1. Malnutrition and Anemia
Session 5
Malnutrition and Anemia
Malnutrition is the biggest single contributor to child mortality in 1-3 years old group in developing countries including the Philippines.
Children are brought to clinic or health center for an acute illness. Usually there is no specific complaints indicating malnutrition or anemia. The child’s family may not notice the problem, or the attending physicians overlook the telltale signs of malnutrition and anemia and focus on acute problem at hand. Physician must be able to identify these children who has a higher risk of many types of disease and death, likewise in children with mild to moderate malnutrition
Identifying and treating children at risk could decrease the morbidity and mortality accompanying malnutrition and anemia. Appropriate referral to a hospital for special feeding or blood transfusion and treatment of underlying diseases leading to severe malnutrition or anemia is necessary.

2. Learning Objectives
By the end of this session, the students will be able to:
(1) define malnutrition and anemia;
(2) differentiate the forms of malnutrition and anemia;
(3) demonstrate proper weighing and use of growth chart;
(4) recognize the signs of malnutrition and anemia
(5) assess and classify; and
(6) demonstrate how to counsel mothers on proper nutrition

3. Malnutrition
a pathological state secondary to relative or absolute deficiency or excess of one or more essential nutrients
it can also develop in children with diet lacking in the recommended amounts of essential vitamins and minerals( iron)

4. Major Causes of Malnutrition
There are several causes of malnutrition. They may vary from country to country. Immediate causes of malnutrition are:
infection
inadequate food consumption
inadequate nutrient intake
Other intermediary causes of malnutrition include: (a) unequal intra-family food distribution, lack of home food production, © insufficiency of available food (at the household level). (All these result from the inability of the family to purchase food because of poor income and poor food production that leads to highly-priced, unaffordable food supplies. Food consumption is also influenced by a number of socio-cultural factors.
More specifically, a child becomes malnourished (in the form of protein-enerygy malnutrition) if his/her intake of energy or protein is inadequate. A child whose diet lacks recommended amounts of essential vitamins and minerals can develop malnutrition. The child may not be eating enough of the recommended amounts of specific vitamins (such as vitamin A) or minerals (such as iron). For example, not eating foods that contain vitamin A can result in vitamin A deficiency. A child with vitamin A deficiency is at risk of death from measles and diarrhea. The child is also at risk of blindness. Not eating foods rich in iron can lead to iron deficiency and anemia.

5. Forms of Malnutrition
(1) Protein Energy Malnutrition is a deficiency of calories and or protein in a child’s diet
Forms of PEM
(1) marasmus
(2) kwashiorkor
PEM is present if:
The child is severely wasted
The child develop edema
The child do not grow well and become stunted
One type of malnutrition is protein-energy malnutrition. Protein-energy malnutrition develops when the child is not getting enough energy or protein from his food to meet his nutritional needs. A child who has had frequent illnesses can also develop protein energy malnutrition. The child’s appetite decreases, and the food that the child eats is not used efficiently. When the child has protein-energy malnutrition:
 The child may become severely wasted, a sign of marasmus.
 The child may develop edema, a sign of kwashiorkor.
 The child may not grow well and become stunted (too short).
Both forms of malnutrition (marasmus and kwashiorkor) may present with Growth Failure manifested as poor weight gain or a low body weight.

6. Forms of Malnutrition (2) Nutrient Deficiencies
- anemia (lack of iron)
- Vitamin A deficiency

7. Kwashiorkor and Marasmus
The chart shows that marasmic children are those that are highly deficient of protein while kwashiorkor children suffer from high inadequacy of energy. Both forms of malnutrition may present with Growth Failure manifested as poor weight gain or a low body weight. Note that the bulk of children are suffering from mild PEM but there is substantial proportion of children suffering from moderate to severe PEM.

8. Marasmus occur at all ages, more common at 0-2 years old
child is not getting enough energy from his regular diet
balanced starvation
result of unsuccessful breast feeding or insufficient breast supply
severely wasted

9. Marasmus
gross loss of subcutaneous fat; “ all skin and bone; “ loose skin folds in buttocks
potbelly and winged scapulae
poor appetite
apathetic

10. Marasmus

11. Kwashiorkor - dyspigmented (light brown, reddish brown blonde
* usually years old
* results from a low protein diet
* presence of bipedal is a cardinal sign
Common signs :
- Hair changes – sparse
- straight
- dyspigmented (light brown, reddish brown
blonde
- flag sign (light and dark bands in hair)
- Diffuse depigmentation – flaky paint or enamel dermatoses
- Puffy and moon faced
- Anemia

