guidelines for the integrated management of severe acute malnutrition

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ACF-In Guidelines for the integrated management of SAM Glossary 12 GLOSSARY Under nutrition is a “catch-all” term for a deficiency of any of the essential nutrients (protein, essential fatty acids, electrolytes, minerals and vitamins) or energy. It not only encompasses stunting, wasting (type II deficiency) but also clinical illness brought about by deficiencies of any of the specific essential nutrients which may not be associated with any anthropometric change (and can occur in obese people). Different forms of under nutrition are not necessarily exclusive and often co-exist within the same individual. Stunting or Chronic malnutrition Stunting is a retardation of growth and is indicated by a low height-for-age. It can occur when a child suffers from chronic (long-term) nutrient deficiencies. Wasting: Acute Malnutrition Wasting occurs when a person has lost weight and become excessively thin; it is indicated by a low weight for height or MUAC. This form of acute malnutrition is either moderate (MAM) or severe (SAM) depending upon how severe the wasting becomes. 1 Kwashiorkor: Acute malnutrition This is a clinical syndrome characterised by bilateral oedema. It is often also associated with lesions of the skin, fatty liver, atrophy of the organs and mental changes. The exact cause is unknown but it is thought to be due to deficiency of antioxidant nutrients. Under weight This index indicates when a child has a low weight for his/her age. It cannot distinguish between wasting and stunting as it does not indicate whether the child has a low weight-for-age because of a low weight-for-height or a low height-for-age. Over weight For a malnourished young child, there can be a quick transition – over a matter of weeks or a few months – from being wasted (low weight for height or MUAC) to being overweight or even obese (excess weight for height). In most cases, these children remain stunted (low height for age), a legacy of their original condition of chronic malnutrition. The diets used in the past, and that the child will return to at home, have sub-optimal levels of some of the essential nutrients, so that the children, although of normal weight-for-height did not return functionally to normal or have catch-up in height. They then became more vulnerable to obesity and diabetes. 1 The term “protein-energy malnutrition” is no longer used as it is not thought that protein or energy deficiency, are the usual causes of severe acute malnutrition.
ACF-In Guidelines for the integrated management of SAM Introduction 13 INTRODUCTION 1. The nature of malnutrition Malnutrition is primarily due to failure to take and absorb sufficient essential nutrients to grow and develop normally. This is normally due to a poor appetite secondary to nutritional deficiency because of the poor quality of the diet or infection; pathological losses or mal-absorption increase the requirement for increased amounts of a high quality diet. Those that depend upon others for their food are particularly vulnerable (children, the elderly and infirm, mentally deficient, prisoners, the indigent, displaced and refugees). There are about 40 different nutrients that are essential for health [1]. If any one of these is deficient in the diet the person will not be fully healthy and able to resist the agents of disease. After an acute illness they will not have the necessary nutrients to convalesce successfully and return to normal. This failure of convalescence is the usual reason why there is an association between infection and nutritional state. The nutrients are divided into two classes. Type I nutrients are the functional nutrients that are required for the hormonal, immunological, biochemical and other processes of the body to function normally. Most of the micronutrients fall into this category. Individuals can be very deficient in these nutrients and not have any anthropometric abnormalities (i.e. they can have grown normally and have a normal body weight, or even be obese and have nutritional deficiency of this class of nutrient). Anthropometric surveys do not give us information about the prevalence of type I nutrient deficiencies. Their deficiency does cause major illness and increased likelihood of death (e.g. iron, iodine, vitamin A, riboflavin, etc. deficiency). Deficiency of several of these nutrients, particularly the anti-oxidant nutrients, is the probable cause of oedematous malnutrition (kwashiorkor). Type II nutrients are the growth nutrients that are required to build new tissue. They have been, and are, deficient when there has been failure to grow, to repair tissue that is damaged, to replace rapidly turning over cells (intestinal lining and immune cells in particular) or to gain weight after an illness to have a normal convalescence. Deficiency of these nutrients (nitrogen, essential amino-acids, potassium, magnesium, sulphur, phosphorus, zinc, sodium and chloride) leads to stunting and wasting with generalised physiological adaptation of all systems. Replenishment of all these nutrients, in the correct balance, is essential for recovery from malnutrition and convalescence from acute illness. As there are no body stores of these nutrients they all have to be given in the right balance for the malnourished to regain functional and anthropometric normality. More than half of all deaths in children have stunting and wasting as the underlying cause [2,3]: that is, they are too thin for their height or too short for their age because they have not had sufficient type II nutrients to grow properly and many have lost weight. These children would have recovered from other illnesses if they had not been malnourished, but because they are malnourished they die. To this toll must be added the deaths of children with type I nutrient deficiencies. Thus, most deaths in childhood have some form of malnutrition as the underlying cause. Acute Malnutrition is classified according to the degree of wasting and the presence of oedema. It is acute severe malnutrition (SAM) 2 if the wasting is severe (in children, MUAC
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Cover photography: © ACF, Anne-Dom
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guidelines for the integrated management of severe acute malnutrition

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