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There are numerous emotional and physical disorders that have been linked to stress including depression, anxiety, heart attacks, stroke, hypertension, immune system disturbances that increase susceptibility to infections, a host of viral linked disorders ranging from the common cold and herpes to AIDS and certain cancers, as well as autoimmune diseases like rheumatoid arthritis and multiple sclerosis.
As demonstrated in the above list, stress can have wide ranging effects on emotions, mood and behavior.
The American Institute of Stress is a non-profit 501(c) 3 corporation established in 1979 pursuant to section 405 of the New York State Not-For-Profit Corporation Law. Protein-energy malnutrition (PEM) in young children is currently the most important nutritional problem in most countries in Asia, Latin America, the Near East and Africa.
The term protein-energy malnutrition entered the medical literature fairly recently, but the condition has been known for many years. The term PEM is used to describe a broad array of clinical conditions ranging from the mild to the serious. It has been known for centuries that grossly inadequate food intake during famine and food shortages leads to weight loss and wasting and eventually to death from starvation. The current view is that most PEM is the result of inadequate intake or poor utilization of food and energy, not a deficiency of one nutrient and not usually simply a lack of dietary protein. PEM, unlike the other important nutritional deficiency diseases, is a macronutrient deficiency, not a micronutrient deficiency. The cause of PEM (and of some other deficiency diseases prevalent in developing countries) should not, however, be viewed simply in terms of inadequate intake of nutrients.
Prematurity or low birth weight may predispose the child to the development of nutritional marasmus. The view that kwashiorkor is the result of protein deficiency and nutritional marasmus the result of energy deficiency is an oversimplification, as the causes of both conditions are complex. There is not yet broad agreement on the actual cause of the oedema that is the hallmark of kwashiorkor.
In severe PEM there is usually biochemical evidence, and often clinical evidence, of micronutrient deficiencies, which is not surprising in a child or adult who consumes a grossly inadequate diet. Irrespective of which theory of aetiology may be proved correct, improving the quantity of food consumed, taking steps to ensure that diets are nutritionally well balanced and controlling infection all help to prevent PEM. The condition of PEM is often likened to an iceberg, of which 20 percent is visible above the water and about 80 percent submerged.
As shown by the iceberg diagram (Figure 5), the prevalence of highly visible, serious PEM (kwashiorkor, marasmic kwashiorkor and nutritional marasmus) is usually between about 1 and 5 percent, except in famine areas.
The percentage of children classified as having severe, moderate and mild PEM depends on how these terms are defined. The so-called Wellcome classification of severe forms of PEM has been widely used for over 20 years (see Table 19).
In the 1950s and 1960s the degree of malnutrition was almost always based on the child's percentage of standard weight for age. In the early 1970s a number of nutrition workers began to suggest that judging the degree of malnutrition only on the basis of weight for age had many disadvantages. This classification makes a distinction between current and past influences on nutritional status. As is discussed in Chapter 33, which deals with assessment of nutritional status, it is now generally recommended that malnutrition be judged on the basis of SD below the growth standards of the United States National Center for Health Statistics (NCHS) as published by WHO.
Policy-makers and health workers need to decide which growth standards to use as a yardstick for judging malnutrition and for surveys, monitoring and surveillance. The attempt to control the extent and severity of PEM using many different strategies and actions is at the heart of nutritional programmes and policies in most developing countries.
Kwashiorkor is relatively easy to diagnose based on the child's history, the symptoms reported and the clinical signs observed (Figure 6). In most countries marasmus, the other severe form of PEM, is now much more prevalent than kwashiorkor.
Perhaps the most important precipitating causes of marasmus are infectious and parasitic diseases of childhood.
Children with features of both nutritional marasmus and kwashiorkor are diagnosed as having marasmic kwashiorkor. In kwashiorkor there is a reduction in total serum proteins, and especially in the albumin fraction.
Serum albumin determinations are relatively easy and cheap to perform, and unlike the other biochemical tests mentioned below, they can be done in modest laboratories in many developing countries.
Levels of two other serum proteins, pre-albumin and serum transferrin, are also of use and not too difficult to determine. Levels of retinol binding protein (RBP), which is the carrier protein for retinol, also tend to be reduced in kwashiorkor and to a lesser degree in nutritional marasmus. Other biochemical tests that have been used or recommended for diagnosing or evaluating PEM have limited usefulness. These tests are not specific, and most cannot be performed in ordinary hospital laboratories. All children with severe kwashiorkor, nutritional marasmus or marasmic kwashiorkor should, if possible, be admitted to hospital with the mother. Infections are so common in severely malnourished children that antibiotics are often routinely recommended. If anaemia is very severe it should be treated by blood transfusion, which should be followed by ferrous sulphate mixture or tablets given three times daily. If a stool examination reveals the presence of hookworm, roundworm or other intestinal parasites, then an appropriate anthelmintic drug such as albendazole should be given after the general condition of the child has improved. Severely malnourished children not infrequently have tuberculosis and should be examined for it. On the above regime, a child with serious kwashiorkor would usually begin to lose oedema during the first three to seven days, with consequent loss in weight.
When the diarrhoea has stopped, the oedema has disappeared and the appetite has returned, it is desirable to stop tube-feeding if this method has been used.
Children with severe nutritional marasmus may consume very high amounts of energy, and weight gain may be quite rapid. In both conditions, as recovery continues, usually during the second week in hospital, the patient gains weight. If the disease is not to recur, it is important that the mother or guardian participate in the feeding at this stage. After discharge, or if a moderate case of kwashiorkor has been treated at home and not in the hospital, the child should be followed if possible in the out-patient department or a clinic.
