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Severe malnutrition 

Severe malnutrition

Chapter:
Severe malnutrition
Author(s):

Alan A. Jackson

DOI:
10.1093/med/9780199204854.003.1103

May 29, 2014: This chapter has been re-evaluated and remains up-to-date. No changes have been necessary.

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date: 29 April 2017

Severe malnutrition is the consequence of systemic deficiency of energy and nutrients over a prolonged period: in children development is stunted and the individual is at risk of fatal (often clinically ‘silent’) infection and other illnesses. It is a medical and societal emergency: mortality is high, despite attempts to provide appropriate care.

When severe malnutrition affects several individuals in a society, it reflects a state in which basic needs and justice are not met. Severe malnutrition may also result from clinical disorders affecting a single person with gastrointestinal disease, poor appetite or reduced food intake for other reasons.

Classification

The World Health Organization has produced guidelines for facility-based care of patients suffering severe malnutrition. Prompt classification into groups of differential risk assists in the identification of those requiring the most immediate clinical care (severe acute malnutrition, defined as weight for height more than 3 standard deviations below the reference mean, or the presence of oedema of both feet) and in monitoring the outcomes of intervention. Low height for age indicates long-term malnutrition or poor health (stunting); low weight for height indicates recent or continuing severe weight loss (wasting); low weight for age implies stunting and/or wasting.

Prevention

Malnutrition is a preventable condition and the early identification of those at risk (e.g. by regular weighing) and the implementation of interventions (e.g. advice and demonstration of best practice in child care and feeding) which correct underlying problems and prevent further deterioration is central to strategies for effective care.

Childhood malnutrition is a clinical problem for the individual, but also a symptom of ineffective public health policy. Aside from feeding, important aspects are to recognize and treat infection, immunize against infection, enhance the child-rearing skills of the parents, and strengthen general hygienic practices.

Severe acute malnutrition

Severe malnutrition results from the interaction of three distinct but related processes: (1) reductive adaptation, which is a general response to preserve essential function that takes place when the demands of the body for energy and nutrients are not adequately met; (2) inflammatory/immune responses and healing, which are impaired as a result of reductive adaptations; (3) specific nutrient deficiencies, when failure because of marginal diet to correct excessive losses of nutrients (e.g. through diarrhoea and vomiting) leads to major imbalances. These combine to put the child at risk of the deadly triad of infection, hypothermia, and hypoglycaemia, often compounded by marked fluid and electrolyte disturbances.

Sick malnourished individuals have no appetite for food, with loss of appetite being an important protective mechanism against consuming food which is likely to stress the systems of the body. Attempts (well meaning) to force feed are dangerous: the potentially fatal ‘recovery syndrome’ (manifest as heart failure, progressing to circulatory collapse, often with severe secretory diarrhoea) must be avoided. Aside from the provision of a sympathetic and quiet environment during treatment, key aspects of management include: (1) resuscitation—management of infection, fluid and electrolyte imbalances, and shock, also treatment of vitamin A deficiency; (2) stabilization—give small frequent meals (every 3–4 h throughout 24 h; 100 kcal/kg per day; 1–1.5 g protein/kg per day), add specific nutrients to food to correct deficiency (potassium, magnesium, folic acid, zinc, copper, multivitamin), treat infections, transfuse for severe anaemia, treat skin lesions, exclude tuberculosis; (3) weight gain (rapid catch up growth)—ad libitum intake, continue with micronutrient supplements, add supplemental iron.

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