these children in the North
and Northeast (country's poorest regions), indicates that the problem
is not completely under control().
It is common knowledge that severe child malnutrition cases, even
in small numbers, are just the tip of the iceberg. For each severe
case, there are others that are less severe, and that sometimes
show no clinical signs of malnutrition. Mild and moderate malnutrition
is sometimes only observed in children who fail to thrive().
The secular challenge of malnutrition
The literature shows that physicians in the 19th and early 20th
century already admitted that starvation, derived from low food
intake, provoked growth retardation in children().
Several authors, also from Mexico and Chile, described different
aspects of the disease from the 1800s onwards, and drew attention
to the fact that extreme emaciation or nutritional edema caused
by the disease could lead to child mortality ().
However, the description of the disease as syndrome and the first
denomination that configured its existence took place in the early
1930s. Williams(described Kwashiorkor, which was much more visible than child
emaciation (marasmus). In Brazil, the disease was first registered
in the 1950s ().
Once described, child malnutrition was recognized as a problem of
medical nature that also included problems related to vitamin deficiency
such as beriberi, pellagra, xerophthalmia and scurvy. The cure for
the disease, found in the 1950s, widespread in Africa, Central America
and Brazil, was attributed to the intake of high-protein foods().
Protein intake requirements were increased by FAO experts in 1973(),
and the production of complementary high-protein foods was then
stimulated. This was the "Age of Protein Science" .
On the other hand, still in the 70's, the so-called "great
protein fiasco" took place().
Nutritional surveys extensively carried out by FAO showed that,
in all studied countries, the diet met protein requirements but
did not provide the energy needs that had been preconized by consultants
from the same organization, in 1973().
Since then, it is known that protein-energy malnutrition results
mainly from energy deficiency. Distribution, access of poor people
to food, was identified as the crucial factor. Poverty was considered
to be the major cause of malnutrition(,).
The subsequent discovery of physiopathological aspects of the disease
and the discovery of the synergistic relationship and association
between malnutrition and infection ()
added to previous findings.
Malnutrition, due to its multifactorial nature, began to be regarded
as a social problem and not a merely public health issue. This way,
malnutrition, once within the realms of medical and health sciences,
moved into the domain of technical and bureaucratic planning. This
was the time of the so-called "theory of intersectorial nutrition
planning", which took for granted that the nutritional problems
in underdeveloped countries would be overcome through planning and
rational resource allocation. However, the theory failed, getting
in the way of the implementation of nutrition policies and discouraging
the effective action of health professionals().
Nutrition planning can hardly benefit poor people as an anonymous
Hindu()
wittily remarked in his complaint about how discouraged he felt
with the food donation policy:
"I was hungry and you set up a committee to investigate my
hunger;
I was homeless and you filled out a form with my complaint;
I was sick and you organized a debate on poor people's nutrition;
You looked into all the aspects of my complaint and, still, I am
hungry, homeless and sick".
In the 80's, the participation of the health sector was clearly
involved in the fight against child malnutrition once again, through
the policy of "health for all the people of the world by the
year 2000", set up by Alma-Ata International Conference()
The natural history of child malnutrition
The challenge of maintaining good nutrition standards is present
throughout life().
Malnutrition usually begins in the mother's womb, affects children,
and by means of girls and women, extends into adulthood and then
from a generation to the next, through its negative cumulative effect
on low infant weight. Low-weight babies who have intrauterine growth
retardation are born with malnutrition and are at greater risk of
death than normal babies. If they survive, it is unlikely that they
have catch-up growth, and they will probably present a series of
growth deficiencies. In addition, current evidence indicates that
low weight at birth is associated with a greater risk for chronic
diseases in adulthood ().
In childhood, frequent and prolonged infections, and inadequate
intake of nutrients, especially energy, protein, vitamin A, zinc
and iron, exacerbate the effects of intrauterine growth retardation.
Fail-to-thrive occurs quickly up to the age of 2, resulting in low
weight and height. It is known that the major causes of inadequate
growth today in developing countries are nutritional deficiencies
and infections, usually combined ().
Presently, from the point of view of natural history of the disease,
there are two types of child growth deficiency: emaciation and low
height().
Emaciation is defined by the weight for height, and 1 level of thinness
below -2DP of the NCHS/WHO average reference standard is regarded
as pathological. Low height is defined by the height for age, and
when below -2SD of the NCHS/WHO average reference standard, it is
called "stunting". These two types of deficiency represent
distinct biological processes. Although they can be found in the
same child, they are, actually, statistically independent and their
respective prevalence rates, as recommended by the World Health
Organization, are presented all over the world in a separate way().
The peak of emaciation prevalence occurs in the second year of life,
coinciding with the initiation of complementary feeding and a high
incidence of diarrhea ()
. The cause seems to be extremely direct: inadequate diet (quantitatively
and qualitatively) and a high incidence of diarrheal diseases. Once
the infectious episode is under control, and there is the possibility
of feeding, children recover weight. The necessary amount of food
necessary for growth enhancement is not very high and the diet needs
to be rich in energy and proteins (,)
.
