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- Protein energy malnutrition
- Vitamin deficiencies
- Trace element and mineral deficiencies
- Iron deficiency
- Case studies
When you have completed this chapter you should be able to:
- Define normal nutrition and malnutrition.
- List the main food groups.
- List the important forms of malnutrition.
- Diagnose and manage protein-energy malnutrition.
- Diagnose and manage vitamin deficiencies.
- Diagnose and manage iron deficiency.
- List the common causes of anaemia.
4-1 What is nutrition?
Nutrition is the food (diet) that a child eats and drinks.
4-2 What is the nutritional state?
The nutritional state (or the state of nutrition) is the child’s physical appearance which indicates whether he/she is well nourished or poorly nourished. The nutritional state can also be affected by medical conditions such as chronic diarrhoea or tuberculosis.
The nutritional state is evaluated by clinical examination to determine whether the child is underweight or overweight, stunted, wasted or obese, or shows any signs of nutritional deficiency. Therefore, the nutritional state is an indirect measure of the child’s diet.
Nutrition is what we eat, while our nutritional state is what we look like. Good nutrition in a healthy child results in a normal nutritional state and normal growth.
4-3 What is normal nutrition?
Children with normal nutrition receive the correct amount of all the essential types of food necessary for normal growth and good health. They have a diet which contains the correct amount of each nutrient (food type).
Although the type of food varies with age, it is important that all children have an adequate diet which contains all the main nutrients in the correct proportion. If the amount of one or more of the nutrients is inadequate, the result is malnutrition. Excessive nutrients can also cause problems, especially obesity.
Good nutrition is a diet which contains the correct amount of all the main nutrients.
4-4 What are the main nutrients in the diet?
The major nutrients (food groups) are:
- Energy foods
- Protein foods
4-5 What are energy foods?
- Fats and oils
Both carbohydrates and fats are important because they provide the body with energy. Too much energy food causes obesity while too little results in failure to thrive or even weight loss.
4-6 Which foods are carbohydrates?
Sugars (simple carbohydrates) and starches (complex carbohydrates). Household sugar is an important source of carbohydrates while syrup, honey and fruit juice are rich in sugars. Common foods that are rich in starches are bread, porridge, potatoes, maize and rice.
4-7 Which foods are rich in fats and oils?
Fats are present in food from animals while oils are found in vegetable foods and fish. Both fats (solids) and oils (liquids) are high in energy. Vegetable oils are better for good health than animal fats.
Foods rich in fat include meat and dairy products (milk, cream, butter).
Foods rich in oils include maize, sunflower oil, margarine, peanuts and fish.
4-8 Which foods are rich in protein?
Many animal and vegetable foods contain proteins. Proteins are made up of amino acids. Unfortunately, many animal sources of protein are expensive.
Animal sources of protein include meat, eggs and dairy products.
Vegetable sources of protein include legumes (beans, peas, lentils), nuts, millet (sorghum) and, to a lesser degree, maize.
Meat, dairy products, beans, peas and lentils contain high quality protein rich in essential amino acids. Maize contains poor quality protein.
4-9 What are micronutrients?
- Minerals and electrolytes such as sodium, potassium, calcium, chloride and bicarbonate
- Trace elements such as copper, zinc, iodine and selenium
- Vitamins such as fat soluble vitamins (A, D and E) and water soluble vitamins (B and C)
4-10 What is a well-balanced diet?
A well-balanced diet contains adequate amounts of all the major food groups. A diet that contains too much or too little of one or more food groups is not balanced. Ideally each meal should contain fat, carbohydrate, protein and all the essential micronutrients.
Many foods are made up of more than one food group, e.g. nuts contain carbohydrates, oils and proteins. Mixing foods can give a balanced meal, e.g. maize for energy with beans for protein or milk for protein and porridge for energy.
A well-balanced diet contains adequate amounts of all the major food groups.
4-11 What foods are needed by children?
All children need a balanced diet, but a child’s age, maturity and physical size determines how this is best achieved. Young children have relatively bigger nutritional requirements per kg than adults because of their need to grow.
Infants under 6 months need a liquid diet because chewing and swallowing must still develop and mature. Breast milk alone is the ideal diet (designed by nature) for these infants. It meets the nutritional needs and is a balanced diet. Breastfeeding avoids the risks attached to unsafe handling and contamination of alternative feeds. If breast milk is not available, formula feeds should be given. If a formula has to be chosen, select a suitable commercial starter formula feed and follow the mixing instructions and recommended volumes as given on the tin. Usually one scoop (provided by the manufacturer) of milk powder is added to 25 ml water.
Beyond 6 months of age the infant’s nutritional needs can no longer be met completely by breast milk or formula alone. Solids must be introduced. Breast milk or formula feeds should, however, still form an important part of the diet. Soft family foods such as porridge, mashed vegetables or fruit should be started. By 8 months children can chew and ‘finger foods’ can be started. Solids should be given 3 times a day to infants that are still breastfeeding or are formula fed.
By one year of age most children can be given family foods 5 times a day. Small children have small stomachs and therefore need more frequent meals than adults to achieve an adequate total nutritional intake. Breastfeed as often as the child wants. If possible, breastfeeding should be continued until at least 2 years of age. Most children will tolerate cow’s milk from 1 year of age. After 1 year of age, a normal child who is not breastfed should not receive more than about 500 ml milk per day.
