This document provides information on the definition, causes, clinical presentation, diagnosis, and management of malnutrition. It discusses different types of malnutrition including marasmus, kwashiorkor, and protein-energy malnutrition. It describes the pathophysiology, signs and symptoms, complications, diagnostic tests, and principles of inpatient and outpatient treatment for severely malnourished children. The management is outlined in three phases: initial stabilization, transition, and ongoing care and feeding until recovery is achieved.

1. By Habtamu A

2.  Definition
 Epidemiology
 Causes
 Pathogenesis/ Pathophysiology
 Clinical manifestations
 Diagnosis/Laboratory tests
 Complications
 Principles of management
 Prognosis and mortality
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3.  Hunger – physiological state when food is not able to meet energy needs
 Malnutrition – impaired development linked to both deficient and excessive
nutrient intake & could be overnutrition(obesity) or Undernutrition
 Undernutrition – most common form of malnutrition in developing countries;
energy, protein and micronutrients
 overnutrition(obesity) common on developed countries
 Severe acute malnutrition (macro- &micronutrient
deficiency)
 Bilateral pitting edema or
 WFH < 70 % or
 MUAC < 11 cm or
 Based on the Welcome classification, if the child has
Kwashiorkor, Marasmus, or Marasmic-Kwash
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4.  Protein-energy malnutrition
 Obesity
 Micronutrient deficiency problems
◦ Iron deficiency anemia
◦ Vitamin A deficiency
◦ Iodine deficiency disorders
◦ Zinc deficiency
◦ Folate deficiency
HSERV 544 - Nutrition in Children 4

5.  Frequently observed in children 6 months-to- 5
years.
 Marasmus peaks in the first year
 Kwashiorkor peaks b/n 1-3 years of age.
 PEM is more common during weaning period and
rainy season.
 Malnutrition is much more serious than the other
conditions that are getting big attention.

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Neonatal, 25%
Malaria, 20%
Pneumonia,
28%
Diarrhea, 20%
AIDS, 1%
Measles, 4%
Other, 2%
Malnutrition
57%
HIV
11%

7.  Basic Causes:- Inequality, drought, War
 Underlying - poverty & Social disadvantage
 Immediate - Lack of Food, Infections
 Manifestation- Malnutrition

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10. Different proposed mechanisms :
1. Protein-energy deficiency
2. Adaptation
3. Free radical theory ( imbalance between
oxidants and antioxidants)
No adequate explanation so far why some
children develop edematous malnutrition
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11.  It is a multi deficiency state, There are
different theories proposed:
A) Theory of Low Protein & Calorie
intake(Protein & Calorie Deficiency)
B) Theory of Dys-adaptation(Effect of Hormonal
Difference)-
I.e Marasmus is well adapted to the
deficiency state due to the high cortisol
levels
Kwashiorkor is a poorly adopted form of
PEM.

12. C) Theory of Free-Radical Damage:
1)Increased production of free radicals(oxidants)-
Peroxides,Epoxides, due to Infections, Bowel bacteria,
contaminated food, aflatoxine AND
2) Decreased scavenger mechanism that removes free
radicals from the body because of deficiency of
micronutrients (Vitamines-A,C,E & Minerals- zinc, selenium,
etc.) and Glutathione( a very important antioxidant in the
body)
 Accumulation of free radicalsDamage of the
cell membranes & Blood vessels
 Kwashiorkor-fatty
liver,Dermatosis,edema etc.

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Weight loss
Growth faltering
Immunity lowered
Appetite loss
Nutrient loss
Malabsorption
Altered Metabolism
Inadequate dietary
intake
Disease Incidence
Severity
Duration

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18.  Body Composition: Diagnostic &
Theraputic
Implications
- TBW and ECF increased  Assessement of dehydration is
difficult
- Increased ICF Na+
- Decreased body K+ and Mg+  They need large doses of
K+ & Mg+
- Marked loss of fat and muscle
 Liver:-Fatty Liver  Hepathomegaly
-Reduction in synthesis of proteins Ability to take up,metabolise &
excrete toxins is limited.
-Impaired gluconeogenesis Hypoglycemia

19.  GIT
- Villi atrophy and reduced dissachardase  malabsorption
- small intestinal bacterial overgrwth  AGE
- Decreased biliary secretion  reduced in digestion &
absorption of fatty meals Steatorrhea
-Pancreatic acinar cells atrophyDecreased digestive
pancreatic enzymes Maldigestion
- chronic pancreatic inssuficiency
-

20. Defense against infection(Immunity)
- All aspects of immunity are impaired but CMI profoundly
affected:
- Reduced secretory IGA
- Impaired phagocytic function
- Impaired acute phase response
- WBC do not migrate to area of infection
- Non-specific defense is weakened
CVS and renal
- Atrophied myocardium
- Reduced cardiac output and stroke volume.
- Blood pressure is low
- Easily develop heart failure-Restrict IV fluid, rehydrate slowly.
-Decreased renal blood flow
-Poor concentrating and filtration capacity

