One Nurse At A Time modules are intended to help nurses understand disease processes that are uncommon in our work practices at home. They are intended to be practical guides and not exhaustive dissertations. Education is a dynamic, ongoing process. We value your input and comments on the content of this module. Please feel free to write to OneNurseAtATime@gmail.com.
When the Liberian mother pointed to her three year old son’s brittle orange hair and missing teeth, I did not recognize the symptoms of malnutrition. In the Internally Displaced Persons (IDP) camp called Kakata, malnutrition was a regular occurrence. I had no idea what life was like inside the camp. People waited for food rations to be delivered once or twice a month by a United Nations (UN) agency: 80% corn meal mixed with 20% soy flour and distributed along with a can of cooking oil. Sometimes those rations were late or never arrived. I didn’t understand tens of thousands of people live like this with no other access to food – no marketplaces, no gardens, no money and nothing to barter.
My untrained eye missed the drastic physical signs produced by lack of calories and micronutrients. All the children had big bellies and looked thin, dirty, snotty nosed and covered in flies. I could diagnose and treat pneumonia, malaria, otitis or giardia but missed the underlying malnutrition that complicated each disease entity. I still wonder if the orange haired child survived and if I could have helped if I’d only known what to do.
This module is about malnutrition in the developing world and how you as a nurse can diagnose and treat it. The World Health Organization (WHO) says malnutrition is the number one threat to the world’s public health. It is the biggest contributor to under five year old mortality, and half of all kids who die each year are malnourished. Negative effects of malnutrition in the first two years of life are irreversible. Children who don’t get adequate nutrition are slow in their physical and mental development and may have mental retardation as a result. Malnutrition not only exacerbates other disease processes, it causes other diseases such as iron deficiency anemia and blindness from lack of Vitamin A.
The first “in your face” images of mass starvation came in the 1960s when television was young. Biafra, the eastern part of Nigeria, declared independence from the rest of the country. To quash the rebellion, the Nigerian government blockaded food deliveries to Biafra and starved the population into submission. Now the media routinely airs pictures of famine and starvation and malnutrition in India, in sub Saharan Africa, in Central America, in Asia. Year after year it continues. As providers of humanitarian medical care, we need to know how to diagnose and treat, and work to break the cycle.
Malnutrition is a medical condition created by inadequate intake of essential calories (in adults about 2000 calories per day), macro-nutrients (proteins, carbohydrates and fats) and micro-nutrients (vitamins and minerals). Children under 5 are the most vulnerable group because their metabolic needs are great and their reserves are low. Breastfeeding, especially in the first six months of life, is an essential part of preventing/treating malnutrition. However, lactation puts additional nutritional stress on women, who may also be malnourished, especially when it overlaps the next pregnancy. Not meeting the increased metabolic needs of pregnant and lactating women may result in increased risk of malnutrition in the fetus or young child. Malnourished pregnant women can’t pass adequate nutrients to a growing fetus. Poor nutrition may produce poor breast milk which can’t sustain a growing child. The physical and neurological consequences of early life malnutrition may be irreversible.
To put the problem in perspective, approximately 20 million people suffer from acute malnutrition worldwide and double that number have moderate malnutrition.
Malnutrition can be chronic – from lack of food due to poor harvests, inclement weather, disruption in distribution (for example, due to conflict), societal issues (men eat first and best), local culture, food preferences and seasonal availability – these are multifactorial causes without simple solutions. Malnutrition can also be acute, affecting a large population in extremis who have been displaced by epidemics, conflict, natural disasters or otherwise without reserves to withstand a rupture in food supplies. Some medical conditions like measles and waterborne infections can lead to acute malnutrition in a large unprotected population. In each situation, children are the most affected.
Chronic malnutrition results in stunting. Stunting happens gradually over time and cannot be reversed. The body does not have proper nutrition to grow appropriately for age. Stunting within a population reflects global nutritional status and fragility.
TYPES OF MALNUTRITION
Marasmus is a generalized wasting of muscle mass and subcutaneous fat producing the gaunt, bony, skeletal appearance we’ve come to associate with starvation. Bodies literally consume themselves trying to create enough calories to survive. Children have faces that look like wizened old people and heads look too large and heavy to stay upright on the neck. Bones seem to poke out from the skin. The individual is weak and lethargic and the skin sags like loose clothing.
