Indian Journal of Paediatric Dermatology

ORIGINAL ARTICLE
Year
: 2021  |  Volume : 22  |  Issue : 3  |  Page : 226--230

A cross sectional study of nutritional dermatoses among malnourished children in a tertiary care centre


Vishalakshi S Pandit1, K Udaya2,  
1 Department of Dermatology, Venereology and Leprosy, Koppal Institute of Medical Sciences, Koppal, Karnataka, India
2 Department of Pediatrics, Koppal Institute of Medical Sciences, Koppal, Karnataka, India

Correspondence Address:
K Udaya
Department of Pediatrics, Koppal Institute of Medical Sciences, Hospet Road, Koppal - 583 231, Karnataka
India

Abstract

Background: Nutritional deficiencies are most prevalent in underdeveloped and developing countries of the world. An impaired nutritional status alters the structural integrity and biological function of the skin, resulting in an abnormal skin barrier. The objective was to study the various cutaneous spectrums of nutritional deficiency (ND) in children. Methods: A total of 100 malnourished children were included over a period of 6 months. Preliminary data of children regarding age, start of complementary feeding, maternal education, and parity were recorded. All children were examined thoroughly for the presence of cutaneous, mucosal, hair, and nail changes. Results: Majority were in the age group of 6–24 months, followed by 25–36 months. M:F ratio was 1:1.1. Majority of mothers were illiterate (43%). Only 8% babies were bottle-fed and complementary feeding was started in 56% of children between the months of 6 and 12. Seventy percent children were born to multiparous mothers. Approximately 50% children were of low-birth weight. Ninety-four percent of families resided in the rural areas. The cutaneous features seen include xerodermia (58%), lusterless hair (53%), pigmentary changes (36%), loss of subcutaneous fat (31%), flag sign (29%), angular cheilities (20%), etc. Other features seen were monkey-like facies (4%), long eyelashes (16%), ichthyotic and lichenoid skin changes (16%), and flaky paint dermatosis (2%). Conclusions: The most common cutaneous feature seen was xerodermia and least frequent one was flaky paint dermatosis. Many cases of ND are diagnosed only after evident skin changes. There is significant morbidity and sometimes mortality associated with certain nutritional deficiencies. Their prompt recognition, diagnosis, and treatment by clinicians are of great importance.



How to cite this article:
Pandit VS, Udaya K. A cross sectional study of nutritional dermatoses among malnourished children in a tertiary care centre.Indian J Paediatr Dermatol 2021;22:226-230


How to cite this URL:
Pandit VS, Udaya K. A cross sectional study of nutritional dermatoses among malnourished children in a tertiary care centre. Indian J Paediatr Dermatol [serial online] 2021 [cited 2021 Jul 24 ];22:226-230
Available from: https://www.ijpd.in/text.asp?2021/22/3/226/319941


Full Text



 Introduction



Nutritional deficiencies are most prevalent in underdeveloped and developing countries of the world. Malnutrition in children occurs when the nutritional requirements are not met during the periods of rapid growth along with marked developmental changes in organ function and composition. The factors such as young infant's lack of teeth, immature digestive and metabolic processes, and dependence on caregivers to provide sufficient nutrients during this time further contribute to the malnourishment.[1]

An impaired nutritional status alters the structural integrity and biological function of the skin, resulting in an abnormal skin barrier.[2] There is a scarcity of reports of cutaneous features of nutritional deficiency (ND) in children. Many cases of ND are diagnosed only after evident skin changes. The exact pathophysiological mechanisms for many of the dermatological features associated with the ND are not known. There is significant morbidity and sometimes mortality associated with certain ND;[3] their prompt recognition, diagnosis, and treatment by clinicians are of great importance.

The objective of this study was to document the various characteristic cutaneous features of nutritional deficiencies (ND) in children.

 Methods



This was a hospital-based, cross-sectional study conducted from July 2019 to December 2019. A total of 100 malnourished children attending pediatric outpatient department and admitted in the pediatric ward were examined. The minimum sample size was calculated using the following formula:

[INSIDE:1], where “n” is the sample size, “Zα” is the Z value for 95%, “p” is the anticipated prevalence rate of nutritional dermatosis = 55%, “q” is 100 − p = 45%, and “d” is the margin of error. The minimum sample size calculated was 96 with absolute precision of 10% and significance level of 0.05% and taking 55% prevalence according to recent estimates.[3] All children who fulfill the criteria for severe acute malnutrition (SAM) were included in this study. SAM is defined as weight for height less than 3SD and/or visible severe wasting and/or edema of both feet (excluding other causes of edema), mid arm circumference (MAC) <11.5 cm (in infant more than 6 months of age).[3]

Inclusion and exclusion criteria

Children between the age group of 6 and 59 months and who fulfill the criteria for SAM were included in this study. Children were excluded if they were in shock, had severe respiratory difficulty, or significant bleeding at the time of admission. Children with primary cutaneous disorders and immunodeficiency were also excluded.

