Recognition and Management of Malnutrition
5. Micronutrient Deficiencies
Objectives
- List specific micronutrient deficiencies, their risk factors, and clinical signs.
- Describe the epidemiology, pathophysiology, and clinical presentation of vitamin A, iron, and zinc deficiencies.
- Describe the general management for micronutrient deficiency prevention and treatment in acute emergency settings.
Different dietary insufficiencies may lead to specific micronutrient deficiencies. Some of these have typical clinical manifestations. Specific dietary risk factors for important micronutrient deficiencies and possible solutions are outlined in Table 2. Table 3 summarizes the classic physical findings associated with significant micronutrient deficiencies.
Case 2.
You are providing pediatric care to a population that has been displaced after a flood. A mother comes to the health care unit with her 4-month old son, who was born after 35 weeks of gestation and is exclusively breastfed. Physical findings are normal. The weight and height are at the 50th percentile (age corrected for gestational age).
- What are your recommendations regarding iron intake?
TABLE 2. Micronutrient deficiencies: risk factors and possible solutions
| Niacin (pellagra) | |
|---|---|
| Dietary risk factor | Maize-based diet |
| Possible solutions | Foods rich in proteins and whole grain cereals |
| Thiamin (beri-beri) | |
|---|---|
| Dietary risk factor | Polished rice/or other cereal/cassava/manioc-based diet |
| Possible solutions | Whole or parboiled rice, legumes, beef, fish, eggs, milk; fortified cereal blends |
| Vitamin A | |
|---|---|
| Dietary risk factor | Diet with not enough fresh fruits |
| Possible solutions | Dark orange fruits and vegetables, yellow corn, fortified cereal, animal products, dark green leafy vegetables, amaranthus, baobab, mango leaves, vitamin A supplements |
| Vitamin C (scurvy) | |
|---|---|
| Dietary risk factor | Diet with not enough fresh fruits and extremely low fat intake |
| Possible solutions | Fresh raw fruits/vegetables, liver, fresh animal milk |
| Iron (ferropenic anemia) | |
|---|---|
| Dietary risk factor | Diet lacking animal products |
| Possible solutions | Animal products (liver, meat); dried fruits; consumption of vitamin C with meals; iron/folate supplements or fortified cereal blends. From ages 6-24 months on, nearly all iron intake is provided by supplementary foods. |
| Zinc | |
|---|---|
| Dietary risk factor | Diet lacking animal products |
| Possible solutions | Animal products (liver, meat); fortified cereal, peanuts, Gombo (Okra), sesame and pumpkin seeds, avocado, all legumes: niebe, lentils, peas, Moringa leaves powder. Children 6-24 months on, millet, sorgho. From ages 6-24 months on, nearly all zinc intake is provided by supplementary foods. |
| Riboflavin | |
|---|---|
| Dietary risk factor | Diet lacking animal products |
| Possible solutions | Animal products (liver, eggs, fish), milk, leafy green vegetables. From ages 6-24 months on, nearly all riboflavin intake is provided by supplementary foods. |
| Vitamin D (rickets) | |
|---|---|
| Dietary risk factor | Lack of exposure to sunlight |
| Possible solutions | Apart from a supplement diet vitamin D is negligible |
| Calcium | |
|---|---|
| Dietary risk factor | Lack of milk, dark-green leaves, or fish with bones |
| Possible solutions | Milk, fish with bones (e.g. sardines), fish flour, shell fish, egg shell powder, beans and green peas, dark green leaves, calcium carbonate (used in making tortillas) |
TABLE 3. Physical findings commonly associated with micronutrient deficiencies
| Hair | |
|---|---|
| Physical signs | Dry, dull, easily pluckable; sparse hair loss |
| Possible nutritional deficiencies | Protein-energy malnutrition, zinc, protein, biotin, essential fatty acids |
| Eyes | |
|---|---|
| Physical signs | Pale sclera; Bitot’s spots; night blindness |
| Possible nutritional deficiencies | Iron, vitamin B6, B12, vitamin A |
| Mouth | |
|---|---|
| Physical signs | Red swollen lips; Angular stomatitis (cracks at sides of mouth); Cheilosis |
| Possible nutritional deficiencies | Niacin, riboflavin, iron and/or vitamin B6; Niacin, riboflavin, iron and/or vitamin B6; Niacin, riboflavin |
| Gums | |
|---|---|
| Physical signs | Swollen, bleeding, abnormally red |
| Possible nutritional deficiencies | Vitamin C |
| Tongue | |
|---|---|
| Physical signs | Glossitis; Dark red; Pale |
| Possible nutritional deficiencies | Vitamin B complex*; iron; riboflavin |
| Teeth | |
|---|---|
| Physical signs | Dental caries |
| Possible nutritional deficiencies | Fluoride, vitamin C |
| Taste | |
|---|---|
| Physical signs | Dysgeusia or hypogeusia |
| Possible nutritional deficiencies | Zinc |
| Skin | |
|---|---|
| Physical signs | Loose; Lower extremity edema; Pallor; Poor healing; Rough skin, poor turgor (positive skin pinch); Small, purplish spots; Pellagra (pigmented keratotic scaling lesions); Follicular hyperkeratosis; Ecchymosis |
| Possible nutritional deficiencies | Calories; Protein, thiamine; Folic acid, thiamine, vitamin B12, biotin; Vitamin C; Fluids, marasmus, protein, calories; Vitamin C; Niacin; Vitamin A and/or essential fatty acids; Vitamin K |
| Nails | |
|---|---|
| Physical signs | Brittle or ridged spoon-shaped |
| Possible nutritional deficiencies | Protein; Iron |
| Musculoskeletal | |
|---|---|
| Physical signs | Muscle wasting; Rickets, osteomalacia |
| Possible nutritional deficiencies | Protein, energy; Vitamin D, phosphorus, calcium |
| Neurological | |
|---|---|
| Physical signs | Hyperreflexia; Ataxia; Encephalopathy; Nystagmus; Peripheral neuropathy |
| Possible nutritional deficiencies | Vitamin B6; Thiamine; Sodium chloride |