Severe malnutrition is both a medical and social disorder. Malnutrition mainly affects children under five in developing countries and results in poor health. The malnourished child will also perform poorly at school and will be a less productive adult in the future.

Causes of malnutrition

They can be classified as root causes, underlying causes and immediate causes.

Immediate causes of malnutrition are:

• Inadequate dietary intake: Not getting enough nutrients to meet the nutritional need of the body.
  
• Frequent attacks of illness: a child who has had frequent illnesses can develop malnutrition. During illness, the child's appetite decreases; the food was eaten might not be absorbed, or it may be vomited; the food that the child eats is not used efficiently, or it may not be enough for the increased metabolic need of the child's body.
  

Types of malnutrition

• Protein-energy malnutrition
• Micronutrient malnutrition or deficiency

Chronic protein-energy malnutrition is manifested by stunting (short height or length) for age. Stunting occurs as a result of lack of food, or illness (Stunting indicates chronic malnutrition)

Acute protein-energy malnutrition is the term used to cover both moderate and severe wasting and nutritional oedema or kwashiorkor.

Micronutrient malnutrition or deficiency is the deficiency of the recommended amounts of essential vitamins and minerals. The child may not be eating enough of the recommended amounts of specific vitamins (such as vitamin A) or minerals (such as iron).

Anemia is one of the micronutrient deficiencies that is the lack of iron in the foods. A child can also develop anaemia as a result of:

• Infections.
• Parasites such as hookworm or whipworm: these parasites can cause blood loss from the gut.
• Malaria.

Checking the sick child for malnutrition and anaemia

All children who are brought to the health post (visited at their home) for their complaint of acute illness, the health extension worker should check for malnutrition and anaemia. Since mother may bring her child to the health post because the child has an acute illness and specific complaints may not complain malnutrition. A sick child can be malnourished, but the child's family may not have realised the malnutrition as illness.

Checking for visible severe wasting in infants less than six months of age

An infant with visible severe wasting has marasmus; it is a form of severe malnutrition. Marasmus is characterised by the wasting of muscle mass and the depletion of body fat stores. It is the most common form of protein-energy malnutrition and is caused by inadequate intake of all nutrients, but especially dietary energy sources (total calories). Physical examination findings include:

• Diminished weight and height for age.
• Emaciated and weak appearance.
• Bradycardia, hypotension, and hypothermia.
• Thin, dry skin.
• Redundant skin folds caused by loss of subcutaneous fat.
• Thin, sparse hair that is easily plucked.

Visible severe wasting (Figure 7.1, below) can be assessed by looking at the face, the ribs, arms, the legs and the buttock. Remove the child's clothes for observation. Look to see if the outline of the child's ribs is easily seen. Look at the child's hips. They may look small when you compare them with the chest and abdomen. Look at the child from the side to see if the fat of the buttocks is missing.

When wasting is extreme, there are many folds of skin on the buttocks and thighs. It looks like the child is wearing baggy pants. The face of a child with visible severe wasting may still look normal. The child's abdomen may be large or distended.

Kwashiorkor. Kwashiorkor is characterised by marked muscle atrophy with normal or increased body fat. Pure kwashiorkor is characterised by inadequate protein intake in the presence of fair to good energy intake. Anorexia is almost universal. Physical examination findings include:

• Normal or nearly normal weight and height for age.
• Anasarca (severe generalised oedema).
• Pitting oedema in the lower extremities and periorbital.
• Rounded prominence of the cheeks ("moon-face").
• Pursed appearance of the mouth.
• Dry, atrophic, peeling skin with confluent areas of hyperkeratosis and hyperpigmentation.
• Dry, dull, hypopigmented hair that falls out or is easily plucked.
• Hepatomegaly (from fatty liver infiltrates).
• Distended abdomen with dilated intestinal loops.

Intermittent periods of adequate protein intake restores hair color, resulting in alternating loss of hair color interspersed between bands of normal pigmentation.

Measure the mid-upper arm circumference (MUAC)

For children aged six months or more, the most feasible way to determine wasting or acute malnutrition is by measuring their mid-upper arm circumference (MUAC). A MUAC of less than 11.0 cm indicates severe acute malnutrition.

Steps of MUAC measurement:

• Ask the mother to remove any clothing that covers the child's arm. If possible, the child should stand erect and sideways to the health worker.
• Estimate the mid-point of the left arm.
• Straighten the child's arm and wrap the tape around at the mid-point. Make sure that the numbers are right side up. Make sure the tape is flat around the skin.
• Inspect the tension of the tape on the child's arm. Make sure the tape has the proper tension and is not too tight or too loose. Repeat any step as necessary.
• When the tape is in the correct position and correct tension on the arm, read and call out the measurement to the nearest 0.1 cm.
• Immediately record the measurement.

Look and feel for edema of both feet

A child with oedema of both feet may have kwashiorkor. Kwashiorkor is characterised by marked muscle atrophy with normal or increased body fat. Pure kwashiorkor is characterised by inadequate protein intake in the presence of fair to good energy intake. Anorexia is almost universal

To determine the presence of oedema, press gently with your thumb on the topside of each foot for at least three seconds a depression will occur.

Assessing appetite

For a child aged six months or above has a MUAC less than 11 cm or pitting oedema of both feet and has no medical complications, assess the child's appetite.

Appetite Tests for Children With Severe Acute Malnutrition