12. Kwashiorkor

13. CHECK FOR MALNUTRITION AND ANAEMIA.
Malnutrition and Anemia
For ALL sick children ask the mother about the child’s difficult breathing, diarrhoea, fever, ear problem and then
CHECK FOR MALNUTRITION AND ANAEMIA.
THEN CHECK FOR MALNUTRITION AND ANAEMIA
LOOK AND FEEL:
Look for visible severe wasting.
Look for palmar pallor. Is it: Severe palmar pallor?
Some palmar pallor?
Look for oedema of both feet.
Determine weight for age.
Classify NUTRITIONAL
STATUS
All sick children should be checked. In assessing a sick child’s nutritional status, use the color-coded classification table to classify the child’s illness for malnutrition and anemia. Then check for the immunization status and for other problems.
CLASSIFY the child’s illness using the colour-coded-classification table for malnutrition and anemia
Then CHECK immunization status and for other problems.

14. Malnutrition and Anemia
CHECK FOR MALNUTRITION AND ANEMIA
LOOK AND FEEL:
Look for visible severe wasting
Look for palmar pallor. Is it:
- severe palmar pallor?
- some palmar pallor?
Look for edema of both feet
Determine weight for age
CLASSIFY NUTRITIONAL STATUS
Check all sick children for malnutrition and anemia. Look and feel for the above-mentioned signs like:
(a) severe wasting, (b) palmar pallor (whether severe or some), © edema of both feet, and (d) weight for age.
Then classify the nutritional status.

15. How to check for malnutrition and anemia
Look for visible signs of wasting
Look for palmar pallor
Look and feel for edema of both feet
Determine weight for age
LOOK FOR VISIBLE SIGNS OF WASTING. A child with these signs will be very thin, has no fat, and looks like skin and bones. Remove the child’s clothes. Look for severe wasting of the muscles of the shoulders, arms, buttocks and legs. Look to see if the outline of the child’s ribs is easily seen. Look at the child’s hips. They may look small when you compare them with the chest and abdomen. Look at the child from the side to see if the fat of the buttocks is missing. When wasting is extreme, there are many folds of skins on the buttocks and thigh. It looks as if the child is wearing baggy pants. The child with visible severe wasting may still look normal. The child’s abdomen may be large or distended.
PALMAR PALLOR. It is a sign of anemia. To see if the child has palmar pallor, look at the skin of the child’s palm. Hold the child’s palm open by grasping it gently from the side. Do not stretch the fingers backwards. This may cause pallor by blocking the blood supply. Compare the color of the child’s palm with your own palm and with the palms of other children. If the skin of the child’s palm is pale, the child has some palmar pallor. IF the skin of the palm is very pale or so pale that it looks white, the child has severe palmar pallor.
EDEMA OF BOTH FEET. This is a sign of kwashiorkor. Other signs include thin, sparse and pale hair that easily falls out; dry, scaly skin especially on the arms and legs; and a puffy or “moon” face. Look and feel if the child has edema of both feet by using your thumb to press gently for a few seconds on the top side of each foot. The child has edema if there is a dent that remains in the child’s foot when you lift your thumb.
WEIGHT FOR AGE. This compares the child’s weight with the weight of other children who are the same age. You will identify children whose weight for age is below the bottom curve of a weight for age chart. These are children who are very low weight for age. Children on or above the bottom curve of the chart can still be malnourished. But children who are below the bottom curve are very low weight and need special attention to how they are fed.

16. How to determine weight for age
Weight for age compares the child’s weight with the weight of other children of the same age. Look at the WHO weight for age chart in the IMCI chart booklet. To determine weight for age:
1. Calculate the child’s age in months.
2. Weigh the child, using accurate scale. The child should wear light clothing only (no shoes)
Children whose weights fall below the bottom curve (heavy line) are assessed to have very low weight for age. Those children whose weights fall on or above the bottom curve may be malnourished too, but may not need urgent referral. A child in a very low weight needs urgent referral and pay special attention on how he will be fed.