Out-patient treatment should be based on the provision of a suitable dietary supplement, but in most cases it is best that this supplement be given as part of the diet.
If facilities exist and it is feasible, the SCOM mixture can be used for out-patient treatment. Most deaths in children hospitalized for kwashiorkor or nutritional marasmus occur in the first three days after admission.
It is often difficult to know what to do when the child is cured, especially if the child is under one year of age. There is little doubt that a disorder due mainly to energy deficiency does occur in adults; it is more common in communities suffering from chronic protein deficiency. Some degree of oedema is nearly always present, and this may mask the weight loss, wasting and lack of subcutaneous fat.
In contrast to adult kwashiorkor or famine oedema, which is not very prevalent, the adult equivalent of nutritional marasmus is very common.
Treatment of adult PEM includes therapy related to the underlying cause of the condition and therapy related to feeding and rehabilitation, when the cause makes that feasible. Dietary treatment for adult PEM should be based on principles similar to those described for the treatment of severe PEM in children, including those recovering from kwashiorkor or marasmus. In the late 1950s and 1960s it was thought that most PEM was caused mainly by inadequate intake of protein.
Protein is an essential nutrient, but PEM is more often associated with deficient food intake than with deficient protein intake. Anaemias can be classified in numerous ways, some based on the cause of the disease and others based on the appearance of the red blood cells. Some anaemias do not have causes related to nutrition but are caused, for example, by congenital abnormalities or inherited characteristics; such anaemias, which include sickle cell disease, aplastic anaemias, thalassaemias and severe haemorrhage, are not covered here.
Based on the characteristics of the blood cells or other features, anaemias may be classified as microcytic (having small red blood cells), macrocytic (having large red blood cells), haemolytic (having many ruptured red blood cells) or hypochromic (having pale-coloured cells with less haemoglobin). Although deficiency diseases are usually considered mainly as consequences of a lack of the nutrient in the diet, iron deficiency anaemia occurs frequently in people whose diets contain quantities of iron close to the recommended allowances.
Nutritional anaemias have until recently been relatively neglected and not infrequently remain undiagnosed.
To maintain good iron nutritional status each individual needs to have an adequate quantity of iron in the diet. Human beings have the ability both to store and to conserve iron, and it must also be transported properly within the body. To produce new cells the body needs adequate quantities and quality of protein, minerals and vitamins in the diet.
Of the dietary deficiency causes of nutritional anaemias, iron deficiency is clearly by far the most important. The normal child at birth has a high haemoglobin level (usually at least 18 g per 100 ml), but during the first few weeks many cells are haemolysed.
Although most solid diets, both for children and adults, provide the recommended allowances for iron, the iron may be poorly absorbed. In most of the world, both North and South, the greatest attention to iron deficiency anaemia is directed at women during pregnancy, when they have increased needs for iron and often become anaemic. It is only in recent years that the prevalence and importance of iron deficiency apart from anaemia has been widely discussed. International agencies now claim that iron deficiency anaemia is the most common nutritional disorder in the world, affecting over 1 000 million people.
In most of the developing regions, and particularly among persons with anaemia or at risk of iron deficiency, much of the iron consumed is non-haem iron from staple foods (rice, wheat, maize, root crops or tubers). In many parts of the world where iron deficiency anaemia is prevalent it is due as much to iron losses as to poor iron intakes. Anaemia resulting from folate deficiency is less prevalent than that from iron deficiency or iron loss. Haemoglobin in the red blood cells is necessary to carry oxygen, and many of the symptoms and signs of anaemia result from the reduced capacity of the blood to transport oxygen. These symptoms and signs are not confined to iron deficiency anaemia but are similar in most forms of anaemia.
An experienced health worker can sometimes make a preliminary diagnosis by examining the tongue, the conjunctiva of the lower eyelid and the nailbed, which may all appear paler than normal in anaemia. What is surprising is that many persons with very low haemoglobin levels, especially women in developing countries, appear to function normally. A very important aspect of anaemia in women is that it markedly increases the risk of death of the mother during or after childbirth. Determinations of haemoglobin or haematocrit levels are the most widely used in the diagnosis of anaemia. A thin blood film examined under the microscope can be used to judge if the red blood cells are smaller (microcytic) or larger (macrocytic) than normal (normo cytic). Cut-off points taken from the World Health Organization (WHO) suggestions for the diagnosis of anaemia based on haemoglobin and haematocrit determinations are given in Table 24.
Certain other laboratory tests are useful in judging iron nutritional status rather than for diagnosing anaemia or its severity. Common Symptoms of AnxietyA mind map exploring the many common symptoms of anxiety, such as, GAD OCD and their associated behavioural effects. Who Am I Mind MapSometimes it is hard to know who we really are this mind map explores the many facets of who we are.
Common Types of AnxietyExplore the many types of anxiety disorder and their psychological and behavioural effects on your life. What is Your Personality Type?Take the Free Enneagram Personality Test, Understanding who you are helps you to overcome anxiety and depression. Celebrating at parties, cheering a favorite sports team, and simply enjoying a break from work are common activities throughout the year. Although many people enjoy moderate drinking, defined as 1 drink per day for women or 2 for men, drinking too much can lead to an overdose. Continuing to drink despite clear signs of significant impairments can result in a potentially deadly type of overdose called alcohol poisoning.
At the hospital, medical staff will manage any breathing problems, administer fluids to combat dehydration and low blood sugar, and flush the drinker’s stomach to help clear the body of toxins.
