Malnutritional Disorders
Prepared By
Dr. Sahar Farouk
Lecturer Of Pediatric Nursing
Out Lines
 Introduction
 Definitions
 Prevalence of malnutrition
 Etiology of malnutrition
 Consequences of malnutrition
Comparison between marasmus and kwo in relation to:– Definition
– Incidence and etiology assessment of child and infant with
marasmus & kwo
– Complications
– Ivestigations
– Treatment & prevention of marasmus &kwo
 Nursing management
Out Lines (Cont.)
Rickets
 Definition of rickets
 Information about vit. D
 Causes of rickets
 Contributing factors of rickets
 Clinical picture of rickets
 Complication of rickets
 Laboratory investigations
 treatment of rickets
 Nursing care
Infantile tetany
 Definition
 Etiology
 Clinical Manifestations
 Treatment
 Nursing care
Introduction
Malnutrition means more than feeling hungry or not
having enough food to eat. It is a condition that
develops when the body does not get the proper
amount of protein, calories, vitamins and other
nutrients it needs to maintain healthy tissues and
organ function. It occurs in children who are either
undernourished or over nourished. Children who are
over nourished may become over weight or obese
and those who are under nourished are more likely
to have severe long term consequences.
Definition
Malnutrition includes: under nutrition and
over nutrition.
- Under nutrition: is a consequence of
consuming little energy and other
essential nutrients or using or excreting
them more.
– Malnutrition: is a term referring to poor or
inadequate nutrition.
Prevalence of malnutrition
Malnutrition remains of the worlds highest
priority health issues not only because its effects
are so widespread and long lasting, but also
because it can be eradicated.
More than 35% of all preschool age children in
developing countries are under weight.
The unicef report found that 146 million
children under five years in the developing world
are suffering from insufficient food intake, repeated
infections diseases, muscle wasting and vitamin
deficiencies.
Etiology
The cause of malnutrition may be due to: Poor food availability &preparation
 Recurrent infections (GE)
 Lack of nutritional education
 Lack of sanitation
 Erratic health care provision
 Chronic diarrhea
 Hook worm & malaria
 Chronic infection by (T.B, otitis media)
 Congenital mal formations as (pyloric stenosis)
Consequences of malnutrition
(long term effects)
1.
2.
3.
4.
Slowed growth & delayed development
Difficulty in school
High rates in illnesses
social stress
Protein – energy malnutrition
1- Marasmus
Definition:
It is a clinical syndrome and a form of under nutrition
characterized by failure to gain weight due to inadequate caloric
intake.
Incidence:
commonly in infants between the age of 6mo. - 2years (Infantile
atrophy).
Etiology
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1- Dietary errors
2 – Infection :Acute or chronic as T.B, otitis media pyelo nephritis
3- Gastroenteritis: (acute or chronic )
4- parasitic inf estuations as: Ascaris, ankylostoma ,giardia
5-Congenital anomalies as: Cardiac (P.D.A,V.S.D,F4) ,Renal (renal
agenesis, obstructive uropathy) ,G.I.T (pyloric stenosis , cleftlip or palat
6-Metabolic diseases.: Galactosemia, Fructose intolerance, Idiopathic
hypocalcaemia
7- Prematurety
8- Some cases of mental retardation
9- Low socio economic status
10-Endocrine causes ( DM.hyperthyroidism )
Assessment of Marasmic
Child/Infant
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failure a to thrive ,loss of weight (weight < 60%of expected)
loss of subcutaneous fat : measured at many parts of the body
according to the degress:1 st degree : s.c fat in the abd. wall
2 nd degree : s.c fat in the abd. wall and limbs
3 rd degree : s.c fat in the abd. wall and limbs and face
Assessment of Marasmic
Child/Infant (Cont.)
