(http://www.ugm.ac.

id)

BOOKCHAPTER

Nutrition,FoodSecurity,andHealth
HaroldAldermanandMeeraShekar
NelsonTextbookofPediatrics,Chapter43,170179.e1

MalnutritionastheIntersectionofFoodSecurityandHealthSecurity
Undernutritionisusuallyanoutcomeof3factors:householdlevelfoodsecurity,accesstohealthandsanitationservices,andchildcaringpractices.A
motherwithfeweconomicresourceswhoknowshowtocareforherchildrenandisenabledtodosocanoftenuseavailablefoodandhealthservices
toproducewellnourishedchildren.Iffoodresourcesandhealthservicesareavailableinacommunity,butthemotherdoesnotaccessimmunizations
ordoesnotknowhoworwhentoproperlyaddcomplementaryfoodstoherchild'sdiet,thatchildmightbecomemalnourished(Table431(t0010)).
Table431
THREEMYTHSABOUTNUTRITION

Myth1:Malnutritionisprimarilyamatterofinadequatefoodintake.Notso.Foodisofcourseimportant.Butmostseriousmalnutritioniscausedby
badsanitationanddisease,leadingtodiarrhea,especiallyamongyoungchildren.Women'sstatusandwomen'seducationplaybigpartsin
improvingnutrition.Improvingcareofyoungchildrenisvital.
Myth2:Improvednutritionisabyproductofothermeasuresofpovertyreductionandeconomicadvance.Itisnotpossibletojumpstartthe
process.Again,untrue.Improvingnutritionrequiresfocusedactionbyparentsandcommunities,backedbylocalandnationalactioninhealthand
publicservices,especiallywaterandsanitation.Thailandhasshownthatmoderateandseveremalnutritioncanbereducedby75%ormoreina
decadebysuchmeans.
Myth3:Givenscarceresources,broadbasedactiononnutritionishardlyfeasibleonamassscale,especiallyinpoorcountries.Wrongagain.In
spiteofsevereeconomicsetbacks,manydevelopingcountrieshavemadeimpressiveprogress.Morethantwothirdsofthepeopleindeveloping
countriesnoweatiodizedsalt,combatingtheiodinedeficiencyandanemiathataffectabout3.5billionpeople,especiallywomenandchildrenin
some100nations.About450millionchildrenayearnowreceivevitaminAcapsules,tacklingthedeficiencythatcausesblindnessandincreases
childmortality.Newwayshavebeenfoundtopromoteandsupportbreastfeeding,andbreastfeedingratesarebeingmaintainedinmany
countriesandincreasedinsome.Massimmunizationandpromotionoforalrehydrationtoreducedeathsfromdiarrheahavealsodonemuchto
improvenutrition.

FromWorldBank:Repositioningnutritionascentraltodevelopment,2006(PDF).
http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTHEALTHNUTRITIONANDPOPULATION/EXTNUTRITION/0

(http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTHEALTHNUTRITIONANDPOPULATION/EXTNUTRITION/0),,contentMDK:20787550~menuPK:282580~pagePK:640
AccessedMay23,2010.

Undernutritionisnotsimplyaresultoffoodinsecurity,althoughfoodsecurityisoftenanecessarybutinsufficientconditionfornutritionsecurity.
Manychildreninfoodsecureenvironmentsandfrombetterofffamiliesareunderweightorstuntedbecauseofinappropriateinfantfeedingandchild
carepractices,pooraccesstohealthservices,orpoorsanitation.Inmanycountrieswheremalnutritioniswidespread,foodproductionorevenaccess
tofoodmightnotbethemostlimitingfactor.Themostimportantcausesofundernutritionareofteninadequateknowledgeaboutthebenefitsof
exclusivebreastfeedingandcomplementaryfeedingpractices,theroleofmicronutrients,andthelackoftimewomenhaveavailableforappropriate
infantcarepracticesandtheirowncareduringpregnancy.Thesituationisdifferentinfamineandemergencysettings,wherefoodinsecurityisoften
amongthemostimportantfactors.
Economicgrowthandfoodproductionaswellasbirthspacingandwomen'seducationarealsoimportantbutlessdirectroutestoimproving
nutritionoutcomesindevelopingcountries.Shorterroutestonutritionimprovementsoftencomethroughtheprovisionofhealth,sanitation,and
nutritioneducationandcounselingservices,includingthepromotionofexclusivebreastfeedingandappropriateandtimelycomplementaryfeeding,
coupledwithprenatalcareandbasicmaternalandchildhealthservices.Inmanycontexts,micronutrientsupplementationandfortificationarealso
keyelementsofapublichealthstrategyaimedataddressingundernutrition.

FoodInsecurity
Governmentsseektopromotethefoodsecurityoftheirpopulationbothforitsintrinsicvalueandforitsinstrumentalvalueaswell.Theformerrefers
tothefactthatindividualsvaluefoodsecurityinitsownright,whereasthelatteracknowledgesthecontributionthatfoodsecuritymakestoward
improvednutrition.Butwhatisfoodsecurity?Oneprevalentdefinitionoffoodsecurityviewsitasaccessbyallpeopleatalltimestosufficientfoodin
termsofquality,quantity,anddiversityforanactiveandhealthylifewithoutriskoflossofsuchaccess.Toachievefoodsecurity,itisnecessaryto
lookat3dimensionsoffoodsecurity:availability,access,andutilization.Availabilityreferstothesupplyoffood(generallygraininthe
market,reflectingeconomicconditionsofproductionandtrade),whereasaccessisatthehouseholdlevel,reflectingpurchasingpoweraswellas
transferprograms.Accessalsohasanintrahouseholddimension,becausefoodisnotnecessarilysharedequitablywithinahousehold.Theutilization
pillarreflectsthefactthatevenwhenahouseholdhasaccesstofood,itdoesnotnecessarilyachievenutritionalsecurity.