According to the Dietary Guidelines for Americans,2 moderate alcohol consumption is defined as up to 1 drink per day for women and up to 2 drinks per day for men. Heavy or at-risk drinking for women is the consumption of more than 3 drinks on any day or more than 7 per week, and for men it is more than 4 drinks on any day or more than 14 per week. In addition stress can have direct effects on the skin (rashes, hives, atopic dermatitis, the gastrointestinal system (GERD, peptic ulcer, irritable bowel syndrome, ulcerative colitis) and can contribute to insomnia and degenerative neurological disorders like Parkinson’s disease.
Equally important but often less appreciated are effects on various systems, organs and tissues all over the body, as illustrated by the following diagram. It often results from consuming too little food, especially energy, and is frequently aggravated by infections. In earlier literature it was called by other names, including protein-calorie malnutrition (PCM) and protein-energy deficiency.
At one end of the spectrum, mild PEM manifests itself mainly as poor physical growth in children; at the other end of the spectrum, kwashiorkor (characterized by the presence of oedema) and nutritional marasmus (characterized by severe wasting) have high case fatality rates.
Although termed PEM, it is now generally accepted to stem in most cases from energy deficiency, often caused by insufficient food intake. Failure of breastfeeding because of death of the mother, separation from the mother or lack of or insufficient breastmilk may be causes in poor societies where breastfeeding is often the only feasible way for mothers to feed their babies adequately.
Both endogenous and exogenous causes are likely to influence whether a child develops nutritional marasmus, kwashiorkor or the intermediate form known as marasmic kwashiorkor.
Most researchers agree that potassium deficiency and sodium retention are important in the pathogenesis of oedema. The severe forms of PEM - kwashiorkor, nutritional marasmus and marasmic kwashiorkor - constitute the top, exposed part of the iceberg: they are relatively easy for a doctor or health worker to diagnose simply from their clinical manifestations, described below. In contrast, moderate and mild malnutrition in many countries of sub-Saharan Africa and South Asia add up to 30 to 70 percent.
The two severe forms of malnutrition, kwashiorkor and nutritional marasmus, have very different appearances and clinical features as described below. It has the advantage of simplicity because it is based on only two measures, namely the percentage of standard weight for age and the presence or absence of oedema. A method was suggested that distinguished three categories of mild to moderate PEM based on weight and height measurements of children.
It helps the examiner assess the likelihood that supplementary feeding will markedly improve the nutritional status of the child, and it gives the clinician some clue as to the history of the malnutrition in the patient. Studies from several countries show that the risk of mortality increases rather steadily with worsening nutritional status as indicated by anthropometric measures.
The reduction and eventual prevention of mild or moderate malnutrition will automatically reduce severe malnutrition.
It is seen most frequently in children one to three years of age, but it may occur at any age. Diarrhoea, respiratory infections, measles, whooping cough, intestinal parasites and other infections are common underlying causes of PEM and may precipitate children into either kwashiorkor or nutritional marasmus. The accumulation of fluid in the tissues causes swelling; in kwashiorkor this condition is always present to some degree. The hair of a normal Asian, African or Latin American child is usually dark black and coarse in texture and has a healthy sheen that reflects light. Most cases have some degree of anaemia because of lack of the protein required to synthesize blood cells.
In kwashiorkor some subcutaneous fat is usually palpable, and the amount gives an indication of the degree of energy deficiency. There may be pressure sores, but these are usually over bony prominences, not in areas of friction.
Although not a feature of the disease itself, dehydration is a frequent accompaniment of the disease; it results from severe diarrhoea (and sometimes vomiting). In the Wellcome classification (see above) this diagnosis is given for a child with severe malnutrition who is found to have both oedema and a weight for age below 60 percent of that expected for his or her age. Some biochemical estimations are used, and give different results for children with kwashiorkor and nutritional marasmus than for normal children or those with moderate PEM. However, other diseases, such as liver disease, vitamin A and zinc deficiencies and hyperthyroidism, may also influence RBP levels. The child should be given a thorough clinical examination, including careful examination for any infection and a special search for respiratory infection such as pneumonia or tuberculosis. In that case the best possible medical treatment available at a health centre, dispensary or other medical facility is necessary.

Treatment is often based on dried skimmed milk (DSM) powder.1 DSM may most simply be reconstituted in hospital by adding one teaspoonful of DSM powder to 25 ml of boiled water and mixing thoroughly. If cupor spoon-feeding is difficult - which is possible if the child does not have sufficient appetite and is unable to cooperate or if the child is seriously ill the same mixture is best given through an intragastric tube. They can all be administered in exactly the same way (by spoon, feeding cup or intragastric tube). Children with kwashiorkor or nutritional marasmus who have severe diarrhoea or diarrhoea with vomiting may be dehydrated.
Even in tropical areas temperatures at night often drop markedly in hospital wards and elsewhere. Although it is useful to establish standard procedures for treating kwashiorkor and nutritional marasmus in any hospital or other health unit, each case should nevertheless be treated on its own merits. Benzyl-penicillin by intramuscular injection, 1 million units per day in divided doses for five days, is often used. During this period, the diarrhoea should ease or cease, the child should become more cheerful and alert, and skin lesions should begin to clear. However, the length of time needed in hospital or for full recovery may be longer than for children with kwashiorkor. While feeding of milk is continued, a mixed diet should gradually be introduced, aimed at providing the energy, protein, minerals and vitamins needed by the child.
The mother should be shown a teaspoon and told how many teaspoonfuls to give per day based on the child's weight. Case fatality rates depend on many factors including the seriousness of the child's illness at the time of admission and the adequacy of the treatment given. A child with severe marasmus and lungs grossly damaged by tuberculous infection obviously has poor prospects.
