Course : B Sc Nursing, III Year

Subject Name : Child Health

Nursing
Unit V : Nutritional Deficiency Disorders
PART 1 of 2

Dr. S Hepsibah PhD Nursing

Vice Principal and Research Scientist
 OBJECTIVES

At the end of the class the students will be able to

 define Malnutrition and its components

 identity the factors related to occurrence of Malnutrition

 discuss the causes of Malnutrition

 highlight the consequences of Malnutrition

 INTRODUCTION
Children form one third of our population
45% of child deaths are due to Nutritional Deficiency Disorders (WHO,
2018)
• 41 million are overweight or obese
• 45% of deaths among children under 5 years of age are linked to
undernutrition.
• Every second child in that age group is affected by some form
of malnutrition (World's Children, UNICEF 2019)
 MALNOURISHMENT INDEX
India has largest number of malnourished children in the world

Source: (NFHS-4, 2015-2016)

• 1 in 3 of the world's malnourished children lives in India

• India accounts to have 40% malnourished children in the world
• 69 per cent of deaths of children below the age of 5 years in India is caused
due to Malnutrition
Prevalence of Malnutrition in Children
RECOMMENDED DAILY NUTRITIONAL INTAKE
TYPES OF NUTRIENTS
 MALNUTRITION

Refers to both:
• Under nutrition: not getting
enough nutrients
• Overnutrition: getting more
nutrients than the body needs
(ICMR 2018)
CAUSES OF MALNUTRITION
CLASSIFICATION OF MALNUTRITION IN CHILDREN
CONSEQUENCES OF MALNUTRITION (ICMR 2018)
 MAIN NUTRITIONAL DISORDERS

1. Obesity
2. Starvation
3. Kwashiorkor
4. Marasmus
5. Anorexia nervosa
6. Bulimia nervosa
7. Vitamin deficiency
8. Trace element deficiency
 OBESITY
Obesity is defined as an excess of adipose tissue

that imparts health risk

Etiology

• Genetic predisposition

• diets largely derived from carbohydrates and fats than protein rich food

• hypothyroidism, cushings syndrome, insulinoma, and hypothalamic

disorders
 PATHOPHYSIOLOGY

Obesity is associated with increased adipose stores in the

subcutaneous tissue, skeletal muscles, internal organs such as
the kidneys, heart, liver and fatty liver is also more common in
obese individuals. There is increase in both sizes number of
adipocytes and there is hypertrophy as well as hyperplasia.
 METABOLIC CHANGES

• Hyper insulinaemia
• Non- Insulin dependant diabetes
• Hypertension
• Hyper lipoproteinaemia
• Atherosclerosis
• Coronary artery disease
• Cholelithiasis
• Cancer
• Osteoarthritistt
 SERIOUS HEALTH HAZARDS OF OBESITY

• Stroke
• Coronary artery diseases
• Hypertension
• Fatty liver
• Diabetes
• Atherosclerosis
• Hyperlipidaemia
• Osteoarthritis
 TREATMENT FOR OBESITY

MEDICAL MANAGEMENT
Drug therapy {appetite suppressing drugs}
Phentermine, diethylpropion etc.
SURGICAL MANAGEMENT
Vertical banded gastroplasty
Adjustable gastric banding
HERE ARE FOUR (4) NURSING DIAGNOSIS FOR
OBESITY
• Imbalanced Nutrition: More Than Body Requirements
• Disturbed Body Image
• Impaired Social Isolation
• Deficient Knowledge
May be related to
 Food intake that exceeds body needs
 Psychosocial factors
 Socioeconomic status
Possibly evidenced by
• Weight of 20% or more over optimum body weight; excess body fat by skinfold/other
measurements
• Reported/observed dysfunctional eating patterns, intake more than body requirement
 NURSING MANAGEMENT

• Nutritional therapy
• Behaviour modification
• Support groups
 STARVATION

Starvation is a state of overall deprivation of nutrients

Etiology
• Deliberate fasting
• famine conditions in a country or community
• secondary under nutrition such as chronic wasting diseases,
cancers etc
 SIGNS AND SYMPTOMS

• Dry and scaly skin

• Muscular weakness
• Anemia
• Increased susceptibility to infections
• Loss of appetite
• Wound healing may be delayed
• Brittle nails
• Loss of hair
• Depression
• Decreased B P ,pulse, slight cyanosis
 MANAGEMENT
• Health promotion
• Acute intervention
• Health education
• Try to maintain an optimal body weight
TYPES OF SPECIALISED NUTRITIONAL THERAPY
• Oral feeding
• Tube feeding
•nasogastric and nasointestinal feeding gastrostomy and
jejenostomy
 NURSING IMPLICATIONS

• Health promotion

• Acute intervention

• Health education

• Try to maintain an optimal body weight

 PROTEIN DEFICIENCY MALNUTRITION
It is known as Protein Energy Malnutrition (PEM) / Protein
Calorie malnutrition
Types include