Low height or "stunting" has a natural history that is
different from that of emaciation. Typically, decreased linear growth
has its onset around the third month of life and continues for 2
or 3 years, as demonstrated by studies carried out in Guatemala
and India. The growth rate is just restored around the fifth year
of life, when height deficiency may be approximately 15 cm in comparison
with a normal child; and kept during adult life. Between 5 and 18
years, the growth rate is normal, but there is no growth enhancement().
Recent research suggests that stunting originates from a reduction
in the frequency of growth events in children or from a reduction
in growth intervals when an event occurs(,).
If children affected with stunting continue to live in the same
conditions they were living at the time they developed the disease,
they will not have enough growth enhancement to measure up to their
genetic potential. However, some studies show that it is possible
to reverse stunting when living conditions are changed for the better,
as observed in South Africa, Jamaica and Peru().
Therefore, the presence of stunting is a "proxy" indicator
of a multifaceted deprivation and its prevalence is currently considered
an appropriate quality-of-life indicator of a given population().
The important aspect of low height is its relation to the development
of mental retardation in young children, which is not observed in
emaciation alone. Even if children are able to perfectly recover
their rate of retarded linear physical growth, the effects on mental
development are more long-lasting(,,).
.
The role of infection is very important for the development and
survival of children who suffer from malnutrition. Pelletier()
convincedly argues that the effects of malnutrition and infection,
even in its mild and moderate forms, are not cumulative but multiplicative.
In this analysis, there is no distinction between emaciation and
stunting.
Child malnutrition and its causes
Child malnutrition is a multicausal, complex disease whose roots
are established in poverty-stricken communities. Its onset occurs
when the body does not receive enough nutrients for its physiological
metabolism due to the lack of adequate structure or waste of nutrients.
Thus, in most cases, malnutrution is the result of insufficient
feeding or hunger, and diseases().
There are a considerable number of studies and publications in the
literature related to malnutrition, its causes and effects (,,).
Several causal models have been proposed by a varied number of authors
and organizations to explain the origin of malnutrition(,,).
Causal schemes have also been proposed in an attempt to hierarchize
the importance of causal factors(),
by presenting a more comprehensive scheme that includes child care
and preoccupation with his/her living conditions (),
and by introducing the relevance of mother-child relationship as
vital element in the genesis of malnutrition ().
The World Health Organization()
suggests that the "food-health-care" scheme, presented
by UNICEF ()
be used as a tool to analyze the interaction of the several determinants
of malnutrition in distinct social levels. In this scheme, malnutrition
is shown as the result of an inadequate diet and diseases that originate
from the lack of nutritional security, mother's improper care, and
inefficient health services. The basic causes that contribute to
these factors are social structures and organizations, political
and ideological systems, distribution of richness and potential
resources().
Among the factors that contribute to malnutrition in young children
we find relatively higher energy and protein requirements in comparison
with other family members; low energy content of supplemental foods
which are used and insufficiently fed to the children; inappropriate
availability of foods because of poverty, social inequality, landlessness,
and intrafamiliar distribution problems; recurrent viral, bacterial
and parasitic infections that could cause anorexia and reduce the
intake, absorption and use of nutrients, or cause their loss; hunger
caused by droughts or other natural disasters or wars; inadequate
child care such as feeding of foods that are too diluted and/or
not hygienically prepared(,).
In marasmus, the frequent clinical form of malnutrition in most
developing countries, especially in children under 18 months, all
the factors described above may be present. There is no doubt that
inadequate food intake, mainly insufficient energy to fulfill metabolic
and normal growth needs, plays an important role in malnutrition().
Prematurity and low weight at birth are predispositional causes()
. Other factors that contribute to the disease include non-breast-feeding
and delayed supplementation of approppriate foods, and lack of adequate
support to health professionals when counseling mothers. Mothers,
due to scarce financial resources and/or little knowledge about
health and child nutrition, often use hyperdiluted formulas, prepared
in non-hygienic conditions, and sometimes stored at room temperature
for a long time (,).
The causes of Kwashiorkor are complex. A child who suffers from
kwashiorkor usually has a diet that is poor in energy and proteins()
. Infections play an important role. Some authors argue that when
protein intake is too low, compared to the intake of carbohydrates,
which could be aggravated by the loss of nitrogen caused by infections,
several metabolic changes occur and can lead to edema(,)
. Other authors state that kwashiorkor is a hormonal disadaptation
to protein deficiency. Some others attribute the formation of edema
to endogenic mechanisms related to free radicals().
Therefore, there is not a common ground on the etiology of kwashiorkor.
Hunger and diseases may be caused by different factors, or a long
sequence of interconnected events. This way, it is difficult to
draw conclusions on the determinant factors of malnutrition in a
given population().
Most recent conclusions on the causes of child malnutrition result
from cross-studies and evidence obtained from health interventions().
Randomly-controlled studies are not suitable for investigating the
origins of malnutrition().
Poverty is not homogenous and socioeconomic variables, for instance,
cannot be tested through randomly-controlled studies().
Another difficulty is the nature of the variables themselves. Family
income and education, for example, considered as determinant factors
in child nutritional status, may vary with time. In addition, these
data are not easily collected. Therefore, it is difficult to investigate
the relationship with nutritional status in time either through
long-term cross-studies or prospective studies().
