Malnutrition: An Overview
- Malnutrition is very common among new refugees, internationally adopted children and, to a lesser degree, immigrant children.
- Malnutrition is often subclinical, but may present as a failure to thrive, wasting or stunting. Calorie and protein deficiency are common and micronutrient deficiencies may be very common, depending on the region of origin.
- The majority of refugee or internationally adopted children can be assumed to be malnourished. They may have anemia or other micronutrient deficiencies, though such conditions may be subclinical.
- Asymptomatic newcomer children (who have lived in Canada 5 years or less) should have routine screening, including a CBC and differential. Specialized tests such as vitamin D or A levels are usually reserved for the work-up of symptomatic disease.
- The U.S. Centers for Disease Control and Prevention (CDC) recommends a multivitamin with iron for all refugee children younger than 5 years old. This may also be a consideration for older refugee children.
- Causes or factors that can contribute to malnutrition include poverty, inadequate access to food, infectious diseases such as parasites or malaria, and chronic illness.
The risk of malnutrition depends on the type of newcomer and their region of origin. Rates of malnutrition are high in refugee children1 and in internationally adopted children2 from resource-poor areas. Children who migrate from resource-poor countries may also present with malnutrition. Although data for paediatric newcomers to Canada are lacking, high malnutrition rates in low-resource countries indicate the seriousness of the problem. In many countries in sub-Saharan Africa, for example, one of every four children is underweight and undernutrition is a leading contributor to childhood mortality.3
Malnutrition, which includes micronutrient deficiencies (iron deficiency is the most common), may not manifest any clinical symptoms. It can also present as failure to thrive, wasting or stunting, due to protein-energy malnutrition. The degree of malnutrition depends on factors such as the severity and duration of nutrient deprivation. In some cases, refugee children face food insecurity after resettlement, and consume poor quality foods that may be less expensive than healthier choices. While these foods may have enough calories, they often lack protein or micronutrients. In some cases, children are obese with micronutrient deficiency.4
Here are some common words associated with malnutrition.3
A condition occurring when there is an imbalance of nutrients (e.g., calories, vitamins and minerals) required for growth and function, with what is consumed. Malnutrition can mean either a lack of nutrients (undernutrition) or an excess of nutrients (overnutrition).
A spectrum of malnutrition due to dietary deficiency of either protein or calories or both. Two extremes are marasmus and kwashiorkor.
An extreme form of protein-energy malnutrition, characterized by inadequate calories, presents with severe muscle and tissue wasting.
An acute form of protein-energy malnutrition caused primarily by insufficient protein consumption, which can present with edema, irritability, anorexia, lightening of the hair and liver enlargement.
When food intake does not include enough nutrition to meet minimum physiological needs.
Low weight-for-age, as measured by comparing the weight-for-age of a child with a reference population of well-nourished, healthy children.
Substantial weight loss, usually associated with acute food deprivation due to starvation and/or disease and measured by comparing weight-for-height of a child with a reference population.
Shortness for age and one indicator of chronic malnutrition. Calculated by comparing the height-for-age of a child with a reference population.
Chronic food deprivation initially spares the head (asymmetrical stunting) but with continued duration, a child’s head (and consequently, brain development) is affected (symmetrical stunting).
Diagnosis and treatment
Health professionals need to ask newcomer families about their past and current dietary practices, particularly to learn about transitional foods fed to babies and toddlers that may have low iron bioavailability.
Clinicians can usually assume that refugee or internationally adopted children from resource-poor regions are malnourished and at risk for micronutrient deficiency. Supplementing with a multivitamin with iron is usually indicated.1,2
For asymptomatic newcomer children, routine screening includes a CBC and differential. More specialized testing, such as for vitamin D or A levels, is usually reserved for the work-up of a symptomatic disease, such as rickets, or decreased vision and blindness.
Children with anemia from a region where hemoglobinopathies are common must have hemoglobinopathy testing (using high-performance liquid chromatography [HPLC] or hemoglobin analysis [e.g., Hb electrophoresis]) before starting any therapeutic levels of iron.4
The CDC recommends taking a full history (including dietary history) and physical examination for findings that indicate under- (or over-) nutrition or macro- (and micro-) nutrient deficiencies. Investigating a family’s dietary history includes asking about types of food, the quality and quantity of food, and whether the family experienced food security issues. Focus on periods during pregnancy, early infancy, just after weaning and after arrival in Canada. Recommended anthropometric measures used to identify malnutrition include a child’s weight, height, and body mass index (BMI) in comparison with standard growth indicators published by the World Health Organization.5,6
- WHO growth standards
- Promoting optimal monitoring of child growth in Canada: Using the new WHO Growth Charts (Dietitians of Canada, Canadian Paediatric Society, The College of Family Physicians of Canada, and Community Health Nurses of Canada)
The CDC also recommends:4
- An age-appropriate daily multivitamin for all children aged 6 months to 59 months. Specific supplementation may be of benefit in children older than 5 years.