MeasurementofFoodInsecurity
ThemostcommonlyusedmeasurementoffoodinsecurityistheFoodandAgricultureOrganization's(FAO's)measureofundernourishment,
expressedintermsofthenumberofpersonswhoareassumedtobeunabletomeetdailycalorierequirementsnecessaryforlightactivities.Inthe
period20032005,theFAOestimatedthat848millionindividualswerehungryorundernourished,and97%oftheseindividualswereindeveloping
countries,anincreaseof20millionundernourishedindividualsindevelopingcountriescomparedto19951997.
Thisestimateofundernourishedindividualsisbasedoncountrylevelannualfoodbalancesheetsthattakeintoaccountfoodproductionplusnet
importsminusnettrade.Thisgrossavailabilityisalsoadjustedforseedsusedforreplantingaswellasgrainfedtoanimalsandanallowancefor
waste.Theestimatesalsoacknowledgethattheaveragenationalfoodavailabilityisnotuniformlydistributed,andtheythusmakeadjustmentsforan
assumedinequalityofaccessbasedonhistoricalpatterns.
Thisestimateis,therefore,notbasedondirectmeasurementofhouseholdorindividualconsumption.However,ithastheadvantageofbeing
availableonanannualbasisforvirtuallyallcountries.Therefore,itassistsinmonitoringglobaltrends.Reductionsinthenumberofundernourished
individualsascalculatedusingthisindicatoroffoodaccesshavebeenusedasameasureofprogressinreducingpoverty,albeitotherindicators
(percentunderweightorstuntedchildren)arebetterindicatorsfortrackingchangesathouseholdandnationallevels.
Theundernourishmentmeasurebeingbasedonnationalfoodbalancesheetscannotbedisaggregatedbyregionsorbyincomeorotherhousehold
characteristicsandisthereforenotaveryusefulmeasure,especiallyathouseholdorindividuallevels.Thereareoftendifferenceswithestimated
levelsofhungerusingthisindirectapproachandlevelsderivedbasedonsurveysofconsumptionorexpenditurerecordedatthehouseholdlevel.Such
surveysarecommonlyundertakeninmostcountries,oftenwithsamplesthatarerepresentativeatregionalorsubregionallevelsandthatpermit
analysisofcorrelatesoffoodinsecurity.Thesurveysoftenarecollectedoverrounds,andtheythusallowanunderstandingofseasonalfood
insecurity.Consumptionmaybebasedonrecalloronadiaryofexpendituresandhomeconsumption.Thereisnoconsensusontherelative
advantagesofdiaryapproachescomparedwithinterviewsgiventhelevelofeducationinfoodinsecureregionsoftheworld,andthereisnotfull
agreementontheperiodofrecallthatprovidesthegreatestaccuracyofreporting.Nevertheless,withthewidespreadavailabilityandrangeofdata
containedinthesesurveys,theyprovidethebasisforsubstantialanalysisonthedeterminantsofhouseholdfoodinsecurity.
Individualfoodinsecurityisbetterunderstoodusing24hrfoodrecalldata.Suchmethods,preferablyrepeatedoveraperiodofdayswithinaweek,
allowameasureofindividualintakeandofintrahouseholdvariationoffoodconsumption.Althoughthesedataarehardertocollectandless
available,theyareabettersourceofinformationondietdiversitythanhouseholdornationalindicators.Dietdiversityisastrongpredictorofchild
growthandavaluabletoolforunderstandingmicronutrientintakes,adimensionofnutritionalsecuritythatisgenerallynotemphasizedindataon
foodsecuritybasedonfoodbalancesheets.

Undernutrition
Thegreatestriskofundernutritionoccursduringpregnancyandinthefirst2yearsoflife(Fig.431(f0010))theeffectsofthisearlydamageon
health,braindevelopment,intelligence,educability,andproductivityarepotentiallyirreversible(Table432(t0015)).Governmentswithlimited
resourcesarethereforebestadvisedtofocuspubliclyfundedactionsonthiscriticalwindowofopportunity,betweenpreconceptionand24moofage.
Folatedeficiencyalsoincreasestheriskofbirthdefectsthisparticularwindowofopportunityisbeforeconception,asitiswithiodine.Irondeficiency
anemiaisanotherdimensionofundernutritionthathasmeasurablerisksthatextendoutsideoftheearlyyearsoflife,withparticularriskstothe
healthofamotheraswellasforthebirthweightofherchild.Anemiacanalsoreducephysicalandcognitivefunctionandeconomicproductivityof
adultsofbothsexes.

Figure431
Thewindowofopportunityforimprovingnutritionisverysmall:prepregnancyuntil1824moofage.
(FromTheWorldBank'sHumanDevelopmentNetwork:Betternutrition=lesspoverty:repositioningnutritionascentraltodevelopment:astrategyforlargescale
action,2006[PDF].http://siteresources.worldbank.org/NUTRITION/Resources/2818461114108837888/RepositioningNutritionLaunchJan30Final.pdf
(http://siteresources.worldbank.org/NUTRITION/Resources/2818461114108837888/RepositioningNutritionLaunchJan30Final.pdf).AccessedMay23,2010.)
Table432
WHYMALNUTRITIONPERSISTSINMANYFOODSECUREHOUSEHOLDS

Pregnantandnursingwomeneattoofewcaloriesandtoolittleprotein,haveuntreatedinfections,suchassexuallytransmitteddiseasesthatlead
tolowbirthweight,ordonotgetenoughrest.
Mothershavetoolittletimetotakecareoftheiryoungchildrenorthemselvesduringpregnancy.
Mothersofnewbornsdiscardcolostrum,thefirstmilk,whichstrengthensthechild'simmunesystem.
Mothersoftenfeedchildren<6moofagefoodsotherthanbreastmilkeventhoughexclusivebreastfeedingisthebestsourceofnutrientsand
thebestprotectionagainstmanyinfectiousandchronicdiseases.

Caregiversstartintroducingcomplementarysolidfoodstoolate.
Caregiversfeedchildren<2yrofagetoolittlefoodorfoodsthatarenotenergydense.
Thoughfoodisavailable,becauseofinappropriatehouseholdfoodallocation,womenandyoungchildren'sneedsarenotmetandtheirdietsoften
donotcontainenoughoftherightmicronutrientsorprotein.
Caregiversdonotknowhowtofeedchildrenduringandfollowingdiarrheaorfever.
Caregiverspoorhygienecontaminatesfoodwithbacteriaorparasites.

FromWorldBank:Repositioningnutritionascentraltodevelopment,2006(PDF).
http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTHEALTHNUTRITIONANDPOPULATION/EXTNUTRITION/0

(http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTHEALTHNUTRITIONANDPOPULATION/EXTNUTRITION/0),,contentMDK:20787550~menuPK:282580~pagePK:640
AccessedMay23,2010.

MeasurementofUndernutrition
Thetermmalnutritionencompassesbothendsofthenutritionspectrum,fromundernutrition(underweight,stunting,wasting,andmicronutrient
deficiencies)tooverweight.Manypoornutritionaloutcomesbegininuteroandaremanifestaslowbirthweight(LBW).Prematurityandintrauterine
growthrestriction(IUGR)arethetwomaincausesofLBW,withprematurityrelativelymoreimportantindevelopedcountriesandIUGRrelatively
moreimportantindevelopingcountries(Chapter90).
Inpreschoolandschoolagedchildren,nutritionalstatusisoftenassessedintermsofanthropometry.Internationalreferenceshavebeenestablished
thatallownormalizationofanthropometricmeasuresintermsofzscoresdefinedasthechild'sheight(weight)minusthemedianheight(weight)for
theageandsexofthechilddividedbytherelevantstandarddeviation(Table433(t0020)).TheWorldHealthOrganization(WHO)recentlyrevised
thechildgrowthreferencesbasedondatafromhealthychildrenin5countries.Comparisonsofmalnutritionratesacrosscountriesaremeaningful,
andthesegrowthreferencesareapplicabletoallchildrenacrosstheglobe.
Table433
DEFINITIONSOFMALNUTRITION

CLASSIFICATION DEFINITION

GRADING

CRITERIA

Gomez

Mild(grade1)

75%90%WFA

Weightbelow%medianWFA

Moderate(grade2) 60%74%WFA

Waterlow

WHO(wasting)

WHO(stunting)

Kanawati

Cole

zscores(SD)belowmedianWFH

zscores(SD)belowmedianWFH

zscores(SD)belowmedianHFA

Severe(grade3)

<60%WFA

Mild

80%90%WFH

Moderate

70%80%WFH

Severe

<70%WFH

Moderate

3zscore<2

Severe

zscore<3

Moderate

3zscore<2

Severe

zscore<3

MUACdividedbyoccipitofrontalheadcircumference Mild

zscoresofBMIforage

<0.31

Moderate

<0.28

Severe

<0.25

Grade1

zscore<1

Grade2

zscore<2

Grade3

zscore<3

FromGroverZ,EeLC:Proteinenergymalnutrition,PediatrClinNAm56:10551068,2009.