Usually 120 kcal and 3 g of protein per kilogram of body weight per day are sufficient for long-term treatment. The patient is markedly underweight for his or her height (unless grossly oedematous), the muscles are wasted, and subcutaneous fat is reduced.
Oedema is most common in the legs, and in male patients also in the scrotum, but any part of the body may be affected.
The abdomen is often slightly distended, and on palpation the organs can be very easily felt through the thin abdominal wall. The skin is often dry and scaly, and may have a crazy-pavement appearance, especially over the tibia. Any older child or adult whose diet is grossly deficient in energy will develop signs almost exactly like those of nutritional marasmus, and if the condition progresses it may often be fatal. The second major cause of severe wasting or severe PEM in adults is infections, especially chronic, untreated or untreatable infections. Another cause of wasting in people of any age is malignancy or cancer of any organ once it progresses to a stage not treatable by surgical excision. Thus infections such as tuberculosis or chronic amoebiasis require specific therapy which when effective will eliminate the cause of the weight loss and wasting. Emergency feeding and the rehabilitation of famine victims (described in Chapter 24) have relevance to adult PEM. It is much more difficult than controlling, for example, iodine deficiency disorders (IDD) and vitamin A deficiency, because the underlying and basic causes, as described above, are often numerous and complex, and because there is no single, universal, cheap, sustainable strategy that can be applied everywhere to reduce the prevalence or severity of PEM.
Appropriate nutrition policies and programmes are suggested, and separate chapters deal with, for example, improving food security, protection and promotion of good health, and appropriate care practices to ensure good nutrition. A great deal of emphasis was placed on protein-rich foods as a major solution to the huge problem of malnutrition in the world. In general, when commonly consumed cereal-based diets meet energy needs, they usually also meet protein needs, especially if the diet also provides modest amounts of legumes and vegetables.
These measures are likely to have more impact if accompanied by growth monitoring, immunization, oral rehydration therapy for diarrhoea, early treatment of common diseases, regular deworming and attention to the underlying causes of PEM such as poverty and inequity. Unlike protein-energy malnutrition (PEM), vitamin A deficiency and iodine deficiency disorders (IDD), these anaemias occur frequently in both developing and industrialized countries.
It threatens over 60 percent of women and children in most non-industrialized countries, and more than half of these have overt anaemia.
There are many reasons for the lack of attention, but the most important are probably that the symptoms and signs are much less obvious than in severe PEM, IDD or xerophthalmia, and that although anaemias do contribute to mortality rates they do not often do so in a dramatic way, and death is usually ascribed to another more conspicuous cause such as childbirth. The iron has to be in a form that permits a sufficient amount of it to be absorbed from the intestines. The average male adult has 4 to 5 g of iron in his body, most of it in haemoglobin, a little in myoglobin and in enzymes and around 1 g in storage iron, mainly ferritin in the cells, especially in the liver and bone marrow. Protein is needed both for the framework of the red blood cells and for the manufacture of the haemoglobin to go with it. Good dietary sources of iron include foods of animal origin such as liver, red meat and blood products, all containing haem iron, and vegetable sources such as some pulses, dark green leafy vegetables and millet, all containing non-haem iron. In general, haem iron from foods of animal origin (meat, poultry and fish) is well absorbed, but the non-haem iron in vegetable products, including cereals such as wheat, maize and rice, is poorly absorbed.
The iron liberated is not lost but is stored in the body, especially in the liver and spleen. Many people have increased needs because of blood loss from hookworm or bilharzia infections, menstruation, childbirth or wounds. Pregnant women form the one group of the healthy population who are advised to take a medicinal dietary supplement, usually iron and folic acid. Clearly, however, if the causes of iron deficiency are not removed, corrected or alleviated then the deficiency will lead to anaemia, and gradually the anaemia will become more serious. In females of child-bearing age in poor countries prevalence rates range from 64 percent in South Asia to 23 percent in South America, with an overall mean of 42 percent (Table 23).
In many countries the proportion of dietary iron coming from legumes and vegetables has declined, and rather small quantities of meat, fish and other good sources of haem iron are consumed. It occurs when folate intakes are low and when red cells are haemolysed or destroyed in conditions like malaria. The examiner can compare the redness or pinkness below the nail of the patient with the colour beneath his or her own nails. In this respect it differs from the serious manifestations of PEM, vitamin A deficiency and IDD; kwashiorkor, nutritional marasmus, advanced xerophthalmia, goitre and cretinism can all be diagnosed with some degree of certainty by skilled clinical observation. It is now realized that although these tests provide information on the absence, presence or severity of anaemia, they do not provide information on the iron stores of the individual.
These range from simple colorimetric tests to more advanced tests which require a proper laboratory. In iron deficiency they are microcytic and in folate or vitamin B12 deficiency they are macrocytic. In recent years it has been increasingly recognized that iron status is important because mild or moderate iron deficiency, prior to the development of anaemia, may adversely influence human behaviour, psychological development and temperature control. An overdose of alcohol occurs when a person has a blood alcohol content (or BAC) sufficient to produce impairments that increase the risk of harm. Even small increases in BAC can decrease coordination, make a person feel sick, and cloud judgment. Alcohol in the stomach and intestine continues to enter the bloodstream and circulate throughout the body. Alcohol acts as a depressant, hindering signals in the brain that control automatic responses such as the gag reflex.
Cold showers, hot coffee, or walking will not reverse the effects of alcohol overdose and could actually make things worse. Know that even if you drink within these limits, you could have problems with alcohol if you drink too quickly, have health conditions, or take medications. In fact, it’s hard to think of any disease in which stress cannot play an aggravating role or any part of the body that is not affected (see stress effects on the body stress diagram) or.