- Culturally appropriate nutritional counselling and social support to ensure families have access to healthy foods.
- Ongoing monitoring of growth and development, age-appropriate nutritional screening, and ongoing counselling with nutrition education.
Table 1 lists common sources of macro- and micronutrients. More detailed fact sheets are available on the U.S. National Institutes of Health website.
Recommended daily intakes of macro- and micronutrients are available on the Health Canada website.
Macro- or micronutrient
Milk, yogurt, cheese, vegetables (e.g., kale, broccoli), fortified foods (e.g., fruit juices and drinks, tofu, cereals), canned fish (sardines, salmon)
Leafy green vegetables (e.g., spinach), fruits (e.g., citrus), dried beans and peas, enriched grain products (e.g., breads, cereals, pasta, rice)
Red meats, poultry, fish, shellfish, lentils, beans
Liver, fish, milk, egg, leafy green vegetables (e.g., broccoli), orange/yellow vegetables (e.g., carrots, squash), fortified cereals, fruits (e.g., cantaloupe)
Fish, meat, poultry, eggs, milk, milk products, fortified breakfast cereals, nutritional yeast products
Fatty fish (e.g., salmon, tuna, mackerel), beef liver, cheese, fortified foods (e.g., milk, cereals, juice)
Red meat, poultry, beans, nuts, seafood (oysters, crab, lobster), whole grains, fortified cereals, dairy products
|Source: Information adapted from the National Institutes of Health, Vitamin and mineral supplement fact sheets.|
Many refugee families have experienced hardships that include food scarcity or food insecurity. In Canada, they may be consuming a diet that is high in calories but low in nutrients, perpetuating malnutrition and contributing to obesity.7 More information about screening and prevention of obesity in immigrant children and youth is available in this resource.
For more information on specific macro- and micronutrient deficiencies, see:
- Iron Deficiency/Iron Deficiency Anemia
- Vitamin D Deficiency
- Vitamin A Deficiency
- Vitamin B12 Deficiency
- Iodine Deficiency
- Folic Acid Deficiency
- Zinc Deficiency
- Centers for Disease Control and Prevention. Immigrant and refugee health.
- Country-specific information on common foods, rates of breastfeeding and young child feeding practices are available from the Food and Agriculture Organization (FAO) of the UN.
- Health Canada, 2007. Eating well with Canada’s food guide is available in multiple languages.
- U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases. Guidelines for evaluation of the nutritional status and growth in refugee children during the domestic medical screening process. Bethesda, MD: CDC, April 2012.
- Mason JB, White JM, Heron L, et al. Child acute malnutrition and mortality in populations affected by displacement in the Horn of Africa, 1997-2009. Int J Environ Res Public Health 2012;9(3):791-806.
- Park H, Bothe D, Holsinger E, et al. The impact of nutritional status and longitudinal recovery of motor and cognitive milestones in internationally adopted children. Int J Environ Res Public Health 2011;8(1):105-16.
- World Food Programme, Hunger glossary.
- Centers for Disease Control and Prevention. Guidelines for evaluation of the nutritional status and growth in refugee children during the domestic medical screening examination. Bethesda, MD: CDC, 2012.
- World Health Organization. The WHO Child Growth Standards.
- Dietitians of Canada, Canadian Paediatric Society, College of Family Physicians of Canada, Community Health Nurses of Canada. Promoting optimal monitoring of child growth in Canada: Using the new World Health Organization Growth Charts. Paediatr Child Health 2010;15(2):77-9.
- Rondinelli AJ, Morris MD, Rodwell TC, et al. Under- and over-nutrition among refugees in San Diego county, California. J Immigr Minor Health 2011;13(1):161-8.
Other works consulted
- Centers for Disease Control and Prevention, World Food Programme. A Manual: Measuring and interpreting malnutrition and mortality. Rome: WFP, 2005.
- National Institutes of Health, Office of Dietary Supplements. Vitamin and mineral supplement fact sheets.
- Pottie K, Greenaway C, Feightner J, et al. Evidence-based clinical guidelines for immigrants and refugees. CMAJ 2011;183(12):E824-925.
- WHO. Worldwide prevalence of anaemia 1993–2005. Geneva, Switzerland: WHO, 2008.
- Anna Banerji, MD
- Andrea Hunter, MD
Last updated: April, 2018