BMI,bodymassindexHFA,heightforageMUAC,midupperarmcircumferenceNCHS,U.S.NationalCenterforHealthStatisticsSD,standard
deviationWFA,weightforageWFH,weightforheightWHO,WorldHealthOrganization.
Heightforageisusefulforassessingthenutritionalstatusofpopulations,becausethismeasureofskeletalgrowthreflectsthecumulativeimpactof
eventsaffectingnutritionalstatusthatresultinstuntingandisalsoreferredtoaschronicmalnutrition.Thismeasurecontrastswithweightfor
height,orwasting,whichisameasureofacutemalnutrition.Weightforageisanadditionalcommonlyusedmeasurementofnutritional
status.Althoughithaslessclinicalsignificancebecauseitcombinesstaturewithcurrenthealthconditions,ithastheadvantageofbeingsomewhat
easiertomeasure:Currentweighingscalesallowachildtobeweighedinacaregiver'sarms,butweightforheightrequires2differentinstrumentsfor

measurement.Heightforageisparticularlydifficulttomeasureforthemostvulnerablechildren<2yrofageforwhomrecumbentlengthisthe
preferredindicatorforheight.Inemergenciesandinsomefieldsettings,midupperarmcircumference(MUAC)isoftenusedforscreeningin
lieuofweightforheight(seeTable433(t0020)).
ObesityaswellasenergydeficiencyamongadultsisoftenreportedintermsoftheBodyMassIndex(BMI).BMIiscalculatedbydividingweightin
kilogramsbythesquareofheightinmeters.IndividualsareconsideredtobechronicallyenergydeficientiftheyhaveaBMIbelow18.5,overweightif
theyhaveaBMIgreaterthan25,andobeseiftheyhaveaBMIgreaterthan30.
Anotherdimensionofmalnutritionismicronutrientdeficiencies.Themicronutrientsofparticularpublichealthsignificanceareiodine,vitaminA,
iron,folicacid,andzinc.Iodinedeficiencyanditssequelae(goiter,hypothyroidism,anddevelopmentaldisabilitiesincludingseveremental
retardation)areassessedbyclinicalinspectionofenlargedthyroids(goiter)orbyiodineconcentrationsinurine(g/L).Evenmildformsofiodine
deficiencyduringpregnancyhavebeenimplicatedinpoormentalandphysicaldevelopmentamongchildrenaswellasfetallosses.Thepublichealth
benchmarkforeliminatingiodinedeficiencyinapopulationis<20%ofthepopulationwithurinaryiodinelevels<50g/L(Chapter51).
VitaminAdeficiencyiscausedbylowintakeofretinoloritsprecursor,betacarotene.Absorptioncanbeinhibitedbyalackoffatsinthedietorby
parasiteinfestations.ClinicaldeficiencyisestimatedbycombiningnightblindnessandeyechangesprincipallyBitotspotsandtotalxerophthalmia
prevalence.Subclinicaldeficiencyisassessedasprevalenceofserumretinalconcentrations<0.70mol/L(Chapter45).Thegreatestpublichealth
significanceofvitaminAdeficiencyisitsassociationwithahighermortalityamongyoungchildren.ProphylacticsupplementationofvitaminA
amongdeficientpopulationsforchildren<5yrofagecanreducechildmortalitybyasmuchas23%.
Childrencommonlysufferfromanemia,eitherasaresultoflowironintakesorpoorabsorptionorasaresultofillnessorparasiteinfestation,
althoughsevereproteinenergymalnutritionandvitaminB12orfolatedeficiencycanalsoleadtoanemia.Womenalsohaverelativelyhighratesof
anemiaasaresultoflowironintakes,poorabsorption,illness,orexcessivelossesofblood.SevereproteinenergymalnutritionandvitaminB12or
folatedeficiencycanalsoleadtoanemia.Anemiaismostcommonlymeasuredasgramsofhemoglobinperliterofblood.Cutoffstodefineanemiaare
11g/dLforchildren659mo,11.5g/dLforchildren511yr,and12g/dLforchildren1214yr.Cutoffstodefineanemiaare12g/dLfornonpregnant
women,11g/dLforpregnantwomen,and13g/dLformen.
Zincsupplementationcanreducechildmortality,especiallywhencombinedwithoralrehydrationtherapyfordiarrhealdisease.Plasma
concentrationsrespondinadosedependentmannertodietarychanges,andurinaryexcretioncorrelateswithzincstatusoverall,butthereisnotyeta
biomarkerstandardthatiswidelyusedasacutofftodefineapublichealthconcern.

PrevalenceofUndernutrition
Maternalandchildundernutritionisprevalentinmanydevelopingcountriesandinsomemiddleincomecountries.Itisestimatedthatabout16%of
childrenacrossdevelopingcountriesarebornwithlowbirthweight(LBW).LBWratesarehighestinthesouthcentralAsiaregion(27%)andlowestin
SouthAmerica.In2005,20%ofchildren<5yearsofageinlowandmiddleincomecountrieswereunderweight(weightforage<2standard
deviations[SD]),and32%werestunted(heightforage<2SD).Somewhatsurprisingly,underweightratesinmanysouthAsiancountries(India,
Bangladesh,Nepal,andPakistan)aremuchhigherthan,andoftennearlydouble,theratesinmanysubSaharanAfricancountries.Thecombination
ofthehighprevalenceratesandthelargepopulationsizesinAsiameanthatthisregioncarriesthehighestburdenofunderweightchildren.Even
thoughunderweightandstuntingaremoreprevalentamongthepoor,theprevalenceratesamongthehighestincomequintilesarealsohigh,thereby
reiteratingthefactthatundernutritionisnotjustaresultoffoodinsecurity.
About42%ofpregnantwomenand47%ofchildren<5yrofageindevelopingcountriesareanemic.Zincdeficiencyishardertomeasureandis
assessedonthebasisofindirectindicatorssuchasstuntingitisestimatedtobehighinsouthAsia,subSaharanAfrica,andsomecountriesin
CentralandSouthAmerica.VitaminAdeficiencyrateshaveimprovedsignificantlyinmostdevelopingcountries,primarilyowingtohighcoverage
withhighdosevitaminAsupplementsgiventwiceayeartoeverychild<5yrofageaspartofpublichealthprograms.Nevertheless,100140million
peopleareconsidereddeficientinvitaminA,withdeficientpopulationsfoundinBrazilandAndeanSouthAmericaaswellasmuchofsubSaharan
AfricaandSouthAsia.Largescaleavailabilityofiodizedsalthasreducedtheratesofiodinedeficiencynonetheless,approximately1billionpeopledo
nothaveregularaccesstoiodizedsalt,includinginlargeareasofAfricaandtheformerSovietUnion.