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Muscle wasting ( thin muscles and prominence of
bony surfaces )
G.I.T disturbances as anorexia in advanced
cases, hungry, constipation or
diarrhea or
starvation diarrhea
liability to infection
Hypovolemia
Weak feeble pulse, subnormal temp, pulse rate
Senile face and pallor
Complications of Marasmus
1. Intercurrent
infection
:
Broncho
pneumonia . is the cause of death
2. Gastro enteritis
3. Hemorrhagic tendency, purpura
4. Hypothermia
5. Hypoglycemia
6. Edema(marasmic kwashiorkor )
Investigations for Marasmic Infant
 1.Blood analysis : (W.B.C ,Electrolytes
Sugars, ketones,Plasma proteins , normal or
lowered )
 2. Urire analysis: culture, sugar, ketones,
ca, phosphate, aminoacids
 3.Stool analysis for parasites
 4. X- ray for chest and heart
 5. Tuberculin test for T.B
 6. E.N.T examination for otitis media
Treatment
1- Prevention :–
–
–
–
–
–
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proper diet ( balanced nutritional diet )
encourage breast feeding up to weaning
proper weaning
proper vaccination as measles , T.B. whooping cough
Education regarding the cheap sources of balanced
diet, family planning.
Proper follow up of the growth rate
Early treatment of defects or associated diseases
Treatment (Cont.)
2 – Curative treatment:-
A- Proper dietary management:
Adequate balanced feeding. teaching about nutritional
needs.preparation of diet, technique of administration of
food

If there is vomiting or anorexia, give IV fluids or naso
gastric tube feeding.

Gradual increase the amount and concentration of
formula (total calories is120-200cal kg d)
B – Treatment of the cause
C- Emergency treatment for complications
D – Blood transfusion
E – Vitamins and minerals supplementation
Kwashiorkor
Definition
It is a clinical syndrome and a form of
malnutrition characterized by slow rate of
growth due to deficient of protein intake,
high CHO diet and vitamins & minerals
deficiency (adequate supply of calories).
Incidence
Commonly in toddlers between the age
1-3years, following or with weaning
Etiology
1.
Un balanced diet (of protein, CHO.)
2. improper weaning (during and post weaning
period )
3. faulty management of marasmic baby
4. Ignorance poverty due to lack of basic
health education
5. precipitating factors as(acute infection with
measles, diarrhea and malaria, parasitic
infestations)
Assessment
1- Essential features
(cardinal manifestation):
– Growth retardation :Weight is diminished (60-80%) of
expected
–

Edema :
It is due to hypo proteinemia. It is
starts in the feet and lower parts of the
legs) then becomes generalized
edema . The cheeks become bulky,
pale, waxy in appearance (doll-likecheeks)
1- Essential features
- Diminished muscle fat ratio:
Generalized (muscle wasting) with
subcutaneous fat
- Fatty liver :
It is detected by liver biopsy
- Mental changes :
The infant has apathy never smile, looks
sad his cry is weak
2-Early features
(usual manifestation)
 Hair changes : The hair is sparse , dys
pigmentation( reddish or greyish),atrophic
,easily pickable.
 G.I.T Manifestations: Anorexia ,vomiting in
severe cases, diarrhea due to k
3-Occasional or variable features
- Vitamins and minerals defection and vit.D , A,C
minerals as iron, zinc, Mg,
– Hepatomegaly.
– Skin changes (dermatitis in areas due to pigmentation
,napkin dermatitis, petechiae over the abdomen,
fissures,ulceration
– Poor resistance and liability to infections
Complication of kwashiorkor
1. Secondary infection ,fungal and
bacterial infection
2. Hemorrhagic tendency, purpura
3. Gastroenteritis
4. Hypoglycemia
5. Hypothermia
6. Heart failure due to anemia and
infection.
Investigations for kwashiorkor
 1. Blood analysis: (Albumin < 2.5gmld) , total
protein, amino acids, Enzymes (amylase ,lipase,
alkaline phosphate, , Glucose (hypoglycemia) , k
( hypokalemia )
 2. Low pancreatic and intestinal enzymes
 3. Urine analysis, culture for infection
 4. Stool analysis for parasites
 5. Chest x-ray
 6. Tuberculin test
Common Nursing Diagnoses
of Marasmus and KWO
1. Altered nutrition :less than body requirements
related to knowledge deficit, infection, emotional
problems, physical deficit
2. Body temperature alteration (hypothermia) related
to low subcutaneous fat and deficiency of food
intake
3. Impaired skin integrity related to vitamins
deficiency
4. Fluid volume deficit related to diarrhea
5. High risk for infection related to low body
resistance.
