Overview
Malnutrition means an imbalance between what a child's body needs and what it gets. In children the commonest form is undernutrition, which shows in three ways. Wasting is low weight for height, usually from recent weight loss or a bout of illness. Stunting is low height for age, the mark of a shortage that has gone on for a long time. Underweight is low weight for age, and a child who is underweight may be wasted, stunted or both.
Alongside these sits a shortage of particular vitamins and minerals, such as iron, vitamin A and iodine, which can be present even in a child who looks well fed. All of these can be measured, and most of them can be put right.
Symptoms
Early on there may be nothing to see. The first sign is usually on the growth chart: weight that flattens out or falls, or height that is not keeping pace. Clothes become loose, and a child may seem quieter, less playful and more tired than usual.
As it goes on, the ribs and shoulder bones stand out, the skin over the buttocks hangs in loose folds, and the upper arm becomes thin. Swelling of both feet is a serious sign, because it means a severe form of acute malnutrition. Pale palms, eyelids and tongue point to anaemia, and dry eyes or trouble seeing in dim light point to a shortage of vitamin A. Infections come more often and take longer to clear.
When to see a doctor
See a doctor within a few days if weight has stayed the same or fallen over two or three months, if a child is growing more slowly than others of the same age, if there are repeated infections, if a child is eating very little, if the palms and eyelids look pale, or if a baby is feeding poorly and not gaining weight.
Causes
Undernutrition usually comes from several things at once. There may not be enough food, or enough variety in it, and the cost of milk, pulses, eggs, fruit and vegetables matters. Feeding may not have got off to a good start: a late first feed, other foods given before six months, or solid foods introduced too late or too thin.
Illness is the other half of the story. Repeated diarrhoea, chest infections, tuberculosis, worms and long-term conditions all cost a child weight, and a child who is undernourished catches infections more easily, so each makes the other worse. A mother who was undernourished herself, a low birth weight or a premature birth also set a child back before feeding begins.
Risk factors
- Low birth weight, or being born before 37 weeks
- Not being exclusively breastfed for the first six months
- Solid foods started too late, or too watery to be filling
- Repeated diarrhoea and chest infections
- Unsafe drinking water and poor sanitation
- Poverty, and food that is short or lacking in variety
- The mother's own poor nutrition or ill health
- A long-term illness such as tuberculosis, heart disease or a gut condition
Complications
- Infections that come more often, last longer and turn severe
- Death, when severe acute malnutrition is not treated in time
- Slower brain development, and difficulty learning at school
- Permanent shortness, when stunting is not addressed early
- Anaemia, and shortages of vitamin A, iodine and zinc
- Poor healing and greater risk after illness or surgery
Prevention
- Breastfeeding within the first hour after birth
- Only breast milk, and no water, for the first six months
- Family food from six months, alongside breastfeeding up to two years or beyond
- Two to three meals a day from six to eight months, and three to four from nine months, with snacks
- Food from several groups each day: grains, pulses, milk, eggs, fish or meat, and fruit and vegetables
- Regular weighing, and keeping the growth chart up to date
- Immunisation, vitamin A and deworming as scheduled
- Safe water, handwashing with soap, and prompt treatment of diarrhoea with ORS and zinc
Diagnosis
Diagnosis is by measurement. The child is weighed and measured, and the figures are plotted on a growth chart to see the pattern over time rather than a single point. The mid-upper arm circumference tape, wrapped around the left upper arm, gives a quick reading with green, yellow and red bands.
The doctor also presses on the tops of both feet to look for pitting swelling, checks for pallor and signs of vitamin shortage, and looks for an illness behind the weight loss. Blood tests for anaemia, a test for tuberculosis, a urine test or a stool test may be done depending on what is found.
Treatment
Treatment is decided by how severe the malnutrition is and whether the child is otherwise well. A child with severe acute malnutrition who is alert, feeding and free of complications can usually be treated near home, with ready-to-use therapeutic food, routine medicines and regular weighing.
A child who is too weak to feed, has swelling of both feet with complications, or has a serious infection is admitted, often to a nutrition rehabilitation centre, for careful feeding, treatment of infection, and correction of low blood sugar, low temperature and salt imbalance. Feeding is built up slowly at first, because feeding too fast can be dangerous.
Alongside food, the treatable causes are dealt with: infections, worms, anaemia, and shortages of vitamin A and zinc. Families are shown practical, affordable ways to add energy and protein to the food already cooked at home, and the child is followed up until growth is back on track.
Myths and facts
Things people often say about this. Open each one to see what is true.
Myth“A thin child just has a small build, and will fill out on their own.”What is true?
Fact
Some children are naturally slight, which is why growth is measured rather than guessed at. A child whose weight has stopped rising over two or three months, or whose arm measurement is low, is telling you something that measuring will pick up long before it becomes obvious to the eye.
Myth“A chubby child is a healthy child.”What is true?
Fact
Weight alone does not say whether a child is nourished. A child can be a reasonable weight and still be short for their age, or short of iron, vitamin A or iodine. Malnutrition also includes being overweight, which brings its own problems later. What matters is steady growth in both height and weight, and a varied diet.
Myth“Malnutrition means the parents were careless.”What is true?
Fact
Malnutrition is rarely about one family's choices. Repeated infections, an unsafe water supply, illness in the mother, a difficult pregnancy, the cost and availability of food, and not having help with feeding advice all play a part. Treatment works best when families are supported rather than blamed.
Myth“Once a child is stunted, nothing can be done, so there is no point treating.”What is true?
Fact
The first two years are the most important window, and catching a shortage early gives the best chance of recovery. Even later, treatment matters: a wasted child usually recovers well with the right feeding, and treating infections, anaemia and vitamin shortages improves how a child feels, learns and grows from that point on.
Questions to ask your doctor
Tick the ones you want answered and take them with you.
Common questions
My child eats well but is small. Is that malnutrition?
Not necessarily. Children come in different sizes, and one who is small but growing steadily along their own line on the chart is usually fine. What raises concern is a change in the pattern: weight flattening out or falling, or height falling behind over several months. That is why regular weighing is worth the trip, even when nothing seems wrong.
Do we need expensive foods or supplements to put this right?
Usually not. Most of what a child needs comes from ordinary food used well: dal, khichdi thickened rather than watery, milk and curd, eggs, groundnuts, seasonal fruit and green vegetables, with a little oil or ghee added for energy. A dietician can build a plan around what a family already cooks and can afford.
Can a malnourished child catch up?
Wasted children usually recover well when they are treated in time, and their weight comes back. Height lost to long-term stunting is harder to recover, particularly after the age of two, which is why early action matters so much. Treating infections and vitamin shortages helps a child feel better and learn better whatever their age.
Is it safe to feed a very malnourished child a lot at once?
No. A child who has been severely malnourished for a long time can become dangerously ill if they are fed too much too quickly, because the body cannot cope with the sudden change. Feeding is started small and often, under medical supervision, and increased step by step. This is one of the reasons severe malnutrition is treated by a doctor rather than at home alone.