ConsequencesofUndernutrition
Themostimmediateconsequenceofundernutritionisprematuredeath.Theglobalestimatesconcludethatstunting,severewasting,andIUGR
jointlycontributesto2.2milliondeathsofchildren<5yrofage.Thisaccountsfor35%ofallchildmortalityglobally,eventhoughthisestimateis
lowerthanthosepreviouslyreported.Theearlierandwidelycitedestimatehadsuggestedthatundernutritionwasassociatedwithnearly53%ofall
childdeaths.Theriskofdeathincreasesevenwithmildundernutrition,andastheseverityofundernutritionincreases,theriskincreases
exponentiallytheprobabilityofmortalityforachild<5yrofagewithazscoreofweightforagebelow3isnearly4timestheelevatedriskfora
childwithazscorebetween3and2.Becausetherearemorechildrenwithlessseveremalnutrition,itisthiscategorythatcontributesthegreater
shareoftheglobalburdenofmalnutrition.Aftercontrollingfortheoccurrenceofmultiplenutritionaldeficits,deficienciesofvitaminAandzincare
estimatedtoberesponsibleforanadditional0.6millionand0.4millionchilddeaths,respectively.Morethan3.5millionmothersandchildrenunder
5yearsdieeveryyearduetoundernutritionrelatedcauses,andmanymillionsmorearedisabledorstuntedforlife.Bythetimechildrenreachtheir
firstbirthday,ifundernourished,theycouldsufferirreversiblephysicalandcognitivedamage,therebyimpactingtheirfuturehealth,welfare,and
economicwellbeing.Theseconsequencescontinueintoadulthood,andthecycleofundernutritionispassedontothenextgenerationwhen
undernourishedwomengivebirthtolowbirthweightbabies.
Hungerandundernutritionhavesubstantialconsequencesforsurvivorsandtheirfamiliesbyrequiringthemtospendadditionalresourcesonhealth
careandbyaffectingtheproductivityofmalnourishedpersons.Thereissubstantialevidencethatearlychildmalnutritionisdetrimentalto
productivityinadulthood.Theconsequencesofmalnutritioncanbeidentifiedandquantifiedin5categories:excesscostsofhealthcare,either
neonatalcareforLBWbabiesorexcesscostsofinfantandchildillnessformalnourishedchildrenproductivitylossesassociatedwithstunting
productivitylossesfromreducedcognitiveabilityandachievementincreasedcostsofchronicdiseasesassociatedwithfetalandearlychild
malnutritionandconsequencesofimpairedmaternalnutritiononfuturegenerations.

Thereisa2waycausalityfrommalnutritiontoinfectionsandviceversa.Deficienciesofbothmacroandmicronutrientsimpairtheimmunesystem,
withwelldocumentedconsequences.Conversely,helminthicandotherinfectionsleadtoreducednutrientabsorption,andfeversleadtocatabolism
andanorexiaandthuscontributetomalnutrition.Additionally,caregiversmightrespondtoepisodesofdiarrheabywithholdingfood.
Inmanylowincomesettings,theconsequenceofmalnutritionleadstoreducedlifetimeearnings.Theseeffectscancomeaboutthroughimpaired
cognitivedevelopment,lateschoolentranceleadingtodelayedentryintothelaborforce,fewercompletedyearsofschooling,lesslearningperyearof
schooling,oracombinationofthese.
Theevidencebasefortheimpactofnutritiononearningsissubstantialandgrowing.Whileseparatingthefactorsthatleadtoundernutritionfromthe
constraintsofpovertythatwillindependentlyaffectcognitiveabilityandlimitschoolingregardlessofnutritionalstatuscanbeproblematic,studies
confirmthattheimpactofimprovednutritionisdistinctfromthecontributionofpovertyreduction.Onestudyassessedtheearningsofadultsin
Guatemalaupto42yearsofagewhoreceivednutritionalsupplementsaschildrenorwhosemothersreceivedthemduringtheirpregnancy.Themen
whoreceivednutritionalsupplementsbeforereachingage3earnedwagesthatwere46%higherthanthewagesearnedbymenwhowerenot
supplemented.EvidencefromAfricaconfirmsthatchildrenwhoareunder2yearsoldwhenadroughthitstheircommunityinAfricaarelikelytobe
shorterandtocompletefeweryearsofschoolthantheirsiblingsorincontrasttochildrenindifferentagecohortsinthevillage.Elsewhere,spikesin
thepriceoffoodduringthesecriticalyearsleadbothtostuntingandtodiminishedschooling.
Inadditiontotheassociationofstuntingandcognitiveimpairment,somemicronutrientdeficienciesleadtolossofcognitivepotential.Individuals
withaniodinedeficiencyhave,onaverage,13.5pointslowerIQsthancomparisongroups.Interventionshaveshownthatprovisionofiodineto
pregnantwomencanreducethisgap.Inthecaseofirondeficiencies,anemiaisregularlyassociatedwithimpairedcognitivedevelopment.Moreover,
supplementationtrialsforschoolagechildrenconfirmthisconclusionbecausetheyregularlyindicateimprovedcognition,althoughthisisless
regularlyobservedwithinterventionsaimedatdeficientyoungerchildren.
Trackingtheconsequencesoffetalorchildhooddeprivationforadultchronicillnessimposesadditionalchallengesgiventhelonglatency.The
hypothesisthatearlynutritionalchallengesarepartoftheetiologyofdiabetesandcardiovasculardiseasehasfirstproposedonthebasisof
epidemiologicalevidence,includingtrackingcohortsthatsufferedfromfaminesinHollandandChina.Thishypothesishasbeenbolsteredbystudies
withanimalmodelsthathelpdefineamechanismofembryonicdevelopmentthatprovidesaconceptualbasisfortheepidemiologicalevidence.The
increasedriskofadultchronicdiseasefromthismalnutritioninearlylifeisestimatedtobeaparticularchallengetolowincomecountrieswithrapid
economicgrowthsuchasChinaandIndia,leadingtoprematuredeathaswellassubstantialeconomiccostsfrommedicalexpensesandlost
productivity.
Quantifyingthemagnitudeofsuchlossesofpotentialformalnourishedchildrenwhosurviveis,ofcourse,contextspecific,butvariousstudieshave
shownthatinvestmentsinnutritionthatis,preventingtheselossescanyieldconsiderableeconomicreturns.Thesepreventiveinvestmentscovera
broadrange,includingnutritionaswellasadiversesetofinterventionsineducation,waterandsanitation,tradereform,andprivatesector
deregulation.Addressingmicronutrientdeficiencieshasthehighestrateofeconomicreturn.Forexample,every$1ofexpendituresonvitaminA
supplementationislikelytoproduce$100ofbenefits.Tobefair,suchestimatesarebasedonavarietyofassumptions,suchasthevalueoffuture
benefitscomparedtocurrentbenefitseconomistsgenerallyviewadollartodayasworthmorethanadollarsometimeinthefuture.