Physiopathology of child severe
malnutrition
Malnutrition affects children's whole systems and organs. None of
the functions studied so far have been considered to be normal().
It is suggested that all processes in the body enter a phase of
adaptive functional reduction as a way to ensure survival(,,).
Details on the physiopathology of malnutrition can be found in several
publications(,,,,,,,)
. It is important to get acquainted with details that serve as basis
for the treatment of children with severe malnutrition()
. See the following table.
Table 1 -
Major physiopathological aspects of child severe malnutrition
Edematous malnutrition
The cause of edematous malnutrition is still a controversial topic
in protein-energy malnutrition. Classical theory (,)
affirms that deficient protein supply leads to reduced albumin synthesis.
Fat liver, with a fat content 50% higher than its structure, a ratio
that is higher than that observed in animal experiments or in any
other human condition, is statistically associated with edematous
malnutrition().
The hypothesis that this disease results from a flaw in the transport
of fat out of the liver, and that this is caused, in its turn, by
the reduced apolipoprotein synthesis in parallel with the reduced
albumin synthesis, has not been proved yet. There is also epidemiological
evidence in support to this classical theory: edematous malnutrition
usually affects populations where the staple diet is poor in protein,
including foods such as cassava, or containing poor quality protein
as corn-based diets.
An antagonic theory denies the relationship between edema and hypoalbuminemia
and suggests that the edema originates from the lesion caused by
free radicals on the walls of capillary vessels and cell membranes
().
Malnutrition clinical status
The term protein-energy malnutrition comprises a wide variety of
clinical situations whose severity ranges from extremely severe
to mild cases. At one end of this spectrum, we find kwashiorkor
and marasmus, with high mortality rates, and at the other end, mild
PED (Protein-energy deficiency), whose main manifestation in children
is growth retardation. The clinical status of protein-energy malnutrition
has been described in detail in classic literature(,,,,,,)
.
Kwashiorkor and marasmus have distinct clinical manifestations.
The major characteristics of Kwashiorkor are growth retardation;
muscle loss and subcutaneous fat loss with less intensity than in
marasmus; pitting edema, located especially on the legs of toddlers
but which could spread all over the body; accentuated hepatomegaly
due to hepatic steatosis; and mental and humor behavioral changes.
Generalized or localized (flag-shaped) hair lesions (texture, color,
brightlessness, hairfall), and also skin lesions (depigmentation,
frictional dermatosis, desquamation) may also occur. Anorexia, diarrhea,
infections and micronutrient deficiency (vitamin A, zinc, iron)
are frequent. The presence of a significantly high weight loss rate
and the presence of edema are the essential aspects that help diagnose
kwashiorkor().
A child with advanced marasmus presents an unmistakable appearance:
too thin, with observable loss of muscle mass; extremely thin sides
and, sometimes, protuberant abdomen; face with an old or Siamese
cat-like aspect; and loose skinfolds on the buttocks (mainly). The
major clinical signs are low weight (weight/age ratio less than
60% of the weight expected for the age); growth retardation (low
height for the age); and scarce or inexistent skin fat. Normally,
diarrhea, respiratory infection, parasite infections, and tuberculosis
are present as well as signs of micronutrient deficiency such as
xerophthalmia, vitamin B deficiency, iron deficiency anemia and
others. The state of mind may be characterized by anxiety rather
than apathy. Body temperature tends towards hypothermia.
A percentage of undernourished children may present a mixed form
of malnutrition, marasmatic kwashiorkor, with mingled characteristics
in relation to other clinical forms. Usually, when the edema disappears
with treatment, it is possible to observe that these children are
affected by marasmus.
In children with malnutrition, the signs of dehydration are not
reliable. The children may present sunken eyes due to subcutaneous
fat loss by the eye orbit. Several glands such as sweat, lacrimal
and salivary glands present atrophy. The children have dry mouth
and dry eyes, and reduced sweating. Respiratory muscles are easily
fatigable. The children lack energy.
Children with severe malnutrition are usually apathetic when admitted
to hospital, do not respond well to social stimuli, cry very often,
are extremely thin, unproportionate, and/or present edema restricted
to the dorsum of the foot or hand or generalized edema. These children
also have overall retarded development, being unable to captivate
people, as usually occurs with healthy children. When on their mothers'
lap, they resemble a parcel that is being carried, and not human
beings.
Children who do not present the clinical features of marasmus, but
who present growth deficiency, are considered to have moderate or
mild malnutrition.
At present, the height/age, weight/height and weight/age indicators
are used to determine nutritional status, according to the World
Health Organization recommendation (,)
The cutoff points for determining the nutritional status ( severe
if less than -3 DP, moderate between -2 and -3 DP, and mild between
-1 and -2DP) are based on statistical relations between anthropometric
indicators on the one side, and functional restrictions, increased
risks of morbidity and mortality and other evidences of risk factor
consequences related to food and non-food risk factors, on the other
side. Other publications()contain
a detailed description on anthropometric indicators, including their
construction, application and interpretation.
The results of nutritional, physiological processes for children
are physical growth, activity, morbidity and mortality (related
to immunocompetence and tissue integrity and psychological development
().