A child who manifests growth failure may be shorter in length or height or lighter in weight than expected for a child of his or her age, or may be thinner than expected for height. Factors that adversely influence any of these requisites can be causes of malnutrition, particularly PEM. An underlying cause of PEM is any influence that prevents mothers from breastfeeding their newborn infants when they live in households where proper bottle-feeding may be difficult or hazardous.
In a child who consumes much less food than required for his or her energy needs, energy is mobilized from both body fat and muscle.
Some evidence supports the classical argument that oedematous malnutrition is a sign of inadequate protein intake.
The second is that free radicals are important in the pathogenesis of kwashiorkor; it has been hypothesized that most of the clinical features of kwashiorkor could be caused by an excess free radical stress. However, there is little indication that any one micronutrient deficiency is the main cause of PEM or is by itself responsible for the oedema of kwashiorkor. In these areas often only 15 to 50 percent of young children between six months and 60 months of age do not have evidence of PEM. It is generally agreed that the hallmark of kwashiorkor is pitting oedema, and the overriding feature of nutritional marasmus is severe underweight. In a normal distribution it is expected that 2 to 3 percent of children will fall below the -2 SD cut-off point. The international growth standards have been found to be applicable for developing countries, as evidence shows that the growth of privileged children in developing countries does not differ importantly from these standards, and that the poorer growth seen among the underprivileged results from social factors, including the malnutrition-infection complex, rather than from ethnic or geographic differences.
Recent investigations in Guatemala indicated that teenagers who had manifested poor growth when examined in early childhood were smaller in stature, did less well at school, had poorer physical fitness and had lower scores on psychological development tests than children from the same villages who grew better as young children.
Thus, although it may be tempting (particularly for doctors and other health workers) to put major emphasis on the control of nutritional marasmus and kwashiorkor, resources are often better spent on controlling mild and moderate PEM, which will in turn reduce severe PEM.
It is found in children who have a diet that is usually insufficient in energy and protein and often in other nutrients. These infections often result in loss of appetite, which is important as a cause of serious PEM. All cases of kwashiorkor have oedema to some degree, poor growth, wasting of muscles and fatty infiltration of the liver.
If the child's precise age is known, the child will be found to be shorter than normal and, except in cases of gross oedema, lighter in weight than normal (usually 60 to 80 percent of standard or below 2 SD). The child is usually apathetic about his or her surroundings and irritable when moved or disturbed. It tends to occur first in areas of friction or of pressure such as the groin, behind the knees and at the elbow. The skin lesions are sometimes similar to those of kwashiorkor, but in pellagra they tend to be on areas exposed to sunlight(not the groin, for example). It may occur at any age, most commonly up to about three and a half years, but in contrast to kwashiorkor it is more common during the first year of life. If the age is known, the weight will be found to be extremely low by normal standards (below 60 percent or -3 SD of the standard). Diarrhoea of an infective nature, as mentioned above, may commonly have been a precipitating factor. Children with marasmic kwashiorkor have all the features of nutritional marasmus including severe wasting, lack of subcutaneous fat and poor growth, and in addition to oedema, which is always present, they may also have any of the features of kwashiorkor described above. However, serum transferrin levels are also influenced by iron status, which reduces their usefulness as an indicator of kwashiorkor. The child should receive 150 ml of this mixture per kilogram of body weight per day, given in six feeds at approximately four-hour intervals. The tube should be made of polyethylene; it should be about 50 cm long and should have an internal diameter of 1 mm. Intravenous feeding is not necessary unless the vomiting is severe or the child refuses to take fluids orally.
The seriously malnourished child has difficulty maintaining his or her temperature and may easily develop a lower than normal body temperature, termed hypothermia. Ampicillin, 250 mg in tablet form four times a day by mouth, or amoxycillin, 125 mg three times a day by mouth, can also be given. Her cooperation with and follow-up of this regime is much more likely if the hospital diet of the child is based mainly on products that are used at home and that are likely to be available to the family.
Many supplements, especially DSM, are best provided by adding them to the child's usual food (such as cereal gruel) rather than by making a separate preparation. In some societies sick children are taken to hospital very late in the disease, when they are almost moribund. Instruction and nutrition education are vital for the person who will be responsible for the child.
Mental changes are common: the patient is usually disinterested and appears to be in a dream world.
During palpation there is nearly always a gurgling noise from the abdomen, and peristaltic movements can often be detected with the fingertips. Other features such as hair changes and parotid swelling are common in adult PEM but not in anaemia.
The most common of these now is acquired immunodeficiency syndrome (AIDS) resulting from infection with the human immunodeficiency virus (HIV).
These diseases, of which some are hereditary, result in the inability of the body to digest or absorb certain foods or nutrients.
The most widely described is anorexia nervosa, which occurs much more commonly in females than males, in adolescents or younger adults rather than older persons and in affluent rather than poor societies.
These chapters provide guidance on how to deal with the three underlying causes of malnutrition, namely inadequate food, health and care, which in Chapter 1 were included in the conceptual framework for malnutrition. This inappropriate strategy diverted attention from the first need, which is adequate food intake by children. Primary attention needs to be given to increasing total food intake and reducing infection.
The most common cause of anaemia is a deficiency of iron, although not necessarily a dietary deficiency of total iron intake.
In most industrialized countries in North America, Europe and Asia, 12 to 18 percent of women are anaemic. However, research now indicates that iron deficiency has very important implications, including poorer learning ability and behavioural abnormalities in children, lower ability to work hard and poor appetite and growth.
