Celna Mae L.

Tejare, MD
Head of Program – Nutrition and Psychosocial Care Practices
ACF - Davap
3 octobre 2014 1
Overview of Malnutrition
Acute Malnutrition defined Types of Acute Malnutrition Acute Malnutrition as a disease

UNDERNUTRITION

Underweight
52 MILLION CHILDREN (8%)
are acutely malnourished

Acute
19 MILLION CHILDREN (2.9%)
Chronic
malnutrition
(stunting)
Malnutrition are severely malnourished
(wasted)

1 MILLION CHILDREN
die from severe malnutrition

(This means malnutrition causes 15% of all child’s death)

Micronutrient
deficiency
Sources:
Lancet 2013
UNICEF, WHO, The World Bank. Joint Child Malnutrition Estimates.
(UNICEF, New York; WHO, Geneva; The World Bank, Washington, DC; 2013
Acute Malnutrition defined Under-5 Mortality
Types of Acute Malnutrition Acute Malnutrition as a disease

Maternal and Child

UNDERNUTRITION
contributes to
45%* of under-5
deaths

*Lancet series 2013

Acute Malnutrition defined Types of Acute Malnutrition Acute Malnutrition as a disease

Sources: http://apps.who.int/classifications/icd10/browse/2010/en#/E40-E46
International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) Version for 2010
Acute Malnutrition defined Types of Acute Malnutrition Acute Malnutrition as a disease

Kwashiorkor

Nutritional Marasmus

Kwashiorkor
Marasmic-Kwashiorkor

Marasmus

Marasmic-
kwashiorkor

Sources: http://apps.who.int/classifications/icd10/browse/2010/en#/E40-E46
International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) Version for 2010
Overview of Malnutrition
Acute Malnutrition defined Types of Acute Malnutrition Acute Malnutrition as a disease

= SAM + MAM

Sources: http://apps.who.int/classifications/icd10/browse/2010/en#/E40-E46
International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) Version for 2010
 What is Acute Malnutrition?
• Caused by a decrease in food consumption and/or illness leading to
bilateral pitting edema (manas) or wasting (matinding pangangayayat).

• Types of Acute Malnutrition

– Severe Acute Malnutrition (SAM)
– Moderate Acute Malnutrition (MAM)

Global acute malnutrition (GAM) = SAM + MAM

 Conceptual Framework of Malnutrition
(UNICEF 1990)

Malnutrition
Immediate
Causes
Inadequate
Disease
(Affecting the food intake
Individual)
Underlying Inadequate
Causes Household maternal Public Health
Food security care
(Household
Level )
Access to food Access to Health care, direct caring behaviour, Health environment
Availability women’s role, Basic heath service
Status ,right, social organization
Basic PEST
Causes Local priorities
Formal and informal infrastructures
(Society Political ideology
Level) Resources
Human, Structural, Financial
ACF Pathway to Good Nutrition
Under-5 Mortality
• >9M children under 5y/o die every
year

• Undernutrition is the underlying

cause of >30% of under 5 deaths

• ACUTE MALNUTRITION is a SILENT

and INVISIBLE emergency.
 Types of Malnutrition
• Chronic Malnutrition
– Growth failure
• Underweight (weight for age index)
• Stunted (Height for age index)

• Acute malnutrition
– Wasting (MUAC / Weight for height)
– Edema or “Manas”
 What is Acute Malnutrition?
• Caused by a decrease in food consumption and/or illness leading to
bilateral pitting edema (manas) or wasting (matinding pangangayayat).

• Types of Acute Malnutrition

– Severe Acute Malnutrition (SAM)
– Moderate Acute Malnutrition (MAM)

Global acute malnutrition (GAM) = SAM + MAM

 Why focus on acute malnutrition?
• 20 M children suffer from SAM worldwide

• More than 1 M deaths of <5 children every year is associated with SAM

• Higher mortality

• Related to illness

• Can be treated and identified, and prevented in the

community before complications arise!
Nature of Malnutrition
• Protein Energy Malnutrition (PEM)
– Obsolete term!
– Poor growth in children results not only from a deficiency of protein and energy
but also from an inadequate intake of vital minerals (e.g., zinc) and vitamins, and
often essential fatty acids.