Complementary foods are given to fill the gap between the total nutritional needs of the infant and the nutrition provided by breast milk or formula feeds. Complementary foods are usually not needed before 6 months.
- The advantages and risks of breastfeeding must be carefully considered in infants born to HIV positive women.
4-12 What is malnutrition?
An abnormal nutritional state can be caused by too little or too much of one or more of the important food groups in the diet. Abnormal nutrition leads to a number of different nutritional problems. While obesity is also a form of abnormal nutrition, the term malnutrition is usually used to refer to children with undernutrition.
Children with malnutrition are not receiving adequate amounts of one or more important nutrient.
- In wealthy countries, obesity is the commonest form of abnormal nutrition.
4-13 How is malnutrition recognised clinically?
Most children with malnutrition are underweight, stunted or thin. Therefore, a child’s size for age can be used to help diagnose malnutrition. These children usually are deficient in a number of different nutrients. However, some children may be deficient in only a single nutrient, e.g. a vitamin deficiency.
4-14 Which children are underweight?
These are children who have a body weight for their age that is below the 3rd centile. Therefore, they weigh less than the normal range for their age. Many have been underweight for months or years while others have only recently lost weight. Malnutrition should be considered in all underweight children. There are, however, many causes of being underweight other than malnutrition (e.g. being born preterm).
Malnutrition must be considered in all underweight children.
4-15 Which children are stunted?
These children have a height less than the 3rd centile. They are, therefore, shorter than normal. Stunting suggests slow growth for a long time. Most stunted children are also underweight but often do not appear wasted. As a result their poor growth is often not recognised if they are not measured. Malnutrition or a chronic illness should be considered in all stunted children.
Stunting always suggests a chronic health problem or malnutrition.
4-16 Which children are wasted?
A wasted child has lost weight with a weight for height below the 3rd centile Wasting can be diagnosed by clinically examining the child. These children have very little subcutaneous fat and muscle. Their arms and legs are particularly thin and they have loose skin and soft tissue around the upper arms and thighs. Wasting is an important sign and must always be taken seriously. It indicates a recent serious loss of weight. Wasting in children indicates either fairly recent onset of malnutrition or they have a serious illness such as malabsorption, malignancy or chronic infection (such as tuberculosis or HIV).
Wasting is an important sign of malnutrition.
Assessing weight, height and weight for height by the correct use of centile charts is discussed in chapter 3.
- Measuring the mid upper arm circumference is a good screening test for wasting. These children will also have a low body mass index.
4-17 Why is malnutrition important?
Because malnutrition is common, especially in poor countries. It is directly or indirectly responsible for half of all deaths worldwide in children under 5 years of age. Unless managed correctly, the mortality rate from severe malnutrition can be as high as 50%.
Malnutrition is closely linked with both poverty and ignorance. Preventing malnutrition is one of the main goals of programmes that address poverty.
Malnutrition is a common cause of childhood death, especially in poor countries.
4-18 How is a clinical diagnosis of malnutrition confirmed?
By taking a careful dietary history. You must ask about the type of food, amount of food and frequency of feeds. If the diet appears to be good according to the mother’s history, consider a disease such as chronic diarrhoea or infection as the cause of the child’s poor nutritional state. Many illnesses can lead to malnutrition, e.g. measles. Sometimes, only a response to a good diet confirms the diagnosis of malnutrition due to a poor diet.
The diagnosis of malnutrition is confirmed by taking a careful dietary history.
4-19 What are the common forms of malnutrition?
- Protein-energy malnutrition
- Vitamin deficiencies
- Trace element deficiency
Protein energy malnutrition
4-20 What is protein-energy malnutrition?
Protein-energy malnutrition (PEM) consists of a range of clinical conditions caused by a lack of both protein and energy in the diet (i.e. general undernutrition). PEM ranges from mild to severe and the clinical presentation depends on the degree of deficiency and precipitating factors such as infection. Most children with PEM have both weight and height below the normal range, i.e. they are stunted.
4-21 What are the forms of protein-energy malnutrition?
- Underweight for age (UWFA)
- Marasmic kwashiorkor
Children with marasmus, kwashiorkor or marasmic kwashiorkor have severe malnutrition. These different forms of severe malnutrition are often considered together as their causes are similar and they are managed in the same way.
Children with severe malnutrition have signs of marasmus or kwashiorkor or both.
These different forms of malnutrition are identified by the child’s weight for age, the degree of wasting, and by the presence or absence of oedema of the feet. In addition to examining and measuring these children, it is important to also obtain as detailed a dietary history as possible.
4-22 Which children are underweight-for-age?
Underweight-for-age (or ‘low weight’) is defined as a weight for age that falls below the 3rd centile. This means that they weigh less than the normal range. Many of these children are ‘failing to thrive’. They appear clinically well and do not look undernourished. They do not have oedema. Unless they are weighed, and their weight is plotted on a centile chart, the diagnosis is frequently missed. Underweight-for-age is the commonest form of malnutrition.
Being underweight-for-age is the commonest form of malnutrition.
- Using the Wellcome classification of PEM, children who are UWFA have a weight which is between 60% and 80% of the median (50th centile).
4-23 Why is it important to detect underweight-for-age children?
Marasmus and kwashiorkor are always preceded by ‘underweight-for-age’. Therefore, it is important to identify these children and address their nutritional problems before they become worse.
4-24 What is marasmus?