Nutrition,FoodSecurity,andPoverty
Householdfoodsecuritytracksincomeclosely.Thisisnotthecaseformalnutrition,whichisoftenobservedevenwithinbetteroffhouseholdsinAsia
andAfrica.Datafromhouseholdsurveysaswellasfromcrosscountrycomparisonsconfirmthatincomegrowth,evenwhenevenlydistributedovera
population,hasamodestimpactonmalnutritionrates,eventhoughthisimpactisstatisticallysignificantandpositive.Onaglobalaverage,a10%
increaseofnationalincomepercapitawouldleadtoa10%declineinthepovertyrateinthecountrybutonlya5%declineintherateofmalnutrition
asmeasuredbylowweightsforage.Globalevidenceindicatesthatsucharateofincomegrowthwouldleadtoonlya2.5%declineinanemia.
Theinternationaldevelopmentcommunityhascollectivelyagreedupon8MillenniumDevelopmentGoals(MDGs).Thefirstofthese8goalsrefersto
povertyandhunger.TherecognitionofthecloserelationoffoodinsecurityandpovertyisevidentinthedefinitionofthisfirstMDG,whichaimsto
eradicateextremepovertyandhunger.Thetwotargetsoriginallyproposed(athirdonemploymentwasaddedlater)aretohalve,between1990and
2015:
Theproportionofpeoplewhoseincomeislessthan$1aday
Theproportionofpeoplewhosufferfromhunger
Twomeasureableindicatorsofprogressareusedforthesecondtarget,thepercentageofindividualswhocannotmeettheircalorierequirementsas
measuredbytheestimateofundernourishmentandbythepercentageofchildrenunder5whoareunderweightasmeasuredinnationally
representativehouseholdsurveys.
Whilepriortotheglobalfinancialcrisis,theprognosisingeneralhadbeenthatmostcountrieswereontrackforachievingthepovertygoal.Butof143
countries,only34(24%)wereontracktoachievethenutritionMDGgoal.NocountryinSouthAsia,whereundernutritionratesarethehighest,is
likelytoachievethisMDGalthoughBangladeshwasmostlikelytocomeclosetoachievingit,andAsiaasawholewaslikelytoachieveitbecauseof
theimprovementsinChina.Nutritionstatuswasactuallydeterioratingin26countries,manyoftheminAfrica,wherethenexusbetweenHIVand
undernutritionisparticularlystrongandmutuallyreinforcing.Andin57countries,notrenddatawereavailabletotellwhetherprogressisbeing
made.Arenewedfocusonthisnonincomepovertytargetisclearlycentraltoanypovertyreductionefforts.

KeyInterventions
Thereissubstantialconsensusregardingwhichinterventionsworktoaddresschildundernutritionbasedonaccumulatedfieldevidence(Fig.432
(f0015)).Manyoftheseinterventionsliewithintheresponsibilityofthehealthsector,albeitinvestmentsinothersectorsmaybenecessarytosustain

thebenefitsfromthehealthsectorinterventions.Keyinterventionsthathavebeenprovedtobecosteffectiveinreducinginfantandchildmortality,
improvingunderweightrates,andreversingmicronutrientdeficienciesinclude:

Figure432
Keyinterventions.SAM,severeacutemalnutrition.
(FromWorldHealthOrganizationandLancetGlobalNutritionSeries.www.who.int/nutrition/topics/lancetseries_maternal_and_childundernutrition/en/index.htm
(http://www.who.int/nutrition/topics/lancetseries_maternal_and_childundernutrition/en/index.htm).)

Promotingexclusivebreastfeeding
Promotingadequateandtimelycomplementaryfeeding(at~6moofage)
Promotingkeyhygienebehavior(e.g.,handwashingwithsoap)
ProvidingmicronutrientinterventionssuchasvitaminAandironsupplementsforpregnantandlactatingwomenandyoungchildren
Presumptivetreatmentformalariaforpregnantwomeninendemicmalarialregionsandpromotinglonglastinginsecticidetreatedbednets
Deworminginendemicparasiticareasandoralrehydrationinhighdiarrhearegions
Fortifyingcommonlyeatenfoodswithmicronutrients(suchassaltfortifiedwithiodine)andstaplefoodslikewheat,oil,andsugarwithiron,
vitaminA,andzinc
Birthspacingandfamilyplanninginterventions,aswellasstrategiestoaddresswomen'sempowermentandgender,alsohavestrongimpactson
nutritionandchildhealthoutcomes.Additionally,communitygrowthpromotionprogramscanprovideanopportunitytoimpartknowledgeona
facetofacebasishencethestressoncommunitymobilizationinmanyprograms.Manygrowthpromotionprogramsalsofacilitatetheprovisionof
immunizations,vitaminsupplements,anddewormingmedicineaswellasbeingaplatformtopromotebehavioralchange.
TheemergenceofHIV/AIDSasapublichealthconcernhasintroducednewissuesforpublichealthnutrition.Oneissueistheincreasedrequirements
forbothmacroandmicronutrientsofindividualswithHIV/AIDS,especiallythosewhoareabletoaccessantiretroviraltreatment(ART).In
addition,thereisaparticularconcernforthepreventionofmaternalchildtransmissionfromHIVpositivemothers.In2007,anestimated1.5million
pregnantwomeninlowandmiddleincomecountrieswerelivingwithHIV.Seventyfivepercentofthesewereconcentratedin12countries,which
includeSouthAfrica,Nigeria,UnitedRepublicofTanzania,andMozambique.
EvenifthemotherisabletoreceivenevirapineorotherARTduringpregnancyanddelivery,shefacesadilemmaregardingbreastfeeding.Theoverall
riskofmothertochildHIVtransmissionbyanonbreastfeedingmotheris1525%(withoutinterventionstoreducetransmission)andofa
breastfeedingmotheris2045%.However,theriskislesswhenthemotherisexclusivelybreastfeedingandincreaseswithdurationthemajorityof
thetransmissionafterdeliveryoccursafter6monthsofbreastfeeding.Breastmilksubstitutesarecostlyandriskyinlowincomesettingsanoutbreak
ofdiarrhealdiseaselinkedtoformulafeedinginBotswanawheresubstitutesareprovidedfreebythegovernmentprovedfataltomorethan30
childrenin2007.Thus,inmostlowincomesettings,HIVpositivemothersareadvisedtocontinuewithexclusivebreastfeedingfor6monthsandto
weanmoreabruptlythanisotherwiserecommended.

ClinicalManifestationsandTreatmentofUndernutrition
TreatmentofvitaminandmineraldeficienciesisdiscussedinChapter45,Chapter46,Chapter47,Chapter48,Chapter49,Chapter50,Chapter51.

SevereAcuteMalnutrition(ProteinEnergyMalnutrition)
Deficiencyofasinglenutrientisanexampleofundernutritionormalnutrition,butdeficiencyofasinglenutrientusuallyisaccompaniedbya
deficiencyofseveralothernutrients.Proteinenergymalnutrition(PEM)ismanifestedprimarilybyinadequatedietaryintakesofproteinandenergy,
eitherbecausethedietaryintakesofthese2nutrientsarelessthanrequiredfornormalgrowthorbecausetheneedsforgrowtharegreaterthancan
besuppliedbywhatotherwisewouldbeadequateintakes.PEMisalmostalwaysaccompaniedbydeficienciesofothernutrients.
Historically,themostsevereformsofmalnutrition,marasmus(nonedematousmalnutritionwithseverewasting)andkwashiorkor(edematous
malnutrition),wereconsidereddistinctdisorders.Nonedematousmalnutritionwasbelievedtoresultprimarilyfrominadequateenergyintakeor
inadequateintakesofbothenergyandprotein,whereasedematousmalnutritionwasbelievedtoresultprimarilyfrominadequateproteinintake.A

thirddisorder,marasmickwashiorkor,hasfeaturesofbothdisorders(wastingandedema).The3conditionshavedistinctclinicalandmetabolic
features,buttheyalsohaveanumberofoverlappingfeatures.Alowplasmaalbuminconcentration,oftenbelievedtobeamanifestationofedematous
malnutrition,iscommoninchildrenwithbothedematousandnonedematousmalnutrition.
IntheUSA,severemalnutritionhasbeenreportedinfamilieswhouseunusualandinadequatefoodstofeedinfantswhomtheparentsbelievetobeat
riskformilkallergiesandalsoinfamilieswhobelieveinfaddiets.Manycasesareassociatedwithricemilkdiets,aproductthatisverylowinprotein
content.Inaddition,proteincaloriemalnutritionhasbeennotedinchronicallyillpatientsinneonatalorpediatricintensivecareunitsaswellas
amongpatientswithburns,HIV,cysticfibrosis,failuretothrive,chronicdiarrheasyndromes,malignancies,bonemarrowtransplantation,and
inbornerrorsofmetabolism.