17. How to classify nutritional status
Severe Malnutrition OR Severe Anemia
Anemia OR Very Low Weight
No Anemia AND Not Very Low Weight
If the child has visible severe wasting, severe palmar pallor or edema of both feet, classify the child as having SEVERE MALNUTRITION OR SEVERE ANEMIA. Children with edema of both feet may have other diseases such as nephrotic syndrome. They are at risk of death from pneumonia, measles, diarrhea and other severe diseases. They need urgent referral to the hospital where treatment can be carefully monitored. They may need special feeding, antibiotics and blood transfusions. Before the child leaves for the hospital give him a dose of Vitamin A.
If the child has very low weight for age or has some palmar pallor, classify the child as having ANEMIA OR VERY LOW WEIGHT. This child has a higher risk of severe disease. When you record this classification, you can just write ANEMIA if the child has only palmar pallor or VERY LOW WEIGHT if the child is only very low weight for age.
If the child is not very low weight for age and there are no other signs of malnutrition, classify the child as having NO ANEMIA AND NOT VERY LOW WEIGHT. Children less than 2 years of age have a higher risk of feeding problems and malnutrition than older children do. If the child is less than 2 years of age, assess the child’s feeding.

18. CLASSIFICATION TABLE FOR MALNUTRITION AND ANEMIA
IDENTIFY TREATMENT
(Urgent pre-referral treatments are in bold print.)
SIGNS
CLASSIFY AS
Visible severe wasting or
Severe palmar pallor or
Oedema of both feet.
SEVERE MALNUTRITION OR SEVERE ANAEMIA
Give Vitamin A.
Refer URGENTLY to hospital.
Some palmar pallor or
Very low weight for age.
ANAEMIA OR VERY
LOW WEIGHT
Assess the
feeding according to the FOOD box on the COUNSEL
THE MOTHER chart.
— If feeding problem, follow-up in 5 days.
If pallor:
— Give iron.
— Give oral antimalarial if high malaria risk.
— Give mebendazole if child is 2 years or older and
has not had a dose in the previous 6 months.
Advise mother when to return immediately.
If pallor, follow-up in 14 days.
If very low weight for age, follow-up in 30 days.
Not very low weight for age and no other signs or malnutrition.
NO ANAEMIA AND NOT VERY LOW WEIGHT
If child is less than 2 years old, assess the
feeding and counsel the mother on feeding
according to the FOOD box on the COUNSEL THE
MOTHER chart.
This slide shows the color-coded classification table for malnutrition and anemia
There are three (3) classifications for a child’s nutritional status: (1) SEVERE MALNUTRITION OR SEVERE ANEMIA, (2) ANEMIA OR VERY LOW WEIGHT and (3) NO ANEMIA AND NOT VERY LOW WEIGHT.
If the child has visible severe wasting, severe palmar pallor or edema of both feet, classify the child as having SEVERE MALNUTRITION OR SEVERE ANEMIA. Children with edema of both feet may have other diseases such as nephrotic syndrome. It is not necessary to distinguish these other conditions from kwarshiorkor since they also require referral. These children are at risk of dying from pneumonia, diarrhea, measles and other severe diseases. They need urgent referral to hospital where their treatment can be carefully monitored. Before the child leaves for the hospital, give the child a dose of Vitamin A. Vitamin A will help the immune system. It prevents certain infections as well as Vitamin A deficiency leading to corneal clouding or Bitot’s spot. Vitamin A supplementation will decrease the childhood mortality in measles.
If the child is very low weight for age or has some palmar pallor, classify the child as having ANEMIA OR VERY LOW WEIGHT. A child classified as having this has a higher risk of severe disease. When the child has only palmar pallor it can be recorded as ANEMIA or VERY LOW WEIGHT if the child is only very low weight for age.
Assess the child’s feeding and counsel the mother about feeding her child according to the instructions and recommendations in the FOOD box on the COUNSEL THE MOTHER chart.
A child with some palmar pallor may have anemia. Treat the child with iron. The anemia may be due to malaria, hookworm or whipworm. When there is a high risk of malaria, give an antimalarial to a child with signs of anemia. The presence of these soil-transmitted helminths will warrant giving mebendazole. Give this drug for children 2 years or older and those who have not had a dose of mebendazole for the past 6 months.
A child without signs of malnutrition, is not very low for age is classified as having NO ANEMIA AND NOT VERY LOW WEIGHT. Children less than 2 years of age have a higher risk of feeding problems and malnutrition than older children do. If a child is less than 2 years of age, assess the child’s feeding. Counsel the mother about feeding her child according to the recommendations in the FOOD box on the COUNSEL THE MOTHER chart.

19. Severely malnourished child
A child showing skin lesions and severe wasting of muscles of the shoulders, arms, buttocks and legs.

20. Severely malnourished children
This photo shows several African children suffering from kwashiorkor. Note the edema of the lower extremities of the two children in the foreground. Note of other signs like: sparse and pale hair that easily falls out; dry, scaly skin especially on the arms and legs; and a puffy or “moon” face.

