Medical Care
Following evaluation of the child's nutritional status and identification of the underlying etiology of the malnutrition, dietary intervention in collaboration with a dietitian or other nutritional professionals should be initiated. Children with edema must be assessed carefully for actual nutritional status because edema may mask the severity of malnutrition. Children with chronic malnutrition may require caloric intakes more than 120-150 kcal/kg/d to achieve appropriate weight gain. The formula for determining adequate caloric intake is:
kcal/kg = (RDA for age X ideal weight)/actual weight
Additionally, any micronutrient deficiencies must be corrected for the child to attain appropriate growth and development. Most children with mild malnutrition respond to increased oral caloric intake and supplementation with vitamin, iron, and folate supplements. The requirement for increased protein is met typically by increasing the food intake, which, in turn, increases both protein and caloric intake. Adequacy of intake is determined by monitoring weight gain.
A Cochrane Database of Systematic Reviews study noted that micronutrient powders (MNPs), which are single-dose packets containing multiple vitamins and minerals in powder form for sprinkling onto any semisolid food, can effectively reduce anemia and iron deficiency in children aged 6-23 months. While the benefits of this intervention as a survival strategy or on developmental outcomes are unclear, the use of MNP is possibly comparable to daily iron supplementation and better than placebo or no intervention. [16]
In mild-to-moderate cases of malnutrition, initial assessment and nutritional intervention may be done in the outpatient setting. A patient with malnutrition may require hospitalization based on the severity and instability of the clinical situation. Hospitalization of patients with suspected malnutrition secondary to neglect allows observation of the interactions between parent/caregiver and child and documentation of actual intake and feeding difficulties. It may also be warranted in cases where dehydration and acidosis complicate the clinical picture. In moderate-to-severe cases of malnutrition, enteral supplementation via tube feedings may be necessary.
A study by Stobaugh et al found that the proportion of children that recovered from moderate acute malnutrition was significantly higher in the group that received ready-to-use supplementary food containing dairy ingredients in the form of whey permeate and whey protein concentrate than in the group that received soy ready-to-use supplementary food. The authors added that this study highlighted the importance of milk protein in the treatment of moderate acute malnutrition. [17]
Consultations
Any child at risk for nutritional deficiency should be referred to a registered dietitian or other nutritional professional for a complete nutritional assessment and dietary counseling.
In the United States, children with poor nutrition secondary to inadequate intake should be referred to the appropriate social agencies to assist the family in obtaining resources and providing ongoing care for the child.
Other subspecialty referrals are based on findings in the initial evaluation that may indicate a specific cause of inadequate nutrition other than inadequate food intake.
Diet
Dietary guidelines were released by the US Department of Health and Human Services and the US Department of Agriculture in 2020. [18]
Protein, energy, and other nutrient requirements vary with age, sex, and activity levels.
Following careful assessment of the child's nutritional status, initiate nutritional intervention in collaboration with nutrition support personnel.
Children with chronic malnutrition may require caloric intakes in excess of 120-150 kcal/kg/d to achieve appropriate weight gain. The diet must include adequate amounts of protein and other macronutrients.
Any micronutrient deficiencies must be diagnosed and corrected to achieve adequate somatic growth and psychomotor development.
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Hormonal adaptation to the stress of malnutrition: The evolution of marasmus.
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A classic example of a weight chart for a severely malnourished child.
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This infant presented with symptoms indicative of a dietary protein deficiency, including edema and ridging of the toenails. Image courtesy of the Centers for Disease Control and Prevention.
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This infant presented with symptoms indicative of Kwashiorkor, a dietary protein deficiency. Note the angular stomatitis indicative of an accompanying Vitamin B deficiency as well. Image courtesy of the Centers for Disease Control and Prevention.