Among these, growth is the one that can be measured more easily:
malnutrition leads to early growth curve horizontalization and/or
growth curve reduction ()
and is the cause of most anthropometric deficiencies observed in
children from developing countries().
Currently, there are three forms of malnutrition according to anthropometric
classification: low height, nutritional stunting and weight loss
(emaciation), which were already described in the natural history
of the disease, and low weight. Low weight is detected by the weight/age
indicator, which represents the body mass in relation to age; reflects
linear growth and accumulated weight in the prenatal and postnatal
period (long term) as well as the accumulation of weight on the
short term. Low weight/age may thus reflect a normal growth variation
or growth deficiency. A child is considered to have low weight/age
when his/her weight is below -2DP if compared to the international
growth reference standard().
This indicator may be influenced by the addition of child's rate
of stunting and thinness, and is then difficult to be interpreted.
Therefore, it is not the ideal indicator for either defining the
kind of intervention that should be used or identifying the target
group().
By definition, the average Z-score of the reference population is
zero for any of the indicators. The negative Z-score indicates that
the studied child and/or population is below the nutritional status
standard desired. If the Z-score equals or is less than -3, malnutrition
is severe; between 2 and -2.9, malnutrition is moderate. Conventionally,
a typical healthy population presents less than 1% in severe deficiencies
and around 2.3% in moderate deficiencies(,,).
Another way to classify nutritional status is a percentile-based
method of comparison. If the anthropometric indicator value is below
the 3rd percentile, malnutrition is considered moderate or severe,
and if it is between the 3rd and 10th percentiles, malnutrition
is mild().
This method is commonly used in Brazil by health programs and the
System for Food and Nutrition Surveillance.
For a more detailed description of anthropometric indicators, including
their construction, use and interpretation, see the references at
the end of this article ()
Diagnosis
The diagnosis of malnutrition is made through the child's clinical
history, clinical examination and determination of his/her nutritional
status. To diagnose the disease, define and control its treatment,
it is extremely important that the child be carefully assessed and
followed up. The child's clinical history is efficient throughout
the treatment, even in situations in which lab exams cannot be carried
out or easily interpreted. When there are available resources, lab
exams may be used to help with the treatment. However, it is worth
remembering that, in the case of children with severe malnutrition,
exam results must be carefully interpreted, as they may be altered
by malnutrition itself, establishing confusion among less experienced
health professionals.
The biochemical and metabolic modifications are similar in children
with marasmus, kwashiorkor, and marasmatic kwashiorkor (,).
Lab exams may be confusing or difficult to interpret, due to the
fact that modifications are severe and complex. The total serum
protein in kwashiorkor is low due to albumin reduction, as a result
of the hepatic synthesis alterations. In marasmus, this concentration
is normal. The content of essential aminoacids may be low while,
especially in kwashiorkor, the content of nonessential aminoacids
is normal or high. The concentration of serum immunoglobulin G may
be high because of infections. The concentration of retinol-binding
protein may be low. The concentrations of hemoglobin and hematocrit
are usually low. The concentrations of creatinine and urinary hydroxyproline
are low, especially in patients who are too emaciated.
Biochemical signs of vitamin A, riboflavin thyamin, nyacin and ascorbic
acid may be found in addition to deficiency of minerals such as
iron, zinc and magnesium. There might also be biochemical signs
of hydroelectrolytic imbalance secondary to dehydration caused by
diarrhea.
Treatment
Several aspects in the treatment of children with malnutrition have
been reviewed by several authors(,,,,)
. In Brazil, the necessity to improve the assistance to these children
has given rise to debates on ideas and proposals for improved and
systematized actions (),
including a possible adaptation of the new World Health Organization()
guidelines for the treatment of children with severe malnutrition
to Brazilian reality.
Depending on how severe the case is, children who suffer from malnutrition
may be treated at a hospital, nutrition centers, clinics and in
his/her community/home.
Hospitalization is mandatory for the treatment of children with
clinical manifestations of kwashiorkor, marasmus or marasmatic kwashiorkor,
whose weight/age ratio is less than - 3DP or less than 70% of the
NCHS average reference values, associated with increased inappetence;
and/or diarrhea and/or vomiting; and/or any associated infection.
Children with severe protein-energy malnutrition (W/A < -3DP)
must also be admitted to hospital (they should not be referred to
treatment in clinics, nutrition rehabilitation centers and others()
When it is possible to measure height, the weight/age indicator
should be used; severe malnutrition is characterized by the presence
of edema, severe emaciation (less than 70% of weight/age ratio or
- 3 DP) or clinical signs of severe malnutrition().
The hospital approach is also used for the treatment of children
with kwashiorkor, marasmus and marasmatic kwashiorkor. The treatment
should be initiated at the time of medical assistance; the child
must be handled as little as possible. To facilitate understanding,
the treatment for children with severe malnutrition can be divided
into 3 stages, which are described next. The minimum total duration
for the treatment is 26 weeks, so that rehabilitation is achieved
and relapses can be prevented.