Nursing care of Marasmus
Support the infant and parents
1. provide nutrition rich in essential nutrients
2. Give small amounts of foods limited in proteins, carbohydrates
and fats
3. Maintain body temperature
4. Provide periods of rest and appropriate activity and stimulation
5. Record intake and output
6. Weight daily
7. Change position frequently
8. Proper treatment is given for infection
9. Protection from infected persons and injuries
10. Refer family to social worker for financial support
11. Education for parents about proper nutrition
Nursing care of Kwashiorkor
Support the infant and parents
1. Proper diet intake proteins and CHO vitamins
2. Nursing care for vomiting, diarrhea or dehydration
3. Skin care for child for edema , injuries
4. Avoid any infection and follow hygienic measures for child
5. Frequent assessment of growth and development
6. Safety measures to avoid injuries
7. Nutritional counseling
8. Record intake and out put
9. Health education about medications and follow up
10. Frequent monitoring for any complications
3-Marasmic Kwashiorkor
Definition
– Its a combination of caloric deficiency (marasmus ) and
protein deficiency (KWO) .
Clinical picture
–
The clinical picture of this disease represents
manifestations from both diseases as:
 loss of subcutaneous fat as in marasmus
 Edema, hair and skin changes as in KWO but there is
no moon face.
Rickets (Osteomalacia)
Definition: Its is a systemic metabolic disease due to of
vit.D results in inadequate deposition of calcium in
developing cartilage and bone leading to bone
deformities, hypotonia and some times affecting cns.
Vitamin D:- it is a group of steroid fat soluble
compounds
 It affects the reabsorption of ca and phosphours by the
kidneys
It has two types: Biologically ,D2 and D3 which are present (in-active)
form and Trans formed to (active form) in the liver as
(Calcitriol)
 - D2 called (Calciferol.) and D3called (Chole calciferol.)
Causes of vitamin D. deficiency rickets
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Dietary def of vit. D and Ca
lack of exposure to sun rays
Malabsorption of vit.D as in(obstructive jaundice )
Congenital rickets
Taking of anti convulsive drugs
poor utilization of vit.D by the tissues lead to rickets
as in :–
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–
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hyper para thyroidism, renal disorders
hypo phosphatemia
recurrent attacks of diarrhea due to G.E
High proportion of phosphorous as in cow’s milk leads to
impaired absorp. of ca.
Contributing factors
1.
2.
3.
4.
Age
common in infants (6 months -2years)
Preterm babies and twins
season
more in winter than in summer
Diet
inadequate intake of vitamin D and calcium
and vitamin C in diet. and diet.
the disease is
more common in artificial feed babies than breast
feed infants
5. Heredity factor
6. Atmospheric condition
more common in big
cities and heavy crowded areas with population no
common in tropics areas
7. Race
more common in dark races
Clinical picture
During assessment of the child / infant with
rickets, the chief complains are:
1.
2.
3.
4.
Delayed motor development specially walking
Delayed dentition
Deformities of the bones
presence of one of any complications
Physical examination
A-Early manifestations:
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Craniotabes. (In the head) infant 3-8mo.
Rickety rosary beads (in the thorax)
Enlarged of the lower radio – ulner epiphysis.
Sweating at fore head, irritability
Physical examination (Cont.)
B- Late manifestations:
1. Head
– Enlargement of the head like (box shape skull)
due to frontal and parietal bossing)
– Delayed closure of anterior fontanel
– Delayed eruption of teeth
Physical examination (Cont.)
B- Late manifestations:
2-Thorax
– Rickety rosary beads
– Harrison sulcus (transverse groove at the
lower part of the chest at the costal insertion
of the diaphragm)
– Longitudinal sulcus (lateral groove)
– Pigeon chest
Physical examination (Cont.)