This is the commonest form of severe malnutrition. The child’s weight is far below the 3rd centile and lies below 60% of the 50th centile (the ‘marasmus line’). These children usually appear very thin (severely wasted) and are often ill. They do not have oedema. Marasmus is usually due to starvation or severe illness such as malabsorption or AIDS.
Children with marasmus are severely underweight for their age.
- Children with marasmus have a weight-for-height less than 60% of expected (under 3 SD below the mean). Some serious medical conditions (e.g. malabsorption) can also result in marasmus.
The severe wasting is best seen on the buttocks, thighs and upper arms where the skin hangs in folds. The ribs and shoulder blades stick out and the abdomen is usually distended due to decreased muscle tone. They are anxious, irritable, cry easily and look like an old person.
- Anorexia nervosa causes marasmus in older children and adolescents.
4-25 What is kwashiorkor?
This is another severe form of protein-energy malnutrition. These children present with a characteristic syndrome which always includes oedema, especially of both feet and legs. Kwashiorkor usually occurs in children between 6 months and 2 years of age. It is an acute problem which is often precipitated by an infection such as gastroenteritis in a child who is already underweight for age. These children have a typical appearance:
- They are miserable, with a poor appetite.
- They have oedema of their legs and their face looks swollen with fat cheeks. Pressing on the back of each foot for a few seconds will show the pitting of oedema. Due to the facial oedema they may appear ‘chubby’ and their wasting is often missed.
- Their hair is sparse, fine and may have a reddish colour.
- They have areas of increased or decreased skin pigmentation with scaling, especially in the nappy area (flaky-paint rash). There may also be areas of skin which are wet and look like burns. The skin is easily damaged and may be ulcerated. Secondary bacterial skin infection is common.
- They have a distended abdomen and an enlarged liver.
- Angular stomatitis is common with painful cracking at the angles of the mouth.
- Their nails are pale.
- Their weight usually falls below the 3rd centile but above 60% of the 50th centile. Some infants have a normal weight because of their oedema.
- They often have signs of anaemia and vitamin deficiency.
- While the underlying cause of PEM is an intake of protein and energy that is insufficient to maintain health, not all children with severe malnutrition develop kwashiorkor. The clinical disease is precipitated by an additional stress such as infection.
- Using the Wellcome classification of PEM, children with kwashiorkor have a weight which is usually below the 3rd centile together with nutritional oedema.
4-26 What is marasmic kwashiorkor?
These severely malnourished children have clinical features of both marasmus and kwashiorkor. They are severely underweight (below 60% of the 50th centile) but also have oedema. Children with marasmus may rapidly deteriorate, especially if they develop an infection, and present with oedema to become marasmic kwashiorkor.
- Using the Wellcome classification of PEM, children who have marasmic kwashiorkor have a weight which is below 60% of the median (50th centile) and also have oedema.
4-27 How can you determine whether a child has malnutrition?
- Take a careful dietary and family history.
- Examine the child fully.
4-28 How can the history help in the diagnosis of malnutrition?
The following needs to be known:
- Is the child still breastfed?
- What is the usual diet (type, amount and frequency of feeds or meals)?
- What is the child’s appetite like?
- Are there any signs of illness, e.g. diarrhoea, vomiting or cough?
- The family background (income, parents, carers, abuse)
4-29 How can a general examination help in the diagnosis of malnutrition?
The weight and length must be measured and plotted on a growth chart.
A full general examination must be done, looking particularly for signs of:
- Severe malnutrition (e.g. oedema and wasting)
- Vitamin deficiencies
- Pallor (due to anaemia)
- Illness, e.g. diarrhoea, tuberculosis or AIDS
Most children with severe malnutrition will have other signs of kwashiorkor or marasmus. They may also have signs of vitamin or trace element deficiencies. Severe malnutrition is, therefore, a clinical diagnosis which can be made by examining the child and plotting the child’s weight and height.
Malnutrition is a clinical diagnosis based on history and examination.
4-30 How common is protein-energy malnutrition?
This is very common in poor countries. It is estimated that 170 million children in the world suffer from severe protein-energy malnutrition while a third of all the world’s children are undernourished (30% of all children are underweight and 37% stunted).
- In South Africa 10% of children are underweight and 25% stunted. Less than 5% are wasted. Therefore, chronic malnutrition is common.
4-31 What factors are commonly associated with malnutrition?
Malnutrition is usually due to an inadequate diet. However, the cause is often complex and related to poverty. Common associated factors are:
- Parental neglect and deprivation
- Poor health services
- Frequent infections, especially diarrhoea and measles
- Displaced families, drought, famine and war
Poor education of women, unemployment, young mothers, poor social support in the community, war and violence, neglect and abuse, no breastfeeding, and low birth weight are all common in communities with a high prevalence of malnutrition. Failing to breastfeed in poor, rural communities will almost certainly lead to malnutrition.
In some children, malnutrition is not caused by a poor diet but is due to an illness which prevents the body from using food that is eaten. Chronic diseases and malabsorption may result in malnutrition in spite of a normal diet.
Poverty, infection and malnutrition commonly form a devastating cycle in poor communities.
4-32 What are the complications of severe malnutrition?
These are usually seen in kwashiorkor and marasmic kwashiorkor:
- Serious infections, especially septicaemia or pneumonia. Gastroenteritis, tuberculosis, measles and AIDS often precipitate kwashiorkor.
