Malnutrition

SAM is defined as a weight-for-height that is at least three standard deviations under the mean National Centre for Health Statistics reference values (under the 1st percentile), or by the presence of either nutrition-related bilateral pitting edema or mid-upper-arm circumference of less than 110 mm in children 1 to 5 years of age.

From: Smith's Anesthesia for Infants and Children (Ninth Edition), 2017

Chapters and Articles

Malnutrition: Concept, Classification and Magnitude

J. Ngo, ... L. Serra-Majem, in Encyclopedia of Food and Health, 2016

Severe Acute Malnutrition

SAM was previously known as PEM, or protein–calorie malnutrition, and is an important nutritional condition in developing countries due to its high prevalence and its association with high rates of infant mortality, changes in growth and development, and decreased ability to work, altogether leading to inadequate social and economic development.

SAM occurs when the diet does not provide sufficient protein, energy substrates (calories), or both, to satisfy the body's nutritional needs. It is usually also associated with a deficiency of vitamins and minerals and essential micronutrients needed for growth and tissue renovation. The term SAM includes severe clinical syndromes of kwashiorkor (edema), marasmus (without edema), marasmic–kwashiorkor (edema and the combination of chronic energy deficiency and chronic or acute protein deficiency), and mild and moderate cases that are much more numerous than severe forms. The term ‘malnutrition’ is generally used in common vernacular to refer to SAM.

SAM may be of primary or secondary origin. Primary SAM is caused by inadequate nutrient intake. Secondary SAM results from disorders or drugs that interfere with nutrient use, such as cases of diseases accompanied by low food intake, inadequate nutrient absorption or utilization, increased nutritional requirements, increased nutrient losses, or any or all of these factors. Although SAM is mainly an issue in early childhood, it may also occur in older children and adults, particularly the elderly. This article focuses on primary SAM of gradual onset, with predominance of metabolic disorders and clinical features of protein and energy deficiency.

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Nutrition and Susceptibility to Tuberculosis☆

J. Peter Cegielski, David N. McMurray, in Reference Module in Biomedical Sciences, 2017

Abstract

Undernutrition is an important risk factor for the development of tuberculosis (TB). Understanding the link between undernutrition and susceptibility to TB is based on a conceptual model for the transmission and pathogenesis of TB. The risk of progression from infection to disease increases substantially in undernourished individuals which is likely due to the detrimental effects of undernutrition on cell-mediated immunity (CMI, essential for the control of mycobacterial growth). Evidence in humans linking undernutrition to TB risk is indirect and surprisingly weak from the perspective of scientific rigor. The majority of evidence in humans comes from a large body of uncontrolled observations and ecological studies in which the effects of undernutrition cannot be separated from the effects of socioeconomic disparities. While cross-sectional and case–control studies help to support an association between undernutrition and development of TB, they do not address the temporal relationship. Only two cohort studies have examined the temporal relationship between micronutrients and TB incidence. Experimental animal models have allowed scientists to elucidate causal links between nutritional deficiencies, immune system function, and TB. Although TB is clearly related to undernutrition, the risk relative to specific levels and types of protein-energy deficiency and micronutrient deficiencies remains to be defined.

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URL: https://www.sciencedirect.com/science/article/pii/B9780128012383640953

Nutrition Basics: What Is Inside Food, How It Functions and Healthy Guidelines

Jacqueline B. Marcus MS, RD, LD, CNS, FADA, in Culinary Nutrition, 2013

Undernutrition

Undernutrition describes a condition whereby normal nutritional guidelines and recommendations are not met. It can result from inadequate food intake, poor absorption of nutrients or excessive loss of nutrients. Undernutrition may or may not be accompanied by malnutrition, a medical condition that may be caused by an improper or inadequate diet. Malnutrition may be the consequence of disease, infection or starvation.

While undernutrition and malnutrition are more common in Third World countries, both conditions are found in the United States and other developed countries as well. Poverty and food availability may lead to undernutrition and malnutrition. People who have access to food and choose not to eat it may become undernourished or malnourished, as in the case of eating disorders, discussed in Chapter 10.