In the stabilization stage, from the 1st to the 7th day of treatment,
life-threatening problems are identified and treated, and specific
deficiencies and metabolic abnormalities are corrected; after that,
feeding is initiated. In the rehabilitation stage, from the 2nd
up to the 6th week, the child must be intensively fed so that he/she
can recover most of the weight that was lost. Emotional and physical
motivation is enhanced, the mother, or anyone who takes care of
the child, must be trained in order to proceed with the treatment
at home; and, finally, the child is ready to leave the hospital.
If hospitalization lasts less than 6 weeks, adequate support must
be provided so that the rehabilitation treatment can be concluded
at a nutrition center, clinic or at home. The follow-up stage, from
the 7th up to the 26th week, starts right after the child leaves
the hospital, especially if the child was released before the rehabilitation
stage was complete. The child and his/her family are followed up
to make sure there is no relapse and guarantee the child's emotional,
physical and mental development be continued.
When children finish the first stage of treatment, if they do not
present any complications, and are feeding normally and gaining
weight satisfactorily (usually 2-3 weeks after admission), they
can proceed with the treatment at a nutrition rehabilitation center,
without the need for hospitalization. A nutrition rehabilitation
center()
is a day hospital, a health center or similar institution that provides
day care through a team specialized in child malnutrition. Children
spend the night at home, are brought in every morning, and go back
home at the end of the day. There must be a close collaboration
between the hospital and the health center to ensure that child
continue to be cared for and to provide their immediate referral
to the hospital in the event of any serious problems. In urban areas,
the nutrition centers must be preferably located near hospitals.
In areas where there are no specialized centers, the hospital must
take care of children until they are ready to be released from the
treatment.
Children with severe malnutrition are normally seriously ill and
at risk of death when brought in for treatment. They usually require
emergency treatment. These children must be kept warm, properly
dressed and covered, and away from air drafts, especially at night.
The ideal room temperature should be kept at 25-30 oC because children
with severe malnutrition, especially the younger ones, are prone
to hypothermia. In hot regions, extra care should be taken to prevent
children from being overly warm during the hottest hours of the
day.
All children with severe malnutrition are at risk for hypoglycemia
(blood glucose concentration <54mg/100ml or <3mmol/l), an
important cause of death during the first two days of treatment.
Hypoglycemia may result from a severe systemic infection or from
the lack of feeding during the last 4-6 hours. If there is suspicion
of hypoglycemia, the treatment must be started immediately, without
the need for laboratory confirmation; there will be no harm even
if the diagnosis is not correct. Usually, the only sign before hypoglycemia-associated
death is drowsiness. If it is not possible to dose glycemia, it
should be taken for granted that all children with severe malnutrition
have hypoglycemia. If children are able to drink, they should be
given 50ml glucose or saccarosis at 10%, or fed a preparation that
is suitable for this stage. If the child is unconscious, administer
5ml/kg of body weight of a sterilized glucose solution at 10% intravenous
(IV). If children have convulsions caused by hypoglycemia, keep
intravenous infusion of glucose at a speed between 4 and 6 mg/kg/hour,
until the patient's status is stabilized. When the status is stabilized,
administer 50ml of glucose at 10% or saccarosis through a nasogastric
tube. When children recover consciousness, start to administer the
diet or solution of glucose diluted in water (60g/l). Continue oral
feeding or nasogastric tube feeding every 2 hours, day and night,
at least during the first day, to avoid recurrence().
All children with severe malnutrition suspected of/diagnosed with
hypoglycemia must be treated with broad-spectrum antibiotics for
systemic infections.
Hypopothermia is associated with increased mortality. All hypothermic
children must be treated for hypoglycemia and for severe systemic
infection. Hypothermia is common in children with severe malnutrition,
younger than 12 months; with marasmus, with a large part of the
skin presenting lesions; or severe infections. If axillary temperature
is below 35 oC or cannot be read on the available thermometer, take
for granted that children are hypothermic. Keep children warm, feed
them, and treat existing infections.
It is hard to make a difference between dehydration and septic shock
in children with severe malnutrition. In many septic shock cases,
there is a history of diarrhea and a mild or moderate level of dehydration,
producing a mixed clinical status. Many of the signs commonly used
to assess dehydration are not reliable in children with severe malnutrition,
which does not allow the detection of dehydration and its severity
in a reliable way. In addition, many signs of dehydration are also
found in septic shock, causing dehydration to be overdiagnosed and
its severity to be overestimated. It is very common to treat children
for dehydration and septic shock simultaneously.
When treating dehydration, oral administration is preferred; IV
administration is reserved for cases in which there are definite
signs of shock, as it usually causes hyperhydration and cardiac
insufficiency. The oral rehydration solution should have less sodium
and more potassium than the standard solution recommended by the
World Health Organization. Magnesium, zinc and copper should also
be used to correct the insufficiency of these minerals. The oral
dehydration solution suggested by the World Health Organization
for children with severe malnutrition contains approximately 45mmol
of sodium, 36mmol of potassium and 3mmol of magnesium per liter
().