Kwashiorkor (“Kwash”) is deceptive in appearance and therefore far more dangerous. The child (or adult) is edematous which can hide the severity of malnutrition unless the practitioner is looking carefully. These children do not look bony, in fact, just the opposite: they look fat and swollen. Edema is not normal in children. It is a result of fluid shifts during acute malnutrition. Pitting edema in the feet signals severe malnutrition and meets criteria for inpatient admission, regardless of any other measurements. Edema can be so severe it spreads to the legs, arms and even face, rendering traditional methods of measuring inaccurate. These children must be rehydrated and fed with extreme caution in order to not become fluid overloaded and die. They are far more fragile than Marasmus patients. Kwashiorkor patients may have skin lesions, depigmentation, dry brittle discolored hair, liver and spleen enlargement, lethargy, poor appetite and decreased ability to suck.
For malnutrition patients, “edema” is “pitting edema” – press the area with your thumb for a few seconds. If your pressure left an indentation, this is “pitting edema,” and you diagnose your patient with Kwashiorkor. Edema is measured:
0 = no edema present
+ = edema present below ankles
++ = edema in both feet and legs below knees
+++ = edema in both feet, legs and above knees
Marasmus-Kwashiorkor is common and is a combination of the two. There is bilateral edema AND the child is low weight for height. This combination is often seen in HIV/AIDS.
DETERMINING THE SEVERITY OF MALNUTRITION
There are two widely used methods of measuring malnutrition: MUAC and Weight For Height.
MUAC is the “quick and dirty” approach and measures the degree of muscle wasting. It is a color coded tape used to measure the Middle Upper Arm Circumference of children between the ages of six months and five years – interestingly, the measurements remain consistent from 6 to 60 months of age.
To accurately measure, gently but snugly wrap the MUAC tape around the relaxed arm at the halfway point between shoulder and elbow. For children,
RED measurement of 115 mm or less is considered SEVERELY MALNOURISHED and extremely high mortality risk.
ORANGE measurement of 116 – 124 and is read as MODERATELY MALNOURISHED.
YELLOW measurement of 125 – 134 means AT RISK, but not malnourished.
GREEN measurement of 135mm or above is NOT malnourished.
There is also an adult version of the MUAC tape. Adults (15 years of age or older) are considered severely malnourished with MUAC less than 160 mm. Pregnant/lactating women are severely malnourished if less than 170 mm.
MUAC is an excellent tool used in mass vaccination campaigns, rapid assessments of at risk populations, distribution programs and the like, but is not sufficient to diagnose or manage medical treatment of malnutrition. For those, you must use the World Health Organization’s Weight For Height charts.
Weight For Height. In 2005 WHO surveyed children with adequate diets in six countries around the world and updated growth norms/standards. These standards can be used for all children regardless of location. Take a look now at the Weight For Height (W/H) tables and you will understand how to measure. Each child is assigned a “z score” (pronounced “zee score” or “zed score” in different countries). The “z score” is based on statistical weight for height curves and the Standard Deviation from the median. The “z score” measures the severity of malnutrition (moderate or severe) but not the type (Marasmus, Kwashiorkor or Marasmus-Kwashiorkor).
Moderate malnutrition is <-2 SD (“z score of less than negative 2”).
Severe malnutrition is <-3 SD (“z score of less than negative 3”).
Salter scales are the most commonly used weighing devices. They are washable pants/slings hung on crossbars or tree branches by experienced staff. A plastic basin hung on ropes can be substituted for slings. The scale is zeroed each time and a naked child is weighed in kilos/kg. Height is measured in centimeters/cm. Infants and smaller children are laid on a special wooden measuring board and stretched to their full length by two persons. Older children can be stood against the measuring board. The age of the child is not necessary, which is an advantage in many societies where birthdates are not recorded or recalled.
Marasmus severity is measured in z scores. There is no pedal edema.
Kwashiorkor has bilateral pitting edema. The z score will be -2 or closer to normal because they are heavy from fluid retention and their weight mistakenly seems to be appropriate for their height.
