Pediatric Nutrition in Practice

Primary and Secondary Malnutrition 145

3

Management of Secondary Malnutrition

For the management of secondary malnutrition,
it is crucial to identify the underlying disease by
proper history taking, examination and sugges-
tive laboratory investigations. Without treating
the underlying cause, it is impossible to manage
secondary malnutrition. Preterm and low-birth-
weight infants are at risk of necrotizing enteroco-
litis if aggressive enteral feeding is done. Exclusive
breastfeeding for the first 6 months along with
iron supplementation is a safe way to ensure op-
timal nutrition for such infants.
In mild inf lammatory bowel disease or dis-
ease in remission, encouraging the intake of a
normal diet is important to prevent or treat mal-
nutrition. Commercial, specially prepared liquid
formulas are helpful for some patients with in-
f lammatory bowel disease. Partial or total paren-
teral nutrition can be administered to patients
who cannot tolerate enteral feeding.
Children with chronic liver disease (CLD) be-
come malnourished due to vomiting, poor appe-
tite, infection, gastroesophageal ref lux and the
compressive effects of ascites or hepatospleno-
megaly. In advanced CLD, the diet may need to
be protein sparing for the prevention hyperam-
monemia. A combination of lipids and carbohy-
drates with a minimal amount of protein should
be used. Another important feature in CLD is de-
creased excretion of bile salts into the small intes-
tine, which can cause malabsorption of fats and
fat-soluble vitamins. This can be countered by
using medium-chain triglycerides as the source
of dietary fat, since they do not depend upon bile
acids for absorption. Water-soluble forms of the
usually fat-soluble vitamins (A, D, E and K)
should be used when available.
More than one third of children with chronic
renal disease suffer from impaired linear growth.
This can be prevented by providing high-energy
as well as high-quality protein in quantities that
will not induce or aggravate uremia.

Children with congenital heart disease have

reduced food intake due to fatigue, breathless-

ness and frequent lung infections. The heart fail-

ure and increased breathing efforts induce a hy-

permetabolic state that further increases the de-

mand for more nutrients. The challenge is to

provide sufficient energy and protein without in-

creasing the f luid volume too much.

While TNF-α and tumor metabolites are re-

sponsible for the cachexia observed in children

with cancer, chemotherapy, radiation, surgery

and infections also substantially contribute to

malnutrition in these children. The diet has to be

modified to cater to the increased energy de-

mands. Elemental diets sometimes have to be

provided through nasogastric tubes. Total paren-

teral nutrition, if available, can be used to im-

prove nutrition in children who cannot tolerate

large amounts of food enterally.

The principles of management of severe mal-

nutrition resulting from the underlying diseases

mentioned above are similar to those for primary

SAM. Nutritional support for a child with sec-

ondary malnutrition is as imperative as it is for a

child with primary malnutrition [11].

P r e v e n t i o n

Reducing malnutrition through prevention and

treatment can reduce the incidence of infectious

diseases, most commonly diarrhea and pneumo-

nia. It is now imperative to scale up both nutrition-

specific and nutrition-sensitive interventions in

countries that are burdened with childhood mal-

nutrition. Scaling up essential nutrition-specific

interventions alone can reduce 15% of deaths

among <5-year-old children, control 20% of stunt-

ing and reduce wasting by >60% [12]. To prevent

malnutrition, care should be taken prior to con-

ception. There is a narrow window of opportunity

in utero when the fetus is increasing in length and

weight maximally. Proper antenatal care along

with iron-folic acid supplementation is required to

Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 139–146
DOI: 10.1159/000367880