- Hypoglycaemia due to loss of energy stores
- Heart failure due to a small, weak heart
- Bleeding, usually purpura
- Anaemia due to protein and iron deficiency
- Electrolyte imbalances, especially potassium deficiency
- Tremors (‘kwashi shakes’)
- Sudden death
About 25% of children with kwashiorkor die despite treatment. The long-term effect of severe malnutrition on growth and mental development remain uncertain as these children are also affected by a deprived environment.
Hypoglycaemia, hypothermia, infection and heart failure are the main causes of death in severe malnutrition.
- Children with kwashiorkor have a low serum albumin, potassium, magnesium, sodium, copper and zinc. Also low glucose, transferrin and clotting factors.
4-33 How are malnutrition and infection related?
Severe malnutrition weakens the immune system and makes the child more susceptible to infections such as gastroenteritis, measles, tuberculosis and AIDS. In turn infection (especially diarrhoea) often precipitates severe malnutrition in a child who is underweight-for-age.
4-34 Is malnutrition always due to a poor diet?
No. Some children who fail to thrive are receiving a good diet. They usually have a severe, chronic illness, such as tuberculosis, AIDS, malignancy, bowel or liver disease, or cerebral palsy. AIDS is a common cause of failure to thrive in Africa.
Some stunted children are not malnourished but have a medical condition or had a very low birth weight. Chronic emotional stress can also cause stunting.
4-35 What is the management of an underweight-for-age child?
- A careful history, physical examination and review of the weight and height (and head circumference in infants) growth curves is essential to establish the pattern of growth and the underlying cause of the failure to thrive. Treat any medical problem.
- The child should be given a normal, well-balanced diet (a trial of feeding) if malnutrition is diagnosed. Frequent small feeds increase the total food intake and should be given at least 5 times per day. Peanut butter, vegetable oil or sugar added to the staple diet can be used to increase energy intake. Cheap forms of protein (milk powder, peas, beans) must be encouraged. Food supplements are available at clinics and hospitals under the state’s nutrition programme for qualifying families.
- The child must be closely followed for 2 weeks. If there is no weight gain, the child must be admitted to hospital for a controlled trial of feeding and possibly further investigation.
- If there is weight gain, the child must be carefully followed with repeat weight checks to ensure that weight gain continues. Height will only be gained after a few months of satisfactory weight gain.
- The underlying cause of the poor feeding must be addressed or the problem will simply recur. Nutritional education of the mother is essential. Financial aid may be needed.
- It is best to deworm the child and give vitamin A according to the national vitamin A policy as many underweight for age children have worms and are likely to have mild vitamin A deficiency. Multivitamin syrup is needed during the phase of catch-up growth and also if the usual diet is deficient in fresh vegetables or fruit.
- Measure the haemoglobin concentration and treat anaemia with oral iron.
Good nutrition will correct growth in most children that are underweight.
4-36 What is the management of severe malnutrition?
The management of children with marasmus, kwashiorkor and marasmic kwashiorkor (i.e. severe malnutrition) is very similar and, therefore, can be considered together.
These children are seriously ill and all must be urgently admitted to hospital. The management consists of:
- Initial resuscitation
- Nutritional rehabilitation
- Follow up
4-37 What resuscitation is needed?
Infants presenting with severe malnutrition (especially kwashiorkor) are very sick and a number will die within a week of starting treatment. They must all be hospitalised immediately. This phase of treatment usually lasts about a week:
- Correct and avoid hypoglycaemia, hypothermia or dehydration. Check the blood glucose 6 hourly for the first few days and whenever the child’s temperature falls below 35.5 °C. A feed of 50 ml of 10% glucose orally should correct hypoglycaemia. Correct any dehydration slowly with oral fluids. Avoid intravenous fluids if possible. Do not use diuretics to reduce the oedema.
- Give broad spectrum antibiotics (ampicillin and gentamicin if clinically septic or co-trimoxazole if there is no obvious site of infection) to all children for a week. Assume that all children with severe malnutrition have a bacterial infection.
- Start with oral or nasogastric feeds every 3 hours, both day and night, as soon as possible. Usually a starter formula or, if diarrhoea is present, a lactose-free formula 100 ml/kg/24 hours is used for the first week. High volume feeds may cause heart failure.
- Give oral potassium chloride 0.5 g/kg/day (4 to 6 mmol/kg/day) as these children are severely potassium depleted, especially children with kwashiorkor. Also give extra magnesium, 0.4 to 0.6 mmol/kg/day, as well as zinc 2 mg/kg/day, folic acid 5 mg per day, multivitamin syrup 10 ml per day and vitamin A 50 000 to 100 000 units on day 1.
- Do not give oral iron yet. Iron can be very dangerous as these children do not have enough protein to carry iron safely in the blood stream.
Give frequent, small lactose-free feeds for the first week.
4-38 What nutritional rehabilitation is required?
This phase of treatment starts when the appetite improves and the child is looking better:
- Once the appetite has returned and any oedema has improved, a weaning (follow-on) formula with a higher protein content can be started in infants. As the older child improves, porridge and mixed foods, especially maize, beans and dried peas, can be started. Vegetable oils can be added for energy. A high energy and protein diet is needed. Start introducing solid foods slowly. During this phase, children are often very hungry and take a lot of food. The first sign of recovery is when the child starts to smile.
- Continue folic acid 5 mg daily for 5 days.
- Continue multivitamin syrup 10 ml daily.
- Treat for worms with mebendazole 100 mg twice daily for 3 days and metronidazole (Flagyl) 7.5 mg/kg 8 hourly for 7 days for Giardia.