Marasmus – Kwashiorkor has bilateral pitting edema and z score of <-2 or <-3. These children appear gaunt AND have edematous feet.
There are internationally accepted treatment protocols based on WHO guidelines. Each country’s Ministry of Health creates their own nutrition protocols usually in concordance with WHO. Protocols may vary slightly between organizations providing care, so check with your organization.
This section discusses how you should diagnose and treat individual patients you may encounter. It does not deal with setting up inpatient or outpatient nutrition programs to treat large numbers of patients. Those are complex and costly endeavors that specialty organizations like Doctors Without Borders, Accion Contra La Fam, Save the Children and others organize according to strict protocols and guidelines. Food distribution programs are also large and complex. They are usually managed by the World Food Program (WFP) with various distribution arms, but may also be wholly under one specific organization like Doctors Without Borders. Where and how to distribute massive quantities of food is a logistical task requiring vast resources, expertise, security, coordination with the population being served, local authorities, government officials and many many other considerations.
After determining the type and severity of malnutrition, as a medical practitioner your next step is to determine if the patient’s condition is appropriate for outpatient or inpatient medical and dietary management.
Outpatient treatment: Your patient is 1) medically stable, 2) his/her medical conditions (infections, diarrhea, etc.) are easily treated, AND 3) he/she has an appetite.
If the patient has medical complications or can’t eat, you must find a venue immediately for inpatient treatment. Contact your organization’s field management team or the nearest government health post or other organization working in the area for appropriate referral sources. You should still begin medical treatment at the time of your consultation while you’re arranging the referral.
This module will not cover inpatient dietary treatment for malnourished children as the scope is beyond the intent of this educational piece and best left to specialized malnutrition treatment programs.
MEDICAL TREATMENT PROTOCOLS
Side notes: Remember that children in developing countries weigh less than in the developed world. The children you are treating for malnutrition are small for their age and will not approximate the weight for age you’re used to treating at home.
These protocols are based on WHO recommended “Essential Drugs” with most frequently available formulations of the medications found in the developing world. There are no pharmacies to prepare your doses for incremental weights. Therefore, weight categories are broad and generalizations are made to “do no harm.”
When you encounter a moderate or severely malnourished child, you should provide initial medical management and then refer to IPD or OPD nutrition centers:
- Albendazole A chewable tablet that kills “worms” which can greatly affect a patient’s ability to absorb nutrients from food. Not for children under 6 months or women in the first trimester. Safe for breastfeeding mothers.
Standard one-time dose:
200 mg if under 8 kg
400 if 8 kg or more.
- Vitamin A deficiency can cause blindness, increased risk of infection and death. It is the most common, most serious and most easily treated micronutrient deficiency in malnutrition. Vitamin A is especially critical in post-measles malnutrition (see our Measles module for more specific information about Vitamin A treatment in measles). Vitamin A deficient diets are common across the developing world. Many national Ministries of Health with the help of UNICEF will hold annual “Child Days” where all children receive Vitamin A, deworming, polio vaccine, etc. at school. Vitamin A is an oily preparation, fat soluble, and comes in a soft capsule.
Standard one-time dose: Prick the end of the capsule with a needle and squeeze into the child’s mouth
Under 4 kg: 2 drops
4 to 8 kg: 4 drops
8 – 15 kg: the contents of the entire capsule
NOTE: newborns should not receive Vitamin A since it can increase intracranial pressure. Remember, these children are tiny – newborns may weight only 4 – 5 pounds (2 – 2.5 kg). Acute toxicity can occur at 25,000 iU/kg (one drop).
NOTE: Not given for prevention of vitamin A deficiency above age 5 years of age.
- Folic Acid (Vitamin B9) helps correct and prevent anemia. You may need to crush and mix with clean water for young children. It is safe to give in pregnancy and when breastfeeding. Standard one-time dose
Up to 4 kg: 2.5 mg (half a 5 mg tab)
4 kg and above (including adults) one 5 mg tab
- Amoxicillin Often treatable causes such as respiratory infections and otitis can contribute to malnutrition. All malnourished children are treated prophylactically for infections. (It’s hard enough to see a red, swollen eardrum in a screaming child in the bright lights of the ER at home … now imagine you’re in a mud hut without electricity or an otoscope!) Crush tabs and mix with clean water if liquid Amoxicillin is not available. Safe in all ages. Safe in pregnancy and breastfeeding.
