Approach Considerations
Severe acute malnutrition is managed in health facilities and therapeutic feeding centers in developing countries. However, limited coverage and impact, cost, cross infections, and high mortality rate have been observed.
In Ethiopia, mixed results were reported from implementation of a community-based outpatient management program of children with severe acute malnutrition and without medical complications. [52] Although the recovery rate was 64.9%, the likelihood of recovery was 2.6 times higher for children with kwashiorkor than for those with marasmus. Children residing in areas with less than 25 minutes of travel from the program site had a 1.53 times higher odds of recovery than those residing in regions with travel of 25 minutes or longer. [52]
Surgical care
In general, malnutrition is managed medically. However, some infections, particularly of the skin, may require surgical intervention for debridement and infection stabilization.
Children who are unable to obtain their nutritional requirements via oral intake may be candidates for enteral nutrition, which may require surgical placement of a feeding tube or other method of nutrition.
Medical Care
In both children and adults, the first step in the treatment of protein-energy malnutrition (PEM) is to correct fluid and electrolyte abnormalities and to treat any infections. The most common electrolyte abnormalities are hypokalemia, hypocalcemia, hypophosphatemia, and hypomagnesemia. Macronutrient repletion should be commenced within 48 hours under the supervision of nutrition specialists.
A 1980 double-blind study of eight children with kwashiorkor and skin ulceration found that topical zinc paste was more effective than placebo in healing areas of skin breakdown. Oral zinc supplements were also found to be effective.
The second step in the treatment of protein-energy malnutrition (which may be delayed 24-48 h in children) is to supply macronutrients by dietary therapy. Milk-based formulas are the treatment of choice. At the beginning of dietary treatment, patients should be fed ad libitum. After 1 week, intake rates should approach 175 kcal/kg and 4 g/kg of protein for children and 60 kcal/kg and 2 g/kg of protein for adults. A daily multivitamin should also be added.
For most of the cutaneous manifestations of inflammatory bowel disease, the primary therapy remains treatment of the bowel.
In a study of patients undergoing chemotherapy for advanced hepatic cancer, those who received a late-evening snack enhanced with branched-chain amino acids had improvements in energy metabolism parameters compared with control subjects. [45]
In discussing that protein-energy malnutrition is highly prevalent among peritoneal dialysis patients, Chung et al noted that although nutritional status assessments had improved over the decade from 1997 to 2007, no definitive single test was available to assess nutritional status. [53] Instead, they proposed that several different markers of nutrition must be used to understand nutritional status. For example, the treatment for peritoneal dialysis patients with malnutrition must be multifaceted, and they suggested using nontraditional strategies such as appetite stimulants, anti-inflammatory diets, and anti-inflammatory pharmacologic agents combined with more traditional forms of nutritional support to abate the protein-energy malnutrition. [53]
An intervention that brought "buddies" to the homes of the elderly who were at risk for protein-energy malnutrition was successful at decreasing such malnutrition. [54]
Long-term care
Patients should receive follow-up care with nutrition professionals and social services, and their growth and development should be monitored.
Diet and Activity
Diet
Nutritional support guidelines are available in the National Institute for Health and Clinical Excellence Nutrition Support in Adults quick reference guide.
Dietary Guidelines for Americans, 2015-2020, 8th edition, are available from the US Department of Health and Human Services and US Department of Agriculture. [55]
Activity
It is recommended that children who suffer from malnutrition be started early with exercises and physical therapy, as well as resources to encourage stimulation. Also, parents should be educated on the importance of activity. [56]
Consultations
Any patient at risk for nutritional deficiency should be referred to a registered dietitian or other nutrition professional for a complete nutritional assessment and dietary counseling.
Other subspecialty referrals should be considered if findings from the initial evaluation indicate that the underlying cause is not poor nutritional intake. If signs indicate malabsorption, a gastroenterologist should be consulted. Further, in pediatric cases, a pediatrician, preferably one with experience in the management of protein-energy malnutrition, should oversee care of the patient. Any patient with significant laboratory abnormalities, as discussed previously, may benefit from consultation with the appropriate subspecialty (eg, endocrinology, hematology).