• Kwashiorkor
isprotein deficiency through
calorie intake may be suf icient

• Marasmus
Is starvation in infants occurring due tooverall lack of calories
It is the deficiency of caloric intake .
KWASHIORKOR AND MARASMUS
 CLINICAL FEATURES

KWASHIORKOR MARASMUS
• Occurs in children between 6 months • Growth failure
3 years of age
• Growth failure, Anemia • Wasting of all tissues including
• Wasting muscles but muscles and adipose tissue
preserved adipose tissue • Edema present
• Edema , localized or • No hepatic enlargement
generalized, present
• Enlarged fatty liver • Serum proteins low
• Serum proteins low • Anemia present
• Alternate bands of light and dark • Monkey-like face, protuberant
hair abdomen, thin limbs
 MORPHOLOGY OF MARASMUS

Morphology
• No fatty liver
• Atrophy of dif erent tissues and
organs including
subcutaneous fat
Diagnostic Evaluation
• Severe hypo chromic anemia is
generally diagnosed.
• The plasma proteins level is
usually lowered unless hemo
concentration is present
 PATHOPHYSIOLOGY OF MARASMUS

When adequate calories are not ingested to fulfill the metabolic needs
of the body, reserve food elements such as protein and fat in the
tissues are used to sustain life. This process may be caused by
• An inadequate diet or faulty eating habits
• Congenital anomalies that present the infant taking an adequate diet
Disease condition that interfere with the assimilation of food
• Infections that produce anorexia and decrease the infants ability to
digest food
• Loss of food intake through vomiting and diarrhea
• Food allergy that is not managed appropriate
• Emotional problems such as disturbed mother child relations.
 NURSING DIAGNOSIS FOR
MARASMUS
• Imbalanced Nutrition: Less Than Body Requirements related to
inadequate food intake
• Deficient fluid volume related to diarrhea
• Impaired skin integrity related to impaired nutritional / metabolic
status
• Risk for infection related to damage the body's defense
• Deficient knowledge related to lack of information
• Activity intolerance related to impaired oxygen transport system
secondary to malnutrition
• Excess fluid volume related to lower protein intake
(malnutrition)
 NURSING MANAGEMENT OF MARASMUS

• Increased nutritional intake that is rich in the essential nutrients

• Correct the dietary insufficiency - promote normal growth and

development
• Parenteral fluid therapy - correct the electrolyte imbalance and
dehydration and to restore kidney if oral feedings are not tolerated,
hyper alimentation is used
• In addition vitamins and minerals and blood transfusion may be
necessary
Nurse must carefully observe for infection of mouth, skin and
respiratory and genitourinary tracts
• Infections are to be appropriately treated if they occur
• Maintain infant’s body temperature within a normal range
• Recording intake and output
• Daily weighing, turning and preventing infection
• Protect the infant - Marasmus may also have emotional
deprivation and failure to thrive
Prevention of Marasmus
• Parent education
• Prompt treatment congenital defects
• Prevention of emotional disturbance
 MORPHOLOGY OF KWASHIORKOR

• Enlarged fatty liver

• Atrophy of dif erent

tissues and organs but
subcutaneous fat
preserved
 PATHOPHYSIOLOGY OF KWASHIORKOR
• While growth is occurring, suf icient nitrogenous food must be
consumed to maintain a positive nitrogen balance. Inadequate
amounts of the essential aminoacids are not provided, not
absorbed or abnormally lost, protein under nutrition results.
• The impaired absorption or loss of protein may occur in infants
and children who have chronic diarrhea, nephrosis, hemorrhage,
burns or infection.
• Nutritional edema, results when the body, lacking suf icient
intake or sustaining a loss of high quality protein, burns its own
tissues and destroys the plasma protein so that the level of
plasma albumin becomes low.
 PROTEIN CONTENT FOODS

• Eggs
• Cow’s milk
• Cheese
• Meat cooked
• Fish cooked
• Rice cooked
• Soy beans
• White potato
• Wheat germ
• Nuts
 NURSING DIAGNOSIS FOR KWASHIORKOR

• Imbalanced Nutrition: Less Than Body Requirements

related to the intake that is less (protein) is characterized by not

eating, anorexia, weight loss, height is not increased
• Activity intolerance related to physical infirmity

• Risk for Infection related to low body resistance

 NURSING MANAGEMENT OF KWASHIORKOR
• Replace missing nutrients - intake of protein and calorie to be
increased gradually
• Treat accompanied acute problems such as diarrhea, renal failure and
shock – give supplements over the usual diet
• anemia can be corrected by administering iron and folic acid
• Vitamins and minerals, especially vitamin A, magnesium and potassium are added
to the intake to correct any deficiencies
In spite of this management the infant or child may initially loss weight
because of loss of edema fluid - improvement can gradually be seen
• Infections or infestations to be treated
Long term management
•feed the child with adequate calories, especially one high in protein
of good biologic quality
 PREVENTION of KWASHIORKOR
• Prevention consists of providing a diet containing an adequate
quality of protein of high biologic quality for all infants and
children. In those areas where kwashiorkor is endemic parents
should be taught the nutritional needs of all family members and
adequate amounts of food should be provided to fulfill these
needs.
 ANOREXIA NERVOSA