21. Anemia A reduced number of red blood cells or
A reduced amount of hemoglobin in each red blood cell
Anemia is defined as the reduction in the number of red blood cells of an individual or a reduction in the amount of hemoglobin for each red blood cell. A child can also develop anemia as a result of (a) infections, (b) parasites such as hookworm or whipworm that can cause blood loss from the gut and lead to anemia, (c) repeated episodes of malaria or if malaria was inadequately treated, anemia may develop slowly. Often, anemia in these children is due to both malnutrition and malaria.

22. Conditions Predisposing to Anemia
infections
hookworm and whipworm infections
malaria
A child can develop anemia as a result of infections, parasitic infections due to whipworms and hookworms that can cause blood loss from the gut, and malaria which can destroy red blood cells rapidly by hemolysis. A child can develop anemia if they have had repeated episodes of malaria or if the malaria was inadequately treated. The anemia may develop slowly. Often, anemia in these children is due to both malnutrition and malaria.

23. How to check for Anemia (1) Look for palmar pallor
(2) Hold the child’s palm open by grasping it gently form the side.
DO NOT STRETCH THE FINGERS BACKWARDS
This may cause pallor by blocking the blood supply.
To check for palmar pallor, look at the skin of the child’s palm. Hold the child’s palm open by grasping it gently from the side. Do not stretch the fingers backwards. This may cause pallor by blocking the blood supply.

24. How to check for anemia
(3) Compare the color of the child’s palm with your own palm and with the palm of other children.
Severe palmar pallor - very pale or white
Some palmar pallor - pale
Compare the color of the child’s palm with your own palm and with the palm of other children. If the skin of the child’s palm is pale, the child has some palmar pallor. If the skin of the palm is very pale or so pale that it looks white, the child has severe palmar pallor.

25. How to classify Anemia Severe anemia severe palmar pallor Some anemia
some palmar pallor
No Anemia
Anemia is classified together with the child’s nutritional status.
If the child has severe palmar pallor, his anemia is classified as SEVERE ANEMIA
If the child has some palmar pallor, the anemia is classified as ANEMIA
If the child has no signs of malnutrition and is not very low weight for age, the anemia is classified as NO ANEMIA

26. Children with Anemia and Malnutrition
This picture shows a child without palmar pallor as compared with another child who has some palmar pallor (left).
This child’s hand has severe palmar pallor. Compare that with the adult’s hands which is pinkish (right).

27. How to identify the treatment
Severe Anemia - severe palmar pallor
At risk of death from:
1. Pneumonia
2. Diarrhea
3. Measles
4. Other severe diseases
Needs:
1. Urgent referral to a hospital
2. Special feeding
3. Antibiotics
4. Blood transfusion
Before discharge, give the child a dose of Vitamin A
Treatment for anemia goes hand in hand with counseling the mother feeding.
If the child has severe severe palmar pallor, he has severe anemia.
He must be urgently referred to the hospital because he is at risk of dying from the following: pneumonia, diarrhea, measles and other severe diseases.
He must be given a dose of Vitamin A before leaving for the hospital.

28. How to identify the treatment
Some Anemia – some palmar pallor
Needs:
1. Iron
2. Anti-malarial if infected
3. Mebendazole if infected
Give Mebendazole if the child is 2 years of age or older and has not had a dose of Mebendazole in the last 6 months
If the child has some palmar pallor, he is classified as ANEMIA OR VERY LOW WEIGHT. He should be given iron, an antimalarial if from a high malaria risk group and Mebendazole if the child is 2 years of age or older and has not had a dose of Mebendazole in the last 6 months.

29. How to identify the treatment
No Anemia
If the child is less than 2 years of age,
assess the child’s feeding problems and malnutrition
counsel the mother about feeding her child according to the recommendation in the Food Box on the Counsel the Mother
If the child has no signs of malnutrition, has no anemia and is less than 2 years old, assess the child’s feeding problems and counsel the mother on feeding according to the FOOD BOX on COUNSEL THE MOTHER CHART.

30. Iron Under 12 months of age – Iron syrup 3 mg/kg - maintenance
5 mg/kg – treatment
12 months or older – Iron tablets for 14 days
For a child who is less than 1 year old Iron syrup is given according to the dose of 3 mg/kg body weight if it is for maintenance. If it is for the treatment of anemia, give 5 mg/kg body weight.
If a child is 1 year old or older, give iron tablets for 14 days.

