Update on

Global Child Malnutrition

UNC Global Health Forum
January 2017
Martha C Carlough MD MPH
Professor, Department of Family Medicine
Director, Office of International Activities
UNC/Chapel Hill
 Objectives

• To review the prevalence and

consequences of childhood undernutrition
and malnutrition globally
• To discuss methods of nutritional
surveillance and management of child
malnutrition in emergencies
• To consider the complex interplay of
“development” and malnutrition – politics,
climate and agriculture, shifting food
preferences
What constitutes malnutrition?

UNDERNUTRITION
– Intrauterine growth restriction resulting in low birth
weight
– Underweight: low body weight for age in children, and
low Body Mass Index (BMI) and adults
– Stunting (shortness): linear growth deficits
– Wasting (thinness): reflecting low weight for height
– Protein deficiency malnutrition
– Micronutrient deficiencies – most importantly: Vitamin A,
Vitamin D, zinc, iodine, iron and folate, calcium

MALNUTRITION = UNDERNUTRITION AND

OVERNUTRITION
The Burden of Maternal and Child
Undernutrition
“More than 3.1 million children under 5 die
unnecessarily each year due to the underlying
cause of undernutrition (2/3rds of deaths are in 1 st
year) and 165 million more are permanently
disabled by the physical and mental effects of a
poor dietary intake in the earliest months of life
making yet another generation less productive than
they otherwise would be”

– The consequences of child undernutrition affect

immediate as well as future health and well being
Source: Lancet Child Survival Series 2013
Rates of global stunting are slowly
decreasing

Lancet series, 2013

Wasting is slower to improve

Lancet series, 2013

Adolescent nutrition

Lancet series, 2013

Intergenerational importance of poor maternal
nutrition

• Fetal nutritional sufficiency is a reflection of the

mother’s preconceptional nutritional status
(weight status, fat stores, micronutrient status)
and her diet and nutritional status during
pregnancy
• In the short term, fetal nutritional sufficiency is
reflected in growth and development in young
childhood
• Poor maternal nutrition plays out in the next
generation with increased risk of infectious as
well as chronic diseases (CVD and diabetes)
UN data – attributable child mortality

UNICEF, 2015
 Determinants of malnutrition: The 6 “P’s”

• Production - About half of people in developing countries do

not have an adequate food supply - issues of food production
and local availability of food
• Preservation - 25% of grains are lost to bad post harvest
handling, spoilage and pest infestation; up to 50% of easily
perishable fruits and vegetables are not consumed
• Population - density, distribution, urban migration
• Pathology - nutrition-infection synergism
• Poverty - root cause of malnutrition income inequality,
household food distribution
• Politics - government policies can foster malnutrition directly
by how food is subsidized and distributed; indirectly civil
unrest and natural disasters affect market availability and costs
of foods
Synergy of nutrition and infection

*Malnutrition depresses immune

function and increases susceptibility to infection
*Anorexia (lack of appetite) results in decreased intake
and increased challenge with feeding

Nutrition Infection
* Diarrhea & vomiting speed up
nutrient losses
*Fever increases metabolic needs
*Chronic infection increases protein
needs – breaks down muscles,
deplete fat stores
*Infection and fever result in anorexia
Nutritional anthropometry – WHY?

1. Identify children or groups of children

at risk of morbidity and mortality

2. Survey a population

3. As a tool for individual monitoring and

intervention

BUT, growth monitoring by itself is NOT

an intervention…
 Using growth charts
• A standard suggests a norm or desirable target,
and thus can be a value judgment (e.g. chubby
bottle fed babies in Denver and Ohio were the
basis for international growth standards for
infants and toddlers in the 1970s and 80s)
• A reference is a tool for grouping and analyzing
data: it shows the normal distribution of sizes in
a selected population. Should be based on a
large sample of ethnically diverse, healthy,
optimally fed children
Standard deviation
 Z-score – based on standard deviation