• An eating disorder in which the person experiences hunger but

refuses to eat because of a distorted body image, leading to a
self perception of fatness
• Anorexia nervosa is a condition of self generated weight loss
usually seen in adolescent girls and young women, but also in
middle-aged women or men
 ETIOLOGY OF EATING DISORDERS
The cause of eating disorders is not certain, several factors are

likely to contribute to development of the disorders

• Socio cultural and environmental factors including media and peer
influence

• Family factors includes parental discord, and biologic factors including

genetics, neurotransmitter regulation, and hormonal functioning are
implicated

• Negative affect, low self-esteem, and dieting behaviour commonly predate

the onset of an eating disorder
CLINICAL MANIFESTATIONS OF ANOREXIA NERVOSA

Disordered eating behavior results in obvious weight loss.

Clients may limit themselves to 200 to 500 kcal/day-only
60% to 70% of the amount needed for ideal body weight .
Physical manifestations include dry skin, pallor,
bradycardia, hypotension, intolerance to cold,
constipation, and amenorrhea
 PATHOPHYSIOLOGY OF ANOREXIA NERVOSA

The pathophysiologic changes associated with anorexia nervosa

are similar to those seen in starvation. When caloric intake is
severely limited, the body adapts by using the body's fat stores
and sparing nitrogen stores. With prolonged starvation, significant
shifts in fluid and electrolyte balance can occur and can be life-
threatening. The hypothalamus responds to the lack of nutrient
intake with changes in pituitary function, resulting in amenorrhea
and infertility. The extent of malnutrition will determine the
pathophysiologic changes observed
 BULIMIA NERVOSA

An eating disorder characterized by uncontrollable binge

eating alternating with vomiting or dieting.
• Clients with bulimia nervosa tend to maintain a
relatively normal weight, but go through periods of
eating excessively (binging) and vomiting (purging)
gastric contents to prevent weight gain
• It has been suggested that bulimia nervosa is a form of
depressive illness.
CLINICAL MANIFESTATIONS OF BULIMIA NERVOSA
• Episodes of binge eating followed by self-induced vomiting
• The eating and vomiting episodes occur often in the late afternoon and
evening and are done in secret
• Some clients may abuse laxatives and diuretics as well
• Personality characteristics typical of clients with bulimia are related to
depression
Physical manifestations may not be as obvious, because the client with
bulimia may be of normal weight without any depletion of fat stores. Less
obvious clinical manifestations are erosion of tooth enamel from frequent
vomiting and esophageal and throat irritation
 NURSING MANAGEMENT OF EATING DISORDERS
• Select foods from the Food Guide Pyramid for a nutritionally balanced
diet
• Client is usually allowed to refuse a specific number of foods (such as two
or three) so that some sense of control is felt
• Observe the client during mealtimes, prevent purging
• Educate client, family, care-givers, or co-residents. Accurate calorie count
and regular monitoring of weight
• Parenteral or enteral nutrition may be needed for refractory clients with
extreme malnutrition.
Outcome
The child will be able to resume normal earning behaviours. In children with
severe nutritional depletion, the child will be able to regain weight at a safe
rare (1 to 3 kgs /week)
 REFERENCE
ICMR (2019). Recommended Dietary Allowances and RDA of Indians (ICMR 2010) and their users in planning diet New
Delhi Government of India.

Jijo J. (2014, 3rd April 2020). "Nutritional Disorders " Share Slide, 1, from https://www.slideshare.net/Jijoallsaints/nutritional-
dissorders.

Flynn N. (2012). "Nutrition in Children " Retrieved 1st April 2020, from https://
www.slideshare.net/nutritionistrepublic/nutrition-in- children-10792695.

Hepsibah S. ( 2019). Abiding with Law: The system of Hospital Incident Report. Medico-legal issues and the need for medical
tribunal Salem, Tamil Nadu, The Central Law College.

Nair, K. P. M. and L. F. Augustine (2018). "Country-specific nutrient requirements & recommended dietary allowances for Indians:
Current status & future directions." The Indian journal of medical research 148(5): 522.

Qureshi F. (2016). "Nutritional Problem." Retrieved 3rd April, 2020, from https://
www.slideshare.net/FIROZQURESHI/nutritional- problems.

UNICEF. (2020). "2018 Global Nutrition Report." Retrieved 3rd April 2020, from https://
www.unicef.org/press-releases/2018- global-nutrition-report-reveals-malnutrition-unacceptably-high-and-affects

WHO (2010). Nutrition Landscape Information System (NLIS) Country Profile Indicators. Geneva World Health Organization.