ClinicalManifestationsofSevereProteinCalorieMalnutrition
Nonedematousmalnutrition(marasmus)ischaracterizedbyfailuretogainweightandirritability,followedbyweightlossandlistlessness
untilemaciationresults.Theskinlosesturgorandbecomeswrinkledandlooseassubcutaneousfatdisappears.Lossoffatfromthesuckingpadsof
thecheeksoftenoccurslateinthecourseofthediseasethus,theinfant'sfacemayretainarelativelynormalappearancecomparedwiththerestof
thebody,butthis,too,eventuallybecomesshrunkenandwizened.Infantsareoftenconstipated,buttheycanhavestarvationdiarrhea,withfrequent
smallstoolscontainingmucus.Theabdomenmaybedistendedorflat,withtheintestinalpatternreadilyvisible.Thereismuscleatrophyand
resultanthypotonia.Astheconditionprogresses,thetemperatureusuallybecomessubnormalandthepulseslows(Table434(t0025)).
Table434
CLINICALSIGNSOFMALNUTRITION

SITE

SIGNS

Face

Moonface(kwashiorkor),simianfacies(marasmus)

Eye

Dryeyes,paleconjunctiva,Bitotspots(vitaminA),periorbitaledema

Mouth

Angularstomatitis,cheilitis,glossitis,spongybleedinggums(vitaminC),parotidenlargement

Teeth

Enamelmottling,delayederuption

Hair

Dull,sparse,brittlehair,hypopigmentation,flagsign(alternatingbandsoflightandnormalcolor),broomstickeyelashes,alopecia

Skin

Looseandwrinkled(marasmus),shinyandedematous(kwashiorkor),dry,follicularhyperkeratosis,patchyhyperand
hypopigmentation(crazypavingorflakypaintdermatoses),erosions,poorwoundhealing

Nails

Koilonychia,thinandsoftnailplates,fissuresorridges

Musculature

Musclewasting,particularlybuttocksandthighsChvostekorTrousseausigns(hypocalcemia)

Skeletal

Deformities,usuallyasaresultofcalcium,vitaminD,orvitaminCdeficiencies

Abdomen

Distended:hepatomegalywithfattyliverascitesmaybepresent

Cardiovascular Bradycardia,hypotension,reducedcardiacoutput,smallvesselvasculopathy
Neurologic

Globaldevelopmentaldelay,lossofkneeandanklereflexes,impairedmemory

Hematologic

Pallor,petechiae,bleedingdiathesis

Behavior

Lethargic,apathetic,irritableonhandling

FromGroverZ,EeLC:Proteinenergymalnutrition,PediatrClinNAm56:10551068,2009.

Edematousmalnutrition(kwashiorkor)canoccurinitiallyasvaguemanifestationsthatincludelethargy,apathy,and/orirritability.When
kwashiorkorisadvanced,thereislackofgrowth,lackofstamina,lossofmuscletissue,increasedsusceptibilitytoinfections,vomiting,diarrhea,
anorexia,flabbysubcutaneoustissues,andedema.Theedemausuallydevelopsearlyandcanmaskthefailuretogainweight.Itisoftenpresentin
internalorgansbeforeitisrecognizedinthefaceandlimbs.Liverenlargementcanoccurearlyorlateinthecourseofdisease.Dermatitisiscommon,
withdarkeningoftheskininirritatedareas,butincontrasttopellagra(Chapter46)notinareasexposedtosunlight.Depigmentationcanoccurafter
desquamationintheseareas,oritmaybegeneralized(Figs.433,434,435).Thehairissparseandthin,andindarkhairedchildren,itcanbecome
streakyredorgray.Eventually,thereisstupor,coma,anddeath(seeTable434(t0025)).

Figure433
A,Kwashiorkorina2yroldboy.Notethegeneralizededema,thetypicalskinlesions,andthestateofprostration.B,Closeupviewofthesamechildshowingthehair
changesandpsychicalterations(apathyandmisery)theedemaofthefaceandskinlesionscanbeseenmoreclearly.
(PhotographsmadeavailablebytheInstituteofNutritionofCentralPanama,Guatemala,courtesyofMoisesBehar,MD.)

Figure434
AandB,A7mooldboywithdiffuseerythematouspapulesandplaques,somescaly,andedemaoftheextremities.
(FromKatzKA,MahlbergMH,HonigPJ,etal:Ricenightmare:kwashiorkorin2PhiladelphiaareainfantsfedRiceDreambeverage,JAmAcadDermatol52[5Suppl
1]:S69S72,2005.)

Figure435
A14mooldgirlwithaflakypaintdermatitis.
(FromKatzKA,MahlbergMH,HonigPJ,etal:Ricenightmare:kwashiorkorin2PhiladelphiaareainfantsfedRiceDreambeverage,JAmAcadDermatol52[5Suppl
1]:S69S72,2005.)

Nomaisachronicnecrotizingulcerationofthegingivaandthecheek(Fig.436(f0035)).Itisassociatedwithmalnutritionandisoftenprecededbya
debilitatingillness(measles,malaria,tuberculosis,diarrhea,ulcerativegingivitis)inanutritionallycompromisedhost.Nomamanifestswithfever,
malodorousbreath,anemia,leukocytosis,andsignsofmalnutrition.Untreated,itproducesseverdisfiguration.Polymicrobialinfectionwith
FusobacteriumnecrophorumandPrevotellaintermediamaybeincitingagents.

Figure436
Nomalesion.
(FromBarattiMayerD,PittetB,MontandonD,etalfortheGenevaStudyGrouponNoma[GESNOMA]:Noma:aninfectiousdiseaseofunknownaetiology,Lancet
InfectDis3:419431,2003.)

Treatmentofnomaincludeslocalwoundcare,penicillin,andmetronidazoleaswellastherapyfortheunderlyingpredisposingcondition.

PathophysiologyofSevereProteinCalorieMalnutrition
Whyedematousmalnutritiondevelopsinsomechildrenandnonedematousmalnutritiondevelopsinothersisunknown.Onefactormaybethe
variabilityamonginfantsinnutrientrequirementsandinbodycompositionatthetimethedietarydeficitisincurred.Italsohasbeenproposedthat
givingexcesscarbohydratetoachildwithnonedematousmalnutritionreversestheadaptiveresponsestolowproteinintake,resultinginmobilization
ofbodyproteinstores.Eventually,albuminsynthesisdecreases,resultinginhypoalbuminemiawithedema.Fattyliveralsodevelopssecondary,
perhaps,tolipogenesisfromtheexcesscarbohydrateintakeandreducedapolipoproteinsynthesis.Othercausesofedematousmalnutritionare

aflatoxinpoisoningaswellasdiarrhea,impairedrenalfunctionanddecreasedNa+/K+ATPaseactivity.Freeradicaldamagehasbeenproposedas
animportantfactorinthedevelopmentofedematousmalnutrition.Thisproposalissupportedbylowplasmaconcentrationsofmethionine,adietary
precursorofcysteine,whichisneededforsynthesisofthemajorantioxidantfactor,glutathione.Thispossibilityalsoissupportedbylowerratesof
glutathionesynthesisinchildrenwithedematouscomparedwithnonedematousmalnutrition.