Standard dose 80 mg/kg/day in two divided doses for a total of 5 days.
In addition to nutritional assessment and the standard medical treatment protocol outlined above, there are other treatable conditions to be aware of:
- All children should be screened for measles vaccination. Measles is an opportunistic viral infection frequently found in developing countries struggling to provide adequate vaccination coverage. Malnutrition nearly always follows a case of measles. The disease leaves a weakened immune system and deadly complications such as blindness and neurological deficits. (Please read One Nurse At A Time module on MEASLES). If the child is 6 months of age or older and not up to date on measles vaccination, you should refer to the closest Ministry of Health post.
In malaria-prone regions, all children should be screened for malaria and treated if positive or suspected (Please read One Nurse At A Time module on MALARIA). Malaria can quickly kill a malnourished child. There may be a laboratory capable of performing blood smears. Otherwise, rapid tests such as Paracheck can be performed with a simple finger stick and one drop of blood. Check with the CDC (Centers for Disease Control) or WHO for the area you’ll be working to find recommended malaria treatment protocols. Most country protocols prescribe Artesunate Combination Therapy. Be prepared to treat your patients appropriately and yourselfif you contract malaria.
Malnourished children have difficulty regulating their body temperatures. Be prepared to take temperatures (axillary!) and cool or warm the patient as necessary. Outside temperatures that feel comfortable to you may be extremely cold (especially overnight) for malnourished children. Cover the child’s head and wrap them to preserve body heat. “Space blankets” are especially good for this.
- Most diarrhea is self-limited and does not cause dehydration. Give plain clean water to drink after each watery stool. WHO recommends zinc tabs along with oral rehydration therapy for treatment of acute and persistent diarrhea in under 5 year old children to reduce the duration and severity of symptoms. Diarrhea for more than 3 days and/or diarrhea with fever or blood will require anti-parasitic and/or antibiotic treatment. In high prevalence HIV areas, be suspicious for persistent diarrhea lasting more than 2 weeks
Standard ZINC dosage:
Under 6 months of age, 10 mg daily for 10 days
6 months to 5 years, 20 mg daily for 10 days
The possibility of dehydration should be carefully evaluated in the face of malnutrition. The usual markers of slack skin turgor and sunken eyes may not be readily apparent. Remember, Kwash and Marasmus-Kwash kids have edema but may also be dehydrated. Observe and treat these children very slowly and carefully.
Rapid fluid resuscitation can be deadly and cause heart failure in a malnourished child. Symptoms of fluid overload are rapid breathing (more than 50 breaths per minute in 2 – 12 months, more than 40 breaths per minute in 12 months – 5 years), shortness of breath, increased pulse, increased edema. If any of these symptoms appear, STOP TREATMENT for one hour and reassess.
As a general rule, malnourished children with dehydration from diarrhea should be given ReSoMal, a special powdered solution with high potassium and low sodium. ReSoMal is given to malnourished children under your observation and not routinely given to mothers to take home. If you do not have ReSoMal, dilute ORS (Oral Rehydration Solution) in twice as much water and add 1/4 cup of sugar. This ORS mixture is not the preferred solution, but is an acceptable second choice. Any unused ORS or ReSoMal should be discarded after 24 hours due to risk of bacterial growth (both have high sugar contents).
To PREVENT dehydration from diarrhea in a malnourished patient (meaning, the child has diarrhea but does not yet have signs of dehydration), give:
Child under 2 yrs old : 50 – 100ml ReSoMal orally after each loose stool
Child over 2 yrs old : 100 – 200 ml ReSoMal orally after each loose stool
Adult : 200 – 400 ml ReSoMal orally after each loose stool. ReSoMal is safe for pregnant and lactating women.
To TREAT dehydration from diarrhea in any malnourished patient, give:
5 ml/kg ReSoMal orally every 30 minutes for 2 hours, then 5 – 10 ml/kg/hr orally for 4 – 10 hours until dehydration is corrected.