– Kwashiorkor
• more recently accepted theories suggest that kwashiorkor is likely to be due to deficiency
of one or more essential nutrients that are involved in anti-oxidant protection, including
iron, folic acid, iodine, selenium and vitamin C.
 Types of Nutrients
• Type 1 nutrients • Type 2 nutrients
– Functional nutrients – Growth nutrients
• Required for hormonal, • required to build new tissues
immunological, biochemical – Nitrogen, amino acids, potassium,
& other body processes to magnesium, zinc, sodium, chloride,
function normally phosphorus,etc.
– Micronutrients – Not stored in the body
• Iodine, Iron, Copper, – Deficiency: stunting, wasting
Calcium, Selenium, Vit B,
A,D, E, K
– Has body stores
– Deficiency: normal
anthropometrics
 Types of Nutrients
• Type 1 nutrients • Type 2 nutrients
– Iron – Nitrogen
– Iodine – Essential amino acids
– Copper – Potassium
– Calcium – Magnesium
– Selenium – Phosphorus
– Vit B, A,D, E, K – Sulphur
– Zinc
– Sodium
– chloride
 Chronic Malnutrition
• occurs over the long-term

• caused by insufficient intake of some nutrients

• Frequent infections can also slow down growth and lead to stunting (too
short for his/her age)

• short-term effects: growth faltering and weight loss with associated

micronutrient deficiencies

• longer-term effects: impaired physical and mental development

 Acute Malnutrition
• A drastic deterioration of nutritional status in a short time
can lead wasting (too thin for their height).

• poses more severe health risks

• causes bodily functions to be impaired, especially resistance

to disease

• In its severe form acute malnutrition can lead to death.

 3 clinical forms of
SEVERE ACUTE MALNUTRITION (SAM)
- Have 9.4 times chance of dying as compared to a Normal child

Marasmus Kwashiorkor Marasmic-kwashiorkor

3 octobre 2014 22
Acute Malnutrition
Types of Acute Malnutrition Acute Malnutrition as a disease
defined

Terminologies
NORMAL
ACUTE MALNUTRITION (payat)

MAM (Moderate/ WASTED)

SEVERELY UNDERWEIGHT
SAM (Severely WASTED)

Marasmus (payat)
UNDERWEIGHT
Kwashiorkor(manas)

Marasmic Kwashiorkor
OVERWEIGHT (payat na manas)

CHRONIC MALNUTRITION (pandak)

OBESE/OVERWEIGHT

3 octobre 2014 23
 Types of Malnutrition according to
anthropometry ?

Weight for Age MUAC/

Weight for Height/Length
NORMAL ACUTE MALNUTRITION

UNDERWEIGHT MAM (Moderate) or “wasting”

SAM (Severe) or “severe wasting

SEVERELY UNDERWEIGHT
Marasmus (payat)
OVERWEIGHT
Kwashiorkor (manas)
Edema
check Marasmic-Kwashiorkor
(payat na manas)

Height for CHRONIC MALNUTRITION (pandak)

Age

3 octobre 2014 24
 What is Acute Malnutrition?

Wasted Stunted
(acute (chronic
malnutrition) malnutrition)

Weight for Age Normal Low Low

Weight for Height Normal Low Normal

Height for Age Normal Normal Low

Photo credit: Mike Golden

Acute Malnutrition defined Types of Acute Malnutrition Acute Malnutrition as a disease

“Silent
Emergency”
Acute Malnutrition
Types of Acute Malnutrition Acute Malnutrition as a disease
defined

BRAIN

Well nourished Chronically

4 y.o. child malnourished
4 y.o. child
 MALNOURISHED CHILDREN...

Are less likely to read

a simple sentence at age 8

Score 7% lower
in math tests

Earn 20% less

as adults

Chronically malnourished
4 y.o. child
 Acute Malnutrition
Types of Acute Malnutrition Acute Malnutrition as a disease
defined

HAIR The hair growing from the scalp may

be white: white hair and blond hair
are not the same.

The flag sign is very rare - this is because

the hair normally falls out - most malnourished
children go bald. The ease with which the hair
is pulled out is a measure of the reduction in
protein synthesis and it a useful sign

Photo credit: M. Golden

Acute Malnutrition
Types of Acute Malnutrition Acute Malnutrition as a disease
defined

LETHARGY and IRRITABILITY

The children will lie still for hours resulting
to bed sores

Toys are important but having someone

play with them is more important
Photo credit: M. Golden
31
Acute Malnutrition
Types of Acute Malnutrition Acute Malnutrition as a disease
defined

STOOL

Multiple small green mucoid

stools are a feature of malnutrition. Counting
the stools can give a false impression of
diarrhoea. It is due to changes in the colonic
metabolism and is not related to infections such
as entaemoeba

Photo credit: M. Golden

Acute Malnutrition
Types of Acute Malnutrition Acute Malnutrition as a disease
defined

SKIN

The skin becomes

very thin and
atrophic with
many fine wrinkles
- when the oedema
resolves the skin is
stretched and seems
to large

Photo credit: M. Golden

Acute Malnutrition
Types of Acute Malnutrition Acute Malnutrition as a disease
defined

INTESTINE

Normalintestinal villi Flat intestinal villi

Thin and translucent
intestine

Photo credit: M. Golden

Acute Malnutrition
Types of Acute Malnutrition Acute Malnutrition as a disease
defined

INTESTINE Gas formation, BACTERIAL OVERGROWTH

Photo credit: M. Golden

Acute Malnutrition
Types of Acute Malnutrition Acute Malnutrition as a disease
defined

LIVER

Hepatomegaly (enlarged less functional liver

Photo credit: M. Golden

Acute Malnutrition
Types of Acute Malnutrition Acute Malnutrition as a disease
defined

cell organ
tissue

37
 REDUCTIVE ADAPTATION
• Malnourished children have adapted to low food
intake by:
– Using energy and nutrients more efficiently
– Doing less work.