- Oral iron 6 mg elemental iron/kg/day for 12 weeks, starting ONLY when the child is gaining weight and any oedema has disappeared.
- Monitor daily weight gain.
- A blood transfusion is only used for severe anaemia with associated cardiac failure. Extra magnesium is often added to feeds.
4-39 How can you prevent malnutrition recurring?
- The mother or caregiver must be given the education and financial support to provide a good diet.
- Regular follow up with weighing is essential.
There is a real risk that malnutrition will recur in a previously malnourished child as it is very difficult to correct social and economic problems in a family and community.
Start treating the malnutrition immediately and do not wait to treat the infection first.
4-40 How should you address the underlying causes of malnutrition?
An aggressive attempt must be made to break the cycle of ignorance, poverty, malnutrition and emotional deprivation. Socio-economic factors are most important. The answers lie in the family and community rather than in the primary health care system. Employment, education, social upliftment, pride and responsibility are vitally important. The level of childhood malnutrition is a good measure of the health and wellbeing of the community.
The sources of inexpensive protein, such as beans, must be stressed.
4-41 What can be done to prevent malnutrition in poor communities?
- Breastfeeding to 6 months of age or longer
- Complementary feeding from 6 to 24 months (breast milk plus solids)
- Prevent infections, especially diarrhoea
- Routine weighing, immunisation and use of the chart in the Road-to-Health Card
- Social support for mothers
- School feeding projects
4-42 What is the effect of severe malnutrition on a child’s mental development?
Severe malnutrition results in poor growth and wasting of the brain. These children are lethargic, not interested in their surroundings, irritable and unhappy. Often they are not given the stimulation and love needed for normal mental and behavioural development.
Once they start recovering and smiling, they need to be stimulated and given a lot of loving attention. The hospital ward should provide a happy, stimulating environment with play and physical contact. With good nutrition, loving care and stimulation, many children will recover physically and intellectually.
4-43 What are micronutrients?
In contrast to the major components of the diet (proteins, carbohydrates and fats), micronutrients are needed in much smaller amounts. Micronutrients can be divided into:
- Trace elements (minerals)
4-44 What are vitamins?
Vitamins are essential items in the diet, which are needed for healthy growth and normal metabolism. A deficiency of one or more vitamins (hypovitaminosis) causes nutritional illness.
4-45 What are the common vitamin deficiencies in children?
- Vitamin A deficiency
- Vitamin B group deficiencies (e.g. pellagra)
- Vitamin C deficiency (scurvy)
- Vitamin D deficiency (rickets)
- Vitamin K deficiency (haemorrhagic disease in newborn infants)
- In South Africa maize meal is now fortified with folic acid. Many bakeries also fortify their wheat flour used for bread with folic acid. It is planned to fortify both maize flour and bread with folate, vitamin A and vitamin B complex.
4-46 Which children are at greatest risk of vitamin A deficiency?
- Infants who are not breastfed
- Low birth weight infants
- Underweight infants on a poor diet
- Infants with diarrhoea, measles, tuberculosis or AIDS
Vitamin A deficiency is particularly important as it is common in most poor countries and contributes to the death of many children. It is estimated that as many as 25% of young children in South Africa are deficient in vitamin A, especially in rural areas.
Vitamin A deficiency is common in South Africa, especially in poor rural communities.
4-47 How does vitamin A deficiency present?
Mild vitamin A deficiency usually does not present with any gross clinical signs. Yet it is very important because it is associated with loss of appetite, poor growth and severe infections (especially gastroenteritis and measles) and increased mortality.
Vitamin A deficiency results in an increased risk of severe infections.
Severe vitamin A deficiency causes eye problems and presents with photophobia (keep eyes closed in bright light), night blindness (unable to see in poor light) and xerophthalmia (dry eyes). It also causes corneal clouding, ulcers and softening (keratomalacia) which can lead to corneal scarring and blindness. Severe vitamin A deficiency is the commonest preventable cause of blindness in children in poor countries.
- A patch of dry, raised conjunctiva (appears foamy) over the sclera is called a Bitot’s spot. Vitamin A deficiency causes blindness in half a million children worldwide annually.
4-48 How is vitamin A deficiency prevented?
One of the major challenges to health care of children in the world today is to get vitamin A supplementation or fortification into common foods. Vitamin A supplementation significantly reduces children’s risk of dying from infectious diseases.
One method of supplementing vitamin A is to give a single 50 000 unit dose of oral vitamin A to all children at 6 weeks as part of the routine immunisation schedule. This is followed by 100 000 units at 9 months and then 200 000 units at 12 months and every 6 months thereafter until 5 years. All children with measles should be given 200 000 units of vitamin A orally daily for 2 days.
The body can make vitamin A from carotene which is present in yellow fruits and vegetables (e.g. mangoes, pawpaws, carrots, pumpkin, butternut, sweet potatoes) as well a green leafy vegetables (e.g. spinach). Vitamin A is present in breast milk, liver, butter and margarine. Vitamin A fortification of basic foods is another method of ensuring adequate amounts of vitamin A in the diet.
Yellow fruit and vegetables are rich in vitamin A.
4-49 How is vitamin A deficiency treated?
Children with signs of severe vitamin A deficiency (eye signs) are treated with 100 000 units of oral vitamin A daily for 2 days followed by a third dose at 6 weeks. Children with mild signs only should receive 100 000 units once if they are one year or less, and 100 000 units daily for two days if they are over one year.
