Malnutrition

Malnutrition as an imbalance between nutrient requirement and intake,

resulting in cumulative deficits of energy, protein or micronutrients that may
negatively affect growth, development and other relevant outcomes. Ideally, any
assessment of nutrition and investigations on the role of nutrition in patient
management should include data regarding growth over a period of time: actual
dietary intake available (and provided); evidence for malabsorption; evidence of
inflammatory processes; and evidence of any underlying disease. Simple
measurements, such as height, weight, skinfold thickness or mid-upper arm
circumference, have been the basis of most definitions of nutritional status. It is
not possible to exclude malnutrition of the grounds of normal anthropometry
alone. In the assessment of nutrition status in children, inadequate caloric intake
appears to be the most important cause of malnutrition (Argent et al., 2017).

Figure 1. Defining malnutrition in hospitalized children (Mehta et al., 2013)

Malnutrition defined as “an imbalance between nutrient requirement and

intake, resulting in cumulative deficits of energy, protein, or micronutrients that
may negatively affect growth, development, and other relevant outcomes”.
Ideally, any assessment of nutrition and investigations on the role of nutrition in
patient management should include data regarding growth over a period of time:
actual dietary intake available (and provided); evidence for malabsorption;
evidence of inflammatory processes; and evidence of any underlying disease
(Becker et al., 2015).
In this case, patient was diagnosed as severe malnutrition based on
clinical criteria, history of diet and anthropometry status. Patient experience
weight loss since 3 months ago. Body weight of patients was 35 kg with the
highest body weight was 45 kg 3 months ago. According to parents, patients look
thinner with clinically skinny look and thin subcuntaneous fat (impresses a
malnutrition). Based on anthropometry status, patient with body weight 35 kgs
equal to P3-P10, arm circumferrence was 15,5 cms which is below P5 and ideal
body weight percent was 77%.
Malnutrition can be caused primary due to poor or inappropriate food
intake, this is often happened in low sosio economic communities which the
composition and quantity of food is not sufficient resulting in nutritional disorder to
severe deficiency. Malnutrition can also be caused by secondary causes of other
diseases that result in reduced nutritional intake or adequate nutritional intake,
but increased of nutritional needs along with increased metabolic processes, for
example patient with chronic disease such as cancer (Argent et al., 2017).
Assessment of nutritional status in patients with malignancy is important
because malnutrition can reduce chemotherapy tolerance, increase the incidence
of infection, and decrease survival rate. Malnutrition may associated with immune
response disorders such as impaired phagocyte function, cytokine production,
antibody secretion and complement system defects. A critical review of the
prognostic value of the nutritional status in children with ALL noted that the
mortality rate for children with malnutrition was 1.8 times greater than in ALL
children with good nutrition (Guriek et al. 2015).
Some children were malnourished at the time of diagnosis and their
malnourishment was reported to have increased during the therapy for malignancy,
especially if their treatment involved intensive chemotherapy or bone marrow
transplantation. Children treated for leukemia underwent changes in nutritional status,
as manifested by a reduction in growth, weight gain and weight losses. A child with
newly diagnosed cancer appears to have the same average nutritional status as seen in
thepopulation from which the child come, if the diagnosis is made in a reasonably timely
manner (Kadir et al., 2017).
In general, malnutrition management should pay attention to signs of
emergencies such as dehydration, hypoglicemia, hypothermia and electrolyte
imbalance, known as the 10’s steps of inpatient treatment of severely
malnourished children. Those condition must be addressed in the stabilization
phase in 1-2 days to 1 week. During stabilization phase patient consume F75
with calculation of caloric need for a day was 50% of recommended dietary
allowance equal for his age (45 kcal) multiplied with his ideal body weight (kg),
fluid need was equal with Holliday Segar, protein need was 50% from 0.8-1
g/kg/day and micronutrient suplementation such as vitamin A 1 x 5000 IU, vitamin
C 1 x 100 mg, vitamin E 1 x 100 IU, folic acid 1 x 5 mg for first day continue with
1 x 1 mg and ZnSO4 1 x 20 mg. Patient was also monitored hydration status and
blood sugar level periodically. During transition phase patient was given by F100
without sugar and start solid food consumption with low glicemic index, with
calculation of caloric need for a day was 75% of recommended dietary allowance
equal for his age (45 kcal) multiplied with his ideal body weight (kg), fluid need
was equal with Holliday Segar, protein need was 75% from 0.8-1 g/kg/day.
During rehabilitation phase patient still consume F100 without sugar but caloric
need raised from before which is 100% of recommended dietary allowance equal
for his age (45 kcal) multiplied with his ideal body weight (kg), fluid need was
equal with Holliday Segar, protein need was 0.8-1 g/kg/day (WHO, 2013).

Figure 17. Ten steps to recovery for the inpatient treatment of severely
malnourished children.
Adopted from: WHO, 2003.
 A careful calculation of caloric, fluid and protein had been done. This
patient had started adequate formulation for the inpatient treatment of severely
malnourished children according recommended dietary allowance.

References

Mehta NM, Corkins MR, Lyman B, et al. 2013. Defining pediatric malnutrition: a
paradigm shift toward etiology-related definitions. JPEN J Parenter Enteral Nutr;
37: 460–481.

Becker P, Carney LN, Corkins MR, et al. 2015. Consensus statement of the
Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral
Nutrition: indicators recommended for the identification and documentation of
pediatric malnutrition (undernutrition). Nutr Clin Pract; 30: 147–161.

Guriek Gökçebay D, Emir S, Bayhan T, Demir HA, Gunduz M, Tunc B. 2015.

Assessment of nutritional status in children with cancer and effectiveness of oral
nutritional supplements assessment of nutritional status in children. J Pediatr
Hematol Oncol ;32:423-32.

Kadir, R.A.A., Hassan, J.G. and Aldorky, M.K., 2017. Nutritional assessment of
children with acute lymphoblastic leukemia. Archives in Cancer Research, 5(1).