Losses of iron from the body must not deplete the supply to less than that needed for manufacture of new red blood cells. Iron is essential for the manufacture of haemoglobin, and if a sufficient amount is not available, the cells produced will be smaller and each cell will contain less haemoglobin than normal. However, the total quantity of iron in the diet is not the only factor that influences the likelihood of developing anaemia.
As milk is a poor source of iron, this reserve store is used during the early months of life to help increase the volume of blood, which is necessary as the baby grows. Women have increased needs during pregnancy, when iron is needed for the foetus, and during lactation, for the iron in breastmilk. Increasing evidence suggests that iron deficiency as manifested by low body iron stores, even in the absence of overt anaemia, is associated with poorer learning and decreased cognitive development. Prevalence rates are usually considerably higher in pregnant women, with an overall mean of 51 percent. In some of the regions with the highest prevalence of anaemia the poor are not improving their dietary intake of iron, and in some areas the per caput supply of dietary iron may even be decreasing year by year. Thus iron is lost in menstruation and childbirth and also when pathological conditions are present such as bleeding peptic ulcers, wounds and a variety of abnormalities involving blood loss from the intestinal or urinary tract, the skin or various mucous membrane surfaces. The anaemia of both folate and vitamin B12 is macrocytic, with larger than normal red blood cells. Because none of the symptoms seem severe, dramatic or life threatening, at least in the early stages of anaemia, the disorder tends to be neglected. They may indeed do reduced work, have fatigue and walk more slowly, but they still give the appearance of performing their normal duties even though severely anaemic. Consequently, whereas few district hospitals and practically no health centres have laboratories set up to test, for example, levels of serum vitamin A or urinary iodine, most are able to do haemoglobin or haematocrit determinations. In terms of nutritional assessment to guide nutrition planning and interventions, or for research, it may be important to know more about the iron status of an individual than can be gained from haemoglobin and haematocrit determinations. Some new portable colorimeters can be used in the field; they are simple to use and provide reasonably accurate measurements.
Blood (also obtained from a finger prick) is placed in a capillary tube and centrifuged, usually at 3 000 rpm. A person whose diet is low in iron or who is losing iron goes through a period when body iron stores (which are mainly in the liver) are gradually depleted before he or she develops anaemia as judged by low haemoglobin or haematocrit levels (see Figure 7).
Overdoses can range in severity, from problems with balance and slurred speech to coma or even death. This can lead to injury from falls or car crashes, leave one vulnerable to sexual assault or other acts of violence, and increase the risk for unprotected or unintended sex.
This list will undoubtedly grow as the extensive ramifications of stress are increasingly being appreciated. However, in some regions this fall in percentage has not been as rapid as the rise in population; thus in some regions, such as Africa and South Asia, the number of malnourished children has in fact risen.

It was often described as the most important form of malnutrition, and it was believed to be caused mainly by protein deficiency. It is unknown why a given child may develop one syndrome as opposed to the other, and it is now seen that these two serious clinical forms of PEM constitute only the small tip of the iceberg. Therefore promotion of infant formula and insufficient support of breastfeeding by the medical profession and health services may be factors in the aetiology of marasmus. Gluconeogenesis in the liver is enhanced, and there is loss of subcutaneous fat and wasting of muscles. For example, oedema, fatty liver and a kwashiorkor-like condition can be induced in pigs and baboons on a protein-deficient diet.
This new, relatively untested theory also suggests, however, that kwashiorkor, even if produced by free radicals, is likely to occur only in children who have inadequate food intake and are subjected to infection.
Mild and moderate PEM are diagnosed mainly on the basis of anthropometry, especially using measurements of weight and height and sometimes other measurements such as arm circumference or skinfold thickness. The diagram illustrates that both energy deficiency and protein deficiency play a part, but that energy deficiency is more important. Children who have both oedema and severe underweight are diagnosed as having marasmic kwashiorkor. Today a cut-off point using standard deviations (SD) is considered more appropriate than percentage of standard, but not many children would be reclassified. Prevalence above that level suggests that there is a nutritional problem in the population assessed.
Often the food provided to the child is mainly carbohydrate; it may be very bulky, and it may not be provided very frequently. Infections, especially those resulting in fever, lead to an increased loss of nitrogen from the body which can only be replaced by protein in the diet. Other signs include mental changes, abnormal hair, a typical dermatosis, anaemia, diarrhoea and often evidence of other micronutrient deficiencies.
Nutritional marasmus is in fact a form of starvation, and the possible underlying causes are numerous.
Other common causes of marasmus are premature birth, mental deficiency and digestive upsets such as malabsorption or vomiting. Children with marasmus often violently suck their hands or clothing or anything else available.
There may be skin changes including flaky-paint dermatosis, hair changes, mental changes and hepatomegaly. Serum albumin drops to low or very low levels usually only in clinically evident kwashiorkor. For example, a 5-kg child should receive 5 x 150 ml per day = 750 ml per day, divided into six feeds = 125 ml per feed.
Rehydration should be achieved using standard oral rehydration solution (ORS), as is described for the treatment of diarrhoea (see Chapter 37). If anaemia is still present, the child should now start a course of iron by mouth, and half a tablet (125 mg) of chloroquine should be given weekly. This is not feasible in every case in a large hospital, but the diet should at least be based on locally available foods. A relaxed atmosphere is desirable, and the medical attendant should have time to explain matters to the mother and to see that she understands what is expected of her.