4-50 What are the B group vitamins?
These are a group of water-soluble vitamins that are not stored in the body and therefore have to be present in the diet on a continuous basis. While folic acid deficiency may be seen with severe malnutrition and intestinal parasites, only niacin deficiency is common in some areas in South Africa. Deficiencies of the other group B vitamins are rare.
- The other group B vitamins are thiamine, riboflavin, B12 and pyridoxine. Folate can be added to basic foods to reduce the prevalence of neural tube defect in newborn infants.
4-51 What is pellagra?
This is a condition caused by niacin deficiency. It is seen in communities who depend on a maize diet. In children, pellagra presents with a skin rash on areas exposed to the sun (face, neck and chest in a necklace distribution, arms and legs). The rash is erythematous (red) or pigmented and may be scaly.
Pellagra is treated with nicotinic acid 100 mg orally, every 4 hours for 3 days. Advise on a balanced diet with beans and peas added to maize. Pellagra patients are usually also generally malnourished.
Pellagra presents with a pigmented, scaly rash on exposed areas.
4-52 What is scurvy?
Scurvy is caused by a lack of vitamin C, which is found in fruits and vegetables. It is uncommon in older children but sometimes is seen in infants on a poor diet without breast milk (which is rich in vitamin C). Scurvy causes painful, tender bones (due to bleeding under the periosteum) which presents in infants with irritability and crying when handled. They do not like moving their legs and may be misdiagnosed as osteitis, paralysis or battering. Bleeding gums are rare as they only occur in children old enough to have teeth. An X-ray of the long bones shows diagnostic lifting of the periosteum.
Scurvy is treated with 250 mg vitamin C orally 4 times a day for 5 days. Correct the diet.
- The prevention of scurvy, through the provision of fruit and vegetables, on the long sea voyage from Europe to the spice islands of Indonesia and Malaysia, was the reason for the colonisation of the Cape by the Dutch in 1652.
4-53 What is rickets?
Rickets is a clinical syndrome of deformities of growing bones and delayed physical milestones usually caused by a lack of vitamin D. Vitamin D is present in a mixed diet and can be made in the skin if the child is exposed to sunlight. In South Africa nutritional rickets is usually seen in preterm infants who are exclusively breastfed and not exposed to sunlight. Breast milk contains little vitamin D. Infant formulas are supplemented with vitamin D. Once infants start walking, they usually have adequate sun exposure to make their own vitamin D.
Rickets in infants presents with soft, deformed bones, resulting in:
- A ‘rickety rosary’ with swelling of the ribs where bone meets cartilage
- A chest deformity with a horizontal groove overlying the diaphragm attachment to the ribs (Harrison’s sulcus)
- Craniotabes with a softened ‘ping-pong’ skull above the ears
- Thickened wrists and ankles
- Decreased muscle tone, giving a distended abdomen
- Delayed physical milestones
- An increased risk of pneumonia
Treatment consists of 1000 units of oral vitamin D daily for a month by which time there should be radiological confirmation of healing. Increase exposure to sunlight for 30 minutes a week. For prevention vitamin D 400 units daily (in 0.6 ml of multivitamin drops or 5 ml vitamin syrup) should be given to preterm infants for 6 months as they are at high risk of developing rickets.
- Rickets due to calcium deficiency can occur in older children on a diet which has adequate vitamin D but is low in calcium (e.g. maize without milk). There are also rare renal and metabolic causes of rickets in children who do not respond to the standard treatment. Vitamin D deficiency in adolescents (osteomalacia) presents with bone pain, muscle weakness and hypotonia. Hypovitaminosis D can be confirmed by finding a low concentration of serum 25 hydroxycholecalciferol.
Trace element and mineral deficiencies
4-54 What are trace element and mineral deficiencies?
The important trace elements are iodine, fluoride and zinc, while the common minerals are sodium, potassium, calcium, magnesium phosphate and iron.
- Iodine deficiency causes thyroid enlargement (goitre) and hypothyroidism (with retarded mental development). This is uncommon in South Africa due to iodine being added to table salt. However, it is still seen in mountainous regions where rock salt or non-iodated salt is used.
- Fluoride deficiency is common in some regions of South Africa and results in dental caries. It is prevented by fluoridation of drinking water.
- Zinc deficiency may result in growth failure and an increased risk of infections. Weekly zinc supplements decrease the incidence and severity of both pneumonia and diarrhoea. Zinc fortification of food is an important method of providing adequate amounts of zinc in the diet. .
- Calcium and phosphate deficiency may cause rickets and increase the risk of osteoporosis in adult life. It is prevented by including milk in the diet.
Trace element and mineral deficiency is best avoided by taking a well-balanced diet.
4-55 How common is iron deficiency?
Iron deficiency is common in South Africa and many poor countries. It is usually seen in young children, especially between the ages of 6 months and 2 years when breastfeeding has been stopped.
Iron deficiency is common in South Africa.
4-56 What are the common causes of iron deficiency in children?
- Iron deficiency is usually due to inadequate amounts of iron in the diet. However it is often made worse by chronic bleeding from the gut due to intestinal parasites.
- Cow’s milk contains little iron. Fortunately, most formula feeds contain additional iron which has reduced the incidence of iron deficiency in most formula-fed infants.
- Immediate clamping of the umbilical cord at birth deprives the newborn infant of much iron, while preterm infants have low iron stores.
Iron deficiency in children is usually due to a poor diet and worms.