Children with poor nutrition secondary to inadequate intake and/or neglect should be referred to the appropriate social agencies to assist the family in obtaining resources and providing ongoing care for the child.
Complications
In the setting of malnutrition, the risk of refeeding syndrome represents an additional clinical challenge. Prolonged starvation followed by rapid feeding leads to this condition, [57] in which there is resultant biochemical disturbance and physical symptoms/signs. Insulin release leads to the anabolic activity that underlies the pathophysiology of refeeing syndrome, and feeding overwhelms the dearth of electrolytes and micronutrients, which disrupts cellular function. Tissue edema, hypophosphatemia, and pathologic fluid shifts define refeeding syndrome.
Refeeding syndrome remains underrecognized, and patients on parenteral nutrition are considered to be at high risk. In a United Kingdom study, although refeeding syndrome was identified in 4% of cases of patients on parenteral nutrition, physicians only recognized it in half the cases. [57] Using protocols with slower and lower rates of refeeding reduces deaths attributable to this syndrome. [57]
Death can be avoided if refeeding syndrome is recognized and patients are treated with dietary adjustment and clinical guidelines are followed. A 13-month-old Kuwaiti male with marasmic kwashiorkor presented initially with normal levels of blood sugar and serum electrolytes. [58] However, by admission day 3, refeeding syndrome occurred with severe hypomagnesemia, hypokalemia, hypophosphatemia, and hypocalcemia, and the child then was given a lower calorie intake. The child survived following a gradual increase of caloric intake with vitamins, thiamine, and electrolyte supplementation. [58]
Refeeding syndrome guidelines are available in the National Institute for Health and Clinical Excellence Nutrition Support in Adults quick reference guide.
Refeeding syndrome can also occur in patients with anorexia nervosa who are replenished with food, vitamins, and electrolytes, [59] although some investigators have argued that hypophosphatemia is not a problem in refeeding this patient population. [60]
Protein in 1 gram of food provides approximately 15 mg of phosphorus. [61] Marasmic kwashiorkor is marked by phosphorus deficiency. Chronic phosphorus deficiency in humans causes proximal myopathy, and acute hypophosphatemia can precipitate rhabdomyolysis. Low blood phosphorus impedes the concentration of red blood cell synthesis as well as depletes stored levels of 2,3-diphosphoglycerate, which in turn affects hemoglobin's affinity for oxygen. Moreover, nervous system dysfunction (eg, apathy, weakness, intention tremors, a bedridden state) may occur in severe cases of phosphorus deficiency. [61]
Other groups at risk for refeeding syndrome include alcoholic individuals undergoing detoxification, extremely-low-birth-weight neonates who were intrauterine growth-restricted, cancer patients who have suffered from cachexia, and adults with kwashiorkor who receive enteral rather than parenteral feeding.
Prevention
Prevention of protein-energy malnutrition begins with addressing the underlying cause. Economic and social factors are a major contributor to malnutrition. Extreme poverty leads to poor living conditions and often inadequate hygiene, as well as limited access to food and water. Children often do not receive the care they need. All of these can also lead to an increased risk of infections. In addition, diarrhea and vomiting can exacerbate the malnutrition due to water losses.
Prevention of malnutrition also must involve education. Educate mothers on the importance of breastfeeding and on how to adequately nourish their child. These women should also receive education regarding access to immunizations and the importance of fortification of food with necessary nutrients and vitamins.
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This photograph shows children and a nurse attendant at a Nigerian orphanage in the late 1960s. Note that four of the children have gray-blond hair, a symptom of the protein-deficiency disease kwashiorkor. Image courtesy of Dr Lyle Conrad and the Centers for Disease Control and Prevention Public Health Image Library.
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This late 1960s photograph shows a seated, listless child who was among many individuals found with kwashiorkor in Nigerian relief camps during the Nigerian-Biafran war. Kwashiorkor is a disease that develops due to a severe dietary protein deficiency. This child, whose diet fit such a deficiency profile, presented with symptoms including edema of the legs and feet; light-colored, thinning hair; anemia; a pot-belly; and shiny skin. Image courtesy of Dr Lyle Conrad and the Centers for Disease Control and Prevention Public Health Image Library.