B- Late manifestations:
3- Spine : kyphosis, scoliosis
4- Pelvis : contracted pelvis
5- Extremities : deformities , green stick ,
fractures
6- Muscles : weakness of muscles , hypotonic
laxity of ligaments as (In abdomen)
7- Constipation, enlarged spleen
COMPLICATIONS
1. Bone fractures, limbs deformities as the
following:
2- Tetany due to hypocalcaemia
3- Anemia
4- G.I.T disturbances as: G.E, constipation.
5- Respiratory complications as pneumonia,
broncho -pneumonia
6- low resistance , liability to infection as urinary
tract infections
Treatment
Prevention Of rickets:– Exposure of all infants to ultra violet rays.
– Daily intake of diet rich with vit-D and
supplementation of vit.D (400-800 IU / d). The
infant need 400ivld .premature baby receives
800-1200 IU / d( 2nd -4th ) month of life
– Pregnant and lactating mothers need vit.D
supplementation.
Treatment (Cont.)
2- Active treatment : Oral calcium with vit.D intake should be
increased.
 Vit-D (1500-5000)IU/ d .for 2months or
shock therapy by vit-D (600-000) IU/d .by
IM injection deeply one dose every
2weeks (3doses)
 After healing, give. vit.D (400-800) IU and
repeat blood analysis for calcium.
 Surgical correction of deformities
 Treatment of any complications
Treatment (Cont.)
2- Active treatment : Oral calcium with vit.D intake should be
increased.
 Vit-D (1500-5000)IU/ d .for 2months or
shock therapy by vit-D (600-000) IU/d .by
IM injection deeply one dose every
2weeks (3doses)
 After healing, give. vit.D (400-800) IU and
repeat blood analysis for calcium.
 Surgical correction of deformities
 Treatment of any complications
Common nursing diagnoses
1. Body image disturbance related to bone
deformities
2. Altered nutritional requirements related
to deficiency of calcium
3. High risk for infection related to low of
immunity.
4. High risk for injury related to weakness
of bones and deformities.
Infantile Nutritional Tetany
(Tetany of vit.D deficiency)
Definition:–
It is a disease caused by decrease in
serum calcium level
( < 7mgldl) and
by a deficiency in the intake and
absorption of vitamin .D (not all infants
with rickets have tetany). This condition
leads to hyper excitability of the central
and peripheral nervous system
Etiology
1. Hypocalcemia as by (hypo parathyroid),
vit.D. deficiency intake , exchange
transfusion)
2. hypo magnesemia by (chronic diarrhea
, malabsorption . of mg)
3. alkalosis (pH) due to (severe vomiting,
alkalotic therapy)
4. Severe rickets.
NB. Infantile tetany. has the some
predisposing factors as in rickets.
Clinical manifestations
1- Early manifestations as :
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serum calcium - >7mg /dl
Carpo – pedal spasm
laryngeal spasm
cyanosis
Generalized convulsions in infants
and newborns
– N.B: infantile tetany is due to rapid
deposition of serum Calcium so, spasms
in hands, feet appear
2- late manifestations: serum
Ca
deformities
(7-9)mg
/dl,
bone
Treatment
A. Immediate:
 Give the child infant Ca gluconate .10%
solution (5-10) cc. IV injection slowly.
 If no response search for etiology and
correct it as (Mg deficiency ) by giving Mg
solution sulface .50% (0.2 ml/kg ) IM
 O2 therapy for convulsions and emergency
intubation. for laryngo spasm
B. Maintenance: Diet rich in calcium
 Ca chloride orally (1-3gm /d in milk) or Ca
lactate.
 Vit.D. for treatment of rickets daily
Common Nursing diagnoses
Nursing diagnoses:
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High risk for injury related to convulsions
High risk for infection related to lack of
immunity
Altered body image, related to bone
deformities
Ineffective breathing pattern, related to
laryngeal spasm
Activity intolerance, related to weakness of
bones
Altered parenting related to lack of knowledge
about
the
disease
process
and
its
management.
Thank You