When treating septic shock, use intravenous hydration with an initial
volume of 15 to 20ml/kg during the first hour, with a 0.45% saline
solution (half the physiological solution) with 5%()
glucose (glucosate solution at 5% -1:1.) or Ringer's solution lactate
with glucose at 5%. If possible, add sterilized potassium chloride
(20mmol/l). Monitor children rigorously to avoid hyperhydration,
adapting the subsequent steps to the response obtained. Treat the
infection vigorously. Resume feeding and start oral rehydration
as soon as possible. For further details on rehydration, see the
references at the end of this article().
Congestive heart failure is a usual complication caused by hyperhydration
(especially when IV infusion is carried out or the standard rehydration
solution is used), severe anemia, by blood or plasma transfusion,
or by high-sodium diet. If there are signs of heart failure, all
oral intake and IV fluids must be interrupted until the failure
no longer exists. In this case, the use of an IV diuretic is recommended,
preferably furosemide (1mg/kg). Digitalin should not be administered
unless the heart failure is unequivocal and the levels of plasma
potassium are normal. In this case, 5mg/kg of body weight of digoxin
(single dose) should be IV administered, or orally if the preparation
for IV infusion is not readily available.
All undernourished children present potassium and magnesium deficiency,
which could take 2 or more weeks to be corrected. The edema is partially
resultant from these deficiencies. Total body sodium is too high,
although plasma sodium may be low. High-sodium administration may
lead to child's death. Extra potassium (2-4mmol/kg/day) and magnesium
(0.3-0.6mmol/kg/day) may be added to food during its preparation.
Low-sodium fluids must be used for rehydration. Existing edematous
malnutrition cannot be treated with diuretics.
Almost all the children with severe malnutrition have bacterial
infections at the time they are admitted for hospital treatment,
and it is right to assume that, usually, these infections are subclinical
and have to be treated immediately. The administration of antibiotics
soon after admission, until the results of lab exams are known,
may save many children. The antibiotic therapy may be changed later,
if necessary, according to the results of lab exams.
All children with severe malnutrition have vitamin and mineral deficiencies.
The recommended treatment is : iron-free multivitamin supplementation
for at least 2 weeks, every day; folic acid ( 5mg on the first day
and after that 1mg/day), zinc (2mg/kg/day), copper (0.2mg /kg/day).
When children start to gain weight, which usually occurs at the
beginning of the second week of treatment, start using ferrous sulphate
(3mg of Fe/kg/day). Children with severe malnutrition are at high
risk for blindness due to vitamin A deficiency, and should be given
vitamin A orally, on the first day (infants younger than 6 months:
50,000IU; 6-12 months: 100,000IU; older children: 200,000 IU). The
age-specific dose should be given on the second day and should be
repeated for at least 2 weeks after that.
In case of severe anemia (Hb < 4g/dl or Hb between 4 and 6g/dl
) and/or difficult breathing, infants should be fed a blood meal
(slow administration of 10ml/kg during 3 hours and furosemide 1mg/kg
IV, at the beginning of transfusion). Children need to be monitored
every five minutes for checking heart failure.
Children must be fed light meals, with low osmolarity and low lactose,
every 2, 3 or 4 hours, night and day, right after admission. Oral
administration is preferred; if that is not possible, a nasogastric
tube should be used. The nutritional goal in this stage is to reach
the maximum intake of 100kcal/kg/day (minimum acceptable 80kcal/kg/day
) and 1-1.5g protein/kg/day. A total of 130ml/kg/d of fluid is recommended
(100ml/kg/day if children present important edema) . If children
are being breast-fed, breast-feeding must be discontinued, but adequate
formula-feeding should be provided so that calorie requirements
are met. IV administration is exceptionally used in primary malnutrition.
The amount of food ingested by children has to be rigidly measured
and recorded. If the minimal goal is not achieved, children will
have to be fed through a nasogastric tube, after having been orally
fed. The nasogastric tube must be removed when children start to
orally ingest ¾ of the total daily diet, or the total volume
in 2 consecutive meals. If intake in the next 24 hours does not
reach the minimum of 80kcal/kg/day, the nasogastric tube should
be reintroduced.
The stabilization stage, for children who have good appetite and
who do not have edema, may be completed within 2 to 3 days.
Appetite response indicates that children have entered the rehabilitation
stage, usually one week after admission. In this stage, it is necessary
to have a high rate of intake to allow fast growth to take place,
>10g/kg/day. A gradual transition between the formula used in
the initial stage and the formula used for growth enhancement is
recommended in order to avoid the risk for heart failure, which
could occur when children ingest a large amount of food in the initial
stage. The initial formula (75 kcal/100ml and 0.9g protein/100ml)
must be replaced during 48 hours, with the same volume of milk-based
formula for growth enhancement (containing 100kcal and 2.9g of protein/100ml).
Modified milk porridge or complementary foods may be used provided
that they supply comparable amounts of energy and protein content.
After 48 hours, if children adapt well to the formula, an increase
of 10ml at each successive feeding should be applied until food
is left over. This usually happens when intake reaches 200ml/kg/day.