Treatment
Theusualapproachtothetreatmentofsevereacutemalnutritionincludes3phases(Table435(t0030)andFig.437(f0045)).Theinitialphase(17
days)isastabilizationphase.Duringthisphase,dehydration,ifpresent,iscorrectedandantibiotictherapyisinitiatedtocontrolbacterialorparasitic
infection.Becauseofthedifficultyofestimatinghydration,oralrehydrationtherapyispreferred(Chapter55,Chapter332).Ifintravenoustherapy
isnecessary,estimatesofdehydrationshouldbereconsideredfrequently,particularlyduringthefirst24hroftherapy.Oralfeedingsarealsostarted
withspecializedhighcalorieformula(seeFig.437(f0045)andTable436(t0035)),proposedbytheWorldHealthOrganization,thatcanbemadewith
simpleingredients.TheinitialphaseoforaltreatmentiswiththeF75diet(75kcalor315kJ/100mL).TherehabilitationdietiswiththeF100diet
(100kcalor420kJ/100mL).Feedingsareinitiatedwithhigherfrequencyandsmallervolumesovertime,thefrequencyisreducedfrom12to8to6
feedingsper24hr.Theinitialcaloricintakeisestimatedat80100kcal/kg/day.Indevelopedcountries,2427calorie/ozinfantformulasmaybe
initiatedwiththesamedailycaloricgoals.Ifdiarrheastartsorfailstoresolveandlactoseintoleranceissuspected,anonlactosecontainingformula
shouldbesubstituted.Ifmilkproteinintoleranceissuspected,asoyproteinhydrolysateformulamaybeused.

Figure437
Classificationofsevereacutemalnutritionusedincommunitybasedtherapeuticcare.ICMI,integratedmanagementofchildhoodillnessMUAC,midupperarm
circumferenceWHO,WordHealthOrganization.*Grade1,mildedemaonbothfeetoranklesgrade2,moderateedemaonbothfeet,pluslowerlegs,hands,orlower
armsgrade3,severegeneralizededemaaffectingbothfeet,legs,hands,arms,andface.IMCIcriteria39:60respirations/minchildrenage<2mo50
respirations/minforage212mo40respirations/minforages15yr30respirationsforage>5yr.
(FromCollinsS,DentN,BinnsP,etal:Managementofsevereacutemalnutritioninchildren,Lancet368:19922000,2006.)
Table435
TIMEFRAMEFORTHEMANAGEMENTOFACHILDWITHSEVEREMALNUTRITION[objectObject]

FromWorldHealthOrganization:Managementofseveremalnutrition:amanualforphysiciansandotherseniorhealthcareworkers,Geneva,1999,WorldHealth
Organization.

*Malnutritionandmalnourishedareusedassynonymsforundernutritionandundernourished,respectively.
Table436
PREPARATIONOFF75ANDF100DIETS

INGREDIENT

AMOUNT
F75*(hl0000369) F100(hl0000372)

Driedskimmilk

25g

80g

Sugar

70g

50g

Cerealflour

35g

Vegetableoil

27g

60g

Mineralmix(hl0000376) 20mL

20mL

Vitaminmix(hl0000376) 140mg

140mg

Watertomake

1,000mL

1,000mL

FromWorldHealthOrganization:Managementofseveremalnutrition:amanualforphysiciansandotherseniorhealthcareworkers,Geneva,1999,WorldHealth
Organization.

*TopreparetheF75diet,addthedriedskimmilk,sugar,cerealflour,andoiltosomewaterandmix.Boilfor57min.Allowtocool,thenaddthe
mineralmixandvitaminmix,andmixagain.Makeupthevolumeto1,000mLwithwater.
TopreparetheF100diet,addthedriedskimmilk,sugar,andoiltosomewarmboiledwaterandmix.Addthemineralmixandvitaminmix,and
mixagain.Makeupthevolumeto1,000mLwithwater.
Ifonlysmallamountsoffeedarebeingprepared,itisnotfeasibletopreparethevitaminmixbecauseofthesmallamountsinvolved.Inthiscase,
giveaproprietarymultivitaminsupplement.Alternatively,acombinedmineralandvitaminmixformalnourishedchildrenisavailablecommercially
andmaybeusedinthesediets.Acomparableformulacanbemadefrom35gwholedriedmilk,70gsugar,35gcerealflour,17goil,20mLmineral
mix,140mgvitaminmix,andwatertomake1,000mL.Alternatively,use300mLfreshcow'smilk,70gsugar,35gcerealflour,17goil,20mL
mineralmix,140mgvitaminmix,andwatertomake1,000mL.IsotonicversionsofF75(280mOsmol/L),whichcontainmaltodextrinsinsteadof
cerealflourandsomeofthesugarandwhichincludeallthenecessarymicronutrients,areavailablecommercially.Ifcerealflourisnotavailableor
therearenocookingfacilities,acomparableformulacanbemadefrom25gdriedskimmilk,100gsugar,27goil,20mLmineralmix,140mg
vitaminmix,andwatertomake1,000mL.However,thisformulahasahighosmolarity(415mOsmol/L)andmightnotbewelltoleratedbyall
children,especiallythosewithdiarrhea.Acomparableformulacanbemadefrom110gwholedriedmilk,50gsugar,30goil,20mLmineralmix,
140mgvitaminmix,andwatertomake1,000mL.Alternatively,use880mLfreshcow'smilk,75gsugar,20goil,20mLmineralmix,140mg
vitaminmix,andwatertomake1,000mL.
Anotherapproachistheuseofreadytousetherapeuticfoods(RUTFs)(Fig.438(f0050)).RUTFsreducemortalityinacosteffectivemanner,in
partbecausetheyarelesssusceptibletospoilagethanpowderedmilkbasedsupplementaryfoods.F100iswaterbasedandsubjecttobacterial
contamination,whereasRUTFisanoilbasedpastethathaslittlewatercontentandasimilarnutrientprofilebutahighercaloriedensityandis
equallypalatabletoF100.RUTFisamixtureofpowderedmilk,peanuts,sugar,vitamins,andminerals.

Figure438
Severeacutemalnutrition(SAM)management.RUTF,readytousetherapeuticfoods.
(FromWorldHealthOrganizationandtheUnitedNationsChildren'sFund:WHOchildgrowthstandardsandtheidentificationofsevereacutemalnutritionininfantsand
children,2009(PDF).www.who.int/nutrition/publications/severemalnutrition/9789241598163/en/index.html
(http://www.who.int/nutrition/publications/severemalnutrition/9789241598163/en/index.html).AccessedMay23,2010.)