4-57 What are the clinical signs of iron deficiency?
Iron deficiency results in lethargy, poor appetite, eating soil (pica) and poor school performance. If the iron deficiency is severe enough, anaemia will develop as the result of inadequate amounts of iron to produce normal red cells. Therefore, anaemia is the commonest clinical presentation of iron deficiency. However, children with mild iron deficiency may not yet be anaemic and the diagnosis of iron deficiency is often missed.
Mild iron deficiency, (i.e. without anaemia), is usually managed by improving the diet to make sure the child receives adequate amounts of iron. Meat, eggs and green vegetables are rich in iron.
4-58 How is the diagnosis of iron deficiency confirmed?
With iron deficiency, the red cells usually appear small and pale on a blood smear (microcytic and hypochromic red cells). Therefore, this finding strongly suggests iron deficiency even if anaemia is not yet present. Examining a blood smear is a useful way of screening for iron deficiency. Children with iron deficiency also have a low serum concentration of ferritin. This will prove the diagnosis. With severe iron deficiency the child will develop anaemia. The haemoglobin concentration is usually normal with mild iron deficiency.
4-59 How can iron deficiency be prevented?
- By giving a good, balanced diet
- By regularly deworming children
- By waiting until the infant cries before clamping the umbilical cord after birth
- Children at high risk of iron deficiency, such as preterm infants, should be given prophylactic oral iron. Once discharged home, preterm infants should receive ferrous lactate drops 0.6 ml (e.g. Ferro Drops) daily until 6 months of age.
Always store iron drops, syrup and tablets away safely where children cannot get them.
- The prophylactic dose of iron is 1 mg of elemental iron/kg/day while the therapeutic dose is 1–2 mg of elemental iron/kg 3 times a day.
4-60 What is anaemia?
Anaemia is a haemoglobin concentration below the normal range for the age of the child. Children with anaemia also have a low packed cell volume. The haemoglobin concentration (Hb) normally falls for the first 3 months of life and then rises again at puberty. The normal Hb in children is about 11 g/dl with a lower limit of 9 g/dl. Children with a Hb below 9 g/dl are therefore anaemic.
Anaemia is not a disease but the result of many nutritional and medical problems. Iron deficiency is not the only cause of anaemia.
Children with a haemoglobin concentration below 9 g/dl are anaemic.
4-61 What are the presenting symptoms and signs of anaemia?
- Tiredness and general apathy
- Pallor of the nails and mucus membranes (i.e. pale)
- Heart failure, with shortness of breath on effort, in severe anaemia
Anaemia plus bruising or purpura, hepatosplenomegaly, bone tenderness or jaundice, suggest a serious illness and are indications for urgent referral to hospital.
4-62 What are the common causes of anaemia in children?
- Iron deficiency:
- Early clamping of the umbilical cord at birth (reduces the newborn infant’s iron stores)
- Preterm birth (preterm infants have low iron stores)
- A diet deficient in iron
- Intestinal parasites
- Repeated nose bleeds
- Haemolysis, due to:
- Inherited blood disorders (e.g. spherocytosis, thalassaemia or sickle cell disease)
- Chronic illness, such as tuberculosis and AIDS
- Severe malnutrition (due to lack of protein to produce haemoglobin)
- Less common causes include malignancies, bleeding disorders, folate deficiency, drug side effects and stomach ulcers.
Iron deficiency is by far the commonest cause of anaemia of children in South Africa and most poor societies.
Iron deficiency is the commonest cause of anaemia in children in South Africa.
4-63 What is the simplest method of confirming anaemia due to iron deficiency?
- Showing that the Hb is low (below 9 g/dl). This can be done with a haemoglobinometer but is more accurately measured with a full blood count.
- Examination of a peripheral blood smear to show small, pale red cells
- A trial of iron treatment
- Finding a low mean red cell size and haemoglobin concentration on a full blood count will confirm the finding of microcytosis and hypochromia on a peripheral smear.
4-64 What is the treatment of iron deficiency anaemia?
Oral iron should be given for 4 weeks and the Hb should then be checked. If the Hb has improved, the oral iron should be continued for another 2 months to replace the iron stores. Therefore, full treatment is oral iron for 3 months. If the Hb has not increased by 4 weeks the child must be referred for further investigations.
Iron deficiency anaemia is treated with ferrous gluconate (or sulphate) syrup 0.25 ml/kg 3 times a day. Always deworm the child with mebendazole or albendazole.
All anaemic children with signs of heart failure must be urgently referred to hospital as they may need a blood transfusion.
The commonest mistake in treating iron deficient anaemia is stopping the oral iron too soon.
Case study 1
A 5-year-old child attends a clinic where he is weighed. The weight is then plotted on the weight-for-age chart in his Road-to-Health Card. His weight falls just below the 3rd centile. He appears generally well but thin. The mother is out of work and has no financial support.
1. Does this child have malnutrition?
Yes. He probably has mild protein-energy malnutrition. He is underweight-for-age as his weight falls just below the 3rd centile. There is no evidence on the history that there is a medical reason for being underweight-for-age. The family history suggests that there is not enough money for an adequate balanced diet.
2. How would you confirm the diagnosis?
Firstly, by taking a dietary history and confirming that he receives a poor diet. Secondly, by demonstrating weight gain when his diet is improved.
