Paediatrics: Nutritional disorders

Nutritional disorders

Malnutrition is a common cause of child mortality and morbidity. There is a wide spectrum of nutritional disorders, varying from protein-energy malnutrition to micronutrient nutritional deficiencies to morbid obesity (see Table 10.1). In non-industrialized nations malnutrition and associated infection are leading causes of child death

Causes

• Diets low in protein, energy, or specific nutrients.
• Strict fad or vegetarian diets.
• Diseases causing malabsorption (e.g. coeliac disease, cystic fibrosis, Crohn’s disease), severe GORD, immunodeficiency, chronic infection.
• Eating disorders, e.g. anorexia nervosa.

Assessment of nutritional status

Refer to a paediatric dietician and review the following:

• Recent weight loss ( 10% over 3mths is suggestive of impaired nutritional status).
• Accurately plot serial height and weight (falling across 2 centile lines or below 3rd centile may indicate nutritional impairment).
• Percentage weight for height (= [actual weight/expected weight for height centile] x 100); a value of 90% may indicate impairment.
• Body mass index (BMI) = weight (kg)/height (m)².
• Mid-arm circumference divided by head circumference (malnutrition if <0.31).
• Detailed dietary assessment of 5–7-day food diary.
• Serum albumin.

Protein-energy malnutrition

Kwashiorkor and marasmus usually occur together. Because of oedema, mid-upper arm circumference is a better guide to malnutrition than weight. Kwashiorkor is due to a severe deficiency of protein/essential amino acids.

• Clinical features: growth retardation; diarrhoea; apathy; anorexia;
• oedema; skin/hair depigmentation; abdominal distension with fatty
• liver.
• Investigations: hypoalbuminaemia, normal- and microcytic anaemia,‘fall’ Ca²⁺, ‘fall’ Mg²⁺, ‘fall’ PO³₄^– , and ‘fall’ glucose.
• Marasmus: is due to severe energy (calories) deficiency.
• Clinical features: height is relatively preserved compared to weight; wasted appearance; muscle atrophy; listless; diarrhoea; constipation.
• Investigations: ‘fall’ Serum albumin, Hb, U&E, Ca²⁺, Mg²⁺, PO₄^{3 –}, and glucose; stool M,C&S for intestinal ova, cysts, and parasites.

Treatment

• Correct dehydration and electrolyte imbalance (IV if required).
• Treat underlying infection and/or parasitic infections.
• Treat concurrent/causative disease.
• Treat specific nutritional deficiencies.
•  Orally refeed slowly- watch out for refeeding syndrome.