• Most frequently used reference ranges today

in nutritional assessment – multiple computer
programs use standard distribution curves
(e.g. WHO Anthro – free software)
• The basis of WHO and most standard
national growth charts – “zones”
• GREEN = median
• YELLOW = Z score of -1 (15th%)
• RED - Low = Z score of -2 (3rd%)
• BLACK - Very low = Z score of -3 (<3rd%) or less
 WHO Multi-center growth standards (0-5 yrs)

• Pooled multi-country assessment – most

children grow similarly when nutritional needs
are met
• Brazil, Ghana, India, Norway, Oman, USA
• Breastfeeding was used as the “biologic
norm” – breastfed babies are longer and
leaner in the first few years
• May play an important part in the early
recognition of childhood obesity
For example:
WHO Growth Chart Girl 0-2 years, W/A

In a well nourished population there should be

virtually NO children at < 3rd percentile
Anthropometric Measurements

• Weight
– Scale (hanging vs. standing)
• Height
– board for recumbent for sick or very young
(<2 YOA) children or upright for others
• Middle Upper Arm Circumference
(MUAC): tape

• Head Circumference: tape (<3 YOA)

Length boards Two people required to
properly measure length

locally made
resources
Visual Screening for Nutritional
Assessment
• Marasmus or severe wasting –
shoulders, back, buttocks; ribs easily
visible
• Kwashiokor (protein energy
malnutrition) pedal edema, thin/dry
hair, very thin arms/legs
• Edema – standard technique
– 5 sec pressure, wait 2 sec and
measure depth of impression
 Severe Acute Malnutrition
Marasmus (wasting) Kwashiorkor (edema)

Kwashiokor
Marasmic

Case Fatality: Case Fatality: 50 to

20 to 30 Percent 60 Percent
Measuring other malnutrition states:

• Iron Deficiency
– Hgb/Hct measurements or subjective pallor of palm and nail beds,
conjunctiva, mucous membranes
– Intermediate indicator – % of pregnant women with Fe/folate
• Vitamin A deficiency
– keratomalacia, corneal ulcerations, conjunctival Bitot’s spots
– Night blindness (particularly in young children and pregnant women)
– Intermediate - % of children < 5 with Vitamin A supplementation at
least annually
• Iodine deficiency
– Goiter and cretinism in population
– Intermediate - % of households with iodinized salt
• Overnutrition
– BMI/Obesity measurements
– Cases/1000 population of CV disease, diabetes
Weight for Height (W/H) "wasting"

Advantages:
– age not required
– useful for larger population
surveillance and emergencies
Disadvantages:
– Less sensitive for change over time
– Inter-observer variability in height
measurements more common
Height for Age (H/A) “stunting”

Advantages:
– Assessment multiple SES-based causes,
including LBW and genetic differences
– More genetic differences globally (though
we know from immigrated populations that
this DOES change)

Disadvantages:
– Variability in height measurement
– Need to know age (might be hard in
emergencies; especially if separated from
parents)
Weight for Age (W/A) -“growth faltering”

Advantages:
– Composite of W/H and H/A
– good for following individual children over time (old
“Road to Health” charts…)
– Picks up faltering, due to inadequate weight gain
(wasting) or concomitant illness
– If slow faltering, directed to get more info - H/A and W/H

Disadvantages:
– does not indicate whether child is short and normal
weight or tall and underweight
Recurrent illness episodes:
Median Upper Arm Circumference
(MUAC)

Advantages
– easy to perform
– does not require age (reference applies to
children 6 -60 months of age, MUAC for
pregnant women with separate values)
– May be the "best" predictor of mortality in
children at risk (MUAC of < 115 mm)
Disadvantages:
– measurement error if not trained
– Doesn’t correlate with stunting