A preliminary data of children regarding age, sex, socioeconomic status, and residence were noted in a predetermined pro forma. Socioeconomic status was considered based on per capita monthly income using Modified B G Prasad classification.[4] A detailed history regarding maternal education, parity, interval between pregnancies, maturity at birth, birth weight, history of breast/bottle feeding, and start of complementary feeding was noted by the pediatrician. Anthropometric measurements such as weight, height, and MAC were recorded by trained nursing staff. All children were examined thoroughly by the dermatologist for the presence of cutaneous, mucosal, hair, and nail changes. Written consent was obtained from the parents/guardians of the children. Institutional ethical clearance (approval no. IEC Ref no/06/2019-20) was obtained. All the data were entered, and statistical calculation was done using Microsoft Excel 2010. The results on continuous measurements are presented as median with interquartile range and results on categorical measurements are expressed in number or percentage.

 Results



Out of 100 children, who fulfilled the criteria for SAM, median age of the children was 16 months (interquartile range: 13.5). Most of them were females (55%) with M:F ratio of 1:1.1. Around 96% were term babies, rest were preterm. Most of the children belonged to the families of lower socioeconomic class 41%, followed by middle (39%), lower middle (12%), upper middle (7%), and 1% in the upper class. Maternal education history revealed 43% illiterates and more than 50% mothers had not completed graduation. Only 8% of babies were bottle-fed and in 56% complimentary feeding was started between the months of 6–12. Among 100 children, 70% were born to multiparous mothers. The interval between pregnancies of index children was <1 year in 16% children, 1–2 years in 35%, and more than a 2 years in 49% babies. Approximately 50% of children were of low-birth weight. Most of families (94%) hailed from rural areas. [Table 1] shows the demographic data and various risk factors of SAM. Common cutaneous features seen among malnourished children in the decreasing order of frequencies are as follows: Xerodermia 58%, lusterless and sparse hair 53%, pigmentary changes 36%, loss of subcutaneous fat 31%, flag sign 29%, angular cheilitis 20% [Figure 1], etc. Other features seen in lesser frequency are monkey-like facies 4%, pedal edema 4%, long eyelashes 16%, excessive lanugo hair (4%), ichthyotic and lichenoid skin changes (16%), and flaky paint dermatosis 2%. The cutaneous manifestations such as hyperkeratosis, perianal dermatitis, desquamative and scaly plaques, fissures, and perifollicular petechiae noted in other studies were not seen in this study.{Table 1}{Figure 1}

 Discussion



Severe childhood undernutrition (protein energy malnutrition [PEM]) is a spectrum ranging from mild undernutrition resulting in some decrease in length-for-age and/or weight-for-age through severe forms of undernutrition resulting in more marked deficits in weight-for-age and length-for-age as well as wasting (a low weight-for-length measure). Only a few studies have reported the cutaneous features of nutritional deficiencies.[5],[6] There is a significant mortality associated with ND with skin manifestations and dermatological findings have been strong, independent forecaster of death.[7],[8] The manifestation of undernutrition is multifaceted, and this article presents the clinical characteristics of skin changes in undernutrition.

According to the World Health Organization, more than 50% deaths occurring in children younger than 5 years of age in developing countries are associated with PEM.[9] In contrast with Rytter et al.'s study,[10] who reported 64% of edematous malnutrition, present study showed only 4% of edema [Figure 2] among malnourished children. This less percentage of edematous malnutrition (kwashiorkor) in this study could be explained by the fact that children with edema are less likely breastfed;[11],[12] the number children with bottle-feeding was as low as 8 in our study. There is a common practice of separating the child from pregnant mother causing sudden weaning from breast milk.[10] In our study, approximately 70% of children were born to multiparous mothers and only 16% had interval between pregnancies of <1 year. Hence, this could explain the awareness of breastfeeding in this part of the region and less number of edematous malnutrition. This study was conducted at a tertiary care center in North Karnataka, so it would represent the population in this region. In contrast to this, a few studies showed the occurrence of edematous malnutrition in breastfed children also which raises question of the protective effects of breastfeeding.[13] Later, a study from Sudan showed no association between breastfeeding and the types of malnutrition.[14]{Figure 2}

Among all the malnourished children examined in this study, almost all had one or more subtle cutaneous, hair or nail changes. Xerodermia or dry skin was the most common finding in our study with percentage of 58%. This could be the early manifestation of crazy pavement/flaky paint dermatosis [Figure 3], initially described by William.[15] Normally, glucose provides the carbohydrate backbone for glycosylation of proteins/lipids that comprise the extracellular environment of the skin. Xeroderma occurs as a result of altered levels of glucose in the skin which may cause structural changes and abnormal barrier functions.[16]{Figure 3}

The second most common finding in this study was lusterless and sparse hair seen in 53% of children. Other hair changes usually encountered in malnourished children are straight, thin, and silky hair, which are easily pulled off. Sometimes, hair may become streaky red or gray or presents with alternate dark and light bands, commonly known as “flag sign” [Figure 4] indicating growth arrest.[1]{Figure 4}

The pigmentary changes which include both hyper and hypopigmenation of the skin were seen in 36% of children as compared to 58% in a study in Uganda.[17] The exact pathogenesis of hyperpigmentation is not known, but deficiency of niacin, pyridoxine, Vitamin B12, and zinc has been implicated.[18],[19] Hyperpigmentation is most intense in the flexures, at sites of pressure [Figure 5] and friction, in the creases of the palms and soles, in the nails, in sun-exposed areas, and in normally hyperpigmented areas such as the genitalia and areolae. Hypopigmentation usually follows desquamation of the skin with crazy pavement appearance. In this study, hypopigmentation seen in 22% of children which was almost similar to a study reported by Lowy and Meilman.[20] The dyschromia with hypopigmentation has been attributed to the deficiency of tyrosine, which is critical for melanin synthesis.[21]{Figure 5}

Visible severe wasting is defined as the presence of muscle wasting in the gluteal region, loss of subcutaneous fat, or prominence of bony structures, particularly over the thorax.[22] It was seen only 31% in our study, which supports the fact that it is less sensitive feature for detecting undernutrition among young children. Mogeni el al.[23] have reported that measuring MAC is quick, easy, inexpensive, and more reliable screening method to detect SAM as visible severe wasting failed to detect the same in 50% of the children.

The percentage of stomatitis/angular cheilitis (20%) was less in this study as compared to Dhale et al.'s[24] study.

Lichenoid skin changes were seen in 16% of malnourished children which was similar to study done in Uganda.[17] Lichenoid skin changes present as hyperpigmented papules or irregular, well-defined coalescent patches found mainly over the extremities, buttocks, and trunk.

Nail changes include soft and thin nail plates with subtle fissures and ridges or more prominent koilonychia.[25] Koilonychia and soft nail plates were noted in 14% and 35% of our patients, respectively.

An interesting finding of our study is the diagnosis of a classic case of acrodermatitis enteropathica [Figure 6]. Estimation of serum zinc level was less in this child.{Figure 6}

Certain cutaneous changes such as follicular hyperkeratosis (25%), gingival hyperplasia, and purpuric lesions (35%) observed by Gomez et al.[26] were not seen in our study.

Maternal factors such as mother's education, age at birth, and birth interval between children were the independent determinant factors for SAM,[27],[28] so indirectly may affect the cutaneous manifestations. The present study has some potential limitations. The association of the various maternal and fetal factors with skin manifestations could not be established as it was a cross-sectional study. A small group of cases was the other limitation of this study. Further studies involving the large groups of cases and control are needed to elucidate the association of these risk factors with nutritional dermatoses.

 Conclusions



The present study shows that xerodermia and sparse, lusterless hair are common cutaneous findings among malnourished children attending the tertiary care center. The percentage of classical monkey-like facies and flaky paint dermatoses was less in this study. Cutaneous manifestations of combined nutritional deficiencies are diverse and elusive. A few specific nutritional deficiency disorders have typical clinical features which aid in the diagnosis, but dermatological manifestations of combined nutritional deficiencies pose problem in the diagnosis as they could be mistaken for manifestations of other dermatological diseases. Since the percentage of classical features of ND is decreasing, a provisional diagnosis of malnutrition should be suspected even in the presence of subtle cutaneous features mentioned above. These cutaneous manifestations if recognized early could act as mirrors for the underlying malnutrition in children and corrected easily by the early implementation of nutritional supplements along with proper skincare. Information obtained from this study might help to assess the changing trends of nutritional dermatoses.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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