OneadvantageofRUTFsisthatinmanycasesitcanbeusedincommunitysettingsratherthaninrehabilitationcenterswherethereisahighriskof
infection.Indeed,itmaybehardtoseparateouttheintrinsicadvantageoftheRUTFproductsfromtheadvantagesofthecommunitybased
managementofcare.
Laboratoryevaluation(Table437(t0040))andongoingmonitoring(Table438(t0045)),whenavailable,helpguidetherapyandprevent
complications.Fluidstatusmustbemonitoredverycarefullyinanemicpatients,whomightrequireapackedredbloodcelltransfusion.
Table437
LABORATORYFEATURESOFSEVEREMALNUTRITION

BLOODORPLASMAVARIABLES

INFORMATIONDERIVED

Hemoglobin,hematocrit,erythrocytecount,mean

Degreeofdehydrationandanemiatypeofanemia(iron/folateandvitaminB12

corpuscularvolume

deficiency,hemolysis,malaria)

Glucose

Hypoglycemia

Electrolytesandalkalinity
Sodium

Hyponatremia,typeofdehydration

Potassium

Hypokalemia

Chloride,pH,bicarbonate

Metabolicalkalosisoracidosis

Totalprotein,transferrin,(pre)albumin

Degreeofproteindeficiency

Creatinine

Renalfunction

Creatinine

Renalfunction

Creactiveprotein,lymphocytecount,serology,thickand

Presenceofbacterialorviralinfectionormalaria

thinbloodfilms
Stoolexamination

Presenceofparasites

FromMllerO,KrawinkelM:Malnutritionandhealthindevelopingcountries,CMAJ173(3):279286,2006.2005CanadianMedicalAssociation.Reprintedwith
permissionofthepublisher.
Table438
ELEMENTSINTHEMANAGEMENTOFSEVEREPROTEINENERGYMALNUTRITION

PROBLEM

MANAGEMENT

Hypothermia

Warmpatientupmaintainandmonitorbodytemperature

Hypoglycemia

Monitorbloodglucoseprovideoral(orintravenous)glucose

Dehydration

Rehydratecarefullywithoralsolutioncontaininglesssodiumandmorepotassiumthanstandardmix

Micronutrients

Providecopper,zinc,iron,folate,multivitamins

Infections

Administerantibioticandantimalarialtherapy,evenintheabsenceoftypicalsymptoms

Electrolytes

Supplyplentyofpotassiumandmagnesium

Starternutrition

Keepproteinandvolumeloadlow

Tissuebuilding

Furnisharichdietdenseinenergy,protein,andallessentialnutrientsthatiseasytoswallowanddigest

nutrition
Stimulation

Preventpermanentpsychosocialeffectsofstarvationwithpsychomotorstimulation

Preventionofrelapse

Startearlytoidentifycausesofproteinenergymalnutritionineachcaseinvolvethefamilyandthecommunityin
prevention

FromMllerO,KrawinkelM:Malnutritionandhealthindevelopingcountries,CMAJ173(3):279286,2006.2005CanadianMedicalAssociation.Reprintedwith
permissionofthepublisher.

Thesecondrehabilitationphase(wk26)mayincludecontinuedantibiotictherapywithappropriatechanges,iftheinitialcombinationwasnot
effective,andintroductionoftheF100orRUTFdiet(Tables436and439)withagoalofatleast100kcal/kg/day.Thisphaseusuallylastsan
additional4wk.Atanytime,iftheinfantisunabletotakethefeedingsfromacup,syringe,ordropper,administrationbyanasogastrictuberather
thanbytheparenteralrouteispreferred.Bottlesmaybecontaminatedincertainlocales,andtheiruseisdiscouragedunlesscleanlinessisassured.
Onceadlibitumfeedingsareallowed,intakesofbothenergyandproteinareoftensubstantial.Irontherapyusuallyisnotstarteduntilthisphaseof
treatmentironcaninterferewiththeprotein'shostdefensemechanisms.Therealsoisconcernthatfreeironduringtheearlyphaseoftreatment
mightexacerbateoxidantdamage,precipitatinginfections(malaria),clinicalkwashiorkor,ormarasmickwashiorkorinachildwithclinical
marasmus.Somerecommendtreatmentwithantioxidants.
Table439
COMPOSITIONOFF75ANDF100DIETS

CONSTITUENT AMOUNTPER100mL
F75

F100

Energy

75kcalth(315kJ) 100kcalth(420kJ)

Protein

0.9g

2.9g

Lactose

1.3g

4.2g

Potassium

3.6mmol

5.9mmol

Sodium

0.6mmol

1.9mmol

Magnesium

0.43mmol

0.73mmol

Zinc

2.0mg

2.3mg

Copper

0.25mg

0.25mg

Percentageofenergyfrom:
Protein

5%

12%

Fat

32%

53%

Osmolarity

333mOsmol/L

419mOsmol/L

FromWorldHealthOrganization:Managementofseveremalnutrition:amanualforphysiciansandotherseniorhealthcareworkers,Geneva,1999,WorldHealth
Organization.

Bytheendofthe2ndphase,anyedemathatwaspresenthasusuallybeenmobilized,infectionsareundercontrol,thechildisbecomingmore
interestedinhisorhersurroundings,andhisorherappetiteisreturning.Thechildisthenreadyforthefinalfollowupphase,whichconsistsof
feedingtocovercatchupgrowthaswellasprovidingemotionalandsensorystimulation.Thechildshouldbefedadlibitum.
Indevelopingcountries,thisfinalphaseisoftencarriedoutathome.Inallphases,parentaleducationiscrucialforcontinuedeffectivetreatmentas
wellaspreventingadditionalepisodes.
Refeedingsyndromecancomplicatetheacutenutritionalrehabilitationofchildrenwhoareundernourishedfromanycause(Fig.439(f0055),
Table4310(t0055)).Thehallmarkofrefeedingsyndromeisthedevelopmentofseverehypophosphatemiaafterthecellularuptakeofphosphate

duringthe1stweekofstartingtorefeed.Serumphosphatelevelsof0.5mmol/Lcanproduceweakness,rhabdomyolysis,neutrophildysfunction,
cardiorespiratoryfailure,arrhythmias,seizures,alteredlevelofconsciousness,orsuddendeath.Phosphatelevelsshouldbemonitoredduring
refeeding,andiftheyarelow,phosphateshouldbeadministeredduringrefeedingtotreatseverehypophosphatemia(Chapter52.6).

Figure439
Guidelinesformanagement.
(FromMehannaHM,MoledinaJ,TravisJ:Refeedingsyndrome:whatitis,andhowtopreventandtreatit.BMJ336:14951498,2008.)
Table4310
CLINICALSIGNSANDSYMPTOMSOFREFEEDINGSYNDROME

HYPOPHOSPHATEMIA

HYPOKALEMIA HYPOMAGNESEMIA

VITAMIN/THIAMINE
DEFICIENCY

SODIUM
RETENTION

HYPERGLYCEMIA

Cardiac

Cardiac

Cardiac

Encephalopathy

Fluidoverload

Cardiac

Hypotension

Arrhythmias

Arrhythmias

Lacticacidosis

Hypotension

Decreasedstroke

Respiratory

Neurologic

Death

Pulmonary
edema

volume
Respiratory
Impaireddiaphragm
contractility
Dyspnea

Cardiac
compromise

Respiratory

Failure

Weakness

Hypercapnea

Neurologic

Tremor

Failure

Weakness

Tetany

Other

Paralysis

Seizures

Ketoacidosis

Gastrointestinal Alteredmentalstatus

Coma

Nausea

Coma

Dehydration

Paresthesia

Vomiting

Gastrointestinal

Weakness

Constipation

Nausea

Impairedimmune
function

Muscular

Vomiting

Respiratoryfailure
Neurologic

Confusion
Disorientation

Rhabdomyolysis Diarrhea

Lethargy

Musclenecrosis

Other

Areflexicparalysis

Other

Seizures

Death

Refractoryhypokalemiaand
hypocalcemia

Coma

Death

Hematologic
Leukocytedysfunction
Hemolysis
Thrombocytopenia
Other
Death

DatafromKraftMD,BtaicheIF,SacksGS:ReviewofRFS,NutrClinPract20:625633,2005.FromFuentebellaJ,KernerJA:Refeedingsyndrome,PediatrClinNAm
56:12011210,2009.

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