If the child has been brought by the father, then some female relative should spend a few days in the hospital before the child is discharged. It should be noted that a marasmic child during the early part of recovery may be capable of consuming and utilizing 150 to 200 kcal and 4 to 5 g of protein per kilogram of body weight per day. It is not uncommon for adult kwashiorkor patients to regard their physical state as a consequence of abdominal upset. Famines and severe food shortages resulting from war, civil disturbance or natural disasters such as droughts, floods and earthquakes may result in nutritional marasmus in children and a similar condition in adults, who suffer from weight loss, wasting, diarrhoea, infectious diseases, etc. Other chapters in Part V discuss solutions to particular aspects of the problem, including improving the quality and safety of foods, promoting appropriate diets and healthy lifestyles, procuring food in different ways and incorporating nutrition objectives into development policies and programmes.
There is now much less emphasis on high-protein weaning foods and on nutrition education efforts to ensure greater consumption of meat, fish and eggs, which are economically out of the reach of many families who have children with PEM.
The type of iron in the diet, the individual's requirements for iron, iron losses and other factors often are the determining factors.
On an average monthly basis, the adult pre-menopausal woman loses about twice as much iron as a man. It is well known that phytates and phosphates, which are present in cereal grains, inhibit iron absorption. Premature infants have fewer red blood cells at birth than full-term infants, so they are much more prone to anaemia.
It is stressed that iron from vegetable products, including cereal grains, is less well absorbed than that from most animal products.
Thus half the pregnant women in these regions, whose inhabitants represent 75 percent of the world's population, have anaemia.
Undoubtedly one of the most prevalent and important causes of blood loss is hookworms, which can be present in very large numbers. These tests require quite cheap apparatus and can be performed by a trained technician, nurse or other health worker.
In the laboratory of even a moderate-sized hospital the so-called cyanmethaemoglobin method is frequently used; it is accurate and can be used to test blood collected by finger prick in the field. What tips the balance from drinking that has pleasant effects to drinking that can cause harm varies among individuals. With no gag reflex, a person who drinks to the point of passing out is in danger of choking on vomit, which, in turn, could lead to death by asphyxiation.
In fact the number of underweight children worldwide has risen from 195 million in 1975 to an estimated 200 million at the end of 1994, which means that more than one-third of the world's under-five population is still malnourished. In most populations studied in poor countries, the point prevalence rate for kwashiorkor and nutritional marasmus combined is 1 to 5 percent, whereas 30 to 70 percent of children up to five years of age manifest what is now termed mild or moderate PEM, diagnosed mainly on the basis of anthropometric measurements. Certain factors that contribute to PEM, particularly in the young child, are related to the host, the agent (the diet) and the environment. Prolonged exclusive breastfeeding without the introduction of other foods after six months of age may also contribute to growth faltering, PEM and eventually nutritional marasmus. It has been suggested that under these circumstances, especially when protein intake is very low relative to carbohydrate intake (with the situation perhaps aggravated by nitrogen losses from infections), various metabolic changes take place which contribute to the development of oedema. Epidemiological evidence also shows higher rates of kwashiorkor in Uganda, where the staple diet is plantain, which is very low in protein, than in neighbouring areas where the staple food is a cereal.
Thus even if this theory were to be proved correct, it would merely explain a mechanism for the pathogenesis of kwashiorkor. It suggests that protein deficiency plays a greater part in kwashiorkor and energy deficiency in nutritional marasmus. If measurements are also taken of length or height, then the children can be further divided into those who are wasted, stunted, or wasted and stunted. To diagnose the presence of oedema the medical attendant presses with a finger or thumb above the ankle.
At the same time it lacks lustre, is dull and lifeless and may change in colour to brown or reddish brown. If flaky-paint dermatosis or other signs of kwashiorkor are present, the diagnosis is established.
For whatever reason, the child does not get adequate supplies of breastmilk or of any alternative food. When the skin is taken between forefinger and thumb, the usual layer of adipose tissue is found to be absent.
Serum albumin levels are not useful in predicting imminent kwashiorkor development in moderate PEM cases. The protruding end should be secured to the cheek either with sticky tape or zinc oxide plaster. The vegetable oil increases the energy content and energy density of the mixture and appears to be tolerated better than the fat of full cream milk.
For severely malnourished children, unusually dilute ORS often provides some therapeutic advantage. At home the child may have been kept warm sleeping in bed with the mother, or the windows of the house may have been kept closed.
Thus in a maize-eating area, for example, the child would now receive maize gruel with DSM added.
It is useless just to hand over a bag of milk powder or other supplement, or simply to weigh the child but not provide simple guidance. If he or she is fed only at family mealtimes and the family eats only twice a day, then the mother should be told to feed the child two extra times. She should be instructed in feeding with a spoon or cup and told not to feed the child from a bottle unless he or she is under three months of age.
For this reason, strong purgatives, either proprietary or herbal, and peppery enemas are sometimes used by these patients before they reach hospital, which may greatly aggravate the condition. Throughout Part V there is an emphasis on improving the quality of life of people, especially by reducing poverty, improving diets and promoting good health.
Ascorbic acid, vitamin E, copper and pyridoxine are also needed for production of red blood cells (erythrocytes). In anaemia either the amount of haemoglobin in each red cell is low (hypochromic anaemia) or there is a reduction in the total number of red cells in the body.
In addition, iron deficiency in the mother may affect the infant's vital iron store and render the infant more vulnerable to anaemia. Unlike reported figures for PEM and vitamin A deficiency, which are declining, estimates suggest that anaemia prevalence rates are increasing. The different methods and their advantages are discussed in various books, of which some are included in the Bibliography. To monitor iron stores it is useful to determine serum ferritin levels, because they are the first to decline.
Age, drinking experience, gender, the amount of food eaten, even ethnicity all can influence how much is too much.