After gradual transition, provide frequent feedings, according to
acceptance(unlimited amount), in order to achieve the nutritional
goal of 150-220kcal/kg/day and 4-6g of protein/kg/day. Family food
may be fed to infants older than 24 months, to guarantee nutrition
requirements. The progress of rehabilitation should be assessed
through weight gain. Heart failure is unlikey to occur if gradual
transition is followed. However, to be on the safe side, the presence
of early signs of heart failure should be monitored. If there are
signs suggesting heart failure, the administered volume should be
reduced to 100ml/kg/24 hours and be gradually increased to 115ml/kg/day
during the next 24 hours, 130ml/kg/day for the next 48 hours, and
finally increased to 10 ml at each feeding, as previously described.
If intolerance to lactose with effects on infant growth is diagnosed,
the treatment must be carried out with lactose-free formulas, which
should be modified in order to meet the adequate goals required
for rehabilitation. Whole milk meals should be reintroduced before
children leave the hospital to determine whether intolerance was
eliminated.
As there is behavioral and mental development retardation in children
with severe malnutrition, it is important that basic stimuli, recreation,
affection, and mother-child relationship be enhanced. Mothers should
participate in child care tasks and should be taught to provide
basic stimuli.
During hospitalization, children and mothers should be prepared
to leave the hospital. Children who present 85% -90% of the weight
required for their age or height (equivalent to - 1DP) may be regarded
as rehabilitated. These children may still have low weight for their
age due to stunting. Good feeding practices and psychological stimuli
should be continued at home. Parents, or whoever is taking care
of these children, should be taught how to feed them foods that
are rich in energy and nutrients and how to provide them with structured
recreational therapy/basic stimuli.
During follow-up, children should be weighed every week. If these
children do not lose or gain weight within 2 weeks, they should
be referred to hospital for re-evaluation. If these children respond
well, the frequency of treatment may be progressively changed to
1 time every 15 days during 3 months, every 30 days during 3 months,
every 60 days during 6 months and every 6 months after that, until
these children turn 3 years.
Nutritional rehabilitation in clinics and community is possible,
although it takes longer. In this case, parents have heavier resposibility
for the successful treatment of their children. Therefore, it is
crucial that parents get the necessary guidance and pratical support
from health agents and professionals ().
In general, orientation is similar to that given before the children
leave the hospital and throughout the follow-up of those children
who were hospitalized.
Mothers should be instructed on how to prepare meals with adequate
nutritional value and be informed that their children need to be
fed at least 5 times a day. Usual family food should be prepared
so as to contain approximately 100kcal and 2-3 g of protein per
100g of food. Vitamin, iron and electrolyte/mineral supplements
should be provided.
A follow-up plan has to be followed and an effective treatment routine()
should be adopted, at least until children are totally rehabilitated.
It is essential that community health workers give their support.
If children were discharged from hospital early, supervision must
be reinforced in the clinic or at home, as they have a very high
risk for relapse and death. Children should be carefully assessed
before leaving the hospital and some kind of community support must
be available in order to prevent a relapse. Home treatment, in addition
to having a reduced cost for the health sector, is mothers' favorite
().
Possible alternatives for child malnutrition control
The attempts to control malnutrition as a public health problem
in developing countries began in the postwar period and used to
include increased production of protein-rich foods and the promotion
of nutrition programs and education().
The results were disappointing. Nutritional assistance, which was
provided on a large scale but independently from other social and
developmental efforts, consisted of a symptomatic instead of causal
treatment.
The effective prevention of protein-energy malnutrition cannot have
a distant objective from that of general measures that aim at meeting
poor people's basic needs().
This fact has triggered international decisions on population's
economic improvement through strategies and programs especially
designed for groups at higher risk for malnutrition().
Even though history shows that the solution to poverty is an ambition
that is too difficult to be fulfilled on the short-term, there have
been well-planned interventions by the health sector aimed at preventing
child malnutrition().
Unfortunately, as malnutrition is considered to have multiple causes,
it has often been a preoccupation to many people, but no one has
taken the onus on themselves to combat it().
Several health professionals label child malnutrition as a "social
problem" and approach it with listlessness, unimportance or
defeatism regarding children with or at risk for malnutrition; and
contempt for any child nutrition campaigns. These workers act fragmentally
and often keep a distance from updated information that could be
helpful in controlling malnutrition(,,).
Others, taking for granted that there are fewer children with severe
malnutrition today, underestimate the importance of such problem
and even ignore the existence of a silent hidden starvation and
malnutrition epidemics which is expressed through the number of
children with moderate and mild malnutrition, although less evident
().
The strategies adopted by the health sector as to the prevention
of malnutrition were clearly defined in 1978, when, in Alma-Ata,
the focus on primary attention to health for all in the year 2000(),
and the promotion for adequate nutrition were designed. According
to the World Health Organization, the health sector holds the following
responsibilities as far as nationwide nutrition and feeding are
concerned: a) definition and analysis of nutrition problems; b)
promotion and participation in multisectorial feeding/nutrition
strategies and programs; and c) implementation of a feeding and
nutrition surveillance system ().
In several countries()
, and also in Brazil, well-planned programs for primary attention
to health have made a difference, especially if the instructive
information is not vertically defined and is culturally appropriate
and viable for mothers(,,).
The introduction of the nutritional aspect in children's routine
treatment plays a vital role in the prevention of malnutrition.