WHO, 2009
Most important, evidence based
nutrition interventions for populations at
risk
• Maternal micronutrient supplementation with calcium and
balanced protein supplements
• Exclusive breastfeeding for 6 mo, continued with appropriate
complementary foods until at least 2 YOA
• Vit A supplementation for postpartum women and children
U5
• Fe/folate for anemia (though HARD to reliably take tabs)
• Zinc for diarrhea and measles episodes, and burns in
children12-60 months of age
• Universal salt iodinization
• Supplementary home and/or community based feeding for
moderate malnutrition
• Recognition and management of acute malnutrition
Undernutrition in Emergencies
Major risks for infants and young
children in complex humanitarian crisis

• Separation from family

• Hypo or hyperthermia
• Dehydration
• Starvation
• PTSD/depression
• Abrupt weaning
• Illness – gastroenteritis, respiratory
infection, skin infections, measles and
malaria
 Triage
• Weight for Height
• MUAC
• Signs of micronutrient or kwashiokor
deficiency
• Assess for OTHER complications
Assess for complications  REFER:

–Signs of shock or sepsis

–Concomitant infections
(malaria, HIV, ARI, TB)
–Uncontrolled diarrhea
–Dehydration
–Anorexia
–Edema or Kwashiokor
Emergency contexts
Definitions of global acute malnutrition

Stunting Underweight Wasting (Acute)

(Chronic) (Both)

Index H/A W/A W/H or MUAC

Moderate < -2 SD < -2 SD < -2 SD or MUAC 10-
GAM 11.5 cm

Severe < - 3 SD < - 3SD < - 3SD or MUAC

GAM <11.5 cm, edema or
other complications
Odds Ratio of Mortality by W/H

WHO, 2009
Population Benchmarks

Severity Prevalence of GAM

(Global Acute Malnutrition)

Acceptable <5%

Poor 5-9%
Serious 10 – 14 %
Critical > = 15 %

GAM: children aged 6-59 months on the basis of WHZ <-2

 Food - local

• Supplement local food

resources
• Seasonal alterations
• Integrate cultural issues
• Functionality of markets
and shops
• Consider: fuel, soap,
water availability, fair
distribution and cost
 Food - imported
• Cost and potential to NOT
be culturally acceptable
• Bulk nutritive value may
be higher
• Increased resources spent
on logistics, staff, storage
transportation, set up of
distribution
• Issues of safety and
storage (and politics)
Response
Prevention Support Treat
Vulnerable Severe
Populations Malnutrition

Cost/Benefit

General Food Supplementary Therapeutic

Distribution Feeding Feeding
Supplementary Nutrition Options

• Wet or dry rations (should be taken home

unless there is clear rationale for on-site feeding)
of at least 1000 kcal and 40 g protein per child
per day
• Ration types:
– Fortified blended foods
– Grain + oil, sugar, salt
– High energy biscuits
– Lipid-Based Nutrient Supplements
• Point of Care supplements (usually liquid, HIGHER
micronutrient contents, 20-40g protein “dose” )
• Ready to use therapeutic food (RUTF)
Misconceptions about
breastfeeding in emergencies:
• Women under stress lose supply
• Malnourished women have reduced production
and poor quality milk
• Women who have stopped nursing cannot start
again
• A weaned infant will not nurse again
• BREASTFEEDING, AND
RELACTATION ARE
LIFE SAVING OPTIONS
Breastfeeding

• Infants who do not breastfeed are 14x

more likely to die in the first year of
life than those exclusively breastfed
• Globally approximately 38% of infants
are exclusively breastfed
• Up to 220,000 infant lives could be
saved annually with optimal
breastfeeding practices
Breast milk in the second year of life

Lancet, 2013
 Generalized Acute Malnutrition
Severe Malnutrition
WHZ < -3, MUAC < 11.5 Moderate Malnutrition
or edema WHZ < -2