This stress on kwashiorkor and on protein led to a relative neglect of nutritional marasmus and adequate food and energy intakes for children. The underlying causes could also be categorized as those related to the child's food security, health (including protection from infections and appropriate treatment of illness) and care, including maternal and family practices such as those related to frequency of feeding, breastfeeding and weaning.
More sodium and more water are retained, and much of the water collects outside the cardiovascular system in the tissues, which results in pitting oedema. It would not change the fact that improving diet and reducing infection lead to significant reduction in both kwashiorkor and nutritional marasmus. If oedema is present the pit formed takes a few seconds to return to the level of the surrounding skin. Underneath the flaking skin are atrophic depigmented areas which may resemble a healing burn. It is often true that the more severe the kwashiorkor, the lower the serum albumin, but serum albumin levels are not useful in evaluating less severe PEM. Casein increases the cost of the mixture, but as it often serves to reduce the length of the hospital stay, the money is well spent. Thus if standard ORS packets are used which are normally added to 1 litre of boiled water, in a serious case a packet might be added to 1.5 litres of water.
For an older child, crushed groundnuts can be added twice a day, or, if preferred by custom, roasted groundnuts can be eaten.
The best procedure is usually to provide a thin gruel made from the local staple food plus two teaspoonfuls of DSM (or some other protein-rich supplement) and two teaspoonfuls of oil per kilogram of body weight per day. Advanced tuberculosis and many other long-term chronic infections also lead to wasting and weight loss.
The life of each red blood cell is about four months, and the red bone marrow is constantly manufacturing new cells for replacement. If either is deficient, large abnormal red blood cells without adequate haemoglobin are produced. Recent research has shown that ascorbic acid mixed with table salt and added to cereals increases the absorption of intrinsic iron in the cereals two- to fourfold. A baby's store of iron plus the small quantity of iron supplied in breastmilk suffice for perhaps six months, but then other iron-containing foods are needed in the diet. This is not a simple or cheap test to do, and few small or medium-sized hospitals in developing countries have the ability to do it, but teaching hospitals and nutrition research laboratories sometimes can. The actual role of infection has not been adequately explained, but certain infections cause major increases in urinary nitrogen, which derives from amino acids in muscle tissue. Neither the aflatoxin nor the free radical theory has been proved experimentally, nor is there adequate convincing research to uphold the view of individual dysadaptation as the cause of severe PEM. On examination under a microscope, plucked hair exhibits root changes and a narrower diameter than normal hair.
In most developing countries kwashiorkor is a much more common cause of oedema than nephrosis. Instruction regarding other items in the diet must be given if the child is over six months old. This process requires adequate amounts of nutrients, especially iron, other minerals, protein and vitamins, all of which originate in the food consumed. The consumption of vitamin C-rich foods such as fresh fruits and vegetables with a meal may therefore promote iron absorption. Although it is desirable that breastfeeding should continue well beyond six months, it is also necessary that other foods containing iron be introduced into the diet at this time.
Unfortunately serum ferritin levels are influenced by infections, which are common in developing countries. Surprisingly, no studies have been able to give conclusive proof of either similarities or differences in dietary consumption between children who develop kwashiorkor with oedema and those who show clinical signs of nutritional marasmus without any oedema. Alternatively, the mixture can be administered intermittently using a large syringe and a needle that fits the tube. He or she must be kept in warm clothes and must be kept covered with warm bedding, and there must be an effort to ensure that the room is adequately warm. At one or two meals per day, a small portion of the green vegetable and the beans, fish or meat that the mother eats can be fed to the child, after having been well chopped. The mother or guardian should be advised to attend the hospital or clinic at weekly intervals if the family lives near enough (within about 10 km) or at monthly intervals if the distance is greater.
Egg yolk impairs the absorption of iron, even though eggs are one of the better sources of dietary iron.
Schistosomes or bilharzias, which are of several kinds, also cause blood loss either into the genito-urinary tract (in the case of Schistosoma haematobium) or into the gut. Anaemia is also reported to lead both to abnormalities of the mouth such as glossitis and to pica (abnormal consumption of earth, clay or other substances).
Other determinations that may be done to evaluate iron status and which are described in textbooks include free erythrocyte protoporphyrin (FEP) and transferrin saturation (TS) (Figure 7).
To make a feeding, the desired quantity of the mixture is placed in a measuring jug, and water is added to the correct level. Supplies of a suitable supplement to last for slightly longer than the interval between visits should be given at each visit. Malaria, another very important parasitic infection, causes destruction of red blood cells that are parasitized, which can lead to what is termed haemolytic anaemia rather than to iron deficiency anaemia.
Before and after each feed, 5 ml of warm, previously boiled water should be injected through the lumen of the tube to prevent blockage.
The child can be put on other foods, as mentioned in the discussion of infant feeding in Chapter 6. In programmes to reduce anaemia actions may be needed to control parasitic infections and to reduce blood loss resulting from disease as well as to improve dietary intakes of iron. As with the plain DSM mixture, 150 ml of liquid SCOM mixture should be given per kilogram of body weight per day; a 5-kg child should receive 750 ml per day in six 125-ml feeds, each made by adding five teaspoonfuls of SCOM mixture to 125 ml of boiled water. If eggs are available and custom allows their consumption, an egg can be boiled or scrambled for the child; the mother can watch as it is prepared. A 30-ml portion of made-up liquid feed provides about 28 kcal, 1 g protein and 12 mg potassium.
They are not essential; a good mixture of cereals, legumes and vegetables serves just as well. If suitable vitamin-containing foods are not available, then a vitamin mixture should be given, because the DSM and SCOM mixtures are not rich in vitamins.

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