At the Outpatient/Ambulatory level, a malnourished child can be given a Ready to Use Therapeutic Food (RUTF) such as Plumpy Nut (PPN) or other available product for at home consumption. Only in the last few years has RUTF become the nutritional substance of choice and more products are being developed all the time. PPN is a high calorie peanut -based product used around the world with a goal of 200 cal/kg/day. One small sachet of Plumpy Nut contains 500 cal, animal based protein from non-fat milk plus all essential micronutrients. It comes ready to eat (and kids LOVE it!), requires no mixing, no refrigeration, is easily stored and distributed. PPN is also easily absorbed even in extremely ill children. (photo of PPN)
If a child can eat PPN in your presence and is otherwise uncomplicated medically, he/she can be sent home with a supply of RUTF after your medical treatment as described above. The child should be given small frequent amounts of RUTF (normally 2 sachets per day if 8 kg or under and 3 sachets per day if above 8 kg) prior to consuming normal food at home. You will need to stress that RUTF is medicine and not to be shared with siblings or parents. The child should continue to breastfeed (if appropriate for age). Allergic reactions to peanuts are rare in the developing world, at least for now.
Again, Inpatient treatment will not be discussed in detail in this module.
THE ROOTS OF MALNUTRITION
Why, when it has been calculated there is twice as much food produced in the world as needed, do we still see such huge amounts of malnutrition? It’s a complicated question without an easy fix. Most societies in the developing world are agrarian and depend on growing their own crops and raising their own livestock to feed their families.
Some issues impacting a population’s nutritional status are:
Climate change. A slight change in temperature can cause drastic changes in the land’s ability to produce crops. Climate change also affects rainfall, bees for pollination of crops, livestock, susceptibility to and proliferation of diseases in both crops and animals.
Agricultural techniques. Fertilizer is out of favor with environmental groups and beyond the financial means of many poor farmers. Irrigation of fields is essential and the availability of water is linked with climate change. Access to improved seeds and farming methods are nearly impossible in remote areas that continue to farm the same fields in the same way for centuries.
Distribution. Large quantities of grains and livestock are grown outside the area of need, requiring resources to be spent on transportation and distribution. The US, Russia and Canada grow the majority of cereal crops in the world. To move those products in the quantities required to feed starving populations in sub Saharan Africa or Asia … you can imagine the huge costs involved.
Aid. Increasingly aid groups give cash or vouchers to people to purchase locally grown food rather than importing and distributing tons of donor food. Often, local farmers then inflate the price of their products putting them further out of reach of populations in need. This direct financial aid to farmers is frowned on by the World Bank as “subsidies.
Biofuels. Biofuels are created from food crops like corn, decreasing the quantity available for food in lieu of making fuel. Good for the environment, yes. Good for American farmers, yes. But prices have risen dramatically and crops available for food aid have decreased.
Protectionism. The US and other countries have laws that require aid to be given as actual food and not in the form of money to purchase locally grown food. Donor nations’ farmers reap the financial benefit of growing more food crops. Additionally, costs to transport those products around the world to places in need are double the value of the food. More money is spent on transportation than on the actual food itself.
Nutritional appropriateness. Many cultures do not consume corn, which is one of the main staples in international food aid. After all, corn originated in the Western Hemisphere and only began to be exported a few centuries ago. Single source (for example, rice) cultures do not have broad nutritional value in their main food source(s). The results are evident as stunting and delayed childhood development. (Guatemala, for example, has an estimated 50% stunting across the population – meaning chronic malnutrition.)
Worldwide financial crisis. Donor nations have slashed budgets for food aid as they grapple to prevent economic collapse.
Commodity speculation. Remember “pork belly futures”? There is a broad market (like the stock market) for commodity speculation that can run prices of staples out of reach of poor populations.
Cycle of malnutrition: decreased food intake > decreased energy levels > decreased brain and physical function > can’t work > can’t gain money > decreased food intake and the cycle continues …
As health care practitioners working in developing countries, it’s essential for you to understand and recognize malnutrition. Now you know the treatment protocols and some of the key ingredients to nursing these fragile children back to good health. Stopping malnutrition saves lives. It’s not easy, it’s not quick. But you can make a difference, one nurse at a time.
Valuable websites for more information about malnutrition: