Nutrition And Malnutrition

Malnutrition is a significant public health issue, especially in developing countries like India. It is a leading cause of morbidity and mortality in children under five. Therefore, doctors need to understand the mechanisms, types, and treatment of malnutrition.

Similarly, adequate nutrition is essential for the growth and development of children. Nutrition-related disorders like obesity, anemia, and vitamin deficiencies can have lifelong consequences. Understanding children's nutritional needs at different growth stages is important for preventing and managing these conditions.

This makes both nutrition and malnutrition important pediatrics topics for NExT/NEET PG preparations. In this blog we’ll discuss breast milk and breastfeeding, micronutrients, malnutrition, fluids and electrolytes. 

Breast Milk And Breastfeeding

• When should breastfeeding be initiated?
  • As soon as possible after birth or within 1 hr of childbirth
  • Irrespective of normal vaginal delivery or C-section
• Exclusive breast feeding is recommended for how long?
  • It is recommended for first 6 months of life
  • Exclusive breast feeding means that baby is given only breast milk, not even sips of water unless medically recommended 
• After 6 months of age, what should be started?
  • Complementary feeding: Refers to some semi solid energy dense food that should be affordable, feasible, acceptable, sustainable, safe & that can be given in addition to breast milk
• What is the problem if food grains are started at <age 6 months?
  • More chances of food allergy are seen in babies
  • Some study linked usage of wheat in <6 months of child to celiac disease
• Storage of expressed breast milk can be done for how long?
  • Depend on temperature of storage:
    • At room temperature: 8-10 hrs
    • In refrigerator at 2-8°C: 24 hrs
    • In deep freezer (-20°C): 3 months
• Signs of good positioning while breastfeeding?
  • Body of baby should be:
    • Well supported
    • Turned towards mother
    • Occiput, shoulder and buttocks should be in straight line
    • So close to mother that abdomen of baby should touch abdomen of mother
• What are sign of good attachment while breastfeeding?
  • Related to nipple area of mother and oral cavity of baby:
    • Mouth of baby should be wide open
    • Lower lip of baby should be everted or turned out
    • Whole of areola should be covered by mouth except upper part which may be visible 
    • Chin of baby should touch mother’s breast
• What is the contraindication to breast feeding in neonates?
  • Conditions related to baby: Galactosemia, Congenital lactose intolerance 
  • Maternal condition: Absolute – Mother on chemotherapy or radiotherapy
  • Relative CI:
    • Infective condition like maternal HIV 
    • In developed countries – C.I
    • In developing countries – Indicated: Maternal active TB, Varicella involving breast area, Breast abscess 

Advantages of breast milk (BM) for the baby

1. Composition of breast milk:
   • Carbohydrates: BM - 7 mg/dL, CM (Cow’s milk) - 4.5 mg/dL
   • Protein: BM - 1 gm/dL (i.e., less load on kidney), CM (Cow’s milk) - 3.5 mg/dL
     • AA: Adequate Cysteine, Taurine, Methionine (for CNS development) and BM is richer in whey protein 
   • Lipid: ↑PUFA, ↑DHA in mother’s milk
   • Mineral: Ca:P in breast milk is such that it favors Ca absorption, Fe present in BM is more easily absorbable 
   • Vitamins: BM contains adequate amount of all vitamins expect vit D and vit K 
     • Vit B₁₂ in strictly vegetarian mothers
     • Supplement Vit D 400 IU to all babies in first year of life 
     • Vit K - 1 mg IM given to all babies at birth to prevent hemorrhagic disease of newborn 

2. Anti-infective substances in BM

Tech for PLAB

• TGF – β
• Phagocytic macrophage
• Lactoferrin, Lysozyme
• Antibodies like IgA
• Bile stimulated lipase

3. BM protection against disease

• In neonates: NEC, Neonatal sepsis
• In older age group: Asthma, Obesity, Diabetes, Allergies

4. Breast milk fed babies have:

• Higher IQ
• Helps in maternal and child bonding

Variation in composition of breast milk

1. Based on time after birth

• Colostrum in first 72 hrs - Thick and yellowish, very beneficial that it is called 1^st immunization of baby, no pre lacteal feed is given
• Transitional milk - For next 2 weeks
• Mature milk – Thin and watery

2. Based on gestational age at which baby is delivered

• Preterm breast milk is richer in Na, Immunoglobulins, Protein, Iron, Calories

3. Based on each feeding session 

• Foremilk – Initially watery part, it satisfies mainly thirst of the baby
• Hindmilk – thick, comes at end, rich in lipids, it satisfies mainly hunger of the baby
  • Mother is recommended to feed from one breast completely before switching to other so that baby receives both foremilk and hindmilk

MICRONUTRIENTS

Vitamin A

• Earliest symptoms – Night blindness
• Earliest sign – Conjunctival xerosis/dryness
  • Can be so severe that there will be conjunctival ulcers or even blindness
• Therapeutic dose:
  • <6 months – 50,000 IU
  • 6-12 months – 1 lac IU
  • >12 months – 2 lac IU/dose
• 3 doses given:
  • 1^st – At the time of diagnosis
  • 2^nd – After 24 hours
  • 3^rd – After 14 days
• For prophylaxis – 6 mega doses required, starting from 9 months at 6 months interval

Zinc

• Dermatological manifestation:
  • Acrodermatitis enteropathica
    • Present in later part of infancy
    • Present with diarrhea, dermatitis, rashes everywhere (usually in periorificial area), glossitis, conjunctivitis, hypogonadism
• Treatment – By administration of Zn therapy

Malnutrition

• Best indicator of
  • Acute malnutrition: ↓ in weight for height (wasting)
  • Chronic malnutrition: ↓ in height for age (stunting)

WHO classification of malnutrition

Weight for Height	Height for age	Edema
Between – 2 to - 3 Z score or 70-79% expected Wasting	Between – 2 to - 3 Z score or 85-89% expected Stunting	Edematous
<-3 Z score or <70% of expected Severe wasting	<-3 Z score or <85% of expectedSevere stunting

Kwashiorkor vs Marasmus

	Kwashiorkor	Marasmus
Edema	Present	Absent
Apathy	Present	Absent
Appetite	Poor	Good
CNS	Apathy, Lethargy	Active & Alert
Hepatomegaly	Seen	Not seen
Skin & hair changes	More common (Skin: Flaky Paint Dermatosis)(Hair: Flag sign)	Less common

Also Read: CARBOHYDRATE & Amino Acid Metabolism DISORDERS

Severe Acute Malnutrition (SAM)

• Definition: In a child of 6 months - 5 yrs. of age with presence of 1 or more of the following: 
  • Weight for Height < -3 z score or < 70 % of expected (severe wasting) 
  • Mid upper arm circumference < 11.5 cm 
  • Symmetric bipedal edema of nutritional origin.                            

• Rx of SAM 

1. Initial hospitalization if poor appetite or complications present
2. Look for complication and treat them 

                 Complications of SAM: SHIELDED  

• Sugar deficiency i.e. Hypoglycemia (BG < 54 mg/dl): 10 % Dextrose given
• Hypothermia (Rectal temp < 35.5°C): Warm up, remove wet clothing
• Infections: Antibiotics 
• Electrolyte disturbance (Hypokalemia / Hypophosphatemia): Supplement K, Phosphate (oral/iv)
• Dehydration: WHO ORS (in double dilution) / Resomal - Rehydration solution for malnourished child (↓Na, ↑K), corrected slowly to prevent overload
• Deficiency of Micronutrients 
  • Iron supplementation should be started only in rehabilitation phase not during initial phase

3. Nutritional Rehabilitation 

• Initially F75: 75 kcal / 100 ml and 0.7 gm of protein
• Then F100: 100 kcal / 100 ml 
• Later RUTF: 543 kcal / 100g (Ready to Use Therapeutic Food). 

FLUIDS & ELECTROLYTES

• Calculation of 24 hrs. maintenance fluid requirement in children:
  • First 10 kg: 100 ml / kg 
  • Next 10 kg: 50 ml / kg 
  • Beyond 20 kg: 20 ml / kg

• For example: If the weight of a child is 24 kg. How much fluid is to be given in 24 hrs?
  • For first 10 kg – 10 x 100 = 1000 ml
  • For first 10 kg – 10x50 = 500 ml
  • For first 4 kg - 4x20 = 80 ml
  • So, in first 24 hours – 1580 ml of fluid is given 
• Maintenance fluid
  • Fluid of choice – N/2 in 5% dextrose or DNS with 1ml of KCL/100ml
• In neonates 

• Birth weight >1500 g: Start with 60 ml / kg / day 
• BW < 1500 g: Start with 80 ml / kg / day 
• By Day 7 of life: 150 ml / kg / day 
• 1st 48 hours IV fluid of choice: 10 % Dextrose with no electrolytes 
• >48 hrs: N/5 in 5% dextrose

Management of shock in children

• IV fluid boluses – Normal saline preferred; 20ml/kg can be given up to 3 times
• If child still in shock – Start inotropes
  • Dopamine – usually first line
  • Dobutamine - Given in cardiogenic shock
  • Non epinephrine – Warm shock 
  • Epinephrine – Cold shock  
• IV antibiotics – For septic shock or any infection
• If shock still present after dopamine is given, it is called catecholamine resistant shock
  • IV Hydrocortisone given

To study nutrition and malnutrition in more detail, download the PrepLadder app and learn from engaging video lectures covering the entire topic in depth.