3. What is the danger of being underweight-for-age?
Children who are underweight-for-age are at high risk of developing a more severe form of protein-energy malnutrition if their diet becomes worse or they have an infection such as diarrhoea or measles. Children who are underweight-for-age have a weakened (suppressed) immune system and, therefore, are also at increased risk of a serious infection such as tuberculosis.
4. What is the value of examining this child’s growth curve and growth pattern?
The growth curve will show whether he has been underweight-for-age for a long time or has only recently lost weight. The growth pattern would also be helpful as a height below the normal range will indicate stunting while a normal height will suggest recent weight loss. Recent weight loss may suggest an infection such as AIDS.
5. What are energy foods?
- Carbohydrates such as bread, maize, potatoes, rice, porridge and sugar.
- Fats, such as dairy products, or vegetable and fish oils.
6. What dietary management does this child need?
He needs enough of a balanced diet. His mother needs to be told what cheap foods are high in protein and energy (maize together with beans or milk mixed with porridge). She also needs social and financial assistance. It is important to watch this child’s weight over the next few months to make sure that he is gaining weight adequately. It would be wise to give him 200 000 units of oral vitamin A as he is probably deficient in vitamin A.
Case study 2
An 18 month old child is seen at a local hospital. The child is very thin and wasted. Her weight falls well below the 3rd centile (also below 60% of the 50th centile). There is no rash or oedema. She is pale and has thickening of her wrists and ankles. The mother was drunk when she brought the child to hospital.
1. What is your diagnosis?
Marasmus. The weight falls far below the 3rd centile (below 60% of the 50th centile). The cause is almost certainly starvation and neglect.
2. What should be the initial treatment?
Admit the child immediately to hospital for resuscitation. Look for and treat any hypothermia, dehydration or hypoglycaemia. Small oral or nasogastric feeds should be started. If possible, do not start an intravenous infusion. Start antibiotics even if there is no obvious infection. Her social circumstances will have to be investigated and managed.
3. Why is the child pale?
She probably has iron deficiency anaemia due to a poor diet and possibly because of chronic infection. Only once she is taking feeds well and looking better should oral iron be started.
4. What additional diagnosis is suggested by the swelling of her wrists and ankles?
Rickets, due to a deficiency of vitamin D in her poor diet. She has probably also had very little exposure to sunlight. The treatment would be 1000 units vitamin D daily for a month. She almost certainly needs a multivitamin syrup as she is probably deficient in other vitamins as well.
5. How could the marasmus be prevented?
If she had been taken to the local clinic for routine weighing every month her failure to thrive would have been detected before she reached the stage of severe malnutrition. Steps could then have been taken to manage the nutritional and social problems.
Case study 3
A very miserable child is seen at an urban clinic after he had been brought from a poor rural district by his grandmother. He appears swollen, with oedema of the face and legs. There is a pigmented, scaly rash on the trunk and legs. His weight is plotted on the 3rd centile but this falls to below the 3rd centile during his first week in hospital. His hair is very thin and he has a bad cough.
1. What is wrong with this child?
He has all the clinical signs of kwashiorkor: misery, oedema, thin hair and a rash. Often children with kwashiorkor are not very underweight when they present as they are oedematous. Their weight often falls markedly when they lose their oedema.
2. Why is this child severely malnourished?
Probably as the result of poverty. There may be a drought in the rural area. Sometimes only maize meal is available (which is low in protein).
3. What diagnosis could the cough suggest?
He may have tuberculosis. This will need to be investigated.
4. Is kwashiorkor a fatal illness?
Up to 25% of children with kwashiorkor will die despite treatment.
5. What feeds should be given to this child?
Children with severe malnutrition are usually started on lactose-free feeds. Small feeds are given at first as a high volume intake can cause heart failure. Potassium is added to their feeds as they are severely potassium depleted. Once he is improving he can be given follow-on formula.
6. What cheap food gives high quality protein?
Breast milk, provided the mother can be traced and convinced to restart breastfeeding. Otherwise, milk powder or beans can be added to the diet to increase the amount of protein.
7. What other form of malnutrition can cause a pigmented, scaly rash?
Pellagra, due to niacin deficiency. The rash usually occurs on the face, neck and chest in a necklace distribution, arms and legs (i.e. exposed areas).
Case study 4
An 18 month old girl presents with a history of poor feeding and eating sand. On examination she has a normal weight for age and appears generally well. However her nails and tongue are pale. The mother says that she drinks a lot of cow’s milk and does not want to eat solid foods.
1. Why is this child pale?
She is probably anaemic.
2. How would you confirm this diagnosis?
By measuring her haemoglobin concentration which should be about 11 g/dl. A concentration below 9 g/dl at her age would indicate anaemia.
3. What do you think is the most likely cause of her anaemia?
Iron deficiency. Eating sand (pica) and a poor appetite are common in children with iron deficiency. Cow’s milk is a poor source of iron. She may also have intestinal parasites.
4. What is a simple method of confirming iron deficiency anaemia?
By measuring the haemoglobin concentration and then examining a peripheral blood smear. Small pale red cells strongly suggest iron deficiency. The presence of iron deficiency can be proved by a low serum ferritin concentration. Therefore, a Hb below 9 g/dl plus a typical smear or low serum ferritin would confirm the diagnosis of iron deficiency. The diagnosis would be supported if the Hb increased with a month of iron treatment.
5. What is the management of iron deficiency anaemia?
Ferrous gluconate (or sulphate) syrup 0.25 ml/kg 3 times a day for 3 months. She should also be ‘dewormed.’