COMPLICATED UNCOMPLICATED

Facility Community based

based care therapeutic Food

Discharge based on resolution

of edema, 10-15% weight Supplementary
gain, improved appetite and Feeding
ability to take RUTF
 Inpatient stabilization
• Dehydration – rehydration formula, IV fluids or blood
• Hypoglycemia – frequent feedings
• Hypothermia – appropriate protection from
environmental factors
• Micronutrient Deficiencies – supplementation of
Vitamin A, Zinc, iron/folate
• Anorexia – slow feeding, spoon feeding, naso-gastric
feeding
• Treatment for infections, parasitic infestation, malaria
• EXPENSIVE and DISRUPTIVE, sometimes
INCREASES risk of infections
Facility based care – liquid nutrients

Stabilization phase
– Low protein milk based formula F-75 (75
kcal/100 cc) for 4-7 days
– Restore electrolyte balance (additional ORS as
needed w zinc)
– Treat complications, watch for resolution of
edema and improved appetite

Rehabilitation phase
– Higher protein, high energy formula F-100
(100kcal/100 cc)
– Add iron, other micronutrients
– Start porridge feeds or RUTF as an inpatient
and transition
Ready to Use Therapeutic Food (RUTF)

Home-based
therapy for the
treatment of
moderate to severe
malnutrition
 RUTF

• First produced as “Plumpynut” by Nutriset (France)

• Now numerous local production processes (Malawi,
Haiti, Kenya)
• Ingredients
• Milk powder
• Peanut Paste
• Oil (palm oil with added Vit A)
• Sugar
• Vitamin Mineral Mix
 Easy to feed a child
RUTF
– Few spoons at a time,
multiple times a day
– Continue to breastfeed
(or give clean water)
 No cooking required
 No special storage –
doesn’t spoil easily
 Continue nursing
For any child with moderate malnutrition
oil base with low osmolality
 Ready to use therapeutic food

• Child can go home with

supply
• Follows up in 1 to 2
weeks
• All recovery done at home
• No family separation
• No social isolation
• Can be followed up in
outpatient clinic/feeding
center
Nutrition doesn’t improve in a vacuum…

• Water and sanitation

• Maternal mental health, child
development, family structure
• Access to health care, family planning
• Education, pro-family social services
• Civil society, food security, famine
• NUTRITION TRANSITION
 Nutrition transition -“Progress” in
biology and technology…
• Shift to less physical economic work, urban migration
trends globally and increased taste preferences for
sweet and fatty foods
• Edible oil revolution (easier to extract oil)
• Corn/fructose and soy excess dumping by developed
countries into processed foods
• Unlike undernutrition, overnutrition will not be solved
by economic growth and development
• Need innovative approaches – integrated interventions
to different “types” of malnutrition, linkages between
climate/agriculture and food/development
 References:
1. Black, R and C Victoria, et.al. Maternal and Child Undernutrition in LIC and MIC. The
Lancet Series on Maternal and Child Nutrition. June 2013
2. Chaparro, C and K Dewey. Use of Lipid Based Nutrient Supplements to Improve Nutrition
Adequacy of General Food Distribution Rations for Vulnerable Subgroups in Emergency
Settings. 2010. MCH Nutrition. 6(1): 1-69
3. Medicines San Frontieres. Refugee health: An approach to emergency situations. MSF.
MacMillan Press. 2008
4. Save the Children. Emergency Health and Nutrition Toolkit (2014)
5. Save the Children. Nutrition in the first 1000 days – State of the World’s Mothers. 2012.
New York, NY
6. UNHCR. Guidelines for Effective Feeding Programs in Emergencies 2014. UNHCR/WFP.
Rome
7. World Food Programme. State of Food Insecurity in the World. 2013. Rome.
8. World Health Organization. Rapid Health Assessment Protocols for Emergencies and
WHO Management of Nutrition (1999) in Emergencies (2003)
9. World Health Organization. WHO Child Growth Standards and the Identification of severe
acute malnutrition in infants and children. Joint Statement by WHO and UNICEF. 2009.
Geneva

Software – WHO Anthro 2005, Epi Info Emergency Nutritional Assessment (ENA)
Questions and comments?