21. Temprature:
 Heat generation is impared as a result of:
-Decreased subcutanous fatty tissue
Hypothermia
-Decreased muscle bulk-decreased
shivering
 Sweating is also impaired
 So prone both to hypothermia & hyperthermia

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Clinical manifestation

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24. Marasmus…-Marked loss of weight, almost no subcutaneous tissue and atrophic
muscles.
-Old man face, sunken eye balls, distended abdomen, & usualy have good
appetite.
-Mood changes (always irritable) & mild skin and hair changes.
-Severe wasting

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26. Kwashakor…
-long eyelashes
-brown hair, flag
sign ,easily &
painlessly plukable
-flaky paint
dermatosis
-signs of measels
like maculopapular
rash, red eye…
Mucocutaneous and hair changes

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Neurobehavioral

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Eyes

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35. Signs of rickets
-rachitic rosary
-Harrison's sulcus
-wrist widening

36.  Hct
 Blood glucose level
 Urine analysis
 Blood & urine culture
 Blood film if febrile
 Serum albumin etc

37.  Infection : lung , blood, UT, GIT,
skin
 Metabolic
 hypoglycemia
hypocalcemia
hypomagnesemia
 Hypothermia
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38.  With the current in-patient protocol mortality
can be as low as 3-5%( Jimma experience )
 LOW mortality is achieved by:
 Restricting the use of fluids, specially IV
 Treating in phases
 Preventing hypoglycemia and hypothermia
 “Early” diagnosis and treatment
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40. Two level
 Community
Done by community volunteers
 Health facility
OTP sites
In-patients
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41.  Anthropometry ( wt, ht/lth , MUAC)
 Check for edema
 Check for medical complication
 Appetite test
Fast Tracking : leave test if patient is critically
ill
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42. 6 months to 18 years
 W/H or W/L < 70% or
 MUAC < 110 mm with a Length > 65 cm or
 Presence of bilateral pitting edema
Adults
 MUAC < 170 mm or
 MUAC < 180 mm with recent weight loss or
underlying chronic illness or
 BMI5 < 16 with or
 Presence of bilateral pitting edema (unless
there is another clear cut cause)
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43.  Bilateral pitting edema Grade 3 (+++)
 Marasmus-Kwashiorkor (W/H<70% with
edema or MUAC<11cm with edema)
 Number of breaths per minute:
o 60 for under 2 months
o 50 from 2 to 12 months
o >40 from 1 to 5 years
o 30 for over 5 year-olds
 Or o Any chest in-drawing
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44.  Extensive skin lesions/ infection
 Very weak, lethargic, unconscious
 Fitting/convulsions
 Severe dehydration based on history & clinical
signs
 Any condition that requires an infusion or NG
tube feeding.
 Severe vomiting/ intractable vomiting
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45.  Very pale (severe anemia)
 Jaundice
 Bleeding tendencies
 Hypothermia: axillary’s temperature < 35°C or
rectal < 35.5°C
 Fever > 39°C
 Other general signs the clinician thinks
warrants transfer to the in-patent facility
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46.  anthropometric Vs metabolic malnutrition
 metabolic malnutrition causes death.
 Poor appetite ~severe metabolic malnutrition
 poor appetite indicates :serious infection,
major organ dysfunction( e.g. liver),
electrolyte imbalance, cell membrane damage
or damaged biochemical pathways
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47. 1. Quiet separate area
2. Explain the purpose of the test to the carer
3. The carer, where possible, should wash his
hands.
4. The carer should sit comfortably and offer
the RUTF from the packet or put a small
amount on finger
5. Gently encourage the child (don’t force )
6. Offer plenty of water to drink with the RUTF
child may be frightened, distressed or
fearful of the environment or staff
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49. Routine Drugs
 Antibiotics
 Vitamins ( A and Folic acid)
 Deworming ( mebendazole / albendazole)
Therapeutic diet( F-75 , F-100,RUTF)
Vaccination
Monitoring
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50.  Admit all pts SAM (Wt/Ht< 70% or MUAC < 11cm or having
bilateral pitting edema).
 The treatment includes 3 phases of treatment:
-Phase 1
-Transition phase &
- Phase 2
1) PHASE -I-includes Feeding, Routine medication, Prevent &
treat complications and monotoring
A)Feeding- Feed F-75 which has 75 kcal/100 ml.
- It has less protein, energy & sodium
- Amount- Give 100 kcal (130 ml)/kg/day or use
the look up
table
-Feed 8 times daily using a cup

51.  NG tube is indicated in:
-Pneumonia with fast breathing
-Painful oral lesions
-Disturbances of consciousness
-taking < 75% of the daily milk
B) Routine Medications-
-Vit.A – Give on days 1, 2 and 14
100,000 IU for children of age < 1 yr &
200,000IU for those > 1 yr of age
-Folic asid- give 5 mg po single dose
-Antibiotics- During Phase-1 + 4 days (in transition phase)
-First line - Amoxicilline if there is no
apparent infn.
-Second line- Chloramphenicol or Gentamycin
-If there are signs of infection or complication,
give
Ampicilline & Gentamycin or Penicillin &
Gentamycin