Recent studies show that, as far as infants younger than 3 years
are concerned, stunting begins a few months after birth and goes
up to the 2nd year of life, coinciding with the age at which foods
complementary to breast-feeding are introduced. Thus, it is possible
that innovative program approaches aimed at promoting complementary
feeding for infants aged under 2 years have better cost-effectiveness
than those approaches targeted on preschool children and may have
historically unprecedented success in reducing child malnutrition().
Nutrition guides for the promotion of complementary feeding for
Brazilian infants under 2 years, as an initiative by Pan-American
Health Organization (PAHO/WHO) and Ministry of Health, have been
recently elaborated with the solid participation of health professionals
from all over the country and are just about to be printed. After
that, these guides will be ready for distribution().
In Brazil, in agreement with the governmental objective of reducing
the prevalance of moderate and severe malnutrition to 50% until
the year 2000(),
which was endorsed at the World Summit on Child Care, the Ministry
of Health has earnestly endeavored to promote nutrition and reduce
infant mortality. In an attempt to allow population's access to
these actions, some programs were successively implemented in the
1980s. Namely, these programs are: Community Health Agents Program,
Family Health Program()
and, in partnership with WHO/PHO, the initiative called Full Attention
to Prevalent Childhood Diseases().
It is believed that Community Health Agents may be effective if
they are well-trained and supervised, and if they have enough level
of judgment and accuracy for the reference of cases that cannot
be treated at home().
The Full Attention to Prevalent Childhood Diseases()
currently includes exclusive actions for the promotion of clinic-based
child nutrition treatment.
At clinics or at home, the Familly Health Program teams, with health
agents and professionals, may act on critical aspects(),
providing nutritional counseling to pregnant women, information
on infections, advice on programs that handle shortage of food,
and warning against the apparent negligence towards child care caused
by mothers' misinformation(,).
Although the shortage of food at home is an important factor in
malnutrition, a possibility for effective intervention by the health
sector, working together with mothers in order to reduce malnutrition,
was found by health professionals as Nobrega and Campos ()
, throughout 20 years of work at a nutrition rehabilitation center,
and was recently confirmed by Muniz().
These authors found that around 30% of mothers whose chidren suffered
from malnutrition were paradoxically eutrophic, were overweight
or even obese. An in-depth investigation showed that child care
practices were inadequate. In children assisted by Nóbrega
and Campos, ()
this was due to a withered mother-child relationship. Their multiprofessional
team has enabled mothers to rehabilitate their children and avoid
the recurrence of malnutrition through the support and enhancement
of a positive relationship with mothers.
Muniz (),
found an unfavorable pattern of child care practices. She used an
approach chosen together with mothers with the aim of restoring
their self-esteem, in addition to providing them with practical
knowledge and instructions on how to take care of children with
malnutrition. This education-based intervention carried out by the
Family Health Program in Vitória, state of Espírito
Santo, managed to change mothers' practice to a more favorable pattern,
and rehabilitated 70% of the children with malnutrition through
home treatment and without any additional food supplements.
One of the main characteristics of nutrition enhancement actions
is the potential for prevention and management of infectious diseases(,,).
The appropriate management of children's diet favors the reduction
in the frequency and severity of infections. During an infection,
dietary management is aimed at changing the course and outcomes
of the disease, through adequate food intake during the infection
and rehabilitation period, especially in younger children().
Dietary management actions may be promoted by health professionals
by directly counseling mothers on breast-feeding; complementary
feeding for infants aged 6 months or older, including foods that
are rich in vitamin A, iron, zinc, vitamin B6; feeding of diseased
children; and oral rehydration in case of diarrhea. For further
practical information on these procedures, see the references at
the end of this article(,,,).
Reducing the prevalence of child malnutrition requires focused and
systematized health sector and nutrition safety actions, in special
regard to mothers, so that they can take proper care of their children.
The key elements of such actions include access to education, health
care, good quality water, protection against diseases, and adequate
intake of micronutrients. In addition, an appropriate community
system for following up and supporting children with mild, moderate
and severe malnutrition should be implemented. If this is done in
an effective way, it is possible to quickly reduce malnutrition
rates as in Oman, Thailand, Uruguay, Vietnam, and Zimbabwe().
This quick reduction in malnutrition rates is an urgent need since
it is part of each and every prospective effort into reducing poverty().
Conclusion
Child malnutrition is still the most important public health problem
in developing countries. Its effective reduction depends on integrated
interventions that can reduce poverty and improve the quality of
life of unpriviliged families. This implies wide-scope strategies
developed by the government and involves intense community participation.
Health professionals are not in charge of changing society's political
and economic structure, but they have to understand the inequalities
and limitations experienced by the population they assist and be
able to apply currently available scientific knowledge. The challenge
is to gradually reduce the number of children affected by malnutrition
no matter how severe the disease is. There is much to be done, and
there are several opportunities and ways by which health professionals
who are updated and work in an efficient and correct way may contribute
to the nutrition and health of Brazilian children. Some possibilities
were presented in this article.
Thanks to Helenice Muniz, Roseli Sarni, Ana Augusta Cavalcante
and Virginia Costa for their support and productive exchange of
ideas during this review.
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