31. Iron and Anti malarial Drugs
Iron/folate tablets may interfere with the action of sulfadoxine-pyrimethanine that contains antifolate drugs
Give a child on anti-malarial drugs, iron/folate during the follow-up or after treatment of two weeks
If the child with some pallor is receiving the antimalarial sulfadoxine-pyrimethamine (Fansidar) do not give iron/folate tablets until a follow-up visit in 2 weeks.
Iron/folate may interfere with the action of the sulfadoxine-pyrimethamine which contains antifolate drugs. If the iron syrup at the health center does not contain folate, you can give the child iron syrup with sulfadoxine-pyrimethamine.
Give the child on anti-malarial drugs, iron/folate during the follow-up visit or after treatment of 2 weeks.

32. Mebendazole
Treats anemia by killing whipworms and hookworms that cause anemia through intestinal bleeding
Mebendazole 500 mg/tab or five 100 mg/tab as single dose
Mebendazole is used to treat anemia by killing whipworms and hookworms that cause anemia through intestinal bleeding. It is given at a dose of 500 mg/tab or five 100 mg/tab as single dose. Give it if you know:
1. Hookworms/whipworms are a problem in children in your area and
2. The child is 2 years of age or older and
3. The child has not had a dose in the previous 6 months.

33. Follow-up Care
(a) advise the mother to bring back her child after 14 days of iron treatment
(b) continue to give the mother iron tablets when she returns every 14 days for up to 2 months
(c) if after 2 months the child still has palmar pallor, refer the child.
Follow-up care for a child with anemia is as follows:
Advise the mother to bring back her child after 14 days of iron treatment.
2. Continue to give the mother iron tablets when she returns every 14 days for up to 2 months
3. If after 2 months the child still has palmar pallor, refer the child.

34. Case Study 1
Erika is 18 months old and weighs 7 kg. She was brought by her mother today because the child has had fever for 5 days and has a generalized rash. She does not have cough, runny nose or difficult breathing. She does not have diarrhea. She is able to drink, has not vomited, has not had convulsions, and is neither lethargic nor unconscious.
Erika lives where there is a high risk of malaria.
The health worker checked for danger signs. The health worker saw that Erika looks like skin and bones. Her temperature is 38.5 C. Her rash is generalized She has red eyes but does not have mouth ulcers, pus draining from the eyes nor clouding of the cornea. The rest of the physical examination is normal.
The health worker next checked for malnutrition or anemia. Erika has visible severe wasting. There is no palmar pallor. She does not have edema of both feet. The health worker determined her weight for age.
Questions:
Classify and assess the child’s condition.
How are you going to manage the patient?

35. Case Study 2
Michael is 11 months old and weighs 8 kg. His mother says that he has had cough for at least 3 weeks Michael does not have diarrhea. He has not had a fever during this illness. He does not have an ear problem.
He does not have any general danger signs. His temperature is 37 C. He counted 41 breaths per minute. The health worker does not see chest indrawing. There is no stridor when the child is calm.
The health worker checked him for malnutrition and anemia. He does not have visible severe wasting. His palms are very pale and appear almost white. There is no edema of both feet. The health worker determined Michael’s weight for age. Determine his weight for age.
Questions:
Determine his weight for age.
Assess and classify the patient’s condition.
What are you going to advise the mother?

36. Case Study 3
Alulu is 9 months old and weighs 5 kg. He is at the clinic today because his mother and father are concerned about his diarrhea. He does not have cough nor difficult breathing. He has diarrhea for 5 days. They have not seen blood in the stool. He does not have fever nor an ear problem.
He does not have any general danger signs. He is not restless or irritable. He is not lethargic or unconscious. His temperature is 38 C. His eyes are not sunken. He is thirsty and eager to take the drink of water offered to him. His skin pinch goes back slowly.
The health worker checked for malnutrition and anemia. The child does not have visible severe washing. There is palmar pallor. He does not have edema of both feet.
Questions:
Determine weight for age.
Assess and classify the child’s condition
Does the patient need urgent referral?

37. Case Study 4
Melvin is 37 months old and weighs 9.5 kg. His mother says that he feels hot and has been crying and rubbing his ears. The mother noted ear discharge 5 days prior to consult and Melvin complained of ear pain. He has fever for 3 days accompanied by runny nose. He does not have cough, rashes nor diarrhea. He is able to drink and does not vomit everything he drinks. He has not had any convulsions.
The risk for malaria is high in their area.
He is neither lethargic nor unconscious. His temperature is 37.5 C. The health worker sees pus draining from his ear and does not feel any tender swelling behind either ear.
He then checks the child for malnutrition and anemia. Melvin looks thin but does not have visible severe wasting. He has some palmar pallor. He does not have edema of both feet. The worker determined his weight for age.
Questions:
Determine weight for age.
Assess and classify the child’s condition
What will you advise the mother?