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Nutrition

Malnutrition Introduction & Classification

Overview of malnutrition (undernutrition), its causes (immediate, underlying, basic), consequences, clinical features (marasmus, kwashiorkor, marasmic-kwashiorkor), and classification systems (acute vs chronic).

Also known as: Undernutrition

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Referral and warning signs

When to refer

Children with SAM require referral for specialized therapeutic care.

Red flags

  • Bilateral pitting oedema
  • Visible severe wasting
  • MUAC < 115 mm
  • WFH/L < -3 Z-score
  • Any general danger sign in malnourished child

Signs and symptoms

  • Clinical Features:
  • - Marasmus (Wasting): Severe weight loss, muscle/fat wasting ('skin and bones', 'old man' face), prominent ribs, loose skin folds, apathy/irritability, good appetite.
  • - Kwashiorkor (Oedematous): Bilateral pitting oedema (feet/legs first), misery/apathy, poor appetite, skin changes (flaky paint dermatosis, pigment changes, ulcers), hair changes (sparse, light colour, easily pluckable), hepatomegaly (fatty liver), moon face.
  • - Marasmic-Kwashiorkor: Both wasting AND oedema.
  • General signs: Growth failure (underweight, stunting), Increased infection susceptibility, Impaired development.
  • Specific Micronutrient Deficiency Signs.

Risk factors

  • Immediate Causes: Inadequate diet (quantity/quality), Disease (infections, parasites).
  • Underlying Causes: Food insecurity, Poor care practices, Unhealthy environment (WASH), Poor health access.
  • Basic Causes: Poverty, Lack of education, Poor governance, Conflict, Disasters.

Diagnosis

Clinical assessment

Assessment based on clinical features (wasting, oedema, skin/hair changes) and anthropometry.

Investigations

  • Anthropometry (Weight, Height/Length, MUAC).
  • Clinical examination for oedema and signs of complications/co-morbidities.

Diagnostic criteria

Classification: - Acute Malnutrition (Wasting): Assessed by Weight-for-Height/Length (WFH/L) Z-score or MUAC. Includes Moderate (MAM) and Severe (SAM). Kwashiorkor (oedema) = SAM. - Chronic Malnutrition (Stunting): Assessed by Height/Length-for-Age (HFA/LFA) Z-score (<-2z = stunted). - Underweight: Low Weight-for-Age (WFA) Z-score (<-2z).

Management

Non-pharmacological management

  • See specific management entries (NUT006-NUT010).

Pharmacological treatment

  • See specific management entries (NUT006-NUT010).

Monitoring

  • Regular growth monitoring.
  • Monitoring response to nutritional rehabilitation.

Complications

  • Impaired growth (stunting).
  • Impaired cognitive/physical development.
  • Weakened immunity -> Increased infections.
  • Increased mortality.
  • Increased adult chronic disease risk.
  • Inter-generational cycle.

Prevention

  • Food security.
  • Optimal IYCF.
  • Improved WASH.
  • Prevent/treat childhood illness.
  • Micronutrient programs.
  • Health education.
  • Poverty reduction.

Patient education

  • Importance of balanced diet.
  • Optimal IYCF.
  • Hygiene/sanitation.
  • Immunization/health checks.
  • Recognizing malnutrition signs.

Uganda-specific notes

Double burden exists. Kwashiorkor seen. Poverty, food insecurity, infections significant underlying causes.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 19, Section 19.2, 19.2.1, 19.2.1.1

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