52. -Measles vaccination- for older than 6 months & not vaccinated
-Treat malaria –According to national guideline
C) Prevent & Treat Complications:
1) Hypoglycemia-
-Prevent it by frequent feeding & keeping the temprature to
normal.
-If conscious – give 50 ml 10% sugar water( 5gm or 1 tsp of
sugar in
100 ml of water) or F-75 by mouth.
-If unconscious or convulsing, 5 ml/kg of 10% glucose IV or
give
sugar water by NG tube
-Start second line antibiotics
2) Hypothermia (T< 35.5)
-Environmental temprature must be monitored & kept b/n
28-32
degree celcius
-Don’t wash a severely malnourished child

53. Treatment of hypothermia:
-Warm with kangaroo mathod for young infants
-Put a hat on the child & wrap the mother and the child
together
-Feed frequently
- Treat for hypoglycemia & start second line antibiotics
-Monitor temprature every 30 minutes
-Give hot drinks to the mother to warm her skin
3) Dehydration-
- The treatment is different from normal children
- Rehydrate as much as possible orally
-IV infusions are almost never used unless clearly indicated
(i,e severe dehydration or septic shock)
-ReSoMal, rather than standard ORS, is prefered b/c it has
low
sodium & osmolality and high potassium.
-Rehydration should be slowly over 12 hours.

54. -Before treatment take Wt, PR, RR, Liver size.
-Feed during rehydration
-Monitor closely (every 1 hour)for both under & over
hydration.
-If the child has recent sunkening of the eyes or eager to
drink and conscious, give ReSoMal 5 ml/kg every 30 minutes
for the first 2 hours PO or through NG tube and then 5-10
ml/kg/hr for 10 hrs.
-If the child is unconscious, start IV infusion to give RL or
halve NS with 5% DW, add 20 mmol Kcl/L
- Rate of infusion- 15 ml/kg over 1 hr and reassess. If
improving give 15 ml/kg the next 1 hr
-If the child regains his conscioussness or PR drops, continue
the rest of the rehydration with 10 ml/kg/hr of ReSoMal.
-Monitor Wt, PR, RR, Liver size & heart sound(gallop rhythm).

55. 4) CHF
-Treatment-Stop all Po intakes and IV fluids
-Give small amount of sugar water
-Furosemide 1-2 mg/kg stat
-Give a very small dose of digoxine (5 mic. Gm /kg )
-Do not transfuse even though anemic
5) Anemia
-If Hgb < 4 gm% or Hct < 12% and with in 48 hrs of
admission,
transfuse with 10 ml/kg of packed cell vollume or whole
blood over 3
hrs and give furosemide 1 mg/kg stat.
-If Hgb is > or= 4 gm% or Hct > or= 12% or any level of Hct
2-14 days
after admission, give iron during phase II

56. D) Monitoring:
- Temprature twice daily
-Wt, Edema, diarrhea, vomiting, signs of
dehydration, PR, RR & liver size daily

57.  Progress to transition phase:
-If the edema starts to decrease
-The appetite returns &
-No NGT, infusion & severe medical problems
- For Marasmic children, if the pt tolerates the diet for 2
days, the
appetite returns & no NGT, infusion and severe medical
problems
 Mgt in transition phase-
- Is the same as Phase I (the Feeding, routine medications &
Monitoring) except F-100 is given instead of F-75.
- The same volume is given as F-75 so that the energy
intake increased
by 30% and the child starts to gain tissue without causing
fluid-
overload or CHF.

58.  Indication to return to phase I:
-Increasing edema
-Rate of Wt gain > 10 gm/kg/day which is a sign of fluid
retention
-Any sign of fluid overload, heart failure, or resp. distress
-Tense abdominal distention
-Development of complications that require IV drugs or
rehydration
therapy or poor appetite
- Refeeding diarrhea that result in Wt. loss

59.  Also called phase of recovery
 Criteria to enter this phase(all should be fulfilled):
-Good appetite
-At least 2 days for wasted(marasmic) pts
-When the edema disappears (for edematous pts)
-No other medical problems
 Protocol – Feed, Routine medication & Monitor
A) Feed
-It is the period of catch up growth so they need high protein &
calorie
diet
-Feed F-100 five times a day based on the Wt, refer chart for
the
amount
-Additionally, give porridge if the child's wt is > 8 kg

60. B) Routine Medications:
-Start ferrous sulphate
-Deworming-with mebendazole or albendazole
-Give the 3rd dose of vit. A at day 14.
C) Monitor:
-Weight 3 time/week
-Temprature daily
- Diarrhea, vomiting, dehydration, cough, PR, RR daily
-Degree of edema every 2 weeks
Good response – Wt. gain > 10 gm/kg/day
Return to Phase I if there is any sign of morbidity

61. Greater than 6 months
 WFH > 85 % and
 MUAC > 12 cm and
 No edema for at least ten days and
 No medical illness mandating in-patient
treatment
Less than 6 months( with lactating mother)
 Baby thriving on breast milk
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