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URL: https://www.sciencedirect.com/science/article/pii/B9780123918826000017

Nutrition and Susceptibility to Tuberculosis

J. Peter Cegielski, D.N. McMurray, in Encyclopedia of Human Nutrition (Third Edition), 2013

Abstract

Undernutrition is an important risk factor for the development of tuberculosis (TB) due to its detrimental effects on cell-mediated immunity (CMI). Evidence linking undernutrition to TB in humans is indirect, the majority coming from uncontrolled observations and ecological studies in which the effects of undernutrition cannot be separated from the effects of socioeconomic conditions. Few cohort studies have examined the temporal relationship between macronutrients, micronutrients, and TB incidence. Experimental animal models have allowed scientists to elucidate causal links between nutritional deficiencies, immune system function, and TB. The risk of TB relative to specific levels and types of protein-energy deficiency and micronutrient deficiencies remains to be defined.

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URL: https://www.sciencedirect.com/science/article/pii/B9780123750839002683

Growth

Jaya Sujatha Gopal-Kothandapani, ... Leena Patel, in Practical Pediatric Endocrinology in a Limited Resource Setting, 2013

Undernutrition

Undernutrition, usually secondary to protein calorie malnutrition, is the most important cause of short stature worldwide, is usually accompanied by mineral and vitamin deficiencies and is associated with pubertal delay, aggravating the problem of short stature. Its presence can be assessed as a low weight for height as well as low weight for age and sex-matched peers. Short stature due to undernutrition is complicated by zinc deficiency which alone can cause short stature and delayed puberty. It results in low IGF1 and has been considered as an adaptive mechanism for an energy-restricted environment.

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URL: https://www.sciencedirect.com/science/article/pii/B9780124078222000013

Influence of Nutrition on Neonatal Respiratory Outcomes

Cristina T. Navarrete MD, Ilene R.S. Sosenko MD, in The Newborn Lung: Neonatology Questions and Controversies (Second Edition), 2012

Effect of Undernutrition on Infection Susceptibility

Undernutrition is known to alter pulmonary defense mechanisms, compromising epithelial cell integrity and clearance mechanisms, allowing easier access by pathogens, and jeopardizing cellular and humoral immune function, and thereby decreasing the ability of the host to eliminate pathogens. Thus, undernutrition predisposes to infections. Globally, undernourished children frequently succumb to repeated upper68 and lower69 respiratory tract infections. Animal models of malnutrition have also demonstrated decreased alveolar macrophage count,70 phagocytosis, and microbial killing.71 Newborn rats deprived of adequate protein antenatally were found to develop reduced alveolar macrophage function, which could be reversed by postnatal protein supplementation.72

Individual components of surfactant, specifically surfactant proteins A and D, have important roles in the innate immune response and in defense against microbes.73 As already mentioned, undernutrition has an effect on surfactant, although whether it has any specific impact on surfactant proteins is unknown.

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Nutritional diseases

Ana Maria Mosca de Cerqueira, Wânia Mara del Favero, in Tropical Dermatology, 2006

Pathogenesis

Undernourishment favors the appearance of opportunistic infections and is related to the disease prognosis. Nutrition is an important determinant of the immune response. Poor nutrition reduces cellular immunity, phagocyte function, and the complement system. It also causes a decrease in antibody concentration (immunoglobulin A (IgA), IgM and IgG) and in cytokine production, as well as a deficiency of specific micronutrients, such as iron, zinc, selenium, copper, vitamins A, C, and B-complex, and folic acid, which play an important role in the modulation of the immune response. Although a considerable number of moderately or severely undernourished children are affected by acute diarrhea, there are other associated infections: pneumonia, tuberculosis, malaria, and human immunodeficiency virus (HIV). Between 50% to 90% of patients affected by HIV suffer during the development of their disease from some level of undernourishment.9,10

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Nutritional Assessment

Kathleen J. Motil, ... Claudia Conkin, in Pediatric Gastrointestinal and Liver Disease (Fourth Edition), 2011

Physical Examination

Undernutrition includes two entities: marasmus and kwashiorkor. Marasmus is characterized by the wasting of muscle mass and the depletion of body fat stores, whereas kwashiorkor is characterized by generalized edema (anasarca) and flaky, peeling skin rashes. Children with undernutrition may manifest a broad spectrum of clinical features (Table 86-4). However, it is uncommon to find many of the signs of severe undernutrition in children with acute or chronic gastrointestinal illnesses. A combination of wasting and peripheral edema, signifying a combination of marasmus and kwashiorkor, is found most commonly. The clinician should have a high index of suspicion for micronutrient deficiencies in the presence of these findings, particularly in children with malabsorptive or inflammatory disorders.

Overweight is characterized by increased deposition of truncal and peripheral body fat. Increased body fat is associated with several effects on growth including increased lean body mass, increased height, advanced bone age, and the early onset of menarche. Overweight children may be hypertensive and often display dysfunctional behaviors because of poor self-esteem. Morbid overweight is associated with metabolic complications, such as diabetes mellitus and hyperlipidemia, hepatic steatosis, cholelithiasis, orthopedic disorders including slipped capital femoral epiphysis or bowing of the tibia and femur, and cardiopulmonary problems including congestive heart failure and obstructive sleep apnea. Whereas simple, exogenous overweight is a national epidemic, the type of overweight that occurs in conjunction with medications such as prednisone is more difficult to manage because these drugs ameliorate inflammatory conditions but lead to voracious appetites.

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Dietary factors and health and disease

ProfessorCrispian Scully CBE, MD, PhD, MDS, MRCS, FDSRCS, FDSRCPS, FFDRCSI, FDSRCSE, FRCPath, FMedSci, FHEA, FUCL, FBS, DSc, DChD, DMed (HC), Dr (hc), in Scully's Medical Problems in Dentistry (Seventh Edition), 2014

General aspects

Severe undernutrition results mainly from poverty, especially in children and older people in the developing world or in war zones. Other causes include eating disorders, abuse (food restriction), oral problems, obstruction to the pharynx or oesophagus, malabsorption and cachexia of malignant disease or HIV/AIDS. Undernutrition is the most common cause of immunodeficiency worldwide.

Infants and children are at particular risk of undernutrition because of a high demand for energy and essential nutrients. Protein-energy malnutrition in children consuming inadequate amounts of protein, calories and other nutrients is a particularly severe form of undernutrition, which retards growth and development. Deficiencies of iron, folic acid, vitamin C, copper, zinc and vitamin A may develop in inadequately fed infants and children. An exclusively breast-fed infant can develop vitamin B12 deficiency if the mother is a vegan.

Adolescents are at risk since nutritional requirements go up as the growth rate increases. Requirements for all nutrients rise during pregnancy and lactation. Anaemia due to folic acid deficiency is common in pregnant women, especially those who have taken oral contraceptives, so folic acid supplements are now recommended to prevent neural tube defects (spina bifida) in their children. Aberrations of diet (rarely including pica) are common in pregnancy. An alcoholic mother may have a handicapped and stunted child with fetal alcohol syndrome. Caffeine has been implicated in miscarriages and underweight babies.

Older people, despite a reduction in physical activity lowering their energy and protein requirements, are at risk of undernutrition because of poverty, apathy or dementia. Diminished senses of taste and smell, poverty (real or perceived), loneliness, physical and mental impairments, immobility and chronic illness can also contribute. Furthermore, absorption may be impaired, contributing to iron deficiency, osteoporosis (also related to calcium deficiency), and osteomalacia due to lack of vitamin D and sunshine exposure (Ch. 25).

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Vibrio cholerae (Cholera)

Talia Pindyck, ... Eric Mintz, in Principles and Practice of Pediatric Infectious Diseases (Sixth Edition), 2023

Severe Acute Malnutrition

Children with severe acute malnutrition (SAM) are at increased risk for death.116,117 SAM results in altered physiology with profound electrolyte derangement and altered fluid distribution, including fluid retention due to high intracellular sodium. WHO provides criteria for identifying SAM in children 6–59 months.117 Assessment of the child’s dehydration status is challenging. Children with SAM and suspected or confirmed cholera who meet indications for oral rehydration should receive reduced osmolarity ORS (Table 158.1). The modified oral rehydration solution for malnutrition (ReSoMal), which contains 45 mmol/L sodium and 40 mmol/L potassium, may not adequately correct hyponatremia and is not appropriate for the treatment of cholera or profuse watery diarrhea.117,118 Children with SAM are at risk for overhydration and should be carefully monitored during treatment.100 Evidence to guide optimal management SAM with severe cholera is lacking.119 Given these limitations, Médecins Sans Frontières recommends that children with SAM receive the same volume of fluid as children without SAM but at a slower rate of administration.120 SAM-related complications of rehydration treatment include fluid overload, hypoglycemia, and hypothermia.121 Recent studies on hospitalized children found no increased risk of cardiac complications in children with SAM compared with those without.122–124

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