• The reduced activity affects all the organs and cells in a malnourished
child’s body.
– Causes very profound effects on body functions
39
Source of Graph: Golden, M. “The Child with Marasmus” funded by UNICEF

40
Source of Graph: Golden, M. “The Child with Marasmus” funded by UNICEF

41
Source of Graph: Golden, M. “The Child with Marasmus” funded by UNICEF

42
Source of Graph: Golden, M. “The Child with Marasmus” funded by UNICEF 43
Before After

Source of Graph: Golden, M. “The Child with Marasmus” funded by UNICEF

44
45
Sodium-Potassium Pump
• The functional changes make the child more susceptible to new
infection, malabsorption, losses of nutrients, overgrowth of the
intestine bacteria and specific micronutrient deficiencies.

• malnourished child loses his appetite and reduces his intake he has
entered a downward spiral that will lead to death if the cycle is not
broken. Anorexia is a major danger sign.
• S11 Death
– In hospitals, 1/3 of SAM children
die during “regular” treatment

– When CMAM protocols are

used,the mortality rate is about
<5%

– The children that do not die can

come completely back to normal.

Treatment of disease in the malnourished is different from
the normally nourished

50
• treatments and drugs that are used appropriately in normally
nourished patients can be toxic when given to the severely
malnourished patient

• Liver and kidney function is abnormal

– drugs are not eliminated normally
– paracetamol, metronidazole, anti-emetics

• the standard treatment of complications given to non-

malnourished children can lead to the death if the patient is
severely malnourished

51
Identifying Acute Malnutrition
Treatment of Acute Malnutrition
before was Centralized
(Inpatient/Hospitals)
How CMAM came about

A number of cases that need treatment

in the IN-PATIENT FACILITY is TREMENDOUS

FEW HEALTH
• Usually HUGE NUMBER of CASES WORKERS
>30 days
of
inpatient
care

• Expensive
 Centralized (Inpatient/Hospitals))

Decentralized (Outpatient/Health Centers))

we call it now,
Community-based Programming (CMAM)

How CMAM came about

 Principle 1: Maximum access and coverage

From few areas From few areas

Municipal level
Distance and Travel time
Barangay level
 Principle 2: Timeliness

 Find children before

SAM becomes serious
and medical
complications arise

 Good community
outreach is essential

 Screening and referral

by outreach workers
(e.g., community health
workers [CHWs],
Less complication if early More complication if volunteers)
detected seen later

61
Principle 3: Appropriate Medical and Nutrition
Care

62
 Integrated Management
of Acute Malnutrition VS Current Intervention

- APPROPRIATE TREATMENT - NO DIRECT TREATMENT

- HIGH CALORIE READY TO USE - HIGH CARBOHYDRATE DIET

THERAPEUTIC FOOD (LUGAW )
(1 BOX/ CHILD = PhP 2,500)
- RECURRENT DISEASE/INFECTION,
(HOSPITALIZATION = PhP 10,000)

- RESTORE THE HEALTH OF THE CHILD - WORSEN MALNUTRITION

PHYSICALLY AND MENTALLY

- CUT THE CYCLE OF POVERTY

- CONTINUE THE CYCLE OF POVERTY
64
 Case 1 Case 2 Case 3

PRE
Treatment

3-4 mos
treatment

POST
Treatment
 10

6
Current Weight:
5 Target Weight: 9.3 kg
8.3 kg Weight (kg.)
4

Start2 Weight:
6.9 kg
1

Davao pilot case

0
First ITP admission at SPMC Davao

-admitted due to dehydration

-enrolled in the program last April 25,
2014
 CYCLE OF POVERTY
Most likely to be Miss classes in
hospitalized school
Child Gets sick
Not able to
easily
finish school

Children becomes
malnourished No stable job

Can not
provide
children with Life in poverty
right nutrition
 1000 DAYS* =Window of Opportunity
*start of woman’s pregnancy up to the child’s 2 nd birthday

• Prenatal Check-up • Exclusive Breastfeeding Complementary Feeding

(Iron, Folic Acid, Tetanus Toxoid for 1st 6 months Appropriate & Adequate

• Healthy Diet
• Healthy Diet
• Postpartum Check-up
• Family Planning
69
 CIVIL SOCIETY ORGANIZATIONS
PARENTS
EVERYONE ELSE IN THE COMMUNITY

bns
GOVERNMENT -African Proverb
Barangay and city nurses,
bhws
leaders midwives,
doctors Day care workers and teachers

Other